Anatomy, Abdomen and Pelvis, Large Intestine


Article Author:
Preet Kahai
Pujyitha Mandiga


Article Editor:
Stany Lobo


Editors In Chief:
Jasleen Jhajj
Cliff Caudill
Evan Kaufman


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/18/2019 2:18:53 AM

Introduction

The large intestine is within the alimentary tract where water is absorbed from indigestible contents. The large intestine includes the cecum, appendix, entire colon, rectum, and anal canal. It begins at the terminal ileum with the cecum. Unlike the small intestine, it has a shorter length but a much larger lumen. It is distinguished further from the small intestine by the presence of omental appendices, haustra, and teniae coli.[1][2][3]

The cecum is the proximal blind pouch of the ascending colon, lying at the level of the ileocecal junction. The terminal ileum contents open into the cecum on the medial wall, and the ileocecal valve guards this opening. The appendix is a thin cylindrical organ with a blind attachment to the cecum. The base of the appendix lies on the posteromedial wall of the cecum about 1 to 2 centimeters below the ileocecal junction. The tip of the appendix frequently floats in the peritoneal cavity and most commonly located in a retrocecal position. It has a short triangular mesentery called the mesoappendix.

The cecum is continuous with the second part of the large intestine: the ascending colon. The ascending colon runs superiorly on the right side of the abdomen from the right iliac fossa to the right lobe of the liver. At this point, it makes a left turn at the right colic flexure (hepatic flexure). Ascending colon is a retroperritoinal organ  and  has paracolic gutters on either side.  The transverse colon is the third, most mobile, and longest part of the large intestine. It is found between the right and left colic flexures. The left colic flexure is less mobile than the right and is attached to the diaphragm through the phrenicocolic ligament. The transverse colon is attached to a mesentery, the transverse mesocolon, which has its root along the inferior border of the pancreas. The transverse colon continues as  descending colon.  The decending colon is a retroperitonial organ and  related to paracolic gutters on either side. It terminates into the sigmoid colon, which is the fifth part of the large intestine. The sigmoid colon links the descending colon to the rectum. Sigmoid colon  is an S-shaped loop of varying length and becomes the rectum at the level of S3.

The rectum occupies the concavity of the sacrococcygeal curvature.  It is fixed, primarily retroperitoneal, and subperitoneal in location. It transitions to the anal canal at the level of the puborectal sling which is formed by the fibers of the levator ani muscles. The rectum has an expanded middle segment called the ampulla.  The rectum  is anterorly related to  the rectovesical pouch, prostate, bladder, urethra, and seminal vesicles in males. In females  the rectum is anteriorly related to  the recto-uterine pouch, cervix, uterus, and vagina.

Structure and Function

The key functions of the colon include the following:

  • Water and nutrient absorption
  • Vitamin absorption
  • Feces compaction
  • Potassium and chloride secretion
  • Moving waste material toward the rectum

Embryology

Embryologically, the colon develops from the midgut (cecum to the distal transverse colon), the hindgut (distal transverse colon to the dentate line in the anorectum), and the proctodeum (below the dentate line).

Blood Supply and Lymphatics

The blood supply to the colon is provided by the superior mesenteric artery (SMA) and the inferior mesenteric artery (IMA). Communication between these two vessels happens via the marginal artery which runs parallel to the length of the entire colon. The branches supplying specific portions of the bowel are as follows:

  • The cecum is supplied by the ileocolic artery, which is a terminal branch of the SMA. The ileocolic artery gives rise to the appendicular artery to supply the appendix.
  • The ascending colon and the right colic flexure are supplied by the ileocolic and right colic arteries, both branches of the SMA. 
  • The arterial supply to  the transverse colon is mostly from the middle colic artery which is a branch of  SMA. It may also receive blood supply from the anastomotic arcades between the right and left colic arteries which collectively form the marginal artery.
  • The descending and sigmoid colon receive their blood supply from the left colic and sigmoid arteries which are branches of the IMA. The transition of blood supply at the left colic flexure from the SMA to the IMA indicates  the embryological transition from the midgut to hindgut that occurs at this point, respectively.
  • The rectum and anal canal are supplied by the superior rectal artery which is a continuation of the IMA. They also receive supply from branches of the internal iliac arteries, the middle and inferior rectal arteries. Further, the inferior rectal artery is a branch of the internal pudendal artery.

Venous drainage usually accompanies arterial colonic supply. Ultimately, the Inferior mesenteric vein (IMV) drains into the splenic vein, while the Superior  mesenteric vein (SMV) joins the splenic vein to form the hepatic portal vein. Lymphatics of the large intestine drain into the lymph nodes associated with the main vessels which supplies them. 

Nerves

The midgut-derived ascending colon and proximal two-thirds of the transverse colon receive parasympathetic, sympathetic, and sensory nerve supply from the superior mesenteric plexus.

The hindgut-derived structures, which include the distal one-third of the transverse colon, descending, and sigmoid colon, receive parasympathetic, sympathetic, and sensory nerve innervation from the inferior mesenteric plexus.

Surgical Considerations

The appendix, transverse colon, and sigmoid colon  are considered to be intraperitoneal  organs. The cecum also is located intraperitoneally, but it lacks a mesentery. It is considered to be an intraperitoneal organ; however,  as it is covered on all sides by peritoneum. The ascending colon, descending colon, rectum, and anal canal are retroperitoneal structures.

Clinical Significance

The marginal artery of Drummond is a large collateral that supplies the colon and is of importance when there is occlusion of one of the major vessels supplying blood to the colon. There are several disorders that can affect the colon, including diverticular disease, colon cancer, bowel obstruction, lower gastrointestinal (GI) bleeding from polyps and AV malformations, strictures, and peristalsis.


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Anatomy, Abdomen and Pelvis, Large Intestine - Questions

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A 79-year-old male with a past medical history of coronary artery disease with drug-eluting stent placement to the left anterior descending artery and atrial fibrillation presents to the emergency department with severe abdominal pain. Most of the history was obtained from the wife since the patient was unable to speak from the severe abdominal pain. As per wife, the patient has not been compliant with home medications, which include aspirin, clopidogrel, warfarin, and atorvastatin. Physical examination reveals pain out of proportion on soft palpation of the abdomen and absent bowel sounds. CTA abdomen and pelvis reveals ischemia of splenic flexure. Which of the following arteries are most likely affected by the underlying disease process?



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During surgery, in what position is the base of the appendix?

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Which of the following arteries does not supply the right colon?

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At which of the following vertebral levels does the sigmoid colon continue as the rectum?

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A 65-year-old male with a past medical history of colon cancer with recent total colectomy to the terminal ileum presents for a follow-up. The patient reports that he has to clean his colostomy bag daily. He says he is able to tolerate food without any nausea or vomiting. On physical examination, the colostomy site looks healed with no erythema or drainage. The patient is requesting education regarding the functions of the colon and dietary changes that are required to be made for his health. Which of the following below is the main function of the colon?



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Anatomy, Abdomen and Pelvis, Large Intestine - References

References

Chaudhry SR,Bhimji SS, Anatomy, Abdomen and Pelvis, Stomach null. 2018 Jan     [PubMed]
Dumont F,Da Re C,Goéré D,Honoré C,Elias D, Options and outcome for reconstruction after extended left hemicolectomy. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2013 Jun     [PubMed]
Smereczyński A,Kołaczyk K, Pitfalls in ultrasound imaging of the stomach and the intestines. Journal of ultrasonography. 2018     [PubMed]

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