局部血液循環(huán)障礙講解專家講座

ChapterIIILocalCirculatory

Disturbance局部血液循環(huán)障礙講解第1頁(yè)Itconsistedof:a.changeinvascularpermeabilityandintegrityhemorrhage出血,edema水腫b.disturbanceofbloodvolumecongestion充血,ischemia缺血c.changeinintrvascularcontentsthrombosis血栓,embolis栓塞局部血液循環(huán)障礙講解第2頁(yè)

SectionIHyperemiaandCongestionHyperemiaandcongestionarealsoincreasedbloodvolumewithdilatedvesselsinanorganorpartofthebody.

局部血液循環(huán)障礙講解第3頁(yè)IHyperemia

充血

Arterialhyperemia(activehyperemia)increasedarterialbloodtothepart.(I).Typesofhyperemia1.Physiologicalhyperemia2.Pathologicalhyperemiaa.inflammatoryhyperemiab.collateralhyperemiac.removepressureofhyperemia局部血液循環(huán)障礙講解第4頁(yè)IICongestion淤血Congestion(venoushyperemia,passivehyperemia)Increasedvenousbloodtothepartduetoaccumulationofbloodinthevenousvasculartree.Itmaybeeithergeneralorlocal.Generalvenouscongestionisbyfarmostimportant.局部血液循環(huán)障礙講解第5頁(yè)(I).Cause三個(gè)原因1.pressureonthevein靜脈受壓

tumormass,ligature,tightbandage,strangulatedherniaetc.腫瘤團(tuán)塊、結(jié)扎、繃帶過緊、疝絞窄2.intraluminalocclusionofthe

veinthrombosis靜脈血栓3.cardiacfailure

心力衰竭局部血液循環(huán)障礙講解第6頁(yè)(II).ChangeandeffectofveneouscongastionChr.Veneouscogestion

Anoxiaincreaseveneouspressureparenchy-interstitialbloodmatouscelltissuevesselsatrophyfibroustissuepermeabilitydegenerationcollagenizationnecrosisofreticulinfiberscogestiveedema(cogestivesclerosis)cogestivehemorrhaga(hemosiderin)

局部血液循環(huán)障礙講解第7頁(yè)四個(gè)后果：淤血性水腫（毛細(xì)血管流體靜壓增高）淤血性出血實(shí)質(zhì)細(xì)胞萎縮、變性壞死間質(zhì)（纖維結(jié)締組織）增生局部血液循環(huán)障礙講解第8頁(yè)(III).Congestionofmajororgan兩個(gè)主要器官1.Chronicveneousncongestionoflungduetoleftheartfailure左心衰

usuallycausedbymitralstenosis二尖瓣狹窄duetorheumaticheartdisease.

局部血液循環(huán)障礙講解第9頁(yè)

Morphylogicalcharacteristic:Earlystage:congestivelung,edemaoflung

Alveoli;largeamountofphagocyticcellsfilledwithyellowbloodpigment(heartfailurecells心衰細(xì)胞).Latestage:browninduration肺褐色萎縮Darkbrownincolorandtoughinconsistency.局部血液循環(huán)障礙講解第10頁(yè)browninduration肺褐色萎縮

含鐵血黃素褐色間質(zhì)增生硬化局部血液循環(huán)障礙講解第11頁(yè)2.Chronicvenouscongestionofliver:

Occuresearlyingeneralveneouscongestion

duetorightheartfailure右心衰.Motphlogicalchracterisic:

Earlystare:Mutmegliver檳榔肝

Latestage:Cogestiveliversclerosis淤血性肝硬化

局部血液循環(huán)障礙講解第12頁(yè)

Gross:Cutsurfaceshowsamottledappearanceofdarkbrown(congested淤血centerofeachlobule)andlightyellowareas(fatty

changes脂肪變性oflivercells).LM:Centeroftheloule------distendedsinusoids,atrophicdegeneration

livercells.Peripheralpartofthelobule-----fattychanges局部血液循環(huán)障礙講解第13頁(yè)Cogestiveliversclerosis

