Caecum, Appendix

& Colon
Dr Yasrul Izad Abu Bakar
Faculty of Medicine, UniSZA
 Learning outcome
• Differentiate between small and large intestines

• Describe gross anatomy of the colon, caecum and appendix

• State the positions of appendix

• Explain about the attachments and contents of mesocolon

• Describe the microscopic features of the colon and

appendix

• Discuss their clinical aspects

 Large intestine
Is the site where water is
absorbed from
indigestible intestinal
contents & converting it
into semisolid stool that
is temporarily stored
until defecation

• It extends from
ileocaecal junction to
anus
 Large intestine
• Consists:
1. Caecum
2. Appendix
3. Colon – ascending,
transverse, descending &
sigmoid colon
4. Rectum
5. Anal canal
 Large Intestine: gross features
Large intestine
• The large intestine are different
from small intestine because it
has:
1) Greater internal diameter

2) Omental appendices
Small intestine

3) Haustrations (sacculations)

4) Taeniae coli
 Large intestine
Epiploic
Large intestine has epiploic appendices
(omental) appendices

Appendices epiploicae:
• Small bags of peritoneum filled
with fat

• Scattered over the large

intestine (except in ‘CAR’ = caecum,
appendix & rectum)

• Most numerous – on the sides

of sigmoid colon & posterior
surface of transverse colon
 Large intestine
• Large intestine has
taeniae coli
Taenia coli

Taeniae coli:
• Are the outer
longitudinal muscle coat
(smooth muscle) of
muscularis externa in the
form of 3 bands
Layers of GIT (general)

Muscularis
externa
layer
 Outer longitudinal muscle layer & Taeniae coli

• The outer longitudinal layer

(of muscularis externa) of Base of
the appendix is complete Appendix

• However, at base of
appendix, it splits into 3
bands (taeniae coli) Appendix
→ run along cecum & colon

• Then, the outer longitudinal

layer become a complete
layer in rectum
Teniae
*large intestine has taeniae coli coli
except appendix & rectum
 Taeniae coli
Free Taenia
(libera)
Types (based on peritoneal
fold attached to it):

1. Taenia libera / free

2. Taenia mesocolic

Omental
3. Taenia omental Taenia
Mesocolic
Taenia
 Taeniae coli
In transverse colon:

• Free taenia (inferior) – no

mesentery attachment

• Mesocolic taenia (posterior) – at

the site of attachment of
transverse mesocolon

• Omental taenia (anterosuperior) –

at the site of posterior layer of
greater omentum attached Free taenia
(libera)
 Taeniae coli Anterior layer
of greater
omentum (cut)

• Mesolic taenia –
site of transverse
mesocolon
attached

• Omental taenia –
site of posterior
layer of greater
omentum
attached
Posterior layer
Transverse
of greater
mesocolon
omentum
 Large intestine
Taeniae coli
Haustration
Appendices
epiploicae

Large intestine showed haustrations (sacculations)

• The taeniae coli are shorter than the large intestine
• Therefore large intestine becomes sacculated
• The sacculations of colon are called haustra
 Large intestine VS small intestine

Features Large Small

intestine intestine
Appendices Present Absent
epiploicae
Taeniae coli Present Absent

Sacculations Present Absent

Diameter Greater Lesser

 Mr. X: Right iliac fossa pain
• Mr. X, is a 20 years old male presented with
abdominal pain for 2 days.

• The pain started at umbilical region then radiated

to right iliac fossa.

• Maximum tenderness felt when you press the

lateral 1/3 line joining the right anterior superior
iliac spine (ASIS) to umbilicus.

• Diagnosis ?
 Large intestine
• Consists: Transverse
colon

1. Caecum
2. Appendix Ascending Descending
colon colon
3. Colon – ascending,
transverse, descending &
Sigmoid
sigmoid colon Caecum
colon
4. Rectum
5. Anal canal Appendix
 Caecum
• Is the 1st part of large intestine

• Is a blind intestinal pouch (7.5cm

long & broad) Caecum

Communicates:
• medially with the ileum
• posteromedially with the appendix
• superiorly with the ascending colon
Ileocecal
junction
Situated:
• inferior to the level of ileocecal Caecum
junction
• in the right iliac fossa (above lateral
half of inguinal ligament)
 Caecum

