PowerPoint Handout: Lab 4, Midgut, Hindgut, & Anal Canal

Slide Title Slide Number Slide Title Slide Number

Small Intestine: Review Slide 2 Tributaries of the Hepatic Portal Vein Slide 15
Small Intestine: Continued Slide 3 Review: Portacaval Anastomosis Slide 16
Large Intestine: Review Slide 4 Rectum Slide 17
Large Intestine: Continued Slide 5 Anal Canal Slide 18
Appendix Slide 6 Summary of Anal Canal Innervation, Arterial Supply, and
Slide 19
Lymph and Venous Drainage
Ileal Diverticulum of (Meckel) Slide 7
Hemorrhoids Slide 20
Diverticulosis Slide 8
Pelvic Ligaments, Osseous Features, & Spaces Slide 21
Blood Supply: Midgut & Hindgut Slide 9
Pelvic Cavity Boundaries Slide 22
Superior Mesenteric Artery (SMA): Branches Slide 10
Perineum Slide 23
Superior Mesenteric Artery (SMA): Branches Slide 11
Ischio-anal Fossa Slide 24
Superior Mesenteric Artery (SMA): Branches Slide 12
Anal Fistulas and Fissures Slide 25
Splenic Flexure Watershed Area Slide 13
Summary of Abdominal/Inguinal Innervations Slide 26
Inferior Mesenteric Artery (IMA): Branches Slide 14
Summary of Abdominal/Inguinal Innervations Slide 27
 Small Intestine: Review
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The small intestine is a 20 ft long (in a cadaver), highly coiled tube. The process
of digestion is completed in the lumen of small intestine, which results in
nutrients that can be transported across its wall by a process called nutrient
absorption.
The small intestine consists of three regions.
• The duodenum (“twelve finger widths long”) is the first 10 inches of small
intestine.
• The jejunum (“empty”) is the middle portion of the small intestine that is 8
feet in length.
• The ileum (“twisted”) is the distal 12 feet of the small intestine that joins
with the large intestine at the cecum.
 Small Intestine: Continued

Plicae circulares (“circular folds”) are visible circular ridges along the wall of
the small intestine that are formed by folds of the mucosa and submucosa.
They function to increase surface area and reduce the speed of passage of
chyme, the now liquefied remnants of the meal, through the small intestine.
The density and size of plicae circulares is the greatest in the distal duodenum
and the jejunum.

The external feature that can be used to differentiate the jejunum from the
ileum is the the location of fat within the mesentery.
• The mesenteric fat of the jejunum does NOT encroach upon the intestinal
wall.
• The mesenteric fat of the ileum DOES encroach upon the intestinal wall.

Fat Encroaching
Upon Wall
 Large Intestine: Review

The large intestine is five feet long and surrounds the small intestine on
three sides. Its major functions include water absorption from the
remaining indigestible material and formation of solid waste called feces.
The large intestine consists of the cecum, the colon, and the rectum.
• The cecum is the first part of the large intestine. It is a pouch-like
cul-de-sac of the colon just inferior to the ileocecal valve.
•The ileocecal valve is a sphincter at the junction of the
ileum to the cecum in the lower right abdominal quadrant.
It controls the movement of chyme into the cecum from
the small intestine.
•The vermiform appendix, is a small ‘worm-like’ appendage
dangling from the cecum that contains immune cells.
• The colon is the largest portion of the large intestine consisting of
four regions.
•The ascending colon (retroperitoneal) rises along the right
abdominal wall and leads to the first bend in the colon, the
hepatic flexure.
•The transverse colon (intraperitoneal) runs horizontally
across the abdomen just superior to the small intestine and
leads to the second bend in the colon, the splenic flexure.
•The descending colon (retroperitoneal) descends down https://3d4medic.al/mnWJcsMq
the left abdominal wall.
•The sigmoid colon (intraperitoneal) is the S-shaped
portion that leads into the fecal storage region, the rectum
and then to the anal canal and anus, through which feces
pass during elimination.
 Large Intestine: Continued
Epiploic Appendages

