ANATOMY OF DIGESTIVE SYSTEM LARGE INTESTINE

Dr. Hermizi Hapidin School of Health Sciences Health Campus Universiti Sains Malaysia hermizi@kck.usm.my h i i@k k 1st March 2012

OBJECTIVES:
At the end of this lecture, the students should understand: ,
a) b) c) d) e) f) g) h)

Embryology of digestive system Subdivisions of large intestine Anatomy of cecum & appendix Anatomy of colon (ascending, transverse, descending & sigmoid) Anatomy of rectum Anatomy of anal canal Histology of large intestine Blood supply of large intestine pp y g

Three Embryonic Germ Layers

Embryonic Germ Layers = the three primary layers of cells of the th embryo (ectoderm, mesoderm & endoderm), from which b ( t d d d d ) f hi h the tissues and organs develop.

GUT

DEVELOPMENT OF DIGESTIVE SYSTEM

During

4th week of development, cells of endoderm form cavity called primitive gut
a) b) c)

Primitive gut elongates & differentiates into :

Foregut (anterior) Midgut (intermediate) Hindgut (posterior)

Foregut

develops into pharynx, esophagus, stomach & part of duodenum (1st & 2nd parts)

Midgut - remainder of duodenum, jejunum,

ileum & portions of large intestine (cecum, appendix, ascending colon & right 2/3 of pp , g g transverse colon)

Hindgut - reminder of large intestine (left 1/3 of

, g , g transverse colon, descending colon, sigmoid colon & rectum), except for portion of anal canal (derived from proctodeum)

Primitive Gastrointestinal System

FOREGUT

Celiac trunk

MIDGUT

Superior Mesenteric artery

HINDGUT

Inferior Mesenteric artery

The boundaries of the foregut, midgut and hindgut are determined by their respective blood supply

Primitive Gastrointestinal System

DIVISION FOREGUT

ARTERY
CELIAC ARETERY

VEIN
PORTAL VEIN Spleenic vein Gastric vein SUPERIOR MESENTERIC VEIN

LYMPHATICS
CELIAC NODES

SYMPATHETIC PARASYMPATHETIC
CELIAC GANGLIA VAGUS

MIDGUT

SUPERIOR MESENTERIC ARTERY

SUPERIOR MESENTERIC NODES INFERIOR MESENTERIC NODES

SUPERIOR MESENTERIC GANGLIA GANGLIA HYPOGASTRIC PLEXUS

VAGUS

HINDGUT
INFERIOR MESENTERIC ARTERY INFERIOR MESENTERIC VEIN

PELVIC SPLANCHNIC NERVES

DIGESTIVE SYSTEM - LARGE INTESTINE

Mouth (oral cavity) ( y) Tongue

Parotid gland Sublingual gland Salivary Submandibular glands gland Pharynx Stomach Pancreas (Spleen) Transverse colon Descending colon Ascending colon Cecum Sigmoid colon Rectum Vermiform appendix Anal canal

Esophagus

Liver Gallbladder Duodenum Small intestine Jejunum Ileum

Large intestine

Anus

Functions of Large Intestine

1. Haustral churning, peristalsis and mass peristalsis drive the contents of the colon into the rectum 2. Bacteria in the large intestine convert protein to amino acids, break down amino acids & produce some B vitamins & vitamin K itamins itamin 3. Absorbing some water, ions & vitamins 4. 4 Forming feces 5. Defecation (emptying the rectum) LI - receives ~ 500 mL of ingestible food residue per day, g p y, reduces to 150 mL of feces by absorbing water & salts & eliminates feces by defecation

LARGE INTESTINE
General description p Terminal portion Extends from ileum to the anus Length: It is about 1.5 meters l h b long Diameter: 6.5 cm Attached to posterior abdominal wall by its mesocolon Can be distinguished from small intestine by :
Teniae coli (3 thickened bands of muscles cecum & colon) H Haustra ( t (sacculations of colon b t l ti f l between t i ) teniae) Omental appendices (small fatty projections of omentum) Caliber (internal diameter is much larger)

LARGE INTESTINE

Omental appendices di Haustrum

Teniae coli

LARGE INTESTINE
Teniae coli are three thickened band formed by longitudinal fibers of smooth muscle in muscular coat of large intestine extending from vermiform appendix to rectum th they are visible and can b seen i ibl d be on outside surface of ascending, transverse, descending & sigmoid colons teniae coli contracts length wise to produce haustra (bulges in colon)
Haustra Teniae coli

