ANATOMY

OF THE
LARGE
COLON,
RECTUM
AND ANAL
CANAL
Large intestine
consists of

1. Cecum
2. Appendix
3. Ascending colon
4. Transverse colon
5. Descending
colon
6. Sigmoid colon
7. Rectum
8. Anal canal
 External feature of large intestine
• Total length of large intestine = 150cm
• Larger internal diameter
Parts of large intestine Diameter (cm) Length ( cm )
Cecum 7.5-8.0 6
Ascending colon 6.0-6.5 15
Transverse colon 5.0-6.5 50
Descending colon 6.0-7.0 20
Sigmoid colon 4.0-7.5 40

• According to Laplace law dictates that the intraluminal pressure needed to

stretch the wall of a hollow tube is inversely proportional to its radius.
The cecum is the largest diameter of the colon, and as such, requires the
least amount of pressure to distend , therefore has high risk of perforation
• Teniae coli = triple band of longitudinal smooth muscle
Tinea libra ( free tenia ) No attachment to any mesentery
Tenia mesocoli Attachment to mesentery of transverse and sigmoid colon
Tenia omentum Attachment to greater omentum

-Tenia is shorter than the large intestine

• Haustra – sacculation of the large intestine
• Omental epiploicae – small
pouches of peritoneum distended
with fats
 Caecum
• First part of large intestine
• Location : Right iliac fossa , inferior to ileocecal
valve
• A blind pouch/recess
• Covered by peritoneum
• No mesentery
• Terminal ileum joined caecum at posteromedial
aspect  opening : ileocecal orifice
• The superior and inferior lip of ileocecal orifice RELATION OF CAECUM
forms ileocecal valve 1. Anteriorly
• Ileocecal valve ( 1 way valve ) = prevents reflux -Distended – Parietal peritoneum of anterior abdominal wal
of large bowel contents into the ileum during -Collapsed – The coils of ileum
peristalsis
2. Posteriorly – Psoas m , ilacus m , femoral n , lateral femoral
cutaneous n
3. Inferiorly – Pelvic brim
Vermifor
m
appendix
• Length = 2-20 cm
• Diameter = few mm
• 3 tenia coli converge at base of appendix
• Has a short mesentery = mesoappendix
• Mobile , position invariable
• Most common position = retrocecal
• Surface anatomy = 1/3 the distance from
right ASIS to umbilicus @ McBurney’s point
 Ascending colon
• 2nd part of large intestine
• Located on right side of abdominal cavity
• Retroperitoneal ( no mesocolon )
• Covered anteriorly and on sides by
peritoneum attaching it to posterior
abdominal wall ( retrocecal recess may
extend to its lower end )
RELATION
Anteriorly Greater omentum
Laterally Right paracolic gutter – space between abdominal wall and right and left
large colon
Importance : site of collection for infected peritoneal fluid
Posteriorly Quadratus lumborum m , iliohypogastric n and ilioinguinal n
 Transvers
e colon
• 3rd part of large intestine
• Longest & most mobile part

