动脉和毛细血管扩张-

Local

hemodynamicdisorders局部血液循环障碍白求恩医学院病理学系李

伟2010.9.27A

clinical

case病例摘要死者熊卓为，49岁，北大医院心血管研究所研究员。2006年初，

因腰腿疼痛，到北大医院门诊接受保守治疗。1月18日，其X光检

查结果显示：腰椎骨关节病、腰4-5椎间盘病变、腰4Ⅰ度滑脱伴峡部裂。于2006年1月23日入住北大医院。次日，熊接受了“L4/5椎管减压，椎弓根钉内固定，后外侧植骨融合术”手术。术后第六天，即1月30日，熊在下地行走时忽感头晕，摔倒于地，恶心呕吐，血压、脉搏测不出。经抢救无效，于31日死亡。√状告北京大学第一医院(以下简称北大医院)“非法行医”√3年多后，2009年11月3日，经由央视《经济半小时》报道√2010年4月28日，对于熊卓为的丈夫王建国状告北大医院“非法行医”一案，北京市高级人民法院作出终审(二审)判决。1、该患者的死亡原因是什么？2、其死因是否与之前的骨科手术有关？Proper

function

of

Heart

and

lungIntegrity

of

the

vasculaturemaintenance

of

balance

between

thecoagulation

and

fibrinolytic

systemsstability

of

normal

fluid

homeostasiIntact

Circulation

---Local

hemodynamic

disordersThrombus血栓Abnormal

substancesEmbolism栓塞---Infarction梗死Water

extravasationEdema水肿/积液Blood

contentsHyperemia充血Congestion/淤血Ischemia缺血vascular

injuryHemorrhage出血A

local

increased

volume

of

bloodin

a

particular

tissue局部组织血管内血液含量的增多Section

1Hyperemia

or

congestionAn

active

process

resulting

from

augmentedblood

flow

due

to

arteriolar

dilation器官或组织因动脉输入血量的增多而发生的充血Hyperemia动脉性充血Hyperemia动脉性充血Physiologic，Pathologic

(inflammation)Types:Morphology:组织器官体积轻度增大，颜色鲜红，温度增高细动脉和毛细血管扩张充血Consequence:Hyperemia动脉性充血常见类型：生理性充血Physiologic：病理性充血Pathologic：炎症反应的早期减压后充血：受压的组织或器官→突然解除压力→细动脉反射性扩张充血,如一次性大量抽取胸水或腹水→血压下降肉眼：组织器官体积轻度肿胀，颜色鲜红，温度升高，代谢功能亢进镜下：动脉和毛细血管扩张、充满血液后果：暂时性变化，去除原因即可恢复正常，因而影响小但血管本身有病变时，充血可以是血管破裂的诱因Congestion淤血A

passive

process

resulting

from

impairedvenous

return

from

a

tissue器官或组织静脉血流回流受阻，血液淤积于小静脉和毛细血管内，称淤血CausesSystemically,

in

cardiac

failureLocal--venous

obstruction--

venous

compressedCongestion淤血Morphology

and

ConsequencesSwollen,

cyanosis

(Blue-red

color),

low

temperature肿胀，发绀(蓝紫色），体表温度下降Dilatation

of

local

venules

and

capillaries局部静脉和毛细血管扩张Congestive

edema淤血性水肿Congestive

hemorrhage，hemosiderin–ladenmacrophage淤血性出血Parenchyma

cell:

atrophy,

reversible

injury,

necrosis实质细胞萎缩、变性、坏死Interstitial

hyperplasia:

fibrosis,

congestivesclerosis间质纤维组织增生Congestion淤血Dilatation

of

localvenules

and

capillariesCongestion淤血Morphology√Parenchyma

cell:

atrophy,reversible

injury

and

necrosis√Interstitial

hyperplasia:fibrosis,

congestive

sclerosisLung

congestion肺淤血Left

heart

failureCongestion淤血Acute

pulmonarycongestionChronic

pulmonarycongestionCongestion淤血Acute

pulmonary

congestionCongestion淤血Acute

pulmonary

congestion√

Alveolar

capillaries

engorged

with

blood√

Alveolar

septal

edema√

Intra-alveolar

edema

fluid

and

hemorrhageChronic

pulmonary

congestionThe

septa

become

thickened

and

fibroticThe

alveolar

spaces

contain

hemosiderin–laden

macrophagesCongestion淤血normal

lungChronic

pulmonary

congestionThe

septa

become

thickened

and

fibroticThe

alveolar

spaces

contain

hemosiderin–laden

macrophagesCongestion淤血Heart

failure

cellsChronic

pulmonary

congestionCongestion淤血Brown

duration（肺褐色硬化）---肝淤血Liver

congestionRight-sided

heart

failureAcute

hepatic

congestion:Gross:

