#3

Tasneem
Alremawi
Almuhtaseb
In this color are important notes mentioned by the doctor.

PELVIC COLON
Begins as a continuation of the descending colon left side of pelvic brim
(inlet of pelvic), at the ending point of descending colon.
• Parts of the pelvic colon:
- Sigmoid colon.
- Rectum.
- Upper part of the anal canal.
The anal canal is divided into two parts that differ in their origin,
innervation and blood supply…
Upper half: is a continuation of the rectum, as its origin is from the
endoderm.
Lower half: originate from the ectoderm.

SIGMOID COLON
- The sigmoid colon is 10-15 inch (25 to 38 cm) long (it varies
between individuals).
- It is a part of large intestine in pelvic cavity.
• Begin: left side of the pelvic brim (inlet of the pelvis).
• End: it becomes continuous with the rectum in front of the
third sacral vertebra (mid of the sacrum). the sacrum is one
bone with 5 vertebra.
• Parts:
- Lateral limb → contains lower left colic
artery.
- Medial limb → contains superior rectal
artery (the continuation of inferior
mesenteric artery).
- Free margin → curved to right of mid
line (From left to right).
- Root (mesentery) → has an inverted V
shape attachment.
• The sigmoid colon is mobile and hangs
down into the pelvic cavity in the form of
a loop. It is attached to the posterior
pelvic wall by the fan-shaped sigmoid
mesocolon.
Attachment of the root of mesocolon:
• Medially: middle piece of sacrum.
• Laterally on the left side: Bifurcation of left
common iliac artery (attached to its facia).
• Most laterally: Middle of left external iliac
artery.
Sigmoid colon has the same characteristics as
the large intestine which are: tenia coli,
appendices epiploicae and mesentery. The
appendices epiploicae (omental appendages) are
very long in the sigmoid colon.

RELATIONS OF SIGMOID COLON:

• Left:
- Left external iliac vessels (the most lateral attachment
of the mesocolon of the sigmoid).
- Lateral wall of pelvis and Vas defferance or ovary.

• Right: Small intestines (usually ilium).

• Superior: Coils of small intestine.

• Inferior: In male: urinary blabber. In female: uterus.

• Posteriorly: rectum, sacrum, lower coils of the

terminal part of the ileum, Sacral plexus (going
out of the foramen of sacrum), Left periformis
muscle (which originates from the upper 3
pieces of the sacrum), Left Ureter, Left external
iliac vessels, Left internal common iliac artery
(the external is in front of the internal common
iliac artery).
- Small intestines are seen above and on the
right side of the sigmoid colon, and can be
seen on the left and the posterior side.
The sigmoid colon usually occupies the
rectovesical pouch in males and the
rectouterine pouch in females. And
internal hernia cannot happen there
because it’s open 

BLOOD SUPPLY OF SIGMOID COLON

• Arteries: Sigmoid branches of the inferior mesenteric artery (since the
sigmoid colon is hindgut).
Hindgut = inferior mesenteric
The most superior sigmoid artery anastomoses with the descending branch
of the left colic artery (remember lower left colic artery is in the lateral limb of the
sigmoidal mesocolon, also it supplies the descending colon).
• Veins: The veins drain into the inferior mesenteric vein → to the splenic
vein → to the portal venous system.

▪️ Notice that the veins are always outer or lateral to the arteries (see
superior and inferior mesenteric arteries and veins)
LYMPH DRAINAGE OF SIGMOID COLON
• The lymph drains into nodes along the course of the sigmoid arteries →
the inferior mesenteric nodes (around the origin of inferior mesenteric
artery).
NERVE SUPPLY OF SIGMOID COLON
• The sympathetic and parasympathetic nerves from the inferior
hypogastric plexuses. (Plexus means it has sympathetic and
parasympathetic fibers).
• Parasympathetic innervation: starts from S2,3 and 4 spinal nerves →
forms the pelvic splanchnic nerves → the inferior hypogastric plexuses.
• Sympathetic innervation: starts from L1 and 2 spinal nerves → to the
inferior mesenteric ganglia → from the inferior hypogastric plexuses and
get distributed with the blood vessels.

