The rectum

Dr. Haider Abdulridha Baqer

 Surgical anatomy

❑The rectum begins where the tinea coli of the

sigmoid colon join to form a continuous outer
longitudinal muscle layer at the level of the sacral
promontory.
❑The rectum follows the curve of the sacrum and
ends at the anorectal junction.
 Surgical anatomy

❑The adult rectum is approximately 12–18 cm in length and is

conventionally divided into three equal parts:
❑the upper third, which is mobile and has a peritoneal covering
anteriorly and laterally;
❑the middle third, where the peritoneum covers only the anterior
and part of the lateral surfaces; and
❑the lowest third, which lies deep in the pelvis below the peritoneal
refection.
Blood supply
The blood supply consists of superior, middle and inferior rectal
vessels.
The superior rectal artery is the direct continuation of the inferior
mesenteric artery and is the main arterial supply of the rectum.
The middle rectal artery arises on each side from the internal iliac
artery and passes to the rectum in the lateral ligaments.
The inferior rectal artery arises on each side from the internal
pudendal artery as it enters Alcock’s canal.
 Blood
supply to
the rectum.
Venous drainage

❑The superior haemorrhoidal veins draining the upper half of the

anal canal above the dentate line pass upwards to become the
rectal veins; these unite to form the superior rectal vein, which
later becomes the inferior mesenteric vein.
❑This forms part of the portal venous system and ultimately drains
into the splenic vein.
❑Middle rectal veins exist but are small, unimportant channels
unless the normal paths are blocked.
Lymphatic drainage

❑The lymphatics of the rectal mucosa communicate freely with those of the
muscle layers. The usual drainage flow is upwards, and only to a limited
extent laterally and downwards.
❑For this reason, surgical clearance of malignant disease concentrates mainly
on achieving wide resection of proximal lymph nodes.
❑However, if the usual upward routes are blocked, for example by metastatic
disease, the flow can reverse and it is possible to find involved lymph nodes
on the side walls of the pelvis (along the middle rectal vessels) or even in the
inguinal region (along the inferior rectal artery).
Main symptoms of rectal disease
Bleeding;

• This is often painless and bright red in colour and should be

carefully investigated at any age.

Altered bowel habit;

• Early morning stool frequency (spurious diarrhoea) is a

symptom of rectal carcinoma, while bloodstained, frequent,
loose stools characterise the inflammatory diseases.
Main symptoms of rectal disease
Discharge;

• Mucus and pus are associated with rectal inflammation.

Tenesmus;

• Often described by the patient as ‘I feel I want to go but nothing

happens’, this is normally an ominous symptom of rectal cancer,
but can occur with other rectal conditions and is a common
symptom of rectal prolapse.
Main symptoms of rectal disease
Prolapse;

• This usually indicates either mucosal or full thickness rectal wall

protrusion from the anus. Internal prolapse or intussusception refers to
a telescoping of the rectum into itself without protrusion from the anus.

Pain: ‘proctalgia’

• This is usually a severe and episodic pain resulting from spasm of the
levator ani muscle. It may last for a few seconds to minutes then recur,
or it can be constant
Examination of the rectum

Visual inspection of the perineum

Digital examination
Proctoscopy
Sigmoidoscopy – rigid and/ or flexible
INJURIES
❑The rectum or anal canal may be injured in a number of
ways, all of which are uncommon:
1. by falling in a sitting posture onto a pointed object;
2. penetrating injury (including gunshots) to the buttocks;
3. sexual assault or sexual activity involving anal penetration;
4. by the fetal head during childbirth, especially forceps
assisted.
Diagnosis
⮚The anus should be inspected and the abdomen palpated.
⮚If abdominal rigidity or tenderness is present, early
laparoscopy or laparotomy is indicated.
⮚A water-soluble contrast enema may help in delineating the
injury, but a computed tomography (CT) scan is often
preferred and will provide additional information on other
pelvic injuries, such as accompanying urethral injury.
Treatment
⮚The rectum is examined under general anaesthetic with a finger and
a sigmoidoscope.
⮚ If penetrating injury is confirmed, laparotomy or laparoscopy is
required.
⮚If an intraperitoneal rupture of the rectum is found, the perforation is
closed with sutures and the rectum defunctioned with a stoma.
⮚The defunctioned distal segment should be irrigated to remove all
residual faecal matter.
Treatment
⮚In the event that the rectal injury cannot be repaired, a Hartmann’s
procedure may be needed.
⮚If the rectal injury is below the peritoneal reflection, wide drainage
from below is indicated, with rectal washout and a defunctioning
colostomy.
⮚Care must be taken to preserve or restore anal sphincter integrity
during debridement of the perineal wounds.
⮚Antibiotic cover must be provided against both aerobic and
anaerobic organisms.
Rectal prolapse
⮚It may be mucosal or full thickness
⮚If full thickness, the whole wall of the rectum is included
⮚It may begin as a rectal intussusception (internal rectal prolapse)
⮚In children, the prolapse is usually mucosal and should be treated
conservatively
⮚In adults, the prolapse is often full thickness and is frequently associated
with constipation and incontinence
⮚Surgery is almost always necessary for full-thickness rectal prolapse
⮚The operation is performed either via the perineum or via the abdomen
 Proctitis

