A Review on Clinical Study on Treating Postoperative Constipation in Mixed Hemorrhoids with Traditional Chinese Medicine

BI Chuan-chuan (毕川川), CUI Ya-ping (崔亚萍), JIANG Hua (姜 华),XIAO Xia (肖 霞), GUO Zi-hua (郭子华)

1. The First Clinical Medical College of Shaanxi University of traditional Chinese Medicine, Xianyang 712000, China

2. Anorectal Department 1, Affiliated Hospital of Shaanxi University of traditional Chinese Medicine, Xianyang 712000, China

ABST RACT Mixed hemorrhoids belong to a common disease in proctology. Surgery is the main clinical treatment, but postoperative constipation is prone to occur in patients, causing unnecessary physical pain to the patients. At the same time, it also affected uneventful recovery after the surgery. In diagnosis and treatment for the postoperative constipation in mixed hemorrhoids, TCM has its own features, such as oral administration of Chinese materia medica, acupuncture therapy, Chinese materia medica retention enema,acupoint catgut embedding, etc., which have significant efficacy. However, there are also some problems,such as inconsistency of clinical syndrome differentiation, lack of large sample studies, and insufficient follow-up visits. In order to provide reference for clinical treatment in mixed hemorrhoids, this paper reviews academic studies on its postoperative constipation by traditional Chinese medicine in recent years.

KEYWORDS Postoperation in hemorrhoids; Constipation; Traditional Chinese medicine; Reviews

Hemorrhoids are formed by varicose veins of the lower rectum and anal canal. In clinical practice,they can be divided into internal hemorrhoids,external hemorrhoids and mixed hemorrhoids according to their anatomical positions. Relevant literature reports that the incidence of rectal and anal diseases accounts for 59.1% of the incidence of human diseases, while the incidence of hemorrhoids accounts for 87.25% of the incidence of rectal and anal diseases, and the incidence in men is slightly lower than that in women[1]. At present, surgery is still the most effective way to treat hemorrhoids[2].However, constipation often occurs in patients after the surgery[3]. It has adverse effects on postoperative recovery of patients and may also lead to failure of the surgery[4]. Therefore, adopting effective measures to prevent and treat postoperative constipation can relieve the pain of patients and is beneficial to postoperative recovery. There are many therapies for treating postoperative constipation in mixed hemorrhoids in Traditional Chinese Medicine(TCM), such as oral administration of TCM, enema with TCM, acupuncture therapy, catgut embedding at acupoints, etc., with characteristics like definite efficacy, relatively low recurrence rate and few side effects. Clinically, TCM is more and more widely used for postoperative constipation in mixed hemorrhoids. This paper reviews progress of studies in this field in recent years.

ETIOLOGY AND PATHOGENESIS

It is believed in TCM that the main causes of constipation include exogenous cold and heat pathogens, internal damage due to improper diet and emotions, feebleness after an illness, deficiency of Qi(气), blood, Yin (阴) and Yang (阳), etc.. Its etiology has long been described. For example,Inner Canon of Huangdi(《黄帝内经》) records, "Recession in the major Yin results in abdominal fullness and bloating,as well as inhibited defecation." "Retention of heat Qi into the small intestine causes intestinal pain,fever, thirst and retention of dry feces. That is why it causes pain and constipation." "If the kidney pulse is slightly rapid, it indicates anuria and constipation."Here, constipation is considered to be related to pathogens affecting the spleen, stomach, small intestine and kidney.General Treatise on Causes and Manifestations of All Diseases(《诸病源候论》)records, "Constipation is caused by disharmony of five zang viscera, rise and fall of Yin and Yang,deficiency and excess, as well as combination of cold and heat due to disharmony of Sanjiao (三焦)." Here,the deficiency, excess, Yin and Yang of constipation are believed to be related to the five Zang (五脏)viscera and Sanjiao. Modern doctors also have different opinions on the etiology and pathogenesis of constipation. For instance, based on the theory of"the anus being in charge of discharging for five zang viscera", WANG Xiao-hong[5]explored the mechanism of constipation. She believed that proper or improper opening and closing of the anus is closely related to the function of the five zang viscera, and if the anus is closed but not opened, constipation will occur.HAN Xue-piao[6]summed up Professor LIU Qi-quan's experience in treating constipation, and believed that occurrence of constipation is not only related to the spleen, lung and kidney, but also closely related to the liver and heart. The liver controls conveyance and dispersion, and liver Qi stagnation leads to conveyance losing control. The heart is the most important controller among the five zang viscera and six-fu (六腑) viscera. If the heart function is abnormal, the five zang viscera are also affected,resulting in abnormal large intestine function and constipation. Moreover, postoperative constipation in mixed hemorrhoids also belongs to the TCM category of "constipation". From the TCM perspective, after the surgery for mixed hemorrhoids, Qi, blood and fluid are consumed, and vital Qi is deficient, with poor circulation of Qi and blood, accumulation of dampness and heat, and blockage of meridians,which is easy to form dry feces and constipation.

