第三章局部血液循环障碍课件.ppt
Chapter3 Local Fluid and Hemodynamic Derangements第三章局部血液循环障碍,概 述全身性：出血和休克局部性：心肌梗死，肺栓塞和脑血管意外,important contents,充血和瘀血 hyperemia and congestion血栓形成thrombosis栓塞embolism梗死infarct,出血hemorrhage(study by yourself),Section1 hyperemia and congestion充血和淤血,A local increased volume of blood in a particular tissue may cause hyperemia or congestion 局部组织血管内血液含量的增多动脉性充血 arterial hyperemia简称充血hyperemia静脉性充血venous hyperemia简称淤血congestion,一充血hyperemia Active hyperemia主动性充血 器官和局部组织因动脉输入量的增多而发生的动脉性充血,MECHANISM机制：TYPES分类：1physiologic hyperemia生理性充血 2pathological Hyperemia病理性充血图 decreasing pressure减压后充血MORPHOLOGY病变：RESULT结果:,阑尾浆膜充血 appendiceal inflammation,二淤血Congestion,被动性充血passive hyperemia 是由于静脉回流受阻，导致末梢静脉，小静脉和毛细血管被动扩张，局部含血量增加也称静脉性充血,静脉性充血,Congestion,(一)Causes原因：,1、静脉受压(pressure of the venous)2、静脉腔阻塞（venous obstruction）3、心力衰竭（heart failure）,（二）Morphology形态变化Microscopy镜下:edema水肿hemorrhage出血atrophy、degeneration、necrosis实质细胞萎缩、变性、坏死Sclerosis硬化thrombosis血栓形成,（三）重要器官的淤血important organs congestion,1 lungs congestion肺淤血Pathogenesis发病机理：Pathological change病理变化：Acute pulmonary congestion 急性肺淤血 acute left heart failure,lungs congestion肺淤血,lungs congestion肺淤血,In chronic pulmonary congestion 慢性肺淤血 1，2，3“心力衰竭细胞heart failure cells”含铁血黄素hemosi derin 肺褐色硬变(肺棕色硬化)Brown duration临床表现：,lungs congestion肺淤血,2 肝淤血liver congestion,Pathogenesis发病机理：Pathological change病理变化：acute hepatic congestion 急性肝淤血,慢性肝淤血 chronic passive congestion of the liver,Grossly(大体):体积,包膜,颜色Microsopically(镜下):“槟榔肝nutmeg liver”淤血性肝硬变cardiac cirrhosis,“槟榔肝nutmeg liver”In chronic hepatic congestion，the central regions of the hepatic lobules are grossly red-brown and slightly depressed,while the peripheral zones are uncongested tan or pale tissue,which sometimes fatty 慢性肝淤血时,肝小叶中央区淤血，肝细胞萎缩、变性、坏死周围因脂肪变而呈黄色,切面上因此表现为红黄相间,nutmeg liver,槟榔肝nutmeg liver（Grossly）,Chronic passive congestion of the liver,案例:病例摘要 患者，男，33岁，因心慌、胸闷月，咳嗽、气急20天入院。既往有风湿病史，二尖瓣狭窄。近日症状加重，夜间不能平卧，痰中带血，尿量减少，双下肢水肿，腹胀、胃纳差。体检：体温37度、脉搏124次/分，呼吸31次/分，血压140/90mmHg，颈静脉怒张，肝右肋下2cm、剑突下3cm，腹部有移动性浊音，双下肢凹陷性水肿。X线检查：双肺纹理增粗，心界扩大。问题（1）该患者左心衰竭的临床表现有哪些？（2）该患者右心衰竭的临床表现有哪些？