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Large intestine

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From Wikipedia, the free encyclopedia
(Redirected from Rectosigmoid colon)
Large intestine
Gray1223.png
Front of abdomen, showing surface markings for the liver (red), and the stomach and
large intestine (blue). The large intestine is like an upside down U.
Details
Part of Gastrointestinal tract
System Digestive system
Artery Superior mesenteric, inferior mesenteric and iliac arteries
Vein Superior and inferior mesenteric vein
Lymph Inferior mesenteric lymph nodes
Identifiers
Latin Colon or intestinum crassum
MeSH D007420
TA98 A05.7.01.001
TA2 2963
FMA 7201
Anatomical terminology
[edit on Wikidata]
Stomach colon rectum diagram-en.svg
Major parts of the
Gastrointestinal tract
Upper gastrointestinal tract
Lower gastrointestinal tract
See also
vte
The large intestine, also known as the large bowel, is the last part of the
gastrointestinal tract and of the digestive system in tetrapods. Water is absorbed
here and the remaining waste material is stored in the rectum as feces before being
removed by defecation.[1] The colon is the longest portion of the large intestine,
and the terms are often used interchangeably but most sources define the large
intestine as the combination of the cecum, colon, rectum, and anal canal.[1][2][3]
Some other sources exclude the anal canal.[4][5][6]

In humans, the large intestine begins in the right iliac region of the pelvis, just
at or below the waist, where it is joined to the end of the small intestine at the
cecum, via the ileocecal valve. It then continues as the colon ascending the
abdomen, across the width of the abdominal cavity as the transverse colon, and then
descending to the rectum and its endpoint at the anal canal.[7] Overall, in humans,
the large intestine is about 1.5 metres (5 ft) long, which is about one-fifth of
the whole length of the human gastrointestinal tract.[8]

Structure
Main article: Digestion

Illustration of the large intestine.

The colon of the large intestine is the last part of the digestive system. It has a
segmented appearance due to a series of saccules called haustra.[9] It extracts
water and salt from solid wastes before they are eliminated from the body and is
the site in which the fermentation of unabsorbed material by the gut microbiota
occurs. Unlike the small intestine, the colon does not play a major role in
absorption of foods and nutrients. About 1.5 litres or 45 ounces of water arrives
in the colon each day.[10]

The colon is the longest part of the large intestine and its average length in the
adult human is 65 inches or 166 cm (range of 80 to 313 cm) for males, and 61 inches
or 155 cm (range of 80 to 214 cm) for females.[11]

Sections

Inner diameters of colon sections

In mammals, the large intestine consists of the cecum (including the appendix),
colon (the longest part), rectum, and anal canal.[1]

The four sections of the colon are: the ascending colon, transverse colon,
descending colon, and sigmoid colon. These sections turn at the colic flexures.

The parts of the colon are either intraperitoneal or behind it in the

retroperitoneum. Retroperitoneal organs, in general, do not have a complete
covering of peritoneum, so they are fixed in location. Intraperitoneal organs are
completely surrounded by peritoneum and are therefore mobile.[12] Of the colon, the
ascending colon, descending colon and rectum are retroperitoneal, while the cecum,
appendix, transverse colon and sigmoid colon are intraperitoneal.[13] This is
important as it affects which organs can be easily accessed during surgery, such as
a laparotomy.

In terms of diameter, the cecum is the widest, averaging slightly less than 9 cm in
healthy individuals, and the transverse colon averages less than 6 cm in diameter.
[14] The descending and sigmoid colon are slightly smaller, with the sigmoid colon
averaging 4–5 cm (1.6–2.0 in) in diameter.[14][15] Diameters larger than certain
thresholds for each colonic section can be diagnostic for megacolon.
3D File generated from computed tomography of large intestine
Cecum and appendix
The cecum is the first section of the large intestine and is involved in digestion,
while the appendix which develops embryologically from it, is not involved in
digestion and is considered to be part of the gut-associated lymphoid tissue. The
function of the appendix is uncertain, but some sources believe that it has a role
in housing a sample of the gut microbiota, and is able to help to repopulate the
colon with microbiota if depleted during the course of an immune reaction. The
appendix has also been shown to have a high concentration of lymphatic cells.

