2020年10月29日星期四

hemorrhoids essential oils,Chronic functional constipation

    Chronic functional constipation (CFC) is a group of multiple population-onset, multi-factors, and the main complaint is the difficulty of defecation, the discomfort of defecation and the prolonged defecation schedule. A large number of studies have shown that the occurrence of CFC has been increasing year by year. Since the 1980s, with the improvement of various research methods, the research on the pathophysiology of CFC has gradually deepened. The clinical application of a large number of new technologies and advanced surgical instruments has made great progress in the diagnosis, prevention and treatment of CFC.

    1 CFC incidence

    1.1 CFC clinical classification and its significance CFC classification methods are many, according to the cause can be divided into primary (idiopathic) constipation and secondary constipation. Idiopathic constipation is also called "refractory" or "primary" because of its unclear etiology and difficult treatment. Secondary constipation includes drug-induced, traumatic, and congenital. At present, domestic scholars classify CFC into three categories based on the pathophysiological mechanism of defecation dynamics: 1) Slow transit constipation (STC), or delayed motor constipation (DMC) ), mostly related to tortuosity, lengthy, and coiled deformity of part of the colon, congenital or acquired reduction or absence of intestinal wall ganglion cells, such as Hirschsprung disease, colonic mucosal melanosis caused by the abuse of intestinal wall ganglion cytotoxic laxatives (2) Functional outlet obstruction constipation (FOOC), which is mostly caused by the internal and external sphincter incoordination of the rectum and external sphincter and defecation dysfunction caused by abnormal anus and rectum anatomy, such as pelvic floor dysfunction Syndrome (SPFS) and pelvic floor relaxation syndrome (RPFS). SPFS includes internal sphincter dysfunction (ISDA), puborectal hypertrophy (PRMH); RPFS includes rectal protrusion (RC), internal rectal intussusception (IRI), perineal decline (PD), internal rectal hernia (EC), and Visceral sagging (SP), etc.; (3) Combination of STCand FOOC, Liu Jianxin conducted X-ray defecography and barium enema examination on 840 patients with colonic constipation and found that more than 99% of patients with mixed constipation . Pemberton et al. classified irritable bowelsyndrome (IBS) as type 4 constipation. Patients with IBS have normal colonic function and pelvic floor muscle function. This type of constipation does not require surgical treatment and belongs to the medical category. The significance of this classification lies in its great guiding role in the treatment of the primary disease of CFC, because for patients with a clear diagnosis of CFC, the treatment should be performed after eliminating the interference factors that cause FOOC such as eating habits, environmental factors, psychological and spiritual factors, and stress. The above recommends specific 5-TH4 receptor agonists and even surgical treatment to relieve STC symptoms, and FOOC patients can be treated with biofeedback to relieve constipation symptoms, and at the same time, it can greatly avoid the mental, physical and economical abuse of laxatives. The huge burden brought.

    1.2 Gender differences in patients with primary CFC CFC patients with primary disease show significant gender differences. Studies have shown that the frequency of the primary disease in male patients with constipation ranks the first three in the order of rectal mucosal intussusception (78.33%), puborectalis syndrome (24.14%) and pelvic floor spasm syndrome (15.76%). ), while female patients with constipation had rectal mucosal intussusception (91.91%), perineal ptosis syndrome (69.36%) and rectal protrusion (53.68%). Male patients with constipation have a single primary disease of 16.75%, and female patients are 8.58%. There were 49.75% of males and 79.41% of females with three or more primary diseases. It shows that male patients with constipation have simpler complications than female patients. As far as a certain disease is concerned, the difference in the occurrence of CFC patients between men and women is also obvious. For example, rectal protrusion is almost always affected by women after delivery, and simple rectal protrusion is rare, most of which are combined with rectal intussusception, while men suffer from rectal protrusion. Few sudden changes (0.99%).

    1.3 Age differences in patients with primary CFC Although there are few literature reports on the age epidemiological survey of patients with primary CFC, the population with a specific primary disease of CFC has a certain age tendency, such as rectal protrusion almost all The disease occurs in women who have given birth but rarely occurs in unmarried women. The occurrence of constipation caused by male prostatic hyperplasia is positively correlated with aging. At the same time, as the age increases, the function of various organs in the body gradually declines, especially the decrease of gastrointestinal function and sex hormone levels, and the incidence of CFC also shows an increasing trend.

    2 CFC pathophysiological mechanism

    The research on the pathophysiology of CFC is gradually intensified with the improvement of various detection methods. With the application of a large number of new technologies and new equipment in the diagnosis of CFC, the study of its pathogenesis has become more in-depth, and it also provides an important reference for the selection of CFC prevention and treatment methods and the evaluation of treatment prognosis.

    2.1 Research on the motility of rectum and anal canal. It is reported in the literature that CFC is related to anorectal motility, some of which are accompanied by colonic motility disorders.

    2.1.1 Rectal and anal canal manometry: used to evaluate the self-maintaining function of the internal and external sphincter, defecation reflex, rectal sensitivity and compliance 1) The resting pressure of the rectum and anal canal, the minimum anorectal suppression reflex Relaxation volume (MRV) and anal sphincter relaxation rate reflect the function of internal anal sphincter. The maximum compression of the anal sphincter reflects the function of the external anal sphincter. A large number of studies have found that, in patients with FOOC, the resting pressure of the rectum and anal canal is higher than normal, the MRV is significantly increased and the relaxation rate is reduced, resulting in poor diastole of the anal canal and poor defecation passage. A decrease in the maximum squeezing pressure indicates a decrease in defecation motivation. The increased rectal pressure during normal defecation is accompanied by a decrease in the anal canal pressure. This pressure gradient is not reversed. The anal canal pressure curve rises, and the tension contraction of the pelvic floor muscles cannot be inhibited, and even appears Abnormal shrinkage. (2) Rectal sensitivity test: The balloon dilation method is often used to detect changes in rectal perception. The minimum perception of FOOC patients (ml), defecation perception (ml), maximum perception (ml) and minimum perception of defecation reflex (ml) ) Are higher than normal. Rectal defecation and rectal maximum tolerable capacity reflect rectal sensory function. The rectal defecation threshold and rectal maximum tolerable capacity of CFC patients are significantly increased, suggesting that the rectal visceral motor nerve and volume sensory nerve are damaged, which may cause abnormal rectal capacity stimulation. In response, patients often fail to initiate a defecation reflex due to lack of bowel movement, causing constipation. (3) The length of the anal canal high pressure zone (HPZL): It mainly represents the function of the internal anal sphincter, which is related to the normal anal epithelial sensory function, and the HPZL of FOOC patients cannot be effectively shortened. (4) Other detection methods: such as anorectal barrier pressure and motility index (MⅠ) have been widely used in rectal and anal defecation motility research. The newly launched portable anal and rectal manometry can overcome the one-sided and non-physiological shortcomings of short-term manometry, and can record the effects of nighttime, meals and other factors on anal canal dynamics.

