I. Background of constipation diagnosis and treatment process Constipation mainly refers to the dryness of feces, difficulty in defecation or feeling of incompletion, as well as a decrease in the frequency of defecation. Constipation is a common condition caused by a variety of etiologic factors, including gastrointestinal diseases, systemic diseases involving the digestive tract, and many drugs can also cause constipation. Many cases of constipation have no organic cause, and the Rome II Functional Gastrointestinal Diseases (FGID) suggests that constipation is associated with functional constipation, pelvic floor defecation disorders, and constipation-type irritable bowel syndrome. Functional constipation requires the exclusion of organic causes and pharmacologic factors. Pelvic floor dyspareunia needs to meet the criteria for functional constipation and have objective evidence of pelvic floor dyspareunia. Constipation-type irritable bowel syndrome is characterized by constipation. With the change of dietary structure and the influence of mental, psychological and social factors, constipation has seriously affected people’s quality of life, and plays an important role in the occurrence of some diseases such as colon cancer, hepatic encephalopathy, breast disease, and senile dementia; constipation in acute myocardial infarction, cerebrovascular accident, etc. can even lead to life accidents; part of the constipation and anal and intestinal diseases, such as hemorrhoids, fissures and so on, all have a close relationship. China’s Beijing, Tianjin and Xi’an region of the elderly over 60 years of age survey shows that chronic constipation as high as 15% to 20%. A randomized, stratified and graded survey of adults aged 18 to 70 in Beijing showed that the prevalence of chronic constipation was 6.07%, and the prevalence rate of women was more than 4 times that of men, and the mental factor was one of the high-risk factors. Therefore, the prevention and timely and reasonable treatment of constipation will greatly reduce the serious consequences of constipation and social burden, the development of constipation diagnosis and treatment process suitable for our country will benefit the whole society. 2001 China’s gastrointestinal dynamics conference (shenzhen) put forward the constipation diagnosis and treatment process, the last 10 months in all parts of the country to solicit opinions, this year in August in Beijing China chronic constipation forum meeting, China more than 200 Gastroenterologists further discussed the diagnosis and treatment process. Second, China’s constipation process ideas and rationale: constipation diagnostic points: normal bowel movements need to have normal colon transmission function and defecation function. If there is a failure of any link, it can cause constipation. The diagnosis of chronic constipation should include the etiology (and triggers) of constipation, the degree and type of constipation. Knowledge of the extent of involvement associated with constipation (colon, anorectum, or concomitant upper gastrointestinal tract), the tissues involved (myopathy or neuropathy), the presence of local structural abnormalities, and their causal relationship to constipation is useful in formulating treatment and predicting outcome. The severity of constipation can be categorized as mild, moderate, or severe. Mild means that the symptoms are mild, do not affect life, can be improved by general treatment, and do not require medication or less medication. Severe means that the constipation symptoms persist, the patient is unusually painful, seriously affects the life, can not stop the medicine or treatment is ineffective. Moderate is given between the two. The so-called refractory constipation is often severe constipation, which can be seen in the exit obstruction type of constipation, colon weakness, and severe constipation type of irritable bowel syndrome (IBS). The two basic types of chronic constipation are slow-transmitting and outlet-obstructing, with both being mixed. The constipation type of IBS is a similar type of constipation associated with abdominal pain or bloating. Diagnosis of constipation: The history provides important information such as the characteristics of constipation symptoms (frequency of stools, urge to pass stools, whether they are difficult or uncomfortable, and the nature of the stools), concomitant gastrointestinal and other symptoms, and underlying medical conditions and medications. Attention was paid to alarm signs and family history of tumors and psychosocial factors. For patients with constipation who are suspected of having anorectal disease, anorectal fingerprinting is performed when necessary, paying attention to the presence or absence of masses and sphincter function. Fecal examination and occult blood test are important and simple routines that should be included in the routine examination of most patients with constipation. Biochemical and metabolic tests should be performed when necessary. Colonoscopy or barium enema is helpful in determining the presence or absence of organic causes, especially colon cancer, and should be scheduled promptly in patients with chronic constipation of uncertain etiology. There are several ways to determine the type of constipation. A simplified colon transport test suggests that at least one abdominal film be taken 48 h after administration of opaque X-ray markers (normally most markers have already arrived in the rectum or have been excreted), and another film taken 72 h later if necessary, as the distribution of the markers is helpful in determining whether or not there is a slow transport. In practice, the measurement of colonic transit time is not very important, especially in patients