匯管區(qū)間質(zhì)增生，小葉結(jié)構(gòu)完整局部血液循環(huán)障礙講解第14頁(yè)SectionIIHemorrhage

Hemorrhage出血：escapeofbloodfrombloodvessel

I.ThecauseandmechanismofhemorrhageRuptureofbloodvessel破裂性出血:majorcauseistraumaordisease.RBCleakout漏出性出血:majorcauseisincreaseofpermeabilityofbloodvessel.局部血液循環(huán)障礙講解第15頁(yè)RBCleakout:

A.damageofvascularwall血管壁內(nèi)皮細(xì)胞受損(severeinfectionintoxicationetc.)B.changeinthenumberandqualityofplatelets血小板C.disturbanceofcoagulativemechanism血液凝固性障礙局部血液循環(huán)障礙講解第16頁(yè)II.ChangeTermsyoushouldunderstand:Internalhemorrhage內(nèi)出血:Hematocele積血:accumulationofbloodinsomaticcavitye.g.Hemothrorax胸腔積血,hemopericardium心包腔積血,hemoperitoneum腹腔積血.

Hematoma血腫:hemorrhageintothetissueformingtumorlikeswelling.Externalhemorrhage外出血:

局部血液循環(huán)障礙講解第17頁(yè)Externalhemorrhage:Petechiahemorrhage瘀點(diǎn):minutehemorrhage(pinpoint)inskin,mucusmembrane,serosalsurface.Purpura紫癜:hemorrhageupto1cminsizeinskin,mucusmembraneserosalsurface.Ecchymosis瘀斑:alargeblotchhemorrhage(lessthen1-2cmindiameter)inskin,mucusmembrane,serosalsurface.局部血液循環(huán)障礙講解第18頁(yè)Rhinorrhagia鼻衄:nasalhemorrhageHemoptysis咯血:hemorrhageofrespectorytract.Hematemesis嘔血:hemorrhageofupperdigestivetractHematochezia便血:hemorrhageoflowerdigestivetractHematuria血尿:hemorrhageofurinarytract局部血液循環(huán)障礙講解第19頁(yè)III．EffectsTheeffectsofhemorrhageisdependuponthespeed,theadequacyandpartofhemorrhage.

出血速度、量、部位局部血液循環(huán)障礙講解第20頁(yè)SectionIIIThrombosisThrombosis血栓形成:formationofasolidorsemisolidmassfromtheconstituentsofthebloodwithinthevescularsystemduringlife.活體心血管腔血液凝固血小板析出粘集形成固體質(zhì)塊Themassitselfistermedathrombus血栓.

BloodcoagulationsystemAnticoagulationsystem局部血液循環(huán)障礙講解第21頁(yè)I.Theformingconditionand

mechanismofthrombosisTherearetwomajorcourseofthrombosis:兩個(gè)基本步驟Bloodcoagulation

血液凝固Thrombocyticaggregation血小板析出和粘集局部血液循環(huán)障礙講解第22頁(yè)Therearethreemajorfactorsinthrombusformation.三個(gè)條件TheseweredescribedoriginallybyVirchowandareasVirchow’striad.Thethreefactorsare:Endothelialinjury內(nèi)皮細(xì)胞受損Changesinthepatternofbloodflow血流狀態(tài)改變Bloodhypercoagubility血液凝固性增高局部血液循環(huán)障礙講解第23頁(yè)(I).Endothelialinjury:

(1).Plateletadherenceandactivation:adhesionreleasereaction(ADP)aggregation(thromboxaneA2)Endothelialthrombocyticaggregationinjury(2).ExposureofcollagenfibersXII

endogenouscoagulationsystem(3).ReleasethehistofactorsVII

exogenouscoagulationsystem

Bloodcoagulation

局部血液循環(huán)障礙講解第24頁(yè)Sothat,thethrombosisofclinicaloccursforthemostpartintheendothelialinjury.e.g.a.variousendocarditisb.endophlebitisc.atherosclerosis

d.repeatedperformofvenipuncture

局部血液循環(huán)障礙講解第25頁(yè)(II).Changesinthepatternofbloodflow1.bloodflowslowly2.turbulance(whirlpool)3.stasisofbloodflow