Ascending colon
The ascending colon is the first of four main sections of the large intestine. It
is connected to the small intestine by a section of bowel called the cecum. The
ascending colon runs upwards through the abdominal cavity toward the transverse
colon for approximately eight inches (20 cm).

One of the main functions of the colon is to remove the water and other key
nutrients from waste material and recycle it. As the waste material exits the small
intestine through the ileocecal valve, it will move into the cecum and then to the
ascending colon where this process of extraction starts. The waste material is
pumped upwards toward the transverse colon by peristalsis. The ascending colon is
sometimes attached to the appendix via Gerlach's valve. In ruminants, the ascending
colon is known as the spiral colon.[16][17][18] Taking into account all ages and
sexes, colon cancer occurs here most often (41%).[19]

Transverse colon
The transverse colon is the part of the colon from the hepatic flexure, also known
as the right colic, (the turn of the colon by the liver) to the splenic flexure
also known as the left colic, (the turn of the colon by the spleen). The transverse
colon hangs off the stomach, attached to it by a large fold of peritoneum called
the greater omentum. On the posterior side, the transverse colon is connected to
the posterior abdominal wall by a mesentery known as the transverse mesocolon.

The transverse colon is encased in peritoneum, and is therefore mobile (unlike the
parts of the colon immediately before and after it).

The proximal two-thirds of the transverse colon is perfused by the middle colic
artery, a branch of the superior mesenteric artery (SMA), while the latter third is
supplied by branches of the inferior mesenteric artery (IMA). The "watershed" area
between these two blood supplies, which represents the embryologic division between
the midgut and hindgut, is an area sensitive to ischemia.

Descending colon
The descending colon is the part of the colon from the splenic flexure to the
beginning of the sigmoid colon. One function of the descending colon in the
digestive system is to store feces that will be emptied into the rectum. It is
retroperitoneal in two-thirds of humans. In the other third, it has a (usually
short) mesentery.[20] The arterial supply comes via the left colic artery. The
descending colon is also called the distal gut, as it is further along the
gastrointestinal tract than the proximal gut. Gut flora are very dense in this
region.

Sigmoid colon
The sigmoid colon is the part of the large intestine after the descending colon and
before the rectum. The name sigmoid means S-shaped (see sigmoid; cf. sigmoid
sinus). The walls of the sigmoid colon are muscular and contract to increase the
pressure inside the colon, causing the stool to move into the rectum.
The sigmoid colon is supplied with blood from several branches (usually between 2
and 6) of the sigmoid arteries, a branch of the IMA. The IMA terminates as the
superior rectal artery.

Sigmoidoscopy is a common diagnostic technique used to examine the sigmoid colon.

Rectum
The rectum is the last section of the large intestine. It holds the formed feces
awaiting elimination via defecation. It is about 12 cm long.[21]

Appearance
The cecum – the first part of the large intestine

Taeniae coli – three bands of smooth muscle

Haustra – bulges caused by contraction of taeniae coli
Epiploic appendages – small fat accumulations on the viscera
The taenia coli run the length of the large intestine. Because the taenia coli are
shorter than the large bowel itself, the colon becomes sacculated, forming the
haustra of the colon which are the shelf-like intraluminal projections.[22]

Blood supply
Arterial supply to the colon comes from branches of the superior mesenteric artery
(SMA) and inferior mesenteric artery (IMA). Flow between these two systems
communicates via the marginal artery of the colon that runs parallel to the colon
for its entire length. Historically, a structure variously identified as the arc of
Riolan or meandering mesenteric artery (of Moskowitz) was thought to connect the
proximal SMA to the proximal IMA. This variably present structure would be
important if either vessel were occluded. However, at least one review of the
literature questions the existence of this vessel, with some experts calling for
the abolition of these terms from future medical literature.[23]

Venous drainage usually mirrors colonic arterial supply, with the inferior
mesenteric vein draining into the splenic vein, and the superior mesenteric vein
joining the splenic vein to form the hepatic portal vein that then enters the
liver.

