病理学英文课件：第三章 局部血液循环障碍VIP

1、Chapter III Local Circulatory DisturbanceIt consisted of: a. change in vascular permeability and integrity hemorrhage出血出血, edema水肿水肿 b. disturbance of blood volume congestion充血充血, ischemia缺血缺血 c. change in intrvascular contents thrombosis血栓血栓, embolis栓塞栓塞 Section I Hyperemia and CongestionHyperemia

2、andcongestion are also increasedblood volume with dilated vessels in an organ or part of the body. I Hyperemia 充血 Arterial hyperemia ( active hyperemia) increased arterial blood to the part.( I ). Types of hyperemia 1. Physiological hyperemia 2. Pathological hyperemia a. inflammatory hyperemia b. co

3、llateral hyperemia c. remove pressure of hyperemiaII Congestion淤血淤血 Congestion ( venous hyperemia, passive hyperemia) Increased venous blood to the part due to accumulation of blood in the venous vascular tree. It may be either general or local. General venous congestion is by far most important.( I

4、 ). Cause三个原因三个原因 1. pressure on the vein 静脉受压静脉受压 tumor mass, ligature, tight bandage, strangulated hernia etc. 肿瘤团块、结扎、绷带过紧、疝绞窄肿瘤团块、结扎、绷带过紧、疝绞窄 2. intraluminal occlusion of the vein thrombosis静脉血栓静脉血栓 3. cardiac failure 心力衰竭 ( II ). Change and effect of veneous congastion Chr. Veneous cogestion An

5、oxia increase veneous pressure parenchy- interstitial blood matous cell tissue vessels atrophy fibrous tissue permeability degeneration collagenization necrosis of reticulin fibers cogestive edema (cogestive sclerosis) cogestive hemorrhaga ( hemosiderin) 四个后果：四个后果： 淤血性水肿（毛细血管流体静压增高）淤血性水肿（毛细血管流体静压增高）

6、 淤血性出血淤血性出血 实质细胞萎缩、变性坏死实质细胞萎缩、变性坏死 间质（纤维结缔组织）增生间质（纤维结缔组织）增生( III ). Congestion of major organ两个重要器两个重要器官官 1. Chronic veneousn congestion of lung due to left heart failure左心衰左心衰 usually caused by mitral stenosis 二尖瓣二尖瓣狭窄狭窄 due to rheumatic heart disease. Morphylogical characteristic: Early stage: con

7、gestive lung, edema of lung Alveoli ; large amount of phagocytic cells filled with yellow blood pigment ( heart failure cells心衰细胞心衰细胞 ). Late stage: brown induration肺褐色萎缩肺褐色萎缩 Dark brown in color and tough in consistency. brown induration肺褐色萎缩肺褐色萎缩 含铁血黄素含铁血黄素 褐色褐色间质增生间质增生 硬化硬化2. Chronic venous conge

8、stion of liver: Occures early in general veneous congestion due to right heart failure右心衰右心衰. Motphlogical chracterisic: Early stare: Mutmeg liver槟榔肝槟榔肝 Late stage: Cogestive liver sclerosis淤血性肝硬化淤血性肝硬化 Gross: Cut surface shows amottled appearance of dark brown (congested淤血淤血 center of each lobule )

9、 and light yellow areas ( fatty changes脂肪变性脂肪变性 of liver cells ). LM: Center of the loule-distended sinusoids, atrophic degeneration liver cells. Peripheral part of the lobule-fatty changes Cogestive liver sclerosis 汇管区间质增生，汇管区间质增生，小叶结构完整小叶结构完整Section II Hemorrhage Hemorrhage 出血：出血： escape of blood

10、from blood vessel I. The cause and mechanism of hemorrhage Rupture of blood vessel破裂性出血破裂性出血: major cause is trauma or disease. RBC leak out漏出性出血漏出性出血: major cause is increase of permeabilityof blood vessel.RBC leak out: A. damage of vascular wall 血管壁内皮血管壁内皮 细胞受损细胞受损 (severe infection intoxication e

