Splenic flexure and also the descending colon

The splenic flexure lies at a higher level contrasted with the hepatic flexure (Fig. 4.32). The is held on to the diaphragm through a peritoneal fold, the phrenicocolic ligament on i m sorry the spleen sits. It turns downwards together the descending colon, which, like the ascending colon, is retroperitoneal. The to decrease colon lies on the posterior abdominal wall muscles and is closely related come the left ureter. Close partnership of the splenic flexure to the spleen and the tail that the pancreas room taken treatment of when performing a left hemicolectomy.

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Joseph C. Glennon V.M.D., Dip. A.C.V.S., in small Animal Surgery tricks (Second Edition), 2004

1. What is the anatomy of the colon?

The colon is separated into three regionally continuous portions: ascending, transverse, and also descending. The ascending portion begins at the ileocolic valve on the best side that the abdomen and also runs cranially ending at the right colic flexure (hepatic flexure). The transverse colon starts in ~ the best colic flexure, operation transversely from right to left, and also ends at the left colonic flexure (splenic flexure). The diminish colon begins at the left colonic flexure and also runs caudally along the left next of the abdomen come the pelvic inlet, where it becomes the rectum. The diminish colon is the longest segment. The cecum is a diverticulum that the proximal colon separated by a cecocolic orifice located simply distal come the ileocecal sphincter.

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Abdominal pain

Laurence M Blendis, in Handbook of pain Management, 2003

Clinical features

Abdominal ache is mainly periumbilical in youngsters (Milla et al 2001), whereas in adults it has tendency to take place over the surface markings the the colon with the commonest website in the left lower quadrant, less commonly the right or left top quadrant end the hepatic or splenic flexures. It varies from a dull pains to assaults of excruciating severity, lasting from minute to several hours to all day, yet it rarely stays clear of the patient from resting through the night. ‘Meteorism’ is because of ‘air trapping’ in which segmental accumulation of gas occurs.

Alterations of bowel habit, diarrhoea or constipation occur in approximately 90% the the patients. In about half the patients pain is aggravated through eating and relieved by defecation. However, the patient's appetite is rarely affected, and therefore a history of far-reaching weight loss (i.e., an ext than 3.5 kg) is unusual and should progressive suspicions the an alternative diagnosis.

IBS pains is asociated through nausea without vomiting, dyspepsia, urinary symptoms, particularly dysuria, gynaecological symptoms, especially dysmenorrhoea, and headache; IBS symptom may begin after an strike of gastroenteritis (Gwee et al 1999). IBS may have actually been the reason of pelvic pain in 60% females attending gynaecological clinics, having dilatation and also curettage because that dysmenorrhoea, 40% having elective hysterectomy, contrasted to 32% the age-matched controls (Crowell et al 1994). They commonly have a past background of appendicectomy for ‘chronic appendicitis’. Cancer phobia is another frequent monitoring in this patients.

Recently in ~ a second conference in Rome ~ above IBS, the Rome II Criteria developed (Box 8.7). The Rome II Criteria are excellent for standardization of therapeutic trials and the self-control that they carried to the field but their an extremely rigidity brings synthetic constraints the will need to be reconsidered in the future (Camilleri 1998). On examination, over there is normally a disparity between the severity of the patient's symptoms and his or she physical condition, due to the fact that they watch well. The patient will certainly be tender end an area the the colon, most commonly the descending colon. Part patients are exquisitely tender on rectal examination. Sigmoidoscopic check is typically normal yet it is extremely difficult to proceed past the rectosigmoid junction, since of spasm and pain. The patients may also have mucosal hyperalgesia to light touch via the sigmoidoscope. Regimen blood tests, including sedimentation rate, have to be normal.

