The rectum is the lowermost part of the large intestine extending from the rectosigmoid junction to the anal canal. It is around 12 cm long and has three lateral curves. It contains valves called Houston's valves that help support the weight of feces. The rectum receives its blood supply from the superior, middle, and inferior rectal arteries and drains into the superior, middle, and inferior rectal veins. It is an important site of communication between the portal and systemic venous systems. The anal canal extends from the anorectal junction to the anal orifice. It contains two sphincter muscles - the internal and external anal sphincters.
The rectum is the lowermost part of the large intestine extending from the rectosigmoid junction to the anal canal. It is around 12 cm long and has three lateral curves. It contains valves called Houston's valves that help support the weight of feces. The rectum receives its blood supply from the superior, middle, and inferior rectal arteries and drains into the superior, middle, and inferior rectal veins. It is an important site of communication between the portal and systemic venous systems. The anal canal extends from the anorectal junction to the anal orifice. It contains two sphincter muscles - the internal and external anal sphincters.
The rectum is the lowermost part of the large intestine extending from the rectosigmoid junction to the anal canal. It is around 12 cm long and has three lateral curves. It contains valves called Houston's valves that help support the weight of feces. The rectum receives its blood supply from the superior, middle, and inferior rectal arteries and drains into the superior, middle, and inferior rectal veins. It is an important site of communication between the portal and systemic venous systems. The anal canal extends from the anorectal junction to the anal orifice. It contains two sphincter muscles - the internal and external anal sphincters.
The rectum is the lowermost part of the large intestine extending from the rectosigmoid junction to the anal canal. It is around 12 cm long and has three lateral curves. It contains valves called Houston's valves that help support the weight of feces. The rectum receives its blood supply from the superior, middle, and inferior rectal arteries and drains into the superior, middle, and inferior rectal veins. It is an important site of communication between the portal and systemic venous systems. The anal canal extends from the anorectal junction to the anal orifice. It contains two sphincter muscles - the internal and external anal sphincters.
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By: Dr.
Allin Pradhan • RECTUM • Lower dilated part of the large gut(devoid of taenia coli , sacculations , appendices epiploicae and mysentry)
• Extent- rectosigmoid junction
to anorectal junction
• Begins as continuation of sigmoid colon – in front of S3
• Passes downwards - sacro
coccygeal curve- about 2-3 cm in front and below the tip of the coccyx. Measurements
12 cm long and 4 cm wide
Lower part - dilatation -
ampulla
Curvatures or flexures Anteroposterior – sacral curve and perineal curve Lateral - upper, middle and lower curves Lateral curves Upper curve – convex – right –at the junction of 3rd and 4th sacral vertebrae Middle curve – most prominent - convex –left –at the sacro – coccygeal junction. Lower curve – convex –right – at the tip of the coccyx.
IMPORTANCES Along the concavities of the curves – horizontal rectal valves projects- support the weight of the faeces. Peritoneal relation Upper 1/3rd-infront and on sides
• Middle 1/3rd –in front
• Lower 1/3rd –devoid of
peritoneum • Posterior surface – entirely non peritoneal Male-rectovesical pouch Female-rectouterine pouch Lateral- para rectal fossae Visceral relation Anterior • Male – upper 2/3rd-rectovesical pouch.7.5cm above the anus. sigmoid colon and small intestine – Lower 1/3rd-base of urinary bladder, seminal vesicles, vas deferens and prostate -recto vesical fascia of denonvillier – separate– these structures from rectum. • Female – upper 2/3rd– rectouterine pouch 5.5cm above the anus and 7.5 cm above the external orifice of vagina. – Lower 1/3rd- posterior surface of vagina – Recto- vaginal fascia- separate posterior surface of vagina from rectal ampulla Posterior In the middle line • Lower 3 pieces of sacrum, coccyx, anococcygeal raphe, median sacral vessels, superior rectal artery and fascia of waldeyar(ano-rectal junction – the coccyx )
On each side of the rectum
Piriformis, coccygeus, levator ani Sacral plexus and sympathetic trunk Pelvic splanchnic nerves and Lateral Sacral vessels Posterior
Laterally Upper 1/3rd – para-rectal fossae –sigmoid colon and S.I Middle 1/3rd – pelvi –rectal space and levator ani muscles. Lower 1/3rd - ischio-rectal fossae and their contents. Interior of the rectum Mucous fold Longitudinal folds-temporary Transverse folds(Houstonʼs valves) Houston’s valves formed by reduplication of mucous membrane containing submucous tissue and circular muscle of rectum.
