Large intestine

• Main functions: absorb water and electrolytes

• Mass peristaltic movements force feces toward the rectum
• Beginning in the right groin as the cecum (at the ileocecal
valve) with its associated appendix, the large intestine
continues upward as the ascending colon through the right
flank and into the right hypochondrium.
• Just below the liver, it bends to the left, forming the right
colic flexure (hepatic flexure), and crosses the abdomen as
the transverse colon to the left hypochondrium. At this
position, just below the spleen, the large intestine bends
downward, forming the left colic flexure (splenic flexure),
and continues as the descending colon through the left flank
and into the left groin.
Gross Anatomy of Large
Intestine
Parts:

1. Cecum (with appendix)

2. Colon: Ascending, transverse, descending, and sigmoid
colon
3. Rectum
4. Anal canal
 Special features of large intestine
1. Larger diameter compared to that of the small intestine
2. Omental appendices (epiploic appendages): fat-filled
pouches of visceral peritoneum are associated with the colon
3. The taeniae coli: thickening of longitudinal muscularis
primarily observed in the cecum and colon and less visible in
the rectum
4. Haustra of colon: the sacculations of the colon created by
teniae coli
Gross Anatomy of Large
Intestine
Cecum
It lies below the level of the junction of the ileum with
the large intestine. It is a blind-ended pouch that is
situated in the right iliac fossa. It is completely
covered with peritoneum. It possesses a considerable
amount of mobility, although it does not have a
mesentery.
Attached to its posteromedial surface is the appendix.
As in the colon, the longitudinal muscle is restricted to
three flat bands, the teniae coli, which converge on the
base of the appendix and provide for it a complete
longitudinal muscle coat. The terminal part of the
ileum enters the large intestine at the junction of the
cecum with the ascending colon. The opening is
provided with two folds, or lips, which form the so-
called ileocecal valve. The appendix communicates
with the cavity of the cecum through an opening
located below and behind the ileocecal opening.
Relations:

Anteriorly: Coils of small intestine, sometimes part of the

greater omentum, and the anterior abdominal wall in the right
iliac region
Posteriorly: The psoas and the iliacus muscles, the femoral
nerve, and the lateral cutaneous nerve of the thigh. The
appendix is commonly found behind the cecum.
Medially: The appendix arises from the cecum on its medial
side.
Arteries Anterior and posterior cecal arteries form the ileocolic artery,
a branch of the superior mesenteric artery.

Veins The veins correspond to the arteries and drain into the superior
mesenteric vein.

Lymph Drainage
The lymph vessels pass through several mesenteric nodes and finally
reach the superior mesenteric nodes.

Nerve Supply
Branches from the sympathetic and parasympathetic (vagus) nerves
form the superior mesenteric plexus.
The Appendix
•The appendix (or vermiform appendix) is a blind-ended tube connected
to the cecum.
•Among adult humans, the appendix is now thought to be involved
primarily in immune functions.
•Appendix has great variations in position:
McBurney’s
1. Posterior to the cecum or the lower ascending colon, or both
(retrocecal or retrocolic position) point

2. Suspended over the pelvic brim in a pelvic or descending position

3. Below the cecum in a subcecal location
4. Anterior to the terminal ileum, possibly contacting the body wall, in a
preileal position or posterior to the terminal ileum in a postileal
position
The surface projection of the base of the appendix is at the junction of the
lateral and middle one-thirds of a line from the anterior superior iliac spine
to the umbilicus (McBurney's point). People with appendicular problems
may describe pain near this location.
Ascending colon
It lies in the right lower quadrant. It extends upward from the cecum to
the inferior surface of the right lobe of the liver, where it turns to the
left, forming the right colic flexure, and becomes continuous with the
transverse colon. The peritoneum covers the front and the sides of the
ascending colon, binding it to the posterior abdominal wall.
Relations:

Anteriorly: Coils of small intestine, the greater omentum, and the

anterior abdominal wall.
Posteriorly: The iliacus, the iliac crest, the quadratus lumborum, the
origin of the transversus abdominis muscle, and the lower pole of the
right kidney. The iliohypogastric and the ilioinguinal nerves cross
behind it.
Arteries The ileocolic and right colic branches of the superior
mesenteric artery supply this area.

Veins The veins correspond to the arteries and drain into the superior
mesenteric vein.

Lymph Drainage
The lymph vessels drain into lymph nodes lying along the course of the
colic blood vessels and ultimately reach the superior mesenteric nodes.

