便秘

当便秘为急性发病，考虑查找可能的继发原因很重要，包括结肠直肠癌。 继发性病因应该得到适当的治疗。

药物诱发便秘的初始治疗第一步是在病情允许的情况下停用药物。

孕妇的便秘通过纤维素和泻药治疗，并应考虑停用铁补充剂。

针对经选择患者组全部患者的治疗推荐

建议患者增加每日膳食中的纤维素并摄取充足的液体。 同时低热量摄入的患者增加每日的热量摄入。

并定期进行非剧烈运动。 患者应在排便上花些时间，并且当有便意时应避免推迟排便。[47]Brown WJ, Mishra G, Lee C, et al. Leisure time physical activity in Australian women: relationship with well being and symptoms. Res Q Exerc Sport. 2000 Sep;71(3):206-16.http://www.ncbi.nlm.nih.gov/pubmed/10999258?tool=bestpractice.com

患者应花时间进行排便，当感觉到排便冲动时应避免推迟排便。[51]Muller-Lissner SA, Kamm MA, Scarpignato C, et al. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005 Jan;100(1):232-42.http://www.ncbi.nlm.nih.gov/pubmed/15654804?tool=bestpractice.com

容积性泻药和/或粪便软化是初始药物治疗的首选。 主诉粪便干结和排便费力的患者，可首选粪便软化剂而非容积性泻药。 便秘发作间隙偶有排稀便的患者则首选容积性泻药。

容积性泻药，诸如卵叶车前果壳和甲基纤维素，可产生过多气体，导致胀气和膨胀，这可能会妨碍患者继续治疗。[96]Schiller LR. Review article: the therapy of constipation. Aliment Pharmacol Ther. 2001 Jun;15(6):749-63.http://www.ncbi.nlm.nih.gov/pubmed/11380313?tool=bestpractice.com 粪便软化剂的不良反应包括口苦、恶心、腹泻和抽筋。

是一种天然的泻药替代品。 一项双盲随机对照研究已证实：西梅干与车前子（卵叶车前果壳）同样可以改善便秘症状。[66]Attaluri A, Donahoe R, Valestin J, et al. Randomised clinical trial: dried plums (prunes) vs. psyllium for constipation. Aliment Pharmacol Ther. 2011 Apr;33(7):822-8.http://www.ncbi.nlm.nih.gov/pubmed/21323688?tool=bestpractice.com

如出现粪便嵌塞可用灌肠剂、栓剂、大量的聚乙二醇（PEG）溶液、刺激性泻药或镇静下采用嵌塞解除法。

灌肠剂或药物的类型以及对于镇静/麻醉的需求都是可变的，主要根据临床情况和患者的自身特点（例如儿童、成人、老人、焦虑患者、首次发病还是复发）。

剂量方案和镇静类型不在本主题的讨论范围。 建议转诊去找专科医生治疗。

针对经选择患者组全部患者的治疗推荐

甲基纳曲酮 (methylnaltrexone) 是一种外周阿片类受体拮抗剂，具有口服和皮下注射制剂，当阿片类药物诱发的便秘患者对其他泻药疗效不足时可应用该药物。[63]Becker G, Blum HE. Novel opioid antagonists for opioid-induced bowel dysfunction and postoperative ileus. Lancet. 2009 Apr 4;373(9670):1198-206.http://www.ncbi.nlm.nih.gov/pubmed/19217656?tool=bestpractice.com 多项随机临床试验已经证明，大约 50% 的患者能够在首次皮下给药后 4 小时内排便。[63]Becker G, Blum HE. Novel opioid antagonists for opioid-induced bowel dysfunction and postoperative ileus. Lancet. 2009 Apr 4;373(9670):1198-206.http://www.ncbi.nlm.nih.gov/pubmed/19217656?tool=bestpractice.com 一项 Ⅲ 期临床试验发现，口服甲基纳曲酮的患者中大约有一半患者在 4 小时内自发排便，因而美国食品药品监督管理局 (Food and Drug Administration, FDA) 批准了这种口服制剂。[64]Rauck R, Slatkin NE, Stambler N, et al. Randomized, double-blind trial of oral methylnaltrexone for the treatment of opioid-induced constipation in patients with chronic noncancer pain. Pain Pract. 2017 Jul;17(6):820-8.http://onlinelibrary.wiley.com/doi/10.1111/papr.12535/fullhttp://www.ncbi.nlm.nih.gov/pubmed/27860208?tool=bestpractice.com

据报道，甲基纳曲酮最常见的不良反应是腹部绞痛和胀气。 进展期肿瘤患者接受甲基纳曲酮治疗阿片类药物诱发便秘时，出现了严重的腹痛和肠穿孔，已经引起人们的关注。 出于这些担忧，FDA 对美国医生发出警告，对已知或怀疑有肠壁病变患者给予甲基纳曲酮时须谨慎，并且如果胃肠道症状恶化，应立即停止使用该药物。[65]US Food and Drug Administration (FDA). MedWatch safety information: Relistor (methylnaltrexone bromide) subcutaneous injections. August 2013 [internet publication].https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/021964s011lbl.pdf

