Gastrointestinal Dynamics Group of China Digestive Society
Constipation is a common disease caused by many reasons. Patients often have dry stool, difficulty in defecation or endless feeling, and the number of times of completely emptying feces without using laxatives is obviously reduced.
Epidemiology: Different countries have different methods to investigate constipation. In the American population, the prevalence of constipation ranges from 2% to 28%. A survey of the elderly over 60 in Beijing, Tianjin and Xi 'an shows that the chronic constipation rate of the elderly over 60 in China is as high as 15%-20%. A random stratified survey of adults aged 0/8-70 in Beijing showed that the incidence of chronic constipation was 6.07%, more than four times that of women, and mental factors were one of the high-risk factors.
Harmfulness of constipation: With the change of diet structure and the influence of psychosocial factors, constipation has seriously affected the quality of life of modern people; And plays an important role in the occurrence of colon cancer, hepatic encephalopathy, breast disease, Alzheimer's disease and other diseases; Constipation can lead to life accidents such as acute myocardial infarction and cerebrovascular accident; Some constipation is closely related to anorectal diseases, such as hemorrhoids and anal fissure. Therefore, early prevention and reasonable treatment of constipation will greatly reduce the serious consequences and social burden caused by constipation.
Necessity of establishing constipation diagnosis and treatment process: Considering that there are so many constipation patients in clinic, it often costs a lot to make a definite diagnosis, so it is extremely important to find an effective diagnosis and treatment method for constipation. It is simple, effective and operable to make the constipation diagnosis and treatment process suitable for China, so as to make more effective use of limited health resources, which will certainly benefit the whole society. The following will briefly describe the etiology, examination methods, diagnosis and treatment of constipation, review the Rome II diagnostic criteria and international constipation diagnosis and treatment process, and put forward the China chronic constipation diagnosis and treatment process and its principles (draft) which have been widely brewed and discussed. I hope to get in-depth discussion and understanding at the meeting again.
I. Etiology, examination methods, evaluation, diagnosis and treatment of constipation
The defecation habits of healthy people are mostly 1-2 times/day or/kloc-0 times/day, and the feces are mostly tangible or soft (for example, types 4 and 5 in Bristol), and a few healthy people can defecate 3 times/day or/kloc-0 times/day. Feces are semi-formed or sausage-like hard stools (such as types 6 and 3 in Bristol type). Normal defecation requires intestinal contents to pass through the segments at normal speed, reach the rectum in time, stimulate the rectum and anus, cause defecation reflex, coordinate the activities of pelvic floor muscles, and complete defecation. Failure of any of the above links may lead to constipation. Therefore, patients with constipation should understand the link, mechanism, related causes and incentives of defecation failure, and then make a reasonable treatment plan.
(A), the cause of chronic constipation
There are functional and organic reasons for chronic constipation. Organic causes can be gastrointestinal diseases, systemic diseases involving digestive tract such as diabetes, scleroderma and nervous system diseases. Many drugs can cause constipation, as follows: organic intestinal diseases such as tumor, inflammation or other causes of intestinal stenosis or obstruction.
1. anorectal diseases: rectal prolapse, hemorrhoids, proctoptosis, puborectal muscle hypertrophy, pubic separation, pelvic floor diseases, etc.
2. Endocrine or metabolic diseases: such as diabetic enteropathy, hypothyroidism, parathyroid diseases, etc.
3. Nervous system diseases: such as central brain diseases, stroke, multiple sclerosis, spinal cord injury, peripheral neuropathy, etc.
4. Intestinal smooth muscle or neuron injury
5. Colon neuromuscular lesions: pseudointestinal obstruction, Hirschsprung's disease, megarectum, etc.
6. Mental and psychological disorders
7. Drug factors: aluminum antacids, iron agents, opioids, antidepressants, anti-Parkinson drugs, calcium channel antagonists, diuretics and antihistamines.