局部血液循環(huán)障礙講解第26頁(yè)血流遲緩臨床上多見于：長(zhǎng)久臥床病人，如手術(shù)后，久病虛弱，心力衰竭及骨折臥床病人。Inveins,however,thebloodpressureislowertheninarteries,sothatthrombosisinveinsismoretheninarteries(4times).

據(jù)統(tǒng)計(jì)，發(fā)生在V內(nèi)比A內(nèi)多4倍，下肢V比上肢V多3倍，尤其是骨盆內(nèi)V及腿部后面深靜脈。局部血液循環(huán)障礙講解第27頁(yè)

血流漩渦臨床上多見于：①風(fēng)心二狹，左心房可產(chǎn)生渦流，尤其在擴(kuò)大左心耳內(nèi)。②A瘤或曲張V內(nèi)——血液突然流進(jìn)寬闊處，產(chǎn)生血栓。③血管分岔處。④淤血時(shí)V瓣上。局部血液循環(huán)障礙講解第28頁(yè)(III).Bloodhypercoagubility1.genetichypercoagubility:e.g.V-factormutantgene2.acquiredhypercoagubility:e.g.malignancy,abnormalpregnancy,severetrauma,extensiveburns,

grandoperation

局部血液循環(huán)障礙講解第29頁(yè)II.CourseofThrombosisandTypes

ofThrombus(I).Courseofthrombosis:局部血液循環(huán)障礙講解第30頁(yè)(II).TypesofthrombusThethrombuscanbeclassifiedinto4types:四個(gè)類型1.Whitethrombus(palethrombus)

血小板粘集為主

Usuallypresentinhighflowarea(heartvalves,ventricles,arteries)Ittendstobemural(adherenttothewallofthevesselorheart)andnon-occlusiveAttachedfriablegraymassofdegranulatedplatelets血小板andfibrin.局部血液循環(huán)障礙講解第31頁(yè)

2.Mixedthrombus血小板粘集+血液凝固

Itusuallyshowscharacteristiclaminationswhichisproducedbypalepinklayersofplatelets血小板粘集andfibrinalternatewithdarkredlayersofRBC血液凝固層狀血栓

局部血液循環(huán)障礙講解第32頁(yè)‘Muralthrombus’附壁血栓

Thrombusattachedtovesselwall/heartwall,non-occlusive局部血液循環(huán)障礙講解第33頁(yè)3.Redthrombus血液凝固Resemblesbloodclots.

Usuallypresentindeepveinsof‘tail’ofextendthrombus延續(xù)性血栓.局部血液循環(huán)障礙講解第34頁(yè)

‘Extendthrombus’composedofwhite‘head’(initialplateletfibrinnidus)attachtothevascullarwall;mixed‘body’(redandwhitethrombus);redtail(coagulatedredthrombus).局部血液循環(huán)障礙講解第35頁(yè)4．Hyalinethrombus

(microthrombus,fibrinousthrombus)ItwidespreaddepositionoffibrinandplateletsinmicrovasculaturethroughoutthebodyItismostfrequentlyseenDIC(disseminatedintravascularcoagulation).局部血液循環(huán)障礙講解第36頁(yè)III.Fateofthrombus(I).Malacia,lysisandabsorpation(II).Organization機(jī)化andrecanalization再通a.preventfromamotioingrowthofvascularizedconnectivetissue(granulationtissue)intothethrombuswhichbecomefirmlyattachedtothevascular-wallb.recanalization------contractionandlysisofthethrombusendothelialcellaccompaniedbygrowthofendothelialcellsfromtheadjacentintimalsurfacewithrestorationofafunctionalbloodchannel.(III).Calcificationphlebolith靜脈石,arteriolith動(dòng)脈石局部血液循環(huán)障礙講解第37頁(yè)VI.EffectsofThrombus(I).Occlusionofvascularischemia缺血,infarction梗死(II).Embolish栓塞(III).Deformityofheartvalves瓣膜變形Chronicvalvularvitiumoftheheart