治疗方法取决于便秘是原发还是继发（例如药物诱发的便秘、妊娠、帕金森病）。

药物诱发便秘的初始治疗第一步是在病情允许的情况下停用药物。

孕妇的便秘通过纤维素和泻药治疗，并应考虑停用铁补充剂。

建议改善生活方式和膳食，包括每日摄入足够的液体。和更多的膳食纤维。 高纤维饮食会增加粪便的重量并缩短结肠传输时间。[49]Burkitt DP, Walker AR, Painter NS. Effect of dietary fiber on stool and transit times and its role in the causation of disease. Lancet. 1972 Dec 30;2(7792):1408-12.http://www.ncbi.nlm.nih.gov/pubmed/4118696?tool=bestpractice.com 相比之下，缺乏纤维的膳食可能会导致便秘。[50]Tucker DM, Sandstead HH, Logan GM Jr, et al. Dietary fiber and personality factors as determinants of stool output. Gastroenterology. 1981 Nov;81(5):879-83.http://www.ncbi.nlm.nih.gov/pubmed/6269944?tool=bestpractice.com 对于低热量摄取人员 已证实热量摄取不足会导致便秘。[52]Chun AB, Sokol MS, Kaye WH, et al. Colonic and anorectal function in constipated patients with anorexia nervosa. Am J Gastroenterol. 1997 Oct;92(10):1879-83.http://www.ncbi.nlm.nih.gov/pubmed/9382057?tool=bestpractice.com

并定期进行非剧烈运动。 患者应在排便上花些时间，并且当有便意时应避免推迟排便。[47]Brown WJ, Mishra G, Lee C, et al. Leisure time physical activity in Australian women: relationship with well being and symptoms. Res Q Exerc Sport. 2000 Sep;71(3):206-16.http://www.ncbi.nlm.nih.gov/pubmed/10999258?tool=bestpractice.com

患者应花时间进行排便，当感觉到排便冲动时应避免推迟排便。[51]Muller-Lissner SA, Kamm MA, Scarpignato C, et al. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005 Jan;100(1):232-42.http://www.ncbi.nlm.nih.gov/pubmed/15654804?tool=bestpractice.com

针对经选择患者组全部患者的治疗推荐

容积性泻药和/或粪便软化是初始药物治疗的首选。 主诉粪便干结和排便费力的患者，可首选粪便软化剂而非容积性泻药。 便秘发作间隙偶有排稀便的患者则首选容积性泻药。

容积性泻药，诸如卵叶车前果壳和甲基纤维素，可产生过多气体，导致胀气和膨胀，这可能会妨碍患者继续治疗。[96]Schiller LR. Review article: the therapy of constipation. Aliment Pharmacol Ther. 2001 Jun;15(6):749-63.http://www.ncbi.nlm.nih.gov/pubmed/11380313?tool=bestpractice.com

是一种天然的泻药替代品。 一项双盲随机对照研究已证实：西梅干与车前子（卵叶车前果壳）同样可以改善便秘症状。[66]Attaluri A, Donahoe R, Valestin J, et al. Randomised clinical trial: dried plums (prunes) vs. psyllium for constipation. Aliment Pharmacol Ther. 2011 Apr;33(7):822-8.http://www.ncbi.nlm.nih.gov/pubmed/21323688?tool=bestpractice.com

针对经选择患者组全部患者的治疗推荐

如果治疗至少 6 周后无临床反应（临床有效定义为患者对排便习惯和相关症状满意）并且排除协同障碍，可以考虑应用渗透性泻药，例如乳果糖、聚乙二醇化合物（聚乙二醇）[67]Lee-Robichaud H, Thomas K, Morgan J, et al. Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD007570.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007570.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/20614462?tool=bestpractice.com[68]Belsey JD, Geraint M, Dixon TA. Systematic review and meta analysis: polyethylene glycol in adults with non-organic constipation. Int J Clin Pract. 2010 Jun;64(7):944-55.http://www.ncbi.nlm.nih.gov/pubmed/20584228?tool=bestpractice.com 或含镁泻药。

系统综述显示有证据支持对慢性便秘患者应用乳果糖和聚乙二醇。[4]Brandt LJ, Prather CM, Quigley EM, et al. Systematic review on the management of chronic constipation in North America. Am J Gastroenterol. 2005;100(suppl 1):S5-S21.http://www.ncbi.nlm.nih.gov/pubmed/16008641?tool=bestpractice.com[97]Ramkumar D, Rao SS. Efficacy and safety of traditional medical therapies for chronic constipation: systematic review. Am J Gastroenterol. 2005 Apr;100(4):936-71.http://www.ncbi.nlm.nih.gov/pubmed/15784043?tool=bestpractice.com

