Among people with a secret history of defecation, functional constipation accounts for about 50%. 2. Functional Etiology The etiology of functional constipation is unclear, and its occurrence is related to many factors, including: (1) lack of food intake or lack of cellulose or water in food, which has little stimulation to colon movement. (2) Normal defecation habits are disturbed by intense work, too fast pace of life, changes in the nature and time of work, and mental factors. (3) Colonic dyskinesia, which is common in irritable bowel syndrome, is caused by spasm of colon and sigmoid colon. In addition to constipation, abdominal pain or bloating also occurs, and some patients may show constipation and diarrhea alternately. (4) The tension of abdominal muscles and pelvic floor muscles is insufficient, the driving force of defecation is insufficient, and fecal excretion is difficult. (5) Abuse of laxatives leads to drug dependence and constipation. (6) The elderly are weak, have too little activity, have difficulty defecating due to intestinal spasm, or have a long colon. Constipation is mainly divided into two types according to the pathogenesis: slow transit constipation and outlet obstructive constipation. Slow transit constipation is caused by the weakening of intestinal contraction, which slows down the movement of feces from cecum to rectum, or the uncoordinated movement of left colon. It is most common in young women and occurs around puberty. It shows that the frequency of defecation is reduced (the frequency of defecation per week is less than 1 time), the frequency of defecation is less, the feces are hard and it is difficult to defecate. There is no stool or hard stool during anorectal digital examination, but the external anal sphincter has normal anal contraction and forced defecation function; The total gastrointestinal or colonic transit time is prolonged; Lack of evidence of outlet obstruction, such as balloon exhaust test and normal anorectal manometry. Non-surgical treatments such as increasing dietary fiber intake and osmotic laxatives are ineffective. Diabetes, scleroderma complicated with constipation and constipation caused by drugs are mostly slow transmission type. Outlet obstructive constipation is due to the muscle disharmony of abdomen, anorectum and pelvic floor, which leads to the obstacle of fecal discharge. It is especially common in elderly patients, and many patients are ineffective in routine medical treatment. The outlet obstruction type can have the following manifestations: strenuous defecation, endless feeling or falling feeling, less defecation, defecation or insufficient defecation; There is a large amount of muddy feces in the rectum during anorectal examination, and the external anal sphincter may contract violently when defecating forcibly; The total gastrointestinal or colon transit time is normal, and most markers can remain in the rectum; Anorectal manometry showed that the external sphincter of anus contracted sharply or the sensory threshold of rectal wall was abnormal during forced defecation. Many patients with outlet obstructive constipation also have slow transit constipation. [1] With the change of people's diet structure and the influence of psychosocial factors, the incidence of constipation tends to increase. The prevalence of constipation in the population is as high as 27%, but only a small number of constipation patients will see a doctor. Constipation affects people of all ages. There are more women than men, and older people are more than young people and prime of life. Because of the high incidence of constipation and complicated etiology, patients often have a lot of distress, which will affect the quality of life in severe cases. Symptoms of constipation are often manifested as: less defecation times and less defecation volume; Defecation is difficult and laborious; Poor defecation; Dry stool, hard stool and unclean stool; Constipation with abdominal pain or discomfort. Some patients are also accompanied by mental and psychological disorders such as insomnia, irritability, dreaminess, depression and anxiety. The "alarm" signs of constipation include bloody stool, anemia, emaciation, fever, black stool, abdominal pain and family history of tumor. If there are signs of alarm, you should go to the hospital immediately for further examination. Harm of diseases Because constipation is a common symptom with different severity, most people tend to ignore it and think that constipation is not a disease and does not need treatment, but in fact it is very harmful. 1. Constipation plays an important role in the occurrence of some diseases, such as colon cancer, hepatic encephalopathy, breast diseases and Alzheimer's disease. There are many research reports in this field. 2. Constipation can lead to life accidents of patients with acute myocardial infarction and cerebrovascular accident, and there are many painful cases to warn us. 3. 