• In contact with greater omentum & then to

anterior abdominal wall

• Crosses the abdomen from Right colic flexure

to Left colic flexure (splenic flexure)
Relation of the right colic flexure (hepatic)
• Completely covered by peritoneum
• Hangs downwards, suspended by transverse Anteriorly Liver
mesocolon Posteriorly Right Kidney
• Variable in position because freely movable,
usually hanging to the level of umbilicus (L3 Relation of left colic flexure ( splenic )
vertebral level)
Superiorly Spleen & tail of pancreas
 Descendin
g colon
• Extend from left colic flexure
 pelvic brim ( just above
inguinal ligament )
• Retroperitoneal ( no
mesocolon ) RELATION OF DESCENDING COLON
Anteriorly Coils of small intestine , greater omentum
• Anteriorly and laterally Posteriorly
covered by peritoneum- 1 viscera Lateral border of left kidney
binds it to posterior 4 muscle Transversus abdominis m , quadratus lumborum m , iliacus m ,
abdominal wall left psoas
1 bone Iliac crest
• Lateral to descending colon – 4 nerve Iliohypogastric and ilioinguinal n , lateral cutaneous nerve of
left paracolic gutter thigh and femoral nerve
 Sigmoid Colon
• Extend from descending colon ( pelvic
brim )  rectum at 3rd sacral vertebrae (
rectosigmoid junction )
• Hangs inferiorly into true pelvis
• Suspended by sigmoid mesocolon
• Mobile
• Completely covered by peritoneum
• Root of sigmoid mesocolon = inverted V
• Left ureter passed through apex of root
via intersigmoid recess
• Omental appendices and teniae coli
disappear when sigmoid colon ends
 Blood supply
• Appendix, caecum, lower 1/3 of ascending colon are supplied by ileocolic branch of superior
mesenteric artery

• Upper 2/3 of ascending colon is supplied by right colic branch of superior mesenteric artery

• Right 2/3 of transverse colon is supplied by middle colic branch of superior mesenteric
artery

• Left 1/3 of transverse colon and descending colon are supplied by left colic branch of inferior
mesenteric artery

• Sigmoid colon is supplied by sigmoid branches of inferior mesenteric artery

Lymphatic Drainage
PATHOLOGY OF THE ANAL & PERIANAL
Haemorrhoids
Anorectal abscess
Anal fistula
Anal fissure
 HAEMORRHOID DISEASE @ PILES
• Anal cushion = Blood vessel + Smooth muscle @
Trietze muscle + Elastic connective tissue in submucosa
• The anal canal is lined by the anal cushions, which
consist of three thick vascular submucosal bundles
that always lie in the left lateral, right posterior lateral
and right anterior lateral positions.
• Fx : they aid continence and engorge during defecation
to protect the anal canal from abrasions + vascular
spaces contribute to anal pressure and maintain
continence when the sphincter relax and dilate
• ‘Haemorrhoid’ is the pathological term for a
downward displacement of the anal cushions, which
produces dilatation of the venules. Haemorrhoids thus
consist of a dilated venous plexus, a small artery and
areolar tissue.
Pathogenesis
Anal sliding theory by
Thomson ( 1977)
hypothesized that disruption
of Treitz's muscles resulted in
anal cushion prolapse 
venous outflow obstruction 
hemorrhoidal bleeding and
thrombosis
ETIOLOGY
• Constipation and prolonged
straining
• Defecation of hard fecal material
• Pregnancy GRADING OF INTERNAL HAEMORRHOID
• Increased intraabdominal pressure Grade 1 Hemorrhoid don’t prolapse, above
dentate line, reversible, often bleed
CATEGORIES Grade 2 Prolapse on straining, but
• External haemorrhoid spontaneously reduce at rest
• Internal haemorrhoid Grade 3 Prolapse on straining, reducible
• Mixed manually

Grade 4 Irreducible, may be strangulated &

thrombosed with possible ulceration
 HISTORY
Internal Haemorrhoids External Haemorrhoids
Painless bright red bleeding – rarely cause anemia Painful perianal mass – due to congestion of
pile mass below hypertonic sphincter
Before defecate : splashing of blood Otherwise , have similar symptoms such as in
During defecation : Streak of blood internal haemorrhoid
After defecation : stain toilet bowl , dribbling of blood
Itching = due to prolapse of internal haemorrhoids may produce moisture in
the anal region or mucus discharge
Mucus discharge
Bothersome grape-like tissue prolapse appeared on anal orifice –
spontaneously reduced , manually reduced or permanently outside

Anal canal Embryo. origin Epithelium Arterial Lymphatic Innervation Touch, pain,
supply drainage tempera., stretch

