小儿便秘结肠动力学的初步探讨
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摘要
前言
小儿慢性便秘是小儿门诊外科的常见疾病，发病率为3-5％。关于便秘的发病机制目前尚不十分清楚，以往研究大多限于直肠肛管部分；近来的研究发现，结肠动力学异常在便秘的发生过程中可能发挥着重要的作用。本文应用胃肠传输时间测定并结合向量测压技术和X线排便造影，对便秘小儿的结肠动力学变化特点和规律做一初步探讨。
材料和方法
研究对象分为对照组和便秘组。对照组33例，男21例、女12例，平均年龄5岁；便秘组25例，男15例，女10例，平均年龄7岁，均符合Benninga的便秘诊断标准。应用简化的不透X线标记物追踪法，即多次口服标记物一次排片法测定对照组和便秘组儿童的胃肠传输时间(Total gastrointestinal transit time，TGITT)和节段性结肠传输时间，包括：右半结肠传输时间(Right colonic transittime，RCTT)；左半结肠传输时间(Left colonic transit time，LCTT)和直肠乙状结肠传输时间(Rectosigmoid colonic transit time，RSTT)。结合直肠肛管向量测压(肛管最大静息压、肛管最大收缩压、对称指数和向量容积)，部分患儿联合应用X线排便造影(直肠肛管角、直肠肛管交点移位、肛管长度、前突深度和肛尾间距)对便秘患儿的结肠功能进行客观评估。
结 果
对照组儿童的 TGll，RCrIT，LCrIT和 RSTT分别为 2 8．7。
7．7／J’时J7．5＊3．2／J’时、6．5。3．8 ／J’时和 13．4 LS．6／J’时；不同
性别儿童间的胃肠传输时间 TGIn 寸匕（26．1。7．9 ／J’时 VS 27．8
。7．7小时，P＞0．05）无显著性差异；对照组以5岁为界分为两
组，两组的 TG见也无显著性差异（28．3 i 7．5 ／J’时 VS 25．互土 7．9
小时，P＞0．05人便秘组的＊门YFf人＊h和mn均较对照组明
显延长（92．2t55．5小时VS28．7。7．7小日，P＜0．001；16．gi
12．6小时Vs6．5。3．8小日，P＜0．of；和61．5。29．0小时yS13．4 t
5．6小时，P＜0．OO＊。收缩状态下，肛管压力和向量容积均较静
息状态下明显升高，而对称指数无明显变化。与正常组相比，便秘
组肛管最大收缩压明显升高（236。44rnmHs vs 190 t38rnmHg，
P＜O．05），对称指数明显降低山．71。O．06VSO．84。O．08，P＜
0．05厂最大肛管静息压和向量容积则无明显变化。X线排便造影
显示直肠前突、会阴下降综合症和处骨直肠肌痉挛各1例。
讨 论
结肠传输试验是评价结肠转运功能的客观检测方法，是目前
诊断慢传输性便秘的唯一无创手段。由于该方法简捷且无创伤在
国外获得广泛应用，国内也有用于成人的报道；但目前国际上还没
有关于东方儿童结肠传输时间的报道。以往对成人的研究大多采
用一次口服标记物多次排片法，大大增加了病人的放射线辐射量。
因此，我们首次应用简化的不透X线标记物追踪法，即多次口服
标记物一次排片法，定量测定正常儿童的结肠传输时间，既简便了
实验方法，又减少了放射线辐射量，减轻了病人的痛苦，具有明显
·2·
的优越性。我们得到的结果TTGIThJCTh人C’IT和RS’IT分别为
28．7土7．7小时、7．j丈3．2小时、6．5。3．8小时和13．4土5．6 ／J’
时，性别和年龄对传输时间的影响不显著。
鉴于小儿慢性便秘的原因多种多样，而传统的治疗方法往往
只顾解除便秘症状，笼统地使用缓泻剂，不具有针对性。因此有必
要对便秘进行分型，以对症处理。本研究结果显示，便秘小儿的结
肠动力学存在明显异常，表现为全结肠传输时间和节段性结肠传
输时间较对照组均明显延长；说明结肠传输时间对于便秘的诊断
分型有重要意义。按节段性结肠传输时间，将便秘分为以下几种
类型鹏传输型；②出口梗阻型；③混合型；④结肠传输时间正常
型。结肠传输功能迟缓的原因有：①全结肠病变，常常使结肠无
力，即真性慢传输。②出口处器质性病变或排便动力异常，行X
线排便造影检查，可以进一步发现直肠前突、会阴下降综合症和耻
骨直肠肌痉挛等。X线排便造影对于鉴别这一类型的便秘具有重
要价值。③结肠结构异常，如乙状结肠过长、结肠牌曲过长等，常
常引起假性慢传输性便秘，多与儿童的发育特点有关。④外在因
素的影响，如胃肠道的调节机制异常等。联合应用结肠传输时间
和X线排便造影探讨便秘的病因与分型具有重要的临床意义。
直肠肛管向量测压有传统测压无法比拟的优点，其中向量容
积可以对括约肌功能进行迅速、直观的评价并能够对括约肌损伤
进行定位。对称指数是经过计算机处理后向量测压所特有的反映
肛管横向压力分布的重要指标。便秘患儿对称指数多数降低，原
因可能是肛管内外有器质性病变，如直肠套叠，耻骨直肠肌痉挛
等，使肛管的各个平面压力分布不均衡，排便时压力作用方向不一
致所致，也可能与长期慢性便秘引起直肠肛管周围神经肌肉的慢
性继发性损伤有关。
结肠传输时间是研究结肠动力学的重要手段，而向量测压则
是研究直肠肛管动力学的重要方法；两者之间具有互相补充?
Idiopathic chronic constipation is a frequent and distressing com-plaint in childhood. The morbidity is 3 -5%. But its pathophysiologi-cal grounds remain poorly understood. In particular, there is little knowledge about the correlation between distal ( anorectal area) and proximal ( colonic area) motor abnormalities in this condition, espe-cially the proximal colonic motility. For this purpose, we studied chronically constipated patients with simplified method of radio opaque markers and anorectal vector manometry, partly with X defecography to explore the colonic motility of idiopathic chronic constipation.
