Gross Anatomy of the Large Intestine

The large intestine consists of the :

Cecum with the (vermiform) appendix
Ascending, transverse, descending, and sigmoid colon
Rectum and anal canal

The large intestine can be distinguished from the small intestine by:
• Omental appendices: small, fatty, omentum-like projections.
• Teniae coli: three distinct longitudinal bands: (1) mesocolic tenia,
to which the transverse and sigmoid mesocolons attach; (2)
omental tenia, to which the omental appendices attach; and (3)
free tenia, to which neither mesocolons nor omental appendices
are attached.
• Haustra: sacculations of the wall of the colon between the teniae
• A much greater caliber (internal diameter).

Netter, The Atlas of Human Anatomy 6 Ed

Anatomy of
Large
Intestines

Netter, The Atlas of Human Anatomy 6 Ed

Moore-Clinically Oriented Anatomy 7 Ed.
Caecum and Appendix

Moore-Clinically Oriented Anatomy 7 Ed.

 Sigmoid
colon,
rectum,
and anal
canal

Netter, The Atlas of Human Anatomy 6 Ed

 Vasculature of
the Colon

Schwartzs Principles of Surgery

Arterial Supply of Rectum

Sabiston 20 Ed.
Venous Drainage of Colon and
Rectum

Sabiston 20 Ed.
 Physiology of Large Intestine

• Functions
– Completion of absorption, especially final absorption of H2O
– Normal flora manufacture certain vitamins (B complex, K)
– Formation and expulsion of feces
• Anatomy
– 1.5 m L (3 to 5 feet), 6.5 cm W
– Divided into 4 general areas:
• cecum
• colon
• rectum
• anal canal

Sabiston 20 Ed.
 Large Intestine: Digestion
• Mechanical digestion
– Chyme passage regulated by ileocecal sphincter
• valve generally closed - slow passage
• following a meal  gastroileal reflex: ileal motility increases, sphincter
relaxes, chyme moves to the cecum
• when the cecum is full, the sphincter contracts
– Colon movements start when chyme passes sphincter
• haustral churning
– haustra relaxed, distended until full
– then contract, squeeze contents into next haustrum
• peristalsis is slow
• mass peristalsis (gastrocolic reflex)
– during or immediately following a meal, 3-4 times day
– strong peristaltic waves from middle of transverse colon
– push contents into the rectum Sabiston 20 Ed.
 Large Intestine: Digestion
• Chemical digestion
– much mucus but no enzymes are secreted

– some digestion of chyme by bacteria in colon

• final breakdown of substances, mostly carbohydrates

• bacteria produce some vitamins, B complex and K

• some bacterial metabolites are toxic, but the liver normally

deals successfully with them

Sabiston 20 Ed.
 Large Intestine
• Absorption and feces formation
– Chyme
• after 3-10 hours in the large intestine, chyme becomes
solidified (due to water reabsorption) into feces
• large intestine absorbs water, electrolytes, some vitamins
and any toxins
– Feces
• water, inorganic salts, sloughed off intestinal epithelial cells,
bacteria, products of bacterial decomposition, undigested
parts of food
• most water is reabsorbed in small intestine, but the large
intestine is also important in water reabsorption
Sabiston 20 Ed.
Large Intestine
• Physiology of defecation
– Mass peristalsis
• pushes fecal matter into rectum
• distension stimulates stretch
receptors initiating reflex for
defecation

– Parasympathetic ANS
stimulated by stretch receptors
• stimulates contraction of rectum
• shortens and increases pressure in
rectum
• parasympathetic stimulation relaxes internal sphincter

– Conscious stimulation relaxes external sphincter

• feces expelled
Sabiston 20 Ed.
HBP
 Liver
• The liver is the largest gland in the body and,
after the skin, the largest single organ. It
weighs approximately 1500 g and accounts for
approximately 2.5% of adult body weight. In a
mature fetus—when it serves as a
hematopoietic organ—it is proportionately
twice as large (5% of body weight).