Peritoneal relations:
• No mesentery

• Commonly bound to
lateral abdominal wall by
caecal folds

Caecal
folds
 Caecum Lips of
ileocaecal
• Terminal ileum enters (partly valve
invaginates) the caecum obliquely

• Opening of terminal ileum is guarded

by ileocecal valve

• Ileal orifice located at the

posteromedial aspect of caecocolic
junction

Ileocecal valve:
• Commonly seen in cadaver

• has 2 lips & 2 frenula

Frenula
• Frenula are formed by fusion of lips
 The interior of caecum showing the
endoscopic (living) appearance of
Caecum ileocaecal valve

Ileal papilla:
• Seen in living person
(endoscopic observation)

• Is the in vivo appearance of Ileal papilla

ileocecal valve

• Muscular fibres formed

sphincter around the ileal
orifice & papilla

• Close the ileal orifice by tonic

contraction
Muscle fibres at ileal papilla
 Ileocecal valve / papilla
Functions:
• Prevents reflux from caecum to
ileum
• Regulates passage of ileal content
into caecum

Closed due to:

• tonic contraction of ileocaecal
sphincter
• mechanical closure of ileocecal
valve by distension of caecum
 Caecum: Superior view

Caecum Appendix

Anterior relations:
Coils of intestine Testicular
vessels

Posterior relations: Caecum

1. Muscles – right psoas major
2. Vessels – testicular / ovarian
3. Nerves – genitofemoral, Ascending
femoral colon
(cut)
4. Appendix

* All structures of right side

Psoas
major
 Appendix
• Is a blind intestinal diverticulum
that contains masses of lymphoid
tissue

• Traditionally called vermiform (worm-

like) appendix

• Arising from posteromedial wall of

caecum (2cm below ileocaecal
orifice)

• Lies in right iliac fossa

• 6 - 10cm long (longer in children than Appendix

adult)
 Appendix
Lumen of appendix is narrow &
may be partially or completely
obliterated after mid-adult life

Appendicular orifice:
• Situated on posteromedial
aspect of caecum

Appendicular
• Occasionally guarded by valve orifice
of Gerlach (indistinct semilunar fold of
mucous membrane)
 Appendix: positions
• Base of appendix is fixed

• Tip of appendix can point to any direction:

1. Retrocaecal – 12 O’clock (commonest, 65%)

- lie behind caecum

2. Paracolic – 11 O’clock

3. Splenic – 2 O’clock (may be pre-ileal: anterior to

ileum or post-ileal: posterior to ileum)

4. Promontoric – 3 O’clock

5. Pelvic – 4 O’clock (2nd most common, 30%)

6. Subcaecal – 6 O’clock
 Appendix
Mesoappendix:
• Fold of peritoneum (mesentery)
that suspends the appendix

• Small & triangular

• attached to appendix & part of

caecum

• Passes superiorly behind the Mesoappendix

ileum
 Clinical importance
Appendicitis:
• Acute inflammation of appendix

• May resulted by obstruction

due to hyperplasia of lymphatic
masses in the appendix or
obstruction by faecalith

• Common cause acute severe

abdominal pain (acute
abdomen)

• If ruptured may cause

peritonitis
 Mr. X
Maximum tenderness elicited on digital
pressure of the lateral 1/3 line joining the right
ASIS to umbilicus

Why?
 Appendix: clinical importance
McBurney’s point:
• Is the site where base of
appendix lies

• Located at the lateral 1/3

of line joining the right
anterior superior iliac
spine (ASIS) to umbilicus
(spinoumbilical line)

• The site of maximum

tenderness in
appendicitis
 Mr. X

He also claimed the pain increases when you

passively extend the right hip joint / right thigh

Why?
 Caecum: Superior view

Appendix

When the appendix is

retrocaecal, extension of
Caecum
hip joint may cause pain
because right psoas major
is touching / disturbing the
appendicitis

Psoas
major
 Colon
Transverse
Have 4 parts:

1. Ascending (fixed)
Descending
2. Transverse (mobile) Ascending

3. Descending (fixed)
Sigmoid
4. Sigmoid (mobile)
 Ascending colon
Extends from caecum to
the inferior surface of right
lobe of liver
• Narrower than caecum
• Retroperitoneum (fixed)
Ascending

