Constipation diagnosis and treatment in one article!

Constipation is a common symptom and can have many causes Caused, can be divided into secondary constipation, and idiopathic constipation. Systemic diseases and drugs are common causes of secondary constipation. Idiopathic constipation may be related to bowel function/pelvic floor muscle dysfunction. This article describes the etiology, evaluation, and drug treatment of constipation.

Q1: Is it constipation?

Constipation is difficult or infrequent bowel movements, dry or incomplete bowel movements.

The normal frequency of bowel movements is 2-3 times/day to 2-3 times/week. Many people mistakenly believe that they must have a daily bowel movement, and if they don’t, they complain of constipation.

Difficulty defecation includes straining to defecate, difficulty passing a bowel movement, a feeling of anorectal blockage, a feeling of incomplete defecation, time-consuming defecation, and Manual defecation is required. Occasionally,patients complain of poor bowel movements or a feeling of incomplete bowel movements, also known as constipation.

Physicians should carefully understand the patient’s actual bowel movements and choose the method of defecation carefully.

Q2: What are the causes of constipation?

In most patients, constipation is caused by the passage of stool through the colon for too long. May be due to drugs, organic diseases, bowel dysfunction (eg, abnormal pelvic floor muscle function) or dietary factors. Common causes are listed in Table 1.

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Q3: How to evaluate?

1)History of present illness

History of present illness needs to clarify the patientDefecation frequency, stool character, defecation effort or assistance Defecation conditions (eg, pressing on the perineum, buttocks, or rectovaginal wall during a bowel movement), satisfaction after a bowel movement,, and frequency and duration of use of laxatives or enemas . Some patients deny history of constipation, but when asked specifically, they often admit that each bowel movement takes 15 to 20 minutes. It is necessary to determine whether there is blood in the stool, and if so, the amount of blood and the duration of bloody stool should be asked.

2)Prior History

Attention should be given to known possible causes,including previous abdominal surgery, symptoms of metabolic disease (eg, hypothyroidism, diabetes), and neurological disorders (eg, Parkinson’s disease, multiple sclerosis, spinal cord injury). Ask carefully about your medication history, both prescription and over-the-counter. Particular attention should be paid to asking about anticholinergic and opioids.

3)Physical Exam

Palp for abdominal mass. Perform a digital rectal examination,noting for anal fissures, strictures, bleeding, or masses (including fecal impaction).

4)alarm symptoms

Chronic constipation with the following manifestations suggests a more serious cause:Bloating, gas; vomiting; bloody stools ; Weight loss; New severe constipation in elderly patients, or worsening of constipation.

5)Clinical Tips

a: Sensation of anorectal obstruction, prolonged or difficult defecation, need for manual defecation Indicates bowel dysfunction.

b:Tightness, bloating , with nausea and vomiting, and mechanical ileus should be considered.

c:Patients with chronic constipation with mild Severe abdominal discomfort, and long-term use of laxatives, suggests slow transit constipation.

d: patient with acute constipation, onset Consistent with the use of a certain constipation drug, and without alarm symptoms, consider the drug effect.

e:New onset of constipation that persists for several weeks Increased frequency or progressive severity of attacks with no clear etiology.Colon tumors, or other diseases causing partial intestinal obstruction should be considered.

f:Patients with fecal impaction may present for cramping abdominal pain;

g:intestinal Agitated patients with prone syndrome often have abdominal pain and disordered bowel habits.

Q4: Need help Is there an examination?

Auxiliary examination should be carried out according to the clinical symptoms and dietary history of the patient. If there are symptoms of intestinal obstruction, abdominal radiographs and other examinations should be performed. The vast majority of patients with unknown etiology require colonoscopy and laboratory evaluation (including complete blood, thyrotropin, fasting blood glucose, and serum calcium).

If the cause of constipation is clear (eg medication, trauma, bed rest), no further examination is required, Symptomatic treatment is available. Symptomatic treatment is ineffective, and needs further examination. If experimental use of fiber supplements and/or laxatives fails, anorectal manometry and balloon expulsion should be performed to exclude Pelvic floor dysfunction. If manometry is negative and infrequent bowel movements are the primary complaint, colonic transit should be measured usinga radiopaque marker, scintigraphy, or a wireless exercise capsule Time.

anorectal manometry:by inserting a manometry device into the rectum , to check the function and coordination of the internal and external sphincter, pelvic floor, and rectum.

Balloon expulsion test: Use a liquid or gas-filled balloon to simulate stool to test the rectal and anal canal Empty capacity, which has diagnostic value for outlet obstruction constipation and fecal incontinence.

