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# Hyperemia = ++ amount of blood in a vessel : (1) Active (arterial) : increase in bl.flow to organ d.t vasodilation of arterioles
Physiologic a- muscular exercise
b- glands during secretion
Pathologic c- acute inflammation
(2) Passive (venous congestion ) : ++ bl flow to organ d.t obstruction of venous out flow
b - chronic
General . . . . . . a - acute
b - chronic
Acute
a - Causes : Sudden complete venous obstruction d.t :
- Thrombosis
- Ligature
- Twisting of Pedicle movable organ (ovary)
- Strangulated hernia .
b - Pathology : Rapid severe dilatation of ! veins & capillaries w may rupture edema
c - Fate : (1) sufficient venous anastomosis
no harmful effect.
(2) insufficient venous anastomosis (as in mesenteric veins)
Chronic
a - Causes :
gradual incomplete venous obstruction as compression by :
- Tumor
- Enlarged L.N.
- Pregnant uterus
- Liver cirrhosis & fibrosis.
b - Pathology : 1) ! veins, venules & capillaries proximal to
obstruction become dilated & congested edema
2) Gradual opening of ! collaterals & anastomatic veins
c - Examples of chronic local venous congestion :
1 - Liver cirrhosis or fibrosis : obst. of veins portal hypertension
2 - C V.C. of ! lungs ( brown induration )
II- General : d.t total ( congestive = Rt & Lt ) heart failure So Congestion occurs all over ! body.
1- Acute
in acute H.F all organs show acute congestion.
2- Chronic
Def : gradual venous congestion affecting ! whole venous system.
Causes : both Rt. Sided & left sided H.F.
Rt. Sided H.F : show chronic venous congestion ( v. c. ) all over ! body except lungs.
Left sided. H.F : show chronic venous congestion ( v. c. ) of lungs
Pathology of Rt. Sided H.F.
I - General effects
1 - Congested neck veins
2 - Cyanosis = (purple - blue coloration) of lips, bed of nails ... etc. d.t ++ reduced Hb
& inadequate tissue perfusion & - - oxygenation.
3 - Cardiac edema : in dependent parts of ! body =
Gravitational edema ( discussed later in edema )
4 - increase blood volume
Liver
N/E
Size : enlarged
Shrunken ( -- size )
Shape : preserved
Distorted
Surface : smooth
2S
congestion.
2C
Consistency : soft to firm
Firm
Capsule : Tense
Thick by fibrosis
1- white ( fibrosis )
2- show cirrhotic nodules
followed by fibrosis
fibrosed area
join each other by fibrous bands.
dilated
congested
show
( Fatty change ).
= regenerating nodules.
c - cells of peripheral zone show
(Normal OR cloudy swelling)
d - Von Kuppfer cells
necrosis
show
( Haemosidrine granules )
Spleen
N/E :
M/E:
* Thick capsule & trabeculae.
* Atrophy of lymphoid follicles.
* Fibrous tissue of ! red pulp.
* Rupture of congested capillaries disintegrate hemosiderin
leading to fibrosis & formation of fibrosiderotic nodules
(Gamna Gandy nodules). This contains : 2 minerals
iron + calcium.
2 fibers collagen + elastic.
1 pigment hemosiderin.
Giant cells.
Q : give account on ( Gama Gandy nodules ) :
1 - pathogenesis :
Severe congestion in splenic sinusoids
Haemosiderine
fibrosis
rupture
haemolysis of RBCs
calcification
2 - Component :
as before
3 - Prussian blue :
Kidneys
N/E :
Size : enlarged.
2S
Shape : preserved.
Surface : smooth.
Colour : dark red congested.
2C
Cosistency: soft.
Capsule : stretched
Borders : rounded
C/S : a - yellow cortex (d.t fatty change) containing dark red dots &
streaks w` are ! glomeruli & ! congested vessels
b - dark red medulla.
M/E : * Congestion of ! glomerular capillaries.
* Fatty change of ! proximal convoluted tubules.
Causes
2 - Mitral stenosis
Pathogenesis :
- Blood accumulates in Lt. Atrium pulmonary veins venules
Size : enlarged
Colour : Brown ( d.t hemosiderin )
2C
Consistency : Heavy, firm ( d.t fibrosis )
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Thrombosis
Def : formation of a solid mass ( thrombus ) of blood elements ( mainly platelets & fibrin ) in ! CVS
during life.