    2.1.2 Anal sphincter electromyography (EMG) Use needle-like or cylindrical electrodes to record the pelvic floor myoelectric activity of the anal sphincter to measure the resting state EMG (uⅤ) and maximum squeezed EMG (uⅤ) are mostly used to identify pelvic floor muscles Group and neurological abnormalities. Studies have shown that EMG in patients with FOOC shows paradoxical contraction, and the coordinated relaxation of the external anal sphincter is reduced, causing the internal pressure of the anal canal to exceed the internal rectal pressure and causing difficulty in defecation. EMG is mostly used in the diagnosis of FOOC, and can be used as a basis and evaluation index for biofeedback treatment.

    2.2 X-ray defecography (defecogrphy) and barium enema examination are mostly used to dynamically detect the morphological changes of the colon and rectum, such as dilation, disappearance of pockets, lengthy colon, discus, and rectal protrusion, etc., and can calculate the anus Right angle (ARA), anal canal length, sacral distance, etc., to determine whether there are specific imaging changes such as "goose head sign" and "shelf sign". The diagnosis of the primary disease of FOOC caused by abnormal anatomical structure is of great significance, but the radiation damage caused by repeated imaging has attracted more and more attention of scholars.

    2.3 Colon transpration test (Colon transpration test, CTT) This test mostly uses 20 radiopaque markers (2mmx2mm) in the morning on an empty stomach with the test meal, and the abdominal plain films were taken at 48h and 72h to measure the top markers In vivo memory retention and emptying rate, while measuring the transit index (TI). The normal emptying rate is 48h≥75%, 72h≥95%. TI is the number of markers remaining in the rectum/total colon at 72h. The colonic transit test is currently the first choice for the diagnosis of STC gastrointestinal motility abnormalities. It can not only help understand the pathophysiology of functional bowel problems, diarrhea, abdominal distension and other symptoms, but also help the differential diagnosis of STC and FOOC, and the determination of TI value is more important. It provides an important and reliable basis for the selection of CFC surgical treatment methods and the prognosis evaluation of treatment.

    2.4 Immunohistochemistry (immunohistochemistry) The adoption of immunohistochemical staining marks the beginning of the molecular biology stage of CFC pathophysiology research.Tzavella et al. reported that feeding rats with senna or anthraquinone can cause the colonic mucosal vasoactive intestinal peptide (VIP) and somatostatin (SOM) to decrease, the submucosa SOM, the muscle layer VIP, and P The substance has not changed. DMC is related to abnormal changes in the enteric nervous system and is one of the causes of disorders of colonic motor function. VIP is a neurotransmitter of the non-adrenergic non-cholinergic nerve (NANC) inhibitory system. It is an important component that relaxes the gastrointestinal tract and participates in the modulation of intestinal peristalsis. The decrease of VIP concentration may cause excessive segmental peristalsis in the colon. The effective promotion of movement is weakened. In patients with long-term constipation, the decrease or absence of VIP nerve fibers in the second rectum can lead to the weakening or disappearance of the inhibitory reflex. The tightening or even spasm of these intestinal segments is an important cause of "export obstructive" constipation. Lei Huaicheng et al. used rabbit polyclonal antibodies of SOM and VIP to perform immunohistochemical staining on different sections of the colon of surgically resected patients and the corresponding parts of the control group. The results showed that the DMC colonic myenteric plexus SOM and VⅠP immune response The positive nerve cells were significantly reduced. This abnormal change may be one of the causes of DMC. However, how to apply this research result to pathological diagnosis before surgical treatment, so as to provide a theoretical basis for surgical treatment, is still a topic that needs to be solved urgently.

    3 Treatment status

    3.1 The improvement of traditional medicine Twisting method Traditional medicine believes that STC patients mostly have weak intestines due to spleen deficiency and poor transportation and transformation. Many doctors usually adopt oral Chinese medicine decoctions, acupuncture and other treatment methods to invigorate the spleen and kidney, moisten the intestines and relieve bowel movements The effect of eliminating qi. In recent years, some scholars have improved the methodology of traditional Chinese medicine treatment based on the experience of traditional medicine for the treatment of CFC, and achieved remarkable results. Ge Zonggan et al. conducted a comparative study on the oral Yiqi Runchang Decoction and the retention enema via the multifunctional automatic whole colon applicator. They believed that retention enema can not only significantly improve the symptoms of constipation, but also reduce the irritation of traditional Chinese medicine to the stomach, and the effect is significantly better. oral. Zhu Yinping and others classified STC into positive and deficiency syndromes, using a compound decoction based on Chinese medicine aloe to perform high enema with a computer enema. The control study of colonic transmission test before and after treatment confirmed that STC high enema treatment significantly prolonged the treatment of traditional Chinese medicine in the colon. The retention time of STC, the total effective rate of STC treatment with deficiency and deficiency syndrome reached 93.1% and 93.8%, respectively, and was significantly better than general retention enema.

    3.2 Biofeedback technology (biofeedback) Biofeedback technology uses sound and visual image feedback to stimulate the brain to regulate the functions of the body, thereby training patients to learn to control or prevent the occurrence of constipation. In 1987, Bleijenbery et al. used this technique for the first time to treat 10 patients with constipation, and 7 cases were completely relieved. Wang Jun et al. used Medtronic Synectics' SRS Orion PC-12 for pressure-mediated biofeedback therapy in 30 cases and U-Control TMEMG Home Traiiner? for EMG-mediated biofeedback therapy in 10 cases, with a total effective rate of 62.5% The total score of Hopkins Symptom Self-rating Scale (SCL-90) was also reduced from 47.80±31.27 before treatment to 24.05±20.62 after treatment. All cases were followed up for at least 1 year. Studies have confirmed that biofeedback technology is not only a simple and easy physical therapy method, but also has a certain effect on the psychological treatment of CFC patients, and the long-term effect is definite.

    3.3 Surgical methods Active and cautious surgical treatment of the primary disease is the first choice for the treatment of intractable constipation. This view has been increasingly recognized by anorectal surgeons. The combined application of many effective surgical methods has made CFC treatment a great success. improvement. The purpose of surgery is to restore the anatomical relationship of patients with intractable constipation to improve bowel function, but the problem that cannot be ignored is that there is no unified diagnostic and treatment standard in China, and the indications for surgery need to be further improved.

    3.3.1 Surgical problems of FOOC: Any symptomatic FOOC needs to be treated. First of all, non-surgical treatment should be performed, including dietary treatment, such as crude staple food, drinking a lot of water, eating more vegetables and fruits rich in dietary fiber, and taking laxatives when necessary; increasing physical activity, such as abdominal massage. At present, the surgical treatment of chronic intractable constipation is still controversial. Keighley et al. believe that the status of surgical treatment of constipation needs to be determined by long-term practice results. Therefore, surgical indications should be strictly controlled, and only those who have failed long-term formal conservative treatment can consider surgical treatment.The key to surgical treatment of FOOC is to correct the stool axis to weaken the resistance of the anal canal during defecation and increase the motivation of defecation to relieve the symptoms of constipation. There are many primary diseases of FOOC and multiple factors coexist. Therefore, a comprehensive and complete diagnosis should be made before surgery. All abnormalities found in the examination must be corrected during surgical treatment in order to achieve significant long-term effects. At present, FOOC is common in primary surgery Methods: 1) Rectal protrusion repair: There are three common surgical approaches: transrectal, transvaginal, and transperineal approaches. The ultimate goal is to strengthen the weakened area of ​​the vaginal rectal septum; (2) rectal prolapse and rectum Mucosal intussusception: Incomplete rectal prolapse and rectal mucosal intussusception can be used for sclerosing agents such as Xiaozhiling injection, 6%-8% alum injection or medical ZT glue through the rectal mucosa or around the rectum. Or columnar septal injection combined with tower suture, Graham surgery or Gant-Miwa surgery is possible for complete rectal prolapse; (3) Puborectal hypertrophy: puborectectomy or partial resection, external resection, etc. (4) Internal sphincter achalasia: internal sphincter cut off the wood, etc.; (5) Pelvic floor achalasia syndrome: thread-hanging therapy as a traditional medical treatment of high complex anal fistula has been used as a classic surgical method until now, Yu Suping and others skillfully use In the treatment of FOOC caused by pelvic floor achalasia syndrome, satisfactory results have been achieved. The fundamental reason is to relieve the symptoms of constipation by weakening the resistance of the anal canal during defecation. The attempt of this method expands the application space of traditional medicine, opens up and enriches the treatment approaches of CFC.

