Hemodynamic Disorders复旦大学精品课程(PPT56).ppt

Hemodynamic Disorders,Ye Liu（刘 晔）Dept.Pathology,SMC,ContainingHeart,artery,VeinGeneral circulation Pulmonary circulationFunctionsDeliver oxygen and nutrientsCarry away metabolic wastes,A Healthy circulatory system Normal blood volumn Homeostasis,Normal homeostasis vessel wall integrity intravascular pressure osmolarity normal hemostasis,EdemaHyperemia&congestionThrombosis&EmbolismInfarctionHemorrhageShock,Three Major Causes of morbidity and mortality Myocardial infarction Pulmonary embolism Cerebral vascular accident,EDEMA(水肿),Increased fluid in the interstitial tissue spacesGeneral&localPathogenesisVascular hydrostatic pressurePlasma colloid osmotic pressureLymphatic drainage,EDEMA,Increased hydrostatic pressure(cardiac edema,etc.)Reduced plasma osmotic pressure(nephrotic,hepatic,malnutrient edema,etc.)Lymphatic obstruction(filariasis infection elephantiasis，breast surgery,etc)Sodium and water retention(ARF,etc),Minimal Change Disease,elephantiasis,Pitting edema,EDEMA,LM:Clearing and separation of the extracellular matrix elementsCell swellingSubcutaneous edemaPulmonary edemaEdema of the brain,Morphology,Hydrothorax hydropericardium hydroperitoneum(ascites)anasarcaClinical correlationfrom annoying to fatalindicate subtle diseasebenefit or harmful,EDEMA,HYPEREMIA&CONGESTION,A local increased volume of blood in a particular tissue,Arterial 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 veins,HYPEREMIA&CONGESTION,Hyperemia:Active process;Red,raised tempreture,increased volume;Enhanced function;,Congestion:passive process;general of local;Reddish blue color(cyanosis),low temperature,increased volume,edema;Decreased function,TypesPhysiological:Shy,exercise,taking Meal Pathological:Inflammatory,post-decompressed Significance Benefits Plenty supply of O2,functional enhancement,nutrition substance Hazards Headache,hemorrhage,stroke,HYPEREMIA,Causes:Systemic:general or pulmonary Cardiac dysfunction(right or left)Local:local venous compression or obstruction External Compression-Tumor,Bandage Occlusion of lumen-Thrombosis,Embolism Thickening of venous wall Paralysis of neurogenic modulation-Burn,frostbite,CONGESTION,CONGESTION,Chronic congestion Raised venous pressure Anoxia Metabolite accumulation Enlarged interendothelial gap Base membrane degeneration Parenchymal Interstitial fibrosis Atrophy Reticular fiber collapsed Increase permeability Degeneration Collagen increased Necrosis Fibroblast proliferation Microscopic scarring Edema Hemorrhage,Congestive sclerosis,MorphologyGrossly hemorrhagic and wetMicroscopically rich of red blood cells in small vessels,CONGESTION,CONGESTION,Lung:Acute pulmonary congestionGross:Plump swollen lung with shining pleura,edematous fluid flowing out while cutting the lung LM:Alveolar capillaries highly dilated(rosary-like appearance)and engorged with blood Alveolar cavity filled with eosinophilic edema fluidManifestation Pink colored foamy sputum,CONGESTION,Lung:Chronic pulmonary congestionGross:Hard,with brown spots scattered Brown indurationLM:Septa thickened and fibrosis Alveolar spaces containing heart failure cells hemosiderin-laden macrophagesManifestation Rusty sputum,dyspnea,etc.,CONGESTION,Liver:Acute hepatic congestionLM:Dilation of central vein and sinusoids with blood Atrophy,degeneration and necrosis of central hepatocytes,CONGESTION,Liver: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:hepatic 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:sever infection,anoxia,toxinsChange in number and quality of platelets uremia,leukemia,idiopathic Disturbance of coagulation mechanism congenital disease,DIC,deficiency of Vit.K,hemorrhage,PetechiaePurpurasEcchymosesHematomaHemothoraxHemopericardiumHemoperitoneumhemoarthrosis,The clinical significancedepends on the volume,the rate of loss and the site.Hemorrhagic shockStroke,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 body,Hemostasis&thrombosis,Hemostasis,Three componentsVascular wallPlateletsCoagulation cascadeEvents in hemostasisvasoconstrictionprimary hemostasissecondary hemostasisantithrombotic counter-regulation,Hemostasis&thrombosis,EndotheliumAntithromboticAntiplateletAnticoagulantfibrinolyticProthrombotic,Hemostasis&thrombosis,PlateletAdhesionSecretionAggregationCoagulation casecade,thrombosis,PathogenesisEndothelial injuryTurbulence of blood flowHypercoagulability,thrombosis,MorphologyArterial thrombiOriginate from injury sitesVenous thrombi(phlebothrombi)Originate from the sites of stasisboth extends to the heartpale platelet and fibrin layersLines of Zahn dark erythrocyte-rich