Causes of thrombosis : ( Virchows triad )
1) Damage of ! vascular endothelium : i.e. roughness of ! intima ! platelets adhere to !
damaged endothelium.
a - Mechanical : trauma, pressure as (ligature).
b - Inflammatory ( phlebitis, arteritis, endocardites )
c - Degenerative (atheroma)
2) Slowing of blood flow = Stasis :- In normal blood stream : ! blood Cs occupy ! central part, & ! plasma in ! peripheral part.
- In a slow stream : ! platelets cross ! plasmatic zone & come in contact to endothelium.
Slowing occurs in ! following :
- In heart failure ( weak pump) stasis esp. in leg veins ( most far )
- In auricles of ! heart in valve diseases
- In aneurysms, varicose veins
- In portal vein 2ry to liver cirrhosis & bilharziasis
- In acute inflammation
3) Composition changes of blood :
I) ++ blood elements :
a) Platelets After severe hemorrhage ( major operations ) ! bone marrow produces
new platelets w` are more sticky adhere to ! vascular endothelium.
b) RBCs ++ in polycythemia ++ viscosity & stasis.
c) WBCs ++ in leukemia ++ viscosity & stasis.
d) All blood elements In dehydration d.t hemoconcentration.
II) Biochemical factors as activation of clotting system as in Disseminated
intravascular coagulation " DIC " in w` there is thrombosis of many small B.Vs. So it is fatal
Cause : endotoxins, septicemia, liver & kidney diseases . . . . etc.
2 - Color :
pale thrombus
Red thrombus
* dark red.
* granular surface
* smooth surface
* firm
* soft.
* adherent to ! intima
* adherent to ! pale
Mixed or laminated
* Consists of alternating
layers of red &
white thrombi
* found in aneurysms
3 - Extension :
a - Mural thrombus : adherent to ! wall
b - Occluding thrombus : occlude ! lumen
c - Propagating thrombus : extend to reach !
Phlebothrombosis
Def
Site
def mattress.
c - hyperfibringenemia that accompany
pregnancy or after operation.
N/E
pyemia,pyemic abscess
Fate of thrombus :
1 - detachment
a - septic
b - mildly septic
mycotic aneurysm
c - Aseptic emboli :
e`poor collateral
ischemia
e` good collateral
no effect
2 - Undetachment thrombi :
-
a - If small
b - dystrophic calcification
c - incorporation
phlebolith
d - Organization
e - Large occluding thrombus may :1 - undergo recanalization by - wide capillary loop derived from granulation tissue.
- Retraction of organized thrombus.
2 - become complicated by: * propagation.
* congestion : in case of occlusion of vein.
* Ischemia : in case of occlusion of an artery e` poor collateral.
Thrombus
Clot
* Blood in motion
* Stagnant blood
* Lines of zahn
* No lines of zahn
* Friable, dry
* soft, moist
* granular surface
* smooth surface
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Embolism
Def : circulation of an insoluble material in ! blood + sudden Impaction in a narrow vessel. !
material is called an embolus.
Types & Sources of Emboli :
(I) - Thrombo embolism : A detached thrombus may originate from :
1 - Veins :
* from systemic veins Rt side of heart lungs
N.B : rare sites of embolism are: Coronary artery ( filled during diastole )
Bronchial artery ( small side way branch )
3 - Arteries :
Emboli originating from arteries are uncommon due to :
* Arterial thrombosis is rare.
* Arteries get narrower in their course & ! thrombus does not move.
pyemia abscess.
b - mildly septic
mycotic aneurysm.
c - Aseptic emboli :
- e`poor collateral
- ischemia
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- e` good collateral
no effect.
(II) - Fat embolism: common in sites containing fat as:* cutaneous burns
* bone fractures
* in abdomen d.t acute pancreatitis
* fatty change liver.
Fat globules enter through ! ruptured veins pulmonary or systemic embolism.
! fatty acids from fat damage ! capillaries hemorrhagic edema.
(III) - Tumor emboli:
Malignant Cs pass as emboli in ! circulation & give metastases in ! organs.
(IV) - parasitic emboli
As bilharzial ova & worms.