    3.3.2 Surgical problems of STC, although the preoperative examination, especially the pathological examination of the absence of ganglion, is still blank, and the patients have insufficient understanding of the surgical solution to constipation, and some patients have overcorrected after the operation, which limits the surgery to a certain extent. However, colectomy is still the first choice to relieve the symptoms of STC patients. What urgently needs to be improved is the diagnosis and treatment criteria to determine the indications for surgical treatment and to avoid blindness in surgical treatment. Liu Jianxin pointed out that in patients with STC who rely on laxatives for defecation for a long time, the effect of defecation is diminished. During the examination, it is found that the structure of the colon is severely changed. The poor effect of auxiliary posture exercise and the disappearance of bag shape are important surgical indications. At the same time, it is proposed to deal with the comprehensive evaluation of the structural variation of the colon, the bag shape, and the transportation test to determine the surgical method. Yu Dehong and others believe that the following points must be met before surgery can be considered: 1) There is clear evidence of no tension in the colon; (2) There is no manifestation of obstruction at the outlet; (3) Anal canal contraction has sufficient tension; (4) There is no clinically obvious evidence Anxiety, depression and other mental disorders; (5) There is no evidence of diffuse intestinal motility disorders such as intestinal stress syndrome. In addition, it is also necessary to consider 1) Do not perform colectomy rashly for patients with a short onset time; (2) Do not use a single examination to diagnose obstructive constipation at the outlet. All patients with mild constipation must first consider conservative treatment, and only when long-term conservative treatment is really ineffective, should surgical treatment be considered. At present, there are 3 types of surgical procedures reported in foreign countries for the treatment of colonic slow transit constipation. 1) Total colectomy plus ileal rectal anastomosis: This is the classic surgical procedure for the treatment of STC, but 1/3 of patients have intractable diarrhea, and 10% of patients Recurrence of constipation; (2) Subtotal resection of the colon and continuous enterostomy of the cecum or ascending colon: Because the cecum and ileocecal valve are preserved, the operation is simple, and diarrhea and other complications can be reduced. But it is suitable for non-diastolic cecum and normal function and pressure. Intestinal pressure is normal, and the pressure during cecum contraction must be greater than the pressure during diastole of the anal canal to facilitate defecation; (3) Partial resection of the colon: If the barium enema is confirmed to be only a certain segment of the colon dilated, the colon can be removed, otherwise the prognosis is poor . Regardless of the method used, attention should be paid to the prevention of complications. Foreign reports have reported that the main complication after STC colectomy is small intestinal obstruction, with an incidence rate of 8% to 44%. In addition to poorly grasped surgical indications, surgical techniques In addition to adhesive intestinal obstruction and other reasons, it may also be due to extensive damage to the muscular layer of the intestinal wall, neurological reflex disorders, and hyposensitive colon and even terminal small intestine. In addition, if the function of the cecum is poor, terminal ileitis caused by reflux of cecal contents is more likely to induce small bowel obstruction. At present, total resection or subtotal resection has become the first choice for the treatment of STC, with a success rate of 70% to 90%.

    3.3.3 Application problems of stapler and laparoscopic surgery (LP): With the massive application of tubular stapler and two stapler (two stapler) in CFC treatment, the reliability and safety of the anastomosis should be ensured as much as possible. It also makes the anastomosis easy to perform and easy to complete. Laparoscopy for partial colectomy started in 1993, and today laparoscopic surgery has penetrated almost every corner of abdominal surgery, every organ, such as LP rectal fixation for complete rectal prolapse, the effect is better. And it has the advantages of less trauma, light postoperative pain, early getting out of bed and low recurrence rate, but the scope of its application in anorectal surgery still needs to be further expanded.Chronic functional constipation (chronic functional constipation, CFC) is a group of multiple populations with multiple factors. Symptoms mainly complained of difficulty in passing stool, uncomfortable defecation, and prolonged defecation schedule. A large number of studies have shown that the occurrence of CFC has been increasing year by year. Since the 1980s, with the improvement of various research methods, the research on the pathophysiology of CFC has gradually deepened. A large number of new technologies and clinical applications of advanced surgical instruments have been used. Make great progress in the diagnosis, prevention and treatment of CFC.

    National follow-up declaration form

    The purpose of surgical treatment of chronic functional constipation is to restore the anatomical relationship of patients with intractable constipation to improve bowel function. However, the problem that cannot be ignored is that there is no unified diagnostic and treatment standard in China. The indications for surgical treatment need to be further improved. There are doubts about the choice of method.

    1. Train clinicians on chronic functional constipation related knowledge

    2. Discuss conservative treatment methods for chronic functional constipation

    3. Discuss the surgical treatment of chronic functional constipation

    4. Demonstration of surgery for chronic functional constipation related cases

    1. The incidence of chronic functional constipation has been increasing year by year, and the research on the pathophysiology of CFC has gradually been deepened. The clinical application of a large number of new technologies and advanced surgical instruments has made great progress in the diagnosis, prevention and treatment of CFC.

    2. At present, there is no uniform diagnosis and treatment standard in China, the indications for surgical treatment need to be further improved, and the choice of surgical methods is doubtful.

    3. Combined with the experience of treating chronic functional constipation in Xinhua Hospital affiliated to Dalian University, domestic experts are invited to discuss the disease, and achieve unified understanding, unified treatment and unified surgical procedures as much as possible.

    4. Develop surgical treatment guidelines for chronic functional constipation.

    The training objects are mainly clinical doctors at the basic level, so that they have a preliminary understanding of chronic functional constipation and can guide clinical work. At present, the cases of chronic functional constipation are gradually increasing. The specific reasons need to be investigated by multi-center cooperation. After training, a collaborative network on chronic functional constipation can be formed nationwide to conduct epidemiological investigations. The vast majority of patients with chronic functional constipation rarely go to a doctor or realize that the disease requires surgical treatment. Through training, the awareness of grassroots doctors will be expanded, the scope of treatment will be expanded, and the disease pain of the masses will be solved.