11、tc.) B. change in the number and quality of platelets血小板血小板C. disturbance of coagulative mechanism血液凝固性障碍血液凝固性障碍II. ChangeTerms you should understand: Internal hemorrhage内出血内出血: Hematocele积血积血: accumulation of blood in somatic cavity e.g. Hemothrorax胸腔积血胸腔积血, hemopericardium心包腔积血心包腔积血, hemoperitoneu

12、m腹腔积血腹腔积血. Hematoma血肿血肿: hemorrhage into the tissue forming tumor like swelling. External hemorrhage外出血外出血: External hemorrhage: Petechia hemorrhage瘀点瘀点: minute hemorrhage(pinpoint) in skin, mucus membrane, serosal surface. Purpura紫癜紫癜: hemorrhage up to 1 cm in size in skin, mucus membrane serosal s

13、urface. Ecchymosis瘀斑瘀斑: a large blotch hemorrhage (less then 1-2 cm in diameter ) in skin, mucus membrane, serosal surface.Rhinorrhagia鼻衄鼻衄: nasal hemorrhageHemoptysis咯血咯血: hemorrhage of respectory tract.Hematemesis呕血呕血: hemorrhage of upper digestive tractHematochezia便血便血: hemorrhage of lower digest

14、ive tractHematuria血尿血尿: hemorrhage of urinary tractIIIEffects The effects of hemorrhage is depend upon the speed, the adequacy and part of hemorrhage. 出血速度、量、部位出血速度、量、部位Section III ThrombosisThrombosis血栓形成血栓形成: formation of a solid or semisolid mass from the constituents of the blood within the vesc

15、ular system during life. 活体心血管腔活体心血管腔 血液凝固血液凝固 血小板析出粘集血小板析出粘集 形成固体质块形成固体质块 The mass itself is termed a thrombus血栓血栓. Blood coagulation systemAnticoagulation systemI. The forming condition andmechanism of thrombosis There are two major course of thrombosis:两个基本环节两个基本环节 Blood coagulation 血液凝固血液凝固 Thro

16、mbocytic aggregation 血小板析出和粘集血小板析出和粘集 There are three major factors in thrombus formation.三个条件三个条件 These were described originally by Virchow and are as Virchows triad. The three factors are: Endothelial injury内皮细胞受损内皮细胞受损 Changes in the pattern of blood flow 血流状态改变血流状态改变 Blood hypercoagubility血液凝固性

17、增血液凝固性增高高 ( I ). Endothelial injury: (1). Platelet adherence and activation: adhesion release reaction(ADP) aggregation(thromboxane A2 ) Endothelial thrombocytic aggregation injury (2) .Exposure of collagen fibers XII endogenous coagulation system (3). Release the histofactors VII exogenous coagulat

18、ion system Blood coagulation So that, the thrombosis of clinical occurs for the most part in the endothelial injury. e.g. a. various endocarditis b. endophlebitis c. atherosclerosis d. repeated perform of venipuncture ( II ). Changes in the pattern of blood flow 1. blood flow slowly 2. turbulance (w

19、hirlpool) 3. stasis of blood flow 血流缓慢临床上多见于：血流缓慢临床上多见于： 长期卧床的病人，如手术后，久病虚弱，长期卧床的病人，如手术后，久病虚弱，心力衰竭及骨折卧床的病人。心力衰竭及骨折卧床的病人。 In veins, however , the blood pressure is lower then in arteries, so that thrombosis in veins is more then in arteries (4 times). 据统计，发生在据统计，发生在V内比内比A内多内多4倍，下肢倍，下肢V比上肢比上肢V多多3倍，特别是骨

