بسم الله الرحمن الرحيم. HEMODYNAMIC DISTURBANCES (Disorders of blood flow) By:...

بسم الله بسم الله الرحمن الرحمن الرحيمالرحيم

HEMODYNAMIC HEMODYNAMIC DISTURBANCESDISTURBANCES

(Disorders of blood flow)(Disorders of blood flow)

By: Dr. Gehan Mohamed

CIRCULATORY DISTURBANCESCIRCULATORY DISTURBANCES

1- Hyperemia1- Hyperemia

2- Congestion2- Congestion

3- 3- ThrombosisThrombosis

4-4- Embolism Embolism

5- Ischemia5- Ischemia

6- 6- InfarctionInfarction

7-7-

HemorrhagHemorrhag

ee

8- Edema8- Edema

Hyperemia & CongestionHyperemia & CongestionThe terms hyperemia & congestion both indicate: The terms hyperemia & congestion both indicate:

a local increase in volume of blood in a particular a local increase in volume of blood in a particular tissuetissue..

HyperemiaHyperemia is an is an active processactive process resulting from resulting from increased arterial blood inflow because of arteriolar increased arterial blood inflow because of arteriolar dilatation.dilatation.

- The affected tissue is reddened because of - The affected tissue is reddened because of engorgement of tissues with oxygenated blood.engorgement of tissues with oxygenated blood.

CongestionCongestion is a is a passive processpassive process resulting from resulting from impaired venous outflow from a tissue.impaired venous outflow from a tissue.

- The tissue has a red-blue color due to accumulation - The tissue has a red-blue color due to accumulation of deoxygenated blood.of deoxygenated blood.

HYPEREMIAHYPEREMIA

Definition:Definition:

Increase in blood flow to an organ as result of active Increase in blood flow to an organ as result of active dilatation of its arterioles.dilatation of its arterioles.

It is an active process, involving change in the muscle It is an active process, involving change in the muscle tone of the arterioles (active hyperemia). tone of the arterioles (active hyperemia).

Types:Types:1- Physiological: 1- Physiological:

- hyperemia in skeletal muscles during exercise.- hyperemia in skeletal muscles during exercise.

- hyperemia in the gut following a meal.- hyperemia in the gut following a meal.

2- Pathological:2- Pathological: e.g. in acute inflammation.e.g. in acute inflammation.

VENOUS CONGESTIONVENOUS CONGESTION(Passive Hyperemia)(Passive Hyperemia)

Definition:Definition: Increase in venous blood in an organ as result of Increase in venous blood in an organ as result of

obstruction of venous outflow.obstruction of venous outflow. - the veins, venules, & capillaries in the organ become - the veins, venules, & capillaries in the organ become

passively dilated (passive hyperemia).passively dilated (passive hyperemia). - although there is excess blood in the tissue, the - although there is excess blood in the tissue, the

blood flow is slow & reduced.blood flow is slow & reduced.

Types:Types: → → Localized acuteLocalized acute chronicchronic Generalized acuteGeneralized acute chronicchronic

Acute localized venous congestionAcute localized venous congestion

Causes:Causes: Sudden complete venous obstructionSudden complete venous obstruction by: by: thrombosis, ligature, strangulation, or twisting of the thrombosis, ligature, strangulation, or twisting of the pedicle of a movable organ. pedicle of a movable organ.

Effects:Effects:

1- Rapid severe distention of the veins and capillaries 1- Rapid severe distention of the veins and capillaries which may rupture → which may rupture → hemorrhagehemorrhage. .

2- 2- EdemaEdema occurs rapidly in the tissues. occurs rapidly in the tissues.

3- In intestine: 3- In intestine: infarction & gangreneinfarction & gangrene may occur may occur

Chronic localized venous congestionChronic localized venous congestion

• • Causes:Causes: Gradual incomplete venous obstructionGradual incomplete venous obstruction by: by: 1- Venous compression by1- Venous compression by: a tumor, enlarged lymph node or : a tumor, enlarged lymph node or

pregnant uterus. pregnant uterus.

2- Liver cirrhosis or fibrosis2- Liver cirrhosis or fibrosis → congestion in mesenteric → congestion in mesenteric

& splenic veins.& splenic veins.

3- Left ventricular failure3- Left ventricular failure → congestion of pulmonary veins → congestion of pulmonary veins

• • Effects:Effects: Chronic dilatation of the veins, venules and Chronic dilatation of the veins, venules and capillaries proximal to the obstruction resulting in:capillaries proximal to the obstruction resulting in:

1- Edema. 2- Stasis predisposes to thrombosis1- Edema. 2- Stasis predisposes to thrombosis

3- Gradual opening of the collateral veins. 3- Gradual opening of the collateral veins.

4- Development of varicoses (e.g. oesophageal varices)4- Development of varicoses (e.g. oesophageal varices)

Acute generalized venous congestionAcute generalized venous congestion

Causes:Causes: - occurs in - occurs in acute heart failureacute heart failure

Effects:Effects:

All viscera show acute congestionAll viscera show acute congestion

(rapid generalized congestion)(rapid generalized congestion)

Chronic generalized venous Chronic generalized venous congestioncongestion

Definition:Definition: Gradual congestion affecting the whole venous Gradual congestion affecting the whole venous

system in the body.system in the body.