(valvularstenosis,valvularinsufficiency)(IV).Widespreadhemorrhage廣泛出血DICconsumptioncoagulopathy局部血液循環(huán)障礙講解第38頁(yè)SectionIVEmbolism

Embolism:Occlusionofsomepartofcardivascularsystembyimpactionofaforeignmasstransportedtothesitethroughthebloodstream.Thisimpactionofforeignmassbeknownasembolus栓子.局部血液循環(huán)障礙講解第39頁(yè)Theembolusmaybesolid,liquidorgaseous.Typesofemboliare(1).thromemboli,(2).fatemboli,(3).airorgasemboli,(4).amnioticfluidemboli羊水栓塞,and(5).tumoremboli,etc.局部血液循環(huán)障礙講解第40頁(yè)I.Thewayofpropagationofembolus

1.embolusofvenoussystemandrightheartPulmonaryembolism2.embolusofarterialsystemandleftheartVascularocclusionoccurmostfrequentlyinthespleen,kidney,brainetc.3.embolusofportalsystem4.crossedembolism(paradoxicalembolism)５．retrogradeembolism

局部血液循環(huán)障礙講解第41頁(yè)II.TypesandEffectsofEmbolism

(I).ThromboembolismThromboembolism血栓栓塞:Anembolusisamassofthrombusinthevascularsystemabletolodgeinavesselandblockitslumen.

Mostemboliarederivedfromthrombi.Over99%ofmajoremboliarederivedfromthrombi.

局部血液循環(huán)障礙講解第42頁(yè)

1.Pulmonaryembolism

Around95%ofpulmonaryembolismoccursindeepveinsofleg;themajorityoftherestoccurinpelvicveinsandaveryfewoccursinthemuralthrombusofrightheart.局部血液循環(huán)障礙講解第43頁(yè)

Theeffectsofpulmonaryembolidependupontheirsizeandquantity.(1).Mediumandsmallembolimayoccurunnoticedandbelysedwithinthelungortheymaybecomeorganisedandcausesomepermenent.

Pulmonaryembolismissometimeaccompaniedwithvenouscongestionoflung肺淤血;theareamayevenbecomeinfarcted

局部血液循環(huán)障礙講解第44頁(yè)

(2).Largemassivethromboembiareoftenimpactedacrossthebifurcationofoneofmajorpulmonaryarteriesasa‘saddleembolus’adescriptivetermfortheirappearance.Inseverecase,itmayberesultin‘suddendeath’.

Theseareusuallylongthrombiderivedfromlegdeepveinsandhavetheshapeofthevesselsinwhicharose.

局部血液循環(huán)障礙講解第45頁(yè)P(yáng)ostmortemexamination:LongthrombiretaintheappearanceofathrombuswithlinesofZahnandgranular,friable,consistency

Postmortemclotsappearanceof‘chickenfat雞脂樣andredcurrantjelly果醬樣’,glossy,andelastic彈性.

局部血液循環(huán)障礙講解第46頁(yè)

(3).Alargenumberofsmallthromboliarealsoresultinsuddendeath.

局部血液循環(huán)障礙講解第47頁(yè)2.Systemicembolism80%ofsystemicemboliariseintheleftheart.