Lymphatic drainage
Lymphatic drainage from the ascending colon and proximal two-thirds of the
transverse colon is to the ileocolic lymph nodes and the superior mesenteric lymph
nodes, which drain into the cisterna chyli.[24] The lymph from the distal one-third
of the transverse colon, the descending colon, the sigmoid colon, and the upper
rectum drain into the inferior mesenteric and colic lymph nodes.[24] The lower
rectum to the anal canal above the pectinate line drain to the internal ileocolic
nodes.[25] The anal canal below the pectinate line drains into the superficial
inguinal nodes.[25] The pectinate line only roughly marks this transition.

Nerve supply
Sympathetic supply: superior & inferior mesenteric ganglia; parasympathetic supply:
vagus & pelvic nerves

Development
The endoderm, mesoderm and ectoderm are germ layers that develop in a process
called gastrulation. Gastrulation occurs early in human development. The
gastrointestinal tract is derived from these layers.[26]

See also: Development of the digestive system

[icon]
This section needs expansion. You can help by adding to it. (March 2017)
Variation
One variation on the normal anatomy of the colon occurs when extra loops form,
resulting in a colon that is up to five metres longer than normal. This condition,
referred to as redundant colon, typically has no direct major health consequences,
though rarely volvulus occurs, resulting in obstruction and requiring immediate
medical attention.[27][28] A significant indirect health consequence is that use of
a standard adult colonoscope is difficult and in some cases impossible when a
redundant colon is present, though specialized variants on the instrument
(including the pediatric variant) are useful in overcoming this problem.[29]

Microanatomy
Further information: Gastrointestinal wall
Colonic crypts

Colonic crypts (intestinal glands) within four tissue sections. The cells have been
stained to show a brown-orange color if the cells produce the mitochondrial protein
cytochrome c oxidase subunit I (CCOI), and the nuclei of the cells (located at the
outer edges of the cells lining the walls of the crypts) are stained blue-gray with
haematoxylin. Panels A, B were cut across the long axes of the crypts and panels C,
D were cut parallel to the long axes of the crypts. In panel A the bar shows 100 µm
and allows an estimate of the frequency of crypts in the colonic epithelium. Panel
B includes three crypts in cross-section, each with one segment deficient for CCOI
expression and at least one crypt, on the right side, undergoing fission into two
crypts. Panel C shows, on the left side, a crypt fissioning into two crypts. Panel
D shows typical small clusters of two and three CCOI deficient crypts (the bar
shows 50 µm). The images were made from original photomicrographs, but panels A, B
and D were also included in an article[30] and illustrations were published with
Creative Commons Attribution-Noncommercial License allowing re-use.
The wall of the large intestine is lined with simple columnar epithelium with
invaginations. The invaginations are called the intestinal glands or colonic
crypts.

Micrograph of normal large instestinal crypts.

Micrograph of normal large instestinal crypts.

Anatomy of normal large intestinal crypts

Anatomy of normal large intestinal crypts

The colon crypts are shaped like microscopic thick walled test tubes with a central
hole down the length of the tube (the crypt lumen). Four tissue sections are shown
here, two cut across the long axes of the crypts and two cut parallel to the long
axes. In these images the cells have been stained by immunohistochemistry to show a
brown-orange color if the cells produce a mitochondrial protein called cytochrome c
oxidase subunit I (CCOI). The nuclei of the cells (located at the outer edges of
the cells lining the walls of the crypts) are stained blue-gray with haematoxylin.
As seen in panels C and D, crypts are about 75 to about 110 cells long. Baker et
al.[31] found that the average crypt circumference is 23 cells. Thus, by the images
shown here, there are an average of about 1,725 to 2,530 cells per colonic crypt.
Nooteboom et al.[32] measuring the number of cells in a small number of crypts
reported a range of 1,500 to 4,900 cells per colonic crypt. Cells are produced at
the crypt base and migrate upward along the crypt axis before being shed into the
colonic lumen days later.[31] There are 5 to 6 stem cells at the bases of the
crypts.[31]

As estimated from the image in panel A, there are about 100 colonic crypts per
square millimeter of the colonic epithelium.[33] Since the average length of the
human colon is 160.5 cm[11] and the average inner circumference of the colon is 6.2
cm,[33] the inner surface epithelial area of the human colon has an average area of
about 995 cm2, which includes 9,950,000 (close to 10 million) crypts.
In the four tissue sections shown here, many of the intestinal glands have cells
with a mitochondrial DNA mutation in the CCOI gene and appear mostly white, with
their main color being the blue-gray staining of the nuclei. As seen in panel B, a
portion of the stem cells of three crypts appear to have a mutation in CCOI, so
that 40% to 50% of the cells arising from those stem cells form a white segment in
the cross cut area.

