Record of first visit
Date of visit
Gender F
Age 41
____________________________________________________________________________________
Chief complaint Constipation for five days
DESCRIBTIONS
ASKING
Present illness This patient has constipation problem all the time for 10 years. This time she has 5 days without defecation and a distension pain on the abdomen. No fever nor chill. No sweating. Abdominal distending pain and fullness under the diaphragm. Patient didn’t eat meals only some biscuits and fruits (mainly apples). Not much drinks a day and doesn’t have much urine. When she visited, she had abdominal distension pain, shortness of breath and also cold hands and feet.
Menstruation 14 4/7
Previous history She has congenital heart valve problem with often palpitation.
Family history Rest of the family are healthy
Allergy No
INSPECTION
General body Very tall and skinny, seriously under weight
Complexion Pale complexion and looks very tired
Tongue Pink tongue body and thin white watery tongue coating
Pulse Moderate forceful pulse
AUSCULTATION
Sound/Odours
PALPATION
Abdomen Palpation Very hard on the abdominal region and prefers hard pressure.
WESTERN MEDICINE in terms of Constipation
Definition
Constipation is a decrease in the frequency of stool (the body's waste product) or difficulty in the formation or passage of stool.
Description of Constipation
Constipation is determined in the colon (large intestine), which is responsible for packaging and eliminating stool.
As food moves through the colon, it absorbs water while forming stool. Muscle contractions (squeezing motions) in the colon push the stool toward the rectum (the lower 8 to 10 inches of the large intestine). By the time stool reaches the rectum, it is solid, because most of the water has been absorbed.
Constipation occurs when the stool becomes hard and dry (due to too much water absorption) and is unable to pass out of the body during a bowel movement.
Causes and Risk Factors of Constipation
The common causes of constipation are:
* Not enough fiber in the diet - The American Dietetic Association recommends 20 to 35 grams of fiber each day, but the average American eats about 5 to 20 grams a day. Examples of fiber-rich foods are unprocessed wheat bran, unrefined breakfast cereals, fresh fruits (except bananas), dried fruits, vegetables (except potatoes), grainy breads and legumes.
* Not enough liquid - Liquids like water and juice add fluid to the colon and bulk to stools, making movements softer and easier to pass. Recommended daily consumption of liquid is eight, eight-ounce glasses (totaling 64 ounces) per day.
* Lack of exercise
* Medications - Some medications that can cause constipation are: analgesics (Codeine, Demerol, Perocdan), antacids (Maalox, Mylanta), anticholingerics (Donnatal), anticonvulsants (Dilantin), anti-depressants (Tricyclics), Beta-blockers (Inderal, Tenormin) iron and calcium supplements, pain medications, antispasmodics and diuretics.
* Irritable Bowel Syndrome (IBS) - IBS is a common condition marked by chronic or occasional diarrhea, alternating with constipation and accompanied by straining and abdominal cramps. (see Health Profile: IRRITABLE BOWEL SYNDROME)
* Lifestyle changes, such as pregnancy, aging and traveling
* Laxative abuse - A laxative is a food or chemical substance that acts to loosen the bowels by softening and increasing the bulk of bowel contents, increasing the amount of water in the colon and lubricating the intestinal walls. Over time, laxatives can damage nerve cells in the colon and interfere with the colon's natural ability to contract.
* Ignoring the urge to have a bowel movement
* Diseases such as multiple sclerosis, Parkinson's disease, chronic idiopathic intestinal pseudo-obstruction, stroke, spinal cord injuries, diabetes, under-active and over-active thyroid gland, uremia (excess urine waste product), amyloidosis (accumulation in the tissues/organs of amyloid), lupus, scleroderma (an autoimmune disorder that affects the tissues/organs), colorectal cancer, depression, colon tumors, diverticulosis and Hirschsprung's disease.
Symptoms of Constipation
Depending on your diet, age and daily activities, regular bowel movements can mean anything from three bowel movements per day to one every three days. If you are experiencing hard, compacted stools that are difficult or painful to pass, the urge to move the bowels (even though you just had a movement), or no bowel movement over three days for adults and four days for children, you may have constipation.
Diagnosis of Constipation
Occasional constipation does not justify visiting a doctor, but if the constipation becomes a persistent problem, you should. The doctor will first take a medical history and ask about the symptoms, duration, frequency and consistency of the stools and bowel movements. Next, the doctor will examine the abdomen for any sign of a hardened mass and conduct a digital rectal exam (DRE). During the DRE, the doctor will insert a gloved, lubricated finger into the rectum to feel for any tenderness, obstruction or blood. In some cases, blood and thyroid tests may be necessary.
