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Med2, Station 5: rectum & anal canal

The anal canal and rectum form the final specialised, terminal part of the alimentary tract that lies
in the pelvis and perineum. Although anatomically separate, they are functional integrated forming
the anorectal unit that is responsible for defaecation and the maintenance of continence.
Embryologically, the rectum and upper anal canal is part of the hindgut but the lower anal
canal develops from a completely separate structure know as the proctodeum. Not only
does this mean they have a different blood supply, they also have a very different nervous
innervation (visceral Vs somatic)

Revise and list the differences in characteristic between somatic and visceral sensory
information:
Visceral - rectum Somatic - anal canal
Characteristic
Character of pain diffuse, and often referred sharp, well-defined,
Ability to localise difficult to locate Well localized
Painful modalities stretch, ischemia, inflammation Thermal (heat), Mechanical (crushing, tearing), Chemical
Nervous system Autonomic NS Somatic NS

With your tutor and in your groups, identify and list the upper and lower extent of the
rectum: Upper limit the anorectal junction continuous with the Rectum
Lower limit is the anal verge (anal orifice, anus)

At the level of the S3 vertebral body, the sigmoid colon loses its mesentery and becomes the
rectum. The taenia coli also flatten and fuse to form an outer longitudinal muscular layer, thus the
rectum does not have the distinctive haustra nor epiploic appendages that the rest of the large
intestine has. The rectum is approximately 15 cm long.
If demarcated from a purely gastrointestinal perspective, the rectum extends from rectosigmoid
junction to proximal anorectal sphincter.
Its upper third is covered by peritoneum anteriorly and laterally, mid third only anterior and its
lower third is not covered.
The lower part of the rectum is dilated and is called the rectal ampulla and there are three
semilunar transverse rectal folds (valves of Houston), which project into the rectum.

The rectum follows the curved of the sacrum and is S-shpaed in the sagittal plane. It perforates
the pelvic diaphragm (more of this next week) joins the anal canal at the level of the coccyx tip at
almost a right angle (Puborectalis muscle) to help prevent leakage of faecal material and thus
maintain continence. The faecal material is stored in the rectal ampulla.

Ultimately, the anal canal is responsible for closure of the GI tract to maintain continence. The anal
canal starts at the anorectal junction, where it is continuous above with the rectum, and
ends at the anus, the external outlet of the alimentary tract. It has 2 muscles closely associated
with it to help achieve this function - the anal sphincter muscles.
With your tutor and in your groups, complete the following about the 2 anal sphincter muscles:
Internal anal sphincter External anal sphincter
+S u r r o u n d s continuation of inner rectal muscle deep, superficial, and subcutaneous parts
which part of thickened, circular muscle fibres,
the canal up to 5 mm thick
+Type of muscle Smooth muscle Skeletal muscle fibres
+Derived from
+Nervous Autonomic NS Somatic NS
innervation
Due to the embryological differences, there is an important transition between the upper and lower
anal canal Complete the following to describe the differences between the upper and lower anal
canal:

Rectum & upper anal canal Lower anal canal


Arterial supply sup. rectal artery (IMA) & Middle rectal (IIA) Inf. rectal (Internal pudendal)
Venous drainage sup. rectal vein (IMV) (Portal) inf & mid rectal v (IIV)(systemic)
Lymphatic drainage above dentate: internal iliac nodes below dentate: superficial inguinal nodes
Nervous system symp& para & afferent: pelvic splanchnic n. inf. rectal branches (pudendal n.)
Painful modalities

The rectum and upper anal canal is part of the hindgut and thus it derives its blood supply from the
inferior mesenteric vessels. However, the lower anal canal also has a connection with the
SYSTEMIC venous system (internal iliac vessels).
Name the blood vessel that is a continuation of the inferior mesenteric artery that supplies the
upper rectum:
Name the blood vessel that supplies the anal canal :
The anus and rectum have a rich venous plexus which consists of 2 parts Name the 2 rectal
venous plexi: 1. Internal hemorrhoidal plexus (Portal)
2. External hemorrhoidal plexus (systemic)

Dilatation of veins in one of these plexus results in haemorrhoids or piles - dilated veins that
prolapse / bleed during defaecation. Haemorrhoids arise from which venous plexus?

Additionally, there is overlap between the portal venous and systemic (caval) systems that
becomes important in chronic liver disease and portal hypertension (see last week), as they open
to provide an alternative pathway back to the circulation that bypasses the liver.

External hemorrhoids develop from ectoderm and are covered by squamous epithelium, whereas
internal hemorrhoids are derived from embryonic endoderm and lined with the columnar
epithelium of anal mucosa. Similarly, external hemorrhoids are innervated by cutaneous nerves
that supply the perianal area. These nerves include the pudendal nerve and the sacral plexus.
Internal hemorrhoids are not supplied by somatic sensory nerves and therefore cannot cause pain.
Internal hemorrhoids drain through the superior rectal vein into the portal system. External
hemorrhoids drain through the inferior rectal vein into the inferior vena cava. Rich anastomoses
exist between these 2 and the middle rectal vein, connecting the portal and systemic circulations.
Nociceptive pain can be divided into visceral, deep somatic and superficial somatic pain.

1. Visceral structures are highly sensitive to stretch, ischemia, and inflammation, but relatively
insensitive to other stimuli that normally evoke pain in other structures, such as burning and cutting.
Visceral pain is diffuse, difficult to locate, and often referred to a distant, usually superficial, structure.
It may be accompanied by nausea and vomiting and may be described as sickening, deep,
squeezing, and dull.
2. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood
vessels, fasciae and muscles, and is a dull, aching, poorly localized pain. Examples include sprains
and broken bones.
3. Superficial pain is initiated by the activation of nociceptors in the skin or other superficial tissue, and
is sharp, well-defined, and clearly located. Examples of injuries that produce superficial somatic pain
include minor wounds and minor (first degree) burns.
External anal sphincter
Composed of skeletal muscle and classically categorised into deep, superficial, and subcutaneous parts:
deep part, circular muscle fibres, blends with puborectalis part of levator ani (posteriorly and laterally) the
aforementioned region is called the anorectal ring, and is palpable on rectal examination
superficial part, elliptical muscle fibres attaches from the the tip of the coccyx posteriorly to the perineal
body anteriorly only part of the sphincter with bony attachment
subcutaneous part circular muscle fibres, lower ends curve inwards, lying below the end of the internal
sphincter, the intersphincteric groove that results is palpable on examination

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