病理生理學教學課件：02 Hemodynamic Disorders-2

1、Hemodynamic DisordersAn Anatomical Study of the Motion of the Heart and of the Blood in Animals, 1628Containing Heart, artery, Vein General circulation Pulmonary circulationFunctionsDeliver oxygen and nutrientsCarry away metabolic wastesA Healthy circulatory system Normal blood volumn HomeostasisNor

2、mal homeostasis vessel wall integrity intravascular pressure osmolarity normal hemostasisEdemaHyperemia & congestionThrombosis & EmbolismInfarctionHemorrhageShockThree Major Causes of morbidity and mortality Myocardial infarction Pulmonary embolism Cerebral vascular accidentCirculation Disturbance G

3、eneral (systemic) Some severe situation affecting all over the body: cardiac dysfunction, shock LocalAbnormal blood volume and the velocity of blood flow: hyperemia and ischemiaAbnormality of vascular integrity and permeability: edema and hemorrhage Occlusion of the vessel lumen: thrombosis, embolis

4、m and infarction 12Words and Vocabularies cyanosisedemasclerosisheart failure cellbrown indurationnutmeg livermixed thrombushyaline thrombusorganizationrecanalizationphlebolith & arteriolithcrossed embolism or paradoxical embolismretrograde embolismthromboembolismcaisson disease decompression sickne

5、ssamniotic fluid embolismseptic infarctEDEMA (水腫)Increased fluid in the interstitial tissue spacesGeneral & localPathogenesisVascular hydrostatic pressurePlasma colloid osmotic pressureLymphatic drainageEDEMAIncreased hydrostatic pressure ( cardiac edema, etc.)Reduced plasma osmotic pressure (nephro

6、tic, hepatic, malnutrient edema, etc. )Lymphatic obstruction (filariasis infection elephantiasis，breast surgery, etc )Sodium and water retention (ARF, etc)Minimal Change DiseaseelephantiasisPitting edemaEDEMAMost common typesSubcutaneous edemaPulmonary edemaEdema of the brainMorphologyLight Microsco

7、pe （LM）:Clearing and separation of the extracellular matrix elementsCell swellingHydrothorax hydropericardium hydroperitoneum (ascites) anasarcaEDEMAClinical correlation from annoying to fatal indicate subtle disease benefit or harmfulHYPEREMIA & CONGESTIONA local increased volume of blood in a part

8、icular tissueArterial hyperemia (hyperemia，充血) an augmented blood flow inducing arteriolar and capillary dilation Venous hyperemia (congestion，淤血) accumulation of Blood in Small Veins and capillaries result from drainage difficulty of veinsHYPEREMIA & CONGESTIONHyperemia:active process;red, raised t

9、empreture, increased volume ;enhanced function;Congestion: passive process;general of local;reddish blue color (cyanosis), low temperature, increased volume, edema;decreased functionTypesPhysiological: shy, exercise, taking meal Pathological: inflammatory, post-decompressed Significance Benefits ple

10、nty supply of O2, functional enhancement, nutrition substance Hazards headache , hemorrhage, stroke HYPEREMIACauses: Systemic: general or pulmonary cardiac dysfunction (right or left)Local: local venous compression or obstruction external Compression - tumor, bandage occlusion of lumen - thrombosis,

11、 embolism thickening of venous wall paralysis of neurogenic modulation - burn, frostbiteCONGESTIONCONGESTIONChronic congestion Raised venous pressure Anoxia Metabolite accumulation Enlarged interendothelial gap Base membrane degeneration Parenchymal Interstitial fibrosis Atrophy Reticular fiber coll

12、apsed Increase permeability Degeneration Collagen increased Necrosis Fibroblast proliferation Microscopic scarring Edema Hemorrhage Congestive sclerosisMorphologyGrossly hemorrhagic and wetMicroscopically rich of red blood cells in small vessels CONGESTIONCONGESTIONLungacute pulmonary congestionGros

13、s: Plump swollen lung with shining pleura, edematous fluid flowing out while cutting the lung LM: Alveolar capillaries highly dilated and engorged with blood rosary- like appearanceAlveolar cavity filled with eosinophilic edema fluid Manifestation Pink colored foamy sputumCONGESTIONLung chronic pulm

14、onary congestionGross: Hard, with brown spots scattered Brown IndurationLM: Septa thickened and fibrosisheart failure cells hemosiderin-laden macrophages Manifestation rusty sputum, dyspnea, etc.CONGESTIONLiver acute hepatic congestionLM: Dilation of central vein and sinusoids with blood Atrophy, de

15、generation and necrosis of central hepatocytesCONGESTIONLiver chronic hepatic congestionNutmeg LiverGross: red-brown zones accentuated against the yellow surrounding zonesLM: centrilobular necrosis and congestion, and perilobular fatty change; fibrosisLong-standing, severe hepatic congestion: hepati