可以使用含镁的渗透性泻药。 常见的不良反应包括恶心、腹泻和高镁血症。

渗透性泻药的最主要不良反应包括腹胀、腹泻、上腹痛、胀气、恶心、呕吐并且少数情况下会出现高钠血症和低钾血症。

建议改善生活方式和膳食，包括每日摄入足够的液体。和更多的膳食纤维。 高纤维饮食会增加粪便的重量并缩短结肠传输时间。[49]Burkitt DP, Walker AR, Painter NS. Effect of dietary fiber on stool and transit times and its role in the causation of disease. Lancet. 1972 Dec 30;2(7792):1408-12.http://www.ncbi.nlm.nih.gov/pubmed/4118696?tool=bestpractice.com 相比之下，缺乏纤维的膳食可能会导致便秘。[50]Tucker DM, Sandstead HH, Logan GM Jr, et al. Dietary fiber and personality factors as determinants of stool output. Gastroenterology. 1981 Nov;81(5):879-83.http://www.ncbi.nlm.nih.gov/pubmed/6269944?tool=bestpractice.com 对于低热量摄取人员 已证实热量摄取不足会导致便秘。[52]Chun AB, Sokol MS, Kaye WH, et al. Colonic and anorectal function in constipated patients with anorexia nervosa. Am J Gastroenterol. 1997 Oct;92(10):1879-83.http://www.ncbi.nlm.nih.gov/pubmed/9382057?tool=bestpractice.com

并定期进行非剧烈运动。 患者应在排便上花些时间，并且当有便意时应避免推迟排便。[47]Brown WJ, Mishra G, Lee C, et al. Leisure time physical activity in Australian women: relationship with well being and symptoms. Res Q Exerc Sport. 2000 Sep;71(3):206-16.http://www.ncbi.nlm.nih.gov/pubmed/10999258?tool=bestpractice.com

患者应花时间进行排便，当感觉到排便冲动时应避免推迟排便。[51]Muller-Lissner SA, Kamm MA, Scarpignato C, et al. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005 Jan;100(1):232-42.http://www.ncbi.nlm.nih.gov/pubmed/15654804?tool=bestpractice.com

针对经选择患者组全部患者的治疗推荐

渗透性泻药包括乳果糖，聚乙二醇化合物（聚乙二醇）[67]Lee-Robichaud H, Thomas K, Morgan J, et al. Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD007570.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007570.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/20614462?tool=bestpractice.com[68]Belsey JD, Geraint M, Dixon TA. Systematic review and meta analysis: polyethylene glycol in adults with non-organic constipation. Int J Clin Pract. 2010 Jun;64(7):944-55.http://www.ncbi.nlm.nih.gov/pubmed/20584228?tool=bestpractice.com 或含镁泻药。

系统综述显示有证据支持对慢性便秘患者应用乳果糖和聚乙二醇。[4]Brandt LJ, Prather CM, Quigley EM, et al. Systematic review on the management of chronic constipation in North America. Am J Gastroenterol. 2005;100(suppl 1):S5-S21.http://www.ncbi.nlm.nih.gov/pubmed/16008641?tool=bestpractice.com[97]Ramkumar D, Rao SS. Efficacy and safety of traditional medical therapies for chronic constipation: systematic review. Am J Gastroenterol. 2005 Apr;100(4):936-71.http://www.ncbi.nlm.nih.gov/pubmed/15784043?tool=bestpractice.com

可以使用含镁的渗透性泻药。 常见的不良反应包括恶心、腹泻和高镁血症。

渗透性泻药的最主要不良反应包括腹胀、腹泻、上腹痛、胀气、恶心、呕吐并且少数情况下会出现高钠血症和低钾血症。

建议改善生活方式和膳食，包括每日摄入足够的液体。和更多的膳食纤维。 高纤维饮食会增加粪便的重量并缩短结肠传输时间。[49]Burkitt DP, Walker AR, Painter NS. Effect of dietary fiber on stool and transit times and its role in the causation of disease. Lancet. 1972 Dec 30;2(7792):1408-12.http://www.ncbi.nlm.nih.gov/pubmed/4118696?tool=bestpractice.com 相比之下，缺乏纤维的膳食可能会导致便秘。[50]Tucker DM, Sandstead HH, Logan GM Jr, et al. Dietary fiber and personality factors as determinants of stool output. Gastroenterology. 1981 Nov;81(5):879-83.http://www.ncbi.nlm.nih.gov/pubmed/6269944?tool=bestpractice.com 对于低热量摄取人员 已证实热量摄取不足会导致便秘。[52]Chun AB, Sokol MS, Kaye WH, et al. Colonic and anorectal function in constipated patients with anorexia nervosa. Am J Gastroenterol. 1997 Oct;92(10):1879-83.http://www.ncbi.nlm.nih.gov/pubmed/9382057?tool=bestpractice.com

