Circulatory Disturbances Circulatory Disturbances

(Disturbances of Blood and Body Fluids) (Disturbances of Blood and Body Fluids)
by
Faten Ghazal Faten Ghazal
Prof. of Pathology, Ain Shams University
Gangrene
Oedema
Haemorrhage
Shock
ecture 3
angrene
9 is necrosis of 9issues wi9h superadded
pu9refac9ion.
Putrefaction is carried out by the proteolytic action of
the pu9refac9ive organisms on the dead 9issues.
These organisms (putrefactive bacteria ) are normally
present on the skin and in organs 9ha9 have ex9ernaI
exi9s as respira9ory, gas9roin9es9inaI, and geni9aI
sys9ems; they don't proliferate and produce their
action unless the tissues are necrosed.
Types of angrene
Dry Gangrene
t occurs in minimaI amount
of tissue fluid, with Ii99Ie &
sIow proIifera9ion of
organisms
t occurs in tissues exposed
to dryness by evaporation.
t occurs in Iower Iimbs
more than the upper limbs.
We9 Gangrene
t occurs in excess tissue fluid,
with excess & rapid
proIifera9ion of organisms
t occurs in tissues no9 exposed
to dryness by evaporation.
t occurs in in9ernaI organs as
lung and intestine and as well
the lower limbs ,in certain cases.
Causes of Necrosis nfarction)
1. therosclerosis (atheroma) of arteries.
2. Thrombosis (Virchow's triad)
3. Embolism (systemic: intracardiac & extracardiac
or pulmonary)
4. rterial vasospasm e.g. raynaud's disease &
ergot poisoning
5. Occlusion of the vessels due to twisting e.g.
volvulus of intestine or pressure by nearby tumour.
are thrombotic or
embolic occlusion
Haemorrhage in an
atheroma
ocal vasospasm
Compression by a
tumour
Venous
9hrombosis or
severe 9wis9ing
(venous
obs9ruc9ion) in
organs with single
venous outflow
Causes of nfarc9ion
ar9ery
vein
$tages of angrene
Occlusion of the vessel Necrosis of 9issues
+
Pu9refac9ive organisms of 9he cIos9ridia group
Proliferation of organisms & liberation of proteolytic enzymes
that des9ruc9s muscles, blood vessels, nerves, lymph vessels
& bones.
The affec9ed 9oe
(usuaIIy, as i9 is 9he
far9hes9 poin9 from bIood
suppIy) becomes
paIe & coId
Then it becomes
red due to
diffusion of bIood
pigmen9
Then it becomes
bIack due to iron
suIphide ,shriveIed
(wrinkIed) ,
mummified & dry
Pale & impending gangrene
(bluish) terminal phalanges
Black, mummified & dry terminal
phalanges
$tages of angrene
BIack, mummified & dry 9erminaI phaIanges
$tages of angrene
The condition advances slowly but
steadily through the foot extending
in the limb. The dead tissue elicits
infIamma9ion, which may lead to
further thrombosis of vessels &
gangrene. The gangrene extends
until it reaches a level at which
blood supply is sufficient to keep
the tissues alive. t that level a red
zone (band) of demarca9ion is
formed between 2 different
colours, the gangrenous part below
& the normal part above.
$tages of angrene
The infIamma9ory reac9ion in the neighboring
living tissue may end in:
1.Forma9ion of granuIa9ion 9issue which proceeds to
erode the dead tissue, till it reaches a point where the blood
supply cannot be maintained to get adequate nourishment.
UIcera9ion then follows & a Iine of separa9ion is produced.
This most commonly occurs when the infec9ion is minimaI
i.e. in dry gangrene so separation occurs neatly,
(separa9ion by asep9ic uIcera9ion).
ConicaI S9ump
because the blood supply of skin & subcutaneous
tissue are Iess abundan9 than that of the muscles &
bone
$tages of angrene
2. Suppura9ion may occur at the zone of
demarcation when the infec9ion is more, as in
we9 gangrene. $uppuration extends even in
healthy tissue, therefore the line of separation
(separa9ion by sep9ic uIcera9ion) is at higher
level than that of dry gangrene when comparing a
similarly occluded artery.
This is why dry gangrene mus9 be kep9 as dry and
aseptic as possible, and effort should be made 9o
conver9 wet gangrene into the dry type.
.Wet angrene of the ower imb
1. n diabe9ic pa9ien9s: atherosclerosis is more
common & high sugar content in tissues
2. Oedema of Iower Iimbs as in heart failure
3. Severe crush injury: thrombosis occurs in both
veins (congestion, oedema) & arteries ( ischaemia,
necrosis).
The gangrenous part is swoIIen & oedema9ous.