    Guidelines for the diagnosis and treatment of chronic constipation in China (draft)

    1. The background of the constipation diagnosis and treatment process

    Constipation mainly refers to dry stools, difficulty or incomplete defecation, and reduced defecation frequency. Constipation is a common condition caused by a variety of causes, including gastrointestinal diseases, systemic diseases involving the digestive tract, and many drugs can also cause constipation. Many constipation has no organic cause. Rome II functional gastrointestinal disease (FGID) suggests that the symptoms related to constipation are functional constipation, pelvic floor dysfunction, and constipation-type irritable bowel syndrome. Among them, functional constipation should be excluded from organic causes and drug factors. The pelvic floor defecation disorder must meet the criteria for functional constipation and have an objective examination basis for the pelvic floor defecation disorder. Constipation-type irritable bowel syndrome so that constipation is prominent.

    With the changes in dietary structure and the influence of mental, psychological and social factors, constipation has seriously affected people’s quality of life. It plays an important role in the occurrence of some diseases such as colon cancer, hepatic encephalopathy, breast disease, and Alzheimer’s; Constipation during myocardial infarction and cerebrovascular accidents can even lead to life accidents; some constipation is closely related to anorectal diseases such as hemorrhoids and anal fissures. A survey of people over 60 years old in Beijing, Tianjin and Xi'an in China shows that chronic constipation is as high as 15% to 20%. A randomized, stratified, and graded survey of adults aged 18 to 70 in Beijing showed that the incidence of chronic constipation was 6.07%, and women were more than 4 times that of men, and mental factors were one of the high-risk factors. Therefore, the prevention and timely and reasonable treatment of constipation will greatly reduce the serious consequences and social burden of constipation. The development of a constipation diagnosis and treatment process suitable for China will surely benefit the entire society. In 2001, the China Gastrointestinal Motility Conference (Shenzhen) proposed the diagnosis and treatment process of constipation. In the past 10 months, opinions have been widely sought across the country. In August this year, at the Beijing China Chronic Constipation Forum, more than 200 Chinese gastroenterologists further discussed the diagnosis and treatment process. .

    2. The thinking and basis of China's constipation process:

    Diagnosis of constipation: normal bowel movement requires normal colonic transit and bowel function. Any failure in any link can cause constipation. The diagnosis of chronic constipation should include the cause (and triggers), degree and type of constipation.If you can understand the extent of involvement (colon, anorectum, or upper gastrointestinal tract) related to constipation, the affected tissues (myopathy or neuropathy), whether there are local structural abnormalities, and the causal relationship with constipation, you can formulate treatment And predict the efficacy is very useful. The severity of constipation can be divided into 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 less medication. Severe refers to the persistent symptoms of constipation, the patient is abnormally painful, which seriously affects the life, the drug cannot be stopped or the treatment is ineffective. Moderate in view of the difference between the two. The so-called refractory constipation is often severe constipation, which can be seen in outlet obstructive constipation, colon weakness, and severe constipation-type irritable bowel syndrome (IBS). The two basic types of chronic constipation are slow transit type and outlet obstruction type, both of which are mixed. The constipation type of IBS is a type of constipation related to abdominal pain or bloating, and there are similar types.

    Diagnosis of constipation: medical history can provide important information, such as the characteristics of constipation symptoms (the frequency of defecation, constipation, whether it is difficult or uncomfortable, and stool characteristics), accompanying gastrointestinal and other symptoms, underlying diseases and medications. Pay attention to warning signs and family history of tumors and psychosocial factors. For patients with constipation suspected of having anorectal diseases, perform a digital anorectal examination if necessary, paying attention to whether there is a mass and the function of the sphincter. Stool examination and occult blood test are important and simple routines and should be included as routine examinations for most patients with constipation. When necessary, conduct biochemical and metabolic inspections. Colonoscopy or barium enema can help to determine whether there is an organic cause, especially colon cancer. It is necessary to arrange in time for patients with chronic constipation whose cause is unclear. There are many ways to determine the type of constipation. The simplified colonic transit test recommends taking an abdominal radiograph at least 48 hours after taking the opaque X-ray markers (normally most markers have reached the rectum or have been discharged), 72 hours if necessary One, the distribution of markers is very helpful for judging whether there is slow transmission. In fact, it is not very important to measure the colonic transit time, especially for patients with few stools. If it is extended to 5-6 days to take a film, it will be difficult for the patient to adhere to and self-use laxatives, and the sensitivity to the diagnosis of mild to moderate constipation will decrease. Anorectal manometry can check the anorectal function without obstacles, such as the contradictory contraction of the external anal sphincter during force discharge, the lack of anorectal suppression reflex after rectal airbag insufflation, and the abnormal sensory function of the rectal wall. The air sac expulsion test reflects the ability of the anorectal to expel air sacs, but air sacs and hard stools in the rectum are not the same. Some refractory constipation, such as the lack of specific propulsive systolic wave (SPPW) in 24-hour colonic pressure monitoring and the lack of response to waking up and eating in the colon, all indicate colon weakness and require surgical resection. Defecography can dynamically observe the anatomical and functional changes of the anorectum. Anal pressure measurement combined with ultrasound endoscopy can show whether the anal sphincter has mechanical or anatomical defects, which provide clues to the operation. Application of perineal nerve latency or electromyography can distinguish whether constipation is myogenic or neurogenic. For patients with obvious anxiety and depression, relevant investigations should be made, and the causal relationship with constipation should be judged.

    Chronic constipation requires comprehensive treatment to restore bowel physiology. It is proposed to strengthen the physiological education of bowel movement, establish reasonable eating habits (such as increasing the content of dietary fiber, increase the amount of drinking water) and adhere to good bowel habits, and at the same time increase activities. In the selection of laxative drugs, attention should be paid to the efficacy, safety and drug dependence. It is recommended to use leavening agents (such as wheat bran, psyllium, etc.) and osmotic laxatives (such as fosone, dumic). China has observed the randomized controlled results of Fusong in the treatment of functional constipation and showed that it has a good effect on increasing the frequency of bowel movements and improving stool characteristics. For slow transit constipation, prokinetic agents such as cisapride or mosapride can be added. Long-term application or abuse of stimulant laxatives should be avoided. Many Chinese patent medicines have a laxative effect, and it is necessary to pay attention to the possible side effects of long-term treatment and the ingredients in the medicine. For patients with fecal impaction, clean the enema or use a short-term stimulant laxative to relieve the impaction, and then choose a leavening agent or an osmotic drug to keep the bowel movement smooth. Kaisailu and glycerin suppository have the effects of softening stool and stimulating bowel movements. Compound carrageenan can be used to treat hemorrhoidal constipation. For functional outlet obstructive constipation, biofeedback is used to determine whether the patient can grasp the essentials to determine success. Psychotherapy especially has a positive effect on patients with severe constipation. Before surgical treatment, attention should be paid to whether there are serious psychological disorders, abnormalities of the digestive tract outside the colon, and predictions need to be made before surgery.