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 caused by constipation, improve the quality of life and reduce the burden on society and families. Diagnosis and Differentiation Not every constipation patient needs a clinical examination. The inspection should be carried out in a targeted manner, not that the more inspections, the better. Too many unnecessary examinations for constipation patients will increase the burden on patients. We oppose the aimless "net-casting" examination of patients. Auxiliary examination In the diagnosis and differential diagnosis of constipation, necessary examinations should be carried out according to clinical needs. First of all, we should pay attention to whether there are alarm symptoms and evidence of other organic lesions in the whole body; Those over 50 years old who have a long-term history of secret defecation and have aggravated symptoms in a short period of time should undergo colonoscopy to rule out the possibility of colorectal tumors; For those who abuse laxatives for a long time, colonoscopy can determine whether there is laxative colon or (and) colon melanosis; Barium enema is helpful for the diagnosis of Hirschsprung's disease. If OOC is suspected, digital anal examination and defecography are necessary. Special examination methods include gastrointestinal transit test (GITT), anorectal abnormality test (RM), anorectal reflex test, tolerance sensitivity test, balloon ejection test (BET), pelvic floor electromyography, pudendal nerve latency test and anal ultrasound examination. These tests are only for intractable constipation. The commonly used examination methods for intractable constipation are as follows: 1. Routine stool examination and occult blood examination should be routine examination. 2. Biochemical and metabolic tests. If clinical manifestations suggest that symptoms are caused by inflammation, tumor or other systemic diseases, hemoglobin, erythrocyte sedimentation rate and related biochemical tests (such as thyroid function, blood calcium, blood sugar and other related tests) should be carried out. 3. Anorectal finger examination can tell whether there is a lump and the function of anal sphincter. 4. colonoscopy or barium enema is helpful to determine whether there is an organic cause. Especially when there are recent changes in stool habits, bloody stool or other warning symptoms (such as weight loss and fever), it is recommended to do a whole colon examination to determine whether there are organic diseases such as colon cancer, inflammatory bowel disease and colon stenosis. 5.GITT is very helpful to judge whether there is slow transmission, and often shoots at 48h and 72h. 6. defecography can dynamically observe the anatomical and functional changes of anus and rectum. Defecography can evaluate the speed and completeness of rectal emptying, the right angle of anus and the descending degree of perineum. In addition, defecography can find organic lesions such as huge rectocele, rectal mucosal prolapse or intussusception. 7. Anorectal manometry can check whether anorectal function is accessible. 8.24-hour monitoring of colon pressure has certain guiding significance for operation or not. If there is no specific propulsive contraction wave (SPPW) and the colon does not respond to eating after waking up, it means that the colon is weak, and surgical resection can be considered. 9. Anal manometry combined with endoscopic ultrasonography can show the weakness and anatomical defects of anal sphincter and provide clues for surgery. 10. Using perineal nerve latency or electromyography, constipation can be distinguished from myogenic or neurogenic. 1 1. Other patients with obvious symptoms of anxiety and depression should be investigated to determine the causal relationship with constipation. Disease treatment Constipation patients need to take comprehensive treatment according to the severity, etiology and types of constipation, including general life therapy, drug therapy, biofeedback training and surgical treatment, so as to restore normal defecation physiology. Pay attention to life therapy, strengthen the education of patients, adopt reasonable eating habits, such as increasing dietary fiber content and drinking water to stimulate the colon, develop good defecation habits, such as defecation in the morning, defecation in time when you feel comfortable, avoid forced defecation and increase activity. Attention should be paid to removing excessive feces from the distal rectum during treatment; It is extremely important to actively adjust the mentality for effective treatment. Life therapy 1. Analyze the causes of constipation and adjust lifestyle. Develop the habit of regular defecation; Quit smoking and drinking; Avoid drug abuse. You need to defecate in time when defecating, so as not to inhibit defecation. Repeated suppression of defecation for a long time can lead to the increase of defecation reflex threshold, the disappearance of defecation and constipation. 