Polyp shapes: flat or raised/stalk

 Adenomatous: 50%, small % become cancerous, nearly all began like this.
 Hyperplastic: serrated flat common and low risk of cancer
 Serrated large: typically flat, hard to detect, located in upper colon, precancerous
 Inflammatory: IBD, called pseudopolyps
 Villous Adenoma: 15%, high cancer risk, commonly sessile (diff to remove)

 • Omental appendices: small, fatty, omentum-like pro- jections.

 • Teniae coli: three distinct longitudinal bands: (1) meso- colic tenia, to which the transverse and sigmoid meso- colons attach; (2) omental
tenia, to which the omental appendices attach; and (3) free tenia (L. t. libera), 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).
Cecum and appendix

 The cecum is a blind intestinal pouch, approximately 7.5 cm in both length and breadth. It lies in the iliac fossa of the right lower quadrant of
the abdomen, inferior to the junction of the terminal ileum and cecum
 The cecum usually lies within 2.5 cm of the inguinal liga- ment; it is almost entirely enveloped by peritoneum and can be lifted freely. However,
the cecum has no mesentery. Because of its relative freedom, it may be displaced from the iliac fossa, but it is commonly bound to the lateral
abdominal wall by one or more cecal folds of peritoneu
 The appendix (vermiform appendix; L. vermis, worm- like) is a blind intestinal diverticulum (6–10 cm in length) that contains masses of
lymphoid tissue.
 It arises from the posteromedial aspect of the cecum inferior to the ileocecal junction.
 The appendix has a short triangular mesentery, the meso-appendix, which derives from the posterior side of the mesentery of the terminal
ileum
 Venous drainage from the cecum and appendix flow through a tributary of the superior mesentery vein, the ileocolic vein
  Lymphatic drainage of the cecum and appendix passes to lymph nodes in the meso-appendix and to the ileocolic lymph nodes that lie along
the ileocolic artery. Efferent lymphatic vessels pass to the superior mesenteric lymph nodes.
 The nerve supply to the cecum and appendix derives from the sympathetic and parasympathetic nerves from the superior mesenteric plexus.
The sympathetic nerve fibers originate in the lower thoracic part of the spinal cord, and the parasympathetic nerve fibers derive from the vagus
nerves. Afferent nerve fibers from the appendix accompany the sym- pathetic nerves to the T10 segment of the spinal cord

Colon
 The ascending colon is usually cov- ered by peritoneum anteriorly and on its sides. he ascending colon is separated from the anterolateral
abdom- inal wall by the greater omentum. A deep vertical groove lined with parietal peritoneum, the right paracolic gutter, lies between the
lateral aspect of the ascending colon and the adjacent abdominal wall
 The transverse colon is the third, longest, and most mobile part of the large intestine (Fig. 2.52). It crosses the abdomen from the right colic
flexure to the left colic flexure, where it turns inferiorly to become the descending colon.
 The left colic flexure (splenic flexure) is usually more superior, more acute, and less mobile than the right colic flexure.
 The transverse colon and its mesentery, the transverse mesocolon, loops down, often inferior to the level of the iliac crests. The mesentery is
adherent to or fused with the posterior wall of the omental bursa. The root of the transverse mesocolon (see Fig. 2.49A) lies along the inferior
border of the pancreas and is continuous with the parietal peritoneum posteriorly.
 Venous drainage of the transverse colon is through the SMV
 The lymphatic drainage of the transverse colon is to the middle colic lymph nodes, which in turn drain to the superior mesenteric lymph nodes
 The nerve supply of the transverse colon is from the supe- rior mesenteric nerve plexus via the peri-arterial plexuses of the right and middle
colic arteries
 The descending colon occupies a secondarily retro- peritoneal position between the left colic flexure and the left iliac fossa. Thus, peritoneum
covers the colon anteriorly and laterally and binds it to the posterior abdominal wall. Although retroperitoneal, the descending colon, especially
in the iliac fossa, has a short mesentery in approximately 33% of people; however, it is usually not long enough to cause vol- vulus (twisting) of
the colon.
 at approximately the left colic flexure, a second transition occurs in the blood supply of the abdominal part of the alimentary canal: the SMA
supplying blood to that part orad (proximal) to the flexure (derived from the embryonic midgut), and the IMA supplying blood to the part aborad
(distal) to the flexure (derived from the embryonic hindgut).
 Venous drainage from the descending colon and sigmoid colon is provided by the inferior mesenteric vein, flowing usually into the splenic vein
and then the hepatic por- tal vein on its way to the liver
 ymphatic drainage from the descending colon and sig- moid colon is conducted through vessels passing to the epico- lic and paracolic nodes,
and then through the intermediate colic lymph nodes along the left colic artery (Fig. 2.56B). Lymph from these nodes passes to the inferior
mesenteric lymph nodes that lie around the IMA. However, lymph from the left colic flexure may also drain to the superior mes- enteric lymph
nodes.
 The sympathetic nerve supply of the descending and sig- moid colon is from the lumbar part of the sympathetic trunk via lumbar
(abdominopelvic) splanchnic nerves, the superior mesenteric plexus, and the peri-arterial plexuses following the inferior mesenteric artery and
its branches. The parasympathetic nerve supply is from the pelvic splanchnic nerves via the inferior hypogastric (pelvic) plexus and nerves,
which ascend retroperitoneally from the plexus