The skin appears 9ense, uIcera9ed & shows bIebs.
There is bIackish discoIora9ion.
There is no sharp Iine of demarca9ion.
Dry and Wet angrene
Dry gangrene Wet gangrene due to presence of more
infection
2.Wet angrene of the ntestine
t may develop in:
1. n9ussuscep9ion: invagination of a loop of
intestine into another one
2. VoIvuIus: twisting of a loop of intestine with
occlusion of the vessels
3. S9ranguIa9ed hernia :a loop of intestine is
forced through an opening in the abdomen.
4. Thrombosis and emboIism of one the
mesenteric vessels
Wet angrene of the ntestine
$trangulated hernia
Gangrenous Ioop of smaII in9es9ine
voIvuIus
3.Wet angrene of the ung
t is rare. The predisposing factors are
severe Iung infec9ions as lung abscess,
bronchiectasis, pneumonia (IocaI causes) in
addition to marked Iowering of resis9ance
as in diabetes mellitus, senility& chronic
nephritis (generaI causes).
The gangrenous area is sof9 , bIack with
9issue breakdown i.e. formation of muI9ipIe
smaII ragged cavi9ies.
The condition is serious & fa9aI.
Death is due to marked 9oxemia or due to
rup9ure of 9raversing bIood vesseI
(hemop9ysis).
.Other Forms of Wet angrene
A. Bed sores: s a complication of
prolonged recumbence (coma,
paralysis, fractures). t is due to
pressure by the bed over a bony
prominence on vessels of skin
leading to ischaemia, &necrosis.
The dead tissue is casted off
leaving an ulcer.
B. Fros9 bi9e: t is due to severe
cold producing arteriolar spasm in
fingers, toes & nose. t starts as
wet gangrene (cold damp weather
prevents evaporation) but with
conservative treatment it can
change to dry gangrene as in the
figure.
.Other Forms of Wet angrene
C. Gas Gangrene:
t is rapidIy necro9izing infIamma9ion caused by a group of gram
positive exotoxic anaerobic clostridia most commonly clostridia welchii
and cl. septicum.
The infection begins in a si9e of previous injury and rapidly spreads to
muscles and connective tissue. t occurs in () neglected wounds
(wars),(2) large traumatic wounds,(3)compound fractures,() in uterus
in criminal abortion &(5) surgical aseptic operations.
The spreading necrotizing inflammation is due to elaboration of many
products as fibrinoIysin, hyaIuronidase, coIIagenase & Ieci9hinase
which help the spread of infection.
Gas bubbIes causing crepi9us in the affected region appear early.
Bad generaI condi9ion due to severe 9oxemia.
.Other Forms of Wet angrene
D. Cancrum Oris
t is a type of infective
gangrene, involving the
mouth & cheeks of
marasmic or debilitated
children caused by
Treponema vincenti and
Bacillus fusiformis due to
decreased immunity &
bad mouth hygiene.
Oedema
Oedema means excessive accumulation of fluid in interstitial tissue,
serous cavities (pleura, pericardium &peritoneum) or pulmonary alveoli.
1. CapiIIary
hydros9a9ic
pressure expeIs fluid
& nutrients to the
interstitial tissue
2. Osmo9ic
capiIIary pressure
absorbs & re9ains
fluid in blood
vessels
3. Osmo9ic pressure of 9he
in9ers9i9iaI 9issue re9ains
fluid in the interstitial tissue
4. Adequa9e Iympha9ics
remove residual fluid in
the interstitial tissue
NormaI Con9roI of n9ers9i9iaI FIuid:
Normally the exi9 of fIuid a9 9he ar9erioIar end of the microcirculation is
baIanced by the infIow a9 9he venuIar end; a small residual amount is
drained by the Iympha9ics .
Causes of Oedema
1. CapiIIary
hydros9a9ic
pressure as in active
hyperaemia (arteriolar
end), congestive heart
failure generalized)
& deep venous
thrombosis (at venular
end due to impaired
venous return-localized)
2. Osmo9ic
capiIIary pressure
due to loss or reduced
synthesis of albumin
as in nephrotic
syndrome 5rotein losing
glomerulone5hro5athies),
liver disease cirrhosis) &
protein malnutrition
3. Osmo9ic pressure of
9he in9ers9i9iaI 9issue as in
acute or chronic infammation
4. ndequa9e Iympha9ics as in
inflammatory (e.g. filariasis) or
neoplastic infiltration (cancer breast in
skin) or in arms (after operation ) or
postirradiation
n bo9h conges9ive hear9 faiIure& nephro9ic syndrome 9here is renaI hypoperfusion Ieading
9o renin &an9idiure9ic hormone reIease aIdos9erone renaI Na reabsorp9ion as weII
as wa9er re9en9ion Ieading 9o increase in pIasma voIume & more 9ransuda9ion.
