局部血液循环障碍.ppt

Local hemodynamic disorders,局部血液循环障碍,2010.9.27,A clinical case,病例摘要,死者熊卓为，49岁，北大医院心血管研究所研究员。2006年初，因腰腿疼痛，到北大医院门诊接受保守治疗。1月18日，其X光检查结果显示：腰椎骨关节病、腰4-5椎间盘病变、腰4度滑脱伴峡部裂。于2006年1月23日入住北大医院。次日，熊接受了“L4/5椎管减压，椎弓根钉内固定，后外侧植骨融合术”手术。术后第六天，即1月30日，熊在下地行走时忽感头晕，摔倒于地，恶心呕吐，血压、脉搏测不出。经抢救无效，于31日死亡。,状告北京大学第一医院(以下简称北大医院)“非法行医” 3年多后，2009年11月3日，经由央视经济半小时报道 2010年4月28日，对于熊卓为的丈夫王建国状告北大医院 “非法行医”一案，北京市高级人民法院作出终审(二审)判决。,1、该患者的死亡原因是什么？ 2、其死因是否与之前的骨科手术有关？,Proper function of Heart and lung Integrity of the vasculature maintenance of balance between the coagulation and fibrinolytic systems stability of normal fluid homeostasis,Intact Circulation -,Water extravasation,Abnormal substances,Blood contents,vascular injury,A local increased volume of blood in a particular tissue 局部组织血管内血液含量的增多,Section 1 Hyperemia or congestion,器官或组织因动脉输入血量的增多而发生的充血,An active process resulting from augmented blood flow due to arteriolar dilation,Hyperemia 动脉性充血,Hyperemia 动脉性充血,Physiologic，,Pathologic (inflammation),Types:,Morphology: 组织器官体积轻度增大 ，颜色鲜红，温度增高 细动脉和毛细血管扩张充血,Consequence:,肉眼：组织器官体积轻度肿胀，颜色鲜红，温度升高，代谢功能亢进 镜下：动脉和毛细血管扩张、充满血液 后果：暂时性变化，去除原因即可恢复正常，因而影响小 但血管本身有病变时，充血可以是血管破裂的诱因,Hyperemia 动脉性充血,常见类型： 生理性充血Physiologic ： 病理性充血Pathologic：炎症反应的早期 减压后充血：受压的组织或器官突然解除压力细动脉反射性扩张充血,如一次性大量抽取胸水或腹水血压下降,Congestion 淤血,器官或组织静脉血流回流受阻，血液淤积于小静脉 和毛细血管内，称淤血,A passive process resulting from impaired venous return from a tissue,Systemically, in cardiac failure Local-venous obstruction - venous compressed,Causes,Congestion 淤血,Dilatation of local venules and capillaries 局部静脉和毛细血管扩张 Congestive edema 淤血性水肿 Congestive hemorrhage，hemosiderinladen macrophage 淤血性出血 Parenchyma cell: atrophy, reversible injury, necrosis 实质细胞萎缩、变性、坏死 Interstitial hyperplasia: fibrosis, congestive sclerosis 间质纤维组织增生,Morphology and Consequences,Swollen, cyanosis (Blue-red color), low temperature 肿胀，发绀(蓝紫色），体表温度下降,Congestion 淤血,Dilatation of local venules and capillaries,Morphology,Congestion 淤血,Parenchyma cell: atrophy, reversible injury and necrosis Interstitial hyperplasia: fibrosis, congestive sclerosis,Lung congestion 肺淤血,Congestion 淤血,Left heart failure,Acute pulmonary congestion,Congestion 淤血,Acute pulmonary congestion,Congestion 淤血,Alveolar capillaries engorged with blood Alveolar septal edema Intra-alveolar edema fluid and hemorrhage,Chronic