dusky

red,

tense,

slightly

heavy;LM:

central

vein

and

sinusoids

are

distended

withbloodThere

may

be

central

hepatocyte

necrosisChronic

hepatic

congestion:Gross:

nutmeg

liverLM:

centrilobular

necrosis

and

peri-lobular

fattychange;hemorrhage;

atrophylong

standing

congestion—hepatic

fibrosisCongestion淤血Congestion淤血Chronic

hepatic

congestionnutmeg

liver

—in

chronic

hepatic

congestion,

the

centralregions

of

the

hepatic

lobules

are

grossly

red-brown,accentuated

against

the

surrounding

zones

ofuncongested

tan.在慢性肝淤血时，肝小叶中央区因严重淤血呈暗红色，两个或多个肝小叶中央淤血区可相连，而肝小叶周边部肝细胞则因脂肪变性呈黄色，致使在肝的切面上出现红（淤血区）黄（肝脂肪变区）相间的状似槟榔切面的条纹，称为槟榔肝Chronic

hepatic

congestionnutmeg

liverCongestion淤血---肝淤血Liver

congestioncentral

vein

and

sinusoids

are

distended

with

bloodcentrilobular

necrosis,

peri-lobular

fatty

changehemorrhage

and

hemosiderinCongestion淤血congestion

of

liverCentrilobular

necrosis

withhemorrhage

and

hemosiderinCongestion淤血congestion

of

livercongestion

of

liverCentrilobular

necrosisCongestion淤血Chronic

congestion

oftheliverfibrosisCongestion淤血淤血性肝硬变(Congestive

cirrhosis)Congestion淤血√

Dilatation

of

local

venules

and

capillaries√

Congestive

edema√

Congestive

hemorrhage√

Parenchyma

cell:

atrophy,degeneration,necrosis√

Interstitial

hyperplasia:

fibrosis,

congestivesclerosisMorphology

andConsequences

of

congestion出血(Hemorrhage)Loss

of

blood

from

the

vascular

compartment,

usuallyas

a

result

of

trauma

or

disease

of

the

vessel

wall.This

can

involve

large

vessels,

e.g,

aorta

or

smallvessels,

e.g.,

capillaries.血液从血管或心腔逸出,称出血.破裂性出血

漏出性出血-外出血--鼻出血，咯血，呕血，血便，血尿淤点，紫癜，淤斑-内出血体腔积血:

(心包腔,胸腔,腹腔,关节腔)软组织血肿:

(硬脑膜下血肿，腹膜后血肿，皮下血肿)petechia淤点(1-2mm)purpura紫癜(3-5mm),ecchymosis淤斑(大于1-2cm)hematoma血肿出血(Hemorrhage)脑出血心脏破裂及心包积血硬膜下血肿ecchymosis淤斑petechia淤点Thrombosis

血栓形成The

formation

of

a

clotted

mass

of

blood

in

thenoninterrupted

cardiovascular

system

is

known

asthrombosis,

and

the

mass

itself

is

termed

a

thrombus.在活体的心脏和血管内，血液发生凝固或血液中某些有形成分凝集形成固体质块的过程称为血栓形成(thrombosis)。所形成的固体质块称为血栓(thrombus)Virchow’s

triad

in

thrombosis.

Endothelial

integrityis

the

single

most

important

factor.

Injury

to

endothelial

cells

can

affect

local

blood

flow

and/orcoagulability.

Abnormal

blood

flow

(stasisorturbulence

can

cause

endothelial

injury.