SUBDIVISION OF LARGE INTESTINE

It consists of : Cecum & vermiform appendix Colon Rectum A l canal Anal l
Transverse colon

Descending colon Ascending colon

Sigmoid colon Cecum Vermiform appendix Rectum Anal canal

SUBDIVISION OF LARGE INTESTINE

Transverse colon

Ascending colon

Descending colon

Cecum

Sigmoid colon Vermiform appendix Rectum

Anal canal

SUBDIVISION OF LARGE INTESTINE

Right colic (hepatic) flexure Transverse colon Superior mesenteric artery Haustrum Ascending colon IIeum IIeocecal valve Cecum Vermiform appendix Rectum Anal canal External anal sphincter Left colic (splenic) flexure Transverse mesocolon Epiploic appendages Descending colon Cut edge of mesentery Teniae coli Sigmoid colon

LARGE INTESTINE - CECUM

The beginning of large intestine that is continuous with ascending

colon Blind-ended pouch that is situated in right iliac fossa & rest in iliacus muscle It is about 6 cm long & completely covered with peritoneum Attached to its posteromedial surface is the appendix

LARGE INTESTINE - APPENDIX

Vermiform appendix (vermi = wormlike, form = shaped) Narrow & muscular tube containing a large amount of lymphoid tissue Varies in length from 8 13 cm Mesentery of appendix = mesoappendix (attaches appendix to inferior

part of mesentery of ileum) Mesoappendix contains appendicular vessels & nerves

Mesentery = A fold of peritoneum that connects intestines to posterior abdominal wall

LARGE INTESTINE - APPENDIX

Ileum

Appendix removed after appendectomy

Ileum
Mesoappendix

Appendicular artery

Cecum

Appendix

CECUM & APPENDIX

Drawing of interior of cecum showing endoscopic appearance of ileocecal valve, ileocecal orifice & opening of vermiform appendix

LARGE INTESTINE - COLON

The open end of cecum merges with long tube called

co o ( ood pa ag ) colon (= food passage) Is divided into 4 parts : a) Ascending b) T Transverse c) Descending d) Sigmoid ) g

Transverse

Ascending

Descending

Sigmoid

a) Ascending Colon
It is about 13 cm long Situated in right lower quadrant

(right lumbar region) It extends f t d from cecum t under to d surface of liver, where it turn to g left & form right colic flexure or hepatic flexure and continuous with transverse colon Is narrower than cecum Lies retroperitoneally along right p side of posterior abdominal wall

Liver Ascending colon l Transverse colon

Left colic flexure / splenic flexure

Right colic flexure / hepatic flexure

b) Transverse Colon
It is about 38 cm long Is the largest & most mobile part of
Spleen

large intestine Extends across abdomen & occupying umbilical region It begins at right colic flexure It hangs downward & suspended by b transverse mesocolon l Then, ascends to left colic flexure or splenic flexure below spleen p p (where it bends inferiorly to become descending colon Left colic flexure is higher but less mobile than right colic flexure

Transverse colon

Descending colon

b) Transverse Colon
Transverse (fold of peritoneum, mesocolon which connects the

transverse colon to the posterior wall of the abdomen)

c) Descending Colon
It is about 25 cm long Lies

in left upper & lower upp o quadrants (left lumbar region) It extends downward from left colic flexure to pelvic brim where it becomes continuous with sigmoid colon P i Peritoneum covers anterior & i lateral sides and binds it to posterior abdominal wall
1. Sacrum 2. Ilium 3. Ischium 4. Pubic bone 5. Pubic 5 P bi symphysis h i 6. Acetabulum 7. Foramen obturator 8. Coccyx

Right colic flexure / hepatic flexure

Left colic flexure / splenic flexure

Descending colon

Sigmoid colon

Red line: Pelvic inlet/pelvic brim (the upper limit of the pper pelvic cavity)

d) Sigmoid Colon
It is about 25 - 38 cm long g It

begins as a continuation of descending colon in front of pelvic brim Below, it becomes continuous with rectum in front of third sacral vertebra (S3 vertebra) t b t b ) It is mobile & hang down into pelvic cavity in form of a loop Is attached to posterior wall by fanshaped sigmoid mesocolon It lies in pelvic cavity = pelvic colon

Right colic flexure / hepatic flexure

Transverse colon

Left colic flexure / splenic flexure

d) Sigmoid Colon
Greater omentum Transverse colon Transverse mesocolon Descending colon Jejunum Jej n m Mesentery Sigmoid mesocolon Sigmoid colon Ileum