pulmonary congestion,Congestion 淤血,The septa become thickened and fibrotic The alveolar spaces contain hemosiderinladen macrophages,normal lung,Chronic pulmonary congestion,Congestion 淤血,The septa become thickened and fibrotic The alveolar spaces contain hemosiderinladen macrophages,Heart failure cells,Chronic pulmonary congestion,Congestion 淤血,Brown duration （肺褐色硬化）,-肝淤血 Liver congestion,Right-sided heart failure Acute hepatic congestion: Gross: dusky red, tense, slightly heavy; LM: central vein and sinusoids are distended with blood There may be central hepatocyte necrosis Chronic hepatic congestion: Gross: nutmeg liver LM: centrilobular necrosis and peri-lobular fatty change; hemorrhage; atrophy long standing congestionhepatic fibrosis,Congestion 淤血,nutmeg liver in chronic hepatic congestion, the central regions of the hepatic lobules are grossly red-brown, accentuated against the surrounding zones of uncongested tan.,Chronic hepatic congestion,Congestion 淤血,在慢性肝淤血时，肝小叶中央区因严重淤血呈暗红色，两个或多个肝小叶中央淤血区可相连，而肝小叶周边部肝细胞则因脂肪变性呈黄色，致使在肝的切面上出现红（淤血区）黄（肝脂肪变区）相间的状似槟榔切面的条纹，称为槟榔肝,Chronic hepatic congestion,Congestion 淤血,nutmeg liver,-肝淤血 Liver congestion,central vein and sinusoids are distended with blood centrilobular necrosis, peri-lobular fatty change hemorrhage and hemosiderin,congestion of liver,Congestion 淤血,Centrilobular necrosis with hemorrhage and hemosiderin,congestion of liver,Congestion 淤血,congestion of liver,Centrilobular necrosis,Congestion 淤血,Chronic congestion of the liver,fibrosis,Congestion 淤血,淤血性肝硬变(Congestive cirrhosis),Congestion 淤血,Dilatation of local venules and capillaries Congestive edema Congestive hemorrhage Parenchyma cell: atrophy,degeneration, necrosis Interstitial hyperplasia: fibrosis, congestive sclerosis,Morphology and Consequences of congestion,出血 (Hemorrhage),血液从血管或心腔逸出,称出血. 破裂性出血 漏出性出血,Loss of blood from the vascular compartment, usually as a result of trauma or disease of the vessel wall. This can involve large vessels, e.g, aorta or small vessels, e.g., capillaries.,外出血- 鼻出血，咯血，呕血，血便，血尿 淤点，紫癜，淤斑,内出血 体腔积血: (心包腔,胸腔,腹腔,关节腔) 软组织血肿: (硬脑膜下血肿，腹膜后血肿，皮下血肿),出血 (Hemorrhage),petechia 淤点(1-2mm) purpura 紫癜(3-5mm), ecchymosis 淤斑(大于1-2cm) hematoma 血肿,hemorrhages,皮下出血,心脏破裂及心包积血,脑出血,硬膜下血肿,ecchymosis 淤斑,petechia 淤点,Thrombosis 血栓形成,在活体的心脏和血管内，血液发生凝固或血液中某些有形成 分凝集形成固体质块的过程称为血栓形成(thrombosis)。 