Clinical Practice Guidelines For The Evaluation And Surgical Management Of Chronic Constipation in Chinese Adults (2022 Edition)
Oct 12, 2023
Summary
The Colorectal Surgery Group of the Surgery Branch of the Chinese Medical Association first released the surgical diagnosis and treatment guidelines for chronic constipation 2008, which played a positive role in standardizing the surgical diagnosis and treatment of chronic constipation in my country. In recent years, research on the basic and clinical diagnosis and treatment of chronic constipation has progressed. However, there is still a lack of gold standards and high-level clinical research evidence in clinical practice. Surgeons have to consider preoperative evaluation, surgical selection, and postoperative efficacy. There is a lack of authoritative references for evaluation and other aspects. To further standardize the diagnostic evaluation and surgical management of chronic constipation, the Colorectal Surgery Group of the Surgery Branch of the Chinese Medical Association selected relevant experts in the field of constipation surgery in my country to form the editorial committee of the "Clinical Practice Guidelines for the Evaluation and Surgical Management of Chronic Constipation in Adults in China". This guideline has been updated based on relevant foreign literature and the clinical experience of experts. The "Clinical Practice Guidelines for the Assessment and Surgical Treatment of Chronic Constipation in Adults in China" formulated this time are oriented to common problems existing in the clinical assessment and treatment of constipation (non-surgical treatment and surgical treatment), are based on evidence, and include current domestic and foreign standards. The main results and conclusions of the study were evaluated based on the GRADE system for evidence quality assessment and recommendation strength grading. It is hoped that it will contribute to the learning and practice of Chinese constipation surgeons and other related medical practitioners, and improve the overall diagnosis and treatment level of constipation surgery in China.
Chronic constipation (CC) has become an important factor affecting people's quality of life. With the continuous improvement of living standards and the aging of my country's population, the prevalence of chronic constipation has shown a significant upward trend. The prevalence of chronic constipation in adults in my country is 4% to 6% and increases with age. The prevalence of chronic constipation in people over 60 years old can be as high as 22% [1]; in European and American countries, the incidence is as high as 14% to 30%. %[2]. Chronic constipation is usually characterized by reduced defecation frequency (less than 3 times per week), dry and hard stools, and/or difficulty in defecation. Difficulties in defecation mainly include time-consuming and laborious defecation, hand-assisted defecation, difficulty in defecation, a feeling of incomplete defecation, and a feeling of swelling in the anus. Currently, the diagnosis of functional constipation in the world mainly refers to the Rome IV criteria.
The Colorectal Surgery Group of the Surgery Branch of the Chinese Medical Association released the "Guidelines for the Surgical Diagnosis and Treatment of Constipation (Draft)" in 2008, which played an important role in the standardized diagnosis and treatment of constipation in my country [3]. Over the past 10 years, domestic and foreign research on the basic and clinical diagnosis and treatment of chronic constipation has made certain progress, and it is necessary to formulate a new "Clinical Practice Guidelines for the Assessment and Surgical Treatment of Chronic Constipation in Chinese Adults". This guideline committee is composed of experts selected from the Colorectal Surgery Group of the Surgery Branch of the Chinese Medical Association in the field of constipation surgery in my country. This guideline was formulated by studying relevant domestic and foreign literature and combining the clinical experience of the experts.
This guideline aims at common problems in the evaluation and treatment of constipation. It is problem-oriented and evidence-based. It covers the main results and conclusions of current domestic and foreign research. This guideline evaluates the quality of evidence and grades the strength of recommendations based on the GRADE system. The quality of evidence is graded into four levels: "A", "B", "C", and "D". The strength of recommendations is divided into "strong recommendation" and "weak recommendation." Two levels[4].
1. Clinical evaluation of constipation
1. Detailed medical history inquiry and physical examination are the basis for the initial clinical evaluation of constipation (quality of evidence: B, strength of recommendation: strong).