Paul J. Limburg, David A. Ahlquist, in Encyclopedia of Gastroenterology, 2004


Surgical excision is the mainstay the CRC treatment, especially when a curative outcome might be possibly achievable. The kind of operation and also extent the resection space dependent on lot of factors, including tumor location, size, and preoperative stage. In general, appropriate hemicolectomy is performed because that CRCs arising from the cecum, ascending colon, or hepatic flexure. The transverse colon and both flexures are generally removed when cancers originate native anywhere in between the ascending colon and also the descending colon. Because that distal colon cancers, left hemicolectomy is normally the procedure that choice. For any cancers above the rectum, at least a 5 cm margin that grossly uninvolved tissue have to be derived and local lymph nodes need to be aggressively sampled. Most colonic lesions have the right to be resected v a primary anastomosis. Adenocarcinomas in the middle and upper rectum space usually eliminated by anterior resection. Cancers in the lower rectum (0–5 cm over the anal verge) may require preoperative chemoradiation therapy and/or abdominoperineal resection through a irreversible colostomy.

The ascending colon is mainly involved in absorptive procedures that at some point lead come feces formation. The ventral element is spanned by the peritoneum, whereas the posterior surface is retroperitoneally addressed to the iliac fascia. A poorly formed mesocolon deserve to occasionally be observed. The anatomic relationships of the ascending colon include the appropriate kidney and also ureter, the duodenum, the liver, and also the gallbladder. The appropriate colic flexure, also called the hepatic flexure, is composed of a curve at the junction v the transverse colon. A peritoneal fold expanding from the hepatorenal ligament most most likely supports this section of the big intestine. The transverse colon is totally intraperitoneal with the exemption of its ideal end, i m sorry is in close contact with the duodenum and the pancreas. It process diagonally across the top abdomen from the ventrally situated hepatic flexure to the left colic (splenic) flexure, which is situated in the posterior plane of the ab cavity in a more cranial position than its equivalent on the right (Fig. 2). The left flexure develops an acute angle resolved to the diaphragm by the phrenicocolic ligament, which likewise sustains the reduced pole the the spleen. The position of the middle component of the transverse colon is variable. In asthenic individuals, it may reach the pelvis. The descending colon very first passes the lateral border the the left kidney and then curve medially, reaching the pelvic rim. The anterior surface ar is spanned by peritoneum, whereas the posterior challenge lies retroperitoneally or is periodically sustained by a mesentery. The sigmoid colon begins at the pelvic entrance. It is characterized by an S shape of variable length, a brief mesentery, and also therefore an excellent mobility. The sigmoid colon may be in close contact with the urinary bladder, the ventral surface of the upper rectum, or, in females, the uterus and also annexes. The junction in between the sigmoid colon and the rectum is situated 15 cm indigenous the anal verge. It is identified by combination of the teniae right into the complete longitudinal muscle layer of the rectum and by an abrupt ns of appendices epiploicae.


Anthony Ramsanahie, Ronald Bleday, in Encyclopedia that Gastroenterology, 2004

Right Hemicolectomy

Right hemicolectomy is undertaken v the patient put in a supine position. The surgeon stands ~ above the left side of the patient. The procedure incorporates the remove of the last few centimeters that the ileum, the ascending colon, and also the first couple of centimeters that the transverse colon. Intraabdominally, the colon is mobilized follow me the avascular plane—the white heat of Toldt (which fixes the colon come the lateral abdominal wall)—from the cecum to beyond the hepatic flexure. In mobilizing, the surgeon have to be conscious of the appropriate kidney, second component of duodenum, appropriate ureter, and right gonadal vessels.

The colon is reflect medially to expose the origin of the ileocolic artery. The operated doctor performs ligation and division of the appropriate branches the the middle colic artery, appropriate colic vessels, ileocolic vessels, and vessels to critical 5–10 cm the the ileum. The major vascular trunks need to be double ligated to protect against risk of knot slippage and also hemorrhage. If clamps are used, they are put at the site of resection that both end of the bowel, and the bowel is excised flush v the clamps. Plenty of surgeons usage staplers come divide and also occlude the ends of the bowel before anastomosis. After removal the the specimen, the ileum is anastomosed in a side-to-side (functional end-to-end) fashion come the transverse colon. The side-to-side plan is used since the caliber the the little bowel and big bowel is very different.