所形成的固体质块称为血栓(thrombus),The formation of a clotted mass of blood in the noninterrupted cardiovascular system is known as thrombosis, and the mass itself is termed a thrombus.,Pathogenesis of thrombosis,Three important elements in thrombosis virchow triad:,心血管内皮细胞的损伤 血流状态的改变 血液凝固性增加,Thrombosis 血栓形成,血栓形成条件,正常心血管内膜的内皮细胞具有抗凝和促凝两种功能，生理情况下以抗凝作用为主，使血液保持流动状态。,是血栓形成的最重要条件,内膜损伤，内皮下胶原暴露，活化X因子，启动内源性凝血系统 损伤内皮能释放组织因子，激活因子VII，启动外源性凝血系统 血小板的活化在触发凝血过程中起核心作用（凝血酶激活血小板）,1.心血管内皮细胞的损伤 endothelial injury：dominant influence,血栓形成条件,粘附反应(adhesion) 血小板粘附于局部内皮下胶原,分泌和释放反应(secretion and release reaction) 血小板被激活，释出ADP等，使血小板互相粘集,粘集反应(aggregation) 血小板活化时生成的血栓素A2，可促成血小板不可复性粘集,血小板活化表现为：,动脉粥样硬化溃疡 风湿性或细菌性内膜炎 心肌梗死 结节性多动脉炎 同一静脉经过多次注射 缺氧、休克、败血症等，全身广泛内皮损伤，弥散性血管内凝血,心血管内膜损伤常见于：,血栓形成条件,血流缓慢、停滞或涡流形成。,血栓形成条件,2.血流状态的改变 changes in the pattern of blood flow,正常轴流消失，血小板与内膜接触机会增加，促进血小板粘集 局部凝血因子和凝血酶浓度增加，达到凝血所需浓度 内皮细胞缺氧，受损,血流缓慢静脉血栓 涡流动脉和心脏血栓,为什么静脉比动脉更易发生血栓？,静脉血栓常见于心衰、久病和术后卧床患者 原因：静脉瓣，不搏动，壁薄易受压，血液粘滞性增加,常见于：夜间熟睡，心力衰竭，久病卧床者 部 位：静脉瓣，血管分叉处，曲张的静脉 二尖瓣狭窄的左心房，动脉粥样硬化斑块，动脉瘤内 静脉血栓 ：动脉血栓=4 ：1 下肢血栓 ：上肢血栓=3 ：1,血栓形成条件,指血液的高凝状态。血小板数量或粘度增加，凝血因子增多,血栓形成条件,恶性肿瘤时癌细胞释放出促凝因子 DIC及游走性血栓性脉管炎 妊娠，手术后、大面积烧伤、产后,遗传性高凝状态：第V因子基因突变,获得性的高凝状态,3.血液凝固性增加 changes in the blood constituents,Pathogenesis of thrombosis,Three important elements in thrombosis,心血管内皮细胞的损伤 血流状态的改变 血液凝固性增加,Thrombosis 血栓形成,Process of thrombogenesis 血栓形成的过程,Thrombosis 血栓形成,静 脉 内 血 栓 的 形 成,Thrombosis 血栓形成,白色血栓pale thrombi 混合血栓mixed thrombi 红色血栓red thrombi 透明血栓hyaline thrombi,Morphology and types of thrombi,按形态分类：,发生于心血管系统的任何部位 心脏或主动脉壁上血栓 -层状血栓（lines of Zahn),为混合血栓（mixed thrombi) ：由灰白色的血小板和纤维素层以及暗红色的红细胞层相间而成，并混有变性的白细胞 -附壁血栓（mural thrombi)底部与心壁、血管壁相连 - 球形血栓（ball thrombi)左心房内血栓 静脉红色血栓,Morphology and types of thrombi,按发生部位分类,层状血栓（lines of Zahn 混合血栓（mixed thrombi),Morphology and types of thrombi,Morphology of thrombi,左心房附壁血栓（mural thrombi) 球形血栓,Morphology and types of thrombi,动脉血栓（arterial thrombi) 静脉血栓(venous thrombi, phlebothrombi) 微循环内血栓(fibrin thrombi, microthrombi) 心脏瓣膜血栓(cardiac valve thrombi),按发生部位分类,Morphology and types of thrombi,动脉血栓（arterial thrombi),pale thrombus,动脉粥样硬化斑块基础上 血管损伤,白色或混合血栓,mixed thrombus,Morphology and types of thrombi,静脉血栓(venous thrombi, phlebothrombi),阻塞性血栓 常见于下肢深静脉,头部-白色血栓 体部-混合血栓 尾部-红色血栓,Morphology and types o