The Gastrointestinal Dynamics Group of the Chinese Society of Digestion. With the changes in dietary structure and the influence of mental, psychological and social factors, constipation has seriously affected the quality of life of modern people; and in colon cancer, hepatic encephalopathy, breast disease, Alzheimer’s, etc. It plays an important role in the occurrence of diseases; constipation can lead to life accidents in acute myocardial infarction and cerebrovascular accidents; some constipation is closely related to anorectal diseases, such as hemorrhoids and anal fissures. Therefore, early prevention and reasonable treatment of constipation will greatly reduce the serious consequences and social burden of constipation.
1 The necessity of establishing a constipation diagnosis and treatment process Considering that there are many patients who are clinically troubled by constipation, a clear diagnosis often requires a high cost, so it is extremely important to find an effective way to diagnose and treat constipation. The development of a simple, effective and operable constipation diagnosis and treatment process suitable for China's current situation in order to make more effective use of limited health resources will benefit the entire society.
2 The cause, examination methods, diagnosis and treatment of constipation. Healthy people's bowel habits are mostly 1 to 2 d or 1 (1 to 2) d. The stools are mostly shaped or soft (such as Bristol types 4 and 5). A small number of healthy people have bowel movements up to 3 days, or 1 time 3 days, and the stools are half-shaped or hard sausage-like stools (such as Bristol types 6 and 3). Normal defecation requires intestinal contents to pass through each segment at a normal speed, reach the rectum in time, and stimulate the rectum and anus, causing defecation reflex, and the pelvic floor muscles coordinate activities during defecation to complete defecation. Failure of any of the above links may cause constipation. Therefore, it is necessary to understand the links, mechanisms and related etiology and incentives that cause constipation in patients with defecation failure in order to formulate a reasonable treatment plan.
2.1 "Causes 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, scleroderma, and neurological diseases. The diseases and drugs that can cause constipation are: (1) Intestinal stenosis or obstruction caused by organic diseases of the bowel such as tumor, inflammation or other reasons; (2) Rectal and anal diseases: internal rectal prolapse, hemorrhoids, prerectal bulge (3) Endocrine or metabolic diseases: diabetic enteropathy, hypothyroidism, parathyroid disease, etc.; (4) Nervous system diseases: such as central brain Diseases, stroke, multiple sclerosis, spinal cord injury and peripheral neuropathy; (5) Intestinal smooth muscle or neuronal disease; (6) Colonic neuromuscular disease: pseudo intestinal obstruction, Hirschsprung's disease, giant rectum, etc.; ( 7) Neuropsychological disorders; (8) Drug factors: aluminum antacids, iron agents, opioids, antidepressants, anti-Parkinson's drugs, calcium channel antagonists, diuretics and antihistamines.
2.2 "Examination methods and evaluation of chronic constipation" The diagnosis methods of chronic constipation include medical history, physical examination, related laboratory examinations, imaging examinations and special examination methods.
2.2.1 "Disease history" A detailed understanding of the medical history, including the symptoms and course of constipation, gastrointestinal symptoms, accompanying symptoms and diseases, and medication can often provide very important information. Pay attention to whether there are alarm symptoms (such as blood in the stool, anemia, weight loss, fever, melena, abdominal pain, etc.); the characteristics of constipation symptoms (time of stool, intention to defecate, whether it is difficult or uncomfortable, and the characteristics of stool); accompanying gastrointestinal symptoms; Medical history related to the cause, such as abnormal anatomical structure of the gastrointestinal tract or systemic disease and constipation caused by drug factors; mental, psychological state and social factors.
2.2.2 General examination methods Digital anorectal examination can often help understand fecal impaction, anal stenosis, hemorrhoids or rectal prolapse, rectal masses, etc., and can also understand the function of anorectal sphincter; blood routine, stool routine, stool occult blood test It is an important and simple routine laboratory examination item to exclude organic diseases of the colon, rectum, and anus. If necessary, perform biochemical and metabolic examinations; for suspected anal and rectal disease, proctoscope, sigmoidoscopy, colonoscopy, or barium enema can observe the intestine directly or display imaging data.
2.2.3 "Special examination methods" For patients with chronic constipation, the following related examinations can be selected as appropriate.