In addition, clinically, mixed hemorrhoids are mainly treated by surgery. Due to skin sensitivity of the anus, patients' fear of pain in the incision and reluctance to defecation caused by pain prolong stool stagnation time and make it become too hard to discharge, so constipation occurs finally[7].Plus, application of anesthetics and painkillers,patients' subjective control of defecation, changes in postoperative diet structure and lack of exercise are also important causes of postoperative constipation.Postoperative constipation in mixed hemorrhoids is easy to cause patient's anxiety, and adverse effects on their daily life, such as eating and sleeping. Due to the dry feces and difficulty in defecation, it is prone to aggravate complications of surgery, such as edema, infection, bleeding, pain and poor wound healing. Sometimes overexertion when defecating can also lead to splitting of open surgical wounds,delaying wound healing and increase the pain and bleeding, which makes the patients more fearful of defecation, and creats a vicious circle.

INTERNAL TREATMENT

Syndrome Differentiation

Syndrome of Yin deficiency and depletion of fluid

The spleen plays an important role in fluid formation, which accomplishes transformation and generation of body fluid together with functions of the large intestine, small intestine and stomach[8].After surgery for mixed hemorrhoids, due to the patient's fear of defecation pain, he eats less food. Dysfunction of spleen in transportation and transformation results in lack of refined essence to generate Qi and blood. Or the wound is bleeding during the surgery and other situations, result in blood deficiency, Yin deficiency and body fluid consumption, which causes deficiency of fluid in the intestine, making it difficult to defecate and resulting in constipation. If the five zang viscera are nourished to supplement Yin blood, and the intestine is moistened to defecate, a good efficacy can be achieved. ZHENG Wen-bin[9]et al. used the Sanren Zengye Decoction (三仁增液汤) to treat postoperative constipation in mixed hemorrhoids,and found that in the treatment group, the effective rate reached 92%. Compared to that in the control group, it was increased by 10%, with a certain difference (P＜0.05). It suggested that the Sanren Zengye Decoction had obvious effects on nourishing Yin and promoting production of fluid, which was quite helpful for patients with postoperative constipation in mixed hemorrhoids, and it could speed up the patients' recovery.

Syndrome of depletion of fluid causing intestine dryness

Due to damage of the surgery to the body and consumption of fluid, feces are dry and hard,defecation intervals are prolonged, and drynessheat is accumulated in the body, which consumes fluid in the intestine and stomach. The dryness-heat and deficiency of Yin fluid form a vicious circle[10].Therefore, its treatment should focus on clearing heat and purging fire, promoting fluid production, as well as moistening dryness for relaxing bowels. If there is no lack of fluid in the body and the intestine is moistened for a long time, constipation can be healed. SUN Er-xia[11]treated constipation after hemorrhoid surgery, who belonged to syndrome of depletion of fluid causing intestine dryness, with the self-made Qingzao Runchang Decoction (清燥润肠汤), which includedRadix Angelicae Sinensis,Fructus Cannabis,Radix Rehmanniae Recens,Radix Ophiopogonis,Fructus Aurantii Immaturus,etc.. Compared with applying the Ziyin Runchang Oral Liquid (滋阴润肠口服液), it was found that after 2 courses of treatment, the self-made prescription was more effective after the hemorrhoid surgery,who had constipation belonging to syndrome of depletion of fluid causing intestine dryness.