(B), chronic constipation inspection methods and evaluation
The diagnosis methods of chronic constipation include medical history, physical examination, related tests, imaging examination and special examination methods.
Medical history: A detailed understanding of medical history, including symptoms and course of constipation, gastrointestinal symptoms, accompanying symptoms and diseases, medication, etc., can often provide very important information.
pay attention to
(1), whether there are alarm symptoms (such as bloody stool, anemia, emaciation, fever, melena, abdominal pain, etc. ), (2), the characteristics of constipation symptoms (defecation, defecation difficulty or obstruction, fecal characteristics), (3), accompanying gastrointestinal symptoms, (4), medical history related to the cause, such as abnormal intestinal anatomical structure.
General inspection methods:
(1), anorectal digital examination can often help to understand the symptoms such as fecal impaction, anal stenosis, hemorrhoids or rectal prolapse, rectal mass, and the function of anal sphincter.
(2) Blood routine, stool routine and stool occult blood test are important and simple routines to exclude organic colorectal and anal lesions. When necessary, biochemical and metabolic tests are carried out. (3) For patients with suspected anorectal lesions, colonoscopy or sigmoidoscopy/colonoscopy, or barium enema can directly observe the intestine or display imaging data.
Special examination method: For patients with chronic constipation, you can choose the following related examinations as appropriate.
1. gastrointestinal transmission test (GITT): X-ray opaque markers are usually used, and 20 markers are swallowed with the test meal at breakfast. After a certain interval (for example, 24 hours, 48 hours and 72 hours after taking the marker), abdominal films were taken and the excretion rate was calculated. In general, most of the markers have been excreted 48-72 hours after taking them. According to the distribution of markers on abdominal film, it is helpful to evaluate whether constipation is slow transmission type or outlet obstruction type, which is a simple and feasible method.
2. Anorectal manometry: Perfusion manometry (the same as esophageal manometry) is often used to measure the resting pressure of anal sphincter, the systolic pressure of external anal sphincter and the relaxation pressure during forced drainage, whether anorectal inhibitory reflex occurs after gas injection in rectum, and also to measure rectal sensory function and compliance of rectal wall. It is helpful to evaluate whether anal sphincter and rectum have dyskinesia and sensory dysfunction.
3. Colon pressure monitoring: put the sensor in the colon and continuously monitor the change of colon pressure for 24-48h under relative physiological conditions. It is of guiding significance to determine whether there is colonic weakness and its treatment.
4. BalloonePulse Testbet: Put an air bag in the rectum, inflate it or fill it with water, and let the subjects eject it. It can be used as a screening test for the presence or absence of excretory disorders, and those who are positive need further examination.
5.bariumdefecographyBD: The simulated feces were poured into rectum, and the functional changes of anus and rectum during defecation were dynamically observed under radiation, so as to know whether the patient had accompanied anatomical abnormalities, such as proctoptosis and intussusception.
6. Others: For example, pelvic floor electromyography can help determine whether the lesion is myogenic. The measurement of pudendal nerve latency can show whether there is abnormal nerve conduction. Anal endoscopic ultrasonography can know whether the anal sphincter is defective.
(3) Diagnosis of chronic constipation
The diagnosis of chronic constipation should include: the etiology (and inducement), degree and type of constipation. If we can understand the scope of constipation (colon, anorectum or upper digestive tract), the involved tissues (myopathy or neuropathy), whether there are local structural abnormalities and their causal relationship with constipation. This is very useful for making treatment plan and predicting curative effect. The severity and types of chronic constipation are described below.
Severity of chronic constipation: constipation can be divided into three levels: mild, moderate and severe. Mild refers to mild symptoms, which do not affect life, and can be improved after general treatment, without medication or less medication. Severe refers to the persistent constipation symptoms, the patient is extremely painful, seriously affecting his life, unable to stop taking drugs or the treatment is ineffective. Moderation is due to the difference between the two. The so-called intractable constipation is often severe constipation, which can be seen in outlet obstructive constipation, colonic weakness, irritable bowel syndrome (IBS) with severe constipation.
