integridad de la pared vascular           hemorragia

Presión intravascular o volumen vascular          isquemia          hiperemia          edema

Mantenimiento de la sangre como un líquido        trombosis        embolismo        infarto

Hiperemia:Hiperemia:Hiperemia ArterialHiperemia ArterialHiperemia VenosaHiperemia Venosa

a local increased volume of blood in a particular tissue.

Fluido normal de sangre

Hiperemia

Congestion

Fisiologica: ejercicioPatologica : Inflammatory

Post-ischemic

Hiperemia Arterial:Hiperemia Arterial:•Hyperemia is a local increased volume of blood in a particular tissue resulting from augmented blood flow due to arteriolar dilation.

• Gross: Larger; redder; increased temperature; cut

surface is hemorrhage and wet.• LM: Dilatation of arteriole and capillary.

Morfologia de la hiperemia

Congestion is a local increased volume of blood in capillaries and veinules resulting from impaired venous return from a tissue.

Sistemica —cardiac failure•Etiologia

-L. heart failure

-R. heart failure

Pulmonary cong.

Systemic cong.

1. External pressure1. External pressure2. Internal occlusion 2. Internal occlusion LocalLocal

EdemaEdemaHemorragiaHemorragiaHeart failure cellsHeart failure cellsBrown indurationBrown induration

• Gross:

Increased volume and weight of organs; blue-red color (cyanosis); reduced temp.; wetness and excessive blood on the cut surface.

Morfologia

Acute pulmonary congestion

Chronic pulmonary congestion

AtrophyAtrophyFatty changeFatty changeNutmeg liverNutmeg liverCentrilobular necrosisCentrilobular necrosisliver cirrhosisliver cirrhosis

Central veins and hepatic sinuses of the centrilobular regions are distended with blood.

• Microscopically: nutmeg liver：

1) Degeneration, atrophy and/or necrosis of the liver cells in the centrilobular regions

2) Fatty degeneration of the liver cells in the peripheral part of the lobules

The central regions of the lobules become red-blue surrounded by a yellow-brown zone of uncongested liver substance.

“ Nutmeg liver”

Cardiac cirrhosis of the liver in the longstanding cases

ThrombosisThrombus

ThrombosisThrombus

Thrombosis is the process of formation of a clotted mass of blood within blood vessels or the heart in living body.

The resultant mass is called a thrombus.

Normal hemostatic process

Endothelium Platelets Coagulation cascade

Fig 5-6

Pro- and anticoagulant activities of endothelial cells

Platelet adhesion and aggregation

Fig 5-8

The coagulation cascade

Fibrinolytic system

• Endothelial injury (most important). Endothelial injury (most important).

Alone can induce thrombosis.Alone can induce thrombosis.• Alterations in normal flow.Alterations in normal flow.• Hypercoagulability.Hypercoagulability.

When the last two are both present, When the last two are both present,

endothelial injury is not requisite.endothelial injury is not requisite.

Fig 5-6

Pro- and anticoagulant activities of endothelial cells

• Ulcerative atherosclerosis• Transmural myocardial infarction• Vasculitis• Trauma• Radiation• Bacterial toxins

• Platelets activated by contact with Platelets activated by contact with endothelium.endothelium.• Slowed flow retards dilution of activated Slowed flow retards dilution of activated clotting factors and hepatic clearance.clotting factors and hepatic clearance.• Stasis or turbulence retards the inflow of Stasis or turbulence retards the inflow of inhibitors.inhibitors.• Turbulence may induce endothelial Turbulence may induce endothelial

injuryinjury

Primary (genetic):Primary (genetic):

Antithrombin III deficiencyAntithrombin III deficiency

Protein C deficiencyProtein C deficiency

Protein S deficiencyProtein S deficiency

Other combined deficiencyOther combined deficiency

Secondary (acquired):Secondary (acquired):High risk:High risk:Prolonged bed rest or immobilization.Prolonged bed rest or immobilization.Myocardial infarction. Tissue damage Myocardial infarction. Tissue damage (surgery, fractures, burns). Cardiac failure. (surgery, fractures, burns). Cardiac failure. Cancer. Acute leukemia. DIC. Cancer. Acute leukemia. DIC. Thrombotic thrombocytopenia.Thrombotic thrombocytopenia.

Secondary (acquired):Secondary (acquired):Low risk:Low risk:Atrial fibrillation. Cardiomyopathy. Atrial fibrillation. Cardiomyopathy. Nephrotic syndrome. Hyperlipidemia. Nephrotic syndrome. Hyperlipidemia. Late pregnancy/postdelivery. Late pregnancy/postdelivery. Oral contraceptives. Lupus anticoagulant. Oral contraceptives. Lupus anticoagulant. Sickle cell anemia. Smoking. Sickle cell anemia. Smoking. Thrombocytosis.Thrombocytosis.

White thrombusWhite thrombusRed thrombusRed thrombusMixed thrombusMixed thrombusFibrin thrombusFibrin thrombus

Types of thrombusTypes of thrombus

White thrombusWhite thrombusSite: heart valve , arterySite: heart valve , artery

Component: Platelet, fibrinComponent: Platelet, fibrin

Mixed thrombus Site: heart chamber, veinSite: heart chamber, veinComponent: Platelet, fibrin,RBCComponent: Platelet, fibrin,RBC

Mural thrombosis

Mural thrombosis

RED THROMBUS

Fibrinous thrombi are visible within parts of capi. of the glomerulus

hyaline thrombi in a glomerulus

AbsorptionAbsorptionOrganizationOrganizationCalcificationCalcificationDetachmentDetachment

Fate of thrombusFate of thrombus

Organization and recanalization of thrombus

During organization, the thrombus dissolved and blood could flow again.

