Constipation refers to a group of symptoms related to stool excretion disorder. The frequency of bowel movements in the normal population is 3 times a day to 3 times a week, which is caused by a single or multiple causes. It is manifested by a significant decrease in the number of bowel movements, 1 bowel movement every 2 to 3 days or longer, irregular, dry and hard feces, with or without a sense of incomplete defecation. The bowel habits of constipated patients vary greatly from person to person. Food types and habits, lifestyle, environment, mental state, etc. can all affect bowel habits. Because the factors affecting its onset are complex and changeable, and there is inconsistent understanding, it is also difficult to define constipation. Constipation is a common syndrome in the elderly population, which seriously affects the quality of life of the elderly and even becomes one of the main complaints of elderly patients. Chronic constipation can be functional or organic, and can be caused by a variety of diseases. Many drugs can also cause constipation. Among the causes of chronic constipation, most are functional diseases, including functional constipation, functional defecation disorders, and constipation-type irritable bowel syndrome. Although it does not directly threaten life, it causes physical and mental pain to patients and seriously interferes with normal life and work.
Epidemiology
Prone populationAmong the elderly population over 60 years old, the incidence rate of women is higher than that of men
symptom
Typical manifestations
Constipation can occur in people of all ages. The elderly population has a high incidence of constipation and complex causes, so the symptoms are also different.
1. Primary disease manifestations
For example, hypothyroidism may cause fear of cold, myxedema, etc.; anal fissure may cause painful defecation and bloody stools; colorectal cancer may cause mucus, bloody stools, and lumps; chronic intussusception may cause abdominal pain and masses; spinal cord tumors may have neurological localization signs.
2. Symptoms of defecation disorder
The frequency of natural bowel movements is less than 3 times per week, the amount of stool is small, the interval between natural bowel movements is prolonged, and it may gradually worsen. Defecation difficulties can be divided into two situations: hard and dry stools that are difficult to pass and soft and difficult to pass.
3. Associated symptoms
Common associated symptoms include abdominal distension, abdominal pain, thirst, nausea, perineum pain, irritability, and some patients also have bitter taste in the mouth, headache, rash, etc. A small number of patients show neurosis, and some have suicidal tendencies.
reason
OverviewA variety of factors can lead to constipation in the elderly, which is often related to the patient’s weakened gastrointestinal motility, reduced activity, and low fiber in the diet. In addition, various diseases can also lead to constipation in the elderly.
Cause of symptoms
1. Decreased physiological function and bad eating habits
The elderly suffer from tooth loss, gastrointestinal mucosa atrophy, reduced mucus secretion, reduced digestive juice secretion from the salivary glands, stomach, intestines, pancreas, etc., decreased gastrointestinal reflex function, abnormal visceral sensation, weakened gastrointestinal smooth muscle tension and peristalsis, weak contraction or coordination disorders of the abdominal muscles, pelvic floor muscles, and internal and external anal sphincters; the elderly have restricted diets, resulting in reduced food intake, insufficient intake of dietary fiber and water, etc.
2. Bad living and bowel habits
Some elderly people have reduced physical activity, sit for long periods of time, or stay in bed for long periods of time; in addition, they have not developed the habit of defecating on time, or have long ignored or suppressed the urge to defecate due to inconvenient movements, environmental conditions, or changes in defecation posture.
3. Social and psychological factors
The impact of negative life events or being in a state of tension, depression, anxiety, etc. for a long time.
4. Functional diseases
Functional constipation, functional defecation disorder, irritable bowel syndrome (constipation type), pelvic floor spasm syndrome, perineal descent syndrome, etc.
5. Iatrogenic
(1) Medication
Including opioid analgesics, antipsychotics, antidepressants, sedatives and anticonvulsants, anticholinergics, anesthetics, calcium ion antagonists, diuretics, aluminum-containing antacids, iron-containing preparations, calcium preparations, drugs containing heavy metals such as arsenic, lead, mercury, barium sulfate or warm and spicy Chinese medicines, etc.
(2) Braking.
