HEMATOLOGY 2: LECTURE

Villa, M.D. MLS 4C

Role of Blood Vessels in Hemostasis 4. SMC, EC & Fibroblasts: tissue factor

Parts of the Blood Vessel Anti-coagulant Properties

Vascular Intima 1. Endothelial cell: smooth surface

-rhomboid shape of the EC has a smooth
1. Endothelium- innermost layer, where primary surfae so that cells will lyse and maintain
hemostasis occurs depending on the degree of hemostasis and prevent clotting.
injury.
2. Nitric oxide: relaxing factor
2. Internal elastic lamina -EC secrete nitric oxide for vasodilation to
 Elastin occur and for blood to circulate back into the
 Collagen system.

3. Subendothelial connective tissue- outermost 3. Heparan sulfate: anticoagulant

layer, where secondary hemostasis occurs -when circulating in the body it is called
depending on the degree of injury. heparan.
 Collagen
 Fibroblast 4. Prostacylin: platelets inhibitor
 Smooth muscle cell
5. Thrombomodulin: protein C activation
-protein C is an inhibitor of coagulation

6. TFPI: extrinsic pathway inhibitor

-TFPI (Tissue Factor Pathway Inhibitor)

Fibronlytic properties

1. TPA- Tissue Plasminogen Activator

2. PAI- Plasminogen Activator Inhibitor

CELLULAR ELEMENTS PLASMA COMPONENTS

Procoagulant Properties
Vascular intima Coagulation
1. Smooth muscle cell: vasoconstriction
-1st reaction to injury Extravascular tissue factor
-blood vessel constrict to concentrate blood Fibronocytic proteins
(TF) -bearing cells
cells in the injury so that thrombocytes can
function. Platelets Inhibitors
2. Subendothelial collagen: binds
vWF(vonWillebrand Factor) & platelets
-when collagen is exposed vWF and platelets Primary Hemostasis
bind. (Platelets will bind to vWF and vWF will  Activated by desquamation and small injuries
bind with collagen) to blood vessels.
 Involves vascular intima and platelets.
3. Endothelial cell: secrete vWF adhesion
molecules  Rapid, short- lived response.
-vWF is needed for platelet adhesion.  Procoagulant substance exposed or related by
damaged o activated endothelial cells.

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 HEMATOLOGY 2: LECTURE
Secondary Hemostasis
 Activated by large injuries to blood vessels
and surrounding tissues.
 Involves platelets and coagulation system.
 Delayed, long-term response.
 The activator, tissue factor is exposed on
cell membrance.
*THEY CAN GO TOGETHER, DEPENDING
ON THE INJURY.
Anti-coagulant Properties of Intact Vascular
Intima
 Endothelial Cell (structural and secretion
of substances)
1. Prostacyclin- platelet inhibitor,
vasodilator, relaxing factor.
2. Nitotic oxide- relaxing factor,
vasodilator, platelet inhibitor.
3. Tissue factor pathway inhibitor
4. Thrombomudulin- protein C activator,
inhibits F5 and F8
5. Heparan sulfate
Procoagulant properties of Damaged Vascular
intima
1. Smooth muscle cell in arterioles and arteries.
2. Exposed subendothelial collagen.
3. Damaged or activated endothelial cell.
4. Exposed smooth muscle cells and fibroblasts.
5. Endothelial cell inflammation.
Fibrinolytic Properties of Vascular intima
1. TPA- Tissue Plasminogen Activator
2. PAI- Plasminogen Activator Inhibitor
3. TAFI- Thrombin-Activatable Fibrnolysis
Inhibitor
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Villa, M.D. MLS 4C
VASCULAR DISORDERS
Manifests in: Mucosal Surfaces
 Easy bruising
 Spontaneous bleeding
Diagnosis:
 Laboratory tests (not so helpful)
 Medical history
 Ruling out of sources.
 Petechia(e)- red spot less than 3mm
 Purpura- in between 3mm & 1cm
 Ecchymosis- red spot greater than 1cm
 Epistaxis- nose bleed
 Hemarthrosis- joints
 Hematemesis- vomit blood
 Hemoptysis- blood in sputum/
 Hematoma
 Hematuria- blood in urine
 Melena- blood in stool
 Menorrhagia- excessive menstrual flow
HEREDITARY VASCULAR DISORDERS
1. Hereditary hemorrhagic Telangiectasia
(Rendu- Oster- Weber syndrome)
-Hereditary structural malformations
DEFECT:
 Thin-walled blood vessel with discontonuous
endothelium.
 Inadequate smooth muscle and elastin
 Fragile and prone to rupture.
MANIFESTATIONS:
 Face, lips, tongue, conjunctiva, nasal mucosa,
fingers, toes, trunk.
 Often in organs (bleeding), epistaxis
 Blanching lesions
-appears when there is no pressure applied
and disappears when pressure is applied.
 From puberty, throughout life time
OTHER RELATED TELANGIECTASIA
 Liver disease and pregnancy
-cherry red hemagiomas
-ataxia- telangiectasia(Louis-Bar syndrome)
-Chronic actinic telangiectasia
LAB FINDINGS:
 Normal bleeding time, tourniquet test
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 HEMATOLOGY 2: LECTURE
Villa, M.D. MLS 4C

