病理学ppt课件-局部血液循环障碍.ppt

局部血液循环障碍,充血出血血栓形成栓塞梗死水肿,局部血液循环障碍,充 血,hyperemia,概念,器官或组织的血管内血液含量增多,分类,动脉充血静脉充血,动脉性充血,概念：,指器官或组织动脉输入量增多。又称主动性充血（active hyperemia），简称充血。,一、原因,细动脉扩张,（一）、血管舒张神经兴 奋性,（二）、舒张血管活性物质释放。,Arterial hyperemia,二、分 类,生理性充血,炎症性充血,减压后充血,（一）,（二）,（三）,三、病理变化和后果,（一）、病理变化：1、肉眼：充血的器官或组织：体积轻度增大，颜色鲜红，温度升高。2、镜下：小动脉和毛细血管高度扩张、充满血液。,（二）、后果：1、常为暂时性血管反应，对机体无明 显影响。2、炎症性充血一般对机体有利，但对已 有病变的动脉，充血可导致血管破裂。,Inflammation,炎扁桃体,静脉性充血(淤血）,概念,指器官或组织由于静脉血液回流受阻，血液淤积在毛细血管和小静脉内。又称被动性充血（passive hyperemia），简称淤血（congestion）。,心衰引起的慢性淤血性水肿,chronic congestion of liver(nutmeg liver),chronic congestion of liver,出 血,hemorrhage,概念,血液由心腔或血管内逸出。,临床分类,内出血外出血,血肿瘀点瘀斑体腔积血,病理分类,破裂性出血：心脏和较大的血管破裂漏出性出血,一、类型：,（二）外出血1.咯血呼吸道出血2.呕血上消化道出血3.血尿泌尿道出血4.血便下消化道出血5.淤点浆、粘膜较小出血6.紫殿浆、粘膜稍大出血7.淤斑直径超过2cm的皮下出血,漏出性出血,概念,因毛细血管和毛细血管后微静脉通透性增加，红细胞经内皮间隙和受损的基底膜漏出。,（一）、原因,1、血管损害2、血小板减少或功能障碍3、凝血因子缺乏,肺出血 pulmonary hemorrhage,Aneurysm and dissection,Marfans syndrome,Tearing of aortic wall,Hemopericardium(Cardiac tamponade),Hemorrhage of subarachnoideales,The dura has been reflected back(with a small portion visible at the lower right)to reveal a subdural hematoma.Such a blood clot is usually the result of trauma with tearing of the bridging veins.,The hematoma interdigitates with the adjacent gyri and sulci,but compresses the brain,血栓形成,thrombosis,Thrombosis,血栓形成,概念：活体心脏、血管内，血液某些成分析出、凝集形成固体质块的过程称血栓形成。形成的固体质块叫血栓（thrombus）。,凝血 抗凝血意义：出血时止血又防止血栓形成,一、血栓形成条件及机制,血液凝固、血小板粘集和纤维蛋白溶解过程,（一）心血管内膜损伤：,和,见于,见于 静脉内膜炎、动脉炎、动脉粥样硬化继发的溃疡、风湿性心内膜炎、细菌性心内膜炎、心梗等,Endothelium injuryan important factor which could cause thrombosis directly,动脉粥样硬化伴发血栓形成 Atherosclerosis of the artery with thrombus,（二）血流状态改变：,血流缓慢,涡流,如 静脉曲张、动脉瘤内或血管分枝处等。静脉比动脉发生血栓多4倍。,Thrombus in iliac vein,（三）血液凝固性增高：,1.遗传性：V因子基因突变protein C无抗凝性；（如抗凝 血酶、蛋白C、S缺乏）2.手术，创伤，妊娠，分娩,恶性肿瘤使促凝因子释放 3.DIC,上述血栓形成的条件往往是同时存在的，但心血管内膜的损伤是血栓形成最重要也是最常见的原因。,二、血栓形成的过程和血栓的形态,延续性血栓（propagating thrombus）：从静脉内膜表面的血小板粘集堆开始，血栓不断沿血管延伸增长，形成头、体、尾三部分。,白色血栓,红色血栓,混合血栓,透明血栓,Morphology of thrombi,thrombus tail body head,白色血栓,肉眼,1、延续性血栓的头部，与内膜 紧连。2、呈灰白色，质实。,镜下,主由血小板组成。白色血栓主要见于心脏和动脉及静脉血栓的起始部。,thrombus in coronary artery,红色血栓,Red thrombus,肉眼,1、主要见于静脉，为延续性血栓尾部。2、红色。3、新鲜时为表面光滑，湿润、富于弹性。4、陈旧红色血栓干燥、无弹性、易脱落。,镜下,为正常血液分布的血细胞。,红色血栓肉眼图示,红色血栓,混合血栓,Mixed thrombus,肉眼,1、为延续性血栓的体部。2、呈粗糙、干燥的圆柱状。3、灰白与暗红色相间的条纹状（波纹状）结构。,混合血栓镜下图示,透明血栓,Hyaline thrombus,1、见于DIC。2、发生于全身微循环内，只能在 显微镜下见到，故又称微血栓。3、主要由纤维蛋白构成。,肺微血栓,四、血栓的结局、血栓的结局,1.软化溶解吸收2.机化再通3.钙化血管内结石4.脱落栓子栓塞梗死,五、血栓对机体影响,有利:TB、溃疡病出血时止血不利:1.