Causes:Causes: Right sided heart failure

Effects:Effects:

1- Hypoxia & cyanosis.

2- Dyspnea (due to pulmonary Congestion).

3- Generalised oedema.

4- Chronic

venous congestion in different organs.

Effects of chronic generalized Effects of chronic generalized venous congestionvenous congestion

Hypoxia & Cyanosis: Hypoxia & Cyanosis:

- Hypoxia is due to defective oxygenation of blood in the - Hypoxia is due to defective oxygenation of blood in the congested lungs.congested lungs.

- Cyanosis is due to increased amounts of reduced - Cyanosis is due to increased amounts of reduced hemoglobin (due to stasis).hemoglobin (due to stasis).

Dyspnea:Dyspnea: due to pulmonary congestion. due to pulmonary congestion.

Generalized edema (cardiac edema).Generalized edema (cardiac edema).

Effects in different organs.Effects in different organs.

ThrombosisThrombosis1- Definition 1- Definition

2- Causes2- Causes

3- Composition3- Composition

4- Types4- Types

5- Sites5- Sites

6- Fate6- Fate

7- N.B.7- N.B.

Definition of thrombosisDefinition of thrombosis

Thrombosis is:Thrombosis is:

- The formation of a solid mass (compact mass)- The formation of a solid mass (compact mass)

- Composed of the blood elements.- Composed of the blood elements.

- In a blood vessel or heart.In a blood vessel or heart.

- In circulating blood.In circulating blood.

- During life.- During life.

Causes of thrombosisCauses of thrombosisThere are 3 major factors which There are 3 major factors which

predispose to thrombosispredispose to thrombosis

((Virchow’s triadVirchow’s triad))

1- Endothelial damage1- Endothelial damage

2- Slowing & turbulence of blood flow2- Slowing & turbulence of blood flow

3- Changes in blood composition3- Changes in blood composition

Virchow triad in thrombosisVirchow triad in thrombosis

Causes of thrombosisCauses of thrombosis1- Endothelial damage:1- Endothelial damage:- This is the most important factor in thrombus - This is the most important factor in thrombus

formation.formation.- Endothelial damage may be:- Endothelial damage may be: Mechanical, inflammatory, or degenerative. Mechanical, inflammatory, or degenerative.

The injured endothelium becomes The injured endothelium becomes swollen with rough surface.swollen with rough surface.

2- Staisis: 2- Staisis: There is slowing of blood flow in the heart as in There is slowing of blood flow in the heart as in mitral stenosis and in blood vessels as in mitral stenosis and in blood vessels as in varicose veins.varicose veins.

3- Changes in composition of blood:3- Changes in composition of blood:- ↑ platelets e.g. after operations.

- ↑ fibrinogen as in pregnancy.

- ↑ R.B.Cs. (polythycaemia) → ↑ viscosity of blood → staisis → thrombosis.

- ↑ W.B.C. as in leukaemia → ↑ viscosity of blood → staisis → thrombosis.

Pathogenesis (Mechanism) of Pathogenesis (Mechanism) of thrombosis:thrombosis:

- - Platelets leave the blood stream, agglutinate and adhere to the damaged endothelium.

- They form laminae, which are arranged vertical to the blood stream and called lines of Zhan.

- Soon, fibrin accumulates around them with red and white blood cells.

Lines of ZhanLines of Zhan

Classification of thrombiClassification of thrombiAccording to the color & composition of thrombiAccording to the color & composition of thrombi

According to the site of thrombus:According to the site of thrombus:

According to presence or absence of bacteria:According to presence or absence of bacteria:

According to the color & composition According to the color & composition of thrombi:of thrombi:

1- Pale thrombus: formed only of platelets and 1- Pale thrombus: formed only of platelets and fibrin. fibrin.

2- Red thrombus: formed mainly of red cells 2- Red thrombus: formed mainly of red cells and fibrin. and fibrin.

3- Mixed thrombus: containing all blood 3- Mixed thrombus: containing all blood elements. elements.

According to the site of thrombus:According to the site of thrombus: 1- 1- Venous thrombus (the most common): Venous thrombus (the most common):

formed in veins as in varicose veins and after formed in veins as in varicose veins and after major abdominal operations. major abdominal operations. 2- Arterial thrombus: found in atherosclerosis 2- Arterial thrombus: found in atherosclerosis and aneurysm. and aneurysm.

3- Cardiac thrombus: found in the heart, either 3- Cardiac thrombus: found in the heart, either in the heart chambers called in the heart chambers called mural mural

thrombusthrombus or on the heart valves called or on the heart valves called vegetationsvegetations..

4- Capillary thrombi4- Capillary thrombi

According to presence or absence of According to presence or absence of bacteria:bacteria:

1- 1- Septic thrombus: containing pyogenic Septic thrombus: containing pyogenic bacteria. bacteria. 2- Aseptic thrombi: without 2- Aseptic thrombi: without bacteria.bacteria.