6. Neurological diseases
(1) Central nervous system diseases include cerebrovascular disease, tumors, Parkinson’s disease, multiple sclerosis and multiple radiculitis.
(2) Peripheral types include neurofibroma, multiple neuritis, etc.
7. Mental illness
Depression, anorexia nervosa, etc.
8. Endocrine abnormalities and metabolic diseases
Hypothyroidism or hyperthyroidism, diabetes, hypopituitarism, pheochromocytoma, lead poisoning, porphyria and hypokalemia, etc.
9. Connective tissue disease
Scleroderma, dermatomyositis, etc.
10. Extraintestinal lesions
Compression of prostate cancer, ovarian cysts, pregnancy, endometriosis, etc.
11. Intestinal diseases
(1) Mechanical obstruction of the colon, including benign and malignant tumors of the colon and rectum, intestinal tuberculosis, inflammatory bowel disease, diverticulitis, colon torsion, colon intussusception, anastomotic stenosis, etc.
(2) Obstruction of the rectum or anal canal outlet, including rectal intussusception or prolapse, rectocele, puborectalis hypertrophy, sacrorectal separation, pelvic floor hernia, anal canal or rectal stenosis, anal fissure, anal fistula, hemorrhoids, etc.
(3) Colorectal nerve and muscle diseases, including intestinal pseudo-obstruction, megacolon, megarectum, etc.
Common diseases
Irritable bowel syndrome, pelvic floor spasm syndrome, perineal descent syndrome, Parkinson’s disease, multiple sclerosis, multiple radiculitis, neurofibroma, multiple neuritis, depression, anorexia nervosa, hypothyroidism, hyperthyroidism, diabetes, pheochromocytoma, lead poisoning, porphyria, hypokalemia, scleroderma, dermatomyositis, prostate cancer, ovarian cyst, endometriosis, intestinal tuberculosis, inflammatory bowel disease, diverticulitis, colon torsion, colon intussusception, anal fissure, anal fistula, hemorrhoids, pseudo-intestinal obstruction, megacolon, megarectum, etc.
Medical treatment
Outpatient Indications
1. Elderly people have difficulty defecating for a long time, their feces are lumps or hard lumps, they feel that their bowels are not completely defecate, their anus is blocked, and they even have to use their hands to assist with defecation. They also have bowel movements less than 3 times a week. These are all manifestations of constipation in the elderly.
2. Long-term constipation in the elderly is combined with depression, indifference, anxiety, etc.
3. Other severe, persistent or progressive symptoms and signs occur.
All of the above patients need to seek medical treatment in a timely manner at outpatient clinics such as the Department of Gastroenterology.
Department
If the elderly experience constipation, they can go to the gastroenterology department or geriatrics department for medical consultation.
Medical preparation
1. Make an appointment in advance and bring your ID card, medical insurance card, medical card, etc.
2. Keep the anus clean and dry.
3. On the day of consultation, it is best to wear clothes that are easy to put on and take off to facilitate examination.
4. If you have had medical treatment recently, please bring relevant medical records, examination reports, test results, etc.
5. If you have taken some medicine to relieve symptoms recently, you can carry the medicine box.
6. It is best for family members to accompany the patient to seek medical treatment.
7. It is best for family members to help patients prepare a list of questions they want to ask in advance.
Questions your doctor may ask you
1. When did you start to have constipation? Is it new or persistent?
2. Under what circumstances will your constipation symptoms be relieved or aggravated?
3. In addition to constipation, do you have other symptoms or signs of discomfort, such as anal pain during defecation or blood in the stool?