Relations:
• Laterally, there is a
vertical groove lined by
parietal peritoneum –
right paracolic gutter
 • Rt paracolic gutter
lies between lateral
aspect of ascending
colon & adjacent
abdominal wall

Right paracolic
gutter
 Right colic flexure
• A.k.a hepatic flexure

• Lies at the junction of ascending &

transverse colon

• Lies on the lower part of right

kidney

• Anterosuperiorly related to colic

impression on inferior surface of
liver
 Transverse colon
• Longest & most mobile part
of large intestine
• Hangs as a loop & suspended
by transverse mesocolon (most
of its root attached to the pancreas)
• Located at the level of
umbilicus (L3) Pancreas

Relations:
• Anterior – greater omentum Greater omentum

• Posterior – 2nd part of Transverse

duodenum, head of pancreas mesocolon
Root of transverse
mesocolon
 Left colic flexure
• A.k.a splenic flexure

• Lies at the junction of transverse &

descending colon

• Slightly superior than hepatic flexure

• Lies on the lower part of left kidney,

behind the stomach & below the
spleen

• Attached to the diaphragm (at 11th rib,

midaxillary line) by phrenicocolic
ligament (supports spleen & forms Phrenicocolic
upper limit of left paracolic gutter) ligament
 Descending colon
• Extends from splenic
flexure to sigmoid colon

• Retroperitoneal (fixed)

• Has left paracolic gutter

on its lateral aspect
 Sigmoid colon Sigmoid
mesocolon

• A.k.a pelvic colon

• Characterized by S-shaped loop (40cm)

• Extends from left iliac fossa (end of

descending colon) to the S3 segment
(continues as rectum)

• Suspended by sigmoid mesocolon

(mobile)

• Hangs down in true pelvis over the

bladder & uterus

• Rectosigmoid junction indicated by

termination of taenia coli Sigmoid colon
 Sigmoid
mesocolon
Sigmoid mesocolon
Is a triangular fold of
peritoneum that
suspends the sigmoid
colon

• Root of sigmoid
mesocolon has an
inverted V-shaped
attachment
 Sigmoid mesocolon
Attachment of root (inverted V- Root of Sigmoid mesocolon
shaped):

• Its apex lies over the left

ureter & termination of left
common iliac artery

• Left limb of ‘V’ attached along

the left external iliac artery

• Right limb of ‘V’ is from the

bifurcation of left common
iliac artery to the anterior
aspect of sacrum (posterior
pelvic wall)
 Sigmoid mesocolon
Contents:
• Sigmoid vessels

• Superior rectal
vessels

• Nerves, LN &
lymphatics of
sigmoid colon

Sigmoid mesocolon
 Rt colic Middle
Blood Supply a. colic a. SMA

Part of LI Blood supply from

SMA
1 Cecum Cecal artery (branches
of Ileocolic a.)

2 Appendix Appendicular a. (br. of

ileocolic a.)

3 Ascending Ileocolic & Right colic

colon a. (branches of SMA)

4 Transverse Middle colic artery Ileo-

colon (branch of SMA) colic
a.

LI proximal to splenic flexure is served by branches of superior mesenteric artery

(SMA)
Blood supply: Caecum & appendix
Caecum:
Anterior
• Cecal branches of cecal
Ileocolic
ileocolic artery (terminal arteries
artery
branch of SMA)

Appendix:
• Artery – appendicular
artery (branch of
ileocolic artery)

Appendicular artery
 Lt colic art

Blood Supply

Part of LI Blood supply

from IMA Sigmoid
arteries

1 Descending Left colic artery

colon

2 Sigmoid Sigmoid arteries

colon
IMA

LI distal to splenic flexure is served by

branches of inferior mesenteric artery
(IMA)
 Venous Drainage
Portal
vein
Part of LI Blood drain
into
1. Cecum Superior
2. Appendix mesenteric
3. Ascending c. vein (SMV)
4. Transverse c. → hepatic IMV
SMV
portal vein

1. Descending c. Inferior
2. Sigmoid c. mesenteric
vein (IMV)
→ splenic
vein →
hepatic
portal vein
 Lymphatic Drainage
Superior
mesenteric
Part of LI Drain into LN
1 Cecum, Superior
appendix, mesenteric
ascending & lymph
transverse nodes (LN)
colon
2 Descending Inferior
& sigmoid mesenteric
colon LN
Inferior
mesenteric
LN
 Innervation

