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The Large Intestine

It extends from the


ileocaecal junction to the
anal verge.
It is formed from the
distal midgut, all of the
hindgut, and the
proctodeum.
Subdivided into
Cecum, vermiform
appendix, colon,
rectum and anal canal

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Special features of large intestine
Teniae coli
thickening of
longitudinal
muscularis
absent in the caecum,
vermiform appendix
and rectum
Haustra
puckering
(sacculations ) created
by teniae coli
more pronounced
beyond the middle of
the transverse colon
Epiploic appendages-fat-filled pouches of visceral peritoneum
absent in rectum
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Teniae coli: three distinct longitudinal bands:
1. Mesocolic tenia, to which the transverse and
sigmoid mesocolons attach
2. Omental tenia, to which the omental appendices
attach
3. Free tenia (libera), to which neither mesocolons nor
omental appendices are attached.

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The large intestine begins as the caecum and
vermiform appendix, which are usually located in the
right iliac fossa.
The ascending or right colon passes upwards in the
right flank and bends to the left to form the hepatic
flexure (right colic flexure) and become the
transverse colon.
The transverse colon curves inferiorly to form the
splenic flexure (left colic flexure).

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The descending or left colon continue as the sigmoid
colon in the left iliac region.
The sigmoid colon descends into the true pelvis and
becomes the rectum anterior to the third sacral
vertebra.
The rectum transitions to the anal canal at the level of
the pelvic floor.

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In the adult 1-1.5 m long
It has a greater caliber
More fixed in position
Its caliber is greatest near the caecum, gradually
diminishes towards the sigmoid colon, and then
increases again in the rectum, where the lower third is
dilated to form the rectal ampulla.
The mean internal diameter of the large intestine is
4.8 cm.

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Peritoneal relations of the large intestine
Retroperitoneal
Ascending colon, descending colon, rectum and anal
canal.
Intraperitoneal
The caecum is often completely covered by
peritoneum
Transverse colon is suspended by a mesocolon and is
freely mobile within the upper abdomen.
The hepatic and splenic flexures may have a short
mesentery.
Sigmoid colon has a mesentery of variable length.
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Histology of large intestine
Corresponds to the general pattern of the gut wall, having a
mucous membrane consisting of epithelium, lamina propria
and muscularis mucosa, surrounded by an inner circular and
outer longitudinal layer of muscle and a serosa.

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The mucosa is occupied mostly by tubular intestinal
glands extending as deep as the muscularis mucosae
and by lamina propria rich in MALT.
Unlike the small
intestine, the
mucosa of the large
intestine lacks villi
and the glands
(crypts) contain a
high proportion of
goblet (mucin -
secreting) cells.
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(a)Transverse section of the colon shows the muscularis externa (ME), the submucosa (S),
the mucosa (M) filled with tubular intestinal glands.(b): Transversely cut glands are seen to
consist of simple columnar epithelium surrounded a tubular lumen (asterisk) and embedded
in lamina propria (LP) with many free lymphocytes. Lymphocytes can also be seen
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penetrating the epithelium (arrow).
The lamina propria is rich in lymphoid cells and in
lymphoid nodules that frequently extend into the
submucosa.
The richness in MALT is related to the large bacterial
population of the large intestine.
The large intestine is well suited to its main functions:
absorption of water, formation of the fecal mass from
indigestible material, and production of mucus that
lubricates the intestinal surface.

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The appendix is characterized by a relatively small
and irregular lumen, shorter
and less dense tubular glands,
and no taeniae coli.
Although it has no function
in digestion, the appendix is
a significant component of
the MALT, with abundant
lymphoid follicles in its wall.
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B/c the appendix is a closed sac and its contents are
relatively static, it can easily become inflamed.

With the small lumen and relatively thin wall of the


appendix, inflammation and the growth of lymphoid
follicles in the wall can produce swelling that can lead to
bursting of the appendix.

Severe appendicitis is a medical emergency since a burst


appendix will produce infection of the peritoneal cavity.

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At the recto-anal junction, the lining of the mucosa is
replaced by stratified squamous epithelium.
In this region, the lamina propria contains a plexus of
large veins that, when excessively dilated and varicose,
can produce hemorrhoids. The simple columnar
epithelium with tubular
glands that lines the
rectum (left side)
changes abruptly to
stratified squamous
epithelium in the anal
canal (right side), as
seen in this longitudinal
section. 16
Arterial supply
The arterial supply
of the large
intestine is derived
from both the supe-
rior and the inferior
mesenteric arteries

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The caecum, appendix, ascending colon and proximal
two thirds of the transverse colon (derived from the
midgut) are supplied from ileocolic, right colic and
middle colic branches of the superior mesenteric
artery.
The distal third of the transverse colon, descending
and sigmoid colon, rectum and upper anal canal
(hindgut derivatives) are supplied predominantly
from the inferior mesenteric artery via the left colic,
sigmoid and superior rectal arteries, with a small
contribution from branches of the internal iliac artery
(the middle and inferior rectal arteries).