1- Venous thrombosis1- Venous thrombosis

Thrombosis in veins is more common than Thrombosis in veins is more common than other sites because of their slow blood, other sites because of their slow blood, and thin wall. and thin wall.

Thrombosis in veins may be either: Thrombosis in veins may be either:

I.I. ThrombophlebitisThrombophlebitis

II.II. PhlebothrombosisPhlebothrombosis

ThrombophlebitisThrombophlebitis● ● Thrombosis is caused by inflammation of venous wall.Thrombosis is caused by inflammation of venous wall.

● ● Two types occur: Two types occur:

1- Septic thrombophlebitis: 1- Septic thrombophlebitis: - Occurs in veins draining septic lesions.- Occurs in veins draining septic lesions.

- e.g.: appendicular vein in case of acute appendicitis.- e.g.: appendicular vein in case of acute appendicitis.

- suppuration of the thrombus causes its softening- suppuration of the thrombus causes its softening

- fragments of infected thrombus may break away → pyaemia- fragments of infected thrombus may break away → pyaemia

2-Aseptic thrombophlebitis: 2-Aseptic thrombophlebitis: - Inflammation is caused by factors other than bacteria.- Inflammation is caused by factors other than bacteria.

- e.g.: trauma and radiations. - e.g.: trauma and radiations.

- a small fixed aseptic thrombus occurs. - a small fixed aseptic thrombus occurs.

PhlebothrombosisPhlebothrombosisThis is thrombosis in non-inflamed veins.This is thrombosis in non-inflamed veins.

The thrombus may propagate and may fragment The thrombus may propagate and may fragment causing pulmonary embolism.causing pulmonary embolism.

Examples include:Examples include:

1- Thrombosis in varicose veins1- Thrombosis in varicose veins due to stasis. due to stasis.

2- Thrombosis in calf veins (DVT) in chronic cardiac pts 2- Thrombosis in calf veins (DVT) in chronic cardiac pts confined to bedconfined to bed (stasis & compression of calf ms). (stasis & compression of calf ms).

3- Thrombosis in pelvic & femoral veins after labour or 3- Thrombosis in pelvic & femoral veins after labour or operations operations (↑platelets, bed recumbence, surgical injury). (↑platelets, bed recumbence, surgical injury).

2- Arterial thrombosis2- Arterial thrombosis

● ● Less common than venous thrombosis because of the Less common than venous thrombosis because of the rapid blood flow in the arteries and the thick elastic rapid blood flow in the arteries and the thick elastic arterial wall which resists injury. arterial wall which resists injury.

● ● Thrombosis occurs in arteries affected by: Thrombosis occurs in arteries affected by:

atherosclerosis, arteritis, & aneurysmsatherosclerosis, arteritis, & aneurysms (due to stasis, disordered blood flow & roughness of the intima).(due to stasis, disordered blood flow & roughness of the intima).

● ● Arterial thrombosis Arterial thrombosis →→ ischemia. ischemia.

Fate of thrombiFate of thrombi It depends upon its size & whether it is septic It depends upon its size & whether it is septic

or aseptic.or aseptic.● ● Septic thrombi:Septic thrombi: Fragments by proteolytic enzymes into septic emboli Fragments by proteolytic enzymes into septic emboli

→→ pyaemic abscesses. pyaemic abscesses.

● ● Aseptic Thrombi:Aseptic Thrombi: may undergo:may undergo: - Small thrombi is dissolved and absorbed.- Small thrombi is dissolved and absorbed. - Large thrombus undergoes:- Large thrombus undergoes: 1- Organization (fibrosis)1- Organization (fibrosis) 2- Organization & canalization2- Organization & canalization 3- Calcification3- Calcification 4- Fragmentation and embolism.4- Fragmentation and embolism.

Thrombus: organized & recanalizedThrombus: organized & recanalized

Blood ClotBlood Clot

A mass of blood elements formed by transformation of A mass of blood elements formed by transformation of fibrinogen to fibrin, in stagnant blood. fibrinogen to fibrin, in stagnant blood.

The clot is dark red with a glistening smooth surface, The clot is dark red with a glistening smooth surface, and is not adherent to the vessel wall.and is not adherent to the vessel wall.

Clotting of blood may be: → Outside the CVSClotting of blood may be: → Outside the CVS

Inside the CVS:Inside the CVS:

During life after deathDuring life after death

((e.g. in stagnant blood) (postmortem clots)e.g. in stagnant blood) (postmortem clots)

red yellowred yellow

Difference between thrombus and clot:Difference between thrombus and clot:

ThrombusThrombus ClotClot1- Occurs in circulating 1- Occurs in circulating blood during liveblood during live

2- Firmly attached 2- Firmly attached

3- Friable and dry3- Friable and dry

4- Pale, pale red or red4- Pale, pale red or red

5- May show lines of Zhan5- May show lines of Zhan

1- Occurs in stagnant blood 1- Occurs in stagnant blood during life or after deathduring life or after death

2- Loosely attached 2- Loosely attached

3- Soft and moist 3- Soft and moist

4- Red and yellow4- Red and yellow

5- No lines of Zhan5- No lines of Zhan

EMBOLISMEMBOLISM

DEFINITIONDEFINITION

CAUSES & TYPESCAUSES & TYPES

EmbolismEmbolism● ● DefinitionDefinition

Embolus:Embolus: An insoluble (solid, liquid or An insoluble (solid, liquid or gaseous) mass circulating in the blood stream. gaseous) mass circulating in the blood stream.