Anorectal
 The terminal part of the intestine consists of the rectum and the anal canal, which extends from the rectosigmoid junction, at the level of the
third sacral vertebra (S3), 10 to 15 cm (4-6 inches) downward to the anorectal line

 The inferior mesenteric artery arises typically from the anterior aspect
or left side of the aorta, 3 to 5 cm above its bifurcation, which is situated
on the level of the lower third of the fourth lumbar vertebra (L4). The
inferior mesenteric proceeds down and forks into the last of the sigmoid
arteries and the superior rectal artery. This creates a rich blood supply in
the rectum (see Fig. 126-1). The sigmoid arteries, in combination with
the right pudendal arteries, the rectal arteries, and some of the blood
vessels that supply the muscles of the pelvis, create a rich arterial blood
flow to the rectum and anal area.

 where the same veins and arteries are present but rich internal and
external rectal hemorrhoidal plexuses serve essentially the mucosal,
submu- cosal, and perianal tissue. The plexuses encompass the rectal
circumference completely, but the greatest aggregation of small and
large veins takes place in the rectal columns. Generally, the vessels
returning the blood from the plexuses course 10 cm upward in the
submucosa.

 Lymphatics emanating from the rectum and anal canal run in two main
directions. In the lower part of the anal canal, they pass over the
peritoneum, alongside the scrotum or labia majora and the inner margin
of the thigh, to the superior inguinal nodes. The upper part of the anal
canal is drained cranially into preaortic and inferior mes- enteric nodes.

Histology of colon
 Histologically, the large intestines can be distinguished from the small intestines by the absence of villi, plicae circularis, and Paneth cells (in
adults). Simple columnar epithelium lines its mucosa. The crypts of Lieberkühn are deeper in the colon and goblet cells become more
abundant.
 At the anorectal junction, the epithelium changes from simple columnar to stratified squamous. Approaching the anorectal junction, the crypts
of Lieberkühn become shorter and more separated from each other.
Blood in stool:
 Cancer
 Gut changes:
o Motility: anal fissure (forced repetitive bowel movement), constipation
o Structural: peptic ulcer (H.pylori, NSAID), diverticulitis, Meckel diverticulum (omphalo-mesenteric duct remains during embriology)
o Inflammation: Crohn’s disease, UC
 Colitis – Crohn, radiation, drugs (ibuprofen), celiac disease
 Vascular compromisation:
o Varices esophageal
o angiodysplasia
o anal fissure