With the change of diet structure and the influence of psychological and social factors, constipation has seriously affected the quality of life of modern people; it also plays an important role in the occurrence of colon cancer, hepatic encephalopathy, breast disease, progeria and other diseases; in acute myocardial infarction, cerebrovascular accidents and other diseases, constipation can lead to life accidents; some constipation and anal diseases have a close relationship, such as hemorrhoids, anal fissures and so on. Therefore, early prevention and reasonable treatment of constipation will greatly reduce the serious consequences and social burden caused by constipation.
1, the need to establish the process of diagnosis and treatment of constipation, taking into account the many patients clinically troubled by constipation, a clear diagnosis often requires high costs, so it is extremely important to find an effective way to diagnose and treat constipation. The whole society will benefit from the development of a simple, effective and operable procedure for the diagnosis and treatment of constipation that is suitable for the current situation in China, so that limited health resources can be used more effectively.
2, the etiology of constipation, examination methods and diagnosis and treatment of healthy people defecation habits are mostly 1 to 2 d or 1 (1-2) d, stools are mostly formed or soft stools (such as Bristol type 4 and 5), a small number of healthy people up to 3 d, or 1 3d, stools semi-formed or bologna-like hard stool (such as Bristol type 6 and 3). Normal defecation requires that intestinal contents pass through the segments at normal speed, reach the rectum in a timely manner, and stimulate the rectum and anus to cause a defecation reflex and coordinated activity of the pelvic floor muscle groups during defecation to complete defecation. Failure of any of the above links may cause constipation. Therefore, we should understand the link, mechanism and related etiology and causative factors that cause constipation in patients with defecation, so that we can develop a reasonable treatment plan.
2.1, the etiology of chronic constipation Chronic constipation has functional and organic causes. Organic causes can be caused by gastrointestinal diseases, systemic diseases involving the digestive tract such as diabetes mellitus, scleroderma, neurological diseases, etc. Diseases and drugs that can cause constipation include: (1) organic lesions of the intestinal canal such as tumors, inflammation or other causes of intestinal lumen narrowing or obstruction; (2) rectal and anal lesions: endorectal prolapse, hemorrhoids, anterior rectal bulge, puborectal hypertrophy, puborectal separation, pelvic floor disease, etc.; (3) endocrine or metabolic diseases: diabetic enteropathy, hypothyroidism, parathyroid disease, etc.; (4) neurological disorders: such as central brain disorders, stroke, multiple sclerosis, spinal cord injury, and peripheral neuropathy; (5) intestinal smooth muscle or neuronal lesions; (6) colonic neuromuscular lesions: pseudo-intestinal obstruction, congenital megacolon, megarectum, etc.; (7) neuropsychological disorders; (8) pharmacological factors: aluminum antacids, iron, opioids, antidepressants, anti-Parkinson’s disease drugs calcium channel antagonists, diuretics, and antihistamines.
2.2 Examination methods and assessment of chronic constipation The diagnostic methods for chronic constipation include medical history, physical examination, relevant laboratory tests, imaging and special examination methods.
2.2.1, medical history A detailed medical history, including symptoms and duration of constipation, gastrointestinal symptoms, concomitant symptoms and diseases, and medications, can often provide very important information. Pay attention to the presence or absence of alarm symptoms (such as blood in stool, anemia, wasting, fever, black stool, abdominal pain, etc.); characteristics of constipation symptoms (frequency of stool, bowel movement, difficulty or dyspareunia, and stool properties); concomitant gastrointestinal symptoms; history related to etiology, such as abnormalities in gastrointestinal anatomy or systemic diseases and constipation caused by drug factors; mental and psychological status and social factors.
2.2.2, general examination methods Anorectal finger examination can often help to understand fecal impaction, anal stenosis, hemorrhoids or rectal prolapse, rectal masses, etc. It can also understand the functional status of the anorectal sphincter; routine blood, stool routine, fecal occult blood test are important and easy routine laboratory tests to exclude organic lesions of the colon, rectum and anus. If necessary, biochemical and metabolic tests should be performed; for suspected anal and rectal lesions, proctoscopy or sigmoidoscopy colonoscopy, or barium enema can directly observe the intestine or show imaging data.
2.2.3, special examination methods For patients with chronic constipation, the following relevant examinations can be selected as appropriate.
