混合型便秘诊治进展

混合型便秘（MC）是一种同时有慢传输型便秘（STC）和出口梗阻型便秘（OCC）临床表现的功能性便秘,不仅影响患者的生活质量,更对患者的身心健康造成严重损害。由于MC病因复杂、发病机制不明确、目前的诊断方式、方法不能完全满足临床需要、治疗效果欠佳,常称之为顽固性便秘。本文就近年来发表的有关MC的病因、发病机制、诊断及治疗现况文献进行综述,为MC临床诊治寻找新的方式、方法提供参考。     

Electromyographic findings of paradoxical puborectalis contraction correlate poorly with cinedefecography

Abstract. Background: Both intra-anal sponge electromyography (SEMG) and needle electromyography (NEMG) are used to diagnose paradoxical puborectalis contraction (PPC). The aim of this retrospective study was to assess the correlation among SEMG and NEMG and cinedefecography (CD) in the diagnosis of PPC. Methods: Between 1992 and 1999, a total of 261 constipated patients underwent both CD and EMG: 64 had NEMG while 197 had SEMG. PPC was diagnosed by EMG when there was failure to achieve a significant decrease in electrical activity of the puborectalis muscle during attempted evacuation. CD criteria for PPC included lack of straightening of the anorectal angle or persistence of the puborectalis impression during evacuation. CD was considered diagnostic and EMG results were thus compared with those of CD. Agreement was calculated using the kappa statistics () for concordance. Results: Both NEMG and SEMG had low positive predictive rates (33% in NEMG, 28% in SEMG) and high negative predictive rates (91% in NEMG, and 78% in SEMG) when correlated with CD findings. Agreement between NEMG and CD was noted in 46 of 64 patients (72%, =0.274) while there was agreement between SEMG and CD in 120 of 197 patients (61%; =0.067); p>0.05 needle vs. sponge. Conclusion: Although both NEMG and SEMG have a low positive predictive values, they have high negative predictive value for PPC. Therefore, neither NEMG nor SEMG alone are optimal tests for diagnosing the presence of PPC.This work was presented in poster format at the Annual Meeting of the Association of Coloproctology of Great Britain and Ireland, 19–12 July 2000, Brighton, UK.     

Enterochromaffin and serotonin cells are abnormal for patients with colonic inertia

PURPOSE: In recent studies, serotonin and several gut peptides have been shown to serve as regulators of colonic transit. Thus, the distribution, density, and intensity of cells secreting serotonin or certain gut peptides could be abnormal in patients with colonic inertia. The aim of this study was to evaluate the distribution, density, and staining intensity of enterochromaffin and serotonin cells in the colonic mucosa of patients with colonic inertia compared with a control group. METHODS: Between 1993 and 1998 tissue blocks from the right and left side of the colon were obtained in 19 consecutive patients (18 females; mean age, 43.7±11.5 years) who underwent subtotal colectomy for colonic inertia. The control group consisted of colonoscopic biopsies from the right and left colon of 15 patients (all females; mean age, 52.7±16.5 years) for indications other then constipation, inflammatory bowel diseases, or carcinoma. Immunocytochemical staining of enterochromaffin and serotonin cells were performed on 4 µm tissue sections with the primary rabbit antibody against chromogranin A or serotonin, and the biotinylated secondary antibody and enzyme-labeled-streptavidin. The average cell number per microscopic field (×200) was calculated and the proportion of cells with various staining distribution was expressed as the percentage of the entire positive cell population as low, moderate, and high intensity. Student'st-test and chi-squared test were used for statistical analysis, with significance level set atP<0.05. RESULTS: The quantity of both enterochromaffin cells (16.8±10.2) and serotonin cells (12.1±6.4) in the mucosa of the left colon in patients with colonic inertia was significantly higher when compared with the right side of the colon (enterochromaffin cells, 9.4±6.0; serotonin cells, 7.8±3.6;P<0.01). The percentage of both types of cells with low staining intensity was increased, whereas the cells with high and moderate staining intensity were decreased (P<0.01) in the left colon as compared with the right. The number of enterochromaffin cells in left-sided colonic mucosa was significantly higher in the colonic inertia group than in the control group (16.8±10.1vs. 10.4±6.0;P<0.05). Moreover, the numbers of serotonin cells in both the right and left colon was also significantly higher in the colonic inertia group than in the control group (right, 7.8±3.6vs. 4.1±2.4; left, 12.1±6.4vs. 5.8±3.7;P<0.01). In both sides of the colon, the percentage of enterochromaffin and serotonin cells with low staining was significantly higher, whereas percentage of those cells with high or moderate staining was significantly lower in the colonic inertia group than in the control group. In the colonic inertia group there was a significantly positive correlation between numbers of enterochromaffin and serotonin cells (right side,P<0.01; left side,P<0.05). CONCLUSION: In patients with colonic inertia, the number of both enterochromaffin and serotonin cells are significantly increased in the colonic mucosa, especially in the left colon. As indicated by staining distribution, enterochromaffin and serotonin cells contain significantly less hormone than do the same cells in the control group.Funded in part by a grant from the Eleanor Naylor Dana Charitable Trust.Read at The American Society of Colon and Rectal Surgeons' 100th Anniversary and Tripartite Meeting, Washington, D.C., May 1 to 6, 1999.     