RECTUM
• The rectum is about 5 inch (13 cm) long.
• Begins in front of (beyond) the third sacral vertebra as a
continuation of the sigmoid colon.
• Ends 1 inch in front of (beyond) the tip of the coccyx by
piercing the pelvic diaphragm and becoming continuous with
the anal canal.
- beyond is more precise than in front of, it means below and backwards not directly in
front.
• The lower part of the rectum is dilated to form the rectal ampulla (a
reservoir for stool).
• The rectum deviates to the left, but it quickly returns to the median plane.
On lateral view, the rectum follows the anterior concavity of the sacrum
before bending downward and backward at its junction with the anal
canal.
- In the anterior-posterior view, the rectum is concave as the sacrum
(the rectum starts from the mid of the sacrum and ends 1 in.
beyond coccyx).
- In the lateral view, the rectum ٤ ‫ عامل زي األربعة‬convex to the left side
and has two concavities on the right side.
• The puborectalis portion of the levator ani muscles forms a sling at the
junction of the rectum with the anal canal and pulls this part of the bowel
forward, producing the anorectal angle.
▪️ Levator ani muscle: a very important muscle called the
diaphragm of the pelvis, it stabilizes the abdominal and
pelvic organs in the pelvic cavity.
▪️ Puborectalis muscle: a U shaped voluntary muscle, a part
of the levator ani muscle, originate from the pubis, and is
inserted around the junction between the rectum and the
anal canal, it defines the junction between the
rectum and anal canal.
It forms an angle with a muscular sling curving
around the anorectal junction and pulling it
forward, and it is a very important muscle in the
process of defecation.

▪️ The mucus membrane of the rectum is formed from simple columnar

epithelium with goblet cells.
▪️ The anal canal is separated to upper and lower halves by the pectinate
line, and the lower part of the anal canal is called “pectinate” google says
it’s pecten.
▪️ The rectum has two types of folds:
- Transverse folds: three in number, 2 are on the left side (upper and
lower) and one on the right (middle). They are formed by: mucosa,
submucosa and inner circular muscle, they form the rectal ampulla to store
stool.
- Longitudinal folds contain:
1- Anal columns: vertical folds.
2- Anal valves: junctions between the anal columns
3- Anal sinuses: pockets formed by the anal valves.
▪️ The rectum has two types of sphincters:
- Internal anal sphincter: non-voluntary, formed by thickening of the
inner circular smooth muscle.
- External anal sphincter: voluntary with somatic innervation from the
inferior rectal nerves and the loss of control in this sphincter causes
incontinence. Has three parts: deep, superficial and subcutaneous.
▪️ On the lateral sides of the anal canal, there is ischiorectal fossa (between
the ischial tuberosity, and the rectum and the anal canal) forms a wedge
shape surrounded by the obturator internus and its facia from the lateral
side, on the medial side by the levator ani muscle, and its base is formed
by skin. This fossa is filled with fat to give space for descending feces during
deification.
The ischiorectal fossa is crossed by the inferior rectal nerve and vessels.
The ischiorectal fossa has a dangerous disadvantage: the skin on the base
or lower cm of the anal canal can get infected, especially because the latter
is keratinised and has hair follicles and sweat glands, leading to the
formation of abscesses, which can form sinuses and open to the outside, or
form fistulas and open into the rectum and anal canal, the problem here is
that even if it was treated it can reoccur and get back.
PR EXAMINATION (PER RECTAL EXAMINATION)
An internal examination of the rectum,
where the physician insert their index in the
anal canal and palpate the structures
anterior to the rectum.
A question suggested by the doctor: in per
rectal examination in male what structures
can be felt anterior to the index?
There are 3 structures that can be palpated during PR examination in a
male: the most important one is the prostate, vas deferens can be felt
especially if there was calcification, also the seminal vesicle can be felt.
The ureter CANNOT be felt because it opens into the urinary bladder
which is far from the rectum.

▪️ From an inferior view to the anus, the mucosa with the lumen of the
rectum can be seen. And it is represented in a clockwise manner as you can
see in the pic below, it is used to determine the site of structures there, for
example: the most common sites to see hemorrhoids coming out of the
rectum, where piles (hemorrhoids) are often seen in the 3, 7 and 11 o clock
in that circle.
Also transverse folds of the rectum, can be seen here. They are upper and
lower folds on the left side, and the middle fold is on the right side.
Mucosal folds: the transverse or horizontal folds or Houston’ valve: upper
fold projects from right, middle fold projects from anterior and right wall,
lowest fold projects from left wall. (The doctor didn’t mention this in the lec,
and said we should memorise what he said, which is in black, not what the
slides or this pic👇🏼 say, with regards to the directions of the transverse folds.)
The peritoneum of the rectum is divided into 3 parts:
1- first third : covers the anterior and lateral surfaces the
same as the descending colon (fixed in the posterior
abdominal wall, retroperitonial).
2- middle third : only the anterior surface and it forms the
pouches.
3- lower third : devoid of peritoneum (found in the pelvis)
surrounded by connective tissue only.