• The haustra (sing. haustrum) are pouches formed along the length of the colon by muscle tone
exerted by the teniae coli. These structures may not appear in a cadaver due to a lack of smooth
muscle tone.
• The outer longitudinal layer of the muscularis externa doesn’t completely surround the colon; instead,
it is organized into three bands of longitudinal muscle, called teniae coli that extend the length of the
colon.
• Epiploic appendages are fatty structures that hang from the length of teniae coli. Their function is
unknown.
 Appendix
The appendix is a blind-ended tubing attached to the cecum which is highly variable in length, ranging between 2 to 20 cm. It is associated with
its own mesentery that is called the mesoappendix. Its position is usually posterior to the cecum (64% of individuals), but variations exist.

CLINICAL ANATOMY: Acute inflammation of the appendix is a common cause of an acute abdomen (severe abdominal pain arising
suddenly). The etiology of appendicitis depends on age. In the young, it is mostly due to an increase in lymphoid tissue size, which occludes
the lumen. From 30 years old onwards, it is more likely to be blocked due a fecalith. The pain of appendicitis usually begins as a dull, vague
pain (visceral) in the periumbilical region. Later, sharp (somatic) pain develops in the right lower quadrant due to irritation of the parietal
peritoneum lining the abdominal wall. Digital pressure applied to McBurney’s point registers the maximum abdominal tenderness.
• Early: inflammation of visceral peritoneum à visceral pain = poorly localized periumbilical pain
• Late: as inflammation progresses to involve parietal peritoneum à somatic pain = RLQ pain
 Ileal Diverticulum of (Meckel)

CLINICAL ANATOMY: An ileal diverticulum (of Meckel) is a pouch-like remnant of the proximal part of the vitelline duct of the embryo. This
diverticulum is always located within 60-100 cm (i.e., 2 feet) of the ileocecal junction and it is usually 2 inches in length. Approximately 2% of
the population possesses an ileal diverticulum and of these individuals only 2% are symptomatic. Symptoms usually present before the age
of 2 and males are 2x as likely to be affected.
 Diverticulosis

CLINICAL ANATOMY: A diverticulum is a sac-like outpouching of the

wall of the colon (Figure 4.1). These structures are common in
elderly people and can become inflamed (diverticulitis) when their
lumens accumulate fecal material. If an inflamed diverticulum
ruptures, the infection can spread to the peritoneum (peritonitis).
75% of diverticula are found in the sigmoid colon.
 Blood Supply: Midgut & Hindgut

Blood supply to the midgut and foregut is provided by the following anterior
branches of the abdominal aorta.
• Midgut: Superior mesenteric artery (SMA)
• Branches from aorta at the level of the L1 vertebra immediately inferior to
the celiac trunk. It has some important anatomical relationships to other
structures.
• It is posterior to (crossed by) the following structures.
• Pylorus of stomach
• Splenic vein
• Neck of pancreas
• It is anterior to (crosses over) the following structures.
• Uncinate process of pancreas
• 3rd part of duodenum
• Left renal vein
• Supplies organs from the major duodenal papilla up to the last 1/3 of the
transverse colon

• Hindgut: Inferior mesenteric artery (IMA)

• Branches from aorta inferior to SMA
• Supplies the distal 1/3 of the transverse colon and the descending colon
 Superior Mesenteric Artery (SMA): Branches
ARTERY ORIGIN ORGANS SUPPLIED
• Head of pancreas
• Duodenum distal to major duodenal papilla
Inferior pancreatoduodenal a • 1st branch of SMA
• Bifurcates into posterior and anterior aa.
• Forms anastomosis with superior pancreatoduodenal aa.
The initial branches of the superior mesenteric artery distribute to the pancreas and the
portion of the duodenum derived from the midgut. These inferior pancreaticoduodenal
arteries, which are difficult to dissect, anastomose with superior branches derived from
the gastroduodenal artery. The anastomosis between these arteries represents an
anastomosis between the blood supply of the foregut and the blood supply of the midgut.