并定期进行非剧烈运动。 患者应在排便上花些时间，并且当有便意时应避免推迟排便。[47]Brown WJ, Mishra G, Lee C, et al. Leisure time physical activity in Australian women: relationship with well being and symptoms. Res Q Exerc Sport. 2000 Sep;71(3):206-16.http://www.ncbi.nlm.nih.gov/pubmed/10999258?tool=bestpractice.com

患者应花时间进行排便，当感觉到排便冲动时应避免推迟排便。[51]Muller-Lissner SA, Kamm MA, Scarpignato C, et al. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005 Jan;100(1):232-42.http://www.ncbi.nlm.nih.gov/pubmed/15654804?tool=bestpractice.com

针对经选择患者组全部患者的治疗推荐

如果使用渗透性泻药至少 6 周后症状持续存在，应使用刺激性泻药（例如番泻叶和比沙可啶）治疗。证据 A症状缓解：有高质量的证据显示对于慢性便秘比沙可啶是一种有效且耐受性好的治疗，可以改善肠道功能、便秘相关症状和疾病相关的生活质量。[69]Kamm MA, Mueller-Lissner S, Wald A, et al. Oral bisacodyl is effective and well-tolerated in patients with chronic constipation. Clin Gastroenterol Hepatol. 2011 Jul;9(7):577-83.http://www.ncbi.nlm.nih.gov/pubmed/21440672?tool=bestpractice.com系统评价或者受试者＞200名的随机对照临床试验（RCT）。 当使用其他种类泻药无效时，这类药物可以用于挽救治疗（当患者3天不排便时）。

腹部不适是比沙可啶的一种常见的不良反应。[98]Siegel JD, Di Palma JA. Medical treatment of constipation. Clin Colon Rectal Surg. 2005 May;18(2):76-80.http://www.ncbi.nlm.nih.gov/pubmed/20011345?tool=bestpractice.com 使用番泻叶可导致腹痛、恶心、呕吐和腹泻。

灌肠剂、栓剂以及手法助便通常不推荐用于治疗慢性便秘。

针对经选择患者组全部患者的治疗推荐

利那洛肽在健康人[74]Currie MG, Kurtz CB, Mahajan-Miklos S, et al. Effects of a single dose administration of MD-1100 on safety, tolerability, exposure, and stool consistency in healthy subjects. Am J Gastroenterol. 2005;100:S328. 和女性肠易激综合征便秘患者中显示出可加速肠道传输的作用。[99]Johnston JM, Drossman DA, Lembo A, et al. Late-breaking abstract 65A: Linaclotide improves bowel habits and patient reported outcomes in subjects with chronic constipation. Am J Gastroenterol. 2006;101(suppl 2):S470-S494.

类似地，已证明普卡那肽 (Plecanatide) 可升高细胞内环磷酸鸟苷 (cGMP) 水平，并通过囊性纤维化跨膜传导调节因子 (CFTR) 受体促进血管腔分泌，从而有利于排便。[81]DeMicco M, Barrow L, Hickey B, et al. Randomized clinical trial: efficacy and safety of plecanatide in the treatment of chronic idiopathic constipation. Therap Adv Gastroenterol. 2017 Nov;10(11):837-51.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5673020/http://www.ncbi.nlm.nih.gov/pubmed/29147135?tool=bestpractice.com