20、盆内倍，特别是骨盆内V及腿部后及腿部后面的深静脉。面的深静脉。血流漩涡临床上多见于：血流漩涡临床上多见于：风心二狭，左心房可产生涡流，尤其风心二狭，左心房可产生涡流，尤其在扩大的左心耳内。在扩大的左心耳内。A瘤或曲张的瘤或曲张的V内内血液突然流进宽血液突然流进宽阔处，产生血栓。阔处，产生血栓。血管分岔处。血管分岔处。 淤血时的淤血时的V瓣上。瓣上。 ( III ). Blood hypercoagubility 1. genetic hypercoagubility: e.g. V-factor mutant gene 2. acquired hypercoagubility: e.g. ma

21、lignancy, abnormal pregnancy, severe trauma, extensive burns, grand operation II. Course of Thrombosis and Types of Thrombus( I ). Course of thrombosis:( II ). Types of thrombus The thrombus can be classified into 4 types:四个类型四个类型1. White thrombus (pale thrombus) 血小板粘集为主血小板粘集为主 Usually present in hi

22、gh flow area (heart valves, ventricles, arteries) It tends to be mural (adherent to the wall of the vessel or heart ) and non-occlusive Attached friable gray mass of degranulated platelets血小板血小板 and fibrin. 2. Mixed thrombus 血小板粘集+血液凝固 It usually shows characteristic laminations which is produced by

23、 pale pink layers of platelets血小板粘集血小板粘集 and fibrin alternate with dark red layers of RBC血液凝固血液凝固 层状血栓层状血栓 Mural thrombus 附壁血栓附壁血栓 Thrombus attached to vessel wall/heart wall, non-occlusive 3. Red thrombus 血液凝固血液凝固 Resembles blood clots. Usually present in deep veins of tail of extend thrombus延续性血栓延

24、续性血栓. Extend thrombus composed of white head (initial platelet fibrin nidus) attach to the vascullar wall; mixed body (red and white thrombus ); red tail ( coagulated red thrombus).4Hyaline thrombus ( microthrombus, fibrinous thrombus) It wide spread deposition of fibrin and platelets in microvascul

25、ature through out the body It is most frequently seen DIC (disseminated intravascular coagulation).III.Fate of thrombus ( I ). Malacia, lysis and absorpation ( II ). Organization机化机化 and recanalization再通再通 a. prevent from amotio ingrowth of vascularized connective tissue ( granulation tissue) into t

26、he thrombus which become firmly attached to the vascular-wall b. recanalization -contraction and lysis of the thrombus endothelial cell accompanied by growth of endothelial cells from the adjacent intimal surface with restoration of a functional blood channel. ( III ).Calcification phlebolith静脉石静脉石,

27、 arteriolith动脉石动脉石VI. Effects of Thrombus ( I ). Occlusion of vascular ischemia缺血缺血, infarction梗死梗死 ( II ). Embolish栓塞栓塞 ( III ). Deformity of heart valves瓣膜变形瓣膜变形 Chronic valvular vitium of the heart (valvular stenosis , valvular insufficiency ) ( IV ). Widespread hemorrhage广泛出血广泛出血 DIC consumption

28、 coagulopathy Section IV Embolism Embolism: Occlusion of some part of cardivascular system by impaction of a foreign mass transported to the site through the blood stream. This impaction of foreign mass be known as embolus栓子栓子. The embolus may be solid, liquid or gaseous. Types of emboli are (1). th

29、romemboli ,(2). fat emboli, (3). air or gas emboli, (4). amniotic fluid emboli羊水栓塞羊水栓塞, and (5).tumor emboli, etc. I. The way of propagation of embolus 1. embolus of venous system and right heart Pulmonary embolism 2. embolus of arterial system and left heart Vascular occlusion occur most frequently

30、 in the spleen, kidney, brain etc. 3. embolus of portal system 4. crossed embolism (paradoxical embolism)retrograde embolism II. Types and Effects of Embolism ( I ). Thromboembolism Thromboembolism血栓栓塞血栓栓塞: An embolus is a mass of thrombus in the vascular system able to lodge in a vessel and block i