（3）分析该患者肺和肝各有何病理变化？,Section3 Thrombosis血栓形成,在活体的心脏和血管内血液成分形成固体质块的过程称为血栓形成thrombosis 在这过程中所形成的固体质块称为血栓（thrombus）。,血栓形成的条件和机制,血 液 凝 固 性 增 高,心血管内皮细胞的损伤,血 流 状 态 的 改 变stasis,条件,The pathogenesis of thrombosis,The process of thrombosis血栓形成,Venous thrombosis,静脉延续性血栓,血栓的形态学Morphology of thrombi,1.Pale thrombus白色血栓The head of thrombus头部 Grossly:Microscopically:Pale thrombus HE染色100,mixed thrombus混合血栓,The body of thrombus(血栓体部)Grossly:Microscopically:,mixed thrombus HE染色 100,red thrombus红色血栓Grossly:Microscopically:hyaline thrombus透明血栓（微血栓）Grossly:Microscopically:,髂动脉血栓,thrombi,肺动脉内大血栓,三Fate of thrombus血栓的结局,1.fibrinolysis溶解2.organization and recanalization 机化和再通3.Calcifications 钙化(静脉石),四.血栓与临床联系clinical correlation,（一）阻塞血管obstruct blood vessel(二)栓塞thrombosis(三)心瓣膜变形valvular deformity(四)弥漫性血管内凝血(DIC)Disseminated intravascular coagulation,案例病例摘要 患者,男,20岁.因皮肤大面积烧伤急诊入院.住院期间反复从股静脉输血输液,历时2月,终因抢救无效死亡.尸检见:皮肤大面积烧伤并化脓感染,股静脉、脾静脉、肠系膜上下静脉均有血栓形成并与血管壁粘连紧密，右肺中叶有一暗红色楔形出血性梗死（1）该患者股静脉血栓形成的条件有些？（2）血栓有哪些类型？该病例所形成的血栓最可能是那种类型？（3）血栓的结局有哪些？该病例的血栓发生的变化？,问题解答(1)患者股静脉血栓形成的条件有:血管内皮损伤:大面积烧伤及反复多次的股静脉输血输液损伤血管内皮;血流缓慢和血流中涡流的形成:患者久病卧床血流缓慢及股静脉内有静脉瓣,其内血流不但缓慢,而且出现涡流.;血液凝固性增高:大面积烧伤使血液浓缩、粘稠度增加，血中凝血因子含量增多，以及血中补充大量的幼稚血小板，其粘性增加，易于发生粘集形成血栓。（2）血栓类型有4种：白色血栓、红色血栓、混合血栓和透明血栓。该患者静脉血栓属于延续性血栓，其头部为白色血栓，血栓体为混合血栓，血栓尾为红色血栓。（3）血栓的结局有：溶解吸收软化、机化和钙化。本病例多处静脉内血栓形成并与血管壁粘连紧密说明血栓发生了机化，另外右肺中叶的出血性梗死是血栓栓塞所致，股静脉内较大的血栓部分软化脱落后形成栓子，导致肺血栓栓塞而梗死,Section4 embolism栓塞,An abnormal substance appears intravascular and follow blood to obstruct the blood vessel known as embolism and that abnormal substance is known as embolus 概念:血管内出现异常物质,阻塞血管腔的过程称为栓塞（embolism）,这些异常物质被称为栓子(embolus)solid,liquid,or gaseous,embolism栓塞 Contents 1.origin of embolus 栓子的运行途径2.types of embolism and clinical effect 栓塞的类型和对机体的影响,栓子的运行途径origin of embolus,血流的方向一致。1.origin in systemic veins or in the right side of the heart 静脉系统及右心栓子2.Origin in systemic arteries and in the left side of the heart 主动脉系统及左心栓子3.Crossed embolism 交叉性栓塞4.Retrograde embolism 逆行性栓塞,The types of embolus栓子的种类,(一)thromboembolism血栓栓塞1.pulmonary thromboembolism 肺血栓栓塞,肺动脉内大血栓,肺血栓栓塞,2.systemic thromboembolism 体循环动脉栓塞阻塞脑、脾、肾的动脉，引起缺血、梗死(二)脂肪栓塞fat embolism长骨骨折，脂肪小滴入血右心肺栓塞左心脑栓塞。