Syndrome of Qi stagnation in the intestine

Constipation is divided into 5 categories (cold constipation, heat constipation, Qi constipation, wind constipation and dampness constipation) inYan's Formulas for Succouring the Sick(《严氏济生方》),while constipation of syndrome of Qi stagnation in the intestine after mixed hemorrhoid surgery belongs to the category of "Qi constipation" or "excessive constipation"[12]. According to TCM theory, pain in the incision after hemorrhoid surgery leads to emotional disorder and the liver failing to convey and disperse,then Sanjiao fails to transform Qi, the spleen and stomach fails to ascend and descend, and the intestine is obstructed to form constipation[13]. QI Bao-ju et al.[14]applied the Liqi Tongbian Decoction(理气通便汤) by oral administration to treat postoperative constipation of this syndrome in mixed hemorrhoids, which achieved certain efficacy in clinical practice. It indicates that in clinical treatment for constipation, the therapy of moistening the intestine for relaxing bowels should be emphasized.Meanwhile, the purpose of relaxing bowels should also be achieved by regulating Qi movement and other aspects according to the patient's situation.

Syndrome of dampness-heat amassment

Treatise on Spleen and Stomach(《脾胃论》) holds that the reason why the human body suffers from diseases is mostly because the function of the spleen and stomach has declined.Inner Canon of Huangdi(《黄帝内经》) records, "All dampness syndromes with swelling and fullness are ascribed to the spleen." Excessive dampness is easy to damage spleen Yang. If Qi movement of the spleen is disturbed by dampness, ascending and descending as well as exiting and entering of Qi in the intestine will be hindered, which leads to turbid Qi failing to descend, so as to cause constipation easily. However, long time stagnation of dampness can transform heat. The dampness pathogen and the heat pathogen combine to invade downward to the intestine and burn fluid in the large intestine,thus aggravating the original constipation[15]. Patients after mixed hemorrhoid surgery suffer from spleen and stomach damage as well as internal stagnation of fluid-dampness, which transforms into heat after a long time, resulting in constipation of dampnessheat amassment syndrome. QIAN Hua-song[16]gave patients the Shimi Prescription (实秘方) by oral administration, and compared it to the treatment with the Maren Pills (麻仁丸). Results showed that the Shimi Prescription had a higher effective rate than that of the Maren Pills. It indicates that the Shimi Prescription has certain advantages for postoperative recovery in constipation patients of this syndrome.

Syndrome of heat bound in intestine

After mixed hemorrhoid surgery, due to decrease in the patient's defecation times, feces stagnation time in the intestine becomes longer,resulting in large intestine fluid consumption, and stagnant heat accumulating in lower-Jiao (下焦),which causes poor movement of fu-visceral Qi, and affects the dreg transmission function of the large intestine.Jing-yue's Complete Works(《景岳全书》)records, "Yang binding syndrome must be caused by excessive pathogenic fire, which results in dryness of fluid." To treat this kind of disease, it is necessary to clear stagnant heat, remove indigestion in the bowels, and preserve fluid to moisten the intestine.ZHAO Feng-qin et al.[17]treated with the Yiqing Capsules (一清胶囊), which basically consisted ofRadix et Rhizoma Rhei,Rhizoma CoptidisandRadix Scutellariae, by oral administration. After 7 days of continuous treatment, it was found that postoperative edema, pain, feces characteristics,first defecation time and other symptoms were improved.