阻塞血管:A血栓形成 梗死；V内血栓形成淤血 2.心瓣膜赘生物（血栓）瓣膜病 3.血栓脱落栓塞梗死 4.广泛出血DIC,white/pale thrombus in cardiac valve,Organization of thrombus organization and recanalization of thrombus,钙化和静脉石 Calcification and phlebolith,肺动脉的骑跨式的血栓栓子栓塞 thromboembolus astride the bifurcation of the pulmonary artery(saddle emboli),血栓概要,血栓形成的条件血栓的结局血栓的影响,栓塞（Embolism）,定义 栓子运行的途径类型影响,栓 塞,概念：随血运行的异物，阻塞血管的 现象称栓塞。阻塞血管的异物称 栓子。栓子可以是固体、液体或气体。,栓子的分类,血栓栓子脂肪栓子气体栓子羊水栓子肿瘤栓子细菌栓子其它,一、栓子运行途经,1.V系统和右心栓子:栓塞在肺动脉2.A系统和左心栓子:栓塞全身动脉3.门静脉系统栓子：栓塞到肝 4.交叉栓塞：如先天心病时5.逆流栓塞：极罕见,栓塞的类型及对机体的影响,血栓栓塞（99）,肺栓塞（主要）体循环动脉栓塞,全身的栓子 Systemic embolism,SE,下肢 limbs(70-75%)脑 brain(10%)内脏 viscera(10%)上肢upper limbs(5%),1.肺动脉栓塞：（1）中小分支的栓塞不引起严重后果（2）有慢性肺淤血肺出血性梗死（3）肺动脉大分支及主干呼吸循环衰竭 猝死（4）多数小栓子栓塞右心衰猝死,肺栓塞,小栓子（6080)中小肺动脉栓塞 无临床表现 结果:心衰 梗死,肺栓塞,中等大小的栓塞(10-15%)阻塞中等大小的肺动脉分支处 肺出血,肺动脉的骑跨式的血栓栓子栓塞 thromboembolus astride the bifurcation of the pulmonary artery(saddle emboli),Thromboembolism:Pulmonary embolism,PE,occlusions of PA:always embolicOrigin of thromboemboli:deep veins of legs potential consequences:sizes and number of the emboli,thromboembolus astride the bifurcation of the pulmonary artery(saddle embolus),valves,肺栓塞（PE）,诊断：很难 2/3 的病人在诊断出来以前已经发生了死亡,2.体循环动脉栓塞：,栓子80来自左心常见于亚急性感染性心内膜炎，二尖 瓣狭窄时左心房附壁血栓和心肌梗死的附壁血栓。其余为发生于动脉粥样硬化溃疡或动脉瘤的附壁血栓。,感染性心内膜炎,脂肪栓子Fat embolism,脂肪从哪里来的呢Where do the fat globules come from?长骨骨折（90）fractures of long bone 大面积脂肪组织受损 extensive trauma to fatty tissue 一些疾病 some of diseases 糖尿病 diabetes 镰刀状细胞贫血 sickle cell anemia 胰腺炎 pancreatitis,脂肪栓塞Fat embolism,90的脂肪栓子来自于长骨骨折 只有1到2有临床意义影响大小：视脂肪滴大小和数量多少来定,机理：长骨骨折黄骨髓入血V肺A、肺内毛细血管肺V左心广泛脑A栓塞猝死,脂肪栓子Fat embolism,多少脂肪栓子才有临床意义How many fat globules are necessary for becoming clinically significant?9-20 grams,脂肪栓塞综合征Fat embolism syndrome,临床表现肺循环受阻75%的肺栓塞急性右心衰死亡。贫血血小板减少死亡(10%),脂肪栓塞Fat embolism,病理诊断冰冻切片 特殊染色 Sudan III Oil-red O,脂肪栓子（苏丹III染色）,空气栓塞air embolism,Definition When bubbles of air or gas within the circulation obstruct blood flow,the resultant injury is referred to air embolism,空气栓塞air embolism,空气怎么进入循环的呢？外伤、手术分娩并发症 气胸 大血管破裂肺损伤,职业病减压病 沉箱病,氮气栓塞Air embolism,空气栓子,多少空气才会引起临床表现呢 100ml,空气栓塞的机理air embolism:,气泡 气泡聚集 右心机械性阻塞 心衰,空气栓子 air embolism,羊水栓子发生几率 1/50000 死亡率 80%,栓子影响Effects Embolism,堵塞血管Occlusion of the blood vessel 静脉 veins 充血congestion/水肿edema/出血hemorrhage 动脉arteries 梗死ischemic necrosis(infarct)侧枝循环开放 bypass circulation opened 肿瘤和感染的扩散Dissemination of infections and tumors,栓塞概要Summary for embolism,栓子可能是气体，液体或是固体Emboli may be gas,liquid or solid materials.