Gastrointestinal transit test (gastrointestinal transittest, GIT): It is recommended to take 20 opaque X-ray markers at least 48 hours after stopping the drug, and then take a plain abdominal X-ray film (normally most markers have reached the rectum or have been discharged ), the purpose of choosing 48h filming is to observe the distribution of markers at this time. If most of them have been concentrated in the sigmoid colon and rectum area or have not yet reached this area, it will indicate that the passage is normal or slow, such as after 72h. If one film is taken, most of the markers have not yet reached the sigmoid colon or rectum or remain in the sigmoid colon or rectum, respectively, suggesting passing slow or outlet obstruction constipation. The gastrointestinal pass test is a simple method that can be popularized and applied. If it is extended to 5 to 6 days to take one film, its accuracy may be increased, but the feasibility is poor. Because most patients are difficult to adhere to, they use laxatives by themselves.
Anorectal manometry (ARM): Commonly used perfusion manometry (same as esophageal manometry) to detect the systolic pressure of the anal sphincter and the external anal sphincter, the relaxation pressure during forced defecation, and whether there is an anus after gas injection in the rectum The rectal suppression reflex appears, and the sensory function of the rectum and the compliance of the rectal wall can also be measured, which is helpful to evaluate the anal sphincter and rectal dysmotility. If contradictory contraction of the external anal sphincter occurs during forced defecation, it indicates outlet obstructive constipation; after injecting air into the rectal air sacs, if the anorectal suppression reflex is absent, it indicates Hirschsprung's disease; the rectal wall mucosa is against the air sac The sense of bowel movement caused by gas injection, the capacity of the maximum tolerance, etc., can provide whether the bowel threshold of the rectal wall is normal.
Colonic pressure monitoring: Place the sensor in the colon and monitor changes in colonic pressure for 24 to 48 hours under relatively physiological conditions. Determining the presence or absence of colonic weakness is of guiding significance for treatment.
Balloon expulsion test (Balloonexpulsiontest, BET): Place a balloon in the rectum, inflate or fill it with water, and let the subject expel it. It can be used as a screening test for the presence or absence of discharge barriers, and further examinations are needed for positive patients.
Barium defecography (BD): The simulated stool is poured into the rectum, and the changes of the anus and rectum during defecation are dynamically observed under radiation, so as to understand whether the patient has accompanying anatomical abnormalities, such as prerectal bulge, intestine Nesting and so on.
Others, such as pelvic floor electromyography can help determine whether the lesion is myogenic; pudendal nerve latency measurement can show whether there is abnormal nerve conduction; anal ultrasound endoscopy can understand whether the anal sphincter is defective or not.
2.3 "Diagnosis of chronic constipation" The diagnosis of patients with chronic constipation should include: the cause (and triggers), degree and type of constipation. If you can understand the extent of involvement related to constipation (colon, anorectum or with upper gastrointestinal tract), affected tissues (myopathy or neuropathy), whether there are local structural abnormalities, and the causal relationship with constipation, then it is necessary to formulate treatment plans and Predicting efficacy is very useful. The severity and types of chronic constipation are described below.
Severity of chronic constipation: constipation is divided into mild, moderate and severe degrees. Mild refers to mild symptoms that do not affect life, and can get better after general treatment without medication or less medication; severe refers to persistent constipation symptoms, the patient is abnormally painful, severely affects life, and the drug cannot be stopped or treatment is ineffective; moderate is between two Between. The so-called refractory constipation is often severe constipation, which can be seen in outlet obstructive constipation, colon weakness, and severe constipation irritable bowel syndrome (IBS).
Types of chronic constipation: divided into STC, OOC and mixed type. The constipation type of IBS is a type of constipation related to abdominal pain and bloating. At the same time, it may also have the following characteristics. (1) Slow transit constipation (slow transit contipation, STC) often has reduced defecation frequency, less defecation, hard stool, and difficulty in defecation; no stool or touching hard stool during digital rectal examination, and anal contraction and exertion of the external anal sphincter Defecation function is normal; total gastrointestinal or colon transit time is prolonged; lack of evidence of outlet obstructive constipation, such as normal air sac discharge test and normal anorectal manometry (2) Outlet obstructive constipation (OOC) has difficulty in defecation, feeling of incompleteness or falling, low stool volume, intention or lack of intention, there is a lot of mud-like stool in the rectum during digital rectal examination, and it is outside the anus when forced defecation The sphincter is contradictory contraction; the total gastrointestinal or colon transit time is normal, and most of the markers can be stored in the rectum; anorectal pressure measurement shows that the external anal sphincter is contradictory contraction or the sensory threshold of the rectal wall is abnormal when forced defecation. (3) Mixed constipation: It has the characteristics of (1) and (2).