More extensive testing is reserved for people with severe symptoms. This testing may include a barium enema x-ray, sigmoidoscopy, colonscopy, colorectal transit study or anorectal function tests (anorectal manometry and defecography). A barium enema x-ray involves viewing the rectum, colon and lower part of the small intestine after filling the organs with a chalky liquid to make these areas visible. A sigmoidoscopy is an examination of the rectum and lower colon (sigmoid) using a viewing instrument called a sigmoidoscope.
A colonoscopy is an examination of the rectum and entire colon using an instrument called a colonscope. The colorectal transit study shows how well food moves through the colon. After swallowing capsules containing small markers, the markers’ movements are viewed via an x-ray.
An anorectal manometry evaluates anal sphincter muscle function. A catheter or air-filled balloon inserted into the anus is slowly pulled back through the sphincter muscle to measure muscle tone and contractions. Defecography is an x-ray of the anorectal area that identifies anorectal abnormalities, evaluates rectal muscle contractions and relaxation.
Treatment of Constipation
Most cases of constipation respond to conservative treatment such as dietary and lifestyle changes or mild laxatives.
Dietary changes include getting enough of the recommended daily amount of fiber (20 to 35 grams), drinking 64 ounces of water or juice a day, and limiting foods that have little or no fiber, such as ice cream, cheese, meat and processed foods.
Lifestyle changes consist of exercising, reserving enough time to have a bowel movement and having a bowel movement when needed.
Laxatives may be recommended if the above changes did not help the constipation.
There are four types of laxatives - bulk-forming, stimulant, lubricant and saline. Bulk-forming laxatives, such as Metamucil, Citrucel and Serutan increase the volume of feces, making them softer and easier to pass. Stimulant laxatives, such as Correctol, Ex-Lax, Dulcolax, Purge, Feen-A-Mint and Senokot stimulate the intestinal wall to contract. Lubricant laxatives, such as mineral oil, soften the stool so it is easier to pass. Saline laxatives, such as Milk of Magnesia, Citrate of Magnesia and Haley's M-O, increase the concentration of salts within the feces.
Note: Laxatives can be habit-forming. If laxative use causes asthma, skin rash, dizziness, irregular heartbeat, dehydration, muscle cramping, nausea or other side effects, please see a doctor immediately.
Other treatment methods may include:
* Bowel retraining - may provide relief for people who have gotten into the habit of ignoring the urge. If a tight schedule has produced a tight sphincter, it may help to sit on a toilet, with book in hand, about 20 minutes each morning to encourage a return of reflexes that have disappeared. Straining is not recommended, since it may lead to tightening of muscles that should be relaxed for comfortable defecation.
* Rectal suppositories - helpful in providing lubrication and in stimulating the defecation reflex. They are usually composed of glycerin, which is sometimes blended with sodium sterate, a fatty acid. Bisacodyl-containing suppositories have added potency, because they act directly on the bowel to stimulate emptying.
* Enemas - usually become attractive only when oral laxatives cannot do the job. Introducing water into the colon helps to stimulate defecation. "Disposable" enemas deliver a solution of highly concentrated, nonabsorbable salts into the rectum and sigmoid colon. These salts attract an outpouring of fluid into the bowel and thus promote bowel contraction. Oil-containing enemas are sometimes recommended as softeners for feces that have become hardened within the rectum.
* Biofeedback - may be recommended for people with chronic constipation caused by anorectal dysfunction. Biofeedback involves using a sensor to monitor muscle activity displayed on a computer screen allowing for accurate assessment of body functions. With this information, the doctor helps the person learn how to use the anorectal muscles.
* Surgery - Surgical removal of the colon may be an option for people with severe symptoms caused by colonic inertia (lack of movement in the colon) and unremitting extreme constipation.
TCM - CONSTIPATION
Constipation is a condition of dry compacted feces in the large intestine, difficulty and failure in defecating for more than two days. It is mainly caused by the impaired transmitting function of the large intestine and also related to the function of the spleen, stomach and kidney. Constipation can be divided into tow types, deficiency and excess. Habitual constipation in modern medicine can be treated according to deficiency or excess.
Aetiology and Pathogenesis
Excess Condition
1. Constitutional excess of Yang and Food exaggeration:
Constitutional Yang preponderance, and indulgence in spicy and greasy food may lead to accumulation of heart in the stomach and intestines, consumption of the body fluid which leads to dryness in intestines as well as dry stools.
2. Emotional Factors:
Anxiety and depression may cause stagnation of Qi, impairing the function of the large intestine in transmitting. As a result, the wastes are retained inside and unable to move downward, causing the constipation.
Deficiency Condition
1.Deficiency of Qi and Blood:
It may happen after an illness, or delivery, or in the aged people, which may lead to deficiency of Qi and blood. Qi deficiency results in weakness of the large intestine in transmission. While blood deficiency gives rise to shortage of body fluid, then the large intestine can no longer be moistened, which causes constipation.