Moore Clinically Oriented Anatomy 7th Edition

 Functions of the Liver
• Functions:
– Filters and processes nutrient-rich blood of
carbohydrates, proteins, and lipids from intestine
– Production and regulation of cholesterol
– Production of bile which emulsifies fats
– Removes drugs and hormones from circulation
– Storage of vitamins and minerals
 Anatomy of the Liver
• The liver lies mainly in the right upper quadrant of the
abdomen, where it is protected by the thoracic (rib) cage
and the diaphragm
• The normal liver lies deep to ribs 7–11 on the right side
• The subphrenic recesses are separated into right and left
recesses by the falciform ligament, which extends be
tween the liver and the anterior abdominal wall
• The hepatorenal recess (hepatorenal pouch; Morison
pouch) is the posterosuperior extension of the
subhepatic space, lying between the right part of the
visceral surface of the liver and the right kidney and
suprarenal gland.
Surface of The Liver Related Potential
Space
 Relationships of liver to other
abdominal viscera, lesser omentum,
and portal triad
 BLOOD VESSELS OF LIVER
• The hepatic portal vein brings 75–80% of the
blood to the liver.
• Portal blood, containing about 40% more
oxygen than blood returning to the heart from
the systemic circuit, sustains the liver
parenchyma (liver cells or hepatocytes)
• Arterial blood from the hepatic artery,
accounting for only 20–25% of blood received
by the liver, is distributed initially to
nonparenchymal structures, particularly the
intrahepatic bile ducts.
 BLOOD VESSELS OF LIVER
• The hepatic portal vein, a short, wide vein, is
formed by the superior mesenteric and splenic
veins posterior to the neck of the pancreas.
• The hepatic artery, a branch of the celiac trunk,
may be divided into the common hepatic artery,
from the celiac trunk to the origin of the
gastroduodenal artery, and the hepatic artery
proper, from the origin of the gastroduodenal
artery to the bifurcation of the hepatic artery
 LYMPHATIC DRAINAGE OF LIVER
• Between one quarter and one half of the lymph
entering the thoracic duct comes from the liver
• The superficial lymphatics drain to the hepatic
lymph nodes scattered along the hepatic vessels
and ducts in the lesser omentum
• Efferent lymphatic vessels from the hepatic nodes
drain into celiac lymph nodes, which in turn drain
into the cisterna chyli (chyle cistern), a dilated sac
at the inferior end of the thoracic duct
 LYMPHATIC DRAINAGE OF LIVER
• Superficial lymphatics from the posterior aspects
of the diaphragmatic and visceral surfaces of the
liver drain toward the bare area of the liver
• Here they drain into phrenic lymph nodes, or join
deep lymphatics that have accompanied the
hepatic veins converging on the IVC, and pass
with this large vein through the diaphragm to
drain into the posterior mediastinal lymph nodes
• Efferent lymphatic vessels from these nodes join
the right lymphatic and thoracic ducts.
Lymphatic Drainage
 INNERVATION OF LIVER
• The nerves of the liver are derived from the
hepatic plexus, the largest derivative of the celiac
plexus.
• The hepatic plexus accompanies the branches of
the hepatic artery and hepatic portal vein to the
liver
• This plexus consists of sympathetic fibers from
the celiac plexus and parasympathetic fibers from
the anterior and posterior vagal trunks.
• Nerve fibers accompany the vessels and biliary
ducts of the portal triad. Other than
vasoconstriction, their function is unclear.
INNERVATION OF LIVER
BILLIAY DUCT AND GALLBLADDER
• The biliary ducts convey bile from the liver to
the duodenum.
• Bile is produced continuously by the liver and
stored and concentrated in the gallbladder,
which releases it intermittently when fat
enters the duodenum.
• Bile emulsifi es the fat so that it can be
absorbed in the distal intestine.
 Bile Duct
• The bile duct (formerly called the common bile
duct) forms in the free edge of the lesser
omentum by the union of the cystic duct and
common hepatic duct.
• The bile duct descends posterior to the superior
part of the duodenum and lies in a groove on the
