1, modern medical understanding of the pathophysiology of functional defecation disorders
1.1 Normal defecation process
The entry of feces into the rectum from the sigmoid colon marks the beginning of the defecation process. When the feces entering the rectal jugular reaches a certain volume, it will produce obvious bowel movement, and with the further increase of feces entering the rectum, it will gradually cause a sense of rectal fullness, which stimulates the defecation receptors located in the external sphincter of the puborectal muscle and the pelvic tissue outside the rectal wall, causing anorectal inhibition reflex, leading to relaxation of the internal sphincter and contraction of the external sphincter, causing the rectum to expand and improving rectal compliance. This urge to defecate is transmitted to the defecation center located in the temporal lobe of the brain. It is now known that the external sphincter and the puborectalis muscle consist of type III fibers, and when the cerebral cortex gives the command to defecate, it has been pointed out that the inhibition of the reticular descending excitatory conduction pathway depresses the electrical activity of the r motor neurons in the anterior horn of the spinal cord, so that the tonic electrical activity of the type I fibers innervated by them is reduced and the afferent impulses from them cannot reach the firing threshold of the a motor neurons and therefore cannot The afferent impulses from the type I fibers do not reach the firing threshold of the a-motor neurons, and therefore do not stimulate primary phasic contraction or reflex activity in the type II fibers innervated by the latter. In the resting state, type I fibers still maintain a certain amount of low-frequency resting tone, so the pressure in the anal canal decreases at this time. At the same time, the reflex contraction of rectum and distal colon shortens the intestinal canal and increases the pressure in the intestinal cavity, and the stimulation of the urge to defecate can cause a reflex rise in abdominal pressure, which becomes the driving force for defecation. It can be seen that defecation activity is closely related to the normal function of the sphincter muscle group, intact rectal compliance, sensitive defecation receptors, normal anorectal inhibition reflex, normal nerve reflex conduction pathway, central coordination control ability, etc., which has been reported in domestic research.
1.2 Modern medical understanding of the pathological mechanism of functional defecation disorders
According to the Rome III diagnostic criteria, functional defecation disorders are divided into two subtypes: uncoordinated defecation and defecation propulsion deficiency. The former refers to uncoordinated contraction of the pelvic floor muscles or resting pressure of the anal sphincter <20% relaxation during defecation. The latter refers to insufficient rectal propulsion during repeated attempts to defecate in patients with functional constipation, with or without uncoordinated contractions of the pelvic floor muscles or with less than 20% relaxation of the anal sphincter pressure at basal rest.
1.2.1 The pathological mechanism of insufficient propulsion force type constipation is
Zhang Dongming pointed out that a large number of patients with constipation have chronic increased abdominal pressure due to long-term difficulty in defecation, excessive exertion, which exceeds the physiological limit of the load of the anal raphe, which can lead to a decrease in the tone of the anal raphe, atrophy and sagging, and the pelvic floor drops below the normal range during defecation. The nerve that governs the pelvic floor muscle is short, small and fixed, so when the pelvic floor falls, the nerve is bound to be stretched. If the nerve is still stretched for 20-30 minutes after losing its conductivity, the excitability and conductivity of the nerve will not be restored, and the transverse pelvic floor muscle innervated by it will be gradually weakened and the contraction force will be reduced, which will be manifested as a decrease in the systolic pressure of the anal canal. The relaxed pelvic floor muscles are prone to pelvic floor organ bulging and aggravated pelvic floor nerve strain injury.
Research data show that the colorectal wall of patients with constipation has muscle fiber degeneration, muscle atrophy, degeneration, deformation, and reduction in the number of intermuscular plexus of the intestinal wall, and pelvic parasympathetic nerves can undergo pathological changes such as vacuolar degeneration of axons, loss of myenteric neurons, and degeneration of nonspecific plexuses. This is associated with patients producing abnormal rectal sensory thresholds and even inadequate rectal propulsion.
The disease is most often seen in older women, but some of them can be traced back to the reproductive years. With increasing age, the estrogen level in the body decreases significantly, which may show a decrease in elasticity in the skin and a thinning and decrease in tension of the transverse muscle fibers in the abdominal wall. It has been suggested that the elasticity and tone of the transverse muscle, ligaments and fibrous tissues of the pelvis decrease with decreasing estrogen levels and are not easily recovered.
The core mechanism of defecation insufficiency should be the decline of the pelvic floor, relaxation of the perineal support structures, dysfunction of the motor and sensory nerves innervating the pelvic floor, and decrease in the tension level of the pelvic muscle fibers and ligaments.