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 Superior Mesenteric Artery (SMA): Branches
ARTERY ORIGIN ORGANS SUPPLIED
Intestinal (jejunal and ileal) aa. SMA Jejunum and ileum via arcades and vasa recta

The SMA courses between the layers of mesentery and forms many intestinal
branches that supply the jejunum and ileum. Near the walls of these organs, the
arteries anastomose to form loops called arterial arcades. Branches from the arcades
form straight arteries called vasa recta that course to the wall of the organ. The arcade
and vasa recta anatomy is slightly different in the jejunum as compared to the ileum.
• In the proximal jejunum, the vasa recta are long, and the arterial arcades are few.
• In the distal ileum, the vasa recta are short and arterial arcades are abundant.

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 Superior Mesenteric Artery (SMA): Branches

ARTERY ORIGIN ORGANS SUPPLIED

Ileocolic a. SMA Cecum, ileum, appendix
Right colic a. SMA Ascending colon
Middle colic a. SMA Proximal 2/3 of transverse colon
Forms anastomosis along margin of colon between ileocolic, right colic,
middle colic, and left colic
Marginal a. Forms anastomosis with IMA at left colic (splenic) flexure between middle
Drummond SMA and IMA colic a. (SMA branch) and left colic a. (IMA) branch

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 Splenic Flexure Watershed Area

A watershed area is terminology that refers to a region of the body that receives a
blood supply from two different vessels.
• A watershed area can be protected from ischemia if a blockage occurs in one of the
vessels, but adequate flow is maintained in the other vessel.
• Watershed areas are vulnerable to ischemia if hypoperfusion occurs in both vessels,
which can occur from a variety of conditions, such as hypotension, heart failure,
vasoconstrictive drug use, sickle cell disease, or atherosclerosis. Since both vessels
are the most distal segments of their vascular pathways, a decrease in the vessel’s
blood flow will result in inadequate perfusion to the site of anastomosis.

The splenic flexure is an important watershed area that is susceptible to ischemic colitis
from either an occlusive or non-occlusive hypoperfusion.
 Inferior Mesenteric Artery (IMA): Branches
ARTERY ORIGIN ORGANS SUPPLIED
Left colic a. IMA Last 1/3 of transverse colon and descending colon
Sigmoid a. IMA Sigmoid colon
Superior rectal a. IMA Upper rectum
Forms anastomosis along margin of colon between ileocolic, right colic, middle
Marginal a. (of Drummond) SMA and IMA colic, and left colic
Arc of Riolan SMA and IMA Forms anastomosis between left colic and middle colic at splenic flexure

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 Tributaries of the Hepatic Portal Vein
All of the following veins drain into the hepatic portal vein.
VEIN DRAINS INTO ORGANS DRAINED
Splenic v Joins superior mesenteric vein to form hepatic portal v. Last 1/3 of transverse colon and descending colon
Superior mesenteric v.. Joins splenic vein to form hepatic portal v. Midgut and part of foregut (greater curvature of stomach via greater omental veins)
Inferior mesenteric v. Splenic vein (sometimes SMA) Hindgut including proximal third of rectum
Gastric veins (left and right) Hepatic portal v. Lesser curvature of stomach

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 Review: Portacaval Anastomosis
• Hepatic portal venous system refers to the ”nutrient-rich” venous blood that is transported from the foregut, midgut, and hindgut to the liver.
• Caval (venous) system refers to veins from the lower limbs, pelvis, and posterior abdominal wall that transport venous blood directly to the inferior vena cava.
• A portacaval anastomosis is a junction between areas drained by BOTH the portal and caval systems. The clinically important portal-caval anastomoses include
the following junctions. In severe cases of portal hypertension, these regions become engorged with blood.
• Anterior abdominal wall (Figure = Letter C): Results in caput medusae
• Superficial epigastric veins (skin around umbilicus) à paraumbilical veins à hepatic portal
• Superficial epigastric veins (skin around umbilicus) à epigastric veins à venous circulation
• Distal esophagus (Figure = Letter A): Results in esophageal varices
• Esophagus à azygos vein à superior vena cava
• Esophagus à left gastric v.à hepatic portal v.
• Rectum (Figure = Letter B): Results in internal hemorrhoids
• Superior rectal v. à portal circulation
• Middle and inferior rectal v. à inferior vena cava
 Rectum
The rectum is the portion of the digestive tract located within the pelvic cavity. It is the segment of large intestine between the sigmoid colon proximally,
and the anal canal distally.
• The rectosigmoid junction is located anterior to the S3 vertebra.
• The anorectal junction is located at approximately the top of the coccyx. In this location, the puborectalis muscle wraps around the anorectal junction
causing the lumen to be pulled into an 80° angle. The puborectalis muscle is innervated by perineal nerve branch of the pudendal nerve.
• The rectal ampulla is the dilated distal portion of the rectum.
• Transverse rectal folds are located along the wall of the rectum. These folds function to slow down the movement of feces toward the anal canal.