LARGE INTESTINE - RECTUM

It is about 13 cm long It begins in front S3 vertebra

as a continuation of sigmoid colon It passes downward, following curve of sacrum & coccyx It ends in front of tip of coccyx by piercing pelvic diaphragm & becomes continuous with anal canal

Sagittal view

LARGE INTESTINE RECTUM

Lower part of rectum is dilated

to form rectal ampulla (where feces are stored until they are eliminated via the anal canal) Has three lateral curvatures : Upper curve - convex to right Middle curve - convex to left Lower curve - convex to right

LARGE INTESTINE RECTUM

Ampulla of rectum

LARGE INTESTINE RECTUM

Sigmoid colon

Upper curve

Middle curve Lower curve

LARGE INTESTINE RECTUM

Peritoneum

covers anterior & lateral surfaces of upper third of rectum & only anterior surface of middle third Lower third of rectum devoid of peritoneum Muscular coat is arranged in outer longitudinal & inner circular layers of smooth muscle th l Taenia coli (sigmoid colon) come together, so that longitudinal fibers form a broad band on ant & post surfaces of rectum Mucous membrane together with circular y muscle layers forms transverse folds of rectum (semicircular permanent folds)

Transverse rectal fold t l f ld

LARGE INTESTINE RECTUM

LARGE INTESTINE ANAL CANAL

Terminal part of large intestine It is about 2.5 to 3.5 cm long It
Rectum

Rectal valve

passes downward & backward from rectal ampulla to anus It surrounded by internal and external anal sphincters Its lateral walls are kept in p apposition by levator ani muscles & anal sphincters

Anal canal
Hemorrhoidal veins Levator ani muscle Internal anal sphincter External anal sphincter

Anus

Anal sinuses

Anal columns

Frontal section of anal canal

LARGE INTESTINE ANAL CANAL

Interior of anal canal Upper half mucous membrane characterized by series of longitudinal ridges - anal columns Lower half of anal canal has no anal columns Inferior ends of anal columns are joined by j i d b anal valves l l Superior to valves are small recesses anal sinuses Inferior comb-shaped limit of anal valves forms an irregular line p pectinate line (indicates junction of ( j upper & lower parts of anal canal)

Rectum

Rectal valve

Anal canal
Hemorrhoidal veins Levator ani muscle Internal anal sphincter External anal sphincter

Anus

Anal sinuses

Anal columns

Frontal section of anal canal

Interior of Anal Canal

Anal columns or Columns of Morgagni

Upper part of anal canal Pectinate P ti t or dentate line

(mucous membrane lined by columnar epithelium)

Deep Superficial Subcutaneous

Lower part of anal canal

(mucous membrane lined by stratified squamous epithelium)

LARGE INTESTINE ANAL CANAL

Anal sphincters : Anal canal has 2 sphincters : a) Internal anal sphincter b) External anal sphincter Internal sphincter
an involuntary sphincter formed by thickening of circular

muscle coat surrounding superior two-thirds of anal canal innervated by parasympathetic

LARGE INTESTINE ANAL CANAL

External sphincter an large voluntary sphincter forms broad band on each side of inferior two-thirds of anal canal can be divided into 3 parts ; subcutaneous
encircles

lower part of anal canal & has no bony attachment

External sphincter hi t
Deep Superficial Subcutaneous

superficial
h has b bony attachment tt h t

deep
encircles

upper half of anal canal & has no bony attachment

ANAL SPHINCTERS
Rectal valve Rectum Hemorrhoidal veins Levator ani muscle Anal canal External anal sphincter Internal anal I t l l sphincter Anal columns Pectinate line Anal sinuses Anus
Internal anal sphinctersmooth muscle External anal sphincterskeletal muscle

Anterior view of Sigmoid Colon, Rectum & Anal Canal

Rectosigmoid junction j ti

Sigmoid colon Teniae coli (free taenia) Fibers of taenia spread to form longitudinal muscle of rectum Fibers from longitudinal muscle join circular muscle layer Circular muscle layer underlying longitudinal layer Levator ani muscle
Deep p Superficial Subcutaneous

Rectum

Parts of external anal sphincter muscle

Anal canal

Fibrous septum Corrugator cutis ani muscle

Perineal skin

HISTOLOGY OF LARGE INTESTINE

Wall of large intestine contains typical 4 layers found in GI tract ;