Embolism:Embolism: Is the process of impaction of Is the process of impaction of the embolus in a narrow vessel. the embolus in a narrow vessel.

EmbolismEmbolism● ● Causes & Types:Causes & Types:

1- Detached thrombi (thrombo-embolism) 1- Detached thrombi (thrombo-embolism)

2- Fat embolism: 2- Fat embolism: The fat of the bone marrow reaches The fat of the bone marrow reaches the circulation after fracture of bones.the circulation after fracture of bones.

3- Air embolism: 3- Air embolism: due to injury of neck & chest veins.due to injury of neck & chest veins.

4- Parasitic emboli: 4- Parasitic emboli: e.g. bilharzial worms and ova.e.g. bilharzial worms and ova.

5- Tumor emboli: 5- Tumor emboli: groups of tumour cells penetrate the groups of tumour cells penetrate the wall of blood vessels especially veins.wall of blood vessels especially veins.

6- Amniotic fluid embolism.6- Amniotic fluid embolism.

1- Detached thrombi 1- Detached thrombi (thromboembolism)(thromboembolism)

Sites of impaction:Sites of impaction: 1- Pulmonary embolism1- Pulmonary embolism 2- Portal embolism2- Portal embolism 3- Systemic embolism3- Systemic embolism 4- Paradoxical embolism i.e.the embolus coming 4- Paradoxical embolism i.e.the embolus coming

with venous return to be impacted in lung causing with venous return to be impacted in lung causing pulmonary embolism but instead of that it will pass pulmonary embolism but instead of that it will pass from right side of heart to its left side through septal from right side of heart to its left side through septal defect then pass to systemic circulation.defect then pass to systemic circulation.

Effects of thromboemboliEffects of thromboemboli

Effects depends upon:Effects depends upon: 1- Size of the embolus. 1- Size of the embolus. 2- Nature of the embolus (septic or aseptic). 2- Nature of the embolus (septic or aseptic). 3- State of the collateral circulation in the 3- State of the collateral circulation in the

affected site. affected site.

Effects of thromboemboliEffects of thromboemboliEffects depends upon:Effects depends upon:

1- Size of the embolus. 1- Size of the embolus. 2- Nature of the embolus (septic or aseptic). 2- Nature of the embolus (septic or aseptic). 3- State of the collateral circulation in the affected site.3- State of the collateral circulation in the affected site.

Effects of pulmonary embolism:Effects of pulmonary embolism:

Big embolusBig embolus Medium sized embolusMedium sized embolus Small Small embolusembolus





Acute Rt sidedAcute Rt sidedHeart failureHeart failure

Sudden deathSudden death





Acute Rt sided healthy lungAcute Rt sided healthy lungHeart failureHeart failure no effectno effectSudden deathSudden death





Acute Rt sided healthy lung congested lung Acute Rt sided healthy lung congested lung Heart failureHeart failure no effect no effect lung infarctionlung infarctionSudden deathSudden death





Acute Rt sided healthy lung congested lung Acute Rt sided healthy lung congested lung no effectno effectHeart failureHeart failure no effect no effect lung infarctionlung infarctionSudden deathSudden death

Air embolismAir embolismRare and may result from: Rare and may result from:

1- Injury to the large neck veins. 1- Injury to the large neck veins.

Air is sucked by the negative pressure in the thorax. Air is sucked by the negative pressure in the thorax.

2- During cardiothoracic surgery2- During cardiothoracic surgery → air may enter veins → air may enter veins

3- In criminal abortion3- In criminal abortion → air may pass into uterine veins → air may pass into uterine veins

4- Caisson’s disease4- Caisson’s disease (decompression sickness):(decompression sickness): - In deep dives, the high pressure increases the amount of - In deep dives, the high pressure increases the amount of

gasses dissolved in the blood of the divers. gasses dissolved in the blood of the divers.

- If decompression is done rapidly, gases esp. nitrogen form - If decompression is done rapidly, gases esp. nitrogen form emboli in the blood vessels. emboli in the blood vessels.

- Small amount of air is harmless, but 50-100 cc. interferes with - Small amount of air is harmless, but 50-100 cc. interferes with cardiac contraction and causes acute heart failure. cardiac contraction and causes acute heart failure.

Fat embolismFat embolismRareRare conditionconditionCauses include:Causes include:

(1)(1) Bone fractures and crush limb injuries. Bone fractures and crush limb injuries. (2) Trauma to adipose tissue (infl. or burns). (2) Trauma to adipose tissue (infl. or burns). (3) Trauma to a grossly fatty liver. (3) Trauma to a grossly fatty liver. (4) Major surgery. (4) Major surgery.