16、c fibrosis (cardiac cirrhosis)Hemorrhage （出血）CausesRupture of blood vessels TraumaPeptic ulcer, aneurism, atherosclerosis DiapedesisEnlarged interendothelial gap (basement membrane injury). The intergrity of the vessels remains intactInjury to vascular wall: severe infection, anoxia, toxinsChange in

17、 number and quality of platelets uremia, leukemia, idiopathic Disturbance of coagulation mechanism congenital disease, DIC , deficiency of Vit. KhemorrhagepetechiaepurpurasecchymoseshematomahemothoraxhemopericardiumhemoperitoneumhemoarthrosisThe clinical significance depends on the volume, the rate

18、of loss and the site. Hemorrhagic shock Stroke Normal hemostasisMaintain blood in a fluid, clot-free stateLocalized hemostatic plugThrombosis （血栓形成）Blood clot (thrombus，血栓) formation in cardiovascular system of a living bodyHemostasis & thrombosisHemostasisThree componentsvascular wallplateletscoagu

19、lation cascadeEvents in hemostasisvasoconstrictionprimary hemostasissecondary hemostasisantithrombotic counter-regulationHemostasis & thrombosisEndotheliumAntithromboticantiplateletanticoagulantfibrinolyticProthromboticHemostasis & thrombosisPlateletadhesionsecretionaggregationCoagulation casecadeth

20、rombosis Pathogenesisendothelial injuryturbulence of blood flowhypercoagulabilityVirchow TrianglethrombosisMorphologyArterial thrombioriginate from injury sitesVenous thrombi (phlebothrombi)originate from the sites of stasisboth extend to the heart pale platelet and fibrin layersLines of Zahn dark e

21、rythrocyte-rich layersthrombosisLines of ZahnthrombosisLM: platelets trabeculae + neutrophil fibrin + red cellsthrombosisTypes Mural thrombusOcclusive thrombusGlobular thrombusVegetationBacterial thrombusTumor thrombusPale thrombusMixed thrombusRed thrombusHyaline thrombus Pale thrombusplatelets & f

22、ibrinthe head of a venous/propagating thrombus locate in the cardiac valves, chambers or the aorta (eg. Vegetation, mural thrombus, etc) Mixed thrombuspale trabaculaes alternating with erythrocytes rich layersthe body of a venous/propagating thrombus thrombosis Red thrombuserythrocytestail of a veno

23、us/propagating thrombus Hyaline thrombus (microthrombus)fibrinrelates to disseminated intravascular coagulation (DIC)thrombosisthrombosisMural thrombusVegetation Hyaline Thrombusocclusive thrombusglobular thrombusthrombosistumor thrombusbacterial thrombusthrombosisthrombosisDifference between thromb

24、us and postmortem clot Thrombus Postmortum clots干 dry wet and gelatinous“chicken fat” supernatant糙 rough surface smooth surface硬 hard soft脆 fragile gelatinous層 Lines of Zahn homogenous 緊 firmly attached no attachment裂 slit due to contraction, fragmentation, generate embolus no slitthrombosisFate Pro

25、pagation and obstructionDissolutionEmbolizationOrganization and recanalizationCalcification Case StudyA 59-year old man was admitted to the hospital after a fall, complaining of hip pain and inability to walk. The X-ray was taken and showed femur neck fracture. On the day of admission, he was taken

26、to surgery. Following the surgery, he was immobilized and forced to lie in bed.On the 7 th day after the surgery, he suddenly felt breathlessness and chest pain just following tuning over in bed after a meal. The respiratory rate was 34/min and the heart rate was 120/minQestion: Can you tell the pos

27、sible diagnosis?TO BE CONTINUEDthrombosisClinical correlationsVenous thrombosis (phlebothrombosis)varicosities, embolism (sometimes fatal), DVT, trauma, surgery, post partumcancer associated thrombosis Cardiac and arterial thrombosismural thrombus (MI, AS)rheumatic heart disease, valve diseaseEmboli

28、ze peripherally, brain, kidney, spleen, etcthrombosisDIC (Disseminated intravascular coagulation) Usually happens in many severe disorders severe bacterial or viral infection, allergic disease, anoxia, trauma, shock, malignancy ,etc. Coagulation System is Activated Microthrombi are Formed in Capilla

29、ries of Many Organs Platelets + Fibrin ( lung ,brain ,kidney, liver, GI tract, adrenal gland, etc.) Consumption of coagulation substance and activation of fibrinolytic system hemorrhage diathesis, mutiorgan dysfunction consumption coagulopathy / defibrination syndrome 消耗性凝血病/ 去纖維蛋白綜合征Embolism （栓塞）Oc

