1、血液循環(huán)系統(tǒng)障礙Hemodynamic Disorders,Ye Liu （劉 曄） Department of Pathology,心血運(yùn)動(dòng)論 威廉 哈維 An Anatomical Study of the Motion of the Heart and of the Blood in Animals, 1628,Containing Heart, artery, Vein General circulation Pulmonary circulation Functions Deliver oxygen and nutrients Carry away metabolic wastes,

2、健康的循環(huán)系統(tǒng)： 正常血容量（Normal blood volumn） 血液穩(wěn)態(tài) （Homeostasis）,血液穩(wěn)態(tài) 血管壁完整性 vessel wall integrity 靜水壓 intravascular pressure 膠滲壓 osmolarity 正常凝血 normal hemostasis,Edema 水腫 Hyperemia red, raised tempreture, increased volume （紅 熱 腫） enhanced function 功能增強(qiáng);,Congestion: passive process 被動(dòng)過(guò)程; general of local; re

3、ddish blue color (cyanosis), low temperature, increased volume, edema （紫 冷 腫）; decreased function 功能低下,機(jī)制： 血管舒張神經(jīng)興奮性 血管收縮神經(jīng)興奮性 類(lèi)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： plenty supply of O2, functional enhancement, nutrition substance headache , hemorrhage, stroke,HYPEREMIA,Causes: 全身性: 體循環(huán)淤血，肺循環(huán)淤血 ca

4、rdiac dysfunction (right or left) 局灶性: 局部靜脈受壓或阻塞 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 (cyanosis) Metabolite

5、 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,CONGESTION,慢性淤

6、血 靜脈壓升高 缺氧及代謝產(chǎn)物堆積 (紫紺) 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,Morphology 大體：暗紅、潮濕 鏡下：小血管內(nèi)富含紅細(xì)胞,CONGESTION,CONGESTION,肺 急性肺淤血 acute pulmonary congestion 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 （ edematous fluid ） 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，咯粉紅色泡沫痰（foa

7、my pinky sputum）,CONGESTION,肺 慢性肺淤血 chronic pulmonary congestion 大體: 質(zhì)地較硬，棕褐色，散在分布有棕色小點(diǎn) 褐色硬化 (Brown Induration) 鏡下: 肺泡壁(septa)增厚纖維化 心衰細(xì)胞(heart failure cells) ，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-laden macrophages 臨床表現(xiàn)： 咳嗽，咯鐵銹色痰，呼吸困難,CONGESTION,肝 急性肝淤血 acute hepatic congestion 大

8、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,CONGESTION,肝 慢性肝淤血 chronic hepatic congestion 檳榔肝 Nutmeg Liver 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)淤血甚至出血，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(zhǎng)期嚴(yán)重的肝淤血 hepatic fibrosis (cardiac cirrhosis),Hemorrhage （出血）,

9、Causes 血管破裂 Trauma Peptic ulcer, aneurism, atherosclerosis 出血傾向 Enlarged interendothelial gap (basement membrane injury). The intergrity of the vessels remains intact Injury to vascular wall: severe infection, anoxia, toxins Change in number and quality of platelets uremia, leukemia, idiopathic Dist

10、urbance of coagulation mechanism congenital disease, DIC , deficiency of Vit. K,hemorrhage,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(lèi)型、出血量、出血速度和出血部位 嚴(yán)重后果： Hemorrhagic shock Stroke,Normal hemostasis Main

11、tain blood in a fluid, clot-free state Localized hemostatic plug 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(guò)程稱(chēng)為血栓形成(thrombosis)；所形成的固體質(zhì)塊稱(chēng)為血栓(thrombus)。,Hemostasis MI, aortic aneurysms, ulcerated AS plaques, vegetations 栓塞部位: lower extremities, brain, intestines, kidney, spleen 結(jié)局: INFARCTION,體循環(huán)動(dòng)脈血栓栓

12、塞 Systemic Thromboembolism,Embolism,血栓栓塞 Thromboembolism 99% 非血栓栓塞 Non-thrombotic embolism 脂肪栓塞 Fat embolism 氣體栓塞 Gas embolism 羊水栓塞 Amniotic fluid embolism,Can you answer these questions: Where do they come from? Where do they lodge? What are the features of their impairment?,Fat Embolism 脂肪栓塞,relea