在针对慢性便秘患者的临床试验中，已证实此类药物比安慰剂更加有效，能使排便习惯、肠道和腹部症状、全面缓解以及生活质量出现迅速而持久的改善。[75]Johnston JM, Kurtz CB, Macdougall JE, et al. Linaclotide improves abdominal pain and bowel habits in a phase IIb study of patients with irritable bowel syndrome with constipation. Gastroenterology. 2010 Dec;139(6):1877-1886.e2.http://www.ncbi.nlm.nih.gov/pubmed/20801122?tool=bestpractice.com[77]Rao S, Lembo AJ, Shiff SJ, et al. A 12-week, randomized, controlled trial with a 4-week randomized withdrawal period to evaluate the efficacy and safety of linaclotide in irritable bowel syndrome with constipation. Am J Gastroenterol. 2012 Nov;107(11):1714-24.http://www.nature.com/ajg/journal/v107/n11/full/ajg2012255a.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/22986440?tool=bestpractice.com[78]Chey WD, Lembo AJ, Lavins BJ, et al. Linaclotide for irritable bowel syndrome with constipation: a 26-week, randomized, double-blind, placebo-controlled trial to evaluate efficacy and safety. Am J Gastroenterol. 2012 Nov;107(11):1702-12.http://www.nature.com/ajg/journal/v107/n11/full/ajg2012254a.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/22986437?tool=bestpractice.com[79]Lee N, Wald A. Linaclotide: evidence for its potential use in irritable bowel syndrome and chronic constipation. Core Evid. 2012;7:39-47.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396047/http://www.ncbi.nlm.nih.gov/pubmed/22807692?tool=bestpractice.com[80]Quigley EM, Tack J, Chey WD, et al. Randomised clinical trials: linaclotide phase 3 studies in IBS-C - a prespecified further analysis based on European Medicines Agency-specified endpoints. Aliment Pharmacol Ther. 2013 Jan;37(1):49-61.http://onlinelibrary.wiley.com/doi/10.1111/apt.12123/fullhttp://www.ncbi.nlm.nih.gov/pubmed/23116208?tool=bestpractice.com证据 A症状缓解：有高质量的证据显示利那洛肽治疗慢性便秘可显著减少肠道和腹部症状且显著改善自主排便、粪便性状、排便费力、腹部不适、胀气、全面评估和生活治疗。[73]Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathic constipation: systematic review and meta-analysis. Gut. 2011 Feb;60(2):209-18.http://www.ncbi.nlm.nih.gov/pubmed/21205879?tool=bestpractice.com[76]Lembo AJ, Schneier HA, Shiff SJ, et al. Two randomized trials of linaclotide for chronic constipation. N Engl J Med. 2011 Aug 11;365(6):527-36.http://www.ncbi.nlm.nih.gov/pubmed/21830967?tool=bestpractice.com[77]Rao S, Lembo AJ, Shiff SJ, et al. A 12-week, randomized, controlled trial with a 4-week randomized withdrawal period to evaluate the efficacy and safety of linaclotide in irritable bowel syndrome with constipation. Am J Gastroenterol. 2012 Nov;107(11):1714-24.http://www.nature.com/ajg/journal/v107/n11/full/ajg2012255a.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/22986440?tool=bestpractice.com[78]Chey WD, Lembo AJ, Lavins BJ, et al. Linaclotide for irritable bowel syndrome with constipation: a 26-week, randomized, double-blind, placebo-controlled trial to evaluate efficacy and safety. Am J Gastroenterol. 2012 Nov;107(11):1702-12.http://www.nature.com/ajg/journal/v107/n11/full/ajg2012254a.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/22986437?tool=bestpractice.com[79]Lee N, Wald A. Linaclotide: evidence for its potential use in irritable bowel syndrome and chronic constipation. Core Evid. 2012;7:39-47.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396047/http://www.ncbi.nlm.nih.gov/pubmed/22807692?tool=bestpractice.com[80]Quigley EM, Tack J, Chey WD, et al. Randomised clinical trials: linaclotide phase 3 studies in IBS-C - a prespecified further analysis based on European Medicines Agency-specified endpoints. Aliment Pharmacol Ther. 2013 Jan;37(1):49-61.http://onlinelibrary.wiley.com/doi/10.1111/apt.12123/fullhttp://www.ncbi.nlm.nih.gov/pubmed/23116208?tool=bestpractice.com 然而，需要进一步的研究评价利那洛肽治疗慢性便秘的长期风险和受益。[76]Lembo AJ, Schneier HA, Shiff SJ, et al. Two randomized trials of linaclotide for chronic constipation. N Engl J Med. 2011 Aug 11;365(6):527-36.http://www.ncbi.nlm.nih.gov/pubmed/21830967?tool=bestpractice.com系统评价或者受试者＞200名的随机对照临床试验（RCT）。 此外，与利那洛肽和普卡那肽相关的不良反应事件均极少。

通常不建议孕妇使用这些药物。

它们通常用作单一疗法，而是不与其他泻药联合使用。

建议改善生活方式和膳食，包括每日摄入足够的液体。和更多的膳食纤维。 高纤维饮食会增加粪便的重量并缩短结肠传输时间。[49]Burkitt DP, Walker AR, Painter NS. Effect of dietary fiber on stool and transit times and its role in the causation of disease. Lancet. 1972 Dec 30;2(7792):1408-12.http://www.ncbi.nlm.nih.gov/pubmed/4118696?tool=bestpractice.com 相比之下，缺乏纤维的膳食可能会导致便秘。[50]Tucker DM, Sandstead HH, Logan GM Jr, et al. Dietary fiber and personality factors as determinants of stool output. Gastroenterology. 1981 Nov;81(5):879-83.http://www.ncbi.nlm.nih.gov/pubmed/6269944?tool=bestpractice.com 对于低热量摄取人员 已证实热量摄取不足会导致便秘。[52]Chun AB, Sokol MS, Kaye WH, et al. Colonic and anorectal function in constipated patients with anorexia nervosa. Am J Gastroenterol. 1997 Oct;92(10):1879-83.http://www.ncbi.nlm.nih.gov/pubmed/9382057?tool=bestpractice.com