2. Hemangioma- thrombocytopenia syndrome/ -children ages 3 to 7 years old are mostly

Congenital hemangioma/ Kasabach-Merritt affected.
syndrome -twice greater risk for males than females.

MANIFESTATIONS:
 Vascular tumor- giant cavernous
hemangioma
 Thrombocytopenia
 Bleeding diathesis
 Associated with acute/ chronic DIC &
MAHA
*associated with intravascular coagulation
DEFECTS:
3. Ehlers- Danlos syndrome
 Auto-immune vascular injury
MANIFESTATIONS:
 Auto-immunity to vessel wall
 Hyperextension skin components.
 Hypermobility and laxity of joints  Immunoglobulin ???- secretory IgA.;
 Fragile tissues Vasculitis
 Bleeding and subcutaneous hematoma
 Easy bruising to arterial puncture LAB FINDINGS:
DEFECTS:  Normal platelet count, tourniquet test,
bleeding time, coagulation
 Defective collagen production
 Increased ESR and WBC
 Anemia
4. Pseudoxanthoma elasticum
-fragmentation and mineralization of elastic fibers
2. Drug induced vascular purpura
5. Osteogenesis imperfecta -aspirin, warfarin, barbiturates, anti-biotics,
-defective collegen formation sulfonamides, diuretics, digoxin, methyldopa,
iodides.
6. Marfan syndrome -petechiae to petechial.
-decreased strength and elasticity of blood vessels.
3. Paraproteinemia
ACQUIRED VASCULAR DISORDER -excess production of plasma cell
-present in myeloma patients
Acquired Vascular Purpura

1. Allergic/ Anaphylactoid Purpura

-skin rash, endema, malaise, headache, fever.
-caused by foods, drugs, cold, insect bites,
vaccinations.

 Henoch- Scholein Purpura

-transcient arthralgia, nephritis, abdominal DEFECTS:
pain, purpuric skin lesions.
a. Dysfunction of platelets
-coating of platelet membrane with
RASH: delayed manifestation- difficult in
paraprotein; inhibits receptors and severe
diagnosis SKIN LESION (palable)
hemorrhage.
-uticarial, pinkish red to hemorrhagic
-brown red erruption
b. Inhibit fibrin polymerization
-feet, elbows, knees
- excess IgA & IgG3

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 HEMATOLOGY 2: LECTURE
4. Amyloidosis
-excess Amyloid tissue
-deposition of abnormal quantities of amyloid
tissue in vascular wall and surrounding tissue.
*monoclonal light chains
*purpura, hemorrhage, thrombosis
LAB FINDINGS:
 Abnormal platelet function
 Decreased platelet
5. Senile Purpura/ Cachetic Purpura
-common in elderly men & women
-severity increase with age
DEFECTS:
 Lack of collage support for blood vessels
 Loss of subcutaneous fat & elastic fibers
“AGE SPOTS”
-brown stain
-1 to 10mm flat dark blotches
- do not blanch with pressure & resolve slowly
LAB FINDINGS:
Increased capillary fragility.
6. Scurvy
-insufficient dietary intake of Vit. C
-decrease collagen synthesis
-weakening of capillary veins
-purpuric lesions.
7. Corticosteroid Purpura & Cushing’s Disease
-excessive breakdown of collagen
-thin fragile skin
-vessel wall fragility
-bruising
8. Cutaneous bleeding & bruising
-women w/ emotional problems
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Villa, M.D. MLS 4C
Purpura of Unknown Origin
 Purpura Simplex
 Psychigenic purpura
Infection related Bleeding Disorders
1. Bacterial
-meningococcemia & septicemia, typhoid,
scarlet fever, diptherial, tuberculosis,
endocarditis, leptospirosis.
2. Viral
- small pox, influnza, measles.
3. Rickettsia
- RMST, typhus
4. Protozoal
-malaria, toxoplasma
 Purpura fulminans
-hemorrhagic condition associated with
sepsis or previous infection
-cutaneous manifestation of DIC
-thrombosis
 Waterhouse- Friderichen Syndrome
-adrenal gland failure
-bleeding into adrenal glands
-bacterial infection (Neisseria meningitidis)
PLATELETS
Numerical Characteristics
Size: 2-4 um
Giant platelets: 6um & above
MPV (Mean Platelet Volume): 8-10 fl
Life span (BM to circulation): 8-12 days
Reference Range: 150-400 x 109/L or 150-450 x
109/L
Present in the circulation: 2/3, slpeen: 1/3
(unused platelets are stored in the spleen)
Maturation: 7 days ( 5 days in the BM & 2 days
in the spleen)
Presence of platelets per 100x: 7-21 platelets
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 HEMATOLOGY 2: LECTURE
Villa, M.D. MLS 4C