FUNCTIONAL ANATOMY: The 80° (approximately) anorectal flexure is an important mechanism for fecal continence, being maintained during the resting state
by the tonus of the puborectalis muscle, and by its active contraction during peristaltic contractions if defecation is not to occur.

Rectal
Ampulla
 Anal Canal

The anal canal is approximately 4 cm long and is divided into an upper and
lower canal by the pectinate line.
• The upper anal canal extends from the anorectal junction to the
pectinate line. The following structures are associated with the upper
anal canal.
• The mucosa consists of folds called anal columns (of Morgagni).
• Anal columns are continuous with each other at their inferior
ends to form anal valves.
• The space just superior to each valve is an anal sinus. Parasympathetic innervation
Pelvic Splanchnic (S2-S4)
• Collectively, the anal valves form a circle around the anal canal,
which defines the pectinate line. The pectinate line divides the
nerve and blood supply to, and the lymphatic drainage from, the Somatic innervation
Inferior rectal n. branch
proximal and distal parts of the anal canal. of pudendal n. (S2-S4)
• The lower anal canal extends from the pectineal line to the
anocutaneous line. This junction represents the location where
stratified squamous epithelium transitions to keratinized stratified
Anocutaneous line
squamous epithelium. Pectinate line (yellow)

FUNTIONAL ANATOMY: The anal sinuses contain glands that exude mucus when compressed by feces. This mucus aids in evacuation of feces from the anal canal.

The anal canal is surrounded by muscle.

• The internal anal sphincter consists of smooth muscle surrounding the superior two-thirds of the anal canal. The smooth muscle of the internal anal sphincter
is a thickened region of the muscularis externa’s circular layer that is continuous throughout the GI tract. This muscle is controlled by the parasympathetic
nervous system and is contracted most of the time, but relaxes during defecation.
• The external anal sphincter consists of skeletal muscle surrounding the inferior two-thirds of the anal canal. The skeletal muscle of the external anal sphincter
blends superiorly with the puborectalis muscle. This muscle is controlled voluntarily by the somatic nervous system. Voluntary relaxation results in defecation.
Summary of Anal Canal Innervation, Arterial Supply, and Lymph and Venous Drainage
Rectum & Upper Anal Canal
Arterial Supply:
Inferior mesenteric a. àSuperior rectal a.
Venous Drainage:
à Superior rectal v.à inferior mesenteric v. àhepatic portal v. (internal hemorrhoids: no pain)
Parasympathetic Innervation (Visceral motor) = Motor to internal anal sphincter
• Pelvic splanchnic n. (S2-S4) àInferior hypogastric plexus à ganglia wall of organ
Sympathetic Innervation = Vasomotor
• Lateral horn (T12-L2) àLeast/lumbar splanchnic (T12-L2)àpreaortic ganglia à hypogastric plexuses
Rectum &
Visceral sensory innervation
• Neurons course alongside parasympathetic pelvic splanchnic neurons to spinal cord S2-S4 Upper
Anal Canal
Lymph Drainage
• àinternal iliac lymph nodes
Pectinate Line