IschemiaIschemiaDefinition:Definition:

Deficient arterial blood supply to an organ or tissue Deficient arterial blood supply to an organ or tissue due to partial or complete occlusion of its artery.due to partial or complete occlusion of its artery.

Types:Types: Ischemia may be either:Ischemia may be either:

1- Acute ischemia 1- Acute ischemia

(complete or sudden ischemia)(complete or sudden ischemia)

2- Chronic ischemia 2- Chronic ischemia

(partial or gradual ischemia)(partial or gradual ischemia)

Acute ischemiaAcute ischemiaCauses:Causes: Sudden complete arterial occlusionSudden complete arterial occlusion by: by:

1- Thrombosis or embolism. (most common)1- Thrombosis or embolism. (most common) 2- Surgical ligature of the artery.2- Surgical ligature of the artery. 3- Twisting of the pedicle of a movable organ e.g. 3- Twisting of the pedicle of a movable organ e.g.

intestinal loop. intestinal loop. 4- Arterial spasm as in ergot poisoning. 4- Arterial spasm as in ergot poisoning.

Effects:Effects: depends on the efficiency of collaterals:depends on the efficiency of collaterals:

● ● Sudden occlusion of end arteries or arteries with Sudden occlusion of end arteries or arteries with

poor collaterals poor collaterals → → infarction or gangrene. infarction or gangrene.

● ● Sudden occlusion of arteries with efficient collaterals Sudden occlusion of arteries with efficient collaterals may not cause tissue damage. may not cause tissue damage.

Chronic IschemiaChronic IschemiaCauses:Causes: Incomplete arterial occlusionIncomplete arterial occlusion by: by:

1- Atherosclerosis. 1- Atherosclerosis. 2-2- Pressure on the artery by enlarged lymph node, Pressure on the artery by enlarged lymph node,

tumor ... etc. tumor ... etc. 3- End arteritis oblitrans as in chronic inflammation. 3- End arteritis oblitrans as in chronic inflammation.

Effects:Effects: depends on the efficiency of collaterals:depends on the efficiency of collaterals:

● ● With inefficient collaterals: With inefficient collaterals: - pain on exercise: angina pectoris, intermittent claudication..- pain on exercise: angina pectoris, intermittent claudication..

- cellular degeneration, atrophy followed by fibrosis.- cellular degeneration, atrophy followed by fibrosis.

● ● With efficient collaterals no tissue damage occurs. With efficient collaterals no tissue damage occurs.

InfarctionInfarctionDefinitionDefinition

CausesCauses

Types Types

Pathological featuresPathological features

Fate Fate

Examples Examples

InfarctionInfarction

DefinitionDefinition

An infarct is an area of coagulative necrosis An infarct is an area of coagulative necrosis

(liquefactive in the brain) caused by sudden (liquefactive in the brain) caused by sudden

ischemia.ischemia.

InfarctionInfarctionCausesCauses

11- Thrombosis that may occur inside diseased - Thrombosis that may occur inside diseased arteries. arteries.

2- Embolism.2- Embolism.

3- Strangulation or twisting of an organ as in 3- Strangulation or twisting of an organ as in loops of intestine, testes or ovaries. loops of intestine, testes or ovaries.

Types of infarcts: Types of infarcts: 1- Red infarcts (hemorrhagic): 1- Red infarcts (hemorrhagic): - Occur in vascular organs as the lung, liver and - Occur in vascular organs as the lung, liver and

intestine. intestine.

- The red color is due to hge in the substance of the - The red color is due to hge in the substance of the infarct. infarct.

2- Pale infarcts: 2- Pale infarcts: - - Are more common and occur in firm and less Are more common and occur in firm and less

vascular organs as the kidney, heart and spleen. vascular organs as the kidney, heart and spleen.

3- Liquefactive infarcts:3- Liquefactive infarcts: - Occur in the brain and spinal cord. - Occur in the brain and spinal cord.

Pathological features of the infarctPathological features of the infarct

● ● Gross picture: Gross picture: Shape:Shape: The infarct is wedge shaped or pyramidal. The infarct is wedge shaped or pyramidal.

The base is directed towards the surface of the organ. The base is directed towards the surface of the organ.

Site:Site: The infarct is subcapsular, raised when recent due to The infarct is subcapsular, raised when recent due to edema and depressed when healed due to fibrosis. edema and depressed when healed due to fibrosis.

Size:Size: depends on the size of the occluded vessel. depends on the size of the occluded vessel.

Color:Color: Infarcts are of two types; red and pale. Infarcts are of two types; red and pale.

It isIt is surrounded bysurrounded by a red zone of inflammatory hyperemia. a red zone of inflammatory hyperemia.