• Large intestine (viscera in general) are innervated by autonomic

nervous system
• Thus, they are innervated by:
1) Sympathetic fibres (inhibitory to large intestine, vasomotor)
2) Parasympathetic fibres (motor to large intestine)
3) Visceral afferent (sensory) fibres
• Sensitive to stretching (eg: distension).
• Not sensitive to pain, touch & temperature
 Innervation
Part of LI Sympathetic nerve fibres Parasympathetic nerve fibres

Cecum From lower thoracic (T10-T12) → Vagus nerve → superior

Appendix splanchnic nerves → superior mesenteric nerve plexus
Ascending c. mesenteric nerve plexus
Transverse c.
#pain
Descending c. Lumbar (L1-L2) segment → S2-S4 spinal cord segment →
Sigmoid colon superior hypogastric & inferior pelvic splanchnic nerves →
mesenteric plexuses superior hypogastric &
inferior mesenteric plexuses

#pain
Visceral afferent nerve fibres (sensory):
1. From Caecum to Transverse colon - Pain fibres follow sympathetic fibres
retrogradely to the T10-T12
2. Descending to Sigmoid colon - Pain fibres follow parasympathetic fibres
retrogradely to the S2 – S4
 Innervation – Sympathetic system
• Sympathetic fibres
is from the
thoracolumbar
spinal cord
segment

• Then the fibres

pass through
sympathetic trunk
(chain) →
splanchnic nerves
→ mesenteric
nerve plexuses
 Innervation –
Parasympathetic
system
• Parasympathetic innervation of
intestine:

1) From the stomach to the splenic

flexure is through vagal fibres
(CN X)

2) Descending colon to the rectum

is from S2-S4 → pelvic
splanchnic nerves → hypogastric
plexus
 Superior
mesenteric
plexus

Inferior
mesenteric
plexus

superior
hypogastric
plexus
 Mr. X
The pain started at umbilical
region then radiated to right iliac
fossa.

Why?
 Clinical importance
• Pain in appendicitis:

1. Usually started with vague pain in the

periumbilical area
• because visceral afferent fibres derived from
T10
• due to stretching of visceral peritoneum 2ndary
to inflammation (swelling) – visceral pain

2. Later severe pain in right iliac fossa (or right

lower quadrant)
• resulted when the inflamed appendix irritated
the parietal peritoneum – somatic pain
• extending thigh may elicits pain
Histology of colon, caecum &
appendix
Layers of GIT (general)

Muscularis
externa
layer
Histology: Colon, caecum & appendix
In general for large intestine,

The mucosa (compared to

small intestine):

• NO folds
(plicae circulares)

• NO villi
 Mucosa: colon & caecum
The Epithelium
• Simple columnar epithelium
• Numerous goblet cells (lubrication)
• The intestinal glands
- simple tubular
- lined with goblet cells & absorptive cells
with short microcilli (colonocytes)

The Lamina propria

• Rich in lymphocytes (protection against bacteria)

The Muscularis mucosae

• More prominent compared to small intestine
 Submucosa: colon & caecum
The submucosa
• Consists of CT, Mucosa
adipose tissue,
blood & nerves
(submucosal
ganglion &
plexus)
Submucosa
 Muscularis externa: colon & caecum
The muscularis externa lumen

• Inner circular smooth

muscle
• Outer layer of smooth
muscle forms three
thick longitudinal Inner
circular
bands, the taeniae layer
coli
Muscularis
externa

The serosa Teniae coli:

• Covered the outermost outer
longitudinal
part layer
 Appendix
Characteristics:
• Lumen is very narrow
& irregular

• No villi or fold

• Resembles the large

intestine but have few
characteristic
differences in the
mucosa, submucosa &
muscularis externa
 Appendix: mucosa
• The glands are
shorter & less
dense than large
intestine

• Muscularis
mucosae is ill
defined
 Appendix: submucosa
• Submucosa
have many
lymphoid
nodules &
lymphocytes
(that is why
it is known
as
abdominal
tonsil)

• Lymphoid
nodules may
extends into
mucosa
 Appendix: muscularis externa
Consists of:
• Inner smooth
Outer longitudinal sm
muscle layer
Inner circular sm

• COMPLETE
outer smooth
muscle layer
(i.e. the outer
muscle layer is
NOT bundled
into taenia coli)
Thank you…