The

factors

may

act

independently

ormay

combine

tocause

thrombus

formation.Pathogenesis

of

thrombosisThree

important

elements

in

thrombosisvirchow

triad:心血管内皮细胞的损伤血流状态的改变血液凝固性增加Thrombosis

血栓形成■血栓形成条件1.心血管内皮细胞的损伤endothelial

injury：dominant

influence正常心血管内膜的内皮细胞具有抗凝和促凝两种功能，生理情况下以抗凝作用为主，使血液保持流动状态。是血栓形成的最重要条件内膜损伤，内皮下胶原暴露，活化XⅡ因子，启动内源性凝血系统损伤内皮能释放组织因子，激活因子VII，启动外源性凝血系统血小板的活化在触发凝血过程中起核心作用（凝血酶激活血小板）■血栓形成条件√血小板活化表现为：粘附反应(adhesion)血小板粘附于局部内皮下胶原分泌和释放反应(secretion

and

release

reaction)血小板被激活，释出ADP等，使血小板互相粘集粘集反应(aggregation)血小板活化时生成的血栓素A2，可促成血小板不可复性粘集■血栓形成条件心血管内膜损伤常见于：动脉粥样硬化溃疡风湿性或细菌性内膜炎心肌梗死结节性多动脉炎同一静脉经过多次注射缺氧、休克、败血症等，全身广泛内皮损伤，弥散性血管内凝血■血栓形成条件血流状态的改变changes

in

the

pattern

of

blood

flow血流缓慢、停滞或涡流形成。√正常轴流消失，血小板与内膜接触机会增加，促进血小板粘集√局部凝血因子和凝血酶浓度增加，达到凝血所需浓度√内皮细胞缺氧，受损血流缓慢—静脉血栓涡流—动脉和心脏血栓■血栓形成条件常见于：夜间熟睡，心力衰竭，久病卧床者部 位：静脉瓣，血管分叉处，曲张的静脉二尖瓣狭窄的左心房，动脉粥样硬化斑块，动脉瘤内静脉血栓：动脉血栓=4：1下肢血栓：上肢血栓=3：1为什么静脉比动脉更易发生血栓？静脉血栓常见于心衰、久病和术后卧床患者原因：静脉瓣，不搏动，壁薄易受压，血液粘滞性增加■血栓形成条件血液凝固性增加changes

in

the

blood

constituents指血液的高凝状态。血小板数量或粘度增加，凝血因子增多遗传性高凝状态：第V因子基因突变获得性的高凝状态恶性肿瘤时癌细胞释放出促凝因子DIC及游走性血栓性脉管炎妊娠，手术后、大面积烧伤、产后Virchow’s

triad

in

thrombosis.

Endothelial

integrityis

the

single

most

important

factor.

Injury

to

endothelial

cells

can

affect

local

blood

flow

and/orcoagulability.

Abnormal

blood

flow

(stasisorturbulence

can

cause

endothelial

injury.

The

factors

may

act

independently

ormay

combine

tocause

thrombus

formation.Pathogenesis

of

thrombosisThree

important

elements

in

thrombosis心血管内皮细胞的损伤血流状态的改变血液凝固性增加Thrombosis

血栓形成■Process

ofthrombogenesis■血栓形成的过程Thrombosis

血栓形成静脉内血栓的形成Thrombosis

血栓形成√白色血栓pale

thrombi√混合血栓mixed

thrombi√红色血栓red

thrombi√透明血栓hyaline

thrombiMorphology

and

types

of

thrombi按形态分类：按发生部位分类发生于心血管系统的任何部位心脏或主动脉壁上血栓--层状血栓（lines

of

Zahn),为混合血栓（mixed

thrombi)：由灰白色的血小板和纤维素层以及暗红色的红细胞层相间而成，并混有变性的白细胞--附壁血栓（muralthrombi)—底部与心壁、血管壁相连--球形血栓（ball

thrombi)—左心房内血栓静脉—红色血栓Morphology

and

types

of

thrombi层状血栓（lines

of

Zahn混合血栓（mixed

thrombi)Morphology

and

types

ofthrombiMorphology

of

thrombi左心房附壁血栓（mural

thrombi)球形血栓Morphology

and

types

ofthrombi按发生部位分类动脉血栓（arterial

thrombi)静脉血栓(venous

thrombi,phlebothrombi)微循环内血栓(fibrin

thrombi,microthrombi)心脏瓣膜血栓(cardiac

valve

thrombi)Morphology

and

types

ofthrombi动脉血栓（arterial

thrombi)pale

thrombus动脉粥样硬化斑块基础上血管损伤白色或混合血栓mixed

thrombus