1) First valve close to recto-sigmoid junction ,opposite S3 vertebra 12 to 14cm above the anus arises from right or left side of the gut Second valve – 2.5 cm above the third valves, along the concavity of the upper lateral curve.
Third valve- constant arises from the anterior and right wall of the rectum, along the concavity of the middle lateral curve. Nelaton’s sphincter- sometimes valves encircles the rectum opposite S5 about 5cm the anus .
Fourth valve 2.5 cm below the third valve ,arises from the left wall of rectum along the concavity of lower lateral curve. Third valve divides the interior of rectum into upper and lower chambers . Upper chamber – contain faeces without the reflex act of defaecation Lower chamber- defaecation starts spontaneously.
IMPORTANCE OF HOUSTON’S VALVES
Supports the weight of faeces Prevent the passage of instrument from the anus To avoid injury of the 3rd valve –cannula of rectal washing – passed in left lateral position. Blood Supply Superior rectal artery
Middle rectal artery Superior rectal vein
Middle rectal vein
Inferior rectal vein
Inferior rectal artery
Arterial supply Superior artery – continuation of inferior mesenteric artery. -principal artery of rectum . Middle rectal artery – branch of internal iliac artery Inferior rectal artery- branch of internal pudendal artery. Venous drainage Superior rectal vein- inferior mesenteric vein-(portal system) Middle rectal vein- internal illiac vein(systemic vein) Inferior rectal vein- internal pudendal vein(systemic vein) Importance of rectal veins 1. Rectal veins are important sites of communications between portal and systemic veins The radicles of superior rectal veins- devoid of valves- increased portal pressure –veins – distended. The trunk of superior rectal vein – pierces – posterior wall of rectum- during prolong straining at defecation – radicles of the veins - distended Venous drainage
Rectal veins are arranged –plexus.-
Annulus haemorrhoidalis Venous plexus consist of internal and external sets
Internal VP - surrounds the
analcanal –above Hiltons line-bet – mucous membrane n sphincter ani internus muscles. it drains above into the superior rectal vein. Communicates below freely with the external plexus and thus with the middle and inferior rectal veins. It is important site of communication between portal and systemic veins . External VP – surrounds the anus – bet – peri-anal skin n subcutaneous part of external sphincter muscle. Anal veins are arranged radially around the anal margin. Excessive straining during the defaecation may rupture one of these veins, forming a subcutaneous perianal haematoma known as external piles. Nerve supply Sympathetic fibres – derived from –superior hypogastric plexus,(l1,l2) stimulate the internal sphincter and inhibit rest of the musculature of rectum.
Parasympathetic pelvic splanchnic nerves(S1,S2,S3) secretomotor to the glands ,stimulates peristalsis and relax the sphincters. Supports of rectum
Pubo-rectal sling of levator ani
Reflexion of pelvic fasica
Fascial sheet of waldeyer and
pair of lateral ligaments of rectum.
Pelvi-rectal and ischio-rectal
fasia fat. Applied Anatomy • Colonoscopy • Prolapse of rectum • Cancer CLINICAL ANATOMY OF RECTUM 1. Digital Per Rectum (PR) Examination: The finger enters anal canal before reaching lower end of rectum.help in the palpation of following abnormalities. a. Within the lumen, faecal impaction & foreign bodies. b. In the rectal wall: rectal growths & strictures, & thrombosed piles c. Outside the rectal wall: distended bladder, lower ureteric stones
growths in lower part of rectum. Sigmoidoscopy helps in revealing the ulcers, growths & diverticula, & taking a rectal biopsy.
