Senile constipation

　　The causes of constipation include intestinal diseases and systemic diseases, and some patients' constipation is idiopathic constipation. Intestinal diseases include inflammatory bowel disease, tumor, hernia, rectal prolapse, etc. Systemic diseases include diabetes, uremia, cerebrovascular accidents, Parkinson's disease, etc. Regular use of certain drugs is easy to cause constipation, such as opiate analgesics, anticholinergic drugs, antidepressants, calcium channel blockers, diuretics, etc. In addition, reduced physical activity in the elderly, and a lack of fiber in the diet are factors that promote constipation.
　　Normal defecation includes two processes: the sensation of defecation and the defecation action. After meals, through the gastrocolic reflex, colonic motility is enhanced, and feces are propelled towards the distal colon. When the rectum is filled, the internal anal sphincter relaxes, while the external anal sphincter contracts, increasing the intrarectal pressure. When the pressure stimulation exceeds the threshold, it triggers the sensation of defecation. This impulse of defecation sensation is transmitted along the pelvic nerve and hypogastric nerve to the defecation center in the lumbar sacral spinal cord, and then上行 through the thalamus to reach the cerebral cortex. If the environment allows, the puborectalis muscle and the internal and external anal sphincters are all relaxed, both levator ani muscles contract, the abdominal muscles and diaphragm also coordinate contraction, abdominal pressure increases, and promotes the excretion of feces.

　　Elderly excessive effort in defecation can induce TIA (transient ischemic attack) or syncope, even myocardial infarction and cerebral apoplexy on the basis of atherosclerosis. Constipation can cause or exacerbate hemorrhoids and other perianal diseases. After fecal impaction, intestinal obstruction, fecal ulcer, urinary retention, and fecal incontinence may occur. There are also reports of spontaneous colonic perforation and sigmoid volvulus.

　　The main manifestations of elderly constipation are reduced frequency of defecation and difficulty in defecation. Many patients have less than 2 bowel movements a week, and severe cases may take 2 to 4 weeks to defecate once. However, the reduction in defecation frequency is not the only or necessary manifestation of constipation. Some patients may have prominent difficulty in defecation, with defecation time lasting more than 30 minutes, or defecating multiple times a day but with difficulty, hard stool like sheep dung, and a small amount. In addition, there are symptoms such as bloating, decreased appetite, and abdominal pain before defecation caused by improper use of laxatives. Physical examination shows fecal residue in the lower left abdomen, and digital rectal examination shows fecal masses.

　　Fiber is very important for changing the nature and defecation habits of stool. The fiber itself is not absorbed, can cause the stool to swell, stimulate colonic motility, which may be more effective for patients with insufficient fiber intake. The food with the most fiber is bran, followed by fruits, vegetables, oatmeal, corn, soybeans, pectin, etc. If there is stool impaction, the stool should be excreted first, and then fiber should be supplemented.

　　For elderly patients with constipation, it is necessary to understand the medical history, perform a detailed physical examination, and conduct the following laboratory tests to clarify whether the constipation is simple or due to symptoms caused by other diseases.

　　Firstly, laboratory examination
　　1. Stool examination:Observe the shape, size, hardness, and presence of pus and mucus in the stool. During rectal constipation, due to the relaxation of the rectal smooth muscle, the stool discharged is often in clumps; while in spastic colonic constipation, the stool is often in the shape of sheep dung. Routine stool examination and occult blood test are part of the routine examination.
　　2. Rectal examination:They are helpful in detecting rectal cancer, hemorrhoids, anal fissures, inflammation, stricture, hard stool blockage, and external pressure, anal sphincter spasm or relaxation, etc. When there is rectal constipation, a large amount of dry hard stool can be found in the rectum.
　　Secondly, other auxiliary examinations
　　1. Gastrointestinal X-ray examination:Barium meal examination of the gastrointestinal tract is of reference value for understanding the function of gastrointestinal motility. Normally, barium can reach the splenic area of the colon within 12 to 18 hours and should be completely excreted from the colon within 24 to 72 hours. There may be delayed evacuation during constipation. Barium enema, especially the colon hypotonic double-contrast imaging adopted in recent years, may be helpful in discovering the cause of constipation.
　　2. Special examination:By ingesting a certain amount of non-radioactive X-ray opaque tube fragments as markers, timed abdominal X-ray imaging can provide information on the speed and distribution of the markers within the gastrointestinal tract. If it is rectal constipation, the markers can be seen moving quickly through the colon and finally accumulating in the rectum; if it is colonic constipation, the markers are distributed between the jejunum and rectum.

　　In the diet of elderly patients with constipation, it is appropriate to increase the intake of dietary fiber, and the diet should not be too greasy. Suitable foods include vegetable soup, soy milk, fruit juice, honey, sesame, walnuts, sesame oil, corn oil, vegetable oil, soybeans, mung beans, cowpeas, sweet potatoes, potatoes, brown rice, spinach, water chestnuts, mulberries, white radish, bananas, etc.; taboo foods: alcohol, coffee, strong tea, garlic, chili, unripe persimmons, silver ear, etc.