Treatment with Hospital Preparations of Traditional Chinese Medicine

Hospital preparations of traditional Chinese medicine mostly originate from summarzing clinical experience of TCM practitioners in past dynasties,and have advantages of definite efficacy and strong pertinence[18]. XUN Shao-shan[19]believed that constipation is caused by dryness-heat accumulation and insufficient fluid in the intestine due to long time stagnation of feces in the intestine after mixed hemorrhoid surgery. He treated with oral administration of the Maxing Zipi Capsules (麻杏滋脾胶囊), which consisted of friedFructus Cannabis,Semen Armeniacae Amarum,Radix Paeoniae Alba,Radix et Rhizoma Rhei,Cortex Magnoliae Officinalis,etc. It had effects on clearing heat and dissipating bind, as well as moistening the intestine for relaxing bowels, with remarkable efficacy. KUANG Bi-yan et al.[20]believed that the treatment for constipation after mixed hemorrhoid surgery should not be purgation alone. Since after the surgery, patients often suffer from complications such as wound pain,bleeding and wound edge edema, the treatment need combined with medicines for removing edema,relieving pain, stopping bleeding, etc.. Therefore,the Huaiyu Tongbian Mixture (槐榆通便合剂) was given to patients, which not only effectively solved constipation, but also had obvious advantages in relieving postoperative pain, wound edge edema and bleeding of the patients. JIANG Zhen-zhen et al.[21]treated senile patients with constipation after mixed hemorrhoid surgery with the Huangzhi Capsules (黄枳胶囊), which consisted ofRadix et Rhizoma Rhei,Fructus Aurantii Immaturus,Cortex Magnoliae Officinalis,Herba Cistanches,Fructus Cannabis, etc.. It could not only moisten the intestine for relaxing bowels and clear heat-fire,but had effects of tonifying kidney Yang, benefiting essence and blood, etc., which effectively improved insufficient intestinal motility of the elderly and promoted gastrointestinal peristalsis.

Treatment with Modified Ancient Prescriptions

ZHANG Dan-feng et al.[22]treated postoperative constipation in mixed hemorrhoids with oral administration of the Modified Zengye Decoction (增液汤加味), which consisted ofRadix Rehmanniae Recens,Radix Scrophulariae,Radix Ophiopogonis,Radix Angelicae Sinensis,Fructus Cannabis,Semen Pruni,Fructus AurantiiandRadix Glycyrrhizae. The research results show that the Modified Zengye Decoction (增液汤加味) could not only nourish Yin and moisten dryness, but also accelerate intestinal peristalsis and effectively reduce constipation.DONG Man-man et al.[23]believed that after the surgery for mixed hemorrhoids, Qi stagnates in the body, which inhibits circulation of Qi and blood, so the main treatment should be moistening the intestine for relaxing bowels, activating Qi for removing stagnation, nourishing blood and promoting blood circulation. Results of the study on treatment with the Modified Maziren Decoction (加减麻子仁汤) showed that the effective rate was 93.3%.

Treatment with Empirical Prescriptions

YANG Xiao et al.[24]treated constipation after open-loop PPH surgery for mixed hemorrhoids,based on Professor ZHU Bing-yi, a famous TCM expert's empirical prescription called the Tongbian Decoction (通便汤). Prof. ZHU proposed that"deficiency of fluid and non-distribution of fluid" is the basic cause of constipation due to intestinal dryness, and the Tongbian Decoction can be used for treatment to achieve effects of benefiting Yin, promoting fluid production, regulating Qi and relaxing bowels. The study was to apply the Tongbian Decoction for treatment. Results showed that the total clinical effective rate was 90%, and the recurrence rate was only 9.3% in 60 days after the treatment, indicating that the Tongbian Decoction could be used for constipation after hemorrhoid surgery with considerable efficacy.

Treatment with Self-made Prescriptions

YUAN Yan-ling et al.[25]treated patients in the observation group with oral administration of the self-made Runchang Tongbian Prescription(润肠通便方), which containedRadix Astragali seu Hedysari,Radix Rehmanniae Recens,Radix Angelicae Sinensis,Semen ArmeniacaeAmarum,Semen Pruni,Semen Persicae,Rhizoma Atractylodis Macrocephalae,Rhizoma Corydalis,Rhizoma CimicifugaeandFructus Aurantii. While patients in the control group were treated with oral administration of the Maren Soft Capsules (麻仁软胶囊). After the medication, it was found that in the observation group, scores of dry feces,laborious defecation, epigastric distending pain,etc. were all lower than those in the control group(P＜0.05). Moreover, scores of defecation pain in the observation group were decreased successively after the first time, 3-4 days, 6-7 days and 9-10 days of treatment, all of which were lower than those in the control group (P＜0.05).

