What is the reason behind the constipation that plagues nearly 1.5 billion people around the world?

It is only for medical professionals to read for reference.
Most patients with chronic constipation have autonomic dysfunction, which is manifested as excessive sympathetic nerve movement, especially the lack of sacral reflex and colorectal reflex.

Anorectal motility disorder and constipation are common clinical problems, which not only affect people's daily life and work, but also affect physical and mental health.

In addition, such patients have a high rate of medical treatment, medical expenditures have increased, and economic burdens have increased.

On May 22, 2021, U.
S.
Digestive Disease Week (DDW) held a lecture on anorectal motility disorders and constipation related issues.
This lecture reviewed the epidemiological data of chronic constipation, and understood the pelvic tract from the pathophysiological point of view.
The relationship between uncoordinated contraction of the floor muscles and defecation disorders, the relationship between autonomic dysfunction and chronic constipation, and the latest improvement of the anorectal manometry method.

01 Understand the status quo of chronic constipation: mainly women, and most of the patients are still not receiving treatment.
The National Outpatient Medical Service Survey (NAMCS) conducted by the Centers for Disease Control and Prevention (CDC) uses a weighted sampling method to generate cross-sectional data.
Represents the estimated population of outpatient medical care in the United States.

The scholar Neil Nadpara of Temple University in the United States, through the NAMCS survey, analyzed the adult patients treated with constipation in the United States from 2005 to 2015.

The study selects the survey years from 2005 to 2015, and is divided into three research periods: 2005-2007, 2008-2011, and 2012-2015.

Retrieved using ICD-9 code 564.
00 to identify adult patients diagnosed with constipation.

Drug code retrieval is mainly divided into the following categories: osmotic laxatives, stimulant laxatives, bulking agents, stool softeners and secretagogues.

The survey found that from 2005 to 2015, the number of medical visits due to constipation was as high as 34.
8 million, and the annual number of medical visits was basically the same (2.
3 million to 3.
2 million), except for the number of medical visits in 2009, which was 5.
6 million.

The average age of patients with constipation was 58.
4±19.
5 years old, mainly female (68.
2%).

The proportion of gastrointestinal specialists receiving patients with constipation is gradually increasing.
It was 26.
0% in 2005-2007, 36.
6% in 2008-2011, and 45.
3% in 2012-2015.

The proportion of primary care doctors receiving constipation patients is gradually decreasing.
It was 68.
2% in 2005-2007, 52.
2% in 2008-2011, and 48.
3% in 2012-2015.

Most of the patients (60.
9%) who visited the clinic did not receive treatment for constipation.

For patients undergoing treatment, osmotic laxatives are the first choice, with more than 25.
5% used each year.

Volumetric laxatives were 6.
9%, stimulant laxatives were 5.
4%, stool softeners were 5.
7%, and secretagogues were 5.
1%.

In recent years, the use of secretagogues has increased significantly, from 1% in 2005-2007 to 5% in 2008-2011, and then to 9% in 2012-2015 (p<0.
0001).

In addition, the study also found that gastroenterologists are more likely to prescribe secretagogues than primary care physicians (53.
6% vs.
33.
3%, p<0.
0001).

Studies have shown that from 2005 to 2015, the number of visits to doctors due to constipation in the United States remained at about 3 million person-times per year, while women and the elderly more often visited doctors due to constipation.

From 2005 to 2015, patients with constipation gradually separated from the management of primary care doctors, and more visits to the outpatient clinics of gastrointestinal specialists.

Osmotic laxatives are still the most commonly used drugs to treat constipation in the United States.

Regarding secretagogues, gastrointestinal specialists use them more often than primary care doctors, and the use rate is increasing year by year.

02 Understand defecation disorders in patients with chronic constipation: Colonic motility disorders, abnormal autonomic nerve function and abnormal bowel reflexes.
Constipation is a common gastrointestinal motility disease worldwide, and its incidence can be as high as 20%.

The colonic transit test is commonly used clinically to diagnose constipation, but it can only show whether colonic transit is delayed, and cannot reflect the pathophysiological changes of intestinal function.

In order to better reveal the pathophysiological mechanism of chronic constipation, scholars at McMaster University conducted a prospective study that included a total of 14 chronic constipation patients and 19 healthy controls.

These constipation patients belong to the chronic idiopathic refractory constipation in the Rome IV diagnostic criteria, and meet the indications for surgical intervention.

The age range of the patients was 6 to 43 years old, and none of them met the exclusion criteria: diabetes, familial inherited diseases, systemic diseases, cardiovascular diseases, malignant tumors.