Infarction of the kidneyInfarction of the kidney

Infarction of the spleenInfarction of the spleen

Infarction of the lung Infarction of the lung

(hemorrhagic infarction)(hemorrhagic infarction)

Infarction of the Infarction of the lung lung (hemorrhagic (hemorrhagic infarction)infarction)

Intestinal infarction → GangreneIntestinal infarction → Gangrene

● ● Microscopic picture: Microscopic picture:

Early:Early: the cells show various post-necrotic changes. the cells show various post-necrotic changes.

Next:Next: structural details are lost but the outlines are structural details are lost but the outlines are

preserved. preserved.

Lastly:Lastly: necrotic tissue appears as granular pink necrotic tissue appears as granular pink

debris. debris.

The infarct is surrounded byThe infarct is surrounded by a red zone of a red zone of

inflammatory hyperemia. inflammatory hyperemia.

● ● General reactions: General reactions: Infarcts are associated with general reactions in Infarcts are associated with general reactions in

the form of:the form of:

Fever Fever

Leucocytosis Leucocytosis

Increased sedimentation rate; ESRIncreased sedimentation rate; ESR

Elevation of certain serum enzymes as Elevation of certain serum enzymes as transaminase in myocardial infarction. transaminase in myocardial infarction.

Fate of the infarctFate of the infarct

Small infarct: Small infarct: Necrotic tissues are removed by Necrotic tissues are removed by

macrophages, granulation tissue fills the macrophages, granulation tissue fills the defect followed by fibrosis. defect followed by fibrosis.

Large infarct: Large infarct: Gets surrounded by a fibrous capsule and Gets surrounded by a fibrous capsule and

its substanceits substance may show dystrophic may show dystrophic calcification.calcification.

HAEMORRHAGEHAEMORRHAGE


CausesCauses

TypesTypes

EffectsEffects

HaemostasisHaemostasis

HAEMORRHAGEHAEMORRHAGE

Definition:Definition:Escape of blood outside the blood vessels Escape of blood outside the blood vessels

or cardiac chambers.or cardiac chambers.

(loss of blood from circulation)(loss of blood from circulation)

Causes of haemorrhage Causes of haemorrhage 1- Trauma: involving the heart and blood vessels.2- Diseases of blood vessels: a) Hypertension. b) Varicose veins: as piles. c) Degeneration: as atheroma and aneurysm. d) Infection: as tuberculosis. e) Malignant cells invading blood vessels.3- Haemorrhagic blood diseases: as haemophilia, purpura,

leukaemia and scurvy.

Types of haemorrhage Types of haemorrhage

I.I. External haemorrhageExternal haemorrhage

II.II. Internal haemorrhageInternal haemorrhage

III.III. Interstitial haemorrhageInterstitial haemorrhage

1- External haemorrhage 1- External haemorrhage Escape of blood outside the body.Escape of blood outside the body.

1- Epistaxis:1- Epistaxis: Bleeding from the nose. Bleeding from the nose.

2- Hemoptysis:2- Hemoptysis: Coughing of blood. Coughing of blood.

3- Hematemesis:3- Hematemesis: Vomiting of blood. Vomiting of blood.

4- Melena:4- Melena: Presence of dark digested blood in stools. Presence of dark digested blood in stools.

5- Bleeding per rectum:5- Bleeding per rectum: passage of red blood with stoolpassage of red blood with stool

6- Hematuria:6- Hematuria: Blood in urine.Blood in urine.

7- Menorrhagia:7- Menorrhagia: Excessive or prolonged menstrual bleeding.Excessive or prolonged menstrual bleeding.

8- Metrorrhagia:8- Metrorrhagia: Irregular uterine bleeding unrelated to mensesIrregular uterine bleeding unrelated to menses

9- Bleeding from skin9- Bleeding from skin

2- Internal haemorrhage 2- Internal haemorrhage

Bleeding into body cavities.Bleeding into body cavities.

1- Hemothorax:1- Hemothorax: Hge into the pleural sac.Hge into the pleural sac.

2- Hemopericardium:2- Hemopericardium: Hge. into pericardial sac. Hge. into pericardial sac.

3- Hemoperitoneum:3- Hemoperitoneum: Hge. into peritoneal sac. Hge. into peritoneal sac.

4- Hematocele:4- Hematocele: Hge. into tunica vaginalis sac. Hge. into tunica vaginalis sac.

5- Hemoarthrosis:5- Hemoarthrosis: Hge. into a joint cavity.Hge. into a joint cavity.

3- Interstitial haemorrhage 3- Interstitial haemorrhage

Bleeding into interstitial tissue spaces.Bleeding into interstitial tissue spaces.

1- Petechial haemorrhage:1- Petechial haemorrhage:

escape of small amount of blood of capillary origin → escape of small amount of blood of capillary origin → small spots of haemorrhage.small spots of haemorrhage.

2- Ecchymosis:2- Ecchymosis:

escape of moderate amount of blood → a bigger escape of moderate amount of blood → a bigger patch of haemorrhage.patch of haemorrhage.

3- Hematoma:3- Hematoma:

escape of large amount of blood causing a swelling.escape of large amount of blood causing a swelling.

- - Interstitial haemorrhage is at first dark red (arterial Interstitial haemorrhage is at first dark red (arterial blood) or bluish (venous blood). blood) or bluish (venous blood).