瓣膜贅生物Vegetationsontheheartvalvesareancommonimportantsourceofarterialemboli.(e.g.subacuteinfectiveendocarditis,SBE)局部血液循環(huán)障礙講解第48頁(yè)Anothercommonsourceofthrombosiswithintheleftheartisthepresenceofmuralthrombus附壁血栓intheatrium(mitralstenosis二尖瓣狹窄)andmuralthrombusduetomyocardialinfarction.Therestoccurinmuralthrombusduetoatherosclerosisoraneurysm動(dòng)脈粥樣硬化、動(dòng)脈瘤.局部血液循環(huán)障礙講解第49頁(yè)

Vascularocclusionsoccurmostfrequentlyinthespleen,kidney,brainetc,mayresultinformationofinfarctionoftheorganinvolved.局部血液循環(huán)障礙講解第50頁(yè)

Moredramaticconsequencesdevelopasaresultofembolitravellingtotheintestine;thisimpactioncancausedeathofwholesectionsofsmallbowel腸梗死.

Moreseriously,ininfectiveendocarditisthevegetationsconsistofmicro-organisms,usuallybacteria,andareextremelyfriable.(maycausesepticinfarct敗血性梗死)局部血液循環(huán)障礙講解第51頁(yè)(II).FatembolismFatembolismusuallyarisesfollowingsomeseveretraumawithfracturetolongbones長(zhǎng)骨骨折.Fatfromthebonemarrowisreleasedintocirculationandcomestolodgeinvariousorgans.Asimilarsituationarisesinsevereburns嚴(yán)重?zé)齻鸻ndinextensivesofttissueinjury脂肪組織嚴(yán)重挫傷.局部血液循環(huán)障礙講解第52頁(yè)

Thediameteroffatglobules>20μm,thecirculatingfatentersthelungandthisindicatesthatitmusttravelbywayofthevenoussystemThediameteroffatglobules<20μm,thatmanyalsoenterthesystemicarterialcirculation.(oftenbringonembolisminvesselsofbrain).局部血液循環(huán)障礙講解第53頁(yè)Theeffectsoffatembolismdependupontheirpartandquantity.

Fatenterthecirculationinsmallquantities,theeffectsareunnoticed.Fatenterthecirculationinlargequantities(>200g),theeffectsaresevere.(maybringaboutdeathduetorightheartfailure)

局部血液循環(huán)障礙講解第54頁(yè)病例討論：男性，42歲，因騎車不慎跌倒，右小腿腫痛，急診診療為右小腿脛腓骨骨折，長(zhǎng)靴形石膏固定后，回家臥床休息。今后，小腿腫痛逐步緩解，傷后二周又出現(xiàn)右下肢腫痛，去醫(yī)院復(fù)查，拆除石膏重新包扎，回去后腫脹仍無改進(jìn)，并漸向大腿發(fā)展，四天后坐起吃飯時(shí)，突然高叫一聲，心跳呼吸停頓，搶救無效死亡。病人突然死亡原因是什么？

Ａ、肺動(dòng)脈血栓栓塞Ｂ、脂肪栓塞局部血液循環(huán)障礙講解第55頁(yè)(III).GasembolismTherearevariouscausesofemboliceventsinvolvinggas.

1.airembolism靠近心臟大靜脈破裂Thecausesofairembolismaremainlysurgicalwhensomevesselisopentotheair.(iatrogenic)Thisalsooccursinaccidentallywhenpatientsaredisconnectedfromintravenouslinesandairenters.

Thisalsooccursinsuicideattemptswhentheneckveinsarecut.

局部血液循環(huán)障礙講解第56頁(yè)Thevolumeofairneededtocausedeathinthisfashionisaround100ml.Thepathologicalsignsofthisconditionatautopsyincludevisiblebubblesinthevesselssuchasafrothyballofbloodandairintherightsideoftheheartoccludingoneofthevalves.

局部血液循環(huán)障礙講解第57頁(yè)2.Decompressionsickness減壓病(caissondisease沉箱病,diver’disease潛水員病)Experiencedbydiverswhentheyaretransferredtoorapidlyfromhightolowpressureenviroments

Athighpressure,increasedvolumesofgas氮?dú)馑ㄈ鹍issolveinthebloodandduringrapiddecompressionthesecomeoutasbubbles.

