Diagnosis and treatment of chronic constipation

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Treatment of constipationConstipation (constipation) refers to a variety of causes of defecation difficulties, reduce the number of defecati

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Treatment of constipation

Constipation (constipation) refers to a variety of causes of defecation difficulties, reduce the number of defecation, or defecation, can be divided into functional constipation and secondary constipation two categories. The occurrence of functional constipation may be related to many factors, such as less cellulose content in the diet, inadequate intake of liquid, genetic susceptibility, gastrointestinal motility, gastrointestinal hormones, environmental impact, psychological and other factors. According to the dynamic anomaly can be divided into slow transit constipation (slow transit, constipation, STC), obstructive constipation (out-let obstruction constipation, OOC) mixed constipation and both exist at the same time (MC) and several other types of [3. The present data show the definition of the so-called functional constipation is not accurate, such as the colon wall of patients with constipation often have muscle fibers and myenteric plexus degeneration, OOC syndrome or with Spastic Pelvic Floor Syndrome and other organic diseases comprehensive pelvic floor relaxation. Constipation is the most common clinical symptoms, the incidence of 2%~28% in western countries constipation, China's Beijing, Tianjin, Xi'an area people over the age of 60 survey showed that chronic constipation incidence is as high as 15%~20%, women are men more than 4 times 4. Statistics of age revealed that the first peak of 30-39, suggesting that the onset age younger, if the complaint difficult defecation as evaluation criteria of constipation, the incidence rate of more than 50%.

Further description of the diagnosis

1 of the patients in the diagnosis strategy of difficult defecation, defecation, reduce or defecation imcompletely as chief complaints. Normal time will be 1~2 times a day. Constipation occurs, often less than 3 times a week defecation, severe defecation 2~4 weeks, 1 times. Some patients defecation can be many times, but each time the defecation time up to 30min or more, such as a small number of sheep manure induration. Defecation need to force, sometimes need to help. Often accompanied by poor defecation, defecation, no sense of emptiness, or there will be no feces discharge. There were no positive findings in functional constipation. The diagnosis of constipation is mainly based on the difficulty of defecation, reduce the number of defecation, defecation or other symptoms. History is very important, should pay attention to the interrogation of feces traits, when necessary, stool shape description, in order to determine the extent of constipation or for contrast therapy. Pay attention to ask if there is bad eating habits and laxative abuse history. Some of the more specific features such as prolonged defecation, repeated exertion, rectal fullness, defecation, hand assisted defecation (i.e. with a finger into the anus or vagina or push lower sacral and perianal department to help defecation) often prompt pelvic outlet diseases. Diagnosis should be excluded from the gut itself or the whole body of organic disease. In the past, the clinical diagnosis of functional constipation has been proposed international gastrointestinal tissue Rome II standard, May 2006 in the United States at the Digestive Disease Week conference, launched a functional gastrointestinal disease diagnosis standard - New Rome III standards 5, compared with Rome II, the time required from the symptoms of the past 12 months a total of at least 12 weeks (not necessarily contiguous) "to" before the diagnosis of symptoms for at least 6 months, nearly 3 months to meet the standard of [10]. According to the Rome III standard, the diagnosis of functional constipation is as follows

The standard of functional constipation diagnosis "must meet the following 2 or more

Defecation force

The feces into pieces or induration

Anorectal obstruction during defecation

The defecation is not feeling

The hand.

The weekly defecation less than 3 times.

(these symptoms occur at least 1 times in each of the 4 bowel movements)

We have almost no loose bowels laxative

The diagnosis of IBS condition is not sufficient;

"Before the diagnosis of symptoms for at least 6 months, nearly 3 months to meet the above criteria.