posterior surface of the head of the pancreas
• On the left side of the descending part of the
duodenum, the bile duct comes into contact with
the main pancreatic duct
 Bile Duct
• These ducts run obliquely through the wall of this
part of the duodenum, where they unite, forming
a dilation, the hepatopancreatic ampulla
• The distal end of the ampulla opens into the
duodenum through the major duodenal papilla
• The circular muscle around the distal end of the
bile duct is thickened to form the sphincter of the
bile duct (L. ductus choledochus)
GALLBLADDER
 BLOOD VESSEL OF BILE DUCT
• Cystic artery: supplying the proximal part of the duct
• Right hepatic artery: supplying the middle part of the
duct
• Posterior superior pancreaticoduodenal artery and
gastroduodenal artery: supplying the retroduodenal
part of the duct
• The venous drainage from the proximal part of the bile
duct and the hepatic ducts usually enter the liver
directly
• The posterior superior pancreaticoduodenal vein drains
the distal part of the bile duct and empties into the
hepatic portal vein or one of its tributaries.
LYMPHATIC DRAINAGE OF BILE DUCT
• The lymphatic vessels from the bile duct pass
to the cystic lymph nodes near the neck of the
gallbladder, the lymph node of the omental
foramen, and the hepatic lymph nodes
• Efferent lymphatic vessels from the bile duct
pass to the celiac lymph nodes.
LYMPATHIC DRAINAGE
 GALLBLADDER
• The gallbladder (7–10 cm long) lies in the fossa for the
gallbladder on the visceral surface of the liver
• The pear-shaped gallbladder can hold up to 50 mL of
bile
• The gallbladder has three parts :
– Fundus: the wide blunt end that usually projects from the
inferior border of the liver at the tip of the right 9th costal
cartilage in the MCL
– Body: main portion that contacts the visceral surface of
the liver, transverse colon, and superior part of the
duodenum
– Neck: narrow, tapering end, opposite the fundus and
directed toward the porta hepatis; it typically makes an S-
shaped bend and joins the cystic duct
 GALLBLADDER
• The cystic duct (3–4 cm long) connects the neck
of the gallbladder to the common hepatic duct
• The mucosa of the neck spirals into the spiral
fold (spiral valve)
• The spiral fold helps keep the cystic duct open;
thus bile can easily be diverted into the
gallbladder when the distal end of the bile duct is
closed by the sphincter of the bile duct and/or
hepatopancreatic sphincter, or bile can pass to
the duodenum as the gallbladder contracts
 BLOOD VESSEL OF GALLBLADDER
• The arterial supply of the gallbladder and
cystic duct is from the cystic artery.
• The cystic artery commonly arises from the
right hepatic artery in the triangle between
the common hepatic duct, cystic duct, and
visceral surface of the liver, the cystohepatic
triangle (of Calot)
• Variations occur in the origin and course of
the cystic artery
 BLOOD VESSEL OF GALLBLADDER
• The venous drainage from the neck of the
gallbladder and cystic duct flows via the cystic
veins
• These small and usually multiple veins enter the
liver directly or drain through the hepatic portal
vein to the liver, after joining the veins draining
the hepatic ducts and proximal bile duct
• The veins from the fundus and body of the
gallbladder pass directly into the visceral surface
of the liver and drain into the hepatic sinusoids.
 LYMPHATIC DRAINAGE OF
GALLBLADDER
• The lymphatic drainage of the gallbladder is to
the hepatic lymph nodes often through cystic
lymph nodes located near the neck of the
gallbladder
• Efferent lymphatic vessels from these nodes
pass to the celiac lymph nodes.
 INNERVATION OF GALLBLADDER
• The nerves to the gallbladder and cystic duct pass
along the cystic artery from the celiac (nerve)
plexus (sympathetic and visceral afferent [pain]
fibers), the vagus nerve (parasympathetic), and
the right phrenic nerve (actually somatic afferent
fi bers)
• Parasympathetic stimulation causes contractions
of the gallbladder and relaxation of the sphincters
at the hepatopancreatic ampulla
• However, these responses are generally
stimulated by the hormone cholecystokinin