1.2.2 Pathological mechanisms of incoordinated defecation.
However the mechanism of paradoxical contraction has also not been fully elucidated. It should be related to the uncoordinated central control of defecation in patients with chronic constipation, who have long-term defecation difficulties and excessive mental stress, producing emotional disorders such as anxiety, depression and irritability. Li Xuefeng et al [performed anorectal kinetic examination on 23 patients with outlet obstruction-type constipation and 11 healthy controls, and assessed psychological factors with the Hamilton Depression Scale, and found that the degree of psychosomatic disorders was related to the anal sphincter during simulated defecation EMG voltage (reflecting anal sphincter diastolic coordination) and anal canal resting pressure were positively correlated. The elevated excitability of the patient’s cerebral cortex and the elevated excitatory nerve conduction impulses in the reticular formation continuously excite the r-motor neurons located in the anterior horn of the spinal cord in the low defecation center, causing the type 1 fibers innervated by them to be at a high resting potential and a higher than usual resting tension level of anal canal pressure, so that the electrical activity generated by the type 1 fibers activates the a-motor neurons to cause the type 2 fibers innervated by them to contract in one phase. A paradoxical movement of paradoxical contraction is formed. It has been suggested that this abnormal overload contraction can lead to muscle spasm in the puborectalis muscle of the sphincter due to ischemia and hypoxia and abnormal release of the neurotransmitter acetylcholine, increasing the pressure in the anal canal.
We have now recognized four types of anal and rectal pressure changes during defecation: the normal type shows increased intrarectal pressure accompanied by anal sphincter relaxation; type I shows adequate propulsion (intrarectal pressure ≥45 mmHg) and increased anal canal pressure; type II shows inadequate propulsion (intrarectal pressure <45 mmHg) and incomplete or contracted anal sphincter relaxation; type III shows increased rectal increased internal pressure (≥45 mmHg), accompanied by non-relaxation or incomplete relaxation of the anal sphincter (<20%). Usually we take less than 45 mmHg as the standard [and type I type III is defined as uncoordinated defecation, defining type II as inadequate defecation propulsion.
1.3 Modern medical treatment of this disease
At present, western medicine for constipation treatment is mainly laxatives and gastrointestinal motility drugs, gastrointestinal motility drugs represented by cisapride mosapride, some studies show that cisapride not only enhances the colon motility, but also makes the anorectal uncoordinated contraction tend to be coordinated, so that constipation is improved, laxatives to magnesium sulfate, sodium sulfate, fruit guide, long-term use will produce drug dependence or even addiction, easy to cause colonic melanosis for Surgical treatment, the long-term results are not ideal, because the etiology of the disease is multifaceted, complex, there is no ideal surgery, and there are large trauma, slow healing, postoperative complications, such as the occurrence of urinary retention, incision infection, rectovaginal fistula and other disadvantages. Therefore, the choice of surgery should be cautious.
2, the ancestral medical knowledge of constipation
Modern Chinese medicine classifies it into two categories: real constipation and deficiency constipation. Real constipation includes heat constipation, cold constipation, and qi stagnation constipation, and deficiency constipation includes basic evidence of qi deficiency, blood deficiency, yin deficiency, yang deficiency, etc.
2.1 Chinese medicine symptom recognition of patients with functional bowel disorders
2.1.1 Insufficient pushing power type
This type of constipation should belong to the category of deficiency constipation in ancestral medicine, mostly seen in qi deficiency, damaged spleen and stomach or weakness after prolonged illness or postpartum, damage to yang energy, rectal power to push feces difficult to expel. As “Jing Yue Quan Shu – constipation” cloud: “Where the lower jiao Yang deficiency, then Yang does not work, Yang does not work, it can not be transmitted, and Yin condensation in the lower, this Yang deficiency and Yin knot also.” The symptom is that the stool is not dry and hard, although there is an intention to defecate, but it is difficult to defecate, sweating and short of breath when straining, weakness after defecation, fatigue, lazy speech, light tongue with white fur and weak pulse. The treatment advocates from the deficiency theory of treatment, in order to supplement the Qi, lifting solid regimen, moisten the intestines and laxative for the treatment, the party to supplement the Qi soup is the main, “Xie Yinglu medical case closed door” in the cloud: “the treatment of fecal impassability … there are popular lung Qi method, Qi deficiency and sweating, then use the method of supplementing the Qi”, astragalus Atractylodes and other Qi tonic medicine to make the Qi vigorous and Push powerful, also can make intestinal peristalsis enhance. Astragalus and Radix Angelicae Sinensis and Citrus Aurantium have better therapeutic effect on improving the tone of transverse muscle or smooth muscle and sphincter muscle.