layers,thrombosis,Lines of Zahn,thrombosis,LM:Platelets Trabeculae+Neutrophil fibrin+red cells,thrombosis,Types,Mural thrombusOcclusive thrombusGlobular thrombusVegetation,Bacterial thrombusTumor thrombus,Pale thrombusMixed thrombusRed thrombusHyaline thrombus,thrombosis,Mural thrombus,Vegetation,Hyaline thrombus,thrombosis,Differentiation between thrombus from postmortem clot,thrombosis,Fate Propagation and obstructionDissolutionEmbolizationOrganization and recanalizationCalcification,thrombosis,Clinical correlationsVenous thrombosis(phlebothrombosis)Varicosities,embolism(sometimes fatal),DVT,trauma,surgery,post partumCancer associated thrombosis Cardiac and arterial thrombosisMural thrombuscardiac infarction,rheumatic heart diseaseEmbolize peripherally,brain,kidney,spleen,etc,thrombosis,DIC(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 Capillaries 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/去纤维蛋白综合征,Embolism（栓塞）,Occlusion of cardiovascular system by some insoluble mass.The mass is termed“Embolus（栓子）”.Solid,liquid,gaseous massThromboembolism 99%Fat,air,amniotic fluid,tumor fragments,bits of bone marrow,etc,Embolism,Route of emboliArterial emboli systemic embolismVenous emboli pulmonary embolismPortal 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 emboli,Embolism,Incidence:20-25/100,000 hospitalized patientsSource:95%from DVT above the knee,Pulmonary Thromboembolism,Embolism,Results:(depends 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 Sized Emboli:hemorrhage,infarctionLarge Emboli:sudden death,saddle embolus,Embolism,Source:80%from intracardiac mural thrombi;aortic aneurysms,ulcerated AS plaques,vegetations Target sites:lower extremities,brain,intestines,kidney,spleenConsequences:infarction,Systemic Thromboembolism,Embolism,Fat EmbolismSource:Fractures of long bones Soft tissue trauma Results:20m,pulmonary embolism 20 m,cerebral embolism or other organ embolism Special staining(Sudan III),Embolism,Pathogenesisobstruction anemia and thrombocytopenia,Fat Embolism,Embolism,Gas EmbolismSource:Exogenic:transfusion,operation or trauma in the neck or chest,artificial pneumothorax,pneumoperitoneum Endogenic:caisson disease or decompression sickness Results:Small amount of gas may be absorbedOccupies the heart ventricle,interrupted the blood flow cause death Gas embolism in multiple organs(brain,pulmonary),Embolism,Amniotic Fluid EmbolismLow Incidence(1/10,000080,000)with high mortality rate(70%80%)Amniotic fluid may enter vascular system through Sinusoids which placenta attached Torn cervical vesselsEmboli consists squamous epithelial cells,lanugo hair,fat,fetal feces,mucin and TXA2Cause of death multiple embolism;reflex vasoconstriction,pulmonary embolism;allergic shock;DIC,INFARCTION（梗死形成）,The formation of a localizad area of ischemic necrosis within a tissue or organ due to impaired arterial supply or the venous drainageThe necrosis area is called“infarct”.An extremely important cause of clinical illness:myocardiac infarctioncerebral infarction,CausesOcclusion of arterial supply or venous drainageThrombosis,embolism,athermanous plaques,external compressionFunctional spasm of arterioleTypesWhite infarcts(anemic infarcts)Red infarcts(hemorrhagic infarcts)Septic infarcts,INFARCTION,INFARCTION,White infarctionArterial occlusionSolid,compact organsFew collateral circulation(spleen,kidney,heart,brain,etc.),Morphology GrossDull pale,dry,wedge-shaped necrotic lesion A hemorrhagic zone surrounding,INFARCTION,LMIschemic coagulative necrosis Hemorrhagic zone:inflammatory and granulation tissue.,Most undergo organization and scarring in the end.,INFARCTION,Spleen infarction,INFARCTION,Cardiac infarction,INFARCTION,Brain infarction(liquefied necrosis),INFARCTION,Red infarction Arterial occlusion Venous occlusion Loose tissue Dual circulations:lung,small intestine Previously congestedRe-established blood flow to a site of previous arterial occlusion and necrosis,INFARCTION,Hemorrhagic infarction of the lungGross Roughly wedged shapedDark red,solid area Base beneath the pleura Fibrin exudation LM Coagulative necrosisLarge amounts of RBC filled in alveolar spaceObscure structure,INFARCTION,Hemorrhagic infarction of the intestine,INFARCTION,Septic InfarctionBacteria containing emboliMay form abscess and pus,INFARCTION,Fate of Infarct Enzymatic lysis,liquefaction and absorption Organization with scar formation Encapsulation and Calcification,INFARCTION,Factors that influence development of an infarctNature of the vascular supplyRate of development of occlusionVulnerability to hypoxiaOxygen content of blood,