    3. Chinese constipation process and its principles

    The following principles can be followed: (1) Propose the analysis of the etiology and triggers, types and severity of constipation, and carry out effective stratification (alarm or not) and grade (degree) diversion diagnosis and treatment of constipation patients.(2) When there are warning signs or suspected organic causes, further examinations should be made for organic diseases, especially rectal and colon tumors. (3) For those who are determined to have organic diseases, in addition to the cause of treatment, it is also necessary to judge the type of constipation according to the characteristics of constipation and perform corresponding treatment. (4) For most patients, especially mild patients, detailed medical history and physical examination can help understand the cause and type of constipation. Short-term (1-2 weeks) empirical treatment can be arranged. (5) If the empirical treatment is ineffective, you can further check for organic diseases; if the check does not prove that there is an organic cause, you can enter the empirical treatment according to the characteristics of constipation; you can also perform further related checks to determine the type of constipation. Then carry out the corresponding treatment. 2. For a small number of patients with refractory constipation, it is advisable to conduct related constipation type examinations at the beginning, and even a more detailed examination plan to determine reasonable treatment methods. (7) The basis for proposing empirical treatment is to judge the possible types from the performance of chronic constipation. The four common manifestations are: first, there is less urge to defecate, and the second is difficult and laborious defecation, the third is poor defecation, and the fourth is constipation with abdominal pain or abdominal discomfort. Note that these types can be seen in both slow transmission type and outlet obstruction type constipation, but if carefully distinguished, it will help guide empirical treatment.

    1. Causes of constipation:

    Constipation is the most common gastrointestinal symptom, it is not a disease. According to reports, 2 million to 3 million people with constipation in the United States take medicine to help their stools each year, and the incidence is about 2%. A set of statistics shows that about 900 people die from constipation-related diseases each year. It can be seen that constipation cannot be underestimated. The causes of constipation are complex and can be summarized into the following four categories:

    1. Anorectal disease: ①Congenital diseases, such as Hirschsprung's disease; ②Intestinal stenosis, such as inflammatory bowel disease, stenosis in the later stage of trauma and after intestinal anastomosis, stenosis caused by tumor and its metastasis; ③Exit obstruction, Such as pelvic achalasia, intussusception of the rectum, descent of the perineum, protrusion of the rectum, etc.; ④ Anal and perianal diseases, such as anal fissure, hemorrhoids, etc.; ⑤ Others: such as irritable bowel syndrome.

    2. Extra-intestinal diseases: ①Neural and mental diseases, such as cerebral infarction, cerebral atrophy, paraplegia, depression, anorexia, etc.; ②Endocrine and metabolic diseases, hypothyroidism, diabetes, aluminum poisoning, and vitamin B1 deficiency; ③Pelvic diseases, such as Endometriosis, etc.; ④Drug-induced diseases, such as irritant laxatives (phenolphthalein, rhubarb, senna), long-term large-scale use can cause secondary constipation, anesthetics (morphine), anticholinergics, calcium channel block Drugs, antidepressants, etc. can cause decreased intestinal irritability; ⑤ Myopathy, such as dermatomyositis, scleroderma, etc.

    3. Poor living habits: ①Insufficient food intake, fine food, high food calories, less vegetables and fruits, less drinking water, and insufficient intestinal stimulation; ②Lack of intestinal motility due to lack of exercise, sedentary, and bed rest; ③It is caused by poor bowel habits , If some elementary school students are puzzled because of the short time between classes, they may cause constipation.

    4. Social and psychological factors: ① Tension at work, sedentary, insufficient exercise; ② Tension in interpersonal relationships, family disharmony, and long-term depression in mood can all cause autonomic nerve disorders and cause bowel movement inhibition or hyperactivity; ③ Changes in life patterns, such as Traveling, hospitalization, and the impact of emergencies can all lead to changes in defecation patterns.

    2. Prevention of constipation

    1. Don't ignore convenience. If you want to start with a baby, you should take it seriously from the beginning. Once you have a bowel movement, you should defecate in a timely manner.

    2. Life and bowel movements must be regular, establish bowel conditioned reflex, and develop the habit of regular bowel movements.

    3. Environmental changes, such as business trips, poor sanitation, etc. can easily cause constipation. You can bring your own fruits and laxatives.

    4. Avoid sitting for a long time, and participate in physical exercises appropriately to strengthen the vitality of the colon and promote peristalsis.

    5. Anorexia or too little food intake, especially too little fiber-containing food can cause constipation, so you should eat fresh vegetables and eat wheat bran or whole wheat flour appropriately. However, it is not applicable to patients with organic intestinal obstruction.

    6. Drink plenty of water. Fiber needs to absorb water to have a laxative effect in the intestinal cavity. Therefore, you can drink 3,000 to 5,000 ml of water daily.

    7. Quit the habit of taking laxatives for a long time. Long-term application of laxatives can aggravate constipation. In addition, certain drugs such as opiates, calcium salts, aluminum salts and psychiatric drugs can cause constipation and should be paid attention to.

    8. Organic diseases should be diagnosed and treated in time, such as colorectal tumors and Hirschsprung's disease. Systemic diseases, such as lead poisoning, hypothyroidism, electrolyte disorders, and mental depression can cause constipation, and the primary disease should be treated.

    9. Maintaining a regular life, adequate sleep and a cheerful and optimistic mood is of great significance to preventing constipation.

    3. Symptoms of constipation:

    The main symptom of constipation is difficulty in defecation. For chronically ill patients, due to loss of appetite or fear of defecation but not eating, the frequency and volume of bowel movements are reduced. The frequency of bowel movements and stool characteristics may vary depending on the type of constipation.

    In colonic constipation, such as slow transit constipation, it is manifested as a lack of constipation and few stools, mostly less than 3 times a week; while rectal-anal constipation, such as functional outlet obstruction constipation, has frequent constipation but is difficult to discharge , It can be said that if you want to, you can't, and you can't stop. Patients with chronic intractable constipation, due to long-term large amounts of stimulant laxatives, such as rhubarb, senna, etc., will produce drug-induced constipation, called "abuse laxative syndrome". Patients may experience abdominal distension, abdominal pain, and mental symptoms such as anxiety, irritability, insomnia, depression, and even personality changes. The author once encountered a small number of patients who had failed to undergo various medications and surgical treatments, and even thought of committing suicide due to constipation. It can be seen that patients with constipation are extremely painful.

    4. Auxiliary examination for constipation:

    In the past 20 years, the medical field has continuously deepened the research on constipation, and some new examination methods have provided the basis for the diagnosis and treatment of constipation.

    1. Defecation imaging: simulate the defecation process, study the dynamic and static changes of the anus, rectum, and pelvic floor during defecation. Provide quantitative diagnosis through the appearance of right angle, rectal protrusion, rectal pressure, "shelf sign" after barium filling, for the diagnosis of outlet obstructive constipation, such as rectal protrusion, pelvic achalasia Disease and so on.

    2. Colonic transmission test: use radio-opaque markers and take regular abdominal plain films after oral administration to track and observe the time and location of the markers in the colon to determine the speed of the colon contents and the location of obstruction. Method for the diagnosis of slow transit constipation.

    3. Anorectal pressure measurement: The pressure measurement device is inserted into the rectum to make the anus contract and relax, check the internal and external sphincter, pelvic floor, rectal function and coordination, and provide help in distinguishing the types of export-type constipation.

    4. Anal electromyography examination: the use of electrophysiological techniques to examine the functions of the puborectalis and external sphincter in the pelvic floor muscles.

    Five, the harm of constipation

    1. Occurrence of hemorrhoids: when constipation, defecation is exerted forcefully, the pressure of the rectum neck is increased, the venous return is blocked, the normal anal cushion is enlarged and repetitively displaced distally, and the fibrous interval gradually relaxes until it breaks and is accompanied by venous congestion , Expansion, fusion, and even small arterial and venous fistulas, and finally form hemorrhoids.