局部血液循環(huán)障礙講解第58頁(yè)(IV).Amnioticfluidembolism

Withthevastlyincreasedpressuresintheuterusduringdelivery,andthepressureistransferredtotheamnioticfluidwhichmaybeforcedintothematernaluterineveinsTheseamnioticfluidembolitravelinthecirculationandlodgeinthelungs,causingrespiratorydistresslikeotherpulmonaryemboli

局部血液循環(huán)障礙講解第59頁(yè)Theycanberecognisedhistologicallysincetheycontaintheshedskincellsoftheinfant.

Inthecases,itmaybecausingdeathby(1).anaphylacticshock;(2).reflexangiospasm;(3).DIC局部血液循環(huán)障礙講解第60頁(yè)(V).Otherembolism

Otherembolicmaterialinclude:tragmentsoftumour(causingmetastases),particlesofforeignmatter.局部血液循環(huán)障礙講解第61頁(yè)

SectionVInfarction

Infarction:Localizedareaofischemicnecrosiswithinatissueororganproducedbyocclusionofitsarterialsupplyorvenousdrainageduetothromboticorembolicocclusion.Infarctionisischaemicdeathoftissuewithinthelivingbody.Thismeansthatdeathoftissuefromothercauses,suchastoxinsortrauma,isnotinfarctionbutissimplynecrosis,whichisthegeneraltermfordeathoftissuewithinthelivingorganism.

局部血液循環(huán)障礙講解第62頁(yè)I.TheCausesandConditionofInfarction(I).Thecausesofinfarction1.Thrombolism血栓形成themostcommoncauseofinfarction.(99%ofinfractionarecausedbythromboliceventsandalmostallaretheresultofarterialocclusion.2.Arterialembolism動(dòng)脈栓塞thromboembolism,maybecauseofinfarctionofspleen,kidney,lungandbrain.3.Arteriospasm動(dòng)脈痙攣4.Occlusionbypressureonthevessel血管受壓.局部血液循環(huán)障礙講解第63頁(yè)(II).Theconditionofinfarction1.Thetypesofarterialsupplies

雙重血供Asecondbloodsupplyispresentand,althoughthearterialinflowisblocked,bloodstillenterstheorganfromthissecondsupply.Agoodexampleofthisisthelung,whichhasbothpulmonaryandbronchialarterialsupplies.

Otherexamplesareliverandforearm.局部血液循環(huán)障礙講解第64頁(yè)2.Thesusceptibilitytoischemiaofeffectedtissues缺血敏感性Differenttissuesshowdifferingsusceptibilitytoischemia.Tissuesalsovaryinthedegreeofischemiathattheycantolerate.Nervecellstolerancetoischemiaarelowest.(3-4minutes)Cardiocytes:(20-30minutes)

Skeletalmusclesandconnectivetissuestolerancetoischemiaaremostpowerful.

局部血液循環(huán)障礙講解第65頁(yè)II.AppearenceandTypesofInfarctionMorphologicalcharacterandtypesofinfarction1.Anemicinfarct(whiteinfarct)generallytheresultofocclusionofananatomicalorfunctionalend-arteryofasolidorgan實(shí)性器官(Thereisnopossibilityofcollateralsuppliestakingover).Suchasheart,kidney,andspleenetc.

局部血液循環(huán)障礙講解第66頁(yè)Morphologicalcharacter:Wedgeshape

Triangularoncutsurface,withitsbasetowardthesurfaceandapexnearthesiteofocclusion.局部血液循環(huán)障礙講解第67頁(yè)

Theevolutionofanemicinfarctare:(1).Early,mayappearred(residualbloodorvenousbackflow)(2).Subsequentlybecomepale

(lysisanddecompositionofhemoglobin)(3).laterareddemarcationzoneatthemarginofadjacentnormaltissue(inflammatoryresponseandgr