血液循環(huán)系統(tǒng)障礙

HemodynamicDisorders

DepartmentofPathology1《心血運(yùn)動(dòng)論》威廉

哈維AnAnatomicalStudyoftheMotionoftheHeartandoftheBloodinAnimals,16282ContainingHeart,artery,VeinGeneralcirculationPulmonarycirculationFunctionsDeliveroxygenandnutrientsCarryawaymetabolicwastes健康的循環(huán)系統(tǒng)： ?正常血容量（Normalbloodvolumn） ?

血液穩(wěn)態(tài)（Homeostasis）3血液穩(wěn)態(tài)

血管壁完整性vesselwallintegrity

靜水壓intravascularpressure

膠滲壓osmolarity

正常凝血normalhemostasisEdema水腫Hyperemia&congestion

充血和淤血Thrombosis&Embolism

血栓形成和栓塞Infarction梗死Hemorrhage出血Shock休克ThreeMajorCausesofmorbidityandmortality ?Myocardialinfarction心肌梗死 ?Pulmonaryembolism肺栓塞 ?Cerebralvascularaccident腦血管意外，中風(fēng)4CirculationDisturbanceGeneral(全身性)

Someseveresituationaffectingalloverthebody:

cardiacdysfunction心功能不全

shockLocal（局灶性）Abnormalbloodvolumeandthevelocityofbloodflow:hyperemiaandischemiaAbnormalityofvascularintegrityandpermeability:edemaandhemorrhage

Occlusionofthevessellumen:thrombosis,embolismandinfarction

125WordsandVocabulariescyanosisedemasclerosisheartfailurecellbrownindurationnutmeglivermixedthrombushyalinethrombusorganizationrecanalizationphlebolith&arteriolithcrossedembolismorparadoxicalembolismretrogradeembolismthromboembolismcaissondiseasedecompressionsicknessamnioticfluidembolismsepticinfarct6EDEMA(水腫)組織間隙（interstitialtissuespaces）液體含量增加General&localPathogenesisVascularhydrostaticpressurePlasmacolloidosmoticpressureLymphaticdrainage7EDEMAIncreasedhydrostaticpressure(如心功能不全致心源性水腫，cardiacedema)Reducedplasmaosmoticpressure(nephrotic,hepatic,malnutrientedema,etc.)Lymphaticobstruction(如絲蟲病感染—橡皮腫，乳癌擴(kuò)大根治術(shù)后)Sodiumandwaterretention水鈉潴留(如急性腎衰)MinimalChangeDiseaseelephantiasisPittingedema8EDEMAMostcommontypesSubcutaneousedemaPulmonaryedemaEdemaofthebrainMorphologyLightMicroscope（LM）:ClearingandseparationoftheextracellularmatrixelementsCellswelling9特殊類型Hydrothorax胸腔積液hydropericardium

心包腔積液hydroperitoneum(ascites)腹腔積液Anasarca

全身性水腫EDEMAClinicalcorrelationfromannoyingtofatalindicatesubtlediseasebenefitorharmful10HYPEREMIA&CONGESTION

充血和淤血局部組織血管內(nèi)血液含量的增多Arterialhyperemia(hyperemia，充血)局部器官或組織由于動(dòng)脈血輸入量增多而發(fā)生的充血anaugmentedbloodflowinducingarteriolarandcapillarydilationVenoushyperemia(congestion，淤血)局部器官或組織由于靜脈血液回流受阻，血液淤積于小靜脈和毛細(xì)血管內(nèi)accumulationofbloodinsmallveinsandcapillariesresultfromdrainagedifficultyofveins11HYPEREMIA&CONGESTIONHyperemia:activeprocess主動(dòng)過程;red,raisedtempreture,increasedvolume（紅熱腫）enhancedfunction功能增強(qiáng);Congestion:

passiveprocess被動(dòng)過程;generaloflocal;reddishbluecolor(cyanosis),lowtemperature,increasedvolume,edema（紫冷腫）;decreasedfunction功能低下12機(jī)制：

血管舒張神經(jīng)興奮性↑

血管收縮神經(jīng)興奮性↓類型：

生理性：

如害羞時(shí)，運(yùn)動(dòng)時(shí)，進(jìn)餐后

病理性：炎性充血，減壓后充血

利弊：

－plentysupplyofO2,functionalenhancement,nutritionsubstance

－h(huán)eadache,hemorrhage,stroke

HYPEREMIA13Causes:

全身性:體循環(huán)淤血，肺循環(huán)淤血

cardiacdysfunction(rightorleft)局灶性:局部靜脈受壓或阻塞

externalCompression---tumor,bandage occlusionoflumen---thrombosis,embolism thickeningofvenouswall paralysisofneurogenicmodulation---burn,frostbite

CONGESTION14CONGESTIONChroniccongestionRaisedvenouspressure

AnoxiaMetaboliteaccumulationEnlargedinterendothelialgapBasemembranedegeneration

Parenchymal

InterstitialfibrosisAtrophyReticularfibercollapsedIncreasepermeabilityDegenerationCollagenincreasedNecrosisFibroblastproliferationMicroscopicscarring EdemaHemorrhage

Congestivesclerosis15CONGESTION慢性淤血

靜脈壓升高

缺氧及代謝產(chǎn)物堆積

毛細(xì)血管內(nèi)皮細(xì)胞間隙增寬

基底膜變性

實(shí)質(zhì)細(xì)胞萎縮、變性和壞死間質(zhì)纖維組織增生毛細(xì)血管通透性增加

淤血性水腫

淤血性出血

淤血性硬化16Morphology大體鏡下小血管內(nèi)富含紅細(xì)胞

CONGESTION17CONGESTION肺急性肺淤血acutepulmonarycongestion大體:肺飽滿腫脹，胸膜光澤，色澤暗紅，切面流出泡沫狀紅色血性液體