Colon transit monitoring:suitable for fewer bowel movements of patients, oral administration of a certain number of X-ray-opaque markers, and at regular intervals through abdominal plain films to observe and calculate the movement and distribution of markers in the colon. In patients with chronic constipation, there may be slow transit constipation (abnormal colonic transit test) or pelvic floor muscle dysfunction (markers only found in the distal colon), and it is important to distinguish between the two.

Wireless Power Capsules:Patients ingest the capsules after taking the test meal, the capsules Wirelessly transmit pH, pressure and temperature information to an external logger. The colonic transit time can be measured with a wireless motion capsule.

Q5: Treating Constipation MedicationsIf feasible, discontinue constipation-causing medications (Discontinuation is necessary in some cases); increase dietary fiber intake. See the table below for a summary of the medications used to treat constipation. Click the picture to see the larger image /span>▲ Click to enlargeQ6: strong>Medication options for special populations1)Elderly: elderly Human constipation is mainly related to lack of exercise and taking related drugs due to illness. The treatment methods are mainly to change the lifestyle and stop the drugs that cause constipation as much as possible. Bulk and osmotic laxatives are preferred, and stimulant laxatives can be used for a short time in severe constipation. 2)Pregnant women: lactulose, polyethylene glycol, wheat cellulose. 3)Children: The treatment of constipation in children is mainly based on lifestyle adjustment. When the effect is not good, Kaisailu or normal saline enema can be used. Wheat cellulose, lactulose and polyethylene glycol are safer. Lactobacillus acidophilus or Bifidobacterium can shorten the period of migratory motor complexes and promote colonic transit. 4)diabetic patients: try volume, permeability, and stimulation Sexual laxatives. Lactulose will not be decomposed and absorbed, so it will not cause blood sugar to rise. Although lactulose oral liquid contains a small amount of fructose, galactose and lactose that can increase blood sugar, 15 mL contains only the equivalent of a mouthful of rice. Does not significantly increase blood sugar, when the therapeutic dose reaches 60 per dayIf you need to take it for a long time, you need to pay attention to the effect on blood sugar, and if necessary, you can replace other laxatives such as polyethylene glycol 4000. Q7: Other Key Points1)Use laxatives with cautionSome (eg, phosphates, wheat bran, cellulose) can bind to the drug andinterfere with absorption< /span>. With increased intestinal transit, certain drugs and foods will pass through the intestines quickly, and thus not fully absorbed. Contraindications to laxatives and cathartics include: unexplained acute abdominal pain, inflammatory bowel disease, intestinal obstruction, gastrointestinal bleeding, and fecal impaction. In addition, the doctor must explain that daily bowel movements are not required. Frequentuse of laxatives or enemas (>every 3 days) may interfere with normal bowel function. 2)dietdiet Sufficient fiber (20 g to 30 g per day) should be included to ensure a certain volume of stool. Most plant fibers cannot be digested and absorbed, which can increase stool volume. Certain components of cellulose absorb water and soften stools for excretion. Fruits, vegetables, and gluten-containing grains are recommended. It has a certain effect on constipation patients with normal transit time, but has limited effect on patients with slow transit constipation or defecation disorder. 3)peripheral-acting opioid antagonists (eg, methylnaltrexone , naloxol, naldidin) may be used to treat opioid-induced constipation that is not relieved by other methods. Quick Question:

For patients over 70 years of age, warm water enema is recommended instead of Use a sodium phosphate enema. Have you ever used warm water enema in clinic? How is the effect?

Welcome to comment in the message area~Planning: JINGSubmission email : [email protected]Title: Visual China< span>References:Chinese Medical Association, Journal of Chinese Medical Association, Gastroenterology Branch of Chinese Medical Association, General Medicine Branch of Chinese Medical Association, Guidelines for Primary Care of Chronic Constipation (2019)[J] . Chinese Journal of General Practitioners, 2020, 19(12): 1100-1107.Gastrointestinal Dynamics Group of Chinese Medical Association Gastroenterology Branch, Functional Gastroenterology Collaborative Group, Chinese Expert Consensus on Chronic Constipation Opinion ( 2019, Guangzhou)[J]. Chinese Journal of Digestion, 2019, 39(9): 577-598.Jiang Ya, Lin Lin. Treatment strategies for chronic constipation in special populations[J]. Zhonghua Quan Journal of Scientists, 2018, 17(6): 482-485. Chinese Medical Association Geriatrics Branch, Chinese Journal of Geriatrics Editorial Board, expert consensus on the assessment and management of chronic constipation in the elderly[J]. Chinese Journal of Gerontology, 2017, 36(4): 371-381.uptodate: treatment of chronic constipation in adults.MSD Manual: Constipation.