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Veins
Primarily into the portal vein via the superior
mesenteric and inferior mesenteric veins
Middle portion of rectum via middle rectal veins into
the internal iliac veins
Lower portion of rectum
via Inferior rectal veins
into the internal
pudendal veins.
Those parts of the colon
derived from the midgut
drain into colic branches
of the superior
mesenteric vein, while
hindgut derivatives drain
into the inferior
mesenteric vein. 19
Lymphatic drainage
Lymphatic vessels of the large intestine derived from
midgut drain ultimately into lymph nodes related to the
superior mesenteric artery, while those of the large
intestine derived from hindgut drain into nodes following
the course of the inferior mesenteric artery.

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Caecum
Blind pouch, measuring approximately 6 cm in length
Fluid and electrolyte reabsorption by the large
intestine begins in the caecum but occurs mostly in
the ascending and transverse colon.
The relatively large diameter of the caecum makes it
liable to distension with increased intracolonic
pressure.
At greatest risk of perforation

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Ileocolic junction
The terminal ileum joins the posteromedial aspect of the large
intestine at the junction of the caecum and colon, where it
projects into the lumen of the large intestine as the ileal
papilla.
It consists of two labial folds;
1. Upper labial fold is horizontal
at the junction b/n the ileum and colon
2. Lower lip is longer and more concave
at the junction b/n the ileum and caecum.

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Vermiform (wormlike) appendix
Is a narrow, blind ending tube, 6-10 cm long in adult.
It joins the posteromedial wall of the caecum below the
ileocolic junction.
The base of the appendix lies deep to a point that is one third
of the way along the oblique line joining the right ASIS to the
umbilicus (the McBurney point on the spinoumbilical line).

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The tip of appendix shows positional variation
Retrocaecal (behind the caecum)-64%
Retrocolic (behind the lower ascending colon)
Pelvic (descends over the pelvic brim)-32%
Subcaecal-2%
Preileal (anterior to the terminal ileum)
postileal (posterior to the terminal ileum)-0.5%.
Promonteric-1%
prececal

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Acute appendicitis may develop as a consequence of
obstruction of the lumen from inspissated material, a
faecolith (appendicolith) or lymphoid swelling.

This can lead to suppuration, infarction and necrosis.

The increased size of the appendicular orifice in early


childhood and the decreased lumen in the elderly may
be reasons why acute appendicitis is less common in
these age groups.
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Visceral afferent nerves are responsible for the initial
symptoms of acute appendicitis.

Abdominal pain from appendicitis is poorly localized


initially around periumbilical region of the abdomen

Removal of the appendix is not by itself associated


with any discernible longterm sequelae but this does
not mean that it is an entirely vestigial organ.

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Ascending Colon
Passes upwards from the ileocolic junction to the
right colic (hepatic) flexure.
Separated posteriorly by loose connective tissue from
the iliac fascia, iliolumbar ligament, quadratus
lumborum, transversus abdominis, and the renal
fascia.
The lateral femoral cutaneous nerve, usually the
fourth lumbar artery, and sometimes the ilioinguinal
and iliohypogastric nerves lie posteriorly as they
cross quadratus lumborum.

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Hepatic flexure
The hepatic flexure, forming the junction between
the ascending and transverse colon, is variable in
position, and has a less acute angle than the splenic
flexure.
Transverse Colon
It is highly variable both in length (approximately 50
cm long on average) and position.

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Splenic flexure
Marks the junction between the transverse and
descending colon and lies in the left hypochondrium
Often attached to the splenic capsule by a peritoneal
ligament and inadvertent downward traction on the
flexure during surgery may tear the splenic capsule.
The phrenicocolic ligament attaches the flexure to the
diaphragm below the inferior pole of the spleen.
Forms a very acute angle

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Descending Colon
Descends from the splenic flexure in the left
hypochondrium to the level of the iliac crest.
In most adults it is retroperitoneal, covered anteriorly
and on both sides by peritoneum, but occasionally the
descending colon is more mobile, being suspended
from the posterior abdominal wall by a short meso-
colon.
Appendices epiploicae are more common in this part
of the colon.