Gastrointestinaltransittest (GIT): It is recommended to take one abdominal X-ray after taking 20 impermeable X-ray markers at least 48h after stopping the relevant drugs (normally, most of the markers have already reached the rectum or have been expelled), the purpose of choosing 48h film is to have the possibility to observe the distribution of markers at this time, such as most If most of the markers have been concentrated in the sigmoid and rectal region or have not reached this region, it indicates normal or slow passage, respectively. If one more film is taken at 72h, most of the markers still have not reached the sigmoid or rectum or remain in the sigmoid and rectum, it indicates slow passage or outlet obstruction type constipation, respectively. The gastrointestinal passage test is an easy method that can be extended and applied. Its accuracy may be increased if it is extended to 1 film in 5-6 d, but the feasibility is poor, as most patients have difficulty in adhering to it and use laxatives on their own.
Anorectal manometry (ARM): Perfusion manometry (the same as esophageal manometry) is commonly used to detect the systolic pressure and relaxation pressure of the anal sphincter and external anal sphincter during forceful defecation, the presence or absence of anorectal inhibition reflex after intra-rectal gas injection, and also to determine the perceptual function of the rectum and the compliance of the rectal wall, which can help assess the anorectal sphincter and It is also possible to measure the rectal sensory function and rectal wall compliance. If paradoxical contraction of the external anal sphincter occurs during forceful defecation, it suggests outlet obstructive constipation; if the anorectal inhibitory reflex is absent after air injection into the rectal balloon, it suggests Hirschsprung′s disease; the mucosal sensation of the rectal wall in response to air injection into the balloon, the volume of the maximum tolerance limit, etc., can provide information whether the defecation domain value of the rectal wall is normal.
Colonic pressure monitoring: A transducer is placed into the colon and colonic pressure changes are monitored continuously for 24 to 48 h under relatively physiological conditions. Determining the presence or absence of colonic weakness can be a guide to treatment.
Balloonexpulsion test (BET): A balloon is placed in the rectum, inflated or filled with water, and the subject is made to expel it. It can be used as a screening test for the presence or absence of expulsion disorder, and further examination is required for positive patients.
Bariumdefecography (BD): simulated stool is instilled into the rectum and the changes in the anus and rectum during defecation are dynamically observed under radiation, which can be used to understand whether the patient has concomitant anatomical abnormalities, such as anterior rectal distention and intussusception.
Others, such as pelvic floor electromyography can help clarify whether the lesion is myogenic; pubic nerve latency measurement can show whether there are nerve conduction abnormalities; anal ultrasound endoscopy can understand whether there are defects in the anal sphincter, etc.
2.3 Diagnosis of chronic constipation The diagnosis of patients with chronic constipation should include: the cause (and triggers) of constipation, the degree and type of constipation. If we can understand the extent of constipation-related involvement (colon, anorectum or upper gastrointestinal tract), the involved tissues (myopathy or neuropathy), the presence of local structural abnormalities and their causal relationship with constipation, it is very useful to develop a treatment plan and predict the outcome. The severity of chronic constipation and the type of constipation are described below.
Severity of chronic constipation: Constipation is classified into 3 degrees: mild, moderate and severe. Mild means that the symptoms are mild, do not affect life, and can be improved by general treatment without medication or with less medication; severe means that the constipation symptoms persist, the patient is in unusual pain, seriously affects life, and cannot stop medication or treatment is ineffective; moderate is in between. The so-called refractory constipation, often severe constipation, can be seen in exit obstruction constipation, colonic weakness and severe constipation irritable bowel syndrome (IBS).
Types of chronic constipation: divided into STC, OOC and mixed types. the constipation type of IBS is a type of constipation associated with abdominal pain and bloating, and may also be characterized by each of the following types (1) slowtransitcontipation (STC) often has a reduced number of bowel movements, less bowel movements, hard feces, and thus difficult defecation; no feces or hard feces are palpated on rectal examination, while the contraction and forceful defecation function of the external anal sphincter is normal; prolonged total gastrointestinal or colonic passage time; lack of evidence of outlet obstruction-type constipation, such as air sac expulsion The test is normal and anorectal manometry shows normal. (2) outletobstructiveconstipation (OOC), straining to defecate, feeling of incompleteness or falling, low volume of defecation, with or without the intention to defecate, a lot of mud-like stool in the rectum on anorectal examination, paradoxical contraction of the external anal sphincter during straining to defecate; the total gastrointestinal or colonic passage time is normal, most of the markers can be stored Most of the markers could be stored in the rectum; anorectal manometry showed paradoxical contraction of the external anal sphincter during forceful defecation or abnormal sensory threshold of the rectal wall. (3) Mixed constipation: with the characteristics of (1) and (2).
