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1、局部血液循环障碍 Hemodynamic Disorders,NANJING MEDICAL UNIVERSITY,李芸茜Lyq_Tel:86862046,第四章,局部血液循环障碍的表现,血量异常 血液性状和内容物的异常 血管壁通透性和完整性改变,充血,淤血,充血和淤血,充血 Hyperemia,病因：静脉血流出受阻心衰局部静脉堵塞或受压病变：紫绀cyanosisinadequate tissue perfusion and persistent hypoxiaelevated intravascular pressures,淤血 Congestion,急性肺淤血,急性肺淤血,（Prussio
2、n blue stain）,急性肺淤血,慢性肺淤血,慢性肺淤血，肺褐色硬化,症状：呼吸困难、紫绀、咳痰 体征：湿啰音 检查：痰涂片 治疗：给氧、治疗心衰,肺淤血的临床病理联系,肝淤血,槟榔肝,槟榔肝,槟榔肝,肝淤血,肝淤血,centrilobular hepatic necrosis with hemorrhage,centrilobular hepatic necrosis with hemorrhage,淤血性肝硬化,肝淤血的临床病理联系 症状：肝功能障碍 体征：肝大、触痛 检查：转氨酶升高 治疗：治疗心衰、慢支,血栓形成 Thrombosis,在活体的心血管内，血液发生凝固或血液中某些有
3、形成分析出、凝集形成 固体质块的过程。,The pathologic counterpart of 凝血 hemostasis is 血栓形成 thrombosis,the formation of blood clot(血栓 thrombus)within intact vessel.,hemostasis,血管壁 the vascular wall血小板 platelets凝血因子 the coagulation cascade,Both 凝血hemostasis and 血栓形成thrombosisinvolve three elements：,血管内皮 endothelium,正常时，
4、内皮抗凝 anticoagulant损伤或激活时，内皮促凝 procoagulant,血小板聚集,凝血因子,纤溶系统,TNFIL-1endotoxin,血小板 platelets,TxA2(PLt),PGI2(EC),凝血途径The coagulation cascade,纤溶系统 The fibrinolytic system,Virchows triad in thrombosis,血管内皮损伤,血流状态改变,血液高凝状态,血栓,心肌梗死灶 动脉粥样斑块破裂 血管（瓣膜）炎,高血压 血液涡流状态 放射性损伤高胱氨酸尿症高胆固醇血症吸烟细菌产物,内皮损伤EC injury 举例,Endoth
5、elial dysfunctionproanti,Endothelial damage,Thrombi over ulcerated plaques in atherosclerotic aorta,thrombi in the cardiac chambers after MI,血流状态改变 abnormal blood flow,Both promote EC activation and enhanced procoagulant activity 使内皮促凝 Stasis allows platelets and leukocytes to contact with the EC 致
6、Plt和WBC触壁 Stasis slows the washout of activated clotting factors and impedes the inflow of clotting factor inhibitors 局部凝血因子浓度升高,涡流 turbulance,停滞stasis,风湿性心脏病（二狭左房扩张+房颤）长期卧床或久坐HyperviscositySickle cell anemia,粥样斑块动脉瘤心肌梗死,血流状态改变举例,涡流 turbulance,停滞stasis,高凝血状态 Hypercoagulability,It is loosely defined
7、as any alteration of the coagulation pathways that predisposes affected persons to thrombosis,先天性 primary(genetic)Factor V mutation Prothrombin mutation 获得性 secondary(acquired),妊娠口服避孕药老年扩散的肿瘤创伤手术DIC,血栓的形态 Morphology,起点 走向 层状结构 lines of Zahn,心腔内血栓动脉血栓,静脉血栓,混合血栓/层状血栓,血栓形成的过程,延续性血栓,白色血栓血小板血栓疣状赘生物,血栓的形态
8、类型,混合血栓 mixed thrombus 白色血栓 pale thrombus 红色血栓 red thrombus 透明血栓 hyaline thrombus,透明血栓/微循环纤维素血栓,透明血栓/微循环纤维素血栓,terms,Thrombi occurring in heart chambers or in the aortic lumen are designated mural thrombi 附壁血栓 Thrombi on heart valves are called vegetations 赘生物赘生物发生细菌或真菌感染引起 infective endocarditis 感染性
9、心内膜炎,附壁血栓,感染性赘生物,死后凝血,血栓的结局 fate,Propagation,Embolization,Dissolution,Organization and recanalization,1,2,3,4,hours,血栓对机体的影响,阻塞血管 引起栓塞 心瓣膜病 出血（DIC）,动脉,静脉,心瓣膜,DIC is the sudden or insidious onset of widespread thrombosis within the microcirculation,a potential complication of numerous conditions asso