31、ts lumen. Most emboli are derived from thrombi. Over 99% of major emboli are derived from thrombi. 1. Pulmonary embolism Around 95% of pulmonary embolism occurs in deep veins of leg; the majority of the rest occur in pelvic veins and a very few occurs in the mural thrombus of right heart. The effect

32、s of pulmonary emboli depend upon their size and quantity. ( 1 ). Medium and small emboli may occur unnoticed and be lysed within the lung or they may become organised and cause some permenent. Pulmonary embolism is sometime accompanied with venous congestion of lung肺淤血肺淤血; the area may even become

33、infarcted ( 2 ). Large massive thromboembi are often impacted across the bifurcation of one of major pulmonary arteries as a saddle embolus a descriptive term for their appearance. In severe case, it may be result in sudden death. These are usually long thrombi derived from leg deep veins and have t

34、he shape of the vessels in which arose. Postmortem examination: Long thrombi retain the appearance of a thrombus with lines of Zahn and granular, friable, consistency Postmortem clots appearance of chicken fat 鸡脂样鸡脂样and redcurrant jelly果酱样果酱样, glossy, and elastic弹性弹性. ( 3 ). A large number of small

35、thromboli are also result in sudden death. 2. Systemic embolism 80% of systemic emboli arise in the left heart. 瓣膜赘生物瓣膜赘生物 Vegetations on the heart valves are an common important source of arterial emboli. (e.g. subacute infective endocarditis, SBE) Another common source of thrombosis within the lef

36、t heart is the presence of mural thrombus附壁血栓附壁血栓 in the atrium (mitral stenosis二尖瓣狭二尖瓣狭窄窄) and mural thrombus due to myocardial infarction. The rest occur in mural thrombus due to atherosclerosis or aneurysm动脉粥样硬化、动脉瘤动脉粥样硬化、动脉瘤. Vascular occlusions occur most frequently in the spleen, kidney, brain

37、 etc, may result in formation of infarction of the organ involved. More dramatic consequences develop as a result of emboli travelling to the intestine; this impaction can cause death of whole sections of small bowel肠梗死肠梗死. More seriously, in infective endocarditis the vegetations consist of micro-o

38、rganisms, usually bacteria, and are extremely friable. (may cause septic infarct败血性梗死败血性梗死) ( II ). Fat embolism Fat embolism usually arises following some severe trauma with fracture to long bones长骨骨折长骨骨折. Fat from the bone marrow is released into circulationand comes to lodge in various organs. A

39、similar situation arises in severe burns 严重烧伤严重烧伤and in extensive soft tissue injury脂肪组织严重挫伤脂肪组织严重挫伤. The diameter of fat globules20m, the circulating fat enters the lung and this indicates that it must travel by way of the venous system The diameter of fat globules200g), the effects are severe. (ma

40、y bring about death due to right heart failure) 病例讨论：病例讨论： 男性，男性，42岁，因骑车不慎跌倒，右小腿肿痛，岁，因骑车不慎跌倒，右小腿肿痛，急诊诊断为右小腿胫腓骨骨折，长靴形石膏固急诊诊断为右小腿胫腓骨骨折，长靴形石膏固定后，回家卧床休息。此后，小腿肿痛逐渐缓定后，回家卧床休息。此后，小腿肿痛逐渐缓解，伤后二周又出现右下肢肿痛，去医院复查，解，伤后二周又出现右下肢肿痛，去医院复查，拆除石膏重新包扎，回去后肿胀仍无改善，并拆除石膏重新包扎，回去后肿胀仍无改善，并渐向大腿发展，四天后坐起吃饭时，突然高叫渐向大腿发展，四天后坐起吃饭时，突然高

41、叫一声，心跳呼吸停止，抢救无效死亡。一声，心跳呼吸停止，抢救无效死亡。 病人突然死亡的原因是什么？病人突然死亡的原因是什么？ 、肺动脉血栓栓塞、肺动脉血栓栓塞、脂肪栓塞、脂肪栓塞( III ). Gas embolism There are various causes of embolic events involving gas. 1. air embolism 靠近心脏的大静脉破裂靠近心脏的大静脉破裂 The causes of air embolism are mainly surgical when some vessel is open to the air. (iatrogeni