The autonomic nerve activity was evaluated by high-resolution colonic pressure measurement (HRCM) in the constipation group and the healthy group, and the detection of heart rate variability (HRV).

The study found that: 1.
Regarding the colon-anal reflex, it can be detected in all healthy people, but in some (42%) patients with chronic constipation, the normal colon-anal reflex cannot be detected.

2.
Regarding the sacral reflex, the sacral reflex could not be detected in most (62%) patients with chronic constipation and a small part (15%) of healthy people.

3.
Regarding the gastrocolic reflex, the constipation patients in this study (43%) and the healthy people (21%) lacked a normal gastrocolic reflex.

4.
In general, most patients with chronic constipation have insufficient intestinal propulsion power, or no high-amplitude propulsion contraction (HAPC) at all.

5.
The use of bisacodyl for catharsis is an effective diagnostic stimulus measurement method.

6.
From the supine position to the standing position, the measurement of heart rate variability (HRV) can assess sympathetic tone and predict dysmotility.

7.
In patients with chronic constipation, decreased sympathetic nerve activity and increased parasympathetic nerve activity are more common. To sum up, the pathophysiological mechanisms of patients with refractory constipation are different, but most patients have autonomic dysfunction, which is manifested by excessive sympathetic nerve movement, especially the lack of sacral reflex and colorectal reflex.

Therefore, distal colonic dyskinesia is the main pathological feature of patients with constipation.

The heart rate variability (HRV) test from the supine position to the standing position can predict colonic dyskinesia.

03 The latest improvement of the anorectal pressure measurement method: In the high-resolution anorectal pressure measurement, the improved anal resting pressure maximum voluntary systolic pressure anal canal pressure measurement is to place a pressure meter in the anal canal and rectum, and instruct the patient to contract, Relax the anus or ask the patient to do a simulated bowel movement to measure the pressure change of the anal canal.

At present, this technology is mainly used for the diagnosis of constipation and defecation disorders.
It can also be based on the results of anorectal pressure measurement to establish an individualized biofeedback program to evaluate the efficacy of biofeedback.

High-resolution anorectal manometry technology has been widely used in clinical practice.
However, due to differences in equipment configuration, operating procedures, and analysis methods, there is currently no uniform standard for anorectal manometry.
The number of operations, operation time, and pressure value analysis are different.
It's different.

In order to explore the best detection method, the Mayo Medical Center conducted a cohort study, which included three groups of women who were healthy, defecation disorders, and fecal incontinence, and their anorectal pressure was measured separately.

In the resting pressure measurement process, by comparing the measurement results of the anal resting pressure in the three groups of 20s, 60s, and 300s, it is finally found that the detection time of more than 20s is enough to accurately measure the resting pressure of the anal canal.

In addition, during the measurement of the maximum voluntary systolic blood pressure, the study found that the healthy group and the fecal incontinence group had no significant difference in pressure value and duration during different measurement procedures.
That is to say, in these groups, a maximum voluntary contraction was performed.
The pressure measurement operation is effective.

Finally, among the different detection times of 5s, 10s, 15s, and 20s, the study found that 10s is the best detection time window to distinguish the healthy group from the fecal incontinence group.

In general, the problems of anorectal motility disorder and constipation have become increasingly prominent in recent years.
Chronic constipation is closely related to autonomic dysfunction.
As an important detection method, anorectal manometry technique is currently not uniform and needs to be further explored.

Expert profile Yi Zhihui, Deputy Chief Physician, Department of Gastroenterology, West China Hospital, Sichuan University, Doctor of Medicine, Member of the Neurogastroenterology Committee of the Chinese Research Hospital Association (CRHA) Member of the Eighth Committee of Gastroenterology, Sichuan Medical Association, Youth of the Western Psychiatric Association Member of the Standing Committee of the Sichuan Provincial Committee of the Chinese Digestive Psychosomatic Alliance Member of the PBL Case Bank Committee of China Medical Education After graduating from the doctoral degree in 2002, he has been working in internal medicine and gastroenterology clinics, teaching and scientific research.

Participated in and undertook the support project of Sichuan Provincial Department of Science and Technology, Sichuan Provincial Application Fundamental Project, Chengdu Science and Technology Bureau and Sichuan University Youth Fund Project.

He has published more than 30 papers in academic journals at home and abroad, and participated in editing 9 monographs and textbooks.

He has rich clinical experience in the diagnosis and treatment of common, difficult and critical diseases in the gastroenterology department.

The current research direction is gastrointestinal motility disorders and digestive psychosomatic diseases.