4. Have you ever had intestinal diseases, such as inflammatory bowel disease, rectal stenosis, megacolon, etc.?
5. Do you have diabetes, thyroid dysfunction, nervous system disease, etc.?
6. Do you have any other diseases?
7. Have you had any recent changes in your mood or diet?
8. Have you been sitting for long periods of time, reducing your physical activity, or changing your daily routine?
9. Have you taken any new medications recently?
10. Have you tried any measures to improve constipation? What were the results?
Questions patients can ask their doctors
1. What is the most likely cause of my constipation?
2. Are there any other possible reasons?
3. What tests do I need to do?
4. Is my constipation serious? Do I need to be hospitalized?
5. What treatments can I use? Can it be cured? Will it recur after being cured?
6. Are there risks with these treatments?
7. I have other medical conditions, will this affect my treatment? How should I deal with them at the same time?
8. How should I take care of myself after returning home? Do I need to adjust some habits?
9. If medication is required, what are the usage, dosage, and precautions?
10. Do I need follow-up examinations? How often?
examine
Estimated inspectionThe doctor will first perform a physical examination on the patient to gain a preliminary understanding of the patient’s condition, and then selectively have the patient undergo routine stool tests, occult blood tests, colonoscopy, CT, MRI and other examinations. If necessary, lower gastrointestinal motility measurements and electromyography examinations may be performed.
Physical examinationPay attention to the patient’s nutritional status, whether the skin and mucous membranes are pale; whether the abdomen is bloated, whether there are signs of ascites or huge tumors, whether the liver and spleen are obviously enlarged; whether there are gastric, intestinal patterns and gastrointestinal peristaltic waves; whether there is abdominal muscle tension, tenderness, rebound pain, or splashing sounds.
Laboratory testsRoutine blood tests, stool routine tests and occult blood tests are important and simple basic screening tests to exclude organic lesions of the colorectum and anus; if necessary, relevant biochemical, hormone level and metabolic tests should be performed.
Imaging tests
1. X-ray examination
On the plain abdominal film, the proximal intestinal dilatation and air-fluid level above the site of organic intestinal obstruction can be seen. Barium enema can identify the site of the lesion and show the overall appearance and shape of the lesion. Defecation radiography helps in the diagnosis of rectal mucosal prolapse, rectal intussusception, rectocele, perineal descent syndrome, pelvic floor muscle spasm syndrome, pelvic floor hernia and intestinal hernia, and provides a basis for the selection of treatment methods.
2. Colonoscopy
It helps to determine whether there are organic lesions in the colorectum, such as tumors, inflammation, stenosis, intestinal torsion and intussusception, and pathological biopsy helps to clarify the cause.
3. Computerized tomography (CT)
Organic obstructive diseases can be found, which is very valuable for the diagnosis of constipation caused by organic diseases such as tumors and inflammation; it can directly and objectively show the distribution and properties of feces. The application of multi-slice spiral CT can easily reconstruct images in multiple directions such as coronal and sagittal planes; it can also obtain high-quality three-dimensional simulated endoscopic images and enema images.
4. Magnetic resonance imaging (MRI)
Compared with CT, it has high tissue resolution and is a more sensitive diagnostic method for constipation. It can objectively evaluate the overall distribution of stool; the use of fat-suppressed T1-weighted images can clearly display stool. Dynamic MRI of the pelvic floor can be used to accurately evaluate pelvic organ prolapse and the morphology and functional status of the pelvic floor. MRI dynamic defecography can examine anorectal motility and evaluate the function of the levator ani muscles.
5. Ultrasound examination
Anorectal ultrasound examination can determine whether the anal sphincter has any morphological or functional abnormalities; three-dimensional ultrasound defecography can evaluate the function of the anal levator muscle from a morphological perspective, which is particularly suitable for sphincter dysfunction that cannot be explained by functional evaluation alone. It is a bridge between morphological and functional examinations.
Other tests
1. Measurement of lower gastrointestinal motility
(1) Colonic transit test (GIT)
There are radiopaque markers (ROM) and indium (In) DTPA scintigraphy, which can help determine the type of constipation.
(2) Colonic pressure monitoring
It can determine whether the colon has weak contraction, which is of great guiding significance for the selection of surgical procedures, especially segmental intestinal resection, to treat constipation.
(3) Anorectal pressure measurement
It helps to evaluate the anal canal, rectal motility and sensory function and pelvic floor dysfunction; it helps to distinguish organic from functional constipation; it can also serve as the dynamic basis and basis for biofeedback training. It has become an important means to study anorectal physiology, diagnose anorectal diseases and evaluate the effect of anorectal surgery.
