RECTUM

Malueth Abraham
 Introduction
• Anatomy of the rectum- 15 cm long
• Divided into 3; lower, middle & upper 1/3
• Blood supply- superior, middle & inferior rectal vessels.
• Lymphatic drainage- follows blood supply.
• Relations:
Anterior- bladder, seminal vesicles, prostate, uterus,
cervix, ureters.
Lateral- middle rectal Artery, levator ani muscle
Posterior- superior rectal Artery, sacrum, coccyx.
 Clinical features of rectal disease
• Fresh per rectal bleeding- painless
• Altered bowel habit with loose stool
• Mucus discharge- rectal inflammation.
• Tenesmus
• Prolapse
• Proctalgia(pain)- severe & episodic.
 Examination of rectum
• Patient should be in left lateral position(Sims
position).
• Inspection- rule out anal disease e.g. fissure, fistula
• DRE- tumors in middle& lower 1/3 of rectum
• -check for mucus, pus or blood
• Proctoscopy- inspect anus, anorectal junction &
lower rectum.
• Sigmoidoscopy : flexible & rigid.
 Trauma to rectum
• Fall in a sitting posture onto a pointed object.
• Penetrating injury e.g. gunshot
• Sexual assault- anal penetration
• Fetal head- childbirth especially forceps
assisted.
• Diagnosis- physical examination.
- CT Scan- provide information on
other pelvic injuries.
Management
• Antibiotics (against both aerobic& anaerobic)
• Debridement of perineal wounds
• Surgical options-
Laparotomy/ laparoscopy in penetrating injury
Perforated rectum is sutured & defunctioned
with a stoma.
Hartmann’s procedure in irreparable injury.
 Rectal prolapse
• 2 types- mucosal prolapse
- full thickness prolapse
Mucosal prolapse
Mucous membrane & submucosa protrude out.
• Risk factors
Infants- undeveloped sacral curve
Children-diarrhoeal attack
-weight loss with loss of fat in ischiorectal fossa.
- cystic fibrosis
-Hirschsprung’s disease
-Rectal polyps
-Maldevelopment of pelvis.
Adults- third degree haemorrhoids.
-torn perineum(females)
- straining from urethral obstruction(males)
• Management
Infants & young children- digital repositioning
-address underlying cause
-submucosal injection or
banding.
Adults- submucosal injection
-Banding
-excision
Full thickness prolapse
All layers of rectal wall protrude.
• Risk factors- weak pelvic floor
-Chronic straining
-Elderly
• M: F ratio 1:6
• Complications- rectal ulceration
-Bleeding
-Incontinence
-Incarceration with strangulation of
rectum
• Management-
Surgery- Abdominal rectopexy low recurrence rate
but associated with sexual dysfunction.
Perineal approach- most frequently used.
 Proctitis
• Inflammation of rectum
• Can be acute or chronic
• Clinical Features
Defaecatory frequency + passage of loose motion
Blood in stool
Malaise & pyrexia(acute setting)
• Examination
DRE-Tenderness, blood on glove
Sigmoidoscopy
Colonoscopy with multiple biopsies
• Investigation- stool cultures
• Management- treat underlying condition
• Causes-Ulcerative colitis
-Crohn’s dse
-Radiation
-Infections- clostridium difficile
-Amoebic dysentry
-TB
-Gonococcal
 Rectal Polyps
1. Hyperplastic polyps
2. Tubular adenomas- commonest, potential to
turn malignant >1 cm diameter
3. Villous adenomas- large occupying much of
rectal circumference, increased tendency to
become malignant.
4. Familial adenomatus polyposis
5. Juvenile polyp(cherry tumor)-bright red,
pedunculated sphere
• Management
Adenomas removed to avoid malignant change
Endoscopic mucosal resection(EMR)- polyps <2
cm
Transanal endoscopic microsurgery(TEMS)-
larger polyps
 Benign rectal lesions
Endometrioma-rectal bleeding coincides with menses.
• Management- hormonal manipulation
-Laparoscopic resection
-Isolated deposits- diathermy ablation
Hemangioma-profuse rectal bleeding
GIST- rare
Neuroendocrine tumors- well differentiated (grade 1&2)
• Poorly differentiated (grade 3)
• Rectal NET are majorly grade 1
 Colorectal cancer
• Discussed under colon.
 References
• Bailey & Love Short Practice of Surgery 27th
edition.