,(三)气体栓塞air embolism图 1.空 气栓塞gas embolism：空气栓塞锁骨下（颈）右心肺动脉栓塞猝死 2.氮气栓塞（潜水病）沉箱病或减压病:(caisson disease or decompression sickness):,减压病,caisson disease,羊水栓塞,分娩过程中发生，罕见,子宫强烈收缩，可将羊水压入破裂的子宫壁静脉窦内,肺循环栓塞,患者突然严重呼吸困难，紫绀、休克、抽搐和昏迷，多数死亡。,(四)羊水栓塞 Amniotic fluid embolism,(五)others其他栓塞肿瘤细胞栓塞;细菌栓塞:或寄生虫栓塞,Section5 Infarction梗死,概念：An infarct is an area of ischemic necrosis caused by occlusion of either the arterial supply or the venous drainage in a particular tissue 器官和组织的血液供应减少或中断称为缺血（ischemia）。由血管阻塞引起的局部组织缺血性坏死称为梗死（infarction）。,Contents,1.The Causes of infarct 梗死的病因和形成条件2.Morphology and classification of infarct 梗死的病变和类型,1.The Causes of infarct 梗死的病因和形成条件(1)血栓形成(2)动脉栓塞(3)动脉痉挛(4)血管受压闭塞(5)血供类型(6)组织耐受性,2.Morphology and classification of infarcts梗死的病变及类型,器官 梗死灶形状 梗死类型 梗死性质 肾 脾 肺 心 肠 脑,肾梗死infarct of kidney,心肌梗死infarct of heart,（根据含血量多少）1Anemic(red)infarcts贫血性梗死2Hemorrhagic(white)infarcts 出血性梗死（根据有无细菌感染）1败血性梗死2单纯性、无感染性梗死,贫血性梗死anemic infarcts,条件Organs(器 官):Grossly(肉眼):Microscopically(镜下):有明显的充血和出血带脑梗死：心肌梗死：脾、肾梗死：,脑软化,肾梗死,出血性梗死hemorrhagic infract,条 件：Organs(器 官):Grossly(肉眼):Microscopically(镜下):肺和肠,lung infract肺出血性梗死,肺出性梗死,lung infract肺出血性梗死,bowel infract肠出血性梗死,bowel infract肠出血性梗死,三梗死的临床意义clinical signification of infarction,Affection:梗死的器官和梗死灶的大小和部位1肾梗死2脾梗死3肺梗死4肠梗死5心肌梗死6脑梗死7四肢梗死End:瘢 痕 修 复,病例摘要:男性，50岁，患高血压已20年。近两年来，劳累后心慌气短，体力减退。一年来出现呼吸困难，不能平卧，咳嗽、咳泡沫痰，并发现尿少、双下肢发凉、发麻、行动时腿痛明显，休息后好转，近几天左脚剧疼，足背动脉搏动消失，皮肤逐渐变黑，完全不能活动，最终因心力衰竭死亡。尸解肉眼所见：心脏肥大，左心室壁片状灰白色瘢痕灶，主动脉及冠状动脉粥样硬化，右足胫前动脉内血栓形成，右足坏疽。问题（1）右足胫前动脉内为什么有血栓形成？（2）该患者左心室壁片状灰白色瘢痕灶的原因是什么？（3）患者为什么双下肢发凉、发麻、行动时腿痛明显?,Questions,1.What is the causes,features and results of chronic of lungs congestion 慢性肺淤血的原因,特点和后果?2.What is the Congestion and its causes?淤血及其原因是什么?3.What is the types of infarction and which organs spectively?梗死的类型和分别发生于那些脏器?,4.What is thrombosis and the morphology of its types(four types).何为血栓形成,并简述各型血栓的构成.5.What is fate of the thrombosis?血栓的结局 名词解释:1槟榔肝nutmeg liver2心力衰竭细胞heart failure cells3肺肉质样变pneumonary carnifiedon,5机化organization6再通recanalization7沉箱病或减压病caisson disease or decompression sichness,