Materials and Methods
All the subjects involved in this study were divided into 2 groups. One group was control, 33 healthy volunteers (21 males and 12 fe-males) aged 2-13 years (mean 5 years) were involved in this group. The other was constipation group, in which 25 patients (15 males and 10 females) aged 3-14 years ( mean 7 years) referred to constipation on BenningaS standard according to the informed written consent from the parents were involved. In this study we used the simplified method of radio opaque markers to determine the total gastrointestinal transit time(TGITT) and segmental colonic transit time (right colonic transit
time, RCTT; left colonic transit time, LCTT; and rectosigmoid colonic transit time, RSTT) of the normal and constipated children, combined with anorectal vector manometry and X ray defecography to assess the colonic motor function.
Results
By the simplified method of radio opaque markers we found the total gastrointestinal transit time (TGITT) and segmental colonic tran-sit time ( right colonic transit time, RCTT; left colonic transit time, LCTT; and rectosigmoid colonic transit time, RSTT) of the normal children were 28.7 ?.7hJ.5 ?.2hN6.5 ?.8h and 13.4?.6h respectively. There was no significant difference between males and females in TGITT(26. 1 ?. 9h vs 27. 8 ?. 7h,P >0. 05). All the normal children were divided into two groups by age of 5, and there was also no significant difference between these two groups in TGITT (28.3 ?.5h vs 25. 1 ?.9h, P > 0. 05). In the constipated chil-dren , the TGITT, LCTT and RSTT were significantly longer than those in controls (92.2 ?5. 5h vs 28. 7 ?. 7h,P <0. 001; 16. 9 ?12. 6h vs6.5?.8h,P<0.01;61.5?9.0hvsl3.4?.6h,P< 0. 001 ) , while the RCTT had no difference. The anal pressure and vector volume in squeezing condition were significantly higher than those in resting condition. Compared with controls, the squeezing anal maximum pressure of the constipated children was higher ( 236 ?44mmHg vs 190 ?38mmHg , P < 0. 05 ) , vector symmetric index ( VSI) was lower(0. 71 ?. 06 vs 0. 84 ?. 08, P <0.05) while vec-tor volume had no difference. X defecography demonstrated one recto-cele, one permeal descent syndrome and one puborectal muscle syn-
drome respectively.