⮚May be non-specific or related to a specific infective agent

⮚Non-specific proctitis usually remains confined to the distal bowel but can
involve the proximal colon
⮚Symptoms include defecatory frequency, loose stools, bleeding and
tenesmus
⮚Endoscopic assessment with biopsy is required to establish the diagnosis
⮚Treatment usually involves medical management
 Polyps in the rectum

⮚Adenomas are the most frequent histological type

⮚Villous adenomas may be extensive and undergo malignant change
more commonly than tubular adenomas
⮚All adenomas must be removed to avoid malignant change
⮚All patients must undergo colonoscopy to determine whether
further polyps are present
⮚Most polyps can be removed by endoscopic techniques, but
sometimes major surgery is required
CARCINOMAS

❑Globally, colorectal cancer is the second most common malignancy, being the
second most common cancer in women and the third most common cancer in
men.
❑It is the fourth most common cause of cancer death after lung, gastric and
liver cancer.
❑In western countries the incidence is rising, with an overall 14% increase since
the 1970s, with the largest increase (20%) seen in males.
CARCINOMAS

❑Risk factors include diet, obesity, smoking and lack of physical

exercise.
❑Most colorectal cancers are due to old age, with around 60% of
cases affecting patients 70 years or older.
❑The rectum is the most frequently involved site, accounting for
approximately one-third of the cancers.
Clinical features

⮚Carcinoma of the rectum can occur early in life, but the age of
presentation is usually above 55 years, when the incidence rises
rapidly.
⮚Often, the early symptoms are so insignificant that the patient does
not seek advice for 6 months or more, and the diagnosis is often
delayed in younger patients as the symptoms are attributed to
benign causes.
⮚Initial rectal examination and a low threshold for investigating
persistent symptoms are essential.
Early symptoms of rectal cancer

Bleeding per rectum

Tenesmus

Early morning diarrhoea

Bleeding
❑Bleeding is the earliest and most common symptom.
❑Typically, the bleeding is bright red in colour and painless.
❑It can be mixed with the motions or separate in the toilet
bowel.
❑It can be indistinguishable from haemorrhoidal bleeding, which
is the most common differential diagnosis, particularly in
younger patients.
Tenesmus
❑The patient experiences a sensation of needing to evacuate the
rectum but is unable to pass a motion.
❑This is an important early symptom and is almost invariably
present in patients with tumours of the lower half of the
rectum.
❑The patient may endeavour to empty the rectum several times
a day (spurious diarrhoea), often with the passage of flatus and
a little bloodstained mucus (‘bloody slime’).
Alteration in bowel habit

❑There is frequently a change in bowel habit, with a tendency to more

frequent defecation and the passage of looser stool.
❑A patient who has to get up early in order to defecate, or one who passes
blood and mucus in addition to faeces (‘early morning bloody diarrhoea’),
is usually found to have carcinoma of the rectum.
❑Although a change to looser stools is more common, patients with a
stenosing carcinoma at the rectosigmoid junction may complain of
increasing constipation.
Late symptoms

Pain;
⮚Pain is a late symptom, but pain of a colicky character may accompany
advanced tumours of the rectosigmoid, owing to a degree of obstruction.
⮚Advanced cancers invading outside the mesorectum may infiltrate the
prostate or bladder anteriorly or the sacral plexus posteriorly, giving rise
to severe, intractable pain.
Weight loss;
⮚Weight loss is also a late symptom and is almost always associated with
metastatic disease.
Diagnosis and assessment of rectal
cancer