“Melanosis” in the small and large intestine

Deposition of pigment in the intestinal mucosa is commonly observed by the endoscopist, especially within the colon, and particularly during investigations for constipation. Pigment may also be detected in the small intestine. Although labeled as melanosis, electron microscopy and X-ray analytical methods have provided evidence that this pigment is not melanin at all, but lipofuscin. Often, herbal remedies or anthracene containing laxatives are often historically implicated, and experimental studies in both humans and animal models have also confirmed the intimate relationship with these pharmacological or pseudo-pharmacological remedies. The appearance of melanosis coli during colonoscopy is largely due to pigment granule deposition in macrophages located in the colonic mucosa. The pigment intensity is not uniform, being more intense in the cecum and proximal colon compared to the distal colon. Possibly, this reflects higher luminal concentrations of an offending agent in the proximal compared to distal colon, differential absorption along the length of the colon, or finally, differences in macrophage distribution within the colon. Mucosal lymphoid aggregates normally display a distinct absence of pigment producing a ＂starry sky＂ appearance, especially in the rectosigmoid region. Interestingly, some focal, usually sessile, colonic mucosal neoplastic lesions, rather than submucosal lesions, may be better appreciated as pigment deposition may be absent or limited. If detected, removal and further histopathologic analysis of the polyp may be facilitated.     

急性心肌梗死病人便秘的原因分析及护理对策

目的分析急性心肌梗死病人便秘的原因及探讨其护理措施。方法从2010年3月至2013年3月我院收治的心肌梗死患者中选取50名发生便秘的患者,统计这些患者发生便秘的原因,然后将患者分为两组,对照组进行常规护理,实验组采用针对性的护理。结果患者因心理N素和身体因素导致急性心肌梗死患者便秘的概率明显高于环境因素及饮食因素,统计学有意义（P〈0．05）。实验组总有效率（92．00％）明显高于对照组（64．00％）,统计学有意义（P〈0．05）。结论通过分析原因和实施相应的护理措施,可以改善急性心肌梗死便秘患者的胃肠道功能,很大程度上降低了急性心肌梗死患者的便秘发生率。     

慢性便秘患者生物反馈疗法的疗效预测因素分析

 目的 探讨慢性便秘(CC)患者生物反馈(BF)疗法的疗效预测因素。方法 对70例CC患者进行BF治疗,治疗前应用焦虑自评量表(SAS)、抑郁自评量表(SDS)、生活质量汉化版简明健康调查量表(SF-36)及生活方式量表进行问卷调查,同时对患者进行肛门直肠测压。治疗前后通过症状积分量表评定患者5项主要症状,以治疗前后症状积分变化作为BF疗效判断指标,对治疗前采集的可能影响BF疗效的因素进行单因素、多因素分析,得出BF疗效的独立预测因素。结果 单因素分析结果显示,BF疗效与生活质量中的“生理职能”维度呈正相关(r=0.256,P=0.031),与SDS评分(r=-0.315,P=0.007)、初始感觉阈值(r=-0.278,P=0.020)呈负相关。多因素分析结果显示,SDS评分(β=-0.263,P=0.033)、初始感觉阈值(β=-0.281,P=0.013)是BF疗效的独立预测因素。结论 存在抑郁倾向、直肠低敏感的CC患者BF疗效较差,采用相应的治疗措施有助于优化BF疗效。     

