MRI OF PELVIS (RECTUM)

PREPARATION
X-ray or MRI or CT Scan or USG Films/Images with Reports
Blood for Serum Creatinine (If Contrast)
FNAC/Biopsy/Histopatholgy Test Reports
Old Documents

PROTOCOL
SURVEY

Sag T1+FS
Sag T2
Sag STIR

Cor T2

Ax T2 (1)
Ax T2 (2)
Ax T2+FS
Ax T1
Ax DWI+ADC

Indications for rectal cancer MRI scans

Patients who are suspected of having or are diagnosed with recurrent rectal carcinoma
Patients who have undergone preoperative chemoradiotherapy
Patient with newly diagnosed rectal carcinoma, prior to treatment
MRI to assess the need for neoadjuvant therapy
For the evaluation of tumour recurrence
Local tumour staging

PLANNING

Picture: Pelvis rectum sagittal planning

Picture: Pelvis rectum coronal planning

Picture: Pelvis rectum axial planning

Picture: Planning Anatomy

The Rectum Anatomy

The rectum is the most distal segment of the large intestine, and has an important role as a temporary store of faeces.

It is continuous proximally with the sigmoid colon, and terminates into the anal canal.

In this article we will discuss the anatomy of the rectum – its structure, anatomical relationships, and clinical relevance.

Anatomical Structure

The rectum begins at the level of the S3 (as a continuation of the sigmoid colon). It is macroscopically distinct from the colon, with an absence of taenia coli, haustra, and omental appendices.

The course of the rectum is marked by two major flexures:

Sacral flexure – anteroposterior curve with concavity anteriorly (follows the curve of the sacrum and coccyx).

Anorectal flexure – anteroposterior curve with convexity anteriorly. This flexure is formed by the tone of the puborectalis muscle, and contributes significantly to faecal continence.

There are additionally three lateral flexures (superior, intermediate and inferior), which are formed by transverse folds of the internal rectum wall.

The final segment of the rectum, the ampulla, relaxes to accumulate and temporarily store faeces until defecation occurs. It is continuous with the anal canal; which passes through the pelvic floor to end as the anus.

Fig 1 – The sacral and anorectal flexures of the rectum.

Peritoneal Coverings

In the superior third of the rectum, the anterior surface and lateral sides are covered by peritoneum. The middle third only has an anterior peritoneal covering, and the lower 1/3 has no peritoneum associated with it.

In males, the reflection of peritoneum from the rectum to the posterior bladder wall forms the rectovesical pouch. In females, the peritoneum reflects to the posterior vagina and cervix, forming the rectouterine pouch (pouch of Douglas). See more about the peritoneal cavity here.

Fig 2 – The peritoneal reflections of the rectum in males (A) and females (B).

Anatomical Relations

The rectum is located within the pelvic cavity, and is the most posterior of the pelvic viscera. Its anatomical relations are different in men and women:

Fig 3 – Sagittal section of the female pelvis, showing the anatomical position of the rectum.

Neurovascular Supply

The rectum receives arterial supply through three main arteries:

Superior rectal artery – terminal continuation of the inferior mesenteric artery.

Middle rectal artery – branch of the internal iliac artery.

Inferior rectal artery – branch of the internal pudendal artery.

Venous drainage is via the corresponding superior, middle and inferior rectal veins. The superior rectal vein empties into the portal venous system, whilst the middle and inferior rectal veins empty into the systemic venous system. Anastomoses between the portal and systemic veins are located in the wall of anal canal, making this a site of portocaval anastomosis.

Note: the rectum is also closely anatomically associated with the rectal venous plexus; however this structure is more functionally related to the anal canal.

Innervation

The rectum receives sensory and autonomic innervation.

Sympathetic nervous supply to the rectum is from the lumbar splanchnic nerves and superior and inferior hypogastric plexuses. Parasympathetic supply is from S2-4 via the pelvic splanchnic nerves and inferior hypogastric plexuses. Visceral afferent (sensory) fibres follow the parasympathetic supply.