I. Overview
Constipation is a common clinical symptom that manifests as dry stools, difficulty in defecation, and decreased stool weight and frequency. Constipation can be caused by many reasons such as neurogenic, systemic diseases, etc., called secondary constipation. If constipation does not exist to cause constipation organic lesions called functional constipation, used to be considered simple constipation, habitual constipation or idiopathic constipation, etc.
Second, the disease introduction
Functional constipation refers to the lack of organic causes, no structural abnormalities or metabolic disorders, except irritable bowel syndrome chronic constipation. Patients with functional constipation may have hard stools, difficulty in defecation, incomplete stool feeling and reduced frequency of stool, etc.
Third, the disease classification
Slow transmission type constipation: It refers to constipation in which the contents are retained in the colon or the colon is slow to pass due to colonic dysfunction, and colonic manometry shows reduced colonic dysfunction, resulting in slow propulsion of colonic contents and delayed emptying. It may also be accompanied by other autonomic abnormalities resulting in gastrointestinal dysfunction such as delayed gastric emptying or small bowel motility disorders. Patients complain of infrequent bowel movements, hard stools, and no bowel movement. The diagnosis can be established by scintigraphy or opaque x-ray markers suggesting delayed colonic passage time. It is therefore called colonic weakness, and it is the most common type of functional constipation. It is the most common type of functional constipation. Pro-intestinal motility agents are preferred for treatment.
Exit obstruction constipation: normal colonic transmission function, due to functional abnormalities of the anus and rectum (non-organic lesions) such as defecation reflex deficiency, pelvic floor muscle spasm syndrome or anal sphincter incoordination during defecation. These include transverse muscle dysfunction, abnormal rectal smooth muscle dynamics, impaired rectal sensory function, anal sphincter incoordination, and pelvic floor spasm syndrome. Patients complain of difficulty in defecation, anorectal obstruction, and the need for manual assistance during defecation. It occurs mostly in children, women and the elderly. Biofeedback therapy is an option for treatment.
Mixed constipation: slow-transmission colonic features, abnormal anal and rectal function, or both are atypical, treatment varies from person to person. This type may be due to the development of slow-transmission constipation, and it is also believed that long-term outlet obstruction affects colonic emptying secondary to colonic weakness.
IV. Causes of morbidity
1.Defecation process
Peripheral nerve excitation → primary defecation center and cerebral cortex → coordinated movement of colon, rectal and anal sphincter and pelvic floor muscles
2.Pathogenesis
Clinical manifestations: 1, effortful defecation, rejection of force; 2, hard stool (coarse – rectal type, small grain – colon type); 3, urgent and ineffective stool, urgent and heavy; 4, low frequency of stool (natural defecation less than 3 times a week); 5, sense of incomplete defecation; 6, left lower abdominal distension and pain, left lower abdominal mass; 7, hemorrhoids, anal fissure; 8, upper abdominal discomfort, belching, more exhaust; 9, mild “Toxemia” symptoms, such as loss of appetite, bitterness in the mouth, depression, dizziness and weakness, generalized aches and pains; 10, vague pain and suffocating sensation in the buttocks and posterior thighs, due to the compression of the third, fourth and fifth spinal nerve root anterior branch by the fecal mass.
V. Diagnostic methods
1.Auxiliary examination
(1) Gastrointestinal x-ray examination
According to the operation of barium in the gastrointestinal tract to understand its motor function status. The greater significance of gastrointestinal x-ray examination is to exclude constipation caused by tumor, tuberculosis, megacolon, obstruction and other organic lesions, which is very important to establish the diagnosis of functional constipation.
(2) Proctoscopy, sigmoidoscopy and fiberoptic colonoscopy
Directly examine the state of intestinal mucosa and take biopsy if necessary. In patients with functional constipation, due to the retention and stimulation of hard stool, the colonic mucosa, especially the rectal mucosa, often has different degrees of inflammatory changes. This is manifested as congestion, edema, and vascular blurring. In contracture constipation, in addition to inflammatory changes, sometimes spastic contraction of the intestinal canal can be seen on colonoscopy. This is manifested by the intestinal wall gathering into the lumen, narrowing of the intestinal lumen, difficulty in advancing the colonoscope, and the patient feels abdominal pain. The contraction can be relieved after a short pause, the intestinal lumen is opened and the abdominal pain disappears.
(3) Defecography
It is a method that combines morphology and dynamics to evaluate the function of the anorectal area. The anorectal angle, supra-anal distance and ethmo-pubic distance are measured in each phase of sitting still, raising the anus, forcing and forceful defecation using X-ray imaging technique. It is used to diagnose anatomical abnormalities (rectal prolapse, rectal protrusion, etc.) and local dysfunction of the distal intestine (functional outlet obstruction, rectal weakness, etc.), and is of great value in constipation, and can provide a basis for selecting treatment methods.
(4) Anorectal manometry
Using a manometry device to check the functional status of the internal and external sphincter, pelvic floor and rectum and the coordination between them is important in determining whether constipation is related to the malfunction of the above structures.
(5) Anal canal and rectal sensory examination
The anal sensation is measured by the current stimulation method. The electric probe is placed in contact with the anal mucosa, and the upper, middle and lower anal sphincter are measured respectively. The electric flow is gradually increased until the patient experiences a burning or tingling sensation, the threshold is recorded, and the average threshold is calculated. The normal value is 2,0-7,3mA. rectal sensitivity is measured by balloon dilation method.
