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DISEASES
GROSS ANATOMY
LARGE INTESTINE
5 parts: ascending, transverse,
descending, sigmoid colon and rectum
Begins at the cecum - ileocecal valve
Appendix projects from the
convergence of the teniae at the lowest
part of the cecum
Ascending colon is retroperitoneal,
suspended from above at the hepatic
flexure by hepatocolic ligament
LARGE INTESTINE
ANATOMY
Transverse colon is intraperitoneal, from
hepatic flexure to the splenic flexure,
suspended by splenocolic and gastrocolic
ligaments
Descending colon is retroperitoneal,
continued by sigmoid colon
Sigmoid colon is intraperitoneal
Rectum begins at the level of S3, 12-15
cm. in length, passes the pelvic
diaphragm, ends in the anal canal
LARGE INTESTINE
ANATOMY
Rectum describes 3 lateral curves
Rectal ampulla is the most distal portion of
the rectum
Rectum ends at the anorectal junction
Anal canal, 4 cm. in length, ends at the
anal verge
Internal sphincter- smooth inner muscle
with involuntary control
Striated external sphincter- under
voluntary control
LARGE COLON
HISTOLOGY
Colonic wall- 4 layers: mucosa,
submucosa, muscularis propria, serosa
Mucosa is lined by columnar epithelium,
malignant cells confind to this are reffered
to as carcinoma in situ
1-2 cm. above the dentate line is a zone of
transitional epithelium having both
columnar and squamous cells
Below the dentate line, the anal canal is
lined by modified skin- no hair follicle, no
seb. glands
LARGE COLON
HISTOLOGY
Submucosa contains blood vessels and
lymphatics
Tumor cells must penetrate this layer to
gain access to the lymphatic system,
enabling metastatic spread
Submucosa is the strongest layer of the
bowel wall
Muscularis propria is made up of circular
and longitudinal smooth muscles
Rectum lacks a serosal layer
According to the depth invasion- Duke’s
staging
LARGE BOWEL
ARTERIAL SUPPLY
1.- Ileocolic art.- terminal branch of SMA
2.- Right colic art.- from SMA or ileocolic
3.- Middle colic art.- from SMA
4.- Left colic art- from IMA
5.- Rectosigmoid art.- from IMA
6.- Superior rectal art.- from IMA
7.- Middle rectal art.- from internal ileal
8.- Inferior rectal art.- from internal
pudental art.
LARGE BOWEL
VENOUS RETURN
Differential
Mechanical colonic obstruction
Toxic megacolon
Mesenteric ischaemia
Acute colonic pseudo-obstruction or Ogilvie syndrome is a
condition with clinical and radiological features of colonic
obstruction without any evidence of a mechanical cause.
Abdominal distension in this patient accounted for the respiratory
distress
Treatment:
- reasurence
- adjusting the diet to include adequate fibre
- bulking agents, antispasmodic drugs
- codeine phosphate-analgesic for occasional use
- relaxation therapy
SIGMOID VOLVULUS
Pathophysiology
Chronic constipation- enlarged, elongated,
atonic sigmoid colon= dolicomegacolon
Occasionally, the huge sygmoid loop, heavy
with feces becomes twisted on its
mesenteric pedicle- closed loop obstruction
Venous infarction- perforation-peritonitis
SIGMOID VOLVULUS
Clinical features:
– Elderly, mentally handicaped
– Abdominal distension, abdominal pain
– Assymetrical distension, tympanism
– Variable degree of tenderness
– Absolute constipation for at least 24
hours
– Perforation- peritonitis
– PR- the rectum is empty
SIGMOID VOLVULUS
Management:
– Plain abdominal x ray- single grossly dilated
sigmoid loop often reaching the xiphisternum
– An erect film- a characteristic” inverted U” of
bowel gas in the upper abdomen with fluid
level at the same height in the two bowel limbs
in the lower abdomen
– An abdominal lateral decubitus x ray may
reveal two parallel fluid levels running the full
length of the abdomen
SIGMOID VOLVULUS
Management
– Rectoscope is passed as far as possible into the
rectum and a flatus tube inserted through it
– The end of the flatus tube is then gently
manipulated through the twisted bowel into the
obstructed loop
– If this is successful there is a gush of liquid
feces and flatus relieving the obstruction
– The flatus tube left in-situ for 24 hours
SIGMOID VOLVULUS
Acute large bowel obstruction-
instant enema may define the lesion
Persistent volvulus- urgent operation
Sigmoidectomy with colorectal
anastomosis / Hartmann procedure
After a period of recovery following
Hartmann op.- redo colorectal
anastomosis
DIVERTICULAR DISEASE
Common condition- chronic lack of
dietary fiber