血栓是最常见的类型Thromboembolism is the most common type.大部分的血栓栓子都来自下肢的深静脉 most of thromboemboli come from the deep veins of the legs.栓子是造成梗死的最重要的的原因。Embolism is one of the most important causes for infarction.,梗死Infarction,定义Definition 局部组织因为动脉的阻塞或是静脉的回流受阻而引起的缺血性坏死 a localized area of ischemic necrosis caused by occlusion of either the arterial supply or the venous drainage in a particular tissue,梗死Infarction,原因 causes 动脉阻塞artery obstruction 97 血栓 thrombosis 动脉栓塞 arterial embolism 动脉痉挛 arterial spasm 动脉受压 extrinsic compression of the vessel,影响梗死发展的因素Factors that influence development of an infarct,器官的血液供应情况 阻塞发生的速度 局部组织对氧的耐受 血氧含量,梗死形成的条件,1.动脉血供应阻断2.供血血管的类型 1）双重血液循环供血不易发生梗死 2）单一血管供血相对易发生梗死3.局部组织对缺血的敏感程度：缺血耐受性：脑 心肌 骨骼肌,梗死的分类Infarction-classification,1.是否有出血 with or without hemorrhage 出血性梗死/红色梗死 hemorrhagic infarct/red infarct贫血性梗死/白色或灰色梗死 anemic infarct/white or pale infarct,2.有无细菌感染with or without infection 败血性梗死 septic infarct 单纯性梗死 bland,hemorrhagic infarct of whole small intestine（A61-98),梗死的形态学Infarction-morphology,肉眼 Gross appearance形状 血液供应的形状 shape-pattern of vascular supply特征 坏死的组织学形态 character-histological type of necrosis 颜色 根据有无出血 color-with or without hemorrhage,肾、脾、心贫血性梗死肉眼,Infarction-morphology,镜下 Histology凝固性坏死 Coagulative necrosis液化性坏死 Liquefactive necrosis,Cerebral infarct(Encephalomalacia),Anemic infarct,Structure dense Blood supply end-arterial poor bypass circulation Cause arterial occlusion Organs heart brain kidney spleen limbs,Hemorrhagic infarct,structure looseblood supply dual circulation plenty of bypass circulation cause arterial occlusion and congestionorgans lung/liver/uterus/GIT,Anemic infarct kidney,hemorrhagic infarct of small intestine,Dry gangrene,梗死的影响Infarction-Effects,影响因素部位范围梗死发展的速度有无细菌感染,梗死的结局 Infarction-Fates,1）溶解、吸收、排出 2）机化-疤痕 3）包裹 4）钙化,old myocardial infarct with scar formation,水肿 Edema,水肿：组织间隙或体腔内过量的体液积聚。,正常体液的分布Normal distribution of fluid inside the human body,60%of lean body weight is water 2/3 细胞内intracellular 1/3 细胞外extra-cellular 5%of total body water is in blood,Factors affecting fluid transit across capillary walls,hydropericardium,水肿的分类Edema:classification,炎性水肿 increased vascular permeability protein rich fluid非炎性水肿 fluid imbalance protein poor transudate淋巴性水肿 secondary to reduced lymph drainage,pitting edema of the skin,Edema of the Larynx,脑水肿形成脑疝,Edema secondary to lymphatic obstruction,局部血液循环障碍Hemodynamic disorders,充血血栓形成栓塞梗死出血 水肿,