MEGAKARYOPOIESIS
Morphology
-small anucleated cytoplasmic fragments of
megakaryocytes.
-Gray-blue with purple granules in Wright’s stain

 Giant Platelets
-premature release & increased demand
-may result to false increase in RBC
 Immature Platelets
-Acute Megakaryocytic Leukemia (M7)

MEGAKARYOCYTE

Size: 30-50mm/ 40- 60mm

Population: < 0.5% of all BM cells
-multilobulated nucleus, abundant granular
cytoplsm.
 NF-E2
-Wright stained BM aspirate smear: 2-4 -controls the process of polyploidization
megakaryocytes per 10x lpf -Polyploidization ( 2N 128 N)
 GATA 1
-1 megakaryocyte = 2,000 to 4,000 platelets -Globin Transcription Factor 1
 FOG 1
- Friend of GATA 1

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 HEMATOLOGY 2: LECTURE
Villa, M.D. MLS 4C

PRIMARY HEMOSTASIS
THROMBOPOIESIS
-platelet shedding 1. Adhesion
-thrombocytopoiesis
2. Platelet activation
-granules(substances that are preapred to be
released by platelets.)

3. Platelet change in shape

- filopodia/ pseudooods (long projections)

Basic steps in Hemostasis (Primary &

Secondary)

1. Vasocontriction 4. Platelet secretion

-serotonin, thromboxane A2 (triggers - canalicular system (pathway for the inside
vasocontriction from the Endothelial cells) granules of plts. to be released)

2. Platelet adhesion 5. Aggregation

-collegen--vWF--platelet (direct) -Glycoprotein IIb/ IIIa receptor
-Glycoprotein 1b/ V/ IX receptor
 Receptors are present in platelets
-collagen--platelet (indirect)
 Adhesion occurs first than aggregation
-Glycoprotein Ia/ IIa/ VI receptor
becaused it is based on their receptors.
3. Platelet aggregation
-Glycoprotein IIb/ IIIa (plt.--plt.)

4. Fibrin- platelet interaction

-there will be no plt.--plt. aggregation if
fibrinogen is not present because receptors
will attach on the fibrinogen.

PLATELET STRUCTURE

5. Fibrin stabilization
-FX III (Fibrin stabilization factor)
-if bleeding stops FX III occurs
1. Chromere/ granulomere
-located centrally and is granular
2. Hyalomere (non-granular platelet)
-surrounds the chromere and is nongranular
or clear to light blue.

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 HEMATOLOGY 2: LECTURE
Villa, M.D. MLS 4C

MEMBRANE SYSTEM
Zone and Component
 OCS (Open Canalicular System)
1. Peripheral zone -surface connected canalicular system
2. Structural or Sol-gel zone- maintains the -route for endocytosis and for secretion
structure of the platelet. of α-granule contents.
3. Organelle zone- maintaints platelet function.
 Dense Tubular System
4. Membrane zone- contains DTS and OCS -sequesters Ca2+
-bears series of enzyme for platelet
PERIPHERAL ZONE activation.
 Plasma Membrane
- TO BE CONT’D KAY WALA KO KA ABOT -Phospholipase A2
COPY…. :( sad Control platelet
-Cyclooxygenase activation.
-Thromboxane synthetase
Eicosanoid synthetic pathway

STRUCTURAL or SOL-GEL ZONE

 Circumferential microtubules (tubulin)

-cylindrical on cross section (25 nm)
-parallel the plane of the outer surface

1. Move inward to enble the expression

of α-granule contents.