Overall, the percent of crypts deficient for CCOI is less than 1% before age 40,
but then increases linearly with age.[30] Colonic crypts deficient for CCOI in
women reaches, on average, 18% in women and 23% in men by 80–84 years of age.[30]

Crypts of the colon can reproduce by fission, as seen in panel C, where a crypt is
fissioning to form two crypts, and in panel B where at least one crypt appears to
be fissioning. Most crypts deficient in CCOI are in clusters of crypts (clones of
crypts) with two or more CCOI-deficient crypts adjacent to each other (see panel
D).[30]

Mucosa
About 150 of the many thousands of protein coding genes expressed in the large
intestine, some are specific to the mucous membrane in different regions and
include CEACAM7.[34]

Function

Histological section.
The large intestine absorbs water and any remaining absorbable nutrients from the
food before sending the indigestible matter to the rectum. The colon absorbs
vitamins that are created by the colonic bacteria, such as thiamine, riboflavin,
and vitamin K (especially important as the daily ingestion of vitamin K is not
normally enough to maintain adequate blood coagulation).[35][citation needed][36]
It also compacts feces, and stores fecal matter in the rectum until it can be
discharged via the anus in defecation.

The large intestine also secretes K+ and Cl-. Chloride secretion increases in
cystic fibrosis. Recycling of various nutrients takes place in the colon. Examples
include fermentation of carbohydrates, short chain fatty acids, and urea cycling.
[37][citation needed]

The appendix contains a small amount of mucosa-associated lymphoid tissue which

gives the appendix an undetermined role in immunity. However, the appendix is known
to be important in fetal life as it contains endocrine cells that release biogenic
amines and peptide hormones important for homeostasis during early growth and
development.[38]

By the time the chyme has reached this tube, most nutrients and 90% of the water
have been absorbed by the body. At this point some electrolytes like sodium,
magnesium, and chloride are left as well as indigestible parts of ingested food
(e.g., a large part of ingested amylose, starch which has been shielded from
digestion heretofore, and dietary fiber, which is largely indigestible carbohydrate
in either soluble or insoluble form). As the chyme moves through the large
intestine, most of the remaining water is removed, while the chyme is mixed with
mucus and bacteria (known as gut flora), and becomes feces. The ascending colon
receives fecal material as a liquid. The muscles of the colon then move the watery
waste material forward and slowly absorb all the excess water, causing the stools
to gradually solidify as they move along into the descending colon.[39]

The bacteria break down some of the fiber for their own nourishment and create
acetate, propionate, and butyrate as waste products, which in turn are used by the
cell lining of the colon for nourishment.[40] No protein is made available. In
humans, perhaps 10% of the undigested carbohydrate thus becomes available, though
this may vary with diet;[41] in other animals, including other apes and primates,
who have proportionally larger colons, more is made available, thus permitting a
higher portion of plant material in the diet. The large intestine[42] produces no
digestive enzymes — chemical digestion is completed in the small intestine before
the chyme reaches the large intestine. The pH in the colon varies between 5.5 and 7
(slightly acidic to neutral).[43]

Standing gradient osmosis

Water absorption at the colon typically proceeds against a transmucosal osmotic
pressure gradient. The standing gradient osmosis is the reabsorption of water
against the osmotic gradient in the intestines. Cells occupying the intestinal
lining pump sodium ions into the intercellular space, raising the osmolarity of the
intercellular fluid. This hypertonic fluid creates an osmotic pressure that drives
water into the lateral intercellular spaces by osmosis via tight junctions and
adjacent cells, which then in turn moves across the basement membrane and into the
capillaries, while more sodium ions are pumped again into the intercellular fluid.
[44] Although water travels down an osmotic gradient in each individual step,
overall, water usually travels against the osmotic gradient due to the pumping of
sodium ions into the intercellular fluid. This allows the large intestine to absorb
water despite the blood in capillaries being hypotonic compared to the fluid within
the intestinal lumen.