(6) Anal sphincter electromyography
A needle electrode or column electrode was inserted into the subcutaneous bundle of the external anal sphincter to record electromyographic activity. The most common EMG change in patients with constipation is paradoxical contraction of the puborectalis muscle. EMG can distinguish abnormalities in muscle and nerve function of the random muscle groups of the pelvic floor. 77% of patients cannot relax the pelvic floor muscles during defecation, which is important for the diagnosis of outlet obstruction type constipation.
(7) Colonic transit function test
Using impermeable X-ray markers, abdominal plain films are taken regularly after oral administration to track the markers in the operation of the colon, which is a method to determine the operation speed of the colon contents and the site of obstruction. Subjects are prohibited from taking laxatives and other medications that affect bowel function from 3 days before the test. Two capsules containing 20 markers are taken on the test day, and one abdominal plain film is taken every 24 hours. (Normal subjects should pass 80% of the marker within 72 hours)
VI. Disease treatment
1.Comprehensive measures and overall treatment, the root is to remove the cause of the disease
Correction of poor dietary habits, adjust the content of the diet, increase the fiber-rich vegetables and fruits, appropriate intake of coarse and dregs of mixed grains, such as standard flour, potatoes, corn, barley rice, etc. Oil and fatty foods, plain water, and honey all contribute to the prevention and treatment of constipation. Reasonable arrangements for work and life, to achieve a combination of work and rest. Appropriate physical and cultural activities, especially the exercise of the abdominal muscle is conducive to the improvement of gastrointestinal function. For long-term mental labor, sedentary office less activity is more beneficial.
2, regular bowel movements can prevent the accumulation of feces, which is particularly important for patients with fecal impaction.
Note that before training, it is appropriate to cleanse the intestines, saline can be used to cleanse the intestines, 2 times a day for 3 days. After cleaning the intestine, take a flat film of the abdomen to determine the intestine has no fecal impaction.
3, the diet should be rich in crude fiber vegetables and fruits and rich in B vitamins food.
Such as coarse grains, beans, etc. Sesame seeds, honey, pine nuts, almonds, dogwood, walnuts, bamboo shoots, potatoes, radishes, bananas, silver ears, peanuts, corn, spinach, water spinach, celery, wheat bran, buckwheat, sunflower seeds, vegetable oil, figs, water chestnuts and other foods and mulberry seeds, cassia seeds, raw shouwu, angelica, fire hemp seeds, yu li ren, cistanches and other medicinal food products. Avoid alcohol, tobacco, strong tea, coffee, garlic, pepper and other stimulating foods.
4, food therapy formula.
(1), black sesame and peach paste (black sesame, peach kernel, sugar)
(2), stewed pork heart with cypress kernel — blood deficiency constipation
(3), three kernel porridge (cypress kernel, pine kernel, Yu Li kernel, round-grained rice)
(4), astragalus fire hemp nut honey drink — qi deficiency constipation
(5), senna leaf cassia seed tea — heat accumulation type constipation
5, drug treatment
Preferred prokinetic agents to avoid long-term abuse of laxatives and laxative enteropathy
(1) volumetric laxatives (cellulose)
(2) salt laxatives (magnesium sulfate) used with caution
(3) stimulating diarrhea (diarrhea leaf, phenolphthalein, grated sesame oil, etc.)
(4) osmotic laxatives (polyethylene glycol 4000), lactulose, etc.
(5) prokinetic drugs (cisapride)
(6) lubricating laxatives (open-loop liquid paraffin)
(7) microecological preparations: containing bifidobacteria, lactobacilli, enterococci and other normal intestinal flora.
(8) Chinese medicine laxative
6, Chinese medicine constipation is divided into real constipation, virtual constipation.
Actual constipation and divided into heat constipation, gas constipation, cold constipation
Heat constipation to clear heat and moisten the intestines, can take maren pills; gas constipation should be rationalized to guide stagnation, to suzi descending Qi Tang with flavor; cold constipation should be warm and open constipation, to warm spleen Tang with flavor.
Deficiency constipation is also divided into Qi deficiency and blood deficiency
For Qi deficiency, benefitting Qi and moistening intestine should be the main concern, using Tonic Zhong Yi Qi Tang with addition and subtraction; for Blood deficiency, nourishing Blood and moistening dryness is recommended, using Si Wu Tang.
7.Surgical treatment
(1) Total colectomy with ileo-rectal anastomosis
(2), subtotal colectomy
(3), stoma
(4), STAPRE + buried wire treatment
8.Biofeedback
Using the feedback of sound and image, stimulate and train the patient to correctly control the stretching and contraction of the external anal sphincter to achieve normal defecation. Biofeedback therapy is a training method to correct uncoordinated defecation behavior, mainly used to treat constipation caused by uncoordinated anal sphincter and paradoxical contraction of pelvic floor muscle and external anal sphincter during defecation.
9.High potential therapy
It is the oldest type of electrical therapy in physiotherapy.
Principle: By giving the body in an insulated state with an alternating current potential, a special natural bionic electric field is generated around the body, and the beneficial effects of this electric field on the body (biologic electrophysiological effects) are used to treat the patient. The beneficial electric field generated by the high-potential therapy instrument, through the stimulation of the body surface, intervenes in the neurotransmission and finally acts on the hypothalamus, the upper center of the vegetative nervous system and endocrine system, so that the body’s self-regulatory function can be restored and enhanced, which will restore the body’s biological constancy (the stability of the body’s internal environment) and thus improve the symptoms of discomfort. Through the treatment, we eventually achieve the regulation of intestinal functions, strengthen the intestinal canal rhythmical propulsion, promote intestinal peristalsis and defecation, and mainly soft stools.