(4) Rectal balloon expulsion test
It is mainly used to evaluate defecation motivation and rectal sensitivity. It helps to determine whether there is any abnormality in the function of the rectum and pelvic floor muscles, and can be used as a specific screening test for defecation disorders. However, normal test results cannot rule out functional defecation disorders.
(5) Anorectal sensory examination
Use electric current stimulation to measure anal sensation, gradually increase the current until the patient experiences a burning or tingling sensation, record the threshold, and calculate the average threshold.
2. Electromyography
It can distinguish between abnormal pelvic floor voluntary muscles and nerve function, can distinguish whether there is pelvic floor muscle-induced constipation, and can also help evaluate anal sphincter disorders. Common changes in patients with outlet obstruction constipation are paradoxical contraction of the external anal sphincter and abnormal electromyographic activity of the pelvic floor muscles.
3. Pudendal nerve latency measurement
It can be used for evaluation before and after anal sphincter reconstruction or rectal mucosal prolapse repair; for patients with long-term chronic constipation and defecation difficulties, it can predict the possibility of fecal incontinence after surgery.
4. Others
Imaging examinations such as defecography, pelvic and cystography, quadruple pelvic organ imaging that organically combines defecography, pelvic and cystography, placement of barium markers in the female vagina, and dynamic MRI can diagnose hidden pelvic floor diseases that are difficult to detect clinically, such as pelvic hernia, bladder prolapse, and retroverted uterus. It is a combination of dynamic and static imaging methods that is more vivid, objective, effective, and easy to use.
diagnosis
Diagnostic principles
It is generally not difficult to diagnose based on the patient’s medical history, clinical symptoms, and auxiliary examination results. The doctor will learn in detail about the onset of the patient’s constipation and the course of treatment, recent changes in bowel habits, bowel movement frequency, whether there is difficulty or effort in defecation, and whether there is blood in the stool; whether there is abdominal pain, bloating, upper gastrointestinal symptoms, and other systemic diseases that can cause constipation; if the course of the disease is more than several years and the condition has not changed, it is often a sign of functional constipation. Then the doctor will choose to have the patient undergo relevant examinations, and a comprehensive analysis of the examination results can be used to make a diagnosis.
Diagnosis
The Rome III diagnostic criteria for constipation in the elderly are that symptoms have occurred for at least 6 months and the following conditions have been met in the past 3 months.
1. Must include two or more of the following symptoms
(1) Straining during defecation ≥ 25% of the time.
(2) The stool is lumpy or hard ≥ 25% of the time.
(3) 0 ≥ 25% of the time, there is a feeling of incomplete defecation.
(4) Sensation of anorectal obstruction during defecation ≥ 25% of the time.
(5) ≥25% of the time, defecation requires manual assistance (such as using fingers to assist defecation, supporting the pelvic floor).
(6) Bowel movements less than 3 times per week.
2. There is almost no soft stool without using laxatives.
3. The patient does not meet the criteria for diagnosing irritable bowel syndrome (constipation type).
Differential DiagnosisFirst, differentiate constipation in the elderly from organic constipation, especially in elderly patients with alarm signs. Second, pay attention to differentiate it from irritable bowel syndrome constipation, which is a functional bowel disease associated with abdominal pain or bloating.
treat
Expected treatmentThe treatment principle of this disease is to treat the cause. The causes of different patients may be different, so the treatment methods will also be different. After a clear diagnosis, the commonly used treatment methods include drug therapy, diet therapy, surgical treatment, etc.
Treatment
1. Cause treatment
After a clear diagnosis, appropriate measures can be taken to treat the causes of constipation and the primary diseases that cause constipation. For those with unreasonable diet and unhealthy lifestyle, the diet and lifestyle can be adjusted, such as regular meals, adjusting the diet, regular daily life, active participation in sports activities, eliminating the patient’s tension, and maintaining an optimistic mental state. In case of iatrogenic constipation, the treatment should be stopped or the medication should be discontinued or other drugs that do not cause constipation should be used instead. Constipation caused by mental illness and endocrine and metabolic diseases should be treated accordingly to eliminate the impact of the primary disease on intestinal function as soon as possible. For anorectal diseases, specialized surgery can be used, and anal fissures can be treated with local anesthesia, anal dilation, or internal sphincter lateral resection.