The above three categories are suitable for functional constipation, and also suitable for chronic constipation caused by other reasons, such as diabetes, scleroderma combined with constipation, and drug-induced constipation are mostly slow transit constipation. The constipation type of irritable bowel syndrome is characterized by less frequent bowel movements, often difficult defecation, abdominal pain or bloating after defecation and flatulence, and may have outlet dysfunction combined with slow-pass constipation. It can be further confirmed if combined with related functional tests. Its clinical type.
2.4 "Treatment of chronic constipation" The principle of treatment is based on the severity, cause and type of constipation, comprehensive treatment to restore normal bowel habits and bowel physiology.
2.4.1 "General treatment" Strengthen the physiological education of bowel movement, establish reasonable eating habits (such as increasing dietary fiber content, increase the amount of drinking water) and adhere to good bowel habits, while increasing activities.
2.4.2 "Drug therapy" Use appropriate laxative drugs. The choice of drugs should be based on the principle of low side effects and low drug dependence, usually such as leavening agents (such as wheat bran, psyllium, etc.) and osmotic laxatives (such as fosone, dumic). A randomized controlled observation of the application of Fusong in the treatment of functional constipation has shown 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 also be added. It should be noted that for patients with chronic constipation, long-term use or abuse of stimulant laxatives should be avoided. A variety of Chinese patent medicines have laxative effects, but it is necessary to pay attention to the ingredients and side effects of the medicine when taking Chinese patent medicines for chronic constipation for a long time. For patients with fecal impaction, clean the enema once or use a short-term stimulant laxative to relieve the fecal impaction, and then choose a leavening agent or an osmotic laxative to keep the bowel movement smooth. Kaisailu and glycerin suppository have the effects of softening stool and stimulating bowel movements. The compound carrageenate is effective in treating hemorrhoidal constipation.
2.4.3 "Psychotherapy and biofeedback" Patients with moderate and severe constipation often have psychological factors or disorders such as anxiety or depression. Cognitive therapy should be given to relieve the tension. Biofeedback therapy is suitable for functional outlet obstruction constipation.
2.4.4 "Surgical treatment" If strict non-surgical treatment is still ineffective, and various special examinations show clear pathological anatomy and conclusive functional abnormalities, surgical treatment may be considered. Indications for surgery include secondary megacolon, part of the colon is lengthy, colon weakness, severe prerectocele, rectal intussusception, and rectal mucosal prolapse. However, attention should be paid to whether there is any serious psychological disorder, whether there is abnormality of the digestive tract outside the colon, and the curative effect needs to be predicted before the operation.
3 International diagnostic criteria and diagnosis and treatment process for chronic constipation. In September 1999, the International Rome II Collaboration Committee formulated a series of diagnostic criteria for Rome II functional gastrointestinal diseases on the basis of Rome I. Although the current understanding of constipation in the gastroenterology community is inconsistent, the diagnosis and treatment process of the country is still based on the Rome Ⅱ diagnostic criteria and combined with the actual situation of each country. The following introduces the diagnostic criteria of RomeⅡ's chronic constipation, functional constipation, pelvic floor dysfunction and IBS constipation, and introduces the main points of the "U.S. Guidelines for the Treatment of Constipation" formulated by the United States on the basis of standards in recent years.
3.1 RomeⅡdiagnostic criteria for constipation Chronic constipation (chronic constipation): have at least 12 consecutive or intermittent symptoms of the following 2 or more symptoms in the past 12 months: (1) >1 4 has a time of defecation; )>14, there is a clump or induration of stool; (3)>14, there is a sense of incomplete defecation; (4)>14, there is a sense of anal obstruction or anorectal obstruction during defecation; (5) Manipulative assistance is required for defecation in >14 time; (6) There is no defecation per week for >14 time, there is no loose stool, and it does not meet the diagnostic criteria for IBS.
Functional constipation (functional constipation): According to Rome Ⅱ diagnostic criteria, functional constipation not only meets the above diagnostic criteria, but also constipation caused by intestinal or systemic organic causes and drug factors should be excluded.
Pelvic floor defecation disorder (pelvicfloordyssynergia): RomeⅡ's diagnostic criteria for pelvic floor defecation disorder means that in addition to meeting the above diagnostic criteria of RomeⅡ for functional constipation, the following points must also be met, namely: (1) Anorectal test is required Evidence from pressure, electromyography or X-ray examination shows that the pelvic floor muscles contract inappropriately or cannot relax during repeated defecation movements; (2) The rectum can exhibit sufficient propulsive contraction when defecation is forced; (3) Yes Evidence of poor stool.