The above 3 categories are suitable for functional constipation types, but also for chronic constipation caused by other causes, such as diabetes mellitus, scleroderma combined constipation and drug-induced constipation mostly slow transmission type constipation. Irritable bowel syndrome constipation type is characterized by a low number of bowel movements, defecation is often difficult, abdominal pain or bloating relief after defecation and exhaustion, there may be export dysfunction combined with slow passage type constipation, if it can be combined with the relevant functional examination, the clinical type can be further confirmed.
2.4, the treatment of chronic constipation The treatment principle is based on the severity of constipation, etiology and type, comprehensive treatment, restore normal defecation habits and defecation physiology.
2.4.1, general treatment Strengthen education on the physiology of defecation, establish reasonable dietary habits (such as increasing dietary fiber content and water intake) and adhere to good defecation habits, and at the same time, increase activity.
2.4.2. Drug therapy Select appropriate laxative drugs. The choice of drugs should be based on the principle of small toxic side effects and low drug dependence, usually selected such as bulking agents (such as wheat bran, oxytocin, etc.) and osmotic laxatives (such as Fosone, Dulcolax). Randomized controlled observation of the application of Fosone in the treatment of functional constipation showed good efficacy in increasing the number of bowel movements and improving stool properties. For slow-transmission constipation, prokinetic agents such as cisapride or mosapride can be added. It should be noted that for patients with chronic constipation, long-term application or abuse of stimulant laxatives should be avoided. A variety of proprietary Chinese medicines have laxative effects, but it should be noted that when taking proprietary Chinese medicines for chronic constipation over a long period of time, attention should be paid to the composition and side effects of the drugs. For patients with fecal impaction, clean enema once or combine with short-term use of stimulant laxatives to relieve fecal impaction, and then use bulking agents or osmotic laxatives to keep the bowel movement open. Curettage and glycerin suppositories have the effect of softening feces and stimulating defecation. Compound carrageenan is effective in treating constipation of hemorrhoidal origin.
2.4.3, psychotherapy and biofeedback Patients with moderate or severe constipation often have psychological factors or disorders such as anxiety or even depression, and should be treated with cognitive therapy to make patients eliminate tension. Biofeedback therapy is suitable for functional outlet obstruction type constipation.
2.4.4, surgical treatment If the results are not significant after strict non-surgical treatment, and various special examinations show clear pathological anatomy and conclusive functional abnormalities, surgical treatment can be considered. Indications for surgical procedures include secondary megacolon, partial colonic redundancy, colonic weakness, severe anterior rectal distension, endorectal overlap, and intra-rectal mucosal prolapse. However, attention should be paid to the presence of serious psychological disorders, the presence of abnormalities in the digestive tract other than the colon, and the need for efficacy prediction before surgery.
3.International diagnostic criteria and diagnosis and treatment process of chronic constipation
In September 1999, the International Rome II Collaborative Committee developed a series of diagnostic criteria for Rome II functional gastrointestinal diseases on the basis of Rome I. Although the current understanding of constipation is not uniform in the gastroenterology community, the diagnostic criteria of Rome II are still used as the basis for the development of national diagnosis and treatment procedures, taking into account the actual situation of each country. The following describes the diagnostic criteria for chronic constipation, functional constipation, pelvic floor defecation disorder and IBS constipation type of Rome II, and introduces the main points of the American Guidelines for the Treatment of Constipation developed in the United States in recent years on the basis of the criteria.
3.1, Rome II on the diagnostic criteria of constipation (chronicconstipation): with at least 12 weeks in the past 12 months, two or more of the following symptoms occur continuously or intermittently: (1) >1 4 time with straining to defecate; (2) >1 4 time with lumpy or hard stool; (3) >1 4 time with a sense of incomplete defecation; (4) >1 4 time (4)>1 4 of the time, there is a feeling of anal obstruction or anorectal obstruction during defecation; (5) >1 4 of the time, there is a need for manual assistance during defecation; (6) >1 4 of the time, there is a bowel movement <3 times per week, there is no thin stool, and the diagnostic criteria of IBS are not met.