3. Carcinoma of Rectum: Situated at the rectosigmoid junction
(constricting type) or in the ampulla (proliferating type). Applied Anatomy Rectal examination (cont..) Anal Canal Terminal part of large intestine L- 3.8cm Extent- anorectal junction – anal orifice. Interior of anal canal • 3 parts by pectinate line n Hilton’s line. 1. Upper mucous part- 15mm 2. Middle mucous part/pecten-15mm 3. Lower cutaneous part- 8mm Hiltons line Color contrast between bluish pink area above and black skin below
Represented by the anal inter
sphincteric groove at the lower end of the internal sphincter muscle
Importance of Hilton’s line
Lower end of the internal sphincter HILTONS LINE muscle Anal fascia and the lunate fascia extend up to this line. Upper mucous part • Lined by simple columnar • Shows 6-10 vertical folds(anal columns)
• Lower ends-united by anal valves
• Above each anal valve- depression (anal sinus).
• Anal glands- sinus receives the
duct of anal gland.
• Anal valves-position of the valve
–indicated-(pectinate line)- Pectinate line – correspond with anal valve.muco-cutaneous junction Development 1) Upper-endodermal Lower-ectoderm (proctodeum)
2) Blood supply Upper- superior rectal artery and vein Lower-inferior rectal artery and vein
4) Nerve supply Upper- autonomic N Lower- somatic spinal N Middle mucous part Lined by NKSSE
Between pectinate line and
Hilton’s line
Surrounded by internal rectal
venous plexus
Richly supplied by vessels n
somatic spinal nerves. Lower cutaneous part
• Lined by true skin
• At anus-dry and hairy skin
MUSCULATURE OF THE ANAL CANAL
ANAL SPHINCTERS Internal anal sphincter – - involuntary in nature. - surrounds the upper 3/4th i.e. 30 mm of the anal canal extending from the upper end of the canal to the white line of Hilton. MUSCULATURE OF THE ANAL CANAL External anal sphincter -voluntary control. - made of a striated muscle & is supplied by the inferior rectal nerve & the perineal branch of the 4th sacral nerve . - surround the whole length of the anal canal & has 3 parts, subcutaneous, superficial & deep Subcutaneous part: lies below the level of the internal sphincter & surrounds the lower part of the anal canal. Superficial part: arises of the coccyx & the anococcygeal ligament or raphe. Fibres surround the lower part of the internal sphincter & are inserted into the perineal body. Deep part: surrounds the upper part of the internal sphincter & is fused with the puborectalis. Nerve Supply 1. Above the pectinate line - supplied by the autonomic nerves, both sympathetic (inferior hypogastric plexus; L1, L2) & parasympathetic (pelvic splanchnic; S2, S3, S4). These upper area is insensitive to modalities of cutaneous sensation.(insensitive to pain)
2. Below the pectinate line, it is supplied by somatic (inferior
rectal; S2, S3, S4) nerves. These area possesses all modalities of cutaneous sensation.(sensitive to pain)
3. Sphincters: Internal sphincter is caused to contract by
sympathetic nerves & is relaxed by parasympathetic nerves. External sphincter is supplied by the inferior rectal nerve & by the perineal branch of the S4. Applied anatomy
Anal fissure- damage
to the valve – painful condition. Anal fistula-fibrous tract – communacating with 2 surfaces- ano rectal mucosa n skin.
vein above the pectinate line. Bright red blood. These upper area is insensitive to modalities of cutaneous sensation. Splanchnic innervation –insensitive to pain External haemorrhoids Distended and varicose vein below the pectinate line. External haemorrhoids are covered by skin and may be extremely painful due to thrombosis or rupture of the small peri-anal veins. These area possesses all modalities of cutaneous sensation. Somatic innervation via inferior rectal nerve. Classification of haemorrhoids In portal obstruction distension of the superior rectal vein passing through the anal canal can cause the internal haemorrahage .sites 3 oclock ,7 o clock and 11 oclock position. These are the 3 sites of primary internal plies.