Discussion
Colonic transit test is an important objective test for evaluating the colonic motor function; moreover, it is the only noninvasive meth-od that can diagnose slow - transit constipation. At present it is widely used in studying colonic motor function. But previous study mainly fo-cused on one marker daily ?films technique, and seldom used the sin-gle - film estimate. Up to now there is still no report on colonic transit time of normal oriental children. In the current study, it is the first time that we used the simplified method of radio opaque markers, also named as the single - film technique , to determinate the TGITT( 28. 7 ?7.7) in normal children, which is not significantly influenced by sex and age.
The etiology of chronic constipation is diversified. But the tradi-tional therapy only focused on relieving the symptoms of constipation by generally using laxatives. So it is necessary to find the etiology of constipation to guide its treatment. Colonic transit time is very impor-tant for us to differentiate the types of constipation. According to the segmental colonic transit time the constipated children can be divided into four
小儿慢性便秘是小儿门诊外科的常见疾病，发病率为3-5％。关于便秘的发病机制目前尚不十分清楚，以往研究大多限于直肠肛管部分；近来的研究发现，结肠动力学异常在便秘的发生过程中可能发挥着重要的作用。本文应用胃肠传输时间测定并结合向量测压技术和X线排便造影，对便秘小儿的结肠动力学变化特点和规律做一初步探讨。
材料和方法
研究对象分为对照组和便秘组。对照组33例，男21例、女12例，平均年龄5岁；便秘组25例，男15例，女10例，平均年龄7岁，均符合Benninga的便秘诊断标准。应用简化的不透X线标记物追踪法，即多次口服标记物一次排片法测定对照组和便秘组儿童的胃肠传输时间(Total gastrointestinal transit time，TGITT)和节段性结肠传输时间，包括：右半结肠传输时间(Right colonic transittime，RCTT)；左半结肠传输时间(Left colonic transit time，LCTT)和直肠乙状结肠传输时间(Rectosigmoid colonic transit time，RSTT)。结合直肠肛管向量测压(肛管最大静息压、肛管最大收缩压、对称指数和向量容积)，部分患儿联合应用X线排便造影(直肠肛管角、直肠肛管交点移位、肛管长度、前突深度和肛尾间距)对便秘患儿的结肠功能进行客观评估。
结 果
对照组儿童的 TGll，RCrIT，LCrIT和 RSTT分别为 2 8．7。
7．7／J’时J7．5＊3．2／J’时、6．5。3．8 ／J’时和 13．4 LS．6／J’时；不同
性别儿童间的胃肠传输时间 TGIn 寸匕（26．1。7．9 ／J’时 VS 27．8
。7．7小时，P＞0．05）无显著性差异；对照组以5岁为界分为两
组，两组的 TG见也无显著性差异（28．3 i 7．5 ／J’时 VS 25．互土 7．9
小时，P＞0．05人便秘组的＊门YFf人＊h和mn均较对照组明
显延长（92．2t55．5小时VS28．7。7．7小日，P＜0．001；16．gi
12．6小时Vs6．5。3．8小日，P＜0．of；和61．5。29．0小时yS13．4 t
5．6小时，P＜0．OO＊。收缩状态下，肛管压力和向量容积均较静
息状态下明显升高，而对称指数无明显变化。与正常组相比，便秘
组肛管最大收缩压明显升高（236。44rnmHs vs 190 t38rnmHg，
P＜O．05），对称指数明显降低山．71。O．06VSO．84。O．08，P＜
0．05厂最大肛管静息压和向量容积则无明显变化。X线排便造影
显示直肠前突、会阴下降综合症和处骨直肠肌痉挛各1例。
讨 论
结肠传输试验是评价结肠转运功能的客观检测方法，是目前
诊断慢传输性便秘的唯一无创手段。由于该方法简捷且无创伤在
国外获得广泛应用，国内也有用于成人的报道；但目前国际上还没
有关于东方儿童结肠传输时间的报道。以往对成人的研究大多采