Functional constipation: According to Rome II diagnostic criteria, in addition to the above diagnostic criteria, functional constipation should be excluded from intestinal or systemic organic causes and constipation caused by medication.
Pelvic floor defecation disorder (pelvicfloordyssynergia): Rome II diagnostic criteria for pelvic floor defecation disorder means that in addition to meeting the above Rome II diagnostic criteria for functional constipation, the following points must be met, namely: (1) there must be evidence of anorectal manometry, electromyography or X-ray examination, indicating that the pelvic floor muscles do not contract or cannot relax during repeated defecation movements appropriate contraction or inability to relax; (2) adequate propulsive contraction of the rectum can occur with forceful defecation; and (3) evidence of poor fecal expulsion.
Irritable bowersyndrome (constipation-predominant, IBS) is a functional bowel disease characterized by abdominal discomfort or pain with altered bowel habits and abnormal bowel movements, with no lesions on X-ray barium enema or colonoscopy and no evidence of systemic disease. . Constipated IBS is defined as those who first meet the basic points of the IBS criteria, i.e., the presence of abdominal pain or abdominal discomfort for at least 12 weeks (not necessarily consecutive) within the past 12 months, accompanied by 2 of the following 3: (1) disappearance of the symptoms of appeal after defecation; (2) appearance of the above symptoms with a change in the frequency of stool; or (3) with a change in stool character. This is supported by any one of the following three manifestations: (1) less than 3 bowel movements per week; (2) loose stools; and (3) a sense of urgency in defecation.
3.2. The main points of the diagnosis and treatment process of chronic constipation proposed in the United States The main points of the process of chronic constipation proposed in the United States are based on the medical history and physical examination, combined with relevant laboratory tests, and the first proposed experimental treatment for patients with refractory constipation, followed by barium defecography and relevant power function tests, and the corresponding treatment according to the type of constipation. According to the preliminary assessment results, the diagnosis of constipation is divided into 6 conditions, namely (1) constipation type IBS; (2) slow transmission type constipation; (3) rectal outlet obstruction type; (4) above (2) and (3) coexist; (5) functional constipation (functional obstruction or drug side effects); and (6) constipation secondary to systemic diseases.
4, our constipation diagnosis and treatment process and its principles
Constipation has a degree, type, and etiology and causative factors, therefore, patients with constipation need to be graded and stratified in the diagnosis and treatment triage, so that the diagnosis and treatment process is conducive to the active and effective diagnosis and treatment of patients, and to produce a reasonable efficiency cost ratio.
4.1. Treatment flow Clinically, in order to achieve effective stratified (alarmed or not) and graded (degree) triage of patients with constipation, the etiology and causative factors causing constipation, the type and degree of constipation need to be assessed. For most patients, a detailed history and physical examination will provide an understanding of the cause and type of constipation and empirical treatment; for constipation with alarm signs or suspected organic disease, further examination should be performed to exclude or confirm the presence of organic disease, especially colon tumors; for patients with constipation identified as organic disease, in addition to etiologic treatment, it is also necessary to determine the type of constipation based on its characteristics and treat accordingly; for patients with constipation identified as organic disease, in addition to etiologic treatment, it is necessary to determine the type of constipation and treat accordingly. For cases treated empirically or not confirmed to be organic constipation by examination, further examination can determine the type of constipation and then treat accordingly; for a few patients with refractory constipation, relevant examination of the type of constipation or even more detailed examination is performed at the beginning in order to determine the treatment (see Figure 1).
4.2, principles of treatment (1) Detailed history and physical examination is an important basis for selecting the constipation process. For most patients with constipation, non-invasive methods are used to determine the type of constipation as much as possible, and clinical inferences are verified based on the efficacy of empirical treatment. (2) The type of constipation is an important basis for the selection of treatment. Whether empirical treatment or treatment after further examination, emphasis is placed on the appropriate therapeutic response to different types of constipation. (3) For patients with alarm signs of constipation, emphasis is placed on etiologic investigation, while for those with refractory constipation and lack of alarm signs, the importance of determining the type of constipation is emphasized. (4) The proportion of patients receiving various means of investigation: for most constipation, empirical treatment is the mainstay, for refractory constipation, further investigations should be performed, and a few patients, especially those requiring surgical procedures, require more intensive investigations. (5) Several routes in the process can interpenetrate each other. If the empirical treatment is not effective, further examination should be performed to understand the etiology and type.