IschemiaIschemiaCongestionCongestionHeart valve Heart valve diseasedisease

DICDICEmbolismEmbolism

Effects of thrombosisEffects of thrombosis

Embolism

EmbolusEmbolus

Embolism

EmbolusEmbolus

• Embolism is a partial or complete obstruction of some part of the vascular system by any mass carried there in the circulation.

• The transported material is called an embolus.

• 99% thromboembolism.

ThromboembolismThromboembolism Fat embolism Air embolism Amniotic fluid embolism Other types

Etiology:Etiology:Fractures of long Fractures of long bonesbones

Soft tissue traumaSoft tissue traumaBurnsBurns

Fat embolismFat embolism

90% of individuals with severe 90% of individuals with severe

skeletal injuriesskeletal injuries

10% with clinical findings(1-3 10% with clinical findings(1-3

days)days)

Pulmonary insufficiencyPulmonary insufficiency

Neurologic symptoms Neurologic symptoms

Fat embolismFat embolism

Fig 5-17

Etiology:Etiology:

Intravenous therapeutic proceduresIntravenous therapeutic procedures

Obstetric proceduresObstetric procedures

Chest wall injuryChest wall injury

Decompression sickness (nitrogen)Decompression sickness (nitrogen)

Air embolismAir embolism•Gas bubbles within the circulation can obstruct vascular flow.

•A particular form of gas embolism called decompression sickness occurs when individuals are exposed to sudden changes in atmospheric pressure.

Incidence:Incidence: 1/50 000 deliveries 1/50 000 deliveries

Mortality rate:Mortality rate: 80% 80%

Clinical onset:Clinical onset: Sudden severe dyspnea, Sudden severe dyspnea,

cyanosis, hypotensive shock, DICcyanosis, hypotensive shock, DIC

• Embolus from left heart cavity or Embolus from left heart cavity or arterial systemarterial system• Embolus from right heart cavity or Embolus from right heart cavity or venous systemvenous system• Embolus from portal veinsEmbolus from portal veins• Paradoxical embolismParadoxical embolism• Retrograde embolismRetrograde embolism

Motional pathway of embolus:Motional pathway of embolus:

Fig 5-16

•Instantaneous death (>60%).Instantaneous death (>60%).•Cardiovascular collapse.Cardiovascular collapse.•Right heart failureRight heart failure

PulmonaryPulmonary1.Large emboli (5%):1.Large emboli (5%):

•Clinical silent in patients without Clinical silent in patients without cardiovascular failure.cardiovascular failure.• blood flow from bronchial arteriesblood flow from bronchial arteries(collateral vascular supply)(collateral vascular supply)

3. Between the extremes of large and 3. Between the extremes of large and

small emboli (10-15%):small emboli (10-15%):

Pulmonary hemorrhage.Pulmonary hemorrhage.

4. Multiple small emboli:4. Multiple small emboli:

Pulmonary hypertension and vascularPulmonary hypertension and vascular

sclerosis.sclerosis.

II.. 80-85% from heart, secondary to myocardial infarction. 80-85% from heart, secondary to myocardial infarction.

IIII.. 5-10% from auricular thrombi associated with rheumatic 5-10% from auricular thrombi associated with rheumatic

heart disease and atrial fibrillation.heart disease and atrial fibrillation.

IIIIII.. 5% from the dilated cardiac chamber of myocarditis / 5% from the dilated cardiac chamber of myocarditis /

cardiomyopathy.cardiomyopathy.

VIVI.. Less common sources: Debris from ulcerative atheromata, Less common sources: Debris from ulcerative atheromata,

or thrombi in aneurysms, infectious endocarditis, or thrombi in aneurysms, infectious endocarditis,

prosthetic valves, paradoxical emboli.prosthetic valves, paradoxical emboli.

VV.. Unknown. Unknown.

INFARCTION(INFARCT)

INFARCTION(INFARCT)

An infarct is a localized area of ischemic necrosis in a tissue or organ produced by occlusion of either its arterial supply or its venous drainage.

The process whereby the infarct is developed is known as infarction.

Intrinsic occlusionIntrinsic occlusion for example, thrombosis, for example, thrombosis, embolismembolism expansion of atheromaexpansion of atheromaVasospasmVasospasm

Extrinsic compressionExtrinsic compression for example, twisting of the vesselsfor example, twisting of the vessels

EtiologyEtiology

• Shape: Wedge-shapedShape: Wedge-shaped SegmentalSegmental IrregularIrregular• Nature of necrosisNature of necrosis• Types: Red and white infarctsTypes: Red and white infarcts

Morphology of infarctMorphology of infarct

• LM:

1) Ischemic coagulative necrosis

2) Anemic infarct with few RBC

3) Hemorrhagic infarct has engorgement and hemorrhage

4) The pathology changes secondary to infarct such as hyperemia, hemorrhage, infla., organization and so on.

The myocardial cells shows coagulative necrosis with the outline of the myocardium. In the margin of the infarct there are numerous inflammatory exudation and connective tissue.

arterial occlusionsarterial occlusions firm tissuesfirm tissues

Venous occlusionsVenous occlusionsLoose tissuesLoose tissuesTissues with dual circulationsTissues with dual circulationsTissues previously congestedTissues previously congestedBlood flow reestablishedBlood flow reestablished

Red infarct/hemorrhagic infarctRed infarct/hemorrhagic infarct

The alteration of blood in pulmonary embolism

•Hemorrhagic infarct of the lung

Hemorrhage denotes an escape of blood from the cardiovascular system, usually is the result of the rupture of a blood vessel or the heart.