Constipation can be a secondary symptom of certain diseases or a syndrome of defecation disorders caused by many factors, such as sluggish colon motility, pelvic floor spasm, rectal and pelvic floor prolapse, etc. Asking about the presence of blood in the stool, changes in stool properties, and family history is valuable in diagnosing colorectal tumors. Understanding dietary habits and medication history helps analyze the cause of constipation, its development and change process, and formulating diagnostic and treatment measures [5]. The impact of long-term medication for chronic diseases such as diabetes on defecation function needs to be considered; menopause, endocrine diseases, etc. also have a great impact on constipation. Therefore, detailed questioning of the medical history will help to initially determine the type of constipation, to conduct targeted auxiliary examinations [6]. For example, slow transit constipation (STC) is often characterized by the lack of intention to defecate, while outlet obstruction constipation (OOC) is characterized by anal swelling, incomplete defecation, or a sense of obstruction during defecation [ 7].
Usually, patients with chronic constipation have no special findings on abdominal examination. Patients with megacolon may palpate a significantly dilated colon; anal inspection may reveal a prolapsed rectum or vagina; this is direct evidence to determine pelvic floor prolapse. Digital rectal examination plays an irreplaceable role in the evaluation of constipation. It can understand the tension of the anal sphincter, the relaxation of the rectal mucosa, and whether the anterior rectal wall is weak. Especially when asking patients to do defecation movements, they can feel whether there is an abnormal contraction of the pelvic floor muscles, and the sensitivity is as high as 87% [5]. Of course, digital rectal examination is also meaningful for diagnosing rectal or pelvic tumors.
2. Constipation-related scoring scales and quality of life assessment can be used as the basis for constipation assessment (evidence level: C, recommendation strength: strong).
The definition of constipation described by the Rome IV criteria is widely recognized, but it is not able to assess the severity of constipation [8]. Numerous constipation-related scoring scales have been developed and applied clinically, which can assess the severity of constipation and its impact on quality of life, and can also be used to evaluate clinical treatment effects and conduct related scientific research. Constipation assessment scale (CAS) [9], Wexner constipation rating scale, patient assessment of constipation⁃symptoms (PAC⁃SYM) [10], constipation severity assessment scale (constipation severity instrument (CSI) [11], and the obstructed defecation syndrome (ODS) scoring system [12] can better assess the severity of constipation symptoms and have a different emphasis. The PAC⁃SYM and SF⁃36 scales focus on assessing the quality of life of patients with constipation, and the self-rating anxiety scale (SAS)/self-rating depression scale (SDS) can be used for assessment. The mental and psychological state of patients with constipation. The purpose of applying the scoring system is to establish a relatively unified assessment method to classify the baseline severity of constipation and to track and evaluate the effectiveness of treatment. However, there are differences in the standards of various rating scales, resulting in a lack of comparability among related studies.
3. Imaging examinations such as defecography, colonic transit test, pelvic dynamic MRI, and anorectal manometry are important references for understanding the cause of constipation and classifying diagnosis (evidence level: C, recommendation strength: strong).
Defecography, colonic transit test, pelvic dynamic MRI, and anorectal manometry are currently commonly used clinical examination methods related to constipation, which help classify constipation and determine its cause. Constipation is usually divided into slow transit constipation, outlet obstruction constipation, and mixed constipation [13].
Anorectal manometry (ARM) is generally used to evaluate anal dynamic function. Commonly used parameters include anal canal resting pressure, anal canal systolic pressure, and recto-anal inhibitory reflex. Abnormal detection results mainly include loss of recto-anal inhibitory reflex, reduced anal tension and contractility, abnormal rectal sensitivity, and sphincter coordination disorder [14]. The application of high-definition ARM or 3D⁃ARM provides a more accurate reference for anorectal function testing.