Types of chronic constipation: slow transmission type, outlet obstruction type and mixed type. The constipation type of IBS is a kind of constipation related to abdominal pain or bloating, and may also have the following characteristics.
1, slow transit constipation (STC) has the following manifestations:
(1), frequent defecation frequency is reduced, defecation is hard, and defecation is difficult. (2) There is no stool or hard stool during anorectal digital examination, but the external anal sphincter has normal anal contraction and force discharge function.
(3) The passage time of the whole gastrointestinal tract or colon is prolonged.
(4) Lack of evidence of outlet obstructive constipation, such as normal air bag exhaust test and normal anorectal manometry.
2. Outlet obstructive constipation (OOC) may have the following manifestations:
(1), strenuous defecation, feeling exhausted or falling, less defecation, or poor defecation.
(2) There is a large amount of mud-like feces in the rectum during anorectal finger diagnosis, and the external anal sphincter shrinks violently when forced out.
(3) The transit time of the whole gastrointestinal tract or colon is normal, and most of the markers can remain in the rectum.
(4) Anorectal manometry showed contradictory contraction of external anal sphincter or abnormal sensory threshold of rectal wall.
3. Mixed constipation: it has the characteristics of 1 and more than 2.
The above three categories are applicable to functional constipation and chronic constipation caused by other reasons. For example, diabetes, scleroderma and constipation caused by drugs are mostly slow transit constipation. Constipated irritable bowel syndrome is characterized by fewer defecation times, frequent and difficult defecation, reduced abdominal pain or abdominal distension after defecation and exhaust, and may have outlet dysfunction complicated with slow constipation. If it can be combined with relevant functional examination, its clinical type can be further confirmed.
(4) Treatment of chronic constipation
The principle of treatment is comprehensive treatment according to the severity, etiology and type of constipation, so as to restore normal defecation habits and defecation physiology.
1, general treatment: strengthen defecation physiology education and establish reasonable eating habits (such as increasing dietary fiber)
Vitamin content, increase drinking water) and adhere to good defecation habits, and at the same time should increase the amount of activity.
2, drug treatment: choose the right laxative. The selection of drugs should be based on the principle of low toxicity, low side effects and low drug dependence, such as fillers (such as wheat bran and plantain seeds). ) and osmotic laxatives (such as hibiscus and lactulose). Randomized controlled observation on the treatment of functional constipation with Fusong shows that it is effective in increasing defecation times and improving fecal characteristics. For slow transit constipation, an accelerant such as cisapride or mosapride can also be added. It should be noted that for patients with chronic constipation, long-term application or abuse of irritating laxatives should be avoided. Many kinds of Chinese patent medicines have the function of relaxing bowels, but long-term use of Chinese patent medicines to treat chronic constipation needs to pay attention to ingredients and side effects. For patients with fecal impaction, clean enema once or combined with short-term use of irritating laxatives to relieve impaction. After lifting, choose swelling agent or osmotic agent to keep defecation unobstructed. Kaisailu and glycerin suppository can soften feces and stimulate defecation. Compound carrageenan acid can effectively treat hemorrhoids constipation.
3. Psychotherapy and biofeedback: Patients with moderate and severe constipation often have psychological factors or obstacles such as anxiety and even depression, and should be given cognitive therapy to eliminate their nervousness. Biofeedback therapy is suitable for functional outlet obstructive constipation.
4. Surgical treatment: If the effect is still not significant after strict non-surgical treatment, and various special examinations show that the pathological anatomy is clear and the function is abnormal, surgical treatment can be considered. Surgical indications include secondary megacolon, partial colon redundancy, colonic weakness, severe rectocele, rectal intussusception, rectal mucosal prolapse and so on. However, we should pay attention to whether there are serious psychological disorders, whether there are digestive tract abnormalities outside the colon, and we need to predict the curative effect before operation.