In instances of hepatic flexure tumors, the excision is expanded along the gastrocolic ligament towards the spleen. The splenic flexure and also left colon have the right to be mobilized if necessary. The omentum is resected if connected with cancer, otherwise it can be preserved. Because that an “extended” appropriate hemicolectomy, most of the transverse colon is resected. For cancer cases, the surgeon demands to take it the mesenteric dissection near their origin. The right colic artery must be ligated close come the premium mesenteric artery. Ligation of the center colic artery needs to it is in customized to each patient. Patients v an occluded worse mesenteric artery will require to have actually the left branch of the middle colic artery maintained for adequate blood supply to be maintained to the distal transverse colon and left colon.

Fred A. MettlerJr. MD, MPH, Milton J. Guiberteau MD, in Essentials of Nuclear medicine Imaging (Sixth Edition), 2012

Abdominal and Retroperitoneal Inflammation and Infection

In general, the suitable interpretation of gallium photos in the abdomen hinges ~ above the differentiation of physiologic task from abnormal accumulations the the radiopharmaceutical. A common problem in picture interpretation in the abdomen is the presence of gallium in the bowel, which might mimic lesions or mask disease. Bowel activity is specifically prominent in the colon and also may be diffuse or focal. Frequently, activity is checked out in the areas of the cecum, hepatic and splenic flexures, and rectosigmoid. These accumulations may show up as beforehand as a few hours ~ injection. The progress of excreted gallium with the colon with time may carry out the finest evidence the physiologic activity, vice versa, persistence of gallium in a given area that the abdomen need to be perceived as abnormal.

Abscesses in the retroperitoneum are typically related to associated renal infection. Persistence of much more than faint renal task after 24 hours, progressively enhancing activity, and unilateral discrepancy in gallium activity in the kidneys have to be thought about abnormal. However, abnormally increased activity in one or both kidney can occur in nonspecific pathologic and physiologic states and also may as such present a an overwhelming problem the differential diagnosis. The differential contains urinary obstruction, nephritis, acute tubular necrosis, diffuse infiltrative neoplasm, vasculitis, parenteral iron injections, blood transfusions, and also perirenal inflammatory disease.

In Canine and Feline Gastroenterology, 2013

Macroscopic Anatomy

The large intestine is composed of the cecum, colon, rectum, and anal canal (Figure 58-1). In dogs and also cats, the ileum communicates straight with the colon, and also what is referred to as the cecum in the dog and cat is actually a diverticulum that the proximal colon. The colon is further compartmentalized into ascending, transverse, and descending portions, every segment having actually slightly different functions and properties. The appropriate colic or hepatic flexure separates the ascending and transverse colon, and also the left colic or splenic flexure separates the transverse and descending colon. In dogs and also cats, the big intestine contributes 20% come 25% the the complete (small and also large) minister length.1,2

The arterial blood it is provided to the colon is provided by the cranial and also caudal mesenteric arteries, and venous return indigenous the colon is transmitted to the key portal vein via the cranial and caudal mesenteric veins. Lymph is circulated indigenous the colon to the right, middle, and left colic lymph nodes, and eventually right into the cisterna chyli and thoracic duct. Parasympathetic innervation occurs from the vagus nerve in the proximal colon, and from the pelvic nerves in the distal colon. Sympathetic innervation occurs from the paravertebral ganglia and follows the lumbar splanchnic nerves and also mesenteric arteries come the colonic mucosa and also muscularis. Parasympathetic preganglionic fibers and also sympathetic postganglionic yarn synapse on cell bodies and neurons that the enteric nervous system, respectively.

J. Kevin Kealy MVB, MVM, MRCVS, DVR, DECVDI (Hon), ... John P. Graham MVB, MSc, DVR, MRCVS, DACVR, DECVDI, in Diagnostic Radiology and Ultrasonography that the Dog and also Cat (Fifth Edition), 2011


The large intestine is composed of the cecum, the colon, the rectum, and the anal canal. In the dog, the cecum is a diverticulum of the proximal colon, through which it communicates v the cecocolic valve; this valve lies to the best of the midline at around the level of the 3rd lumbar vertebra. The does not communicate directly v the ileum. The cecum is twisted on chin in a corkscrew shape. The lies within the duodenal loop. In the cat the cecum is a straight, remote pouch.