The X-ray-opaque marker colonic transit test has the advantages of low cost and ease of implementation and is currently the most commonly used examination method for diagnosing slow transit constipation. It is generally believed that failure to excrete 80% of markers within 72 hours can be used as a diagnostic criterion (it is recommended to take plain abdominal X-rays at 6, 24, 48, and 72 hours after oral administration of markers), and multiple examinations can be performed if necessary [15]. Smart capsule testing or scintigraphy technology can also be used to evaluate colonic transit time [16].
Defecography is one of the most important bases for classifying and diagnosing outlet obstruction constipation. It can intuitively determine rectocele, rectal prolapse, pelvic floor spasm, etc. Defecography includes barium X-ray defecography (BD) and magnetic resonance defecography (MRD). BD is simple and easy to perform and is the test of choice for evaluating outlet obstructive constipation. BD combined with pelvic, vaginal, or cystography can dynamically display the abnormal morphological changes of pelvic tissues and organs during defecation. MRD has small radiation and stronger soft tissue resolution. Some studies believe that dynamic multiple pelvic contrast imaging and pelvic quadruple contrast imaging techniques can better display multiple organ prolapse images of the pelvic floor [17].
4. Colonoscopy, barium enema, etc. are of great value in excluding organic diseases or megacolon (evidence level: B, recommendation strength: strong).
Colonoscopy and barium enema examination are of great value in the diagnosis of patients with constipation, especially in the diagnosis of excluding coexisting organic diseases or megacolon. Pepin and Ladabaum [18] reported the results of sigmoidoscopy or colonoscopy in 563 patients with constipation and found that 1.4% of the patients were complicated by colorectal cancer and 14.6% of the patients were complicated by colorectal adenomas. It should be noted that colonoscopy is often more difficult and time-consuming in patients with constipation. Barium enema examination can preliminarily rule out combined organic colorectal lesions and determine whether there is a long colon, megacolon, etc. For adult Hirschsprung disease, a barium enema can clearly show the location and length of the stenotic segment and proximal dilated bowel.
Natural Herbal Medicine For Relieving Constipation-Cistanche
Cistanche is a genus of parasitic plants that belongs to the family Orobanchaceae. These plants are known for their medicinal properties and have been used in Traditional Chinese Medicine (TCM) for centuries. Cistanche species are predominantly found in arid and desert regions of China, Mongolia, and other parts of Central Asia. Cistanche plants are characterized by their fleshy, yellowish stems and are highly valued for their potential health benefits. In TCM, Cistanche is believed to have tonic properties and is commonly used to nourish the kidney, enhance vitality, and support sexual function. It is also used to address issues related to aging, fatigue, and overall well-being. While Cistanche has a long history of use in traditional medicine, scientific research on its efficacy and safety is ongoing and limited. However, it is known to contain various bioactive compounds such as phenylethanoid glycosides, iridoids, lignans, and polysaccharides, which may contribute to its medicinal effects.
Wecistanche's cistanche powder, cistanche tablets, cistanche capsules, and other products are developed using desert cistanche as raw materials, all of which have a good effect on relieving constipation. The specific mechanism is as follows: Cistanche is believed to have potential benefits for relieving constipation based on its traditional use and certain compounds it contains. While scientific research specifically on Cistanche's effect on constipation is limited, it is thought to have multiple mechanisms that may contribute to its potential to relieve constipation. Laxative Effect: Cistanche has long been used in Traditional Chinese Medicine as a remedy for constipation. It is believed to have a mild laxative effect, which can help promote bowel movements and induce constipation. This effect may be attributed to various compounds found in Cistanche, such as phenylethanoid glycosides and polysaccharides. Moistening the Intestines: Based on traditional use, Cistanche is considered to have moisturizing properties, specifically targeting the Intestines. Promoting hydration and lubrication of the Intestines may help soften tools and facilitate easier passage, thereby relieving constipation. Anti-inflammatory Effect: Constipation can sometimes be associated with inflammation in the digestive tract. Cistanche contains certain compounds, including phenylethanoid glycosides and lignans, that are believed to have anti-inflammatory properties. By reducing inflammation in the intestines, it may help improve bowel movement regularity and relieve constipation.