13、sed from the bone marrow and soft tissue due to severe injury 由于嚴(yán)重創(chuàng)傷從骨髓和軟組織釋放 Long bone fracture長(zhǎng)骨骨折 soft tissue trauma or burns 軟組織挫傷或燒傷 squeeze of the fatty changed liver 脂肪肝擠壓 Mainly occurs in the lung and the brain 大多數(shù)無(wú)癥狀，僅10%嚴(yán)重骨骼損傷有臨床表現(xiàn),Fat Embolism,后果取決于脂滴的大小以及數(shù)量 20m, 引起肺栓塞 20 m, 引起腦栓塞和其他器官栓塞

14、特殊染色顯示脂滴 蘇丹 III染色 鋨酸染色,Fatty Embolus in the Vascular Lumen,Pathogenesis 損傷機(jī)制 阻塞 肺栓塞; 反射性血管痙攣; 過(guò)敏性休克 Allergic Shock ; DIC,Alcian Blue PAS staining,Amniotic Fluid Embolism,INFARCTION （梗死形成）,器官或局部組織由于血流中斷導(dǎo)致的缺血性壞死，稱(chēng)為梗死 (infarction)。梗死多由于動(dòng)脈阻塞引起，但靜脈回流中斷，使局部血流停滯組織缺氧，也可引起梗死。發(fā)生壞死的病變區(qū)域稱(chēng)梗死灶。 The formation of a

15、 localizad area of ischemic necrosis within a tissue or organ due to impaired arterial supply or the venous drainage The necrosis area is called “infarct”. An extremely important cause of clinical illness: myocardiac infarction，MI 心肌梗死 cerebral infarction 腦梗死,原因 動(dòng)脈阻塞或靜脈回流不暢 Occlusion of arterial sup

16、ply or venous drainage Thrombosis, embolism, athermanous plaques, external compression 功能性細(xì)動(dòng)脈痙攣 Functional spasm of arteriole 類(lèi)型 White infarcts (anemic infarcts) 白色梗死（貧血性梗死） Red infarcts (hemorrhagic infarcts) 紅色梗死（出血性梗死） Septic infarcts 敗血性梗死,INFARCTION,INFARCTION,White infarction Arterial occlusio

17、n 動(dòng)脈阻塞 Solid, compact organs 質(zhì)實(shí)組織或臟器 Few collateral circulation 缺乏側(cè)支循環(huán) spleen, kidney, heart, brain, etc.,Morphology Gross Dull pale, dry, wedge-shaped necrotic lesion，with a hemorrhagic zone surrounding 灰白，干燥，大致呈楔形，尖端指向門(mén)部，底部緊鄰包膜；病灶周?chē)梢?jiàn)充血出血帶。 新鮮時(shí)病灶腫脹，略隆起于臟器表面，漿膜外可見(jiàn)絮狀纖維蛋白性滲出；陳舊時(shí)病灶收縮，質(zhì)實(shí)。,INFARCTION,LM

18、Ischemic coagulative necrosis （kidney） Necrotic core Inflammatory and granulation tissue. Hyperemic and hemorrhagic zone,Most undergo organization and scarring in the end.,INFARCTION,Spleen Infarction,INFARCTION,Cardiac Infarction,INFARCTION,Brain Infarction ( liquefied necrosis),INFARCTION,Red infa

19、rction Arterial occlusion 動(dòng)脈阻塞 Venous occlusion 靜脈阻塞/淤滯 Loose tissue 組織疏松 Dual circulations: lung , small intestine 雙重血供 previously congested re-established blood flow to a site of previous arterial occlusion and necrosis,INFARCTION,Hemorrhagic infarction of the lung 肺出血性梗死 Gross Roughly wedge shape

20、d Dark red, solid area Base beneath the pleura Fibrin exudation LM Coagulative necrosis Large amounts of RBC filled in alveolar space Obscure structure,INFARCTION,Hemorrhagic infarction of the intestine,INFARCTION,Septic Infarction Bacteria containing emboli May form abscess and pus,INFARCTION,Fate

21、of Infarct Enzymatic lysis, liquefaction and absorption Organization with scar formation Encapsulation and Calcification,INFARCTION,Factors that influence development of an infarct 影響梗死形成和發(fā)展的要素 Nature of the vascular supply Rate of development of occlusion Vulnerability to hypoxia Oxygen content of blood,Case Study,A 59-year old man was admitted to the hospital after a fall, complaining of hip pain and inability to walk. The X-ray was taken and showed femur neck fr