RELATIONS OF THE RECTUM:

• Posteriorly:
The rectum is in contact with the sacrum
and coccyx - the piriformis (its origin) -
levator ani muscle - the sacral plexus
(from the sacral foramina) - the
sympathetic trunks – lateral sacral arteries
- Coccygeus muscle and anococcygeal
body (the last two weren’t mentioned by the
doctor).
• Anteriorly:
- In males:
1. The upper two thirds of the rectum: covered by
peritoneum and related to the sigmoid colon and
coils of ileum (which occupy the rectovesical pouch).
2. The lower third of the rectum: devoid of
peritoneum. Related to: the posterior surface of the
bladder, termination of the vas deferens, seminal
vesicles on each side, prostate and to the perineal
body most inferiorly in front of the anal canal
(perineal body is formed by fibrous connective
tissue).
We have 3 parts of the urethra in males :
A- Prostatic urethra (in the urethra)
B- Membranous urethra (between two membranes).
C- Penile urethra.
- In females:
1. The upper two thirds of the rectum:
Covered by peritoneum, related to the sigmoid
colon and coils of ileum (which occupy the
rectouterine pouch (pouch of Douglas)).
2. The lower third of the rectum: devoid of
peritoneum, related to the posterior surface of the
vagina, the lower part of the uterus (its posterior
wall) and the perineal body.

HISTOLOGY OF RECTUM
• It has the same layers as the previous colon (mucosa, submucosa,
muscularis externa and serosa or adventitia).
• It has transverse and longitudinal folds.
• The lamina propria is filled with crypts of Lieberkühn to lubricate the
feces and secrete mucus.
• The inner circular layer of muscularis externa forms the internal sphincter
of the anal canal.
• The muscular coat of the rectum is arranged in:
1- outer longitudinal layer of smooth muscle.
2- inner circular layer of smooth muscle.
• The three taenia coli of the sigmoid colon however, come together so
that the longitudinal fibers form a broad band on the anterior and posterior
surfaces of the rectum → No taenia coli.
• Transverse folds of the rectum (semicircular permanent folds) → is
formed by the mucous membrane of the rectum + the inner circular
muscle layer.
BLOOD SUPPLY OF THE RECTUM
• Arteries: The superior, middle and inferior
rectal arteries supply the rectum.
1- The superior rectal artery
- It is a direct continuation of the inferior
mesenteric artery and is the chief artery supplying
the mucous membrane.
- It enters the pelvis by descending in the root of the sigmoid mesocolon
(it is related to the mucus membrane) and divides into right and left
branches, which pierce the muscular coat and supply the mucous
membrane.
- They anastomose with one another and with the
middle and inferior rectal arteries.
2- The middle rectal artery
- It is a small branch of the anterior division of the
internal iliac artery.
- It is distributed mainly to the muscular coat.
3- The inferior rectal artery
- It is a branch of the internal pudendal artery
(from the internal iliac artery) in the perineum.
- Supplies the lower half of the anal canal.
- It anastomoses with the middle rectal artery at the anorectal junction.
• Veins: the veins of the rectum correspond to the arteries (superior,
middle and inferior rectal veins).
1- The superior rectal vein
- A tributary of the portal circulation and drains into the
inferior mesenteric vein → to portal vein (portal
circulation).
2- The middle rectal vein→ to the internal iliac vein → IVC
→ right atrium of the heart (systemic circulation).
3- inferior rectal vein→ internal pudendal veins → IVC →
right atrium of the heart (systemic circulation).
- The union between the rectal veins forms an
important portal systemic anastomosis.
When there is portal hypertension due to
blockage in the liver, the portal vein won’t be
able to drain its blood into the live, instead;
the veinous blood coming from the rectum
through the superior rectal vein (portal
circulation) will go back and anastomose with
the middle and inferior rectal veins (systemic
circulation), and blood will collect there to
cause hemorrhoids (piles).
- The hemorrhoidal plexus (or rectal venous plexus) surrounds the rectum,
and communicates in front with the vesicle venous plexus in the male, and
the uterovaginal plexus in the female. A free communication between the
portal and systemic venous systems is established through the
hemorrhoidal plexus. (The doctor didn’t read this).

Hemorrhoids can be
subcutaneous (external) or high
up (internal).
▪️ If the enlarged vein was
superior → internal
hemorrhoids.
▪️ If it the enlarged vein was
inferior or middle → external
hemorrhoids.
LYMPH DRAINAGE OF RECTUM
• the upper part drain → into the pararectal nodes → then into inferior
mesenteric nodes.
• the lower part follow the middle rectal artery → to the internal iliac
nodes.
NERVE SUPPLY OF RECTUM
• The nerve supply is from the sympathetic and parasympathetic nerves
from the inferior hypogastric plexuses. The same as the sigmoid colon
(parasympathetic from S2,3,4 and sympathetic from L1,2 inferior
mesenteric ganglia).
• The rectum is sensitive only to stretch.
PAST PAPERS
All of the following statements concerning the sigmoid colon are correct
EXCEPT:
A) It has parasympathetic innervations from sacral nerves.
B) The blood supply from inferior mesenteric artery.
C) It has inverted V shape mesentery.
D) It ends in front of the mid of sacrum.
E) The medial limb of its mesentery contains left colic artery.

ANSWER: E
 V2
Edits in this color in pages 4, 6, 7.
The pic in page 6.
Past paper question was added..

V3
In page 6: the last sentence was added.
In page 8: above the image what is in this color was added.