Type of functional constipation of slow transit type: 1 (STC): also known as emptying or atony of colon, duodenal contents from proximal colon to the distal colon and rectum velocity lower than normal, and abnormal intestinal motility related. Manometric studies showed colonic contraction frequency and promote peristalsis was reduced, and the myenteric plexus and abnormal intestinal neurotransmitters change, its mechanism mainly include: to promote intestinal contents to the distal movement of the colon high amplitude contraction may promote the decrease in the number, activity of intestine and blood vessel peptide (VIP) receptor decreased somatostatin (SS), and 5-HT, increasing the content of motilin and calcitonin gene related peptide (CGRP), substance P (SP), nitric oxide (NO) and gastrointestinal hormone abnormalities. The main clinical manifestations were lack of stool or fecal material hardness, the whole gastrointestinal or colon transit time delay or colonic motility. 2 outlet obstruction type (OOC): also known as pelvic floor dysfunction, refers to the accumulation of feces in the rectum can not be successfully discharged from the anus, common in the elderly and women. OOC is a group of multiple sexual dysfunction, rectal sensory dysfunction, anorectal reflex, defecation, anal sphincter contraction between pelvic floor dynamic disorder to anal pressure exceeds the pressure of rectum is the basic pathogenesis of outlet obstruction constipation. The clinical manifestations of endless defecation, defecation or defecation less, often accompanied by anal tenesmus. Anal sphincter dysfunction, pelvic floor muscle disorders. 3 mixed type: slow transit and functional outlet obstruction.

2 endoscopic examination of the colon and rectal mucosa can be observed, excluding organic lesions. Some patients with visible colonic mucosa showed diffuse dark brown spots, known as melanosis coli syndrome, intestinal mucosa and lipofuscin pigmentation, the long-term use of laxatives. Excessive accumulation of feces can cause rectal mucosal spasm.

3 on X-ray imaging abdominal X-ray plain film can show intestinal cavity expansion, fecal retention and gas-liquid plane. Barium enema can be found in the giant rectum and colon. CT or MRI is mainly used to detect the presence of intestinal masses or stenosis.

4 functional examination on the basis of the initial diagnosis of functional constipation. Used the colonic transit time (CTT), defecography (BD) and anorectal manometry (ARM) examination [6,7]. Anorectal function examination is helpful for the analysis of anorectal motility and sensory function in patients with constipation, and provides important information for biofeedback treatment of functional constipation. BD can make a clear diagnosis of functional and organic lesions of the anus and rectum, especially for chronic constipation caused by functional outlet obstruction. ARM is helpful in the diagnosis and evaluation of outlet obstructive constipation, and can also be used as a monitoring method for biofeedback therapy.

5 other fecal occult blood test as a routine examination in patients with constipation, can provide colorectal and anal lesions clues. Rectal examination can determine whether fecal impaction and anal stenosis, prolapse of rectum, rectal tumor and other diseases, and can understand the status of anal sphincter muscle. Pelvic floor electromyography can be used to diagnose pelvic floor muscle dysfunction. Such as pelvic floor spasm syndrome can be found in the simulation of abnormal discharge of the pubic and external sphincter muscles. Balloon forcing test can be placed in the balloon rectal ampulla of the subjects, injecting 37 degrees warm water 50ml. Will subjects take the habit of defecation posture as soon as the balloon discharge, the normal discharge in the 5min, there is no abnormal helps determine the rectum and pelvic floor muscle function.

Functional examination of constipation

The colonic transit time (CTT): Swallow capsules containing radiopaque markers, 24h, 48h, 72h respectively (when necessary) take abdominal plain film discharge rate calculation. Under normal circumstances, the discharge rate of > is 90%; 72h. To determine the location of markers in the colon according to the bony markers in the abdomen. On the right of the spine, fifth lumbar and pelvis markers located in the export line over parts of the colon; on the left spine, fifth lumbar markers and left anterior superior iliac spine above site located in the left colon; the marker line is located in the lower part of the rectum B. Most of the markers in the sigmoid colon above the slow transmission type, located in the straight part of the outlet obstruction type.

- defecography (BD): the photographs were removing and meditation, observe the resting pressure, anal contraction and force change of anorectal angle row, evaluate the puborectalis muscle contraction, relaxation function, to understand the abnormal anatomy of pelvic floor of the rectum. Perineal anus distance decreased when the row is larger than 31mm, Spastic Pelvic Floor Syndrome forced defecation for pelvic floor muscle contraction and relaxation, force row does not increase the anorectal angle and more appear puborectal muscle spasm impressio.

The anorectal manometry (ARM): determination by perfusion or air bag method, determination and anal sphincter function.