Nerve Supply
Sympathetic and parasympathetic (vagus) nerves from the superior
mesenteric plexus supply this area of the colon.
 Transverse colon
• It extends across the abdomen, occupying the umbilical region. It begins at the right colic
flexure below the right lobe of the liver and hangs downward, suspended by the
transverse mesocolon from the pancreas.
• It then ascends to the left colic flexure below the spleen. The left colic flexure is higher
than the right colic flexure and is suspended from the diaphragm by the phrenicocolic
ligament.
• The transverse mesocolon is attached to the superior border of the transverse colon, and
the posterior layers of the greater omentum are attached to the inferior border. Because of
the length of the transverse mesocolon, the position of the transverse colon is extremely
variable and may sometimes reach down as far as the pelvis.
• Relations:
Anteriorly: The greater omentum and the anterior abdominal wall (umbilical and
hypogastric regions)
Posteriorly: The second part of the duodenum, the head of the pancreas, and the coils of
the jejunum and the ileum.
Arteries The proximal two thirds are supplied by the middle colic artery, a branch
of the superior mesenteric artery. The distal third is supplied by the left colic artery,
a branch of the inferior mesenteric artery.

Veins The veins correspond to the arteries and drain into the superior mesenteric
vein and inferior mesenteric veins.

Lymph Drainage
The proximal two thirds drain into the colic nodes and then into the superior
mesenteric nodes; the distal third drains into the colic nodes and then into the
inferior mesenteric nodes.

Nerve Supply
The proximal two thirds are innervated by sympathetic and vagal nerves through
the superior mesenteric plexus; the distal third is innervated by sympathetic and
parasympathetic pelvic splanchnic nerves through the inferior mesenteric plexus.
Descending colon
• It lies in the left upper and lower quadrants. It extends downward from
the left colic flexure, to the pelvic brim, where it becomes continuous
with the sigmoid colon. The peritoneum covers the front and the sides
and binds it to the posterior abdominal wall.

• Relations
Anteriorly: Coils of small intestine, the greater omentum, and the
anterior abdominal wall
Posteriorly: The lateral border of the left kidney, the origin of the
transversus abdominis muscle, the quadratus lumborum, the iliac crest,
the iliacus, and the left psoas. The iliohypogastric and the ilioinguinal
nerves, the lateral cutaneous nerve of the thigh, and the femoral nerve.
Arteries The left colic and the sigmoid branches of the inferior
mesenteric artery.

Veins The veins correspond to the arteries and drain into the inferior
mesenteric veins.

Lymph Drainage
Lymph drains into the colic lymph nodes and the inferior mesenteric
nodes around the origin of the inferior mesenteric artery.

Nerve Supply
The nerve supply is the sympathetic and parasympathetic pelvic
splanchnic nerves through the inferior mesenteric plexus.
Sigmoid colon
• It lies in the pelvic cavity, begins as a continuation of the descending
colon in front of the pelvic brim. Below, it becomes continuous with
the rectum in front of the 3rd sacral vertebra. The sigmoid colon is
mobile and hangs down into the pelvic cavity in the form of a loop.
• The sigmoid colon is attached to the posterior pelvic wall by the fan-
shaped sigmoid mesocolon.
• Relations
Anteriorly: In the male, the urinary bladder; in the female, the posterior
surface of the uterus and the upper part of the vagina
Posteriorly: The rectum and the sacrum. The sigmoid colon is also
related to the lower coils of the terminal part of the ileum.
Arteries Sigmoid branches of the inferior mesenteric artery.

Veins The veins correspond to the arteries and drain into the inferior
mesenteric veins.

Lymph Drainage
The lymph drains into nodes along the course of the sigmoid arteries;
from these nodes, the lymph travels to the inferior mesenteric nodes.

Nerve Supply
The sympathetic and parasympathetic nerves from the inferior
hypogastric plexuses.
Rectum
• It begins in front of the S3 as a continuation of the sigmoid colon. It
passes downward, following the curve of the sacrum and coccyx, and
ends in front of the tip of the coccyx by piercing the pelvic diaphragm
and becoming continuous with the anal canal. The lower part of the
rectum is dilated to form the rectal ampulla.
• The rectum deviates to the left, but it quickly returns to the median
plane. On lateral view, the rectum follows the anterior concavity of the
sacrum before bending downward and backward at its junction with
the anal canal.
• The puborectalis portion of the levator ani muscles forms a sling at the
junction of the rectum with the anal canal and pulls this part of the
bowel forward, producing the anorectal angle.
Rectum
• The peritoneum covers the anterior and lateral surfaces of the first
third of the rectum and only the anterior surface of the middle third,
leaving the lower third devoid of peritoneum.
• The muscular coat of the rectum is arranged in the usual outer
longitudinal and inner circular layers of smooth muscle. The three
teniae coli of the sigmoid colon, however, come together so that the
longitudinal fibers form a broad band on the anterior and posterior
surfaces of the rectum.
• The mucous membrane of the rectum, together with the circular
muscle layer, forms two or three semicircular permanent folds called
the transverse folds of the rectum that vary in position.
• Relations:

