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 (omental) appendices
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
Appendix
the appendix is complete

• 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 Taenia
Mesocolic
3. Taenia omental 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
Transverse
• Consists: colon

1. Caecum
2. Appendix Ascending Descending
3. Colon – ascending, colon colon

transverse, descending &

sigmoid colon Caecum
Sigmoid
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: Caecum
• inferior to the level of ileocecal 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 ileocaecal
Caecum valve

Ileal papilla:
• Seen in living person (endoscopic
observation)
Ileal papilla
• Is the in vivo appearance of
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
colon
femoral (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 adult) Appendix

 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 of orifice
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
Mesoappendix
• Passes superiorly behind the 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)
4. Sigmoid (mobile) Sigmoid
 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 Pancreas
umbilicus (L3)

Relations: Greater omentum

• Anterior – greater omentum

Transverse
• Posterior – 2nd part of mesocolon

duodenum, head of pancreas

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
Phrenicocolic
(supports spleen & forms upper limit of ligament
left paracolic gutter)
 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
arteries Ileocolic
ileocolic artery (terminal 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
Part of LI Blood drain vein
into
1. Cecum Superior
2. Appendix mesenteric
3. Ascending c. vein (SMV)
4. Transverse c. → hepatic
portal vein IMV
SMV
1. Descending c. Inferior
2. Sigmoid c. mesenteric
vein (IMV)
→ splenic
vein →
hepatic
portal vein
 Lymphatic Drainage
Superior
Part of LI Drain into mesenteri
c LN
1 Cecum, Superior
appendix, mesenteric
ascending & lymph
transverse nodes (LN)
colon

2 Descending Inferior
& sigmoid mesenteric
colon LN

Inferior
mesenteri
c 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
mesenteri
c plexus

Inferior
mesenteri
c 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 Inner
circular
longitudinal bands, the layer
taeniae 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…