The colon is separated into ascending, transverse, and also descending parts. That is shaped prefer a question note or a shepherd’s crook. The right colic, or hepatic, flexure hold together the ascending and transverse portions, and also the transverse and descending parts form the left colic, or splenic, flexure. The ascending colon lies to the appropriate of the midline ventral to the ideal kidney. It is concerned the ideal limb the the kidneys dorsally and also to the duodenum ~ above the right. To the left and ventrally the is in call with the tiny intestine; cranially, it touches the stomach.

The transverse colon is concerned the stomach cranioventrally and to the left body of the kidneys craniodorsally. It lies cranial to the source of the mesentery. Caudally that is in call with the tiny intestine.

The to decrease colon lies to the left of the midline and also extends from the left colic flexure to the pelvic inlet. Dorsally the is in contact with the iliopsoas muscle; cranially, that is regarded the left kidney and also ureter. Medially that is concerned the ascending duodenum; laterally it is regarded the spleen. In other places it is bounded by the little intestine. Caudally that lies dorsal come the bladder and also uterus. The to decrease colon is sometimes much longer and more tortuous 보다 usual, in which case it might lie partially on the right side. It is then referred to as a redundant colon.

The rectum is the terminal section of the colon, beginning at the pelvic inlet and ending at the anal canal. Ventral to the rectum is the vagina in the female and also the prostate gland and also urethra in the male.

Mark E. Olah, in Side impacts of drugs Annual, 2018



A situation of diclofenac-associated colonic stricture to be reported <14a>. A 57-year-old masculine presented come the hospital with weakness and abdominal pain. Medications contained 75 mg diclofenac double a day, 81 mg aspirin daily and also 75 mg clopidogrel daily. Hemoglobin was 8.8 g/dL and fetal occult blood was positive. A computed tomography scan recognize luminal narrowing the the bowel in ~ the hepatic flexure and a circumferential stricture in the appropriate colon was observed with colonoscopy. Biopsy of the stricture confirmed lamina propria fibrosis and also infiltration that eosinophils. Complying with endoscopic dilation the the stricture, two smaller proximal concentric colonic strictures were found however did not require balloon dilation. The patient was diagnosed through NSAID-induced colonic diaphragm disease and diclofenac was discontinued. ~ 3 months, no more gastrointestinal symptoms were noted.


A 67-year-old guy reported to the emergency room with an evident anaphylactic reaction to dental diclofenac potassium <15a>. Medical history included coronary artery disease, hypertension, chronic renal failure and a report anaphylactic reaction to intramuscular diclofenac. The patience presented with diffuse urticaria, hypotension and also complained the chest pain. Electrocardiogram showed steady ST segment elevation and the cardiac ejection fraction was 25%. Coronary angiography showed complete occlusion the the ideal coronary artery with prominent thrombotic material. Balloon dilatation was performed, however, a stent could not be placed. No cardiovascular complaints were detailed 2 weeks after discharge. The authors made a diagnosis the Kounis Syndrome Type-II in which a patient v preexisting coronary atherosclerosis experiences plaque rupture in response to an extreme acute allergic reaction. In this individual, the offending stimulus showed up to it is in diclofenac.

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Skeletal Muscle

A research of a single patient was performed in which a 65-year-old male obtained a magnetic resonance (MR)-guided intragluteal injection the diclofenac (75 mg/2 mL) because that painful enthesopathy that the musculus gluteus minimus <16a>. Mr imaging revealed hurt muscle through the highest volume of muscle damage detected at 24 hours after injection. In ~ 8 hours postinjection, plasma creatinine kinase was elevated sixfold over baseline and also returned to typical levels after ~ 1 week. The authors attribute the exponentiation of muscle damage to straight cytotoxicity that diclofenac and also not the hypertonicity the the solution. Interestingly, the patience reported no pain in ~ the injection site which the authors acknowledge may be because of local anesthetic effects of diclofenac.