EXTERNAL TREATMENT

Therapy of Acupuncture and Moxibustion

Therapy of acupuncture and moxibustion is a treatment method that stimulates corresponding acupoints and meridians of the human body by acupuncture or moxibustion to dredge the meridians.Its ultimate purpose is to regulate functions of various Zang-Fu (脏腑) viscera in the human body and make the body reach a normal and stable state. In clinical treatment with acupuncture and moxibustion, back-shu points (背俞穴), front-mu points (募穴) and lower-he-sea points (下合穴)of the large intestine and stomach are frequently selected[26]. Acupuncture at the above related acupoints can promote Qi movement in the stomach and intestine, letting them be nourished by Qi and blood, and improving their function of conveyance,thus dredging feces and eliminating constipation.YANG Zhen et al.[27]treated with postoperative constipation in mixed hemorrhoids by needling at Dachangshu (BL25), Zusanli (ST36), Tianshu(ST25), Shangjuxu (ST37), Hegu (LI4), Zhigou (SJ6)and Daheng (SP15). ZHAI Bai-zhi[28]needled maily at Zusanli (ST36), Dachangshu (BL25), Shenque(CV8), Erbai (EX-UE2), Chengshan (BL57) and Tunzhong, and patients' constipation was obviously reduced. XIN Tao[29]needled at Dachangshu(BL25), Zusanli (ST36), Tianshu (ST25), Shangjuxu(ST37), Zhigou (SJ6), Hegu (LI4) and Daheng(SP15). Results showed that constipation was more effectively relieved compared with the conventional constipation therapy, indicating that acupuncture had definite efficacy on postoperative constipation.

Enema with Traditional Chinese Medicine

InTreatise on Cold Pathogenic Diseases(《伤寒论》), there are clear records on treating the enema therapy with TCM. Modern medical studies have shown that the enema therapy with Chinese materia medica can reach the affected part directly and has rapid efficacy[30]. TANG Ying-li[31]treated constipation after hemorrhoid surgery with the Xiaochengqi Decoction (小承气汤), which consisted ofRadix et Rhizoma Rhei,Cortex Magnoliae Officinalis,Fructus Aurantii Immaturus,Radix Aucklandiae,Radix Astragali seu HedysariandCortex Phellodendr. It was made into a TCM medicine prescription that could dissolved in boiling water for enema. Compared with patients only given lactulose oral liquid, it was found that the total effective rate of enema with TCM medicine reached 100%, and its symptoms disappeared faster, indicating that TCM medicine enema could effectively relieve constipation.

Catgut Embedding at Acupoints

YUAN Dong-hui[32]randomly divided 160 patients with constipation after mixed hemorrhoid surgery into the control group and the treatment group. The treatment group was treated by catgut embedding at acupoints after the surgery. The main acupoints selected were Changqiang (GV1), Tianshu(ST25) and bilateral Chengshan (BL57). After the treatment, results showed that aspects like the first time of defecation, pain during defecation and the main symptoms of constipation in the treatment group were significantly improved (P＜0.05).

Massage at Acupoints

ZHA Qin-fang et al.[33]treated constipation after mixed hemorrhoid surgery by massage at acupoints. The control group was given routine nursing, while the treatment group was given acupoint massage on the basis of the routine nursing. The specific acupoints were bilateral Zusanli (ST36), bilateral Daheng (SP15), bilateral Tianshu (ST25), Zhongwan (CV12) and Qihai(CV6). After the treatment, constipation of patients in the treatment group was improved, whose effective rate was 23.85%, higher than that in the other group. The difference between the 2 groups was statistical significance (P＜0.05).

Wet Compress with Traditional Chinese Medicine

Some scholars have suggested that hot compress with peppermint oil on the umbilicus can promote intestinal peristalsis and has a lasting effect[34]. ZHANG Yong-ting[35]treated with constipation after mixed hemorrhoid surgery through hot and wet compress with peppermint oil,and recorded its clinical efficacy. Results showed that the total effective rate of relieving constipation symptoms was 96.3%, with relatively good efficacy on improving defecation time, defecation pain and constipation (P＜0.05).