Constipation-type irritable bowel syndrome (irritable bower syndrome, constipation-predominant, constipation-type IBS) Irritable bowel syndrome is a functional bowel disease characterized by abdominal discomfort or pain with changes in bowel habits and abnormal bowel movements. X-ray barium enema There were no lesions on examination or colonoscopy, and no evidence of systemic disease. Constipation-type IBS refers to the basic point that first meets the IBS standard, that is, those who have had abdominal pain or abdominal discomfort for at least 12 weeks (not necessarily consecutive) in the past 12 months, and accompanied by 2 of the following 3 items: (1) After stool Appellate symptoms disappear; (2) the above symptoms appear with changes in the frequency of stool; or (3) accompanied by changes in stool characteristics. It is supported by any one of the following 3 performances, (1) having less than 3 times a week; (2) loose stools; (3) a sense of urgency to defecate.
3.2 Main points of the diagnosis and treatment process of chronic constipation in the United States The main points of the chronic constipation process proposed by the United States are based on medical history and physical examination, combined with relevant laboratory examinations, and first proposed experimental treatments for patients with refractory constipation, and then barium discharge Stool angiography and related kinetic function tests, according to the type of constipation for corresponding treatment. According to the preliminary assessment results, the diagnosis of constipation is divided into 6 types, namely (1) constipation type IBS; (2) slow transit type constipation; (3) rectal outlet obstruction type; (4) above (2) and (3) Coexistence; (5) functional constipation (functional obstruction or drug side effects); (6) constipation secondary to systemic diseases.
4 China's constipation diagnosis and treatment process and its principles. Constipation is divided into degree, type, etiology and inducement. Therefore, constipation patients need to be classified and hierarchical diagnosis and treatment triage. Such a diagnosis and treatment process is conducive to active and effective diagnosis and treatment of patients, and Produce a reasonable cost-effectiveness ratio.
4.1 "Diagnosis and treatment process" Clinically, in order to achieve effective stratification (alarm or not), grade (degree) diversion diagnosis and treatment of constipation patients, it is necessary to evaluate the causes and triggers of constipation, and the type and degree of constipation. For most patients, through detailed medical history and physical examination, the cause and type of constipation can be understood, and empirical treatment can be performed; when there are alarm signs or suspected organic diseases caused by constipation, further examination should be performed, except or confirmed Whether there are organic diseases, especially colon tumors; in addition to the cause and treatment of constipation patients who are determined to be organic diseases, it is also necessary to judge the type of constipation according to the characteristics of constipation and carry out corresponding treatment; If the case is confirmed to be organic constipation, further examination can determine the type of constipation, and then perform corresponding treatment; for a small number of patients with refractory constipation, check the type of constipation at the beginning, and even more detailed examinations to determine the treatment method (see picture 1).
4.2 "Diagnosis and treatment principles" (1) A detailed understanding of medical history and physical examination is an important basis for choosing a constipation process. For most patients with constipation, try to use non-invasive methods to determine the type of constipation, and verify clinical inferences based on the efficacy of empirical treatment. (2) The type of constipation is an important basis for choosing a treatment method. Whether it is empirical treatment or treatment after further examination, it is emphasized that corresponding treatment strategies should be given to different types of constipation. (3) For constipation patients with warning signs, emphasize the cause of investigation, while for refractory constipation who lacks warning signs, emphasize the importance of determining the type of constipation. (4) Proportion of receiving various examination methods: For most constipation, empirical treatment is the mainstay, and for refractory constipation, further examination should be performed. A few patients, especially those who require surgery, need more in-depth examination. (5) Several routes in the process can pass through each other. If the empirical treatment is not effective, further examination should be conducted to understand the cause and type.
4.3 "Common manifestations of chronic constipation 4.3.1 "Less defecation and less defecation times" This type of constipation can be seen in slow-pass and outlet obstruction constipation. The former is due to the slow passage, which reduces both the frequency of defecation and the intention to defecate, but the intention to defecate can still occur at a certain interval. The stool is often dry and hard, and it is helpful to defecate hard. In the latter case, the sensory threshold is often increased, which is not easy to cause bowel movements, so the bowel movements are reduced, and the stool is not necessarily dry and hard. For these patients, leavening agents or penetrants can be used to increase the water content of feces, increase softness and volume, stimulate colonic peristalsis, and also increase the stimulation of rectal mucosa. At the same time, bowel movements should be scheduled.