    2. Aggravated cardiovascular and cerebrovascular diseases: In elderly patients with constipation and cardiovascular and cerebrovascular diseases, excessive force during defecation will increase blood pressure and increase the body's oxygen consumption. It is easy to induce cerebral hemorrhage, angina pectoris, myocardial infarction, and even life-threatening.

    3. Formation of abdominal hernia: In constipation, due to excessive defecation, the intra-abdominal pressure suddenly increases, and abdominal internal organs such as the small intestine protrude from the weak part of the abdominal wall to the surface of the body, which can form an abdominal hernia.

    4. Psychological and mental disorders: Unhealed constipation has brought great pain to his life, aggravated the mental and psychological trauma, and even felt unhappy. There have been many constipation patients who committed suicide due to unbearable conditions. Some scholars have reported that men with long-term constipation are prone to Parkinson's disease.

    5. Detrimental to beauty: long-term constipation, re-absorption of harmful substances into the blood, resulting in rough skin, dull, acne, pigmentation, facial spots, etc.

    6. Can cause a decrease in libido: long-term constipation causes the pelvic muscles to be chronically stimulated to show a spastic contraction state. Over time, these muscles will affect the normal performance of penile erection, ejaculation and vaginal function. In particular, the pubococcygeus muscle is called the "sexual muscle". It is a broad ligament, such as a bandage bed, which supports the organs in the pelvis and vaginal muscles. If this muscle is often relaxed or abnormally tight, it will cause vaginal sensitivity. Decline, sexual pleasure diminishes.

    6. Classification of constipation:

    Constipation is generally divided into two categories: organic constipation, which is caused by various diseases; functional constipation, which is mostly caused by injury, drugs, and bad life and bowel habits. Clinically speaking, chronic intractable constipation refers to those who have a disease course of more than two years, which is difficult to be effective with drugs and various non-surgical treatments, and requires surgical treatment. Primary constipation refers to those with unclear etiology and difficult treatment; secondary constipation is caused by congenital disease damage, drugs, and surgery.

    Clinical classifications commonly used to guide treatment are as follows:

    1. Rectal and anal canal outlet obstructive constipation: It is stubborn constipation that causes pelvic floor muscle dysfunction due to various reasons. It is more common in women. It is manifested as difficulty in defecation, incomplete defecation, and laxatives are often ineffective. In severe cases, the sacrum is swollen. Women may be accompanied by vaginal or uterine prolapse, and patients often need to squeeze the vagina with their hands or pull out dry stools at the end of the rectum. Digital rectal examination can detect increased pressure in the anal canal, relaxation and accumulation of rectal mucosa, and bulging of the front wall of the rectum toward the vagina. Defecography and rectal pressure can confirm the diagnosis, showing pelvic floor muscle dysfunction, and colonic transit test is normal. This type of constipation can be divided into several situations: ①Rectal protrusion: It is more common in women. It is divided into 3 degrees according to the degree of rectal protrusion to the front, namely mild, moderate, and severe. The severe cases require surgical repair. ②Intussusception within the rectum: also called intrarectal prolapse. It is mostly due to the long rectum and long-term defecation force, which separates the rectal mucosa from the muscle layer. The accumulated mucosa can be touched on the digital examination, and the rectal mucosa can be ligated through the anus, but the effect is not lasting. ③ Puborectalis syndrome: related to spasmodic hypertrophy of the puborectalis muscle. On digital examination, the anal canal is lengthened and muscle tension is increased; the pressure of the anal canal is measured, both resting and systolic blood pressure are increased; X-ray examination has "shelf sign". Partial resection of the puborectalis can be used for treatment.

    ④ Perineal descent syndrome: It is a radiological diagnosis. The upper anal canal is at the junction of the pubic symphysis and the coccyx. If it is less than 2 cm during defecation, it is a perineal drop.

    2. Slow colonic transit constipation: In this type, colonic transit is slow, pelvic floor muscle function is normal, clinically unintentional, less stool, and abdominal distension; oral gastrointestinal motility drugs are effective in mild cases, and subtotal colon resection is feasible in severe cases. Sigmoid colon or rectal anastomosis. But need to rule out irritable bowel syndrome.

    Seven, treatment of constipation

    1. General treatment: including diet, exercise, changing bad habits, etc. For ordinary people without organic diseases, diet therapy is the first choice, that is, adding fiber foods in the diet, such as bran, fruits, vegetables, etc.; exercise is very helpful for ordinary people to defecate, and patients who are bedridden for a long time often have constipation. Conditions that cause fecal impaction; correcting the tension in life, slowing down the pace of work and correcting bad habits such as long-term tolerance of bowel movements are also vital for some constipated patients.

    2. Medication: Despite the above methods, many people with constipation also need laxatives to assist in bowel movements. Occasional use of laxatives for general constipation will not cause adverse consequences, but long-term use of laxatives may cause dependence. Laxatives are generally divided into irritating laxatives (such as rhubarb, senna, phenolphthalein, castor oil), salt laxatives (such as magnesium sulfate), osmotic laxatives (such as mannitol), swelling laxatives (such as bran Intestine filling agent made of skin, konjac flour, agar), lubricating laxative (such as paraffin oil).

    It is very important to select laxatives according to the severity of constipation. Expansive laxatives are appropriate for chronic constipation. Stimulant laxatives should be selected only when necessary, and should not be taken for a long time; for acute constipation, salt laxatives, irritant laxatives and lubricating laxatives can be selected, but the duration should not exceed 1 week. ; For long-term chronic constipation, especially for those who cause fecal impaction, enema can be used. The enema is divided into salt water and soapy water, and the salt water is less irritating than soapy water.

    Cisapride is a new type of prokinetic drug for the treatment of colonic constipation. Its mechanism of action is mainly to promote the release of acetylcholine in the intestinal myenteric plexus, which can strengthen the movement of the intestine and promote the operation of the small and large intestines. After oral administration, the absorption is rapid and complete, reaching the peak blood concentration within 1 to 2 hours, and the half-life is 10 hours. It can be used as an ideal medicine for the treatment of colonic constipation. But for severe constipation, it may take 2 to 3 months to achieve the desired therapeutic effect.

    3. The treatment of fecal impaction: usually use enema, oral laxatives, and ejaculation, which are often ineffective. The perianal can be squeezed by manipulative techniques, and women can press the back wall of the vagina with their fingers to help the stool. The commonly used clinical method is to insert the index finger (wear gloves) into the anus, divide the dry feces mass into small pieces, and then pull out or stimulate the excretion with corkscrew. If it is invalid, the fecal mass should be excavated under local anesthesia.

    4. Hydrotherapy: This is a new and effective treatment for intractable constipation. Through the instrument, the sterilized and purified saline is continuously injected into the anus, and after repeated washing, the feces accumulated in the large intestine are discharged to achieve the purpose of removing intestinal poisons, bacteria and parasites, and restoring the normal absorption and excretion function of the intestine. Different from oral laxatives and common bowel cleansing, this therapy is painless, cleans thoroughly, is suitable for all kinds of constipation, and has the effect of detoxification and beauty. Generally once every 1 to 3 months, every 45 minutes.