Further explanation of treatment

1 on treatment strategies for the regulation of diet, bowel habits, and drug treatment, to avoid the abuse of laxatives, pay attention to individual treatment [13]. Refractory constipation is usually severe constipation, there are serious neuromuscular lesions, drug treatment is difficult. At this time, should pay attention to investigation of the causes, including the understanding of patients with and without diabetes, connective tissue disease caused by underlying disease constipation; clinical analysis of constipation type and degree of colon pressure monitoring to determine whether the presence of colonic inertia or the need for colon resection. In addition, to determine whether chronic constipation patients with pelvic floor disorders such as anorectal lesions and pelvic floor muscle abnormalities, to determine the treatment plan to help.

2 on the diet and life adjustment should encourage patients to drink more water, vegetable juice, fruit juice or honey juice, eat fiber rich foods such as wheat glue, fruits, vegetables, corn, etc., the appropriate increase in activity. Fiberform (Fiberform) for wheat cellulose, because of fiber itself is not absorbed, can make the stool expansion stimulate the colon movement. Bowel habits to adapt to the habit of regular bowel movement to prevent fecal accumulation. Encourage patients after breakfast defecation, such as still can not be discharged in the evening after defecation again, so that patients gradually return to normal bowel habits. In bowel habits training can be combined with drugs to clean the intestines. Regulation of diet, bowel habits can effectively relieve constipation, supplemented by drug catharsis, or application of prokinetic drugs.

3 is to soften the excrement on drug catharsis, promote gastrointestinal motility, stimulate defecation. According to the degree, type and nature of constipation, we should choose the appropriate laxative, we should emphasize the rational use of drugs and individual drugs, the choice of drugs should be to reduce the toxicity, side effects and drug dependence as the principle. Expansive agent (wheat bran, magic, medicine (Yu) permeability lactulose, polyethylene glycol 4000, sorbitol) or saline laxatives (Magnesium Sulfate) can increase the intestinal volume, stimulate bowel to laxative effect, is widely used in clinical. Osmotic laxatives are commonly used lactulose (10~15g, 3 /d) and polyethylene glycol (Forlax, 10g/ times, 1~2 times /d). Side effects are relatively small. A stimulant such as castor oil and senna, phenolphthalein (fruit guide), rhubarb (rhubarb soda tablet), bisacodyl (bisacodyl) has certain side effects, not suitable for long-term use. The rectum in the elderly patients with constipation have large amounts of manure, may be appropriate to use Enema Glycerini or soapy water enema stool softening.

The main clinical evacuant

The volume of laxatives

The main drugs are Magnesium Sulfate, methyl cellulose, agar, pectin, etc.. Because it is not absorbed by the intestinal wall and dissolved in water, in the intestinal absorption of a large amount of water, can play a role in the expansion of intestinal volume, stimulate the intestinal wall. These drugs can be mixed with feces to soften the excrement, promoting defecation. These drugs are cheaper, and less adverse reactions, the majority of patients with constipation can be used. However, patients with colon weakness, slow bowel movement, should not be used.

"Laxative

The main (phenolphthalein phenolphthalein tablets), bisacodyl (bisacodyl), castor oil, rhubarb, senna, Niuhuang Jiedu tablets. Can stimulate the intestinal wall, enhance intestinal peristalsis, thus play a role in relieving constipation. But these drugs can stimulate the intestinal mucosa and intestinal plexus caused by Escherichia gravis, and these drugs most contain anthraquinones, long-term use is easy to form drug dependence and melanosis coli. Therefore, it is mainly used for the treatment of fecal incarceration and the need for rapid defecation of patients, rather than long-term use. Pregnant and lactating women should be disabled.

The lubricating laxative drugs

The main Enema Glycerini and liquid paraffin. The main function is to lubricate the intestinal wall, soften stool, so that stool is easy to discharge. Suitable for hemorrhoids, anal fissure and after surgery, bedridden or hypertensive patients with constipation. But the human body can cause long-term use of fat soluble vitamins and calcium, phosphorus absorption.

Osmotic laxative.

The main lactulose, mannitol, sorbitol and polyethylene glycol 4000 (Fu Song). In the intestinal absorption of small intestine can maintain high osmotic pressure, prevent intestinal absorption of salt and water, thereby expanding the intestinal lumen, stimulate intestinal peristalsis, ease constipation. These drugs should not be used for inflammation, organic bowel diseases and undiagnosed abdominal pain.

