第三章第三章局部血液循环障碍局部血液循环障碍徐芳英xfyzju.edu.cn本章主要内容局部血量异常充血或缺血血管通透性和完整性异常出血、水肿血液性状及内容物异常血栓形成 栓塞、梗死第一节充血和淤血第一节充血和淤血概念：局部组织血管内血液含量的增多分为动脉性和静脉性Hyperemia versus congestion. In both cases there is an increased volume and pressure of blood in a given tissue with associated capillary dilation and a potential for fluid extravasation. In hyperemia, increased inflow leads to engorgement with oxygenated blood, resulting in erythema. In congestion, diminished outflow leads to a capillary bed swollen with deoxygenated venous blood and resulting in cyanosis.一、动脉性充血1原因及类型：生理性充血：器官或组织功能病理性充血：炎症性充血减压后充血 2病理变化：g：体积增大m：小A、Cap扩张、充血3后果：有利、不利二、静脉性充血静脉性充血：又称淤血 1原因：A、外压：静脉受压B、内塞：静脉腔阻塞C、心力衰竭：静脉性充血的基本病变 基本病变： g：器官肿胀、发绀 m：小V、Cap扩张、淤血，常伴水肿后果：取决于时间、程度、速度、部位淤血的后果 淤血性水肿 淤血性出血 实质细胞萎缩、变性、坏死 淤血性硬化重要器官的淤血肺淤血 多见于左心衰竭 出现心力衰竭细胞 肺水肿 肺褐色硬化肺淤血肺淤血的不同时期的病变肺淤血（普鲁士兰染色）肝淤血 多见于右心衰竭 小叶外围肝细胞脂肪变性 槟榔肝 淤血性肝硬化槟榔肝肝淤血放大观Liver with chronic passive congestion and hemorrhagic necrosis. A, Central areas are red and slightly depressed compared with the surrounding tan viable parenchyma, forming the so-called “nutmeg liver“ pattern. B, Centrilobular necrosis with degenerating hepatocytes, hemorrhage, and sparse acute inflammation. 肝内淤血道第二节 出血 血液从心腔或血管内逸出 内出血，外出血 破裂性出血 漏出性出血A, Punctate petechial hemorrhages of the colonic mucosa, seen here as a consequence of thrombocytopenia. B, Fatal intracerebral bleed. Even relatively inconsequential volumes of hemorrhage in a critical location, or into a closed space (such as the cranium), can have fatal outcomes.第三节血栓形成 在活体心血管内血液成分析出凝固,形成固 体质块的过程，称为血栓形成 所形成的固体质块称为血栓(thrombus) 与血凝块有区别血栓形成的条件和机制1.心血管内皮细胞的损伤 2.血流状态的改变 3.血液凝固性升高Virchow triad in thrombosis. Endothelial integrity is the single most important factor. Note that injury to endothelial cells can affect local blood flow and/or coagulability; abnormal blood flow (stasis or turbulence) can, in turn, cause endothelial injury. The elements of the triad may act independently or may combine to cause thrombus formation.Diagrammatic representation of the normal hemostatic process. Schematic illustration of some of the pro- and anticoagulant activities of endothelial cells. Not shorkt are the pro- and antifibrinolytic properties. vWF, von Willebrand factor; PGI2, prostacyclin; NO, nitric oxide; t-PA, tissue plasminogen activator. Thrombin receptor is referred to as protease activated receptor (PAR; see text).血栓形成的过程和血栓的形态心血管内皮细胞的损伤The coagulation cascade. Note the common link between the intrinsic and extrinsic pathways at the level of factor IX activation. The central roles of thrombin in hemostasis and cellular activation. 血流状态的改变 血流缓慢 产生涡流静脉比动脉发生血栓多4倍血液凝固性升高 遗传性：第V因子基因突变 获得性 手术病人 DIC 广泛转移的晚期肿瘤血栓的类型 白色血栓 - 血栓头部 混合血栓 - 血栓体部 红色血栓 - 血栓尾部 透明血栓 ：纤维蛋白构成白色血栓赘生物Mural thrombi. A, Thrombus in the left and right ventricular apices, overlying a white fibrous scar. B, Laminated thrombus in a dilated abdominal aortic aneurysm.These are “lines of Zahn” which are the alternating pale pink bands of platelets with fibrin and red bands of RBCs forming a true thrombus.血栓的结局 溶解、吸收 机化、再通 钙化Potential outcomes of venous thrombosis.机化与再通Low-power view of a thrombosed artery. A, H&E-stained section. B, Stain for elastic tissue. The original lumen is delineated by the internal elastic lamina (arrows) and is totally filled with organized thrombus, now punctuated by a number of small recanalized channels.血栓对机体的影响 阻塞血管：动脉、静脉 栓塞 心瓣膜变形 出血