　　The etiology of elderly constipation is relatively complex. Simple constipation can be relieved by changing dietary habits and strengthening exercise, and systemic treatment is required for severe cases. The methods for treating elderly constipation are as follows:
　　First, non-drug treatment
　　Carry out health education to help patients establish normal defecation behavior; prevent or avoid the use of drugs that cause constipation, do not abuse laxatives; drink at least 1500ml of water every day. Eat more foods rich in rough fiber such as grains, vegetables, fruits, beans, and nuts; persist in endurance exercises, walk at least 2 public stations every day; actively treat systemic and perianal diseases.
　　Second, drug treatment
　　1, Saline mild laxatives: Such as magnesium sulfate, sodium phosphate, due to the osmotic effect, can quickly increase the water content in the stool, and sudden watery diarrhea can occur within half an hour. These laxatives can cause electrolyte and water imbalances and should not be used for a long time. They can be used for enema to remove feces in patients with fecal impaction. Patients with renal insufficiency should not use magnesium-containing preparations.
　　2, Lubricants: Liquid paraffin (paraffin oil) can soften stools and can be taken orally or by enema. It is suitable for elderly patients after myocardial infarction or postoperative perianal diseases to avoid strenuous defecation. It is ineffective for drug-induced constipation. Long-term use can affect the absorption of fat-soluble vitamins A, D, E, and K. It is more appropriate to take it between meals and avoid taking it before bedtime to prevent aspiration into the lungs and cause lipoid pneumonia.
　　3, Stimulant laxatives: These drugs include Dufans, Senna leaves, Oxytropis seeds/Oxytropis seed shells/Senna fruits (Shulitong), Sodium bicarbonate of rhubarb (Rhubarb soda). They stimulate colonic peristalsis and have a defecation effect within 6 to 12 hours, but may cause adverse reactions such as abdominal pain and electrolyte imbalances. Long-term use can lead to loss of protein and weakness, and can form a cathartic colon due to damage to the interspace nerves of the rectum. These preparations contain anthraquinones, and long-term intake can cause melanin deposition under the colonic mucosa, forming what is known as colonic melanosis, a benign and reversible lesion.
　　4, Hypertonic laxatives: Sorbitol and lactulose solutions are electrolyte mixtures containing non-absorbable sugars. Lactulose is a synthetic disaccharide composed of one molecule of fructose and one molecule of galactose linked together. There is no enzyme in the human body that can hydrolyze it into monosaccharides, so lactulose can pass through the gastrointestinal tract to the colon intact after oral administration, and then be decomposed into monosaccharides, followed by decomposition into low molecular weight organic acids, increasing the osmotic pressure and acidity of the intestinal lumen, making defecation easier. Lactulose (Duomici) can be taken orally at a dose of 15ml/d to 30ml/d, and it has a defecation effect within 24 to 48 hours.
　　5. Bulking Laxatives: Such as Jinfu Fiber King, Metamucil, because they contain high molecular weight cellulose and cellulose derivatives, they have the characteristics of hydrophilicity and water absorption expansion, which can increase the water and volume of feces, promote colonic peristalsis. This type of laxative is more suitable for the elderly with low residue diet, not only defecating, but also controlling blood lipids, blood sugar, and preventing the occurrence of colorectal cancer. When taking, it is necessary to drink 240ml of water or juice at the same time to prevent the gel-like material from blocking the intestinal lumen and causing intestinal obstruction.
　　3. Comprehensive Sequential Therapy
　　For habitual constipation, it is advisable to clean the intestines first before training regular defecation, that is, to clean the intestines with physiological saline enema, 2 times/day, for a total of 3 days. After cleaning the intestines, check the abdomen and take an abdominal plain film to determine that there is no fecal impaction in the intestines. After cleaning the intestines, you can give liquid paraffin (paraffin oil), 5ml/(kg·d) to 15ml/(kg·d), or lactulose 15ml/day to 30ml/day, so that the defecation frequency can reach at least once/day. At the same time, encourage patients to defecate after breakfast. If they still do not defecate, they can be encouraged to defecate again after dinner, so that the patients can gradually restore normal defecation habits. Once regular defecation after meals occurs and lasts for more than 2 to 3 months, liquid paraffin (paraffin oil) or lactulose can be gradually discontinued. During this process, if there is no defecation for 2 to 3 days, it is still necessary to clean the intestines to avoid recurrent fecal impaction. Literature reports indicate that this method of cleaning the intestines, taking mild laxatives, and training defecation habits for the treatment of habitual constipation has a success rate of 70% to 80%, but many cases will recur.
　　4. Biofeedback Treatment
　　In recent years, there have been many literature reports on the use of biofeedback measures, with a success rate of defecation reaching 75% to 90%. Biofeedback therapy involves inserting a special anal-rectal manometer into the anus, which is equipped with an observable display, providing many pieces of information, including anal sphincter pressure, rectal compliance, anal-rectal sensation sensitivity, allowing the patient to feel when there may be a defecation response, and then try this response again, stimulating the defecation sensation, and achieving the purpose of defecation.