用一次口服标记物多次排片法，大大增加了病人的放射线辐射量。
因此，我们首次应用简化的不透X线标记物追踪法，即多次口服
标记物一次排片法，定量测定正常儿童的结肠传输时间，既简便了
实验方法，又减少了放射线辐射量，减轻了病人的痛苦，具有明显
·2·
的优越性。我们得到的结果TTGIThJCTh人C’IT和RS’IT分别为
28．7土7．7小时、7．j丈3．2小时、6．5。3．8小时和13．4土5．6 ／J’
时，性别和年龄对传输时间的影响不显著。
鉴于小儿慢性便秘的原因多种多样，而传统的治疗方法往往
只顾解除便秘症状，笼统地使用缓泻剂，不具有针对性。因此有必
要对便秘进行分型，以对症处理。本研究结果显示，便秘小儿的结
肠动力学存在明显异常，表现为全结肠传输时间和节段性结肠传
输时间较对照组均明显延长；说明结肠传输时间对于便秘的诊断
分型有重要意义。按节段性结肠传输时间，将便秘分为以下几种
类型鹏传输型；②出口梗阻型；③混合型；④结肠传输时间正常
型。结肠传输功能迟缓的原因有：①全结肠病变，常常使结肠无
力，即真性慢传输。②出口处器质性病变或排便动力异常，行X
线排便造影检查，可以进一步发现直肠前突、会阴下降综合症和耻
骨直肠肌痉挛等。X线排便造影对于鉴别这一类型的便秘具有重
要价值。③结肠结构异常，如乙状结肠过长、结肠牌曲过长等，常
常引起假性慢传输性便秘，多与儿童的发育特点有关。④外在因
素的影响，如胃肠道的调节机制异常等。联合应用结肠传输时间
和X线排便造影探讨便秘的病因与分型具有重要的临床意义。
直肠肛管向量测压有传统测压无法比拟的优点，其中向量容
积可以对括约肌功能进行迅速、直观的评价并能够对括约肌损伤
进行定位。对称指数是经过计算机处理后向量测压所特有的反映
肛管横向压力分布的重要指标。便秘患儿对称指数多数降低，原
因可能是肛管内外有器质性病变，如直肠套叠，耻骨直肠肌痉挛
等，使肛管的各个平面压力分布不均衡，排便时压力作用方向不一
致所致，也可能与长期慢性便秘引起直肠肛管周围神经肌肉的慢
性继发性损伤有关。
结肠传输时间是研究结肠动力学的重要手段，而向量测压则
是研究直肠肛管动力学的重要方法；两者之间具有互相补充?
Idiopathic chronic constipation is a frequent and distressing com-plaint in childhood. The morbidity is 3 -5%. But its pathophysiologi-cal grounds remain poorly understood. In particular, there is little knowledge about the correlation between distal ( anorectal area) and proximal ( colonic area) motor abnormalities in this condition, espe-cially the proximal colonic motility. For this purpose, we studied chronically constipated patients with simplified method of radio opaque markers and anorectal vector manometry, partly with X defecography to explore the colonic motility of idiopathic chronic constipation.
Materials and Methods
All the subjects involved in this study were divided into 2 groups. One group was control, 33 healthy volunteers (21 males and 12 fe-males) aged 2-13 years (mean 5 years) were involved in this group. The other was constipation group, in which 25 patients (15 males and 10 females) aged 3-14 years ( mean 7 years) referred to constipation on BenningaS standard according to the informed written consent from the parents were involved. In this study we used the simplified method of radio opaque markers to determine the total gastrointestinal transit time(TGITT) and segmental colonic transit time (right colonic transit
time, RCTT; left colonic transit time, LCTT; and rectosigmoid colonic transit time, RSTT) of the normal and constipated children, combined with anorectal vector manometry and X ray defecography to assess the colonic motor function.