(V) - Air embolism : Causes
1 - Injury of large neck veins gaping as they are embedded in
fascia preventing their collapseair is sucked into ! heart.
2 - Faulty technique in doing artificial pneumothorax & in blood transfusion.
3 - Air passes into ! uterine veins in criminal abortion.
* Caisson 'S disease :Deep divers & bridges builders work under a high atmospheric pressure where
their nitrogen gas is dissolved in ! tissues & blood SO
sudden ascent produces nitrogen bubbles w act as gas emboli.
and Spinal cord is mainly affected.
(VI) - Amniotic fluid embolism :
during delivery fatal pulmonary embolism.
(VII) - Pulmonary embolism
- Sources of ! embolus : thrombi of calf veins in ! lower limbs.
- Effects:
1 - Large embolus : Occludes ! pulmonary trunk or one of its main branches produces
sudden death d.t acute Rt. sided H.F. No time for an infarct to occur.
2 - Medium sized emboli : a - If ! lung is healthy no effect as ! lung has
double blood supply ( pulmonary & bronchial )
b - if ! lung shows chronic V.C. lung infarcts
3 - Recurrent small sized emboli pulmonary hypertension d.t lung fibrosis. No Infarction.
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a - Thrombosis or embolism.
c - Twisting of ! pedicle of
b - atherosclerosis.
c - Endarteritis as in syphilis ($)
effects :
The Gradual occlusion gives chance for !
collaterals to open up SO :
infarction or gangrene.
1 - insufficient collaterals
* atherosclerosis
myocardial
Infarction.
2 - Sufficient collaterals
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Infarction
Def : area of coagulative necrosis ( liquefactive in ! brain ) d.t acute sudden ischemia
in an organ e` endarteries = ( arteries e` Insufficiet collateral ) Like brain, retina,
heart, spleen, kidney & intestine.
General features of infarction = N/E :
Site : Sub - capsular ( in the periphery of affected organ )
Size : depend on :
2S
Soft.
C/S : Show 3 zones ( infarct area & zone of inflammation around & surrounding tissue).
M/E of infarction :
1 - The infarct area : * Coagulative necrosis in all organ except C.N.S
* It show post necrotic change
Liquefactive.
3 - The rest of organ : * is normal except in lung infarction( the lung show C.V.C ).
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Types :
- Occur in soft & vascular organs as lung & intestine - occurs in firm & less vascular
- ! red color is d.t hemorrhage in ! substance
organs as ! kidneys & heart.
of ! infarct (! blood pass from ! dilated
marginal vessels into ! necrotic
vessels in ! infarct area).
- When hemolysis occurs in ! red Cs, &
Recent infarct
Surface
* Raised ( edema )
* Depressed ( Fibrosis )
- greyish white.
* No hyperemia ( no inflammation)
M/E
Coagulative necrosis
M/E
@ Fate of infarct : 2H 3 - 2F -6
1 - Healing by organization :
a - Small infarct : replaced by fibrosis
b - Large infarct : surrounded by fibrous capsule
2 - Hyaline degeneration
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3 - Dystrophic calcification.
4 - 2ry infection Abscess
5 - putrefaction Gangrene
6 - In ! brain d.t high lipid content, leaves a cyst surrounded by glial tissue.
Lung
Causes : The lung have double blood supply ( pulmonary & Bronchial arteries ) SO for infarction to
occur Both arteries have to be occulded :* Thrombosis or embolism of pulmonary artery.
* Left ventricular failure or mitral stenosis
decrease C.O.P
C/P
- Chest pain ( pleurisy )
- Dyspnea , Hemoptysis , Hemolytic jaundice.
Kidney
Causes :
a - Emboli originating from left side of ! heart.
b - Thrombosis complicating atheroma of a branch of ! renal artery.
N/E :
No
single or multiple
1S
wedge shaped
Colour : pale
2C
Consistency : firm
Surrounding : red zone of inflammatory hyperemia
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Causes :
(a) Emboli from left side of ! heart.
(b) Leucocytic thrombi in leukemia.
N/E : As w` of ! kidney but capsule is affected so painful ( capsule and the organ
have the same blood supply)
M/E : 1 - The infarct area : the lymphoid follicle & vessels appear as ghosts
Coagulative necrosis) M/E).