2.2.2 Uncoordinated bowel movement
This type is mostly caused by dampness and heat, due to excessive consumption of spicy and thick flavors, damage to the spleen and stomach, loss of spleen health, internal production of water and dampness, dampness and heat, dampness and heat blocking the large intestine, occlusion of qi, internal qi obstruction, large intestine conduction failure, and defecation disorders. It can be accompanied by stagnation of blood and silt as a problem
It can be accompanied by stagnation of blood. Symptoms include progressive worsening difficulty in defecation, dry stool, perineal swelling, dry mouth, dry tongue coating and slippery pulse. For this type of constipation, the treatment is to clear dampness and heat, regulate qi and activate blood, using San Ren Tang with addition and subtraction. San Ren Tang is from Wu Tang’s “Wenzhi Zhuan Zhi Zhi”. In this formula, almonds are pungent, open and bitter, good at opening the upper jiao and promoting lung qi in the upper jiao. Coix seeds are sweet and light to clear dampness and heat and strengthen the spleen, which can channel the lower jiao and make damp heat go away from the stool. Modern experimental research has proven that Coix seed contains Coix seed oil, which has the effect of preventing or reducing the spasmodic contraction of the transverse muscle, thus relieving the spasticity of the pelvic floor muscle and sphincter muscle, facilitating the discharge of feces, while Coix seed also has the effect of adjusting the movement of the intestinal tube. The whole formula is used to promote the flow of Qi, remove dampness and heat, and facilitate the passage of stool.
3. Treatment of the disease by Chinese medicine 3.1 Chinese medicine treatment
Chinese medicine treatment is mainly to pass down, but the emphasis is on identification and treatment, replenish the qi to make the large intestine conductive, nourish the yin and moisten the dryness to make the dregs discharge smoothly, as Zhu Danxi said, “replenish the qi to move the boat powerfully, replenish the yin to increase the water to move the boat”, the progress of Chinese medicine treatment of constipation: Tang Qingzhu used tonifying Zhong Yi Qi Tang to treat 35 cases of pelvic floor relaxation syndrome type constipation, the total effective rate 94.3%. Sun Guangquan and Xu Hong used the method of tonifying the spleen, benefiting qi and nourishing the kidney to treat 86 cases of senile constipation. The total effective rate was 100%. Fan Dongmei and Ou Zhihui used the method of regulating the intestines and strengthening the spleen to promote the flow of qi and lowering the spleen, and at the same time to strengthen the spleen to help the qi-transformation function of the intestines and stomach. The results showed that 6 cases (17.1%) were clinically cured, 17 cases (48.6%) were effective, 9 cases (25.7%) were effective, and 3 cases (8.6%) were ineffective. The treatment of constipation in the elderly is based on the theory of deficiency, using the method of benefitting Qi and nourishing Blood, moistening the bowels and opening the bowels, and self-formulated Ginseng and Gui Run Tong Tang orally (15g each of Radix et Rhizoma Ginseng, Atractylodes Macrocephala, Citrus Aurantium, Radix Angelicae Sinensis, Radix He Shou Wu, Herba Cistanches, Radix et Rhizoma Ginseng, l0g each of Peach kernel, Ma Ren and Almond, 5g of Licorice) with the addition and subtraction of evidence, treating 60 cases of functional constipation in the elderly. The total effective rate was 91.7%. Qiu Xinping and Liu Yuancheng treated slow-transit constipation with Yi Qi and intestine method combined with TCM diagnosis and reduction, using raw Astragalus, Atractylodes, Radix Codonopsis, almonds, peach kernel, melon seeds and powdered licorice, while the control group was treated with polyethylene glycol 4000. The near- and long-term efficacy of the treatment was observed. The results showed that the near-term efficacy of the treatment group for constipation was better than that of the control group (P< 0. 05), and the long-term recurrence rate was lower, which was more significantly different from that of the control group (P<0. 05). Liu Mingyue used the method of tonifying qi and promoting lung to advocate functional constipation by tonifying qi and promoting blood, promoting lung and laxity, and formulated her own formula of Huangqi Tang (Astragalus membranaceus, Fritillariae, Chen Pi, White Honey) with the addition of Radix et Rhizoma Ginseng, Rhizoma Atractylodes Macrocephalae, Rhizoma Gastrodiae, Almond, Radix et Rhizomae, Radix Angelicae Sinensis, Peach kernel, Medlar, Licorice, treating 98 cases, curing 67 cases, showing efficacy in 28 cases, effective in 3 cases, and ineffective in 0 cases.