2. Advocate a balanced diet, increase dietary fiber and drink plenty of water. (1) High-fiber diet: Dietary fiber itself is not absorbed, but it can absorb water in the intestinal cavity, thus increasing fecal volume, stimulating colon and enhancing motivation. Foods rich in dietary fiber include wheat bran or brown rice, vegetables and fruits rich in pectin, such as mango and banana (note: immature fruits containing tannic acid will aggravate constipation). ? (2) Replenish water: drink plenty of water. It is suggested to drink more than 65,438+500 ml every day to keep enough water in the intestine, which is beneficial to the excretion of feces. (3) Adequate supply of B vitamins and folic acid: The use of foods rich in B vitamins can promote the secretion of digestive juice, maintain and promote intestinal peristalsis, and facilitate defecation. Such as coarse grains, yeast, beans and their products. Among vegetables, spinach and cabbage contain a lot of folic acid, which has a good laxative effect. (4) Increase gas-producing food: eat more gas-producing food to accelerate intestinal peristalsis and facilitate defecation; Such as onions, radishes and garlic sprouts. ? (5) Increase the supply of fat: appropriately increase high-fat foods, vegetable oil can directly moisten intestines, and decomposed fatty acids can stimulate intestinal peristalsis. Seeds of dried fruits (such as walnuts, pine nuts, various melon seeds, almonds, peach kernels, etc.). ) contains a lot of oil, which has the effect of moistening the intestines and relaxing the bowels. 3. Appropriate exercise is mainly medical gymnastics, which can be combined with walking, jogging and abdominal self-massage. (1) medical gymnastics: mainly to strengthen abdominal muscles and pelvic muscles. Practice method: Standing posture can do walking with legs lifted in place, squatting and standing up, abdominal back movement, kicking movement and turning movement. When lying on your back, you can lift one leg or both legs in turn at the same time, up to 40, and then put it down after a pause. Legs bend and stretch in turn, imitating riding. Lift your legs, draw circles from the inside out, and sit-ups. (2) brisk walking and jogging: it can promote intestinal peristalsis and help relieve constipation. (3) Deep and long abdominal breathing: When breathing, the diaphragm moves more than usual, which can promote gastrointestinal peristalsis. (4) Abdominal self-massage: Lie on your back in bed, bend your knees, rub your hands hot, put your left hand flat on your navel, put your right hand on the back of your left hand, and press clockwise with your navel as the center. Do it 2 ~ 3 times a day for 5 ~ 10 minutes each time. Drug therapy should be used under the guidance of a doctor. (1) laxatives ① volume laxatives: mainly include soluble cellulose (pectin, plantain, oat bran, etc. ) and insoluble fiber (plant fiber, lignin, etc. ). Volumetric laxatives have a good effect on pregnancy constipation or mild constipation because of their slow onset, small side effects and safety, but they are not suitable for the rapid laxative treatment of temporary constipation. (2) Lubricating laxatives can lubricate the intestinal wall, soften the stool, and make the stool easy to be discharged and easy to use, such as kaisai dew, mineral oil or liquid paraffin. Salt laxatives such as magnesium sulfate and magnesium emulsion can cause serious adverse reactions and should be used with caution in clinic. ④ The commonly used drugs for osmotic laxatives are lactulose, sorbitol and polyethylene glycol 4000. It is suitable for fecal impaction or temporary treatment of chronic constipation, and is a better choice for constipation patients with poor curative effect of volumetric laxatives. Irritating laxatives: including anthraquinone-containing plant laxatives (rhubarb, rhamnose, senna, aloe), phenolphthalein, castor oil, diester, etc. Stimulating laxatives should only be used when volumetric laxatives and salt laxatives are ineffective, and some of them have strong medicinal properties and are not suitable for long-term use. Long-term use of anthraquinone laxatives can cause colon depression or laxative colon, cause smooth muscle atrophy and nerve plexus injury between intestinal muscles, but aggravate constipation, which can be reversed after stopping taking drugs. (2) Motivating agents: Mosapride and Itopride can promote gastrointestinal peristalsis, and Cabily can selectively act on colon, which can be selected according to the situation. Other processing 1. If the stool is hard and stagnant in the rectum near the anus, or the patient is old and weak, and the defecation motivation is poor or lacking, the instrument can be used to assist colon hydrotherapy or clean enema. 2. Biofeedback therapy can be used for constipation patients with anorectal and pelvic floor muscle dysfunction, and its long-term effect is good. Biofeedback therapy uses special equipment to collect information about one's own physiological activities, which is processed and amplified and displayed with familiar visual or auditory signals, so that the cerebral cortex can establish feedback relations with these organs. Through continuous positive and negative attempts, they can learn to control physiological activities at will, correct physiological activities that deviate from the normal range, and enable patients to achieve the purpose of "changing themselves." Biofeedback therapy can train patients to relax pelvic floor muscles during defecation and coordinate the activities of abdominal muscles and pelvic floor muscles during defecation. For patients with abnormal defecation threshold, we should pay attention to the reconstruction of defecation reflex and adjust the training of defecation perception. The training plan has no specific norms, and the training intensity is high, but it is safe and effective. For patients with pelvic floor dysfunction, biofeedback therapy should take precedence over surgical treatment. 