    5. Biofeedback therapy: Biofeedback therapy uses pressure measurement and electromyography equipment to enable patients to intuitively perceive the functional state of their pelvic floor muscles during defecation, and "intentionally" how to relax the pelvic floor muscles during defecation, while increasing intra-abdominal pressure. Defecation therapy. Before the treatment, it is necessary to explain to the patient the anatomy and physiology of the pelvic floor, explain the methods and steps of the treatment, and make it cooperate with the treatment. Master how to adjust bowel movements according to pressure changes, and learn how to relax the pelvic floor muscles, which requires repeated training to establish conditioned reflexes.

    6. Surgical treatment: If constipation is still ineffective after a period of conservative treatment, some inspection methods can be used to see if there is an organic disease. That is, whether there are any surgical diseases that require surgical treatment. Surgical conditions for slow transit constipation: ① No tension in the colon; ② No outlet obstruction; ③ Excluding irritable bowel syndrome. Can do colon segment or subtotal surgery. Outlet obstructive constipation: This type of disease can be diagnosed by defecography. Including: ①Rectal protrusion: the method of repairing the posterior wall of the vagina or the front wall of the rectum is used to solve; ②Intrarectal prolapse: the treatment often adopts ligation of the rectal mucosa to shorten the length, and a combined therapy of injection of sclerosing agent and surgical ligation; ③Pelvic cavity Spastic syndrome (also called pelvic achalasia syndrome): The surgical method of removing part of the puborectalis muscle can be used, but the effect is uncertain.

    Obstructive constipation at exit

    Constipation is not a disease, but a symptom of many diseases, generally refers to the stool volume is too small, too hard, difficult to pass.

    There are many reasons for constipation, and it is difficult to diagnose and treat. In recent years, through defecation imaging, anorectal pressure measurement, colon transit time measurement, pelvic floor electromyography and other technical examination methods, a new type of constipation has been discovered, called outlet obstructive constipation (Or pelvic floor muscle dysfunction). It is characterized by obstruction factors at the pelvic floor during defecation, some of which can be eliminated or relieved by surgery. However, the obstruction at the exit often has multiple factors at the same time, which brings difficulties to the treatment and must be fully considered when dealing with it.

    Guidelines for the diagnosis and treatment of chronic constipation

    Digestive Disease Branch of Chinese Medical Association

    Corresponding author: Kemei Yun, Chinese Academy of Medical Sciences, Chinese Peking Union Medical College Beijing Union Medical College Hospital Department of Gastroenterology, 100 730

    Email: mygcn@public3.bta.net.cn

    The Gastroenterology Branch of the Chinese Medical Association held a national symposium on constipation in Nanchang, Jiangxi in September 2003, and formulated China's "Guidelines for the Diagnosis and Treatment of Chronic Constipation" at this meeting. The relevant content is now introduced as follows

    1. Background of the diagnosis and treatment guidelines

    (1) Concept and cause

    Chronic constipation mainly refers to dry stool, difficult or incomplete defecation, and decreased defecation frequency. Constipation is a common disease caused by a variety of causes, such as gastrointestinal diseases, systemic diseases involving the digestive tract, and many drugs can also cause constipation. The conditions related to functional gastrointestinal disease (FGID) and chronic constipation in the Rome II standard include functional constipation, pelvic floor dysfunction and constipated irritable bowel syndrome (IBS). Among them, functional constipation needs to exclude organic etiology and drug factors; and pelvic floor defecation disorders in addition to meeting the diagnostic criteria for functional constipation, need to have an objective basis for pelvic floor defecation disorders. Constipation in constipated IBS is related to abdominal pain or bloating. Constipation related to gastrointestinal motility disorders includes Ogilvie syndrome (Hirschsprung disease), Hirschsprung's disease, slow transit constipation (M/N disease), and anal sphincter achalasia (Anismus).

    (2) The importance of developing guidelines for diagnosis and treatment

    With the change of dietary structure and the influence of mental and psychological and social factors, the incidence of constipation has gradually increased, which has seriously affected people's quality of life. A survey of people over 60 years old in Beijing, Tianjin and Xi'an in China shows that chronic constipation is as high as 15% to 20%. A randomized, stratified, and graded survey of adults aged 18 to 70 in Beijing showed that the incidence of chronic constipation was 6.07%, and women were more than 4 times that of men, and mental factors were one of the high-risk factors. Chronic constipation may play an important role in the occurrence of colon cancer, hepatic encephalopathy, breast disease, Alzheimer's disease, etc.; Acute myocardial infarction, cerebrovascular accident and other symptoms of constipation can even lead to life accidents; some constipation and anorectal diseases, Such as internal hemorrhoids and anal fissures are closely related. At the same time, the abuse of laxatives causes many adverse reactions, increases medical expenses and wastes medical resources. Therefore, it is necessary to prevent and treat constipation in a timely and reasonable manner, and to develop a constipation diagnosis and treatment process suitable for China. After the China Chronic Constipation Forum launched the diagnosis and treatment process (draft) in 2002, the Gastroenterology Branch of the Chinese Medical Association continued to solicit opinions extensively, and at the constipation symposium (Nanchang) in September 2003, the guidelines for diagnosis and treatment of constipation were discussed again. A consensus was reached initially.

    2. Thinking and basis of diagnosis and treatment process

    (1) Main points of diagnosis

    The diagnosis of chronic constipation should include the cause (and trigger), degree and type of constipation. If you can understand the scope of involvement related to constipation (colon, anorectum or upper gastrointestinal tract), affected tissues (myopathy or neuropathy), whether there are local structural abnormalities and the causal relationship with constipation, then formulate a treatment plan And predict the efficacy is very useful. The severity of constipation can be divided into 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 less medication. Severe refers to the persistent symptoms of constipation, the patient is abnormally painful, which seriously affects the life, the drug cannot be stopped or the treatment is ineffective. Moderate in view of the difference between the two. The so-called refractory constipation is often severe constipation, which can be seen in outlet obstructive constipation, colon weakness, and severe constipation IBS. The two basic types of chronic constipation are slow transit type and outlet obstruction type. If both are combined, they are mixed type.