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Sigmoid Colon
Runs from the lesser pelvis to the beginning of the
rectum at the level of the third sacral vertebra.
Its length and position are highly variable b/c it is
suspended by sigmoid mesocolon.
The taeniae coli of the sigmoid colon are wider than
elsewhere in the colon.
Appendices epiploicae are particularly prominent in
the sigmoid colon.
The length of the sigmoid colon and its mesentery
vary between ethnic groups.

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Rectum
Begins at the 3rd sacral vertebra as a continuation of
the sigmoid colon and ends at the recto anal junction
about 2-3 cm anterior to and slightly below the tip of
the coccyx.
It descends within the sacrococcygeal concavity, at
first running posteriorly and then curving anteriorly.
Lateral flexures=3

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Extends approximately 15 cm above the external anal
margin.
Its upper diameter is similar to that of the sigmoid
colon, but more inferiorly it becomes dilated as the
rectal ampulla.
Unlike the sigmoid colon, the rectum has no
sacculations, appendices epiploicae or taeniae coli.
Upper third-covered by peritoneum anteriorly and
laterally.
Middle third-covered only anteriorly.
Lower third-no peritoneal covering.

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Location and peritoneal relations of the rectum

S3

1 inch infront of
coccyx
Shape (flexures) of the rectum

- Anteroposterior curve
- 3 flexures
1. Upper concave to left
2. lower concave to left
3. Middle concave to right

Rectal ampulla
3 folds of rectum
males females
Anterior o Rectovesical pouch containing o Recto-uterine pouch,
coils of ileum and sigmoid colon coils of ilium and
o Base of urinary bladder. sigmoid colon
o Ampulla of vas deference o Posterior wall of
o Seminal vesicles vagina.
o Prostatic gland
o Terminal part of ureter.
Posterior Muscles As males
o Piriformis, LevatorAni, Coccygeus
Bones
o Sacrum, Coccyx
Vessels
o Superior Rectal Artery and Median
Sacral Artery
Laterally LevatorAni, Coccygeus, Pararectal As males
Fossa
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Anterior relations of the rectum
Arterial supply
1. Superior rectal artery-the continuation of IMA
It supplies the rectum and upper half of anal canal.
2. Middle rectal artery-arises from the anterior
division of internal iliac artery
3. Inferior rectal artery -arises from internal pudendal
artery

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Venous drainage
1. Superior rectal vein continues up as inferior mesenteric
vein which drains into the splenic vein (portal
circulation)
2. Middle rectal vein: drains into internal iliac vein
(Systemic circulation).
3. Inferior rectal vein: drains into internal pudendal vein
(Systemic circulation).
Superior, middle, and inferior rectal veins anastomose
with each other in submucosa of rectum and anal canal.
Hemorrhoids (pilesis): the dilation of the veins at the site
of anastomosis

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Hemorrhoids

Internal hemorrhoids
Tributary of superior rectal
Above white line
Generally painless

External hemorrhoids
Tributary of inferior rectal
Below white line
Generally painful
Lymph drainage of rectum
1. Upper half drains to para rectal L.Ns which drain to inferior
mesenteric L.Ns.
2. Lower half drains to internal iliac lymph nodes.
Anal canal
Beginning: It begins one inch below and anterior to the
tip of the coccyx at the recto-anal junction.
Course: It runs down and backwards.
Termination: It ends at the anus.
Blood supply, nerve supply and lymph drainage of anal canal:
Upper part Lower part
Blood -It is supplied by -It is supplied by:
supply superior rectal artery. 1. Middle rectal artery of
and - It is drained by internal iliac artery.
venous superior rectal vein 2. Inferior rectal artery of
drainage (portal circulation). internal pudendal artery.
-The corresponding veins
drain into internal iliac vein
(systemic circulation.)
Nerve Above pectinate line by Below pectinate line by
supply autonomic nerve fibers. inferior rectal nerve (Sensitive
to pain &touch).
Lymphatic Above pectinate line Below the pectinate line into
drainage into internal iliac LNs. superficial inguinal LNs.
Anal sphincters:
Internal anal sphincter:
-It is the thickened inner involuntary circular muscle
layer of the anal canal.
-Surrounds the upper 3/4th of the anal canal, extending
from ano-rectal junction till the white line.
Nerve supply: autonomic
External anal sphincter:
-Striated voluntary muscle fibers.
Sphincters of the anal canal

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