 Glycocalyx (phospoholipid, submembrane 2. Reassemble in long parallel bundles

area, PF3) to provide rgidity to pseudopods
- 20 to 30 nm
-Exterior coat with glycoprotein receptor sites.  Microfilaments (actin)
-Absorbs albumin, fibrinogen, and other plasma -anchors the plasma membrane GP &
proteins. preteoglycans.
-present througout the cytoplasm
*process of absorption: endocytosis (protein to (20-30% of platelet protein.)
platelets)
1. Resting platelet: globular &
 Glycoprotein receptors amorphous

2.Increased cytoplasmic calcium:

cont’d …. KULANG PA SA KOPYA

 Intermediate filaments (desmin &

vimentin)

-ropelike polymers (8 to 12 nm)

-connect with actin & the tubules

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 HEMATOLOGY 2: LECTURE
Villa, M.D. MLS 4C

PURPOSE OF CYTOSKELETON 2. Serotonin: for vasoconstriction

3. Calcium: for platelet activation
1. Platelet shape change (contraction)
2. Extension of pseudopods α-GRANULES
3. Secretion of granule contents
-50 to 80 per platelet
-stain medium gray in osmium-dye in TEM
ORGANELLE ZONE
 Relase of granule contents:
1. Mitochondria
2. Glycogen 1. Fuse with SCCS
3. Lysosomes & peroxisomes 2. Contents flow to the neaby microfilment.
(stain +: arylsulfatase, β- glucuronidase, acid
phosphatase)
4. Granules
a) Dense granules Storage of protein &
b) α granules non-protein mediators

*Dense granules - non-protein mediators

*α- granules- protein mediators

DENSE GRANULES Present in platelet cytoplasm and α-granules:

-2 to 7 per platelet
 Fibrinogen
-appear later than α-granules
-for platelet aggregation; converted into
-stain black with osmium dye in TEM
fibrin.
 Release of grnule contents:
 Facor V, Factor XI (needed for fibrin clot)
1. Migrates to plasma membrane -fibrin formation.
2. Release contents directly into the plasma
 von Willebrand factor
-for platelet adhesion; carrier of Factor VIII
in plasma.
-VWF-VIII

 Thrombospondin, fibronectin, vitronectin

-adhesive for glycoproteins.

Present in α-granules ONLY:

 Beta-thromboglobulin
-chemoattractant for neutrophils, fibroblasts
-neutralize heparin

 Protein S, TFPI, α-1 protease inhibitor, C1

1. ADP esterase inhibitor (inhibitors of coagulation)
-stimulation and recruitment -inhibition of coagulation.

More platelet  Plasminogen

Increased -converted to plasmin (fibrinolysis)
release
cytoplasmic Ca2+
 PAI-1
Appearance of -fribrinolytic inhibitor
GP IIb/ IIIa

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 HEMATOLOGY 2: LECTURE
Villa, M.D. MLS 4C

 Platelet Factor IV
-neutralizes heparin for neutrophils,
fibroblasts.
-supreses megakaryocytopoiesis
-weak chemoattractant

 PDGF, TGF, EGF, IGF

-promotes regrowth of smooth muscle cells
(wound … CONT’D KAY WAAY KO KA
ABOT KOPYA)

Platelet adhesion

 White clot
-product: platelet clot
-present in primary hemostasis
-usually happens in the arteries
-related to cadio-vascular disorders

-indirect platelet adhesion comes first then

followed by direct platelet adhesion.

1. GP Ib/ IX/ V will attach to your VWF which

is attached to your collagen.
 Red Clot
2. GP VI will bind with your collagen, GP VI
-product: fibrin clot and platelet clot
intitiates the release of TXA2 and ADP,
-present in secondary hemostasis
which activates your GP IIa/ Ib.
-called red clot because of the presence of
RBC.
-usually happens in the veins

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 HEMATOLOGY 2: LECTURE
Villa, M.D. MLS 4C

-related to pulmonary obstruction/ deeep vein

thrombosis.

Platelet secretion

 α-granules and lysosomes: SCCS

Coagulation proteins
 Dense granules- migrate to the plasma
membrane.
Vasoconstrictors/ platelet
agonists

Platelet Activation Pathwways (G-protein

mechanism; messenger of platelets for granules to
release its contents)

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