耻骨直肠肌部分松解术治疗耻骨直肠肌综合征62例

为探讨耻骨直肠肌部分松解术治疗耻骨直肠肌综合征所致便秘的临床疗效,对62例经症状、体征及相关检查确诊为耻骨直肠肌综合征所致便秘患者采用耻骨直肠肌部分松解术治疗,观察治疗后临床疗效及随访3个月疗效。结果显示,62例患者治疗后总有效率为96．7％,随访3个月疗效为95．2％。结果表明,耻骨直肠肌部分松解术治疗耻骨直肠肌综合征所致便秘安全有效。     

滋阴润肠流膏口服治疗功能性便秘的疗效观察

为观察滋阴润肠流膏口服治疗功能性便秘的临床效果,将60例功能性便秘患者随机分为治疗组和对照组,每组各30例。治疗组采用口服滋阴润肠流膏治疗,对照组采用口服六味能消胶囊治疗。两组均以4周为1个疗程,观察两组的临床疗效,并对治愈患者随访2个月,观察远期疗效。结果显示,治疗组在排便不尽感、排便困难、排便频率及大便性状等方面疗效明显优于对照组（P〈0．05）。结果表明,滋阴润肠流膏口服治疗功能性便秘更为有效、安全,具有服用剂量较小、便于久服、服用适口、生物利用度高、强健补益等独特的优点。     

护理干预解决便秘对颅脑手术后并发脑水肿的影响

目的：分析护理干预解决便秘对颅脑手术后并发脑水肿的影响。方法选取我院2008年3月～2012年3月期间收治的100例行颅脑手术的患者,按住院序号分为A、B两组。给予A组患者常规护理解决便秘措施,给予B组患者护理干预解决便秘措施,比较两组患者临床护理效果。结果 A组患者肺部感染发生率为12.0%,水电解质紊乱发生率为10.0%,脑水肿发生率为10.0%;B组患者肺部感染发生率为2.0%,水电解质紊乱发生率为2.0%,脑水肿发生率为0。两组比较,B组患者肺部感染、水电解质紊乱以及脑水肿等并发症发生率最低,差异有统计学意义（P＜0.05）。 A组患者及家属对临床护理工作的满意率为52.0%,B组患者及家属对临床护理工作的满意率为88.0%,两组比较,B组患者满意度更高,差异有统计学意义（P＜0.05）。结论护理干预可有效降低行颅脑手术患者脑水肿等并发症发生率。     

A Longitudinal Study of Predictors of Constipation Severity in Oncology Outpatients With Unrelieved Pain

ContextAlthough constipation is a common symptom in oncology patients, it often goes unrecognized and untreated. In addition, little is known about characteristics associated with interindividual differences in constipation severity.ObjectivesTo describe prevalence, characteristics, and management of constipation; evaluate interindividual differences in constipation severity over 10 weeks; and identify demographic, clinical, and symptom characteristics associated with higher constipation severity scores.MethodsIn this prospective, longitudinal study, 175 oncology patients with unrelieved pain were recruited from eight outpatient cancer settings in the U.S. Patients completed demographic and symptom questionnaires at enrollment. Constipation severity was evaluated over 10 weeks using the Constipation Assessment Scale (CAS). Hierarchical linear modeling was used to identify characteristics associated with higher CAS scores.ResultsAt enrollment, 70.1% of the patients reported constipation [i.e., CAS score of >2; mean CAS score: 3.72 (±3.11)]. While over the first week of the study patients used one to two constipation treatments per day, a large amount of interindividual variability was found in CAS scores. Higher percentage of days with no bowel movement, higher number of constipation treatments, higher state anxiety scores, and higher analgesic side effects scores were associated with higher CAS scores at enrollment. Higher percentage of days with no bowel movement was associated with interindividual differences in the trajectories of constipation.ConclusionOur findings underscore the high prevalence of and large amount of interindividual variability in constipation severity. The characteristics associated with worse CAS scores can assist clinicians to identify high-risk patients and initiate prompt interventions.