(CCK), produced by the duodenal walls (in
response to the arrival of a fatty meal), and
circulated through the bloodstream
 PANCREAS
• The pancreas is an elongated, accessory digestive
gland that lies retroperitoneally, overlying and
transversely crossing the bodies of the L1 and L2
vertebra (the level of the transpyloric plane) on
the posterior abdominal wall
• It lies posterior to the stomach between the
duodenum on the right and the spleen on the left
• The transverse mesocolon attaches to its anterior
margin
 PANCREAS
• The main pancreatic duct begins in the tail of the
pancreas and runs through the parenchyma of
the gland to the pancreatic head: here it turns
inferiorly and is closely related to the bile duct
• The main pancreatic duct and bile duct usually
unite to form the short, dilated hepatopancreatic
ampulla (of Vater), which opens into the
descending part of the duodenum at the summit
of the major duodenal papilla
 PANCREAS
• The sphincter of the pancreatic duct (around
the terminal part of the pancreatic duct), the
sphincter of the bile duct (around the
termination of the bile duct), and the hepa
topancreatic sphincter (of Oddi)—around the
hepatopancreatic ampulla—are smooth
muscle sphincters that control the flow of bile
and pancreatic juice into the ampulla and
prevent refl ux of duodenal content into the
ampulla.
 PANCREAS
• The sphincter of the pancreatic duct (around
the terminal part of the pancreatic duct), the
sphincter of the bile duct (around the
termination of the bile duct), and the
hepatopancreatic sphincter (of Oddi)—around
the hepatopancreatic ampulla—are smooth
muscle sphincters that control the flow of bile
and pancreatic juice into the ampulla and
prevent reflux of duodenal content into the
ampulla
 FUNCTION OF PANCREAS
• An exocrine secretion (pancreatic juice from
the acinar cells) that enters the duodenum
through the main and accessory pancreatic
ducts
• Endocrine secretions (glucagon and insulin
from the pancreatic islets [of Langerhans])
that enter the blood
 BLOOD VESSEL OF PANCREAS
• The arterial supply of the pancreas is derived mainly
from the branches of the markedly tortuous splenic
artery
• Multiple pancreatic arteries form several arcades with
pancreatic branches of the gastroduodenal and
superior mesenteric arteries
• As many as 10 branches may pass from the splenic
artery to the body and tail of the pancreas.
• The anterior and posterior superior
pancreaticoduodenal arteries, branches of the
gastroduodenal artery, and the anterior and posterior
inferior pancreaticoduodenal arteries, branches of the
SMA, form anteriorly and posteriorly placed arcades
that supply the head of the pancreas
 BLOOD VESSEL OF GALLBLADDER
• Venous drainage from the pancreas occurs via
corresponding pancreatic veins, tributaries of
the splenic and superior mesenteric parts of
the hepatic portal vein; most empty into the
splenic vein
BLOOD VESSEL OF PANCREAS
LYMPHATIC DRAINAGE OF PANCREAS
• The pancreatic lymphatic vessels follow the blood
vessels
• Most vessels end in the pancreaticosplenic lymph
nodes, which lie along the splenic artery
• Some vessels end in the pyloric lymph nodes
• Efferent vessels from these nodes drain to the
superior mesenteric lymph nodes or to the celiac
lymph nodes via the hepatic lymph nodes.
LYMPHATIC
DRAINAGE
OF
PANCREAS
 INNERVATION OF PANCREAS
• The nerves of the pancreas are derived from the vagus
and abdominopelvic splanchnic nerves passing through
the diaphragm
• The parasympathetic and sympathetic fibers reach the
pancreas by passing along the arteries from the celiac
plexus and superior mesenteric plexus
• In addition to sympathetic fi bers that pass to blood
vessels, sympathetic and parasympathetic fibers are
distributed to ancreatic acinar cells and islets
• The parasympathetic fi bers are secretomotor, but
pancreatic secretion is primarily mediated by secretin
and cholecystokinin, hormones formed by the
epithelial cells of the duodenum and proximal
intestinal mucosa under the stimulus of acid contents
from the stomach.
INNERVATI
ON OF
PANCREAS