Above dentate line Endoderm Simple columnar Superior Internal iliac Visceral (sympa: inf NOT sensitive,
(Internal/ true) rectal ar LN mesenteric plexus, para: inf painLESS!!
hypogastric plexus, pelvic
splanchnic n)

Below dentate line Ectoderm (Anoderm) Stratified Inferior Superficial Somatic (inferior rectal nerve) Sensitive, PAIN!!
(External/ nonkeratinized rectal ar inguinal LN
false) squamous (anal
pecten)
 EXAMINATION
• Abdominal examination of perineal and rectal area -
presence of external hemorrhoids or prolapse of internal
hemorrhoids may be obvious
• Digital rectal examination - can detect masses, tenderness,
and fluctuance, but internal hemorrhoids are less likely to be
palpable unless they are large , thrombosed or prolapsed.

INVESTIGATION
• Anoscopy - to visualize internal hemorrhoids that look like
purplish bulges through the anoscope
• Proctoscopy – piles prolapse into lumen as cherry red
masses. External haemorrhoid appears bluish
• Flexible sigmoidoscopy and colonoscopy – To rule out
colorectal carcinoma
• Complete blood count – To detect anemia ( if present ,
should raise suspicious for other diagnosis ) as anemia is rare
• Coagulation profile – To rule out bleeding diasthesis
 MANAGEMENT ( only for symptomatic patient )
Grading Management
Grade 1 , 2 and external LIFESTYLE MODIFICATION DIETARY MODIFICATION
• warm water (sitz) baths • high-fiber diet (25 to 35 g per day)
• stool softeners • fiber supplementation
• having regular exercise • increased water intake
• Reduce to an ideal weight if obese • reducing consumption of fat
• improving anal hygiene • avoiding medication that causes
• abstaining from both straining ( > 5 min ) constipation or diarrhea
• Evacuating when natural desires arises
• Adopt a defecatory position to minimize
straining
Symptomatic despite Rubber band ligation
conservative treatment Sclerotherapy
and Grade 3 Infrared coagulation
Grade 3 and Grade 4 • Arterial ligation of hemorrhoids (HAL)
• Submucosal hemorrhoidectomy
• Stapled hemorrhoidopexy
 ANORECTAL ABSCESS (An anorectal abscess refers to a collection of
pus in the anal or rectal region

Epidemiology M>F and high rate of recurrence

Pathogenesis Cryptoglandular theory of intersphincteric anal gland infection ( Parks)
Plugging of the anal ducts fluid stasis  Infection of gland  pus travel
along the path of least resistance spread
Anorectal abscesses are thus categorised by the area in which they occur:
(1) Perianal* most common (2) Ischiorectal (3) Intersphincteric (4)
Supralevator
Organism E.coli, Bacteriodes sp, Enterococcus sp.
Etiology Submucosal abscess following sclerotherapy , infected hematoma , foreign
body , trauma , deep skin related infection , neoplasm , chrons disease ,
Diabetes , AIDS
Presentation Pain in perianal region , exacerbated when sitting down
,Localised swelling
Itching ,Discharge
Systemic features : fever , rigor , general malaise , sepsis
features
O/E : Erythematous , fluctuant , tender , perianal mass with/
without discharging pus and surrounding cellulitis
Management Antibiotic , sufficient analgesia , I&D , heal by secondary
intention , Once drained, proctoscopy should be performed
to check for the presence of any identifiable fistula-in-ano
 Perianal fistula @ Fistula in ano (abnormal connection between the anal canal and the perianal skin )