COMBINATION THERAPY

Combination of Two Kind of External Treatments

WEI Wei[36]treated constipation after mixed hemorrhoid surgery by auricular acupuncture with moxibustion. After the treatment and comparison on results, it was found that the total clinical effective rate was 91.84%. HUANG Mei et al.[37]applied the injection therapy with neostigmine at Zusanli (ST36)with TDP abdominal irradiation. Compared with treatment simply using oral administration of Bibaike Capsules (比拜可胶囊), the total effective rate was 94.40%, and the improvement of other clinical symptoms was more obvious than that in the group treated with Bibaike Capsules alone. SONG Xiao et al.[38]observed effects of abdominal acupuncture with catgut embedding at acupoints on anorectal dynamics and anal function in patients with constipation after mixed hemorrhoid surgery. It was found that the patients' degree of constipation, fecal characteristics and defecation time were improved,indicating that abdominal acupuncture combined with catgut embedding at acupoints had a positive effect on recovery of anal function after the surgery.

Combination of Two Internal Treatments

WANG Bin[39]selected 142 patients with constipation after mixed hemorrhoid surgery, and randomly divided them into the control group and the observation group. The control group was treated by oral administration of phenolphthalein tablets, while the observation group was treated by oral administration of the Modified Zengye Decoction (增液汤加减) and acupoint massage base on the above western medicine. The 2 groups were treated continuously for 7 days. Results showed that improvement of constipation and 5 clinical symptoms in the observation group were more obvious.

External Treatment Combined with Oral Administration of Traditional Chinese Medicine

WANG Bin et al.[40]observed 90 patients with constipation due to Yin deficiency and intestinal dryness after mixed hemorrhoid surgery. They were randomly divided into 2 groups. There were 45 patients in the observation group given the Runchang Decoction (润肠饮) with auricular acupuncture, while patients in the control group were only given oral phenolphthalein tablets. The 2 groups were treated continuously for 1 week.Results showed that the total effective rate in the control group was 75.6%, which was lower than 93.3% in the observation group, and there was certain difference between the 2 groups (P＜0.05).

CONCLUSION AND PROSPECT

At present, Western medicine mainly takes oral western medicine as the treatment for constipation, which can quickly relieve constipation symptoms in a short period of time. However,long-term use is prone to medicine dependence and adverse reactions, and sometimes even makes constipation and other symptoms heavier than those before the treatment. Comparatively speaking, there are various TCM methods for treating postoperative constipation, with remarkable efficacy, fewer side effects and a low recurrence rate. Nevertheless, TCM is not perfect in clinical treatment for constipation after mixed hemorrhoid surgery, and there are still some corresponding problems. Firstly, there is no unified standard for clinical syndrome differentiation on constipation after mixed hemorrhoid surgery, and there is a lack of summary on corresponding rules of TCM medicine prescriptions. Many doctors often give medication as soon as they see the disease in clinical treatment,which lacks syndrome differentiation and treatment,and only choose a fixed treatment scheme based on their own experience. Secondly, current studies on constipation after mixed hemorrhoid surgery are mainly based on clinical observation, lacking rigorous evidence-based medical evidence such as large sample, multi-center, blind methods and randomized control. Finally, the long-term follow-up records are few, without exact longterm efficacy. There is a lack of systematic and indepth exploration on the mechanism and basic experimental studies. Therefore, in the future clinical diagnosis and treatment, we should pay attention to syndrome differentiation, combine theory with practice, proceed from the whole, perform treatment based on syndrome differentiation, and reasonably select treatment schemes. We should strengthen studies on the mechanism of Chinese medicine prescriptions as well as acupuncture and moxibustion in treating constipation after mixed hemorrhoid surgery. Combine TCM thoughts with modern advanced scientific and technological means, so as to alleviate constipation after mixed hemorrhoid surgery to a greater extent in clinical treatment, thus reflecting TCM advantages.