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1、Local Hemodynamic Disorders局部血液循环障碍,基础医学院病理学系罗庚求,Contents,循环血量的异常(充血、缺血)circulation volume 血液内出现异常物质 abnormal material 血管内成分逸出血管外 emit,Hyperemia And Congestion A local increased volume of blood in a particular tissue充血和淤血 局部组织血管内血液含量增多,Hyperemia Arterial hyperemia/Active hyperemia An active process
2、resulting from augmented blood flow due to arteriolar dilation 充血 动脉性充血/主动性充血 动脉输入血量增多,原因：血管舒张神经兴奋性 血管收缩神经兴奋性 舒张血管活性物质释放,Causes:excitability of vasodilatator excitability of vasoconstrictor dilivery of relaxing vasoactive substance,分类：生理性充血 病理性充血 减压后充血,Classification:physiological pathological Post-
3、decompression,physiological,生理性充血,hyperemia of appendix阑尾充血,pathological changesConsequence病变后果,hyperemia,Congestion Venous hyperemia/Passive hyperemia A passive process resulting from impaired venous return from a tissue 淤血静脉性充血/被动性充血静脉血流回流受阻,Reasons:Local congestion：External pressure Thrombosis Sy
4、stemic congestion：Heart failures原因：局部：静脉受压血栓形成全身：心力衰竭,Fate,Atrophy(萎缩）Degeneration（变性）Necrosis（坏死）Edema（水肿）Hemorrhage（出血）Sclerosis（硬化）,Lung congestion Lung brown induration Heart failure cellsEdemaHemorrhage肺淤血 肺褐色硬化 心衰细胞水肿出血,Lung brown induration,heart failure cells,Heart Failure cells,Lung congest
5、ion,Liver congestion 肝淤血,Fatty degeneration(脂肪变性)Atrophy(萎缩)Centrilobular necrosis(小叶中央性坏死)Nutmeg liver(槟榔肝)Congestive liver cirrhosis淤血性肝硬化,Nutmeg liver,Nutmeg,Nutmeg liver,Nutmeg liver,Congestive liver cirrhosis,Thrombosis ThrombusThrombosis is the process of formation of a solid from the blood wi
6、thin living blood vessels or the heart,the resultant is termed a thrombus.血栓形成/血栓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.,Three primary influences predispose to thrombus formation:血栓形成的三个条件:Endothelial injury(most important)Alone can induce thrombosis心血管内皮细胞的损伤 Stasis or turbulence of blood flow血流状态的
7、改变(缓慢,涡流)Blood hypercoagulability血液凝固性增高,心血管内皮细胞的损伤,抗凝,Protective screen,PGI2,NO,ADP酶,ThrombomodulinMembrane-associated heparin-like moleculesProtein S,t-PA,促凝,组织因子,Von Willebrand factor,PAIs,On contact with extracellular matrix(ECM),platelets undergo three general reactions:(血小板的活化)Adhesion reactio
8、n(粘附反应)Release reaction(释放反应)Aggregation reaction(粘集反应),Ulcerative atherosclerosis(溃疡性的动脉粥样硬化)Transmural myocardial infarction(透壁的心肌梗塞)Vasculitis(脉管炎,血管炎)Trauma(创伤,外伤,损伤)Radiation(辐射,放射)Bacterial toxins(细菌毒素),Endothelial injury,Stasis or turbulence of blood flow（血流状态的改变）Platelets activated by contac
9、t with endothelium.（血小板与内皮接触后激活）Slowed flow retards dilution of activated blood coagulation factor（凝血因子浓度升高）Turbulence may induce endothelial injury（涡流导致内皮损伤）,Hypercoagulable states（高凝状态）,Primary(genetic):（原发性）Antithrombin III deficiency（抗凝血酶III缺陷）Protein C deficiency（蛋白缺陷）Protein S deficiency（蛋白缺陷）