并定期进行非剧烈运动。 患者应在排便上花些时间，并且当有便意时应避免推迟排便。[47]Brown WJ, Mishra G, Lee C, et al. Leisure time physical activity in Australian women: relationship with well being and symptoms. Res Q Exerc Sport. 2000 Sep;71(3):206-16.http://www.ncbi.nlm.nih.gov/pubmed/10999258?tool=bestpractice.com

患者应花时间进行排便，当感觉到排便冲动时应避免推迟排便。[51]Muller-Lissner SA, Kamm MA, Scarpignato C, et al. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005 Jan;100(1):232-42.http://www.ncbi.nlm.nih.gov/pubmed/15654804?tool=bestpractice.com

针对经选择患者组全部患者的治疗推荐

鲁比前列酮对于慢性便秘患者在增加自主排便次数、缓解排便费力、改善粪便性状和缓解症状等方面比安慰剂更加有效。[70]Johanson JF, Panas R, Holland PC, et al. Long-term efficacy of lubiprostone for the treatment of chronic constipation. Gastroenterology. 2006;130(suppl 2):M1171.[71]Johanson JF, Gargano MA, Holland PC, et al. Initial and sustained effects of lubiprostone, a chloride channel-2 (ClC2) activator for the treatment of constipation: data from a 4-week phase III study. Am J Gastroenterol. 2005;100(suppl 9):S328.[72]Barish CF, Drossman D, Johanson JF, et al. Efficacy and safety of lubiprostone in patients with chronic constipation. Dig Dis Sci. 2010 Apr;55(4):1090-7.http://www.ncbi.nlm.nih.gov/pubmed/20012484?tool=bestpractice.com[73]Ford AC, Suares NC. Effect of laxatives and pharmacological therapies in chronic idiopathic constipation: systematic review and meta-analysis. Gut. 2011 Feb;60(2):209-18.http://www.ncbi.nlm.nih.gov/pubmed/21205879?tool=bestpractice.com 最常见的不良反应包括恶心（31%）、头痛（13%）、腹泻（13%）、腹痛（7%）和腹胀。

不建议孕妇使用此药物。

通常用做单一疗法而不与其他泻药合并使用。

建议改善生活方式和膳食，包括每日摄入足够的液体。和更多的膳食纤维。 高纤维饮食会增加粪便的重量并缩短结肠传输时间。[49]Burkitt DP, Walker AR, Painter NS. Effect of dietary fiber on stool and transit times and its role in the causation of disease. Lancet. 1972 Dec 30;2(7792):1408-12.http://www.ncbi.nlm.nih.gov/pubmed/4118696?tool=bestpractice.com 相比之下，缺乏纤维的膳食可能会导致便秘。[50]Tucker DM, Sandstead HH, Logan GM Jr, et al. Dietary fiber and personality factors as determinants of stool output. Gastroenterology. 1981 Nov;81(5):879-83.http://www.ncbi.nlm.nih.gov/pubmed/6269944?tool=bestpractice.com 对于低热量摄取人员 已证实热量摄取不足会导致便秘。[52]Chun AB, Sokol MS, Kaye WH, et al. Colonic and anorectal function in constipated patients with anorexia nervosa. Am J Gastroenterol. 1997 Oct;92(10):1879-83.http://www.ncbi.nlm.nih.gov/pubmed/9382057?tool=bestpractice.com

并定期进行非剧烈运动。 患者应在排便上花些时间，并且当有便意时应避免推迟排便。[47]Brown WJ, Mishra G, Lee C, et al. Leisure time physical activity in Australian women: relationship with well being and symptoms. Res Q Exerc Sport. 2000 Sep;71(3):206-16.http://www.ncbi.nlm.nih.gov/pubmed/10999258?tool=bestpractice.com

患者应花时间进行排便，当感觉到排便冲动时应避免推迟排便。[51]Muller-Lissner SA, Kamm MA, Scarpignato C, et al. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005 Jan;100(1):232-42.http://www.ncbi.nlm.nih.gov/pubmed/15654804?tool=bestpractice.com

