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The Rectum & Anal

canal
The Rectum:
 Proximally from the
sigmoid colon to the
anal canal distally
 Curved
anteroposteriorly &
side to side
 Sacculation,appendices
epiploicae & taeniae
coli absent
Situation :
 Posterior part of lesser pelvis,
infront of the lower 3 pieces of
the sacrum & coccyx.
 Begins as the continuation of
the sigmoid colon ( recto-
sigmoid junction ) at the level
of S3.
 Indicated by the lower end of
the s. mesocolon.
 Ends by becoming continuous
with the anal canal ( anorectal
junction ),2-3 cms infront of
the tip of the coccyx.
Measurements :
 12 cms long
 At the upper end
diameter same as that
of s.colon (i.e.4
cms ),but at the lower
end becomes dilated to
form the rectal
ampulla
Course/direction:
 1st runs downwards &
backwards, then downwards
and finally downwards &
forwards.
 Shows 2 types of
curvatures:
-2 anteroposterior curves,
-3 lateral curves
 Anteroposterior curves:
-sacral flexure & perineal
flexure
 3 lateral curves:
upper - convex to the right
middle- convex to the left
lower – convex to the right
Relations :
A)Peritoneal :
 Upper 1/3rd : covered
infront & on the side
 Middle 1/3rd : only
covered infront
 Lower 1/3rd : devoid
of peritoneum
B) Visceral :
 Anteriorly ( in males):
-upper 2/3rd:
rectovesical pouch with its contents
-lower 1/3rd:
base of urinary bladder,
terminal part of ureters,
seminal vesicles,
ducts of vas deferens
& prostate.
 Anteriorly (in females):
upper 2/3rd :
rectouterine pouch with its contents
lower 1/3rd :
lower part of the vagina
C) Posterior relations :
-lower 3 pieces of
sacrum,coccyx &
anococcygeal ligament
-piriformis,coccygeus,levator
ani
-the median sacral,superior
rectal ,lower lateral sacral
vessels
-sympathetic chain,pelvic
splancnic nerves
-lymphatics,lymph nodes &
fat.
Mucosal folds:
 Mucosa of the empty rectum shows 2
types of fold:
longitudinal/transverse
 Longitudinal:
transitory, mainly in the lower part,when
distended becomes obliterated.
 Transverse :
horizontal fold/Houston’s valve/ plicae
transversalis.
permanent folds
clearly seen when distended
3 transverse fold: upper/middle/lower
 Upper :lies near the upper end, may
project from rt. Or lt. wall
 middle :largest fold, lies at the upper
end of the rectal ampulla, projects from
rt. wall.
 Lower:2.5 cm below middle fold,project
from left wall.
Artery supply:
 Superior rectal artery
 Medial rectal artery
 Median sacral artery
Venous drainage:
 Superior rectal vein
 Middle rectal veins
Lymphatic drainage:
 Upper half:
inf.mesenteric lymph nodes
 Lower half:

internal ileac nodes


Nerve supply:
 Sympathetic:L1-L2
 Parasymopathetic:S2-S4
Supports of rectum:
 Pelvic floor
 Fascia of waldeyer
 Lateral ligaments of rectum
 Rectovesical fascia of Denonvillers
 Pelvic peritoneum
Clinical :
 P/R examination:
 Proctoscopy / Sigmoidoscopy:
 Rectal prolapse:
Functional parts:
 2 parts:
upper:related to peritoneum,lies above the
middle fold of rectum,acts as faecal reservior.
lower:devoid of peritoneum,lies below the
middle fold, empty in normal individual,

 Other story:
rectum is empty in normal individual,
passage of faeces in rectum causes desire to
defeacate.
The Anal Canal:
 Terminal part of the LI
 Extends from the rectum (anorectal
junction)to anus ( external outlet of
GIT)
 3.8 cms
 Directed downwards & backwards
 Anorectal junction: marked by the
forward convexity of the perineal
flexure
lies 2-3 cms infront of & slightly below
the tip of the coccyx.
 The anus: situated 4 cms below &
infront of the tip of the coccyx
Relations :
 Anteriorly :
perineal body
membranous urethra &
bulb of the penis
(male)
lower part of the vagina
 Posteriorly :
Anococcygeal ligament
tip of the coccyx
 Laterally :
ischiorectal fossa
Interior of the anal canal:
 Interior can be divided into 3 parts:
 Upper:
-15 mm,
-lined by mucus membrane,
-Anal column of Morgagni: shows 6-10 folds
-Anal valves: lower end of the anal column united with
each other by short transverse fold of mucus
membrane,
-Anal sinus: along the anal valve there is a depression
in the mucosa.
-Pectinate line: the anal valve together form a
transverse line that runs all round the anal canal.

 Middle part:
- 15 mm,also lined by mucus membrane,anal column
or folds not present,
-mucosa has bluish appearance due to deep venous
plexus
-lower limit of the middle parts looks whitish names as
white line of Hilton

 Lower part:
8mm long,
lined by true skin containing sweat & sebaceous gland
Musculature of the anal
canal:
A. Anal sphincters:
internal anal sphincter:
involuntary in nature,
formed by the thickened circular muscle coat of the
anal canal
surrounds upper 3/4th ( 30 mm ) of the anal canal
extends from the upper end of the canal to the
white line of hilton.
external anal sphincter:
under voluntary control,surrounds the whole length
of the anal canal
has 3 parts subcutaneous,superficial, and deep part.

 Anorectal Ring:
muscular ring present at the anorectal junction
formed by the fusion of the puborectalis,deep
external sphincter & internal sphincter.
can be easily felt by the finger in the anal canal
Artery supply:
 Above the pectinate line:
superior rectal artery
 Below the pectinate line:

inferior rectal artery


Venous drainage:
 Internal rectal venous plexus
 External rectal venous plexus
 Anal veins
Lymphatic drainage:
 Above the pectinate line:
internal ileac nodes
 Below the pectinate line:

superficial inguinal lymph nodes


Nerve supply:
 Above the pectinate line:
symp: inf. Hypogastric plexus , L1-L2
parasy: pelvic splancnic, S2-S4.

 Below the pectinate line:


somatic nerves
( inf.rectal,S2-S4 )
Clinical :
 Haemorrhoids :
- Piles
- dilatations of the branches of the internal
rectal venous plexus
- 10%
- above the pectinate line- internal piles,
below – external piles
- S/S : asymptomatic,rectal
bleeding,itching,prolapse etc
 Anal fissure:
- tear in the anal margin mainly due to
passage of hard stool
 Fistula in ano:
- there will be abnormal communication
bet. Anal canal & perianal skin.
 Best of luck!!!!!
 dr_shekh@yahoo.com