Third, the international diagnostic criteria and diagnosis and treatment process of chronic constipation
1999.9 On the basis of RomeI, the International Cooperation Committee for RomeII has formulated a series of diagnostic criteria for RomeII functional gastrointestinal diseases (gut1999,45: Supplii). Although the understanding of constipation in different countries is not consistent at present, it is still based on RomeII diagnostic criteria and combined with the actual situation in various countries to formulate its own diagnosis and treatment process. The following introduces the diagnostic criteria of RomeII chronic constipation, functional constipation, pelvic floor defecation disorder and IBS constipation, and introduces the main points of the latest American constipation treatment guide based on RomeII criteria.
(a), Rome Ⅱ constipation diagnostic criteria:
Chronic constipation: Rome II's diagnostic criteria for chronic constipation are: in the past 12 months, two or more symptoms occurred continuously or intermittently for at least 12 weeks:
(1) > 65,438+0/4 of the time, having difficulty defecating, (2) >; 14 of the time, the feces are fast or hard, (3) >; During 65,438+0/4 of the time, they felt uneasy about defecation, (4) they had anal obstruction or rectal obstruction during defecation for more than 65,438+0/4 of the time, (5) >14 of the time, and defecation needed manual assistance, (6) > 14 of the time with weekly defecation.
Functional constipation: According to Rome II diagnostic criteria, functional constipation not only meets the above diagnostic criteria, but also excludes constipation caused by intestinal or systemic organic reasons and drug factors.
Pelvic floor defecation disorder: Roman II diagnostic criteria for pelvic floor defecation disorder refer to the following points besides the above-mentioned Roman II diagnostic criteria for functional constipation, namely:
(1), there must be evidence of anorectal manometry, electromyography or X-ray examination, indicating that the pelvic floor muscles contract abnormally or cannot relax during repeated defecation; (2) The rectum can push and contract enough when defecating; And (3) there is evidence of poor fecal excretion.
Constipated irritable bowel syndrome (IBS): IBS is a functional bowel disease characterized by abdominal discomfort or pain, changes in defecation habits and abnormal defecation. X-ray barium enema or colonoscopy showed no pathological changes and no evidence of systemic diseases. Constipated IBS refers to the basic point that meets the IBS standard first, that is, at least 12 weeks (not necessarily continuous) abdominal pain or abdominal discomfort in the past 12 months, accompanied by two of the following three items:
(1), the above symptoms disappear after defecation, (2), the above symptoms appear with the change of defecation times, or
(3), accompanied by changes in stool characteristics. There are the following performance supports, that is, there are at least three items of 1: (1), the frequency of defecation is less than 3 times/week, (2) the stool character is lumpy or indurated, and (3) the defecation is laborious and incomplete.
At the same time do not have
(1), defecation frequency is more than 3 times per day, (2), defecation is sparse, (3), defecation is urgent; Or must meet at least two of these three items, and at the same time have
(1), defecation time is more than 3 times/day, (2), loose stool.
(3) One of the urgency of defecation.
(2) Key points of the diagnosis and treatment process of chronic constipation in the United States:
The key point of the process of chronic constipation put forward by the United States is to put forward experimental treatment for the first time on the basis of medical history and physical examination, combined with relevant laboratory examinations. The patients with intractable constipation were examined by barium excretion radiography and related dynamic function, and the corresponding treatment was carried out according to the type of constipation. According to different constipation types, the process is divided into diagnosis steps and corresponding treatment steps. According to the preliminary evaluation results, the diagnosis of constipation is divided into six situations, namely
(1), IBS constipation, (2), slow transit constipation, (3), rectal outlet obstruction, (4), coexistence of the above (2) and (3), (5), functional constipation (functional obstruction or drug side effects), (6), constipation secondary to systemic diseases.
