`
`FRED E. SEILVERSTEIN
`
`DON W. POWELL
`
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`TEXTBOOK OF
`
`astroenterology
`
`VOLUME ONE |
`
`EDITOR
`TADATAKA YAMADA, MD
`John G. Searle Professor and Chairman, Departmentof
`Internal Medicine, Professor of Physiology, Physician~in-Chief,
`University of Michigan Medical Center, Ann Arbor, Michigan
`
`a
`
`ASSOCIATE EDITORS
`DAVID H. ALPERS, mp
`Professor ofMedicine, Chief, Gastroenterology Division, Washington University
`School of Medicine, St. Louis, Missouri
`
`CHUNG OWYANG, mp
`Professor ofInternal Medicine, Division Chief of Gastroenterology, University
`ofMichigan Medical Center, Ann Arbor, Michigan
`
`DON W. POWELL, MD
`The Edward Randall and Edward Randall, fr. Chair in Internal Medicine,
`‘Professor and ChairmanofInternal Medicine, Professor of Physiology and
`Biophysics, The University of Texas Medical Branch Hospitals at Galveston,
`Galveston, Texas
`
`FRED E, SILVERSTEIN, mp
`Professor ofMedicine, University of Washington School of Medicine,
`Seattle, Washington
`,
`
`ct
`
`J.B. LIPPINCOTT COMPANY
`Philadelphia
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`New York
`
`London
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`Acquisitions Editor: Dean Manke
`Developmental Editor: Richard Winters
`Project Editors: Marian A. Bellus and Melissa McElroy
`Indexer: Maria Coughlin
`Designer: Susan Hess Blaker
`Design Coordinator: Doug Smock
`Production Manager: Caren Erlichman
`Production Coordinator: Kevin P. Johnson
`Compositor: TAPSCO,Inc.
`‘
`Printer/Binder: The Courier Book Co./Westford
`
`Copyright © 1991, by J. B. Lippincott Company.All rights reserved, No part of this book
`may be used orreproduced in any manner whatsoever without written permission except
`for brief quotations embodiedincritical articles and reviews. Printed in the United States
`of America, For information write J. B. Lippincott Company, East Washington Square,
`Philadelphia, Pennsylvania 19105.
`
`654321
`
`Library of Congress Cataloging-in-Publication Data
`
`Textbook of gastroenterology/editor, Tadataka Yamada; associate
`editors, David H. Alpers.
`.
`. [et al,]..
`p.
`cm,
`‘
`Includes bibliographical references.
`Includes index.
`ISBN 0-397-51227-9 (vol 1).—ISBN 0-397-50978-2 (2 vol set)
`1. Gastroenterology.
`2. Gastrointestinal system—Diseases.
`1. Yamada, Tadataka.
`II. Alpers, David H.
`(DNLM:
`1. Gastrointestinal Diseases. WI 100 13551]
`RC801.T48
`1991
`616.3°3—de20
`DNLM/DLC
`for Library of Congress
`
`;
`
`90-6386
`cIP
`
`The authors and publisher have exerted every effort to ensure that drug selection and dos-
`age set forth in this text are in accord with current recommendations and practice at the
`time of publication. However, in view of ongoing research, changes in government regula-
`tions, and the constant flow of information relating to drug therapy and drugreactions,
`the reader is urged to check the package insert for each drug for any change in indications
`and dosage and for added warnings and precautions. This is particularly important when
`the recommended agentis a new or infrequently employed drug.
`
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`the common and troublesome symptomsgenerally attributed to
`motor dysfunction of the bowel.
`
`DESCRIPTION OF THE COMPONENT
`PARTS OF THE LARGE INTESTINE
`
`Anatomy ofMotor Structures
`
`| 181
`
`ANATOMY OF MOTOR STRUCTURES
`
`Gross Anatomy
`
`COMPONENT PARTS OF
`THE LARGE INTESTINE
`
`The large intestine is often called by the nameof one ofits com-
`ponent parts, the colon. The large intestine is divided into five
`parts: the appendix, the cecum, the colon, the rectum, and the
`anal canal. These parts are anatomically and physiologically dis-
`tinct. They should be kept in mind as separate structures.
`The colon extends from the ileccolic junction to the rectosig-
`moid junction.It is divided into four regions; the ascending,trans-
`verse, descending, and sigmoid regions, Although the distinctions
`amongthese regions are somewhatarbitrary, this division is useful
`both physiologically and anatomically. The parts of the large in-
`testine are partly delineated by points or loci. These points are
`the ileocolic junction, the hepatic flexure, the splenic flexure, and
`the rectosigmoid junction. Ali these parts and loci are shown in
`Figure 10-1.
`
`The cecum is a blind pouch beyond the ileocolic junction. The
`cecum and the appendix have a generous mesentery and are,
`therefore, quite mobile.
`The ascending colon, extending from the ileocolic junction to
`the hepatic flexure, has no mesentery; the investing peritoneum
`holdsit against the adjacent kidney and dorsal muscles. The trans-
`verse colon, extending from the hepatic flexure to the splenic
`flexure has a broad mesentery so that it generally loops below the
`interiliac line. The descending colon, extending from the splenic
`flexure to the upper aperture of the pelvis, lacks a mesentery so
`that the peritoneum holds it against the kidney and dorsal muscles.
`The sigmoid colon, extending from the pelvic aperture to the rec-
`tosigmoid junction, has a broad mesentery so that it often forms
`a loop that protrudes into the abdomen. The rectum extends from
`the rectosigmoid junction to the anal canal. About 6 to 8 cm above
`the anal canal, the peritoneum is reflected from the rectum to
`adjacent structures so that the distal rectum is extraperitoneal.
`The anal canal is surrounded by the striated musculature of the
`pelvic floor, including the external anal sphincter.
`
`Structure of the Wall
`of the Large Intestine
`
`“4
`
`The large intestinal wall, like the rest of thé gut, has three major
`layers: the mucosa, the submucosa, and the muscularis propria,
`Each major layer has subdivisions.
`
`
`
`\Transverse
`Hepatic
`Colon
`Flexure
`
`Splenic
`Flexure
`
`Ascending
`Colon
`
`Descending
`Colon
`
`Rectosigmoid
`Junction
`
`Tleum \=
`
`Sigmoid
`fo ‘olon
`
`fai
`
`FIGURE 10-1. Gross anatomy of the large intestine.
`
`
`
`Anal Canal
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`Appendix
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