with few bowel movements. If it is prolonged to 5-6 days to take a film, it is difficult for patients to adhere to and self-administer laxatives, and the sensitivity of the diagnosis of mild and moderate constipation is reduced. Anorectal manometry can check whether there is any dysfunction of the anorectal function, such as the paradoxical contraction of the external anal sphincter during forceful evacuation, the absence of anorectal inhibitory reflexes after rectal balloon inflation, and the abnormal sensory function of the rectal wall, etc. The anorectal manometry test can be used to check whether there is any dysfunction of the anorectal function. The balloon expulsion test reflects the anorectal ability to expel the balloon, although the balloon and the hard feces in the rectum are not yet the same. Some refractory constipation, such as the lack of specific propulsive contraction waves (SPPW) on 24-h colonic pressure monitoring and the lack of colonic response to awakening and feeding, are indicative of colonic incompetence and require surgical resection. Defecography provides dynamic visualization of anatomical and functional changes in the anorectum, and anal manometry combined with ultrasound endoscopy reveals the presence or absence of mechanical and anatomical deficits of the anal sphincter, both of which provide clues for surgery. Application of perineural nerve latency or electromyography can distinguish whether constipation is myogenic or neurogenic. Patients with significant anxiety and depression should be investigated and a causal relationship with constipation should be determined. Chronic constipation requires comprehensive treatment to restore the physiology of defecation. It is suggested to strengthen the physiological education of defecation, establish reasonable dietary habits (such as increasing the content of dietary fiber, increase the amount of water intake) and adhere to good defecation habits, and should increase the activity at the same time. In the selection of laxative drugs, attention should be paid to the efficacy and safety as well as drug dependence. We advocate the use of bulking agents (e.g. wheat bran, Ocimum basilicum, etc.) and osmotic laxatives (e.g. Fosamax, Dupuytren). Our observation of the randomized controlled results of Fosamax for the treatment of functional constipation showed that the efficacy of increasing the number of bowel movements and improving the fecal characteristics were claimed to be good. For slow-transmission constipation, prokinetic agents, such as cisapride or mosapride, can also be added. Long-term application or abuse of stimulating laxatives should be avoided. A variety of proprietary Chinese medicines have laxative effects, and attention should also be paid to the possible side effects of long-term treatment and to the ingredients within the proprietary medicines. For patients with fecal impaction, clean enema or combined with short-term use of stimulant laxatives to release impaction, and then use bulking agent or osmotic drugs to maintain bowel movement. Kefir and glycerin suppositories have the effect of softening feces and stimulating defecation. Compound keratolic acid can be used to treat constipation of hemorrhoidal origin. For functional outlet obstruction type constipation, biofeedback is used, and the patient’s ability to grasp the essentials determines success. Psychotherapy has a positive effect especially on patients with severe constipation. Before surgical treatment, attention should be paid to the presence of serious psychological disorders, digestive tract abnormalities outside the colon, preoperative prediction is required. Third, our constipation process and its principles The following principles can be followed: (1), proposed to analyze the etiology and triggers of constipation, type and severity of constipation, constipation patients for effective stratification (alarmed or not), grading (degree) triage diagnosis and treatment. (2), for alarm signs, or suspected organic etiology, should be further examined for organic diseases, especially rectal and colonic tumors. (3) For those who are determined to have organic diseases, in addition to the etiological treatment, it is also necessary to determine the type of constipation according to the characteristics of constipation and the corresponding treatment. (4), for most patients, especially the milder patients, a detailed history and physical examination can help to understand the etiology, the type of constipation, can be arranged for a short course (1-2 weeks) of empirical treatment. (5), such as empirical treatment is ineffective, can be further examined for organic diseases; if the examination does not confirm the organic cause, according to the characteristics of constipation into empirical treatment; can also be further relevant examination to determine the type of constipation, and then carry out the corresponding treatment. For a few patients with refractory constipation, it is advocated that the relevant examination of the type of constipation be carried out at the beginning, or even a more detailed examination plan, in order to determine the reasonable means of treatment. (6) The proposed empirical treatment is based on judging the possible types from the manifestations of chronic constipation. The four common manifestations are: firstly, fewer bowel movements and fewer bowel movements, secondly, difficult and laborious bowel movements, thirdly, irregular bowel movements, and fourthly, constipation accompanied by abdominal pain or abdominal discomfort. Note that these categories can be seen in both slow-transmitting and outlet-obstructing constipation, but can help guide empirical treatment if they are carefully differentiated.