2. Choose the right medicine
The types of drugs commonly used in clinical practice include bulk laxatives, osmotic laxatives, stimulant laxatives, lubricating laxatives, and prokinetics.
daily
Nursing principles
1. Defecation care
(1) Develop good bowel habits.
Have regular bowel movements, squat on the toilet after breakfast or before going to bed, and cultivate the urge to defecate; defecate immediately when you feel the urge to defecate; sit down when defecating, and do not use too much force; concentrate, and avoid reading books or newspapers when defecating. Do not take laxatives for a long time to prevent drug dependence. Ensure a good defecation environment, and the toilet should be clean and warm.
(2) Precautions for defecation
Patients should not ignore any urge to defecate and try not to retain stool; pay attention to defecation techniques, such as leaning forward, relaxing, taking a deep breath first, then closing the glottis, and applying force to the anus.
2. General care
(1) Adjusting dietary structure
Dietary modification is the basis for treating constipation.
① Drink more water: If you have a disease that does not limit drinking water, you should ensure that you drink about 2000-2500 ml of water every day. Drink a glass of warm water on an empty stomach in the morning to stimulate intestinal peristalsis.
② Take in enough dietary fiber: Eat more coarse flour, corn flour, soy products, celery and leeks, etc., and eat more stuffed pasta, such as dumplings, wontons, buns, etc., which will help ensure more comprehensive nutrition and prevent constipation.
③ Eat more gas-producing foods and foods rich in vitamin B, such as sweet potatoes, bananas, raw garlic, raw onions, fungus, white fungus, soybeans, corn and lean meat, etc., to use their fermentation to produce gas and promote intestinal peristalsis.
④Increase intestinal lubrication of food: For patients with normal weight, low blood lipids and no diabetes, they can drink a glass of honey water on an empty stomach in the morning.
⑤ Drink less strong tea or caffeinated beverages, and avoid eating raw, cold, spicy, and fried irritating foods.
(2) Adjust your lifestyle
Change the sedentary lifestyle and keep 30 to 60 minutes of activity every day. Elderly people who are bedridden or in wheelchairs can exercise by turning their bodies, swinging their arms, etc. At the same time, develop the habit of defecating at fixed times (morning or after meals).
(3) Meeting the private space needs of the elderly
If there are more than two people living in the room, screens or curtains can be installed between the beds to facilitate the defecation needs of the elderly. When caring for the elderly to defecate, only assist them with the part that they are unable to complete. Do not wait by their side all the time to avoid the elderly being nervous and affecting their defecation. Do not urge them to avoid making them nervous and unwilling to trouble the caregivers and hold back their defecation.
3. Medication care
(1) Oral laxatives
The principle is to instruct patients not to take laxatives for a long time to prevent the occurrence of drug dependence.
① It is advisable to use mild drugs such as liquid paraffin and Ma Ren Wan, which are not likely to cause severe diarrhea. They are suitable for patients with elderly and frail health, hypertension, heart failure, aneurysm, hemorrhoids, hernia, anal fistula, etc.
② When necessary, use stimulant laxatives according to doctor’s orders, such as rhubarb, senna, etc. Due to their strong effects, they can easily cause severe diarrhea, so use them as little as possible and pay attention to observation during use.
③ Instruct patients to avoid long-term use of laxatives. Long-term use of laxatives may cause dependence, weaken the intestinal function of spontaneous defecation and aggravate constipation; it may also cause loss of protein, iron and vitamins, leading to nutritional deficiencies.
(2) Simple laxatives for external use
Elderly patients often use simple laxatives, such as enema, glycerin suppository, soap suppository, etc., which are inserted through the anus to stimulate intestinal peristalsis, soften the stool, and achieve a laxative effect.