All patients with suspected rectal cancer should undergo:

• Digital rectal examination
• Full colorectal visualisation, preferably by colonoscopy with biopsy or CT
colonography or barium enema

All patients with proven rectal cancer require staging by:

• Imaging of the chest, abdomen and pelvis, preferably by CT
• Local pelvic imaging by magnetic resonance imaging (MRI) and/or endoluminal
ultrasonography
Colonoscopy
A colonoscopy is required in most patients to exclude a synchronous
tumour, be it an adenoma or carcinoma.

If a proximal adenoma is found, it can be conveniently snared and

removed via the colonoscope.

If a synchronous carcinoma is present, the operative strategy is likely to

change.

If a full colonoscopy is not possible, for example when there is a stenosing

cancer, a CT colonography or barium enema can be performed.
Types of carcinoma spread

Local spread

Lymphatic spread

Venous spread

Peritoneal dissemination
Local spread

❑Local spread occurs circumferentially rather than in a longitudinal

direction.
❑If penetration occurs anteriorly, the prostate, seminal vesicles or
bladder become involved in the male; in the female, the vagina or
the uterus is invaded.
❑In either sex, if the penetration is lateral, a ureter may become
involved, while posterior penetration may reach the sacrum and
the sacral plexus.
Lymphatic spread

❑Lymphatic spread from a carcinoma of the rectum above the peritoneal

refection occurs almost exclusively in an upward direction.
❑Below that level, the lymphatic spread is still upwards, but when the
neoplasm lies within the field of the middle rectal artery, primary lateral
spread to the pelvic wall lymphatics occurs in around 20% of cases.
❑Downward spread is exceptional, with drainage along the subcutaneous
lymphatics to the groins being confined, for practical purposes, to the lymph
nodes draining the perianal rosette and the epithelial lining of the distal 1–
2 cm of the anal canal.
Venous spread & Peritoneal
dissemination

Venous spread;
⮚The principal sites for bloodborne metastases are liver (34%), lungs (22%) and
adrenals (11%).
⮚The remaining 33% are divided among the many other locations where
secondary carcinomatous deposits tend to lodge, including the brain.
Peritoneal dissemination;
⮚This may follow penetration of the peritoneal coat by a high-lying rectal
carcinoma.
Dukes’ staging
⮚A: The growth is limited to the rectal wall (15%). The
prognosis is excellent (>90% 5-year survival).
⮚B: The growth extends to the extrarectal tissues, but
without metastasis to the regional lymph nodes (35%). The
prognosis is reasonable (70% 5-year survival).
⮚C: There are secondary deposits in the regional lymph nodes
(50%). The prognosis is poor (40% 5-year survival). These are
subdivided into;
Dukes’ staging
⮚C1, in which the local pararectal lymph nodes alone are involved,
and
⮚C2, in which the nodes accompanying the supplying blood vessels to
their origin from the aorta are involved.
❑This does not take into account cases that have metastasised beyond
the regional lymph nodes or by way of the venous system.
❑A stage D is often included, which was not described by Dukes. This
stage signifies the presence of widespread metastases, usually
hepatic.
Radiological staging
❑All patients with a diagnosis of rectal cancer should
undergo staging CT of the thorax, abdomen and pelvis
(TAP) to stage both local and metastatic disease.
❑Positron emission tomography (PET) scanning can be
helpful in identifying metastases if imaging is
otherwise equivocal or to identify multiple metastatic
foci.
Radiological staging
❑MRI is the best modality to assess soft tissue extent
of the tumour, the degree of infiltration of the
mesorectum and mesorectal lymph node involvement
and to ascertain whether the mesorectal fascia is
potentially involved.
❑These determinations are of great importance in
guiding both surgical and oncological management.
 Treatment
❑Surgical excision of the tumour is the conventional treatment,
provided this can be achieved with clear oncological margins
and acceptable risk of morbidity and mortality.
❑Before treatment can be planned, it is necessary to assess both
the fitness of the patient and the extent of spread of the
tumour.
❑The management needs to be discussed within a
multidisciplinary team (MDT) setting involving surgeons,
radiologists, oncologists, pathologists and specialty nurses.