Gut flora
Main article: Gut microbiota
The large intestine houses over 700 species of bacteria that perform a variety of
functions, as well as fungi, protozoa, and archaea. Species diversity varies by
geography and diet.[45] The microbes in a human distal gut often number in the
vicinity of 100 trillion, and can weigh around 200 grams (0.44 pounds). This mass
of mostly symbiotic microbes has recently been called the latest human organ to be
"discovered" or in other words, the "forgotten organ".[46]

The large intestine absorbs some of the products formed by the bacteria inhabiting
this region. Undigested polysaccharides (fiber) are metabolized to short-chain
fatty acids by bacteria in the large intestine and absorbed by passive diffusion.
The bicarbonate that the large intestine secretes helps to neutralize the increased
acidity resulting from the formation of these fatty acids.[47]

These bacteria also produce large amounts of vitamins, especially vitamin K and
biotin (a B vitamin), for absorption into the blood. Although this source of
vitamins, in general, provides only a small part of the daily requirement, it makes
a significant contribution when dietary vitamin intake is low. An individual who
depends on absorption of vitamins formed by bacteria in the large intestine may
become vitamin-deficient if treated with antibiotics that inhibit the vitamin
producing species of bacteria as well as the intended disease-causing bacteria.[48]

Other bacterial products include gas (flatus), which is a mixture of nitrogen and
carbon dioxide, with small amounts of the gases hydrogen, methane, and hydrogen
sulfide. Bacterial fermentation of undigested polysaccharides produces these. Some
of the fecal odor is due to indoles, metabolized from the amino acid tryptophan.
The normal flora is also essential in the development of certain tissues, including
the cecum and lymphatics.[citation needed]

They are also involved in the production of cross-reactive antibodies. These are
antibodies produced by the immune system against the normal flora, that are also
effective against related pathogens, thereby preventing infection or invasion.

The two most prevalent phyla of the colon are Bacillota and Bacteroidota. The ratio
between the two seems to vary widely as reported by the Human Microbiome Project.
[49] Bacteroides are implicated in the initiation of colitis and colon cancer.
Bifidobacteria are also abundant, and are often described as 'friendly bacteria'.
[50][51]

A mucus layer protects the large intestine from attacks from colonic commensal
bacteria.[52]

Clinical significance
Disease
Main article: Gastrointestinal disease
Following are the most common diseases or disorders of the colon:

Angiodysplasia of the colon

Appendicitis
Chronic functional abdominal pain
Colitis
Colorectal cancer
Colorectal polyp
Constipation
Crohn's disease
Diarrhea
Diverticulitis
Diverticulosis
Hirschsprung's disease (aganglionosis)
Ileus
Intussusception
Irritable bowel syndrome
Pseudomembranous colitis
Ulcerative colitis and toxic megacolon
Colonoscopy
Main article: Colonoscopy

Colonoscopy image, splenic flexure,

normal mucosa. You can see spleen through it : the black part
Colonoscopy is the endoscopic examination of the large intestine and the distal
part of the small bowel with a CCD camera or a fiber optic camera on a flexible
tube passed through the anus. It can provide a visual diagnosis (e.g. ulceration,
polyps) and grants the opportunity for biopsy or removal of suspected colorectal
cancer lesions. Colonoscopy can remove polyps as small as one millimetre or less.
Once polyps are removed, they can be studied with the aid of a microscope to
determine if they are precancerous or not. It takes 15 years or less for a polyp to
turn cancerous.