Lower Anal Canal

Lower
Arterial Supply: Anal Canal
• Internal iliac a. à Internal pudendal a. àInferior rectal a.
Venous Drainage:
• à Inferior rectal v. à internal pudendal v. à internal iliac v. à IVC (external hemorrhoids: painful)
Somatic Motor (motor to external anal sphincter)
• Ventral horn S2-S4àpudendal nà inferior rectal n
Somatic Sensory
• Neurons course within inferior rectal n.à pudendal n.à dorsal horn spinal cord S2-S4
Sympathetic Innervation (vasomotor)
• Lateral Horn Lumbar Region à Paravertebral ganglia S2-S4 Vertebral Level àpudendal nà inferior rectal n
Lymph Drainage:
• àSuperficial inguinal lymph nodes
 Hemorrhoids

CLINICAL ANATOMY: Hemorrhoids are varicosities in the rectal veins.

• Internal hemorrhoids are varicosities of superior rectal veins above the pectinate line that prolapse into the lumen of the anal
canal. Internal hemorrhoids may also prolapse through the anus. Because the mucosa above the pectinate line is derived from
endoderm and, therefore, is innervated by autonomic fibers, there is no pain associated with internal hemorrhoids.
• External hemorrhoids are varicosities of the inferior rectal veins that typically result from the presence of thromboses within
them. External hemorrhoids are located in the superficial fascia around the anus. Because this region of the anal canal is derived
from somatic tissues and is innervated by somatic nerves, significant pain is associated with external hemorrhoids.

Superior
rectal v.

Inferior
rectal v.
Pelvic Ligaments, Osseous Features, & Spaces

Review the following osseous features, ligaments,

and spaces of the pelvis.
• Inguinal ligament
• Lacunar ligament
• Ischial spine
• Ischial tuberosity
• Sacrospinous ligament
• Sacrotuberous ligament
• Greater sciatic foramen
• Lesser sciatic foramen
• Obturator foramen
• Obturator membrane
 Pelvic Cavity Boundaries
Because the distal end of the digestive tract passes through the pelvis, it is important to have a basic understanding of the pelvic cavity.
• Lateral walls: obturator internus muscle: The obturator interns muscle inserts on the internal surface of the obturator membrane and passes through the
lesser sciatic foramen to insert on the greater trochanter of the femur. Within the pelvis, the obturator internus muscle is covered in thick fascia called the
obturator fascia.
• Posterior walls: piriformis muscle: The proximal attachment of the piriformis muscle is on the anterior aspects of the S2-4 vertebral segments and passes
through the greater sciatic foramen to its distal attachment on the greater trochanter of the femur.
• Floor: The pelvic diaphragm (pelvic floor) is a funnel-shaped, muscular structure that supports pelvic organs, including the rectum. It consists of the
the levator ani and the coccygeus (ishiococcygeus) muscles.
• The levator ani muscle is composed of 3 muscles: puborectalis, pubococcygeus, and iliococcygeus. The most important muscle in this unit is the
puborectalis muscle because it forms a U-shaped muscular “sling” around the rectum.
• The coccygeus muscle's superior border is adjacent to the inferior border of the piriformis muscle. Its origin is on the ischial spine and the pelvic surface
of the sacrospinous ligament. It inserts onto the lateral margin of coccyx and the most inferior portion of sacrum.
 Perineum
The perineum is the anatomical term for the region of the body wall located inferior to the pelvic diaphragm. The perineum is the diamond-shaped
region of the body wall inferior to the pelvic diaphragm between the buttocks and thighs.
• Anterior: inferior border of pubic symphysis
• Anteriolateral margin: ischiopubic ramus
• Posteriolateral margin: sacrotuberous ligament
• Posterior: tip of coccyx

The diamond-shaped perineum can be further subdivided into two triangular regions by an imaginary line connecting the two ischial tuberosities.
• The anal triangle contains the anus and the ischioanal fossa. The ischioanal fossae are large fat-filled spaces on either side of the anal canal.
• The urogenital triangle contains the external genitalia.