Posteriorly: The sacrum and coccyx; the piriformis, coccygeus, and levatores ani
muscles; the sacral plexus; and the sympathetic trunks
Anteriorly:
In the male, the upper two thirds of the rectum is related to the sigmoid colon and
coils of ileum that occupy the rectovesical pouch. The lower third is related to the
posterior surface of the bladder, to the termination of the vas deferens and the
seminal vesicles on each side, and to the prostate.
In the female, the upper two thirds of the rectum is related to the sigmoid colon and
coils of ileum that occupy the rectouterine pouch (pouch of Douglas). The lower
third of the rectum is related to the posterior surface of the vagina.
Male Female

Rectum
The inferior mesenteric artery is one of the anterior branches of
the abdominal aorta that supplies the hindgut. It is the smallest of
the three anterior branches of the abdominal aorta and arises
anterior to the body of vertebra L3. Initially, the inferior
mesenteric artery descends anteriorly to the aorta and then passes
to the left as it continues inferiorly.

Its branches include:

1. Left colic artery
2. Sigmoid arteries
3. Superior rectal artery.
Arteries The superior, middle, and inferior rectal arteries supply the rectum.
The superior rectal artery is a direct continuation of the inferior mesenteric
artery and divides into right and left branches, that anastomose with one
another and with the middle and inferior rectal arteries.
The middle rectal artery is a small branch of the internal iliac artery and is
distributed mainly to the muscular coat.
The inferior rectal artery is a branch of the internal pudendal artery in the
perineum. It anastomoses with the middle rectal artery at the anorectal
junction.

Veins The veins of the rectum correspond to the arteries. The superior rectal
vein is a tributary of the portal circulation and drains into the inferior
mesenteric vein. The middle and inferior rectal veins drain into the internal
iliac and internal pudendal veins, respectively. The union between the rectal
veins forms an important portal–systemic anastomosis.
Lymph Drainage
The lymph vessels of the rectum drain first into the pararectal nodes
and then into inferior mesenteric nodes.
Lymph vessels from the lower part of the rectum follow the middle
rectal artery to the internal iliac nodes.

Nerve Supply
The nerve supply is from the sympathetic and parasympathetic nerves
from the inferior hypogastric plexuses. The rectum is sensitive only to
stretch.
Anal canal
• It begins at the terminal end of the rectal ampulla at the pelvic floor. It terminates
as the anus after passing through the perineum. As it passes through the pelvic
floor, the anal canal is surrounded along its entire length by the internal and
external anal sphincters, which normally keep it closed.
• The upper part is lined by mucosa similar to that of rectum and is distinguished by
a number of longitudinally oriented folds known as anal columns, which are
united inferiorly by crescentic folds termed anal valves. Superior to each valve is
a depression termed an anal sinus. The anal valves together form a circle around
the anal canal at a location known as the pectinate line, which marks the
approximate position of the anococcygeal membrane (the simple columnar
epithelium becomes nonkeratinized stratified squamous epithelium).
• Inferior to the pectinate line is a transition zone known as the anal pecten, which
is lined by nonkeratinized stratified squamous epithelium. The anal pecten ends
inferiorly at the anocutaneous line ('white line'), or where the lining of the anal
canal becomes true skin (keratinized stratified squamous epithelium).
Hemorrhoids
• The part of the venous plexus surrounding the rectum and anal canal drains via
superior rectal veins (tributaries of inferior mesenteric veins) into the hepatic
portal system, and via middle and inferior rectal veins into the caval system. This
pelvic plexus is an important portacaval shunt when the hepatic portal system is
blocked
• The inferior part of the rectal plexus around the anal canal has two parts, an
internal and an external.
• The internal rectal plexus is in connective tissue between the internal anal
sphincter and the epithelium lining the canal. This plexus connects superiorly with
longitudinally arranged branches of the superior rectal vein that lie one in each
anal column. When enlarged, these branches form internal hemorrhoids, which
originate above the pectinate line and are covered by colonic mucosa.
• The external rectal plexus circles the external anal sphincter and is subcutaneous.
Enlargement of vessels in the external rectal plexus results in external
hemorrhoids.
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