30、clusion of cardiovascular system by some insoluble mass. The mass is termed as “Embolus （栓子）”.solid, liquid, gaseous massThromboembolism 99%Fat, air, amniotic fluid, tumor fragments, bits of bone marrow, etc EmbolismRoute of emboliArterial emboli systemic embolismVenous emboli pulmonary embolismPort

31、al vein emboli hepatic embolismParadoxical emboli Emboli from veins of the general circulation pass through an atrial or ventricular septal defect, entering arteries of the general circulation.Retrograde emboliEmbolismIncidence: 20-25/100,000 hospitalized patientsSource: 95% from DVT above the kneeP

32、ulmonary ThromboembolismEmbolismResults: depend on the size, number and the clinical setting Few Emboli with Small Size : asymptomatic infarction (pain and dyspnea)Numerous Small Emboli : decrease the volume of pulmonary circulation sharply, pulmonary hypertension and right ventricular failureMedium

33、 Sized Emboli: hemorrhage, usually no infarction, Why?Large Emboli: sudden death, saddle embolusPulmonary ThromboembolismEmbolismSource: 80% from intracardiac mural thrombi; MI, aortic aneurysms, ulcerated AS plaques, vegetations Target sites: lower extremities, brain, intestines, kidney, spleenCons

34、equences: infarctionSystemic ThromboembolismEmbolismThromboembolism 99%Non-thrombotic embolism Fat embolism Gas embolism Amniotic fluid embolism Can you answer these questions:Where do they come from?Where do they lodge?What are the features of their impairment?Fat Embolism 脂肪栓塞released from the bon

35、e marrow and soft tissue due to severe injury long bone fracture soft tissue trauma or burns squeeze of the fatty changed liverMainly occurs in the lung and the brainMostly asymptomatic, only 10% of severe skeletal injuries have some clinical manifestationFat EmbolismResults depend on the diameter a

36、nd the quantity of the fat droplets 20m, pulmonary embolism 20 m, cerebral embolism other organ embolism Special staining (Sudan III ) Osmium stainingFatty Embolus in the Vascular LumenPathogenesisobstruction & toxic effect of free fatty acid the role of platelets adhesion and coagulationSymptomstac

37、hypnea, dyspnea, tachycardia; irritability, restlessness, delirium or coma; anemia and thrombocytopenia diffuse petechial rash ( in 20-50% cases)Fat EmbolismGAS Embolism氣體栓塞Source: air or N2 bubbles Exogenic: transfusion, operation or trauma in the neck or chest, artificial pneumothorax, pneumoperit

38、oneum Endogenic: decompression sickness or caisson disease Results:Small amount of gas may be absorbedOccupies the heart ventricle, interrupted the blood flow cause death Gas embolism in multiple organs (esp. brain & pulmonary)Symptoms: Pains, sudden deathTreatments: RecompressionGAS EmbolismAmnioti

39、c Fluid Embolism 羊水栓塞Low Incidence (1/40,000) with high mortality rate (70%80%)SourceSinusoids which placenta attached Torn cervical vesselsComponents of Amniotic Fluid:squamous epithelial cells, lanugo hair, fat, fetal feces, mucin and TXA2Squamous cells and Keratinization substancesSymptoms: sudde

40、n severe dyspnea, cyanosis and ShockCause of death: multiple embolism; pulmonary embolism; reflex vasoconstriction; allergic shock ; DICAlcian Blue PAS stainingAmniotic Fluid EmbolismINFARCTION （梗死形成）The formation of a localizad area of ischemic necrosis within a tissue or organ due to impaired arte

41、rial supply or the venous drainageThe necrosis area is called “infarct”.An extremely important cause of clinical illness:myocardiac infarctioncerebral infarctionCausesOcclusion of arterial supply or venous drainageThrombosis, embolism, athermanous plaques, external compressionFunctional spasm of art

42、erioleTypesWhite infarcts (anemic infarcts)Red infarcts (hemorrhagic infarcts)Septic infarcts INFARCTIONINFARCTIONWhite infarctionArterial occlusionSolid, compact organsFew collateral circulation (spleen, kidney, heart, brain, etc.)Morphology GrossDull pale, dry, wedge-shaped necrotic lesion A hemor

43、rhagic zone surroundingINFARCTIONLMIschemic coagulative necrosis Hemorrhagic zone : inflammatory and granulation tissue. Most undergo organization and scarring in the end.INFARCTIONSpleen InfarctionINFARCTIONCardiac InfarctionINFARCTIONBrain Infarction ( liquefied necrosis)INFARCTIONRed infarction Arterial occlusion Venous occlusion Loose tissue Dual circulations: lung , smal