针对经选择患者组全部患者的治疗推荐

普卢卡必利是一种 5-羟色胺 4 受体激动剂，有促进胃肠动力的作用。使用该药后，24% 的慢性便秘患者达到每周至少 3 次的完全自主排便。[82]Tack J, van Outryve M, Beyens G, et al. Prucalopride (Resolor) in the treatment of severe chronic constipation in patients dissatisfied with laxatives. Gut. 2009 Mar;58(3):357-65.http://www.ncbi.nlm.nih.gov/pubmed/18987031?tool=bestpractice.com[83]Camilleri M, Kerstens R, Rykx A, et al. A placebo-controlled trial of prucalopride for severe chronic constipation. N Engl J Med. 2008 May 29;358(22):2344-54.http://www.nejm.org/doi/full/10.1056/NEJMoa0800670#t=articlehttp://www.ncbi.nlm.nih.gov/pubmed/18509121?tool=bestpractice.com[84]Camilleri M, Deiteren A. Prucalopride for constipation. Expert Opin Pharmacother. 2010 Feb;11(3):451-61.http://www.ncbi.nlm.nih.gov/pubmed/20102308?tool=bestpractice.com[85]Müller-Lissner S, Rykx A, Kerstens R, et al. A double-blind, placebo-controlled study of prucalopride in elderly patients with chronic constipation. Neurogastroenterol Motil. 2010 Sep;22(9):991-8.http://www.ncbi.nlm.nih.gov/pubmed/20529205?tool=bestpractice.com[86]Quigley EM, Vandeplassche L, Kerstens R, et al. Clinical trial: the efficacy, impact on quality of life, and safety and tolerability of prucalopride in severe chronic constipation - a 12-week, randomized, double-blind, placebo-controlled study. Aliment Pharmacol Ther. 2009 Feb 1;29(3):315-28.http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2008.03884.x/fullhttp://www.ncbi.nlm.nih.gov/pubmed/19035970?tool=bestpractice.com 在3项III期临床试验的4000例患者中超过10%的患者出现头痛、恶心、腹痛和腹泻等表现。无心脏不良反应的临床报道。

建议改善生活方式和膳食，包括每日摄入足够的液体。和更多的膳食纤维。 高纤维饮食会增加粪便的重量并缩短结肠传输时间。[49]Burkitt DP, Walker AR, Painter NS. Effect of dietary fiber on stool and transit times and its role in the causation of disease. Lancet. 1972 Dec 30;2(7792):1408-12.http://www.ncbi.nlm.nih.gov/pubmed/4118696?tool=bestpractice.com 相比之下，缺乏纤维的膳食可能会导致便秘。[50]Tucker DM, Sandstead HH, Logan GM Jr, et al. Dietary fiber and personality factors as determinants of stool output. Gastroenterology. 1981 Nov;81(5):879-83.http://www.ncbi.nlm.nih.gov/pubmed/6269944?tool=bestpractice.com 对于低热量摄取人员 已证实热量摄取不足会导致便秘。[52]Chun AB, Sokol MS, Kaye WH, et al. Colonic and anorectal function in constipated patients with anorexia nervosa. Am J Gastroenterol. 1997 Oct;92(10):1879-83.http://www.ncbi.nlm.nih.gov/pubmed/9382057?tool=bestpractice.com

并定期进行非剧烈运动。 患者应在排便上花些时间，并且当有便意时应避免推迟排便。[47]Brown WJ, Mishra G, Lee C, et al. Leisure time physical activity in Australian women: relationship with well being and symptoms. Res Q Exerc Sport. 2000 Sep;71(3):206-16.http://www.ncbi.nlm.nih.gov/pubmed/10999258?tool=bestpractice.com

患者应花时间进行排便，当感觉到排便冲动时应避免推迟排便。[51]Muller-Lissner SA, Kamm MA, Scarpignato C, et al. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005 Jan;100(1):232-42.http://www.ncbi.nlm.nih.gov/pubmed/15654804?tool=bestpractice.com

与协同障碍有关的症状包括肛门堵塞感、排便费力以及需要手法助便排便。 确诊需要进行生理检查。 生物反馈治疗协同障碍有效。[88]Chiarioni G, Whitehead WE, Pezza V, et al. Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology. 2006 Mar;130(3):657-64.http://www.ncbi.nlm.nih.gov/pubmed/16530506?tool=bestpractice.com[89]Rao SS, Seaton K, Miller M, et al. Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol. 2007 Mar;5(3):331-8.http://www.ncbi.nlm.nih.gov/pubmed/17368232?tool=bestpractice.com[90]Rao SS, Kinkade K, Miller MJ, et al. Randomized controlled trial of long term outcome of biofeedback therapy (BT) for dyssynergic defecation. Am J Gastroenterol. 2005;100:386.[91]Heymen S, Wexner SD, Vickers D, et al. Prospective, randomized trial comparing for biofeedback techniques for patients with constipation. Dis Colon Rectum. 1999 Nov;42(11):1388-93.http://www.ncbi.nlm.nih.gov/pubmed/10566525?tool=bestpractice.com

3种生物反馈技术被用于改善腹部和肛门直肠肌肉协调性：模拟排便膈肌训练，测压指导盆底训练和模拟排便训练。

患者逐渐停用泻药。 建议改善生活方式和膳食，包括每日摄入足够的液体和更多的膳食纤维。 高纤维饮食会增加粪便的重量并缩短结肠传输时间。[49]Burkitt DP, Walker AR, Painter NS. Effect of dietary fiber on stool and transit times and its role in the causation of disease. Lancet. 1972 Dec 30;2(7792):1408-12.http://www.ncbi.nlm.nih.gov/pubmed/4118696?tool=bestpractice.com 相比之下，缺乏纤维的膳食可能会导致便秘。[50]Tucker DM, Sandstead HH, Logan GM Jr, et al. Dietary fiber and personality factors as determinants of stool output. Gastroenterology. 1981 Nov;81(5):879-83.http://www.ncbi.nlm.nih.gov/pubmed/6269944?tool=bestpractice.com 对于低热量摄取人员 已证实热量摄取不足会导致便秘。[52]Chun AB, Sokol MS, Kaye WH, et al. Colonic and anorectal function in constipated patients with anorexia nervosa. Am J Gastroenterol. 1997 Oct;92(10):1879-83.http://www.ncbi.nlm.nih.gov/pubmed/9382057?tool=bestpractice.com