（edematousfluid）

鏡下:肺泡壁毛細(xì)血管高度擴(kuò)張充血——串珠樣，玫瑰樣肺泡腔“虛實(shí)不一”，充滿嗜酸性水腫液

臨床表現(xiàn)：

咳嗽，喀粉紅色泡沫痰（foamypinkysputum）18CONGESTION肺慢性肺淤血chronicpulmonarycongestion大體:質(zhì)地較硬，棕褐色，散在分布有棕色小點(diǎn)——褐色硬化(BrownInduration)鏡下:肺泡壁(septa)增厚纖維化心衰細(xì)胞(heartfailurecells)

，——吞噬紅細(xì)胞并將其中的血紅蛋白分解形成棕黃色的含鐵血黃素（hemosiderin）的巨噬細(xì)胞

—hemosiderin-ladenmacrophages

臨床表現(xiàn)：

咳嗽，喀鐵銹色痰，呼吸困難19CONGESTION肝

急性肝淤血acutehepaticcongestion大體：肝臟體積增大，呈暗紅色鏡下：

小葉中央靜脈和肝竇(sinusoid)擴(kuò)張，充滿紅細(xì)胞嚴(yán)重時(shí)可有小葉中央肝細(xì)胞萎縮、壞死

20CONGESTION肝慢性肝淤血chronichepaticcongestion

檳榔肝NutmegLiver大體：肝小葉中央?yún)^(qū)因嚴(yán)重淤血而呈暗紅色，肝小葉周邊部肝組織因脂肪變性而呈黃色，紅(淤血區(qū))黃(肝脂肪變區(qū))相間，狀似檳榔切面。鏡下：肝小葉中央?yún)^(qū)淤血乃至出血，肝細(xì)胞萎縮，甚至壞死、崩解消失，肝小葉周邊部肝細(xì)胞脂肪變性。長期嚴(yán)重的肝淤血

hepaticfibrosis(cardiaccirrhosis)

21Hemorrhage（出血）Causes血管破裂Trauma Pepticulcer,aneurism,atherosclerosis

出血傾向 Enlargedinterendothelialgap(basementmembraneinjury). TheintergrityofthevesselsremainsintactInjurytovascularwall:severeinfection,anoxia,toxinsChangeinnumberandqualityofplatelets

uremia,leukemia,idiopathicDisturbanceofcoagulationmechanism

congenitaldisease,DIC,deficiencyofVit.K22hemorrhage瘀點(diǎn)petechiae紫癜purpuras瘀斑ecchymoses血腫hematoma胸腔積血hemothorax心包腔積血hemopericardium腹腔積血hemoperitoneum關(guān)節(jié)腔積血hemoarthrosis臨床意義取決于出血的類型、出血量、出血速度和出血部位嚴(yán)重后果：

HemorrhagicshockStroke

23NormalhemostasisMaintainbloodinafluid,clot-freestateLocalizedhemostaticplug血栓形成在活體的心臟和血管內(nèi)，血液發(fā)生凝固或血液中某些有形成分凝集形成固體質(zhì)塊的過程稱為血栓形成(thrombosis)；所形成的固體質(zhì)塊稱為血栓(thrombus)。Hemostasis&thrombosis

（止血和血栓形成）24Hemostasis三個(gè)參與止血的主要成分

血管壁

血小板

凝血級聯(lián)反應(yīng)止血過程

血管攣縮vasoconstriction

一期（初步）止血primaryhemostasis

二期止血secondaryhemostasis

抗血栓形成反向調(diào)節(jié)

antithromboticcounter-regulation

25凝血途徑CoagulationPathway內(nèi)源性凝血途徑；外源性凝血途徑凝血因子Ⅰ~ⅩⅢ,Ca2+，血小板磷脂F(xiàn)Ⅲ：組織因子；FⅡ：凝血酶原；FⅠ：纖維蛋白原“a”代表水解激活后狀態(tài)Hemostasis26Hemostasis&thrombosis血管內(nèi)皮細(xì)胞抗凝特性Antithrombotic（內(nèi)皮完整時(shí)）抗血小板antiplatelet抗凝anticoagulant纖溶fibrinolytic促凝特性Prothrombotic（內(nèi)皮受損時(shí)）輔助血小板黏附激活外源性凝血途徑抑制纖維蛋白溶解27Hemostasis&thrombosis血小板黏附反應(yīng)(adhesion)釋放反應(yīng)

(releasereaction/secretion)黏集反應(yīng)(aggregation)凝血級聯(lián)反應(yīng)28thrombosisPathogenesis心血管內(nèi)皮細(xì)胞損傷血流狀態(tài)異常血液凝固性增加

魏爾嘯三角VirchowTriangle29thrombosisMorphology動(dòng)脈血栓originatefrominjurysites靜脈血栓(phlebothrombus)originatefromthesitesofstasis bothextendtotheheartZahn線，灰白色與暗褐色相間的條紋狀結(jié)構(gòu)

paleplateletandfibrinlayers darkerythrocyte-richlayers30thrombosisLinesofZahn31thrombosisLM:plateletstrabeculae+neutrophil fibrin+redcells32thrombosisTypes

MuralthrombusOcclusivethrombusGlobularthrombusVegetation細(xì)菌性血栓

腫瘤性血栓

PalethrombusMixedthrombusRedthrombusHyalinethrombus33

白色血栓PaleThrombus血小板&