10、,Hypercoagulable states,Secondary(acquired):High risk:Prolonged bed rest or immobilization.（不动）Myocardial infarction(心肌梗死）Tissue damage(surgery,fractures,burns)Cardiac failure(心衰）Acute leukemia（急性白血病）DIC.Cancer Atrial fibrillation（房颤）Cardiomyopathy（心肌病）,Hypercoagulable states,Secondary(acquired):Low
11、 risk:Nephrotic syndrome（肾病综合征）Hyperlipidemia（高脂血症）Oral contraceptives.（口服避孕药）Sickle cell anemia（镰刀细胞贫血）Smoking（吸烟）Thrombocytosis（血小板增多）,Process of thrombus formation,Types of thrombus（血栓的类型）Pale thrombus（白色血栓）Red thrombus（红色血栓）Mixed thrombus（混合血栓）Hyaline thrombus/microthrombus/fibrinous thrombus（透明
12、血栓/微血栓/纤维素性血栓）,Downloaded from:Robbins&Cotran Pathologic Basis of Disease(on 28 August 2005 09:34 AM),2005 Elsevier,Downloaded from:Robbins&Cotran Pathologic Basis of Disease(on 28 August 2005 09:34 AM),2005 Elsevier,mixed thrombus,mixed thrombus,pale thrombus,hyaline thrombus,Fate of the Thrombus（血
13、栓的结局）Dissolution（软化、溶解、吸收）Organization/recanalization（机化/再通）Calcification/phlebolith/arteriolith（钙化/静脉石/动脉石）,recanalization,Effects of thrombosis（影响：“弊大于利”）Ischemia(阻塞血管局部缺血)Embolism（栓塞）Heart valve disease（心瓣膜变形）DIC（广泛性出血）,Embolism（栓 塞）Embolus（栓子）An embolus is a detached intravascular solid,liquid,o
14、r gaseous mass that is carried by the blood to a site distant from its point of origin。,(在循环血液中出现的不溶于血液的异常物质，随血流运行阻塞血管腔的现象称为栓塞。),Motional pathway of embolus（栓子的运行途径）,Embolus from right heart cavity or venous system（右心或静脉系统）Embolus from left heart cavity or arterial system（左心或动脉系统）Embolus from portal
15、 veins（门静脉）Paradoxical/Crossed embolism（反常栓塞，交叉栓塞）Retrograde embolism（逆行栓塞）,Thromboembolism（血栓栓塞）Pulmonary thromboembolism（肺动脉栓塞）Systemic thromboembolism（体循环动脉栓塞）,Pulmonary embolism（肺动脉栓塞）1.Large emboli(5%):（大栓子）,Instantaneous death(60%).（猝死）,pulmonary embolism,这里是位于通向左肺的肺动脉内一个大的肺栓。这类血栓发源于不能走动的病人的大腿
16、静脉或骨盆静脉。,Large embolus derived from a lower extremity deep venous thrombosis and now impacted in a pulmonary artery branch.,2.Small emboli(60-80%):（小栓子）,Infarctions（梗死）,Systemic embolism（体循环栓塞）,I.80-85%from heart（心脏）.Debris from ulcerative atheromata,（动脉粥样硬化溃疡）or in aneurysms(动脉瘤),血栓栓子停留在脑动脉，发源于左心房的
17、一个附壁血栓。心脏是这种拴子的常见来源。,Etiology:Fractures of long bonesSoft tissue traumaBurns,Fat embolism,Fat embolism(脂肪栓塞),Fig 5-17,Fat embolism,clinical manifestation（临床表现）Pulmonary insufficiency（肺功能不全）Neurologic symptoms（神经症状）,Gas embolism（气体栓塞）Air embolism（空气栓塞）Decompression sickness（减 压 病）,Etiology（病因）Intrave
18、nous therapeutic procedures（静脉输液）Obstetric procedures(分娩和流产)Chest wall injury（气胸）Decompression sickness(nitrogen)（减压病）,Air embolism,图a为锁骨下静脉栓塞。图b为上腔静脉和左心室气体栓塞。图c为肺动脉干气栓。,Gas embolism,Clinical effect:100 cc（临床反应）Caisson disease/divers disease（沉箱病/潜水员病）Multiple foci of ischemic necrosis in skeletal sy
19、stem and bends（骨关节缺血性多灶性坏死）,AMNIOTIC FLUID EMBOLISM（羊水栓塞）,Incidence:1/50 000（发病率）Mortality rate:80%（致死率）Clinical onset:（临床）Sudden severe dyspnea（呼吸困难）Cyanosis（发绀）hypotensive shock（休克）Coma（昏迷）,角化上皮,Embolization of the pulmonary microcirculation of the particulate debris in amniotic fluid.（肺的微循环栓塞）Rel