Causes :
a - Mesenteric thrombosis or embolism ( artery )
b - Thrombosis of superior mesenteric vein.
c - Strangulated hernia , intussusception & volvulus.
N/E :
* Infarction is hemorrhagic, ! affected loop appear dark red, thick & edematous.
* ! serous coat is covered by fibrinous exudate.
* ! wall, lumen & peritoneal cavity show hemorrhage.
C/P :
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1 - Dry gangrene
2 - Moist gangrene
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I - Dry gangrene
- Site : Occurs in areas e`
* poor in ! blood supply & tissue fluids.
* Poor collateral circulation
- Cause : due to acute ischemia = sudden complete occlusion of artery in a dry lower limb.
- Pathogenesis : arterial supply is only occluded venous & lymphatic drainage & surface
evaporation occur, so ! gangrene is dry
- Examples of Dry gangrene :
Dry gangrene
cause
type
Site
Putrifaction
Mamification
Wet gangrene
Exposed limb
Slow
Rapid
Present
* line of
Marked
Poor
* line of
Separation
Present
Absent
Self amputation
may occur
Not occur
spread
Slow
Rapid
Toxemia
Mild
Severe
Fatality
Not fatal
Highly fatal
demarcation
Edema
Def : abnormal ++ of interstitial fluid in the tissue spaces.
Causes of edema
1) vascular factors :
a - increase capillary hydrostatic pressure.
b - increase capillary permeability
c - decrease Colloid OP of plasma proteins
d - Obstruction of draining veins & lymphatic vessels
2) Tissue factors :
Increase tissue osmotic pressure.
Classification of edema
Local
Generalized
Miscellaneous
1 - Inflammatory
1 - Cardiac
1 - Angioneuretic (Allergic)
2 - Obstructive
2 - Renal
2 - Milroy's edema
a - Venous
a - Nephritic
b - Lymphatic
b - Nephrotic
c - Nutritional
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Generalized edema..
Localized edema..
M/E :
- Edema fluid is pale red homogenous.
- separates ! tissue Cs & may enter them ( intracellular ).
Milory's edema : = congenital obstruction of ! lymphatics of ! lower limbs dating since birth
# 1ry Shock
= Neurogenic = Vaso-Vagal Attack :an immediate fainting attack w` lasts few minutes & recovery is rapid.
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Hypovolemic Shock
Fatal
Causes :-
a - Hemorrhage
b - Loss of plasma
fluids e.g. Burns.
- infected burns.
- immunodeficiency states.
Pathogenesis :-
- blood volume
decrease VR
decrease COP
mediators -- effective
decrease blood
flow decrease O2
blood flow.
supply to ! tissue
Pathogenesis of 2ry Shock : occurs after few hours, & passes into :
# Reversible Stage: ! following compensatory mechanisms occur :
1 - V.D of bl. V in vital organs ( heart and CNS ).
2 - V.C of rest of bl.v by vasoactive agents as :
- Catecholamines
- renin-angiotensin-aldosterone mechanism
- antidiuretic hormone (ADH) ++ venous blood flow into heart ++ blood pressure.
3 - ++ of aortic arch & carotid sinus ++ HR ++ blood volume.
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Hemorrhage
Def : Escape of blood outside ! cardio - vascular system.
Causes :
1 - Traumatic hemorrhages d.t mechanical injury of ! either accidental or surgical.
2 - Spontaneous hemorrhage d.t : affection of vascular wall by :
a - Diseases of ! vascular wall : atheroma, aneurysms , varicose veins..etc.
b - Destruction of ! vascular wall : TB, malignancy, peptic ulcer... etc.
c - Systemic diseases characterized by hemorrhage :
blood diseases as hemophilia & purpura.
vit. C & K deficiency.
hypertension & fevers.
Types of hemorrhage :
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Effects of hemorrhage : This depends on ! amount & velocity of ! blood loss :1 - Repeated loss of small amount (10%) iron deficiency anemia.
2 - Loss of 15 % of blood volume - - COP - - blood pressure this is compensated by
The same compensatory mech in reversible stage of shock
3 - Loss of 25 % or more of blood volume :
- may recover or decrease VR decrease COP decrease B.P shock & death.
Post - mortem Picture of Hemorrhage :
Similar to ! post-mortem picture of shock but ! organs are pale from blood loss.
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