- Then, hemoglobin breaks down into biliverdin and - Then, hemoglobin breaks down into biliverdin and hemosiderin. hemosiderin.

- BiIiverdin gives the area a green color but is soon - BiIiverdin gives the area a green color but is soon absorbed in the blood. absorbed in the blood.

- The hemosiderin left gives the area a brown color and - The hemosiderin left gives the area a brown color and is gradually removed by macrophages, so the color is gradually removed by macrophages, so the color changes to yellow and gradually fades away. changes to yellow and gradually fades away.

Effects of haemorrhageEffects of haemorrhage● ● Small amount:Small amount: No effect.No effect.

● ● Repeated small amounts Repeated small amounts (chronic hge):(chronic hge): - Causes microcytic hypochromic anemia.- Causes microcytic hypochromic anemia. - e.g. in piles and peptic ulcers.- e.g. in piles and peptic ulcers.

● ● Moderate amount:Moderate amount: (< 750 ml.)(< 750 ml.) →→ Is compensated by: Is compensated by:

1- reflex 1- reflex ↑↑ heart rate heart rate

2- reflex vasoconstriction in the skin, muscles & GIT2- reflex vasoconstriction in the skin, muscles & GIT 3- withdrawal of tissue fluids into the blood.3- withdrawal of tissue fluids into the blood. 4- Proteins are added from the liver.4- Proteins are added from the liver. 5- blood cells are added by the hyperplastic B.M.5- blood cells are added by the hyperplastic B.M.

● ● Massive amount:Massive amount: →→ hemorrhagic shock. hemorrhagic shock.

EdemaEdema


CausesCauses

Classification Classification

Pathological featuresPathological features

EdemaEdema

Definition:Definition:

- - Pathological accumulation of excess fluids in Pathological accumulation of excess fluids in

the interstitial tissue spaces and serous sacs.the interstitial tissue spaces and serous sacs.

- Edema fluid may be either transudate or - Edema fluid may be either transudate or

exudate. exudate.

ExudateExudate TransudateTransudateOccurs in cases of Occurs in cases of inflammation. inflammation.

Caused by conditions Caused by conditions other than inflammationother than inflammation

High protein contentHigh protein content

(4-8 gm%). (4-8 gm%).

Low protein content Low protein content

(below 3 gm%). (below 3 gm%).

Specific gravity above 1018. Specific gravity above 1018. Specific gravity below Specific gravity below 1015. 1015.

Clots on standingClots on standing

(presence of fibrinogen)(presence of fibrinogen)

Does not clot on standing. Does not clot on standing. (no fibrinogen)(no fibrinogen)

Contains inflammatory cells.Contains inflammatory cells. No inflammatory cells.No inflammatory cells.

Approximately 60% of body weight is water, Approximately 60% of body weight is water,

two thirds of which is intracellular with the two thirds of which is intracellular with the

remainder is in the extracellular compartments remainder is in the extracellular compartments

(the interstitial tissue & plasma). (the interstitial tissue & plasma).

Filtration out

35 mmHg

HP

15 mmHgHP

Reabsorption in

Mechanism of edema formation

Rates of filtration & reabsorption across Rates of filtration & reabsorption across the capillary wall depend on:the capillary wall depend on:

Capillary hydrostatic pressureCapillary hydrostatic pressure (n: 35-15 (n: 35-15 mmHgmmHg))

Plasma osmotic pressurePlasma osmotic pressure (n: 20 (n: 20 mmHgmmHg))

- Normally, capillary hydrostatic & osmotic forces are - Normally, capillary hydrostatic & osmotic forces are balanced, so that the amount of Interstitial fluid balanced, so that the amount of Interstitial fluid remains constant.remains constant.

- - At arterial end: H.P. > O.P.→ filtration of tissue fluidAt arterial end: H.P. > O.P.→ filtration of tissue fluid

At venous end: H.P. < O.P.→ withdrawal of tissue fluidAt venous end: H.P. < O.P.→ withdrawal of tissue fluid

Causes of edemaCauses of edema1- Increased capillary hydrostatic pressure: 1- Increased capillary hydrostatic pressure: occurs in cases of : - venous congestion (generalized or localized)occurs in cases of : - venous congestion (generalized or localized)

- sodium & water retention - sodium & water retention → ↑→ ↑ blood volume blood volume

2- Decreased plasma colloid osmotic pressure: 2- Decreased plasma colloid osmotic pressure: occurs in cases of hypoproteinemia (fall of total plasma proteins occurs in cases of hypoproteinemia (fall of total plasma proteins

below 2.5 gm% or fall of serum albumin below 1.5 gm%)below 2.5 gm% or fall of serum albumin below 1.5 gm%)

3- Increased capillary permeability: 3- Increased capillary permeability: - Caused by toxins, hypoxia, & chemicals (e.g. histamine in acute - Caused by toxins, hypoxia, & chemicals (e.g. histamine in acute

infl.). infl.).