10、ciated with widespread activation of thrombin.,冠脉内血栓,冠脉内血栓,冠脉造影,脑血栓,静脉血栓,90%发生于下肢表浅静脉血栓疼痛，水肿，溃疡（淤血）深静脉血栓（DVT）疼痛，水肿 膝关节以上DVT prone to embolize,心衰,久卧久坐,创伤手术烧伤,妊娠,Trousseau syndrome,50y,Deep Venous Thrombosis，DVT,下肢静脉血栓,肺动脉中栓子,DVT致肺骑跨性栓塞,慢性风湿性心瓣膜病,感染性心内膜炎,栓塞 Embolism,An embolus（栓子）is a detached intrava
11、scular solid,liquid or gaseous mass that is carried by blood to a site distant from its origin,血栓栓塞Thrombo-embolism,脂滴,氧/氮气泡,胆固醇（粥样斑块碎片）,肿瘤栓子,羊水,骨髓,栓子运行的途径,体循环血栓栓塞 Systemic embolism肺动脉栓塞 Pulmonary embolism,交叉性栓塞,逆行性栓塞,肺动脉血栓栓塞,Incidence(美国)：2 to 4 per 1000 住院病人，死亡率2%(5万)95%of cases，栓子来源于膝关节及以上DVT 栓塞部
12、位不同后果不同,a major pulmonary arterymedium-sized arteriessmall end-arteriolar pulmonary branches,general state of the circulation,size of the embolic mass,后果,骑跨性血栓栓塞 saddle embolus,肺梗死,肺梗死,临床表现 clinical features,60-80%clinical silent(栓子溶解，支气管动脉维持血供)5%.猝死，急性右心衰，心源性休克(大栓子或多发小栓子致 60%肺循环受阻)10-15%.肺梗死(呼吸困难，咯
13、血，胸痛)3%.慢性肺动脉高压，肺心病，肺动脉硬化(栓塞反复发作),体循环血栓栓塞,80%来源于心腔内附壁血栓2/3左室心梗继发血栓25%左房扩大其他来源：AS斑块继发血栓,动脉瘤内 血栓,瓣膜赘生物,交叉性血栓10-15%Unknown,栓塞部位 下肢(75)脑(10)肠，肾，脾,体循环血栓栓塞,梗 死?,1.2.3.,脂肪栓塞 Fat embolism,病因：软组织挤压伤，长骨骨折10%的病人出现临床症状少数发生脂肪栓塞综合征 fat embolism syndrome，死亡率10%,皮肤瘀斑血小板减少,Neurologicsymptoms易激惹烦躁谵妄昏迷,Pulmonary insuf
14、ficiency呼吸急促呼吸困难心跳加速,脂肪栓塞,脂肪栓塞,脂肪栓塞,脂肪栓塞,Oil red O stain,hypoxia,空气栓塞 air embolism,气体融合后阻塞血流引起缺血进入动脉 进入静脉,death,心,肺,呼出,足够多,心脏搭桥术,头部手术(坐式),产科手术,胸壁损伤,氮气栓塞/减压病Decompression sickness,发病人群：深海作业者，Scuba divers发生机制：临床表现：骨骼肌中和关节气泡集聚疼痛 肺循环中气泡集聚水肿，出血，局部肺不张 或肺气肿，呼吸衰竭骨坏死(慢性，沉箱病 cassion disease)治疗方法：,气体栓塞,气体栓塞,羊水
15、栓塞 Amniotic fluid embolism,罕见的，严重的产科并发症起病：sudden severe dyspnea,cyanosis,and hypotensive shock,followed by seizures and coma肺水肿，DIC发生机制病理变化：羊水栓子，透明血栓，DAD,1/40000,死亡率80%,羊水栓塞,羊水栓塞,肿瘤栓塞,细菌栓塞,梗死 Infarction,An infarct(梗死灶)is an area of ischemic necrosis caused by occlusion of the vascular supply to the
16、affected tissue.the process by which such lesions form termed infarction.,肺梗死,脑梗死,心肌梗死,肠梗死,gangrene,梗死的病因,动脉血栓或动脉栓塞 其他原因的动脉受阻(less common)：动脉痉挛，粥样斑块内出血动脉受压(肿瘤/疝/twisting/夹层动脉瘤)Infarcts caused by venous thrombosis thus usually occur only in organs with a single efferent vein(e.g.,testis or ovary),血管堵
17、塞是否引起组织坏死取决于？,The presence or absence of an alternative blood supplyRate of occlusionTissue vulnerability to ischemiaHypoxemia,侧枝循环肠/四肢,双重血供肝/肺,终末动脉供血心/肾/脾/脑,梗死的类型,贫血性梗死 white(anemic)出血性梗死 red(hemorrhagic)败血性梗死 Septic infarctions,颜 色(白/红),有无感染,肾梗死,心肌梗死,心肌梗死,肺梗死,肺梗死,肠梗死,肠梗死,肠梗死,红色梗死的条件,双重血供或侧枝循环丰富组织疏
18、松 动脉阻塞静脉淤血,缺血再灌注,ovarian torsion,红色梗死特例,脑梗死,脑梗死,肾上腺梗死,肾梗死,肾梗死,心肌梗死,脑梗死,脑梗死,梗死灶的形态特征,梗死灶的形状取决于血管分布方式梗死灶(脑除外)镜下为凝固性坏死梗死灶的颜色取决于病灶内的含血量,梗死的器官（脑、心、肾、脾、肺、肠）梗死灶的大小 有无继发感染,梗死对机体的影响,梗死灶的结局：炎症，机化，瘢痕,Thank You!,Summary,淤血的概念，后果肺淤血（急、慢性）、肝淤血的病理变化心衰细胞，肺褐色硬化，槟榔肝血栓和血栓形成的概念血栓形成的条件（简答）静脉血栓多见的原因四种类型的血栓：好发部位，形成条件，成分，形态血栓的结局血栓对机体的影响（有利、不利）,Summary,栓塞和栓子的概念肺动脉栓塞：来源，后果体循环栓塞：来源，常见疾病，栓塞部位羊水栓塞的病理诊断梗死的概念，原因和条件梗死灶的形态特点：形状质地和颜色梗死的类型，出血性梗死的条件梗死的结局,