Fourth, the process and principle of constipation in China.
Constipation is divided into degree, type, cause and inducement. Therefore, constipation patients need graded and stratified treatment. This diagnosis and treatment process is conducive to active and effective diagnosis and treatment of patients, and produces a reasonable cost-benefit ratio.
(A), diagnosis and treatment process
Clinically, in order to effectively classify (alarm or not) and classify (degree) constipation patients, it is necessary to evaluate the etiology, inducement, type and degree of constipation. For most patients, through detailed medical history and physical examination, we can understand the causes and types of constipation and carry out empirical treatment; When there is a sign or suspicion of constipation caused by organic diseases, further examination should be made to exclude or confirm the existence of organic diseases, especially colon tumors; For constipation patients who are determined to be organic diseases, in addition to etiological treatment, it is necessary to judge the type of constipation according to the characteristics of constipation and carry out corresponding treatment; For cases of organic constipation that have no experience in treatment or examination, further examination can determine the type of constipation and then carry out corresponding treatment; For a few patients with intractable constipation, we should check the relevant constipation types at the beginning, even in more detail, to determine the treatment plan.
(2) Principles of diagnosis and treatment
The principles of diagnosis and treatment of constipation in China include:
1, a detailed understanding of medical history and physical examination is an important basis for choosing constipation process. For most patients with constipation, non-invasive methods should be used as far as possible to judge the type of constipation, and clinical inference should be verified according to the therapeutic effect of experience.
2. Constipation type is an important basis for choosing treatment methods. Whether it is empirical treatment or treatment after further examination, it is emphasized to give corresponding treatment countermeasures for different types of constipation.
3. It is suggested that attention should be paid to the cause investigation of constipation patients with warning signs, and to the determination of constipation types for patients with intractable constipation who lack warning signs.
4. Proportion of accepting various examination methods: for most constipation, empirical treatment is the main method, for intractable constipation, further examination is needed, and a few patients, especially those who need surgery, need further examination.
5. Several routes in the process may cross each other. For example, if the curative effect of empirical treatment is not good, further examination is needed to understand the cause and type, but when no organic lesions are found in the preliminary examination, the constipation type can be determined by understanding the characteristics of constipation, or the constipation type can be treated after further examination.
(3), the basis of empirical treatment
The common manifestations of chronic constipation are as follows:
1, less defecation, less defecation: this constipation can be seen in slow-moving constipation and outlet obstructive constipation. The former is due to the slow passage, so that the number of defecation and the amount of defecation are less, but defecation can still be carried out at regular intervals, and the feces are often dry and hard, and forced defecation is helpful for fecal discharge. The latter is often the feeling threshold increases, which is not easy to cause defecation, so the stool is less and the stool is not necessarily dry and hard. For this kind of patients, swelling agent or penetrant can be used to increase the water content of feces, increase the softness and volume, stimulate colon peristalsis, and also increase the stimulation to rectal mucosa. At the same time, you should defecate regularly.
2, difficulty in defecation, laborious: the outstanding performance is that fecal discharge is extremely difficult, which can also be seen in two situations, especially outlet obstructive constipation. When the patient is forced to drain, the external anal sphincter contracts ambitiously, making defecation difficult. This type of toilet is not necessarily few, but it is time-consuming and laborious. If accompanied by abdominal muscle weakness, defecation is more difficult. In the second case, due to the slow passage, excessive moisture in the feces is absorbed, and the feces are dry and hard, especially if you don't defecate for a long time, it is extremely difficult to discharge the hard feces, and fecal impaction may occur. This kind of constipation can also be treated with swelling agent or osmotic agent, which makes the feces soft and easy to be discharged, and sometimes it needs enema treatment. If the stool is still difficult to be discharged after softening, it is suggested that it is outlet obstructive constipation. Such patients need the guidance of defecation mode and biofeedback treatment if necessary.
