Progress In Diagnosis And Treatment Of Primary Chronic ConstipationⅡ

The symptoms of chronic constipation are usually non-specific, such as hard stools, incomplete defecation, anorectal blockage, etc. According to the latest diagnostic criteria of Rome IV, the diagnosis of chronic constipation needs to follow the following 5 steps: 

① clinical history; 

② Physical examination; 

③ as few laboratory tests as possible; 

④ colonoscopy or other examinations; pathophysiological mechanism. 

Clinicians should first rule out organic diseases that can cause constipation, such as colorectal cancer, which are usually accompanied by some specific alarm signs, including blood in the stool, unexplained weight loss (>10% within 3 months), fever, Family history of colorectal cancer or new symptoms after the age of 50, etc.

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(1) Clinical history and physical examination

Constipation can be secondary to a variety of diseases or medications, so identifying the cause of constipation is critical. A detailed medical history should include the duration of symptoms, frequency of bowel movements, associated symptoms such as abdominal pain, bloating, and relief after defecation. In addition, it should also include the amount, shape, thickness, and effort of defecation. Medication history, surgery history, disease history, smoking history, and drug abuse history are also closely related to the occurrence of constipation and should also be included in the medical history.

Digital rectal examination is important in the evaluation of patients with constipation, to rule out a rectal mass or other mechanical cause of obstruction (eg, anal stenosis, rectal prolapse, intussusception), to observe the perineum at rest and during strained defecation, assess Defecation function can also be used in the diagnosis of pelvic floor dysfunction. Studies have shown that the sensitivity of digital rectal examination for diagnosing pelvic floor dysfunction is 75.9%, and the specificity is 87.0% [11].

(2) Laboratory examination

Before diagnosing the subtype of constipation, it is necessary to perform thyroid function or blood calcium tests based on medical history and physical examination to exclude secondary constipation caused by other diseases. Colonoscopy screening should be performed for all patients with alarm signs or age > 50 years old Check to rule out colonic obstructive lesions or inflammatory lesions. Imaging studies such as barium rectal and magnetic resonance defecography are also helpful in diagnosing anorectal dysfunction (coordinated defecation disorder) and anatomical abnormalities.

(3) Anorectal function test

There is considerable overlap in the symptoms expressed between the various subtypes of constipation. In clinical practice, determining the clinical phenotype is not essential, but patients who do not respond to reasonable empiric therapy (eg, fiber supplementation, osmotic laxatives) should undergo a diagnostic evaluation to identify subtypes of constipation. Identification of subtypes could pave the way for treatment and prognosis, especially in cases where first-line therapy fails.

1. Balloon expulsion test: The balloon expulsion test is simple and reliable, and can be used for the diagnosis of rectal emptying disorders [12]. At the same time, this method has certain limitations, such as failure to distinguish between functional and anatomical causes of rectal emptying disorders, and abnormal results requiring additional tests; normal results do not completely exclude pelvic floor muscle contraction coordination disorders possible.

2. Colonic/anorectal manometry: Conventional anorectal manometry and high-resolution anorectal manometry are physiological methods for assessing resting and contracted anal sphincter tone, recto-anal reflex, rectal sensation, and pressure changes during defecation. Tests to help identify rectal and pelvic floor dysfunction or abnormal rectal sensory thresholds. The anorectal pressure gradient can be used as a useful indicator for diagnosing defecation dyssynergia, but there is a large overlap in all anorectal manometry parameters between constipated patients and healthy volunteers, so the overall diagnostic value of the technique itself is limited [13], and must be combined with clinical indicators (medical history, physical examination). Colonic manometry can measure changes in colonic pressure in a resting state and after stimulation by food and drugs. Patients with slow transit constipation who do not respond well to drug therapy can be considered for colonic manometry. However, due to the difficulty of implementing this method and the differences in intestinal manifestations, there is no exact standard at present, and it is only used as a research tool rather than a clinical examination item.

3. Colonic transit test: colonic transit test can be detected in many ways, and the most widely used method in clinical practice is the detection of radiopaque markers. The test measures the entire intestinal transit time, not just the colonic transit time, although the latter accounts for the largest proportion of the total intestinal transit time. The simplest and most widely used method in clinical practice is the Hinton method: the patient takes 1 capsule containing 20–24 radiopaque markers on the same day, and then takes 1 abdominal X-ray film on the 5th day. If more than 20% of the marker remains, it can be diagnosed as slow colonic transit; if the residual marker is concentrated in the rectum, it can be diagnosed as outlet obstruction constipation. Relative simplicity, low cost, and wide availability are the most acceptable features of radiopaque marker detection, yet lead to more radiation exposure and additional hospital visits.

Scintigraphy can also be used to measure colonic transit time. This method requires oral administration of radioactive isotopes with longer half-lives such as 111In or 99Tc, and nuclide imaging is performed according to time, to calculate the time for passing through a certain intestinal segment. Although this method can detect the transit time of each segment of the colon, it is expensive and difficult to popularize at this stage.

Another method to detect intestinal transit time is the wireless motion capsule test, which can measure the pH, pressure, and temperature of the whole gastrointestinal tract through a wireless capsule to evaluate intestinal transit function. The capsule was also able to detect the magnitude of the contraction along the GI tract, but not the direction of its propagation. At present, this method has been recommended by American and European gastrointestinal motility and neurology for the detection of colonic transit function [14].

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. By promoting hydration and lubrication of the Intestines, it 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.