3. Cognitive therapy Patients with severe constipation often have psychological factors or obstacles such as anxiety and even depression. Cognitive therapy should be given to help patients eliminate their nervousness, antidepressant and anxiolytic treatment should be given when necessary, and psychologists should be invited to assist in diagnosis and treatment. 4. Surgical treatment is ineffective for severe intractable constipation. If constipation is accompanied by colon transmission dysfunction and the condition is serious, surgery can be considered, but the long-term effect of surgery is still controversial, so the case selection must be cautious. In the huge disease group of constipation, very few people really need surgery. [2-3] disease prevention 1. Avoid eating too little or food too thin, lack of residue, and reduce the stimulation to colon movement. 2. Avoid disturbing defecation habits: constipation is prone to occur due to mental factors, changes in life patterns, and excessive fatigue during long-distance travel. 3. Avoid abuse of laxatives: abuse of laxatives will weaken the sensitivity of the intestine, form dependence on some laxatives, and cause constipation. 4. Arrange life and work reasonably, so as to combine work and rest. Appropriate cultural and sports activities, especially abdominal muscle exercise, are conducive to the improvement of gastrointestinal function, which is more important for sedentary and highly focused mental workers. 5. Develop good defecation habits, defecate regularly every day, form conditioned reflex, and establish good defecation rules. Don't ignore when defecating, defecate in time. The environment and posture of defecation should be as convenient as possible, so as not to inhibit defecation and destroy defecation habits. 6. It is suggested that patients drink at least 6 cups of 250ml water every day, exercise moderately, and develop the habit of defecation regularly (twice a day, each time 15 minutes). After waking up and eating, the action potential activity of the colon is enhanced, pushing the feces to the distal end of the colon, so morning and after eating are the easiest time to defecate. 7. Timely treatment of anal fissure, perianal infection, adnexitis and other diseases, laxatives should be used with caution, and strong stimulation methods such as intestinal lavage should not be used. Pay attention to bad eating habits or excessive partial eclipse, correct bad habits and adjust diet content, increase vegetables and fruits with more cellulose, and appropriately intake coarse and dull miscellaneous grains such as standard flour, potatoes, corn and barley. Oily food, cold boiled water and honey are all helpful to prevent constipation, and drink more water and drinks. Eat more foods rich in B vitamins and moistening intestines, such as coarse grains, beans, tremella, honey and so on. , and properly increase the cooking oil during cooking. Avoid alcohol, strong tea, peppers, coffee and other foods. It is very necessary to ask patients about their diet in detail for disease care, because a considerable number of patients' constipation is caused by insufficient dietary fiber intake. It is a rough method to calculate the intake of dietary fiber by recording the amount of grain, whole wheat bread, rice, pasta, vegetables and fruits eaten by patients. For patients who only consume a small amount of dietary fiber every day, the cause of constipation is obvious. Patients were asked to gradually increase their dietary fiber intake to 25g per day. At first, the patient will feel abdominal distension, but generally it will gradually improve. Give patients a recipe rich in fiber food and encourage them to eat the food on the recipe. If patients can't get enough dietary fiber from regular diet, they can supplement fiber preparation. Commonly used fiber preparations include plantain, methylcellulose and polycarbophil. [4] Expert opinion The treatment of constipation lies in establishing reasonable diet and living habits. Develop the habit of regular defecation, drink cold water in the morning to promote defecation and avoid inhibiting defecation; Usually eat more foods containing more cellulose, drink more water, avoid sedentary, and do more relaxation exercises; Adjust your mood and mental state. Check whether there are alarm symptoms. It is necessary for some patients with chronic constipation to receive short-term drug adjuvant therapy, which is helpful to the reconstruction of normal defecation reflex.