- Escape of proteins into ISF - Escape of proteins into ISF → ↓→ ↓ plasma osmotic pr. & plasma osmotic pr. & ↑↑ tissue tissue

osmotic pr. osmotic pr. →→ further edema. further edema.

4- Lymphatic obstruction4- Lymphatic obstruction

- It - It →→ lymphatic edema (lymphedema). lymphatic edema (lymphedema).

- It is caused by:- It is caused by:

1- Lymphangitis and lymphadenitis as in Filariasis 1- Lymphangitis and lymphadenitis as in Filariasis

→→ elephantiasis.elephantiasis.

3- Mechanical compression of lymphatics 3- Mechanical compression of lymphatics e.g. by tumors. e.g. by tumors.

4- Lymphatic permeation by malignant cells.4- Lymphatic permeation by malignant cells.

5- Post-irradiation fibrosis in lymphatics & LNs.5- Post-irradiation fibrosis in lymphatics & LNs.

6- Surgical removal of the lymph nodes. 6- Surgical removal of the lymph nodes.

Classification of edemaClassification of edemaAccording to the site of edema:According to the site of edema:

1- 1- Localized edema:Localized edema:

2- Generalized edema (anasarca)2- Generalized edema (anasarca)

According to consistency of edema:According to consistency of edema: 1- Pitting edema (Soft edema): 1- Pitting edema (Soft edema):

2- Non-Pitting edema (Hard edema). 2- Non-Pitting edema (Hard edema).

Localized edemaLocalized edemaLocalized in a part of the body. Localized in a part of the body.

The total amount of fluids in the body is within The total amount of fluids in the body is within normal but with abnormal distribution normal but with abnormal distribution

It includes:It includes:

1- Inflammatory edema:1- Inflammatory edema: Occurs in acute Occurs in acute inflammation. The edema fluid is an exudate.inflammation. The edema fluid is an exudate.

2- 2- Obstructive edema:Obstructive edema:

A.A. Venous obstruction → ↑ Venous obstruction → ↑ hydrostatic pressure hydrostatic pressure in the veins and capillaries → edema.in the veins and capillaries → edema.

B.B. Lymphatic obstructionLymphatic obstruction

Generalized edema (anasarca)Generalized edema (anasarca)The total amount of body fluids is increased. It includes:The total amount of body fluids is increased. It includes:

1- Cardiac edema:1- Cardiac edema: Occurs in congestive heart failure. Occurs in congestive heart failure. 2- Nutritional edema:2- Nutritional edema: Caused by hypoproteinemia due to: Caused by hypoproteinemia due to: - Malnutrition & Malabsorption states- Malnutrition & Malabsorption states - Chronic liver disease - Chronic liver disease → ↓→ ↓ formation of plasma proteins. formation of plasma proteins. 3- Renal edema:3- Renal edema: Occurs in renal diseases & is of two types: Occurs in renal diseases & is of two types: - Nephritic edema: - Nephritic edema: Occurs in acute diffuse glomerulonephritis. Occurs in acute diffuse glomerulonephritis. - - Nephrotic edema:Nephrotic edema: It is caused by massive albuminuria It is caused by massive albuminuria →→ hypoproteinemia. hypoproteinemia.

Pitting edemaPitting edemaThe accumulated fluid canThe accumulated fluid can

be easily moved on pressing be easily moved on pressing the affected part, leaving a pit at site of pressure the affected part, leaving a pit at site of pressure (it pits on pressure).(it pits on pressure).

This is because the edema fluid has low protein This is because the edema fluid has low protein content → it is present free in the tissue spaces.content → it is present free in the tissue spaces.

Occurs when edema fluid is transutade:Occurs when edema fluid is transutade: 1- All types of generalized edema1- All types of generalized edema (cardiac, renal and nutritional edema).(cardiac, renal and nutritional edema). 2- Localized edema due to venous obstruction2- Localized edema due to venous obstruction

Non-Pitting edemaNon-Pitting edemaThe edematous part does not pit on pressure.The edematous part does not pit on pressure.

This is because the edema fluid is united with This is because the edema fluid is united with the tissue elements.the tissue elements.

Occurs in cases ofOccurs in cases of

lymphatic edema.lymphatic edema.

Cardiac edemaCardiac edema

Definition:Definition: Generalized edema caused by Right side heart failur.Generalized edema caused by Right side heart failur.

Causes: Causes: 1- Congestion 1- Congestion → ↑→ ↑ capillary hydrostatic pressure. capillary hydrostatic pressure.

2- Hypoxia 2- Hypoxia →→ Increased capillary permeability. Increased capillary permeability.

3- Renal congestion 3- Renal congestion →→ sodium and water retention.sodium and water retention.

Sites: Sites: - - Edema begins around the ankle (gravity effect)Edema begins around the ankle (gravity effect)

- Later it becomes generalized and associated with ascitis, hydrothorax - Later it becomes generalized and associated with ascitis, hydrothorax and hydropericardium.and hydropericardium.

بسم الله الرحمن الرحيم. HEMODYNAMIC DISTURBANCES (Disorders of blood flow) By:...

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