GI Tract - Rectum

Question 1

What is the rectum?

Answer 1

The rectum is the most distal segment of the large intestinem and has an important role as a temporary store of faeces.

It is continous proximally with the sigmoid colon, and terminates into the anal canal.

Question 2

Anatomical structure?

Answer 2

The rectum begins at the level of S3 (as a continuation of the sigmoid colon). It is macroscopically distinct from the colon, with an absence of taenia coli, haustra and omental appendices.

The course of the rectum is marked by two major flexures:

• Sacral flexure - anteroposterior curve with concavity anteriorly (follows the curve of the sacrum and coccyx).
• Anorectal flexure - anteroposterior curve with convexity anteriorly. This flexure is formed by the tone of the pubrectalis muscle, and contributes significantly to faecal continence.

There are additionally three lateral flexures (superior, intermediate and inferior), which are formed by transverse folds of the internal rectum wall.

The final segment of the rectum, the ampulla, relaxes to accumulate and temporarily store faeces until defecation occurs. It is continuous with the anal canal; which passes through the pelvic floor to end as the anus.

Peritoneal coverings

In the superior third of the rectum, the anterior surface and lateral sides are covered by peritoneum. The middle third only has an anterior peritoneal covering, and the lower 1/3 has no peritoneum associated with it.

In males, the reflection of peritoneum from the rectum to the posterior bladder forms the rectovesical pouch. In females, the peritoneum reflects to the posterior vagina and cervix, forming the rectouterine pouch (pouch of Douglas).

Question 3

Anatomical relations?

Answer 3

Male (anterior)

• Rectovesical pouch
• Sigmoid colon
• Ileum
• Bladder
• Prostate
• Semial vesicles

Female (anterior)

• Rectouterine pouch
• Sigmoid colon
• Ileum
• Vagina
• Cervix

Posterior (both male and female)

• Sacrum and coccyx
• Coccygeus
• Levator ani
• Sacral plexus

Question 4

Vascular supply?

Answer 4

The rectum receives arterial supply through three main arteries:

1) Superior rectal - terminal continuation of the inferior mesenteric artery.
2) Middle rectal - branch of the internal iliac
3) Inferior rectal - branch of the internal pudendal

Venous drainage is via the corresponding superior, middle, and inferior rectal veins.

Superior rectal vein drians into the portal venous system, whilst the middle and inferior rectal veins empty into the systemic venous system. Anastomoses between the portal and systemic veins are located in the wall of the anal canal, making this a site of the portocaval anastomosis.

Note: the rectum is also closely anatomically associated with rectal venous plexus; however this structure is more functionally related to the anal canal.

Question 6

Innervation?

Answer 6

The rectum receives sensory and autonomic innervation.

Sympathetic nervous supply to the rectum is from the lumbar splanchnic nerves and superior and inferior hypogastric plexuses. Parasympathetic supply is from S2-S4 via the pelvic splanchnic nerves and inferior hypogastric plexuses. Visceral afferent (sensory) fibres follow the parasympathetic supply.

Question 7

Lymphatic drainage?

Answer 7

Lymphatic drainage of the rectum is via the pararectal lymph nodes, which drain into the inferior mesenteric nodes.

Additionally, the lymph from the lower aspect of the rectum drains directly into the internal iliac lymph nodes.

Question 8

Clinical relevance - digital rectal examination?

Answer 8

The anterior wall of the rectum has a number of close anatomical structures. These can therefore be palpated digitally via the rectum. Most significant are the prostate and the seminal vesicles in males, and cervix in females. Bony structure, such as the sacrum and coccyx, may also be palpated in both sexes.