20、ease of vasoconstrictor agents,e.g.,PG reducing pulmonary blood flow.(缩血管物质）Intercurrence of DICShock(休克）,其他栓塞:胆固醇栓子,癌栓,Infarction（梗死）An infarction is an area of ischemic necrosis caused by occlusion of either the arterial supply or the venous drainage in a particular tissue。（器官或局部组织由于血管阻塞，动脉多见、血流停止
21、导致缺氧而发生的坏死。）,Thrombosis（血栓形成）Embolism（栓塞）Twisting of the vessels（血管痉挛）Extrinsic compression（外源性压迫）,Etiology（病原学）,Factors that influence development of an infarct（影响梗死的因素）Nature of the vascular supply（血管类型）Vulnerability to hypoxia（对缺血的敏感性）,INFARCTION（梗死）,Morphology of infarct（形态学）,Shape:Wedge-shaped
22、Irregular Segmentaltexturecolor:Red and white infarcts,Classification（分类）Anemic infarcts/White infarcts（贫血性梗死/白色梗死）:心,肾,脾 Hemorrhagic infarcts/Red infarcts（出血性梗死/红色梗死）:肺、肠 Septic infarcts（败血性梗死）,Tissues previously congested（淤血）Loose tissues(组织疏松）,Hemorrhagic infarcts/Red infarct（出血性梗死）,Spleen infarc
23、t,Lung infarct,梗死区,Intestine infarct,Clinical Effects 决定于梗死的器官、梗死灶的大小和部位、以及有无细菌感染,Hemorrhage（出血）,一、名词解释：congestion Heart failure cellsBrown induration of lung Nutmeg liver Thrombosis Decompression sickness,二、问答题：1、慢性肝淤血时，肝切面为什么会出现槟榔状花纹？2、栓子是如何运行的？3、羊水栓塞的病理特征是什么？4、静脉淤血、血栓形成、栓塞及梗死之间有何联系？,Case discussi
24、on,Case abstract.Female,30-year-old,farmer.Chief complaint.Intermittent palpitation(心悸）and short breathe for 1 years;lower extrem-ities edema and oligouria for 1 month.,Current medical history.Since last year,she felt palpitation and short breath after laboring,and these symptoms were relieved when
25、relaxation.She caught a cold,and presented fever,worsen palpitation and short breath one month before.,Simultaneously,Lower extremities edema,oligouria,and right-upper abdominal turgor(膨隆）began and appetite decreased,Especially she was unable to lie horizontally.She was admitted to hospital because
26、the General medical treatment was ineffective to her.,Past medical history:frequent pharyngodynia(咽痛）and arthralgia（关节痛）10 years before was mentioned.,Physical examination.She was semireclin-Ing position,chronic sickly complexion with terminal and lips cyanosis.Jugular vein dilated,and mild-moderate
27、 rales in the dorsal of both lungs Were noticed.The cardiac border was enlarged bilaterally.,HR 110/min,BP:110/70mmHg,thunder-like murmur during diastolic(舒张）phase was palpated in precordium region.And blowing murmur during systolic phase was ausculated(听诊).The liver was 3 cm beneath the rib and 5 c
28、m beneath the xiphoid process,tough and mild tenderness（触痛）.,hepato-jugular veins regurgitation sign was positive and the lower extremities was depressiveedema.Lab examination:urine:protein(+),BRC 1-2/HP,hyaline cast 1-2/HP.X-ray:the heart was bilaterally enlarged And the texture of both lungs increased.,Diagnosis 1:rheumatic heart disease 2:mitral stenosis and insuficiency 3:pan-heart failure,勤奋、严谨、团结、进取 Diligent,rigorous,solidification,enterprising,Thanks!,