The intestinal motility drug

Mosa Billy et al. Mainly by strengthening the intestinal muscle tension to play a role.

Commonly used drugs: Lactulose Oral Solution Lactulose Oral Solution, Duphalac, 5g/10ml. Synthetic nonabsorbable disaccharides, can make the water and electrolyte retention in the intestinal cavity and produces hypertonic effect. Because there is no intestinal irritation, can be used for the treatment of chronic functional constipation. 10ml oral, 3 times /d, if necessary, can increase the amount of each. Minor side effects, except for a few patients after taking a slight nausea, no other discomfort. Used with caution in patients with diabetes, galactose intolerance should not be taken. Appendicitis, intestinal obstruction, unexplained abdominal pain disable.

Polyethylene glycol 4000 powder, Macrogol, Powders, 4000, 10g/ bag. Macromolecular polyethylene glycol (4000) is a linear long chain polymer, through the hydrogen bonding of water molecules, so that water retention in the colon, increase fecal moisture and soften stool, promote defecation. Because it is not absorbed by the gastrointestinal tract, its toxicity is minimal. Mainly used in the treatment of constipation. 1 bag each time, 1-2 times a day; every day or 2 bags, one ton service. Daily dose can be increased or decreased according to patient's condition. When taking a large dose, there is the possibility of diarrhea, 24~48h can disappear after stopping, and then reduce the dose to continue treatment. Patients with intestinal dysfunction, there may be abdominal pain. Rare allergic reactions such as rash, urticaria, and edema. Inflammatory bowel disease, intestinal obstruction, diagnosis of abdominal pain of unknown disabled

4 prokinetics mosapride on constipation is not currently recommended as conventional drugs, but the drug can promote intestinal motility through activation of 5-HT4 receptor stimulation intestinal myenteric plexus release acetylcholine, improve the rectal resting pressure, accelerate the speed of colonic transit constipation patients, can be used without meaning to slow through the treatment of constipation.

5 on the psychological and biofeedback treatment of constipation patients often accompanied by depression and anxiety disorders, can aggravate constipation, and therefore need to receive psychological treatment. Although antidepressants have adverse reactions caused by constipation constipation, but some heavier day for how to defecate, spirit of nervous managers can try medication therapy. Biofeedback therapy can be used to treat patients with constipation of rectal sphincter and pelvic floor muscles. This method is a kind of training to control the function of the body with the mind, including two kinds of biological feedback method and the biofeedback method. The training of patients can improve the clinical symptoms of constipation.

Biofeedback treatment of constipation

1) biofeedback therapy (Bioedback therapy) also called biological feedback therapy, or autonomic learning method, is developed based on behavioral therapy on a new type of psychotherapy techniques / methods.

2) biofeedback treatment of constipation is a kind of equipment and equipment electromyographic biofeedback therapy combined with the host, including a 2.5cm diameter, 8cm long treatment electrode, a signal collector, and a connected with the host computer and biofeedback therapy.

3) biofeedback principle using biofeedback therapy in the treatment of constipation, is the physiological function of patients with the use of modern electronic instruments to be recorded and converted into sound, light, such as feedback signal, and thus make it according to the feedback signal, learning to adjust their body Suiyi visceral function and other body functions to.

4 the role of biofeedback can be achieved through the control of the patient's own muscle relaxation training to control and eliminate abnormal bowel movements. After repeated training treatment, so that patients learn to relax the anal sphincter in the defecation action, diaphragm and abdominal muscle force, thus eliminating constipation problems, help to correct pelvic floor dyssynergia, restore healthy and relaxed life.

5. The results of long-term follow-up study showed that the majority of patients still maintained good spontaneous defecation after biofeedback treatment for more than one year.

About 6 for surgical treatment after ineffective medical treatment, and various tests showed clear anatomical pathology and conclusive functional abnormalities, surgery may be considered, such as secondary megacolon, part dolichocolon, atony of colon, rectocele, rectal intussusception, rectal prolapse, spastic pelvic floor syndrome etc.. It is worth noting that the female rectovaginal rectal wall composed of pelvic fascia, support, constipation often is associated with dysfunction of colonic transit and rectal emptying in surgical treatment, at the same time to solve the resulting or abnormal rectal evacuation disorder.

 

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