Epidemiolo 50 % of anorectal abscess patient will develop fistula

gy
Aetiology Perianal abscess
Inflammatory bowel disease – Crohn’s disease or ulcerative colitis
Systemic diseases – Tuberculosis, diabetes, HIV
History of trauma to the anal region
Previous radiation therapy to the anal region
Clinical Recurrent perianal abscess
features Intermittent or continuous discharge onto perineum ( mucus , blood , pus , feces)
O/E : external opening on perineum , can be fully open or covered in granulation
tissue
DRE : fibrous tract felt beneath skin
Goodsall used clinically to predict the trajectory of a fistula tract, depending on the location of
Rule the external opening
(within 3cm External opening posterior to the transverse anal line – fistula tract will follow a
of anal curved course to the posterior midline
verge) External opening anterior to the transverse anal line – fistula tract will follow a
straight radial course to the dentate line
Investigation Proctoscopy – to visualise the opening of the tract in anal canal
MRI fistulogram– required for complex fistula to visualise the anatomy of tract
Anal manometry - to measure pressure within anal canal, allow objective assessment of sphincter function
Park Divide anal fistula into 4 distinct type - (** determine site of internal opening, external
classification opening, course of primary track, presence of secondary extension**)
system - Inter-sphincteric fistula (most common)
- Trans-sphincteric fistula
- Supra-sphincteric fistula (least common)
- Extra-sphincteric fistula
Management Fistula: to maintain continence (puborectalis)
Inter-sphincteric – Fistulotomy (best mx )
Trans-sphincteric – (Low)Fistulotomy; (High/Anterior) Cutting seton, partial fistulectomy & endoanal flap,
injection of fibrin glue (induce clot formation)
Supra-sphincteric – Cutting seton, endorectal advancement flap, sphincter reconstruction
Extra-sphincteric – Endorectal advancement flap
Fistulotomy/lay open: probe passed from external to internal opening, track laid open over probe; track curette
to remove granulation tissue (secondary track), edges of wound trimmed, wound marsupialized (wound healed
by secondary intention)
Fistulectomy: Core out of fistula with diathermy cautery
Seton: (Loose)for long-term palliation, temporary before op; part of staged fistulotomy // (Tight)cut through
tissue inside loop while scarring behind loop
Endorectal advancement flap: stop the communication between the track and the bowel, cover the internal
opening with disease free anorectal wall
Seton placement Fistula plug
 Anal fissure
Definition Longitudinal tear of anal canal, distal to dentate line.
Etiology Primary (local trauma)
• 90% at posterior commissure (6 o’clock in lithotomy position)
• Types: Chronic constipation/diarrhea, anal sex, vaginal delivery
Secondary (U/L disease)
• Lateral/anterior to posterior commissure
• U/L:: previous anal surgery, IBD (Crohn’s), TB, infection (HIV)
Pathophysio Overdistension of anal mucosa  laceration of anoderm
• Spasm of exposed internal anal sphincter  pulling along laceration  impairs healing, worsens
extent of laceration with bowel movement
• Pain  voluntary avoidance of defecation & constipation, worsens distension of anal mucosa
Clinical • Sharp, severe pain during defecation
features • PR bleed (bright red, minimal)
• Perianal pruritus
• Chronic constipation
 Anal fissure
Clinical • Superficial/deep laceration in anterior, lateral or posterior anal canal
exam • Chronic fissures : fibrotic, infective changes
- wide, raised edges
- Skin tags (sentinel pile) at fissure’s distal end
- Hypertrophied anal papillae at fissure’s proximal end

If uncertain/TRO suspected pathology (rectal tumor)

DRE
Anoscopy • If clinical findings unclear / Sx persist despite tx
• Possible biopsy & histo to exclude CA
Treatment • Conservative (1st line)
Dietary improvement (fibre, water), stool softener (docusate), 2% lidocaine
jelly, Sitz bath, topical vasodilator therapy (nifedipine gel)
If persist despite >8wks conservative  endoscope TRO IBD  Defintive
surgical tx
• Outpatient: Botulinum toxin A (BTX) injection into internal anal sphincter
• Surgical
Risk of fecal incontinence (High/Low)
Anal fissure

Chronic anal fissure triad:

• Anal fissure
• Hypertrophic papilla
• Sentinel pile (thickened mucosa/skin distal end