動(dòng)脈和毛細(xì)血管擴(kuò)張-

Local

hemodynamicdisorders局部血液循環(huán)障礙白求恩醫(yī)學(xué)院病理學(xué)系李

偉2010.9.27A

clinical

case病例摘要死者熊卓為，49歲，北大醫(yī)院心血管研究所研究員。2006年初，

因腰腿疼痛，到北大醫(yī)院門診接受保守治療。1月18日，其X光檢

查結(jié)果顯示：腰椎骨關(guān)節(jié)病、腰4-5椎間盤病變、腰4Ⅰ度滑脫伴峽部裂。于2006年1月23日入住北大醫(yī)院。次日，熊接受了“L4/5椎管減壓，椎弓根釘內(nèi)固定，后外側(cè)植骨融合術(shù)”手術(shù)。術(shù)后第六天，即1月30日，熊在下地行走時(shí)忽感頭暈，摔倒于地，惡心嘔吐，血壓、脈搏測(cè)不出。經(jīng)搶救無效，于31日死亡?！虪罡姹本┐髮W(xué)第一醫(yī)院(以下簡(jiǎn)稱北大醫(yī)院)“非法行醫(yī)”√3年多后，2009年11月3日，經(jīng)由央視《經(jīng)濟(jì)半小時(shí)》報(bào)道√2010年4月28日，對(duì)于熊卓為的丈夫王建國狀告北大醫(yī)院“非法行醫(yī)”一案，北京市高級(jí)人民法院作出終審(二審)判決。1、該患者的死亡原因是什么？2、其死因是否與之前的骨科手術(shù)有關(guān)？Proper

function

of

Heart

and

lungIntegrity

of

the

vasculaturemaintenance

of

balance

between

thecoagulation

and

fibrinolytic

systemsstability

of

normal

fluid

homeostasiIntact

Circulation

---Local

hemodynamic

disordersThrombus血栓Abnormal

substancesEmbolism栓塞---Infarction梗死Water

extravasationEdema水腫/積液Blood

contentsHyperemia充血Congestion/淤血Ischemia缺血vascular

injuryHemorrhage出血A

local

increased

volume

of

bloodin

a

particular

tissue局部組織血管內(nèi)血液含量的增多Section

1Hyperemia

or

congestionAn

active

process

resulting

from

augmentedblood

flow

due

to

arteriolar

dilation器官或組織因動(dòng)脈輸入血量的增多而發(fā)生的充血Hyperemia動(dòng)脈性充血Hyperemia動(dòng)脈性充血Physiologic，Pathologic

(inflammation)Types:Morphology:組織器官體積輕度增大，顏色鮮紅，溫度增高細(xì)動(dòng)脈和毛細(xì)血管擴(kuò)張充血Consequence:Hyperemia動(dòng)脈性充血常見類型：生理性充血Physiologic：病理性充血Pathologic：炎癥反應(yīng)的早期減壓后充血：受壓的組織或器官→突然解除壓力→細(xì)動(dòng)脈反射性擴(kuò)張充血,如一次性大量抽取胸水或腹水→血壓下降肉眼：組織器官體積輕度腫脹，顏色鮮紅，溫度升高，代謝功能亢進(jìn)鏡下：動(dòng)脈和毛細(xì)血管擴(kuò)張、充滿血液后果：暫時(shí)性變化，去除原因即可恢復(fù)正常，因而影響小但血管本身有病變時(shí)，充血可以是血管破裂的誘因Congestion淤血A

passive

process

resulting

from

impairedvenous

return

from

a

tissue器官或組織靜脈血流回流受阻，血液淤積于小靜脈和毛細(xì)血管內(nèi)，稱淤血CausesSystemically,

in

cardiac

failureLocal--venous

obstruction--

venous

compressedCongestion淤血Morphology

and

ConsequencesSwollen,

cyanosis

(Blue-red

color),

low

temperature腫脹，發(fā)紺(藍(lán)紫色），體表溫度下降Dilatation

of

local

venules

and

capillaries局部靜脈和毛細(xì)血管擴(kuò)張Congestive

edema淤血性水腫Congestive

hemorrhage，hemosiderin–ladenmacrophage淤血性出血Parenchyma

cell:

atrophy,

reversible

injury,

necrosis實(shí)質(zhì)細(xì)胞萎縮、變性、壞死Interstitial

hyperplasia:

fibrosis,

congestivesclerosis間質(zhì)纖維組織增生Congestion淤血Dilatation

of

localvenules

and

capillariesCongestion淤血Morphology√Parenchyma

cell:

atrophy,reversible

injury

and

necrosis√Interstitial

hyperplasia:fibrosis,

congestive

sclerosisLung

congestion肺淤血Left

heart

failureCongestion淤血Acute

pulmonarycongestionChronic

pulmonarycongestionCongestion淤血Acute

pulmonary

congestionCongestion淤血Acute

pulmonary

congestion√

Alveolar

capillaries

engorged

with

blood√

Alveolar

septal

edema√

Intra-alveolar

edema

fluid

and

hemorrhageChronic

pulmonary

congestionThe

septa

become

thickened

and

fibroticThe

alveolar

spaces

contain

hemosiderin–laden

macrophagesCongestion淤血normal

lungChronic

pulmonary

congestionThe

septa

become

thickened

and

fibroticThe

alveolar

spaces

contain

hemosiderin–laden

macrophagesCongestion淤血Heart

failure

cellsChronic

pulmonary

congestionCongestion淤血Brown

duration（肺褐色硬化）---肝淤血Liver

congestionRight-sided

heart

failureAcute

hepatic

congestion:Gross:

dusky

red,

tense,

slightly

heavy;LM:

central

vein

and

sinusoids

are

distended

withbloodThere

may

be

central

hepatocyte

necrosisChronic

hepatic

congestion:Gross:

nutmeg

liverLM:

centrilobular

necrosis

and

peri-lobular

fattychange;hemorrhage;

atrophylong

standing

congestion—hepatic

fibrosisCongestion淤血Congestion淤血Chronic

hepatic

congestionnutmeg

liver

—in

chronic

hepatic

congestion,

the

centralregions

of

the

hepatic

lobules

are

grossly

red-brown,accentuated

against

the

surrounding

zones

ofuncongested

tan.在慢性肝淤血時(shí)，肝小葉中央?yún)^(qū)因嚴(yán)重淤血呈暗紅色，兩個(gè)或多個(gè)肝小葉中央淤血區(qū)可相連，而肝小葉周邊部肝細(xì)胞則因脂肪變性呈黃色，致使在肝的切面上出現(xiàn)紅（淤血區(qū)）黃（肝脂肪變區(qū)）相間的狀似檳榔切面的條紋，稱為檳榔肝Chronic

hepatic

congestionnutmeg

liverCongestion淤血---肝淤血Liver

congestioncentral

vein

and

sinusoids

are

distended

with

bloodcentrilobular

necrosis,

peri-lobular

fatty

changehemorrhage

and

hemosiderinCongestion淤血congestion

of

liverCentrilobular

necrosis

withhemorrhage

and

hemosiderinCongestion淤血congestion

of

livercongestion

of

liverCentrilobular

necrosisCongestion淤血Chronic

congestion

oftheliverfibrosisCongestion淤血淤血性肝硬變(Congestive

cirrhosis)Congestion淤血√

Dilatation

of

local

venules

and

capillaries√

Congestive

edema√

Congestive

hemorrhage√

Parenchyma

cell:

atrophy,degeneration,necrosis√

Interstitial

hyperplasia:

fibrosis,

congestivesclerosisMorphology

andConsequences

of

congestion出血(Hemorrhage)Loss

of

blood

from

the

vascular

compartment,

usuallyas

a

result

of

trauma

or

disease

of

the

vessel

wall.This

can

involve

large

vessels,

e.g,

aorta

or

smallvessels,

e.g.,

capillaries.血液從血管或心腔逸出,稱出血.破裂性出血

漏出性出血-外出血--鼻出血，咯血，嘔血，血便，血尿淤點(diǎn)，紫癜，淤斑-內(nèi)出血體腔積血:

(心包腔,胸腔,腹腔,關(guān)節(jié)腔)軟組織血腫:

(硬腦膜下血腫，腹膜后血腫，皮下血腫)petechia淤點(diǎn)(1-2mm)purpura紫癜(3-5mm),ecchymosis淤斑(大于1-2cm)hematoma血腫出血(Hemorrhage)腦出血心臟破裂及心包積血硬膜下血腫ecchymosis淤斑petechia淤點(diǎn)Thrombosis

血栓形成The

formation

of

a

clotted

mass

of

blood

in

thenoninterrupted

cardiovascular

system

is

known

asthrombosis,

and

the

mass

itself

is

termed

a

thrombus.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)塊的過程稱為血栓形成(thrombosis)。所形成的固體質(zhì)塊稱為血栓(thrombus)Virchow’s

triad

in

thrombosis.

Endothelial

integrityis

the

single

most

important

factor.

Injury

to

endothelial

cells

can

affect

local

blood

flow

and/orcoagulability.

Abnormal

blood

flow

(stasisorturbulence

can

cause

endothelial

injury.