42、c) This also occurs in accidentally when patients are disconnected from intravenous lines and air enters. This also occurs in suicide attempts when the neck veins are cut. The volume of air needed to cause death in this fashion is around 100 ml. The pathological signs of this condition at autopsy in

43、clude visible bubbles in the vessels such as a frothy ball of blood and air in the right side of the heart occluding one of the valves. 2. Decompression sickness 减压病减压病(caisson disease沉箱病沉箱病, diverdisease潜水员病潜水员病) Experienced by divers when they are transferred too rapidly from high to low pressure

44、enviroments At high pressure, increased volumes of gas氮气栓塞氮气栓塞 dissolve in the blood and during rapid decompression these come out as bubbles. ( IV ).Amniotic fluid embolism With the vastly increased pressures in the uterus during delivery, and the pressure is transferred to the amniotic fluid which

45、 may be forced into the maternal uterine veins These amniotic fluid emboli travel in the circulation and lodge in the lungs, causing respiratory distress like other pulmonary emboli They can be recognised histologically since they contain the shed skin cells of the infant. In the cases, it may be ca

46、using death by (1).anaphylactic shock; (2).reflex angiospasm; (3).DIC ( V ). Other embolism Other embolic material include: tragments of tumour (causing metastases), particles of foreign matter. Section V Infarction Infarction: Localized area of ischemic necrosis within a tissue or organ produced by

47、 occlusion of its arterial supply or venous drainage due to thrombotic or embolic occlusion. Infarction is ischaemic death of tissue within the living body. This means that death of tissue from other causes, such as toxins or trauma, is not infarction but is simply necrosis, which is the general ter

48、m for death of tissue within the living organism. I. The Causes and Condition of Infarction ( I ). The causes of infarction 1. Thrombolism血栓形成血栓形成the most common cause of infarction. (99% of infraction are caused by thrombolic events and almost all are the result of arterial occlusion. 2. Arterial e

49、mbolism 动脉栓塞动脉栓塞 thromboembolism, may be cause of infarction of spleen, kidney,lung and brain. 3. Arteriospasm动脉痉挛动脉痉挛 4. Occlusion by pressure on the vessel血管受压血管受压. ( II ). The condition of infarction 1. The types of arterial supplies 双重血供双重血供 A second blood supply is present and , although the ar

50、terial inflow is blocked, blood still enters the organ from this second supply. A good example of this is the lung, which has both pulmonary and bronchial arterial supplies. Other examples are liver and forearm. 2. The susceptibility to ischemia of effected tissues缺血敏感性缺血敏感性 Different tissues show d

51、iffering susceptibility to ischemia. Tissues also vary in the degree of ischemia that they can tolerate. Nerve cells tolerance to ischemia are lowest. (3-4minutes) Cardiocytes:(20-30minutes) Skeletal muscles and connective tissues tolerance to ischemia are most powerful. II. Appearence and Types of

52、Infarction Morphological character and types of infarction1. Anemic infarct (white infarct) generally the result of occlusion of an anatomical or functional end-artery of a solid organ 实性器官实性器官(There is no possibility of collateral supplies taking over). Such as heart, kidney, and spleen etc. Morpho

53、logical character: Wedge shape Triangular on cut surface, with its base toward the surface and apex near the site of occlusion. The evolution of anemic infarct are: ( 1 ). Early, may appear red (residual blood or venous backflow) ( 2 ). Subsequently become pale (lysis and decomposition of hemoglobin) ( 3 ).later a red demarcation zone at the margin of adjacent normal tissue ( inflammatory response and granulation formation). 2. Hemorrhagic infarct (Red infarct) prominent hemorrhage occurs in soft, loosely organized ti