    (2) Diagnostic methods

    Medical history can provide important information, such as the characteristics of constipation (stools, constipation, difficulty or poor bowel movement, and stool characteristics, etc.), accompanying digestive tract symptoms, underlying diseases, and drug factors. The four common manifestations of chronic constipation are: (1) less urge to defecate and less frequent defecation; (2) difficult and laborious defecation; (3) poor defecation; (4) constipation accompanied by abdominal pain or abdominal discomfort. The above categories can be seen in both the slow transit type and the outlet obstruction type constipation, which need to be carefully distinguished and can help guide treatment. Attention should be paid to warning signs such as blood in the stool, abdominal mass, etc., as well as family history of tumors and social psychological factors. For patients with constipation suspected of having anorectal diseases, a digital anorectal examination should be performed to help understand the presence of rectal masses, fecal deposits, and the function of the sphincter. Stool examination and occult blood test should be listed as routine examinations. If necessary, conduct relevant biochemical inspections. Colonoscopy or imaging can help determine whether there is an organic cause. The simple way to determine the type of constipation is the gastrointestinal transit test. It is recommended to take a abdominal radiograph at 48 hours after taking 20 opaque X-ray markers (normally most markers have reached the rectum or have been discharged), and then take an abdominal radiograph at 72 hours if necessary One sheet, observing the distribution of markers is very helpful for judging whether there is slow transit constipation.Anorectal manometry can check the anorectal function without obstacles, such as the contradictory contraction of the external anal sphincter during forced defecation, the lack of anorectal suppression reflex after rectal airbag insufflation, and the abnormal sensory threshold of the rectal wall. The air sac expulsion test reflects the ability of the anorectal to expel air sacs, but the meaning of expelling air sacs and hard feces is not completely consistent. Some refractory constipation, such as the lack of specific propulsive systolic waves in 24h colonic pressure monitoring, and the lack of response of the colon to waking up and eating, can help the diagnosis of colon weakness. In addition, defecography can dynamically observe the anatomical and functional changes of the anorectum. Anal manometry combined with ultrasound endoscopy can show whether there are biomechanical defects and anatomical abnormalities in the anal sphincter, which provide clues for surgical positioning. Application of perineal nerve latency or electromyography can distinguish whether constipation is myogenic or neurogenic. For patients with obvious anxiety and depression, relevant investigations should be made, and the causal relationship with constipation should be judged.

    (Three) treatment

    Patients with chronic constipation need to receive comprehensive treatment to restore bowel physiology. Pay attention to general treatment, strengthen education on bowel physiology and bowel management, adopt reasonable eating habits, such as increasing dietary fiber content, increasing drinking water to strengthen the stimulation of the colon, and developing good bowel habits, avoiding forced bowel movements, and at the same time Activities should be increased. During treatment, attention should be paid to removing excessive fecal accumulation in the distal rectum; positive adjustment of mentality is required, which are extremely important to obtain effective treatment.

    In the selection of laxatives, attention should be paid to the efficacy, safety and drug dependence. It is recommended to use leavening agents (such as wheat bran, psyllium, etc.) and osmotic laxatives (such as polyethylene glycol 4000, lactulose). For slow transit constipation, intestinal prokinetics can be added when necessary. Long-term application or abuse of stimulant laxatives should be avoided. Many proprietary Chinese medicines have a laxative effect, so attention should be paid to the ingredients of the medicines, especially the possible side effects of long-term medication. For patients with fecal impaction, clean the enema or use a short-term stimulant laxative to relieve the impaction, and then use a leavening agent or an osmotic drug to keep the bowel smooth. Kaisailu and glycerin suppository have the effects of softening stool and stimulating bowel movements. If internal hemorrhoids are combined with constipation, compound carrageenate suppositories can be used.

    For outlet obstructive constipation and contradictory contraction of the sphincter during forced defecation, biofeedback therapy can be used to coordinate the activities of the abdominal muscles and pelvic floor muscles during defecation. For patients with abnormal bowel intention threshold, attention should be paid to the reconstruction of defecation reflex. And adjust the training for the perception of stool. For patients with severe constipation, it is still necessary to pay attention to the positive effects of psychotherapy. Surgery should strictly control the indications, and predict the efficacy of surgery.

    3. Diagnosis and treatment triage

    For patients with chronic constipation, it is necessary to analyze the causes, triggers, constipation types and severity of constipation, and it is recommended to make a stratified and graded three-level diagnosis and treatment triage (Figure 1).

    click to zoom in

    First-level diagnosis and treatment triage:

    Suitable for most patients with mild to moderate chronic constipation. First of all, you should have a detailed understanding of the relevant medical history, physical examination, and if necessary, a digital anorectal examination. Routine fecal examination (including occult blood test) should be done to decide on empirical treatment or further examination. If the patient has alarm signs, is suspected of having organic lesions, especially those with cancer of the rectum and colon, and at the same time is over-stressed and anxious, and is over 40 years old, further examinations are required, including biochemical, imaging and/or colonoscopy to determine the cause. And deal with it accordingly. Otherwise, empirical treatment can be used, and according to the characteristics of constipation, empirical treatment lasts for 2 to 4 weeks, emphasizing general and etiological treatment, and choosing leavening agents or osmotic laxatives. If the treatment is ineffective, increase the dose or use a combination of drugs if necessary; if there is fecal impaction, care should be taken to remove the feces accumulated in the rectum.

    Second-level diagnosis and treatment triage:

    The main targets are patients who have not found organic diseases after further examination and those who have failed to undergo empirical treatment. Gastrointestinal transmission test and/or anorectal pressure measurement can be performed to determine the type of constipation and further treatment. For those with outlet obstruction Patients with constipation should choose biofeedback therapy and strengthen psychocognitive therapy.

    The third level of diagnosis and treatment classification:

    The main target is those patients who are ineffective in the second-level diagnosis and treatment triage. Re-evaluate the diagnosis and treatment of chronic constipation, pay attention to whether there is constipation caused by special reasons, especially the abnormal structure of the colon or anorectum related to the secretion of stool, whether there is any mental and psychological problems, whether there is unreasonable treatment, whether it has changed unreasonable lifestyle Wait for qualitative and positioning diagnosis. Most of these patients are intractable constipation patients with unsatisfactory results after various treatments. Special examinations need to be further arranged, and even consultations in multiple disciplines, including psychology, are needed to determine a reasonable treatment plan.

    Clinically, you can choose to enter the above diagnosis and treatment triage program according to the patient's condition, diagnosis and treatment history. For example, for severe constipation, empirical treatment is not required, and the second or third-level diagnostic procedure can be entered at the beginning. In the first-level diagnosis and treatment triage, patients who are ineffective or have poor curative effect after empirical treatment can undergo further examination. Similarly, for those who show organic disease after further examination, in addition to treatment for the cause, the same can be done. According to the characteristics of constipation, empirical treatment can also be given, or the second-level diagnosis and treatment triage program can be entered to determine the type of constipation.

    The above graded diagnosis and treatment of chronic constipation will reduce unnecessary examinations and reduce treatment costs, but its feasibility and cost-benefit ratio need to be further supported by evidence-based medicine.

    Obstructive constipation at exit

    Constipation is not a disease, but a symptom of many diseases, generally refers to the stool volume is too small, too hard, difficult to pass.

    There are many reasons for constipation, and it is difficult to diagnose and treat. In recent years, through defecation imaging, anorectal pressure measurement, colon transit time measurement, pelvic floor electromyography and other technical examination methods, a new type of constipation has been discovered, called outlet obstructive constipation (Or pelvic floor muscle dysfunction). It is characterized by obstruction factors at the pelvic floor during defecation, some of which can be eliminated or relieved by surgery. However, the obstruction at the exit often has multiple factors at the same time, which brings difficulties to the treatment and must be fully considered when dealing with it.

    Here is an article for everyone

    Treatment of 388 cases of outlet obstructive constipation

    Liu Jianxin, Chengdu Sino-American Hospital of Sino-American Group (610031) Chinese Journal of Anorectal Diseases, Volume 20, Issue 1, 2000

没有评论:

发表评论

hemorrhoids natural remedy,Do patients with external hemorrhoids need surgery?

    External hemorrhoids are more common, mainly manifested as skin tags around the anus, usually without any symptoms, only when they atta...