Mucosa b) Submucosa c) Muscularis d) Serosa Mucosa consists of epithelium, lamina propria with intestinal glands (crypts of Lieberkuhn) & muscularis mucosae Submucosa consists of areolar CT Muscularis consists of external layer of longitudinal smooth muscle & internal layer of circular smooth muscle (portion of longitudinal muscles are thickened & forming teniae coli) Serosa layer of large intestine is part of visceral peritoneum (small pouches of visceral peritoneum filled with fat are attached to teniae coli = epiploid appendages)
a)

HISTOLOGY OF LARGE INTESTINE

HISTOLOGY OF LARGE INTESTINE

Crypts of Lieberkuhn (intestinal glands) are simple, tubular glands which arise as evaginations into the mucosa of the intestine (small and large intestine)

HISTOLOGY OF LARGE INTESTINE

Villi are absent and the crypts appear deeper than the ones you observed in small intestine. Goblet cells are numerous

Differences between Small & Large Intestine

Differences between Small & Large Intestine

Small Intestine Mobile (except duodenum) No taenia coli No fatty tags Mesentery Wall of SI is smooth Has plicae circulares Mucous membrane has villi Has Peyers patches y p Large Intestine Fixed (ascending & descending colon) Has taenia coli Has appendices epiploicae Mesocolon Wall of LI is sacculated No plicae circulares Absent of villi No Peyers patches y p

Differences between Small & Large Intestine

Jejunum

Ileum Il

Colon

BLOOD SUPPLY OF LARGE INTESTINE

Cecum Arteries Anterior and posterior cecal arteries from ileocolic artery (branch of superior mesenteric artery) Veins Veins correspond to arteries and drain into superior mesenteric vein
Cecum

Ileocolic artery

Posterior cecal artery

Anterior cecal artery

BLOOD SUPPLY OF LARGE INTESTINE

Vermiform appendix Arteries Appendicular artery (branch of posterior cecal artery) it passes to tip of appendix in mesoappendix Veins Appendicular vein drains into posterior cecal vein

Posterior cecal artery

Appendicular artery

Appendix

BLOOD SUPPLY OF LARGE INTESTINE

Ascending colon Arteries Ileocolic & right colic branches of superior mesenteric artery Veins V i Veins correspond to arteries d i & drain into superior mesenteric vein

Ascending colon

BLOOD SUPPLY OF LARGE INTESTINE

Transverse colon Arteries Proximal two-thirds is supply by middle colic artery pp y y y (branch of superior mesenteric artery) Distal-third is supplied by Distal third left colic artery (branch of inferior mesenteric artery) Veins Veins correspond to arteries & drain into superior and inferior mesenteric veins
Transverse colon

Middle colic artery

Left colic artery

BLOOD SUPPLY OF LARGE INTESTINE

Descending colon Arteries Left colic & branches of mesenteric artery Veins Veins correspond to & drain into mesenteric vein

sigmoid inferior

Descending colon

arteries inferior

Left colic artery t Sigmoid arteries

BLOOD SUPPLY OF LARGE INTESTINE

Sigmoid colon Arteries Sigmoid branches of inferior mesenteric artery y Veins Tributaries of inferior mesenteric vein which join vein, portal venous system

Sigmoid arteries

Sigmoid colon

BLOOD SUPPLY OF LARGE INTESTINE

Cystic vein

Right & Left Gastric veins Splenic vein

PORTAL VEIN

Inferior mesenteric vein t i i Superior Mesenteric vein

Portal venous system (*tributaries of portal vein)

BLOOD SUPPLY OF LARGE INTESTINE

Rectum Arteries Superior rectal artery (branch of inferior mesenteric artery) Middle rectal artery (branch of internal iliac artery) Inferior rectal artery (branch of internal pudendal artery) Veins Superior rectal vein drains into inferior mesenteric vein) Middle rectal & inferior rectal veins drains into internal iliac & internal pudendal veins, respectively

Superior rectal artery y Middle & inferior rectal arteries

Rectum

BLOOD SUPPLY OF LARGE INTESTINE

Anal Canal Arteries Upper half is supply by superior rectal artery (branch of inferior mesenteric artery) Lower half is supply by inferior rectal artery (branch of internal pudendal artery) Veins Upper half is drained by superior rectal vein i t i t l i into inferior mesenteric vein Lower half is drained by inferior rectal vein into internal pudendal vein

Superior rectal artery y Middle rectal artery Inferior rectal artery

Anal canal

BLOOD VESSELS OF LARGE INTESTINE

Arteries

BLOOD VESSELS OF LARGE INTESTINE

Veins

Superior mesenteric artery and its branches

Superior mesenteric artery

(supply the midgut derivatives)

Inferior mesenteric artery and its branches

Inferior mesenteric artery

(supply the hindgut derivatives)