2. Cold Deficiency of the Lower Energizer
Deficiency of Yang Qi in the Lower Energizer leads to congealment of interior cold which obstructs the Qi flow of large intestine, resulting in constipation.
Differentiation
Excess Condition
Main manifestations: Difficult passage of dry, hard stool, defecation every three to five days, or even longer. General fever, thirst, foul breath, rapid pulse, yellow dry tongue coating or fullness and distending pain in the abdomen and hypochondria regions, frequent belching, loss of appetite, thin, sticky tongue coating, string-taut pulse.
Deficiency Condition
Main manifestations: Difficult passage of dry stools, pale complexion and lips, dizziness and palpitation, lassitude, shortness of breath, pale tongue, thin tongue coating, thready and weak pulse, or abdominal pain, preference for warmth and aversion to cold, pale tongue, white and moist tongue coating, deep, slow pulse.
Treatment
Principle: Select the back shu and front mu points of Large Intestine meridian and the points of Triple Energizer and Kidney meridians as principal points. For excess condition, the reducing manipulation is applied to remover the heart and Qi stagnation and moistening the intestine, while for deficiency condition, the reinforcing manipulation is used to reinforce Qi and blood and intestines. Constipation due to cold can be relieved by moxibustion to warm the Lower Energizer for defecation.
Prescription
Dachangshu, Tianshu, Zhigou, Zhaohai, Shuidao
Additional Points
Add Quchi, Hegu for accumulation of heart; Zhongwan, Taichong for stagnation of Qi, Pishu, Weishu, Zusanli for deficiency of Qi and Blood, Mixibustion on Shenque and Qihai is applied for congealment of cold.
Explanation
The causes of constipation are various, but they are common in impairing the transportation of the large intestine, because of the failure of body liquid to moisten the large intestine. Therefore, Dachangshu, the backshu of the large intestine, Tianshi, the front mu point of large intestine are used to promote the flow of Qi in the large intestine, the transportation can be regained when the Qi of the Fu-organ flows smoothly then constipation can be relieved, Zhigou, the fire point of Triple Energizer can eliminate fire from the large intestine to promote bowel motions. Zhongwan can remover stagnation of Triple Energizer. Taichong is to soothe the liver Qi in order to remover the stagnation of intestine. Reinforceing to Pishu, Weishu, and zusanli is able to reinforce Qi in the spleen and stomach. Once the spleen and stomach Qi is vigorous, Qi and blood can be produced as a natural consequence, so this is the approach of treating the main cause of constipation in deficiency conditions. Moxibustion to Shenque and Qihai is foffered to regulate the flow of Qi and loosen the bowels. Zushuidao is an empirical point for constipation.
DIAGNOSIS Chronic Constipation
Syndrome
Differentiation Qi stagnation due to Qi deficiency
Explanation According to the patient’s daily diet and drinks, that the food patient took couldn’t produce enough Qi and nutrients for the body and the useless substances slowly build up in the body cause food stagnation and impair the Qi manifested in Qi stagnation and constipation. This is a chronic constipation the Qi has been impaired for a long time and it turns to deficient.
Treatment principles To tonic the Qi and body fluid.
Points and therapies I didn’t have needles when patient visited, so I used another person to use acupressure on Zusanli足三里 Shangjuxu上巨虛 and I did on Tianshu (left and right)天樞x2, Guanyuan關元, Qihai氣海 at the same time and use An Rou fa for 25 minutes. Mo Fu 摩腹 clockwise for another 25 minutes. After the acupressure and massage, gave the patient some warm water (half glass) and asked her to have a rest.
Result The patient had defecation in an hour after the acupressure massage and completely relieved the abdominal pain and distension.
Life style advice Advise the patient to have regular meals and drinks sufficient fluid. Take some alternative food such as 紅棗Dazao 黑棗Hezao instead of fruits. Also some slow exercise such as Yoga or Palate. Regular abdominal massage to promote the bowl movement to reduce the symptoms.
Follow up the result Three weeks follow up. The patient had followed the instructions as advised. She hasn’t have constipation since.
CONCLUSION
This patient has congenital heart valve problem. She suffers obvious Qi deficiency due to Qi stagnation manifested in the hypochondriac pain. She hasn’t taken enough energy food to promote the Qi circulation, so as lack of fluid intake affects her Qi flowing. In this case, I suggested the patient having regular meals is essential for her condition. Taking nutrition food to generate the Qi and Blood in order to get the viscera functions back to normal. This patient was very co-operative and willing to change her life style. After the first treatment, she left NZ the following day and I rang her after three weeks to follow up her condition after the treatment.
I would use this method again if there is another similar patient with the same complaint.
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