Ischioanal Fossa
 Ischio-anal Fossa

CLINICAL ANATOMY: The ischio-anal fossae are filled with fat that is continuous with the fat of the
subcutaneous fascia. Infections within the ischio-anal fossae (ischio-anal abscesses) are quite painful
and are indicated by fullness and tenderness between the anus and the ischial tuberosity.
 Anal Fistulas and Fissures

CLINICAL ANATOMY: Anal fistula versus anal fissure

• An anal fissure is a short longitudinal tear in the anal mucosa. They may be restricted to the epithelium of the mucosa or involve the entire thickness
of the mucosa. Anal fissures are commonly caused by hard stools as they pass through the lower anal canal. Physiological changes, such as
hypertonicity and hypertrophy of the internal anal sphincter can occur in response to anal fissures. Constipation and hypertrophy of the internal
sphincter leads to increased pressure within the anal canal, which compresses the stool against the epithelium making the pain worse with each
bowel movement.
• A peri-anal fistula is a communication between the anal canal and the perianal skin. They often occur secondary to a perianal abscess that develops a
drainage tunnel to the perianal skin.
 Summary of Abdominal/Inguinal Innervations

Summary of the innervation of the abdomen and inguinal region

Visceral motor innervation of the abdomen
NERVE COMPONENT(S) MAJOR DISTRIBUTION Pre-fiber cell Post-fiber cell bodies Post-fiber axon Organs
Pre-fiber axon
Intercostals (T7-T11) GSA skin of the abdominal wall bodies (synapse) location innervated
Subcostal (T12) Exits sympathetic foregut
Iliohypogastric (L1) GSE muscles of the anterior abdominal wall T5-T9 travels with branches
chain as greater celiac ganglia suprarenal
spinal levels of celiac trunk
splanchnic medulla
GSA skin of medial thigh, scrotum/labia majora
Ilioinguinal (L1) Exits sympathetic
T10-11
GSE muscles of the anterior abdominal wall chain as lesser

Sympathetic
spinal levels travels with branches midgut
splanchnic superior mesenteric,
GSA scrotum/labia majora
of superior mesenteric kidney
Genital branch of Exits sympathetic renal ganglia
T12 and renal arteries ureter
genitofemoral chain as least
GSE cremaster muscle spinal level
splanchnic
Muscular branches of Exits sympathetic travels with branches
GSE muscles of posterior abdominal wall L1-L2 inferior mesenteric hindgut
lumbar plexus chain from L1-L5 as of inferior mesenteric
spinal levels ganglia ureter
lumbar splanchnics a.
GVA pain/sensation from foregut organs
Greater splanchnic abdominal ganglia (on foregut
GVE sympathetic foregut organs, suprarenal medulla brain vagus nerve on organ
organ) midgut

sympathetic
GVA pain/sensation from midgut organs, kidney, ureter
Lesser and least S2-S4 abdominal ganglia

Para-
splanchnics pelvic splanchnics on organ hindgut
GVE sympathetic midgut organs, kidney, ureter spinal levels (on organ)

GVA pain/sensation from hindgut organs, ureter

Lumbar splanchnics
GVE sympathetic hindgut organs, ureter

GVA pain/sensation from foregut and midgut organs Key of Acronyms:

Vagus
GVE parasympathetic foregut and midgut organs
• GSA = General Somatic Afferent Neurons
• GSE = General Somatic Efferent Neurons
GVA pain/sensation from hindgut organs
Pelvic splanchnics • GVA = General Visceral Afferent Neurons
GVE parasympathetic hindgut organs
• GVE = General Visceral Efferent Neurons
 Summary of Abdominal Blood Supply

ARTERY ORIGIN MAJOR STRUCTURES SUPPLIED

Superior epigastric Internal thoracic artery abdominal wall

Inferior epigastric External iliac artery abdominal wall

Intercostals/lumbar Abdominal aorta abdominal wall

Gonadal Abdominal aorta testis and ovary

Celiac Abdominal aorta foregut organs

Superior mesenteric Abdominal aorta midgut organs

Inferior mesenteric Abdominal aorta hindgut organs

Renal Abdominal aorta kidney

Suprarenal Inferior phrenic, aorta, and

suprarenal gland
(superior, middle, inferior) renal arteries respectively