The

factors

may

act

independently

ormay

combine

tocause

thrombus

formation.Pathogenesis

of

thrombosisThree

important

elements

in

thrombosisvirchow

triad:心血管內(nèi)皮細(xì)胞的損傷血流狀態(tài)的改變血液凝固性增加Thrombosis

血栓形成■血栓形成條件1.心血管內(nèi)皮細(xì)胞的損傷endothelial

injury：dominant

influence正常心血管內(nèi)膜的內(nèi)皮細(xì)胞具有抗凝和促凝兩種功能，生理情況下以抗凝作用為主，使血液保持流動(dòng)狀態(tài)。是血栓形成的最重要條件內(nèi)膜損傷，內(nèi)皮下膠原暴露，活化XⅡ因子，啟動(dòng)內(nèi)源性凝血系統(tǒng)損傷內(nèi)皮能釋放組織因子，激活因子VII，啟動(dòng)外源性凝血系統(tǒng)血小板的活化在觸發(fā)凝血過程中起核心作用（凝血酶激活血小板）■血栓形成條件√血小板活化表現(xiàn)為：粘附反應(yīng)(adhesion)血小板粘附于局部?jī)?nèi)皮下膠原分泌和釋放反應(yīng)(secretion

and

release

reaction)血小板被激活，釋出ADP等，使血小板互相粘集粘集反應(yīng)(aggregation)血小板活化時(shí)生成的血栓素A2，可促成血小板不可復(fù)性粘集■血栓形成條件心血管內(nèi)膜損傷常見于：動(dòng)脈粥樣硬化潰瘍風(fēng)濕性或細(xì)菌性內(nèi)膜炎心肌梗死結(jié)節(jié)性多動(dòng)脈炎同一靜脈經(jīng)過多次注射缺氧、休克、敗血癥等，全身廣泛內(nèi)皮損傷，彌散性血管內(nèi)凝血■血栓形成條件血流狀態(tài)的改變changes

in

the

pattern

of

blood

flow血流緩慢、停滯或渦流形成?！陶］S流消失，血小板與內(nèi)膜接觸機(jī)會(huì)增加，促進(jìn)血小板粘集√局部凝血因子和凝血酶濃度增加，達(dá)到凝血所需濃度√內(nèi)皮細(xì)胞缺氧，受損血流緩慢—靜脈血栓渦流—?jiǎng)用}和心臟血栓■血栓形成條件常見于：夜間熟睡，心力衰竭，久病臥床者部 位：靜脈瓣，血管分叉處，曲張的靜脈二尖瓣狹窄的左心房，動(dòng)脈粥樣硬化斑塊，動(dòng)脈瘤內(nèi)靜脈血栓：動(dòng)脈血栓=4：1下肢血栓：上肢血栓=3：1為什么靜脈比動(dòng)脈更易發(fā)生血栓？靜脈血栓常見于心衰、久病和術(shù)后臥床患者原因：靜脈瓣，不搏動(dòng)，壁薄易受壓，血液粘滯性增加■血栓形成條件血液凝固性增加changes

in

the

blood

constituents指血液的高凝狀態(tài)。血小板數(shù)量或粘度增加，凝血因子增多遺傳性高凝狀態(tài)：第V因子基因突變獲得性的高凝狀態(tài)惡性腫瘤時(shí)癌細(xì)胞釋放出促凝因子DIC及游走性血栓性脈管炎妊娠，手術(shù)后、大面積燒傷、產(chǎn)后Virchow’s

triad

in

thrombosis.

Endothelial

integrityis

the

single

most

important

factor.

Injury

to

endothelial

cells

can

affect

local

blood

flow

and/orcoagulability.

Abnormal

blood

flow

(stasisorturbulence

can

cause

endothelial

injury.

The

factors

may

act

independently

ormay

combine

tocause

thrombus

formation.Pathogenesis

of

thrombosisThree

important

elements

in

thrombosis心血管內(nèi)皮細(xì)胞的損傷血流狀態(tài)的改變血液凝固性增加Thrombosis

血栓形成■Process

ofthrombogenesis■血栓形成的過程Thrombosis

血栓形成靜脈內(nèi)血栓的形成Thrombosis

血栓形成√白色血栓pale

thrombi√混合血栓mixed

thrombi√紅色血栓red

thrombi√透明血栓hyaline

thrombiMorphology

and

types

of

thrombi按形態(tài)分類：按發(fā)生部位分類發(fā)生于心血管系統(tǒng)的任何部位心臟或主動(dòng)脈壁上血栓--層狀血栓（lines

of

Zahn),為混合血栓（mixed

thrombi)：由灰白色的血小板和纖維素層以及暗紅色的紅細(xì)胞層相間而成，并混有變性的白細(xì)胞--附壁血栓（muralthrombi)—底部與心壁、血管壁相連--球形血栓（ball

thrombi)—左心房?jī)?nèi)血栓靜脈—紅色血栓Morphology

and

types

of

thrombi層狀血栓（lines

of

Zahn混合血栓（mixed

thrombi)Morphology

and

types

ofthrombiMorphology

of

thrombi左心房附壁血栓（mural

thrombi)球形血栓Morphology

and

types

ofthrombi按發(fā)生部位分類動(dòng)脈血栓（arterial

thrombi)靜脈血栓(venous

thrombi,phlebothrombi)微循環(huán)內(nèi)血栓(fibrin

thrombi,microthrombi)心臟瓣膜血栓(cardiac

valve

thrombi)Morphology

and

types

ofthrombi動(dòng)脈血栓（arterial

thrombi)pale

thrombus動(dòng)脈粥樣硬化斑塊基礎(chǔ)上血管損傷白色或混合血栓mixed

thrombus