并定期进行非剧烈运动。 患者应在排便上花些时间，并且当有便意时应避免推迟排便。[47]Brown WJ, Mishra G, Lee C, et al. Leisure time physical activity in Australian women: relationship with well being and symptoms. Res Q Exerc Sport. 2000 Sep;71(3):206-16.http://www.ncbi.nlm.nih.gov/pubmed/10999258?tool=bestpractice.com

患者应花时间进行排便，当感觉到排便冲动时应避免推迟排便。[51]Muller-Lissner SA, Kamm MA, Scarpignato C, et al. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005 Jan;100(1):232-42.http://www.ncbi.nlm.nih.gov/pubmed/15654804?tool=bestpractice.com

药物治疗无效且症状持续存在（持续数月至数年）的患者可转诊专业中心，考虑手术治疗， 患者需接受上消化道和小肠的动力评价并通过结肠测压对结肠动力进行详细的评估。

手术是难治性重症结肠病变且保留胃和小肠的蠕动功能的患者的治疗选择。 盲肠造瘘术尤其适用于儿童、养老机构的患者及神经病变的患者，其成功率较高；40%-78%的患者可达到满意的疗效。[93]Lees NP, Hodson P, Hill J, et al. Long-term results of the antegrade continent enema procedure for constipation in adults. Colorectal Dis. 2004 Sep;6(5):362-8.http://www.ncbi.nlm.nih.gov/pubmed/15335371?tool=bestpractice.com

现已提倡采用多种结肠切除技术治疗慢性便秘，包括节段性结肠切除术、回肠直肠吻合术、回肠乙状结肠吻合术、盲肠直肠吻合术、结肠直肠切除回肠肛门吻合术及囊袋形成或回肠造口术。[94]Pemberton JH, Rath DM, Ilstrup DM. Evaluation and surgical treatment of severe chronic constipation. Ann Surg. 1991 Oct;214(4):403-11.http://www.ncbi.nlm.nih.gov/pubmed/1953096?tool=bestpractice.com 大多数手术可经腹腔镜实施。

如果患者对所有其他治疗无效且有胃或小肠动力障碍的证据，手术不能使患者获益。 可以尝试多学科合作，包括营养调整、行为疗法、生物反馈、心理治疗和周期性泻药。 目前有关这类疗法的证据大多数为个案记录。

患者逐渐停用泻药。 建议改善生活方式和膳食，包括每日摄入足够的液体和更多的膳食纤维。 高纤维饮食会增加粪便的重量并缩短结肠传输时间。[49]Burkitt DP, Walker AR, Painter NS. Effect of dietary fiber on stool and transit times and its role in the causation of disease. Lancet. 1972 Dec 30;2(7792):1408-12.http://www.ncbi.nlm.nih.gov/pubmed/4118696?tool=bestpractice.com 相比之下，缺乏纤维的膳食可能会导致便秘。[50]Tucker DM, Sandstead HH, Logan GM Jr, et al. Dietary fiber and personality factors as determinants of stool output. Gastroenterology. 1981 Nov;81(5):879-83.http://www.ncbi.nlm.nih.gov/pubmed/6269944?tool=bestpractice.com 对于低热量摄取人员 已证实热量摄取不足会导致便秘。[52]Chun AB, Sokol MS, Kaye WH, et al. Colonic and anorectal function in constipated patients with anorexia nervosa. Am J Gastroenterol. 1997 Oct;92(10):1879-83.http://www.ncbi.nlm.nih.gov/pubmed/9382057?tool=bestpractice.com

并定期进行非剧烈运动。 患者应在排便上花些时间，并且当有便意时应避免推迟排便。[47]Brown WJ, Mishra G, Lee C, et al. Leisure time physical activity in Australian women: relationship with well being and symptoms. Res Q Exerc Sport. 2000 Sep;71(3):206-16.http://www.ncbi.nlm.nih.gov/pubmed/10999258?tool=bestpractice.com

患者应花时间进行排便，当感觉到排便冲动时应避免推迟排便。[51]Muller-Lissner SA, Kamm MA, Scarpignato C, et al. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005 Jan;100(1):232-42.http://www.ncbi.nlm.nih.gov/pubmed/15654804?tool=bestpractice.com