3, poor defecation: anorectal often has a sense of obstruction, poor defecation. Although defecation is frequent, but the number of times is more, even if it is laborious, it will not help, and it is difficult to defecate smoothly. It may be accompanied by anorectal irritation symptoms, such as falling and discomfort. Such patients often have lower sensory threshold and high rectal sensitivity, or are accompanied by rectal anatomical abnormalities, such as rectal intussusception and internal hemorrhoids. The threshold of rectal sensation is increased in some cases, and similar symptoms appear, which may be related to the local anatomical changes of anus and rectum. The treatment of these patients needs to raise the sensory threshold, reduce the frequency of defecation, and treat local anorectal diseases, such as hemorrhoids and constipation.
4, constipation with abdominal pain or abdominal discomfort: common in IBS constipation, symptoms are relieved after frequent defecation.
The above-mentioned types of constipation are not only seen in functional constipation, but also in IBS constipation (there may be the above-mentioned types of manifestations). At the same time, chronic constipation caused by organic diseases such as diabetes and constipation caused by drugs can have the above types of manifestations. Pay attention to analysis. In addition, there are often combinations of the above situations.
(3) related etiological examination
Imaging or endoscopic examination, if necessary, combined with pathological examination to determine whether there are intestinal organic diseases, such as suspected diabetes, endocrine diseases, connective tissue diseases, nervous system diseases, etc., and corresponding biochemical and immune examinations should be done.
(4) Common methods to determine the type of constipation: The common inspection methods to determine the type of constipation are gastrointestinal passing test and anorectal manometry, and it is suggested that anorectal digital examination is helpful for diagnosis.
1. Gastrointestinal passing test: It is recommended to take 20 radiopaque markers after stopping using related drugs for at least 48h (most of the markers have reached the rectum or been discharged normally). The purpose of patting for 48 hours 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 reached this area, it is suggested to pass normally or delay, for example, take it again 72 hours. If most of the tags have been taken, it is possible to observe the distribution of tags at this time. Gastrointestinal passing test is a simple and feasible method, which can be popularized and applied. If it is extended to 5-6 days, the accuracy may be improved, but the feasibility is poor, because it is difficult for most patients to insist on using laxatives themselves. The sensitivity of the test is reduced, especially it is difficult to judge the type of constipation unless it is a series of photos.
2. Anorectal manometry: it can provide whether there is an anorectal local mechanism that causes constipation, such as contradictory contraction of external anal sphincter during forced drainage, suggesting outlet obstructive constipation; If anorectal inhibitory reflex disappears after air injection into rectal balloon, it indicates Hirschsprung's disease. As well as the feeling of defecation after balloon inflation and the maximum tolerance of rectal wall mucosa, can provide whether the defecation threshold of rectal wall is normal.
3. Anorectal digital examination: It should be emphasized here that anorectal digital examination is not only an important method to check whether there is rectal cancer, but also a common and simple method to judge whether there is outlet obstructive constipation. In particular, the tension of sphincter is enhanced, and the sphincter cannot be relaxed when forced to discharge, but it is more tense, suggesting that long-term severe defecation leads to sphincter hypertrophy, and at the same time it is in a state of contradictory contraction when forced to discharge.
(5) Examination of the particularity of intractable constipation: For example, severe chronic constipation that does not respond to various treatments often indicates colon weakness, and for example, the lack of special propulsive contraction wave (SPPW) for 24-hour colon pressure monitoring indicates the need for surgical treatment. Defecography can dynamically observe the anatomical and functional changes of anus and rectum. Anal manometry combined with endoscopic ultrasonography showed that anal sphincter was mechanically absent and anatomically weak. The army provides important clues for anorectal surgery. A small number of constipation need to distinguish whether the lesion is myogenic or neurogenic, and it is necessary to check the perineal nerve latency or electromyography. Patients with obvious symptoms of anxiety and depression should be investigated.
Inquire more constipation information