4.3.2 "Difficult and laborious defecation" is prominently manifested as abnormally difficult stool excretion, which is also seen in two situations, and outlet obstructive constipation is more common. When the patient forced a bowel movement, the external anal sphincter showed contradictory contraction, which made it difficult to defecate. This type of convenience is not necessarily small, but it takes time and effort. If it is accompanied by weakness in abdominal muscle contraction, it will be more difficult to re-defecate. The second situation is due to slow passage, excessive moisture in the feces is absorbed, and the feces are dry and solid, especially if the feces are not defecate for a long time, making it difficult to discharge the dry and hard feces, and fecal impaction may occur. For this type of constipation, leavening agents and penetrants can be tried to make the stool soft and easy to discharge, sometimes combined with enema treatment. If the stool is still difficult to pass after softening, it is indicated as outlet obstructive constipation. Such patients need to guide the bowel method and perform biofeedback treatment if necessary.
4.3.3 "Unsmooth defecation" There is often a sense of obstruction in the anus and rectum. Although there are frequent defecations, there are many times, but even if it is laborious, it will not help. It is difficult to have a smooth defecation. May be accompanied by anorectal irritation, such as falling, discomfort, etc. Such patients often have reduced sensory threshold, high rectal sensitivity, or abnormal anatomical structures in the rectum, such as internal rectal intussusception and internal hemorrhoids. In some cases, the sensory threshold of the rectum is increased, and similar symptoms appear, which may be related to the changes in the anorectal anatomy. The treatment of these patients needs to improve the sensory threshold, reduce the frequency of bowel movements, and treat local anorectal diseases, such as local treatment of hemorrhoidal constipation.
4.3.4 Constipation is often accompanied by abdominal pain or abdominal discomfort. It is common in constipated IBS, and the symptoms are relieved after defecation.
The above types of constipation are not only found in functional constipation, but also in constipated IBS (there may also be manifestations of the above types). At the same time, organic diseases such as chronic constipation caused by diabetes and constipation caused by drugs can have the above types of performance, which should be analyzed. In addition, there are often combinations of various situations.
4.4 related to etiological examination, imaging or endoscopy, if necessary, combined with pathological examination to determine whether there are intestinal organic diseases, such as suspected diabetes, endocrine diseases, connective tissue diseases and neurological diseases, corresponding biochemical and Immune check.
4.5 "Commonly used methods to determine the type of constipation" Commonly used examination methods to determine the type of constipation include gastrointestinal pass test and anorectal pressure measurement, and digital anorectal examination can help diagnosis.
Digital anorectal examination: Digital anorectal examination is not only an important method to check for rectal cancer, but also a common and simple method for judging whether there is outlet obstructive constipation. In particular, the increased sphincter tension, the sphincter cannot relax when forced to defecate, but contract and become more tense, suggesting long-term extremely laborious defecation, leading to sphincter hypertrophy, and contradictory contraction occurs during forced defecation.
4.6 Special examinations for refractory constipation. Severe slow-pass constipation is ineffective for various treatments. It often indicates colon weakness. For example, the lack of specialized propagating pressure wave (SP PW) in 24h colon pressure monitoring indicates the need for surgery; Defecography can dynamically observe the anatomical and functional changes of the anorectum; anal pressure measurement combined with ultrasound endoscopy, and at the same time show that the anal sphincter has mechanical defects and anatomical weakness, which provide important clues for anorectal surgery; a few constipation needs to be distinguished If the lesion is myogenic or neurogenic, it is necessary to check the perineal nerve latency or electromyography; for patients with obvious anxiety and depression, relevant investigations should be done.
Functional gastrointestinal disease
FGID was discussed at the International Gastrointestinal Conference in 1984, and a functional gastrointestinal expert committee composed of dozens of experts-the Rome Committee was established. In 1994, 25 diagnostic criteria for functional gastrointestinal diseases were formulated. Namely, according to the Rome I standard, functional gastrointestinal disease is defined as chronic or recurrent gastrointestinal symptoms, but no organic diseases and biochemical abnormalities. With continued in-depth research on the diagnostic criteria of functional gastrointestinal diseases, 10 working groups that participated in international research and clinical appraisal (including the functional gastrointestinal pediatric expert working group established in 1997) repeatedly discussed and researched, after 4 years , Functional gastrointestinal disease Rome II diagnosis came out in 1999. Since then, the expert committee revised the Rome Ⅱ diagnostic criteria based on the new research results and their experience. In 2006, the FGID Rome Ⅲ standard was launched, which divided functional gastrointestinal diseases into eight categories (Table 1). At present, the diagnosis of functional gastrointestinal disease is based on Rome III criteria in China.