Results
By the simplified method of radio opaque markers we found the total gastrointestinal transit time (TGITT) and segmental colonic tran-sit time ( right colonic transit time, RCTT; left colonic transit time, LCTT; and rectosigmoid colonic transit time, RSTT) of the normal children were 28.7 ?.7hJ.5 ?.2hN6.5 ?.8h and 13.4?.6h respectively. There was no significant difference between males and females in TGITT(26. 1 ?. 9h vs 27. 8 ?. 7h,P >0. 05). All the normal children were divided into two groups by age of 5, and there was also no significant difference between these two groups in TGITT (28.3 ?.5h vs 25. 1 ?.9h, P > 0. 05). In the constipated chil-dren , the TGITT, LCTT and RSTT were significantly longer than those in controls (92.2 ?5. 5h vs 28. 7 ?. 7h,P <0. 001; 16. 9 ?12. 6h vs6.5?.8h,P<0.01;61.5?9.0hvsl3.4?.6h,P< 0. 001 ) , while the RCTT had no difference. The anal pressure and vector volume in squeezing condition were significantly higher than those in resting condition. Compared with controls, the squeezing anal maximum pressure of the constipated children was higher ( 236 ?44mmHg vs 190 ?38mmHg , P < 0. 05 ) , vector symmetric index ( VSI) was lower(0. 71 ?. 06 vs 0. 84 ?. 08, P <0.05) while vec-tor volume had no difference. X defecography demonstrated one recto-cele, one permeal descent syndrome and one puborectal muscle syn-
drome respectively.
Discussion
Colonic transit test is an important objective test for evaluating the colonic motor function; moreover, it is the only noninvasive meth-od that can diagnose slow - transit constipation. At present it is widely used in studying colonic motor function. But previous study mainly fo-cused on one marker daily ?films technique, and seldom used the sin-gle - film estimate. Up to now there is still no report on colonic transit time of normal oriental children. In the current study, it is the first time that we used the simplified method of radio opaque markers, also named as the single - film technique , to determinate the TGITT( 28. 7 ?7.7) in normal children, which is not significantly influenced by sex and age.
The etiology of chronic constipation is diversified. But the tradi-tional therapy only focused on relieving the symptoms of constipation by generally using laxatives. So it is necessary to find the etiology of constipation to guide its treatment. Colonic transit time is very impor-tant for us to differentiate the types of constipation. According to the segmental colonic transit time the constipated children can be divided into four
引文
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8．杜嗣廉，郑明新．小儿胃肠病学，人民卫生出版社，1995：47-57．`
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13．柯美云，李若群，潘国宗等．胃肠通过时间测定及生理和病理意义的探讨．中华内科杂志，1990，29(12)：723-726．
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11. Bautista Casasnovas A, Varela Cives R, Villanueva J, et al. Measurement of colonic transit time in children. J Pediatr Gastroenterol Nutri 1991, 13 (1):42-5.
12. Zaslavsky C, Da Silveira TR, Maguilnik I. Total and segmental colonic transit time with radio -opaque markers in adolescents with functional constipation. J Pediatri Gastroenterol Nutri,1998, 27(2):138-142.
13．柯美云，李若群，潘国宗等．胃肠通过时间测定及生理和病理意义的探讨．中华内科杂志，1990，29(12)：723-726．
14．刘世信，张殿文，吴菲．结肠传输试验对诊断便秘的价值．中华医学杂志，1993，73(2)：75-78．
15．潘世友，曹长贵，段胜．结肠传输试验的临床应用．中国肛肠病杂志，1995，15(1)：7-9．
16. Schouten WR, ten Kate FJ, De Graaf ET, et al. Visceral neuropathy in slow transit constipation: an immunohistochemical investigation with monoclonal antibodies against neurofilament. Dis Colon Rectum, 1993, 36 (12): 1112-1117.
17. Mellgren A, Bremmer S, Johansson C. Defecography results of inveseigation in 2816 patients. Dis Colon Rectum, 1994, 37(11):1133-41.
18. Taylor BM, Beart RW, Phillips SF, et al. Longitudinal and radical variations of pressure in the human anal sphincter. Gastroenterology, 1984,86 (4):693.
19. Bassotti G, Chiarioni G, Vantini I, et al. Anorectal manometric abnormalities and colonic propulsive impairment in patients with severe chronic idiopathic constipation. Dig Dis Sci, 1994, 39 (7):1558-1564.