(3) Enema method
Severe constipation can be treated with enema if necessary. You can follow the doctor’s advice to use “1, 2, 3” solution, vegetable oil or soapy water for small-volume non-retention enema.
4. Psychological adjustment
Patients should understand the causes of constipation, regulate their emotions, relax their minds, and avoid constipation caused by mental stress and stimulation. Patients should actively participate in group activities and improve their family and social support levels.
5. Exercise and exercise properly
(1) Participating in general sports
The elderly can participate in sports according to their own circumstances. If their physical condition permits, they can participate in appropriate physical exercises such as walking, jogging, Tai Chi, etc.
(2) Avoid sitting or lying down for long periods of time
Avoid long-term bed rest or wheelchair use. If the patient cannot move on his own, assistive devices can be used to help him stand or perform passive activities.
(3) Abdominal massage
You can do abdominal massage in supine position, start from the right lower abdomen and use your palm to move clockwise upwards, to the left, and then downwards to the left lower abdomen. Increase the strength when massaging to the left lower abdomen. Do it 2 to 3 times a day, 5 to 15 times each time. You can also do this activity while standing.
(4) Abdominal and anal muscle exercises
Contract the abdominal and anal muscles for 10 seconds and then relax. Repeat the training several times to increase the contraction force of the auxiliary muscles of defecation and enhance the ability to defecate.
(5) Bed exercise method
Lie on the bed, bend one leg and raise it to your chest, practice 10 to 20 times for each leg, 3 to 4 times a day, turn from one side to the other (10 to 20 times), 4 to 10 times a day.
6. Develop a healthy lifestyle
(1) Cultivate good bowel movement habits and instruct patients to have a bowel movement in the morning or before breakfast. Even if they do not feel like defecation, they should squat on the toilet for 3 to 5 minutes or go to the toilet one hour after a meal.
(2) Correct bad eating habits, eat more foods high in crude fiber, and drink more water.
(3) Patients with hypertension, coronary heart disease, and cerebrovascular accident should avoid straining during bowel movements. If defecation is difficult, they should promptly inform medical staff and take appropriate measures to avoid accidents.
7. Use laxatives correctly
(1) When taking bulk laxatives, you need to drink 250 ml of water.
(2) Lubricating laxatives should not be taken for a long time, as they may affect the absorption of fat-soluble vitamins.
(3) Mild oral laxatives usually take effect 6 to 10 hours after taking them, so they should be taken 1 hour before bedtime.
(4) How to use simple laxatives: The elderly should lie on their left side, relax the anal sphincter, squeeze the medicine into the anus, retain it for 5 to 10 minutes, and then defecate.
prevention
Precautions
1. Develop the habit of regular bowel movements
You need to determine a bowel movement time that suits you. No matter whether you have the urge to defecate or whether you can defecate, you must go to the toilet on time. As long as you persist for a long time, you will form a conditioned reflex of regular bowel movements.
2. Adjust your diet
The elderly should eat more foods high in fiber, such as whole flour, brown rice, corn, celery, leeks, spinach and fruits, to increase dietary fiber and stimulate and promote intestinal peristalsis. Sesame and walnut kernels have a laxative effect, so the elderly can also eat more of them.
3. Drink more water
It is best for the elderly to drink a glass of warm water or honey water on an empty stomach every morning to increase intestinal peristalsis and promote defecation. The elderly should also drink more water on a regular basis and not wait until they are thirsty to drink water.
4. Participate in sports appropriately
The elderly should participate in sports appropriately, especially abdominal muscle exercises, in order to strengthen the abdominal muscles and promote intestinal peristalsis and improve defecation ability. For the elderly who have been bedridden for a long time due to illness, their family members can give them abdominal massages, gently pushing from the right upper abdomen to the left lower abdomen to promote intestinal peristalsis.
5. Stay optimistic
Negative emotions such as mental tension and anxiety can cause or aggravate constipation. Therefore, the elderly should always keep a happy mood and not get angry easily to avoid constipation.