4.3, common manifestations of chronic constipation
4.3.1, less bowel movements, reduced number of stools This type of constipation can be seen in the slow passage type and outlet obstruction type constipation. The former is due to the slow passage, so that the number of stools and bowel movements are reduced, but at certain intervals can still appear bowel movements, stools are often dry and hard, forceful defecation helps to expel feces. In the latter case, the value of the sensory domain is often elevated, and it is not easy to cause the desire to defecate, so the frequency of defecation is reduced, while the stool is not necessarily dry and hard. For these patients, bulking agents or osmotic agents can be applied to increase the water content of stool, increase the softness and volume, stimulate peristalsis of the colon, and also increase the stimulation of the rectal mucosa. At the same time, regular bowel movements should be performed.
4.3.2. Difficult and laborious defecation is highlighted by abnormally difficult fecal discharge, which is also seen in two cases, with exit obstruction type constipation being more common. Patients force to defecate, the external anal sphincter presents paradoxical contraction, resulting in difficult defecation. This type of constipation is not necessarily less frequent, but it is time-consuming and laborious. If accompanied by weakness of the abdominal muscle contraction, the difficulty of defecation is aggravated. The second case is due to slow passage, too much water in the stool is absorbed, the stool is dry, especially for a long time without defecation, making the discharge of dry hard stool difficult, can occur fecal impaction. This type of constipation can be treated with bulking agents and osmotic agents to soften the stool for easy discharge, sometimes combined with enema treatment. If the stool is still difficult to pass after softening, it is suggested to be outlet obstruction type constipation, and these patients need to be guided to defecation mode and biofeedback treatment if necessary.
4.3.3, poor defecation There is often a sense of obstruction in the anorectum, and although there is frequent desire to defecate, and the number of bowel movements is not small, even with great effort, it does not help, and it is difficult to have a smooth defecation. It may be accompanied by anorectal irritation symptoms, such as cramping and discomfort. These patients often have reduced sensory field values, rectal sensory hypersensitivity, or abnormalities in the anatomy of the rectum, such as endorectal overlap and internal hemorrhoids. Individuals with elevated rectal sensory field values also present with similar symptoms, which may be related to the combination of anorectal anatomical changes. Treatment of this group of patients requires raising sensory domain values, reducing the number of bowel movements, and treating local anorectal lesions, such as local management of constipation of hemorrhoidal origin.
4.3.4. Constipation often accompanied by abdominal pain or abdominal discomfort is commonly seen in constipated IBS, and the symptoms are relieved after defecation.
The above types of constipation are not only seen in functional constipation, but also in constipated IBS (which may also present with all of the above types). Chronic constipation caused by organic diseases such as diabetes mellitus and constipation caused by medications can have the above types of manifestations and should be analyzed. In addition there is often a combination of conditions.
4.4.Related etiological examination Imaging or endoscopy, if necessary combined with pathological examination to determine the presence of organic intestinal diseases, such as suspected diabetes, endocrine diseases, connective tissue diseases and neurological diseases, the corresponding biochemical and immunological tests should be done.
4.5, to determine the type of constipation of the common methods used to determine the type of constipation of the common examination methods are gastrointestinal passage test and anorectal manometry, anorectal examination can help diagnose.
Anorectal finger examination: anorectal finger examination is not only an important method to check whether there is rectal cancer, but also a common and simple technique to determine whether there is exit obstruction type constipation. In particular, the enhanced sphincter tone, the sphincter cannot relax during forceful defecation, but becomes more contracted and tense, suggesting long-term extremely strenuous defecation, resulting in sphincter hypertrophy, and at the same time paradoxical contraction during forceful defecation.
4.6, the special examination about refractory constipation severe slow-passage constipation on various treatments are ineffective, often suggesting colonic weakness, such as 24h colon pressure monitoring lack of specific propagatingpressurewave (Specializedpropagatingpressurewave, SP PW) suggests the need for surgical treatment; defecography can dynamically observe anorectal anatomy and functional changes. The combination of anal manometry and ultrasound endoscopy shows both mechanical deficiency and anatomical weakness of the anal sphincter, both of which provide important clues for anorectal surgery; a small number of constipations require differentiation of lesions of myogenic or neurogenic origin, which requires examination of perineal nerve latency or electromyography; patients with significant anxiety and depression should be investigated.