Colonoscopy is similar to sigmoidoscopy—the difference being related to which parts

of the colon each can examine. A colonoscopy allows an examination of the entire
colon (1200–1500 mm in length). A sigmoidoscopy allows an examination of the distal
portion (about 600 mm) of the colon, which may be sufficient because benefits to
cancer survival of colonoscopy have been limited to the detection of lesions in the
distal portion of the colon.[53][54][55]

A sigmoidoscopy is often used as a screening procedure for a full colonoscopy,

often done in conjunction with a stool-based test such as a fecal occult blood test
(FOBT), fecal immunochemical test (FIT), or multi-target stool DNA test (Cologuard)
or blood-based test, SEPT9 DNA methylation test (Epi proColon).[56] About 5% of
these screened patients are referred to colonoscopy.[57]

Virtual colonoscopy, which uses 2D and 3D imagery reconstructed from computed

tomography (CT) scans or from nuclear magnetic resonance (MR) scans, is also
possible, as a totally non-invasive medical test, although it is not standard and
still under investigation regarding its diagnostic abilities. Furthermore, virtual
colonoscopy does not allow for therapeutic maneuvers such as polyp/tumour removal
or biopsy nor visualization of lesions smaller than 5 millimeters. If a growth or
polyp is detected using CT colonography, a standard colonoscopy would still need to
be performed. Additionally, surgeons have lately been using the term pouchoscopy to
refer to a colonoscopy of the ileo-anal pouch.

Other animals
The large intestine is truly distinct only in tetrapods, in which it is almost
always separated from the small intestine by an ileocaecal valve. In most
vertebrates, however, it is a relatively short structure running directly to the
anus, although noticeably wider than the small intestine. Although the caecum is
present in most amniotes, only in mammals does the remainder of the large intestine
develop into a true colon.[58]

In some small mammals, the colon is straight, as it is in other tetrapods, but, in

the majority of mammalian species, it is divided into ascending and descending
portions; a distinct transverse colon is typically present only in primates.
However, the taeniae coli and accompanying haustra are not found in either
carnivorans or ruminants. The rectum of mammals (other than monotremes) is derived
from the cloaca of other vertebrates, and is, therefore, not truly homologous with
the "rectum" found in these species.[58]

In fish, there is no true large intestine, but simply a short rectum connecting the
end of the digestive part of the gut to the cloaca. In sharks, this includes a
rectal gland that secretes salt to help the animal maintain osmotic balance with
the seawater. The gland somewhat resembles a caecum in structure but is not a
homologous structure.[58]

Additional images
Intestines
Intestines

Colon. Deep dissection. Anterior view.

Colon. Deep dissection. Anterior view.

See also
This article uses anatomical terminology.
Large intestine (Chinese medicine)
Colectomy
Colonic ulcer
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09-118h. at Merck Manual of Diagnosis and Therapy Home Edition
vte
Anatomy of the gastrointestinal tract, excluding the mouth
Upper
Pharynx
MusclesSpaces peripharyngeal retropharyngeal parapharyngeal retrovisceral
dangerprevertebralPterygomandibular raphePharyngeal rapheBuccopharyngeal
fasciaPharyngobasilar fasciaPyriform sinus
Esophagus
Sphincters upperlowerglandscrop
Stomach
Curvatures greaterlesserAngular incisureCardiaBodyFundusPylorus
antrumcanalsphincterGastric mucosaGastric foldsMicroanatomy Gastric pitsGastric
glandsCardiac glandsFundic glandsPyloric glandsFoveolar cellParietal cellGastric
chief cellEnterochromaffin-like cell
Lower
Small intestine
Microanatomy
Intestinal villus MicrovillusIntestinal glandEnterocyteEnteroendocrine cellGoblet
cellPaneth cell
Duodenum
Suspensory muscleMajor duodenal papillaMinor duodenal papillaDuodenojejunal
flexureBrunner's glands
Jejunum
No substructures
Ileum
Ileocecal valvePeyer's patchesMicrofold cell
Large intestine
Cecum
Appendix
Colon
Ascending colonHepatic flexureTransverse colonSplenic flexureDescending
colonSigmoid colonContinuous taenia colihaustraepiploic appendix
Rectum
Transverse foldsAmpulla
Anal canal
AnusAnal columnsAnal valvesAnal sinusesPectinate lineInternal anal
sphincterIntersphincteric grooveExternal anal sphincter
Wall
Serosa / AdventitiaSubserosaMuscular layerSubmucosaCircular foldsMucosaMuscularis
mucosa
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Anatomy (1918)Large intestineDigestive systemOrgans (anatomy)
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