Types of Oedema
LocaIized Oedema LocaIized Oedema
Acu9e nfIamma9ion: The oedema is
due to increased capillary hydrostatic
pressure, increased capillary
permeability & increased osmotic
pressure of interstitial pressure.
LocaI venous conges9ion: t is due
to increased capillary hydrostatic
pressure.
Chronic Iympha9ic obs9ruc9ion as
in skin of the breast (peau d'orange), in
arm after removal of lymphatics in
radical mastectomy,& in filariasis
GeneraIized Oedema GeneraIized Oedema
1. Cardiac Oedema
2. RenaI Oedema
3. Nu9ri9ionaI Oedema
4. Hepa9ic Oedema
5. O9her 9ypes of Oedema
eneralized Oedema
1. Cardiac Oedema: t occurs in righ9 side hear9 faiIure
with chronic venous congestion due to increased
hydros9a9ic pressure and due to saI9 & wa9er re9en9ion.
eart failure results in low cardiac out5ut leading to
decreased renal 5erfusion which stimulates renin
secretion. Renin will stimulate aldosterone secretion by
adrenal cortex resulting in salt & water retention which
stimulates AD secretion by neurohy5o5hysis, leading to
increased absor5tion of water and salt.
2. RenaI Oedema: t occurs in nephri9ic (due to acute
impairment of renal function & renin secretion), nephro9ic
(due to loss of albumin) syndromes, &in acu9e 9ubuIar
necrosis (due to retention of water & electrolytes).
eneralized Oedema
3. Nu9ri9ionaI Oedema: t is due to hypoproteinaemia
which results in decrease osmo9ic pressure of bIood. t is
caused by maInu9ri9ion, interference with digestion
&absorption i.e. maIabsorp9ion, & decreased formation by
liver as in chronic Iiver disease (Iiver cirrhosis).
4. Hepa9ic Oedema: t occurs in liver cirrhosis &liver
failure. t results due to decreased synthesis of albumin
leading to decreased osmotic pressure and development
of portal hypertension.
5. O9her 9ypes of oedema: Oedema in toxemia of
pregnancy (due to proteinuria & salt & water retention ) &
oedema in cushing's syndrome (due to salt & water
retention).
Oedema
Iymphydema
Massive oedema
Modera9e oedema
Pitting oedema
Nonpitting oedema
Oedema
$ubcutaneous oedema may have different
distributions depending on the cause. t can be
diffuse or it may be prominent in the regions of
with highes9 hydros9a9ic pressures, influenced
by gravi9y & is called dependent. Oedema of
dependent parts of the body legs in standing &sacrum
when recumbent) is a prominent feature of righ9 side
hear9 faiIure.
Oedema of renaI faiIure is more severe & diffuse
affects all 5arts equally), however it may start in loose
connective tissues as eyelids causing periorbital
oedema.
Haemorrhage
t is extravasation of blood due to rupture of blood vessels,
including arteries, veins and capillaries.
Causes
A. Trauma9ic
1. Acciden9aI
2. SurgicaI: primary (at the
time of operation) or
secondary (after 7- days
due to infection)
B. Spon9aneous
1. BIood vesseI disease:
atherosclerosis, aneurysm, varicose
veins
2. ncreased in9ravascuIar pressure:
hypertension, CVC, oesophageal
varices, haemorrhoids (piles)
3. Des9ruc9ion of bIood vesseIs: T.B.,
malignancy, peptic ulcer, septicaemia
4. Haemorrhagic bIood diseases:
scurvy (vit C def), thrombocytopenia, DC
Classification of Haemorrhage
Ex9ernaI
. $kin
2. Respiratory $ystem:
epistaxis, haemoptysis
3. T: haematemesis, melena,
bleeding per rectum
. Urinary system: haematuria
5. Female system:
menorrhagia, metrorrhagia
n9ernaI
. Pleura : haemothorax
2. Pericardium :
haemopericardium
3. Peritoneum :
haemoperitoneum
. Joint: haemoarthrosis
5. Tunica vaginalis :
haematocele
n9ers9i9iaI
. Petechiae
2. Purpura
3. Ecchymosis
. Haematoma
n9ers9i9iaI Haemorrhage
Pe9echiae:1-2mm
n9ers9i9iaI Haemorrhage
Purpura:3-10 mm Ecchymosis: more 9han 1cm.
Fate & Effects of Haemorrhage Fate & Effects of Haemorrhage
1. Si9e of haemorrhage : $mall amount in brain or
in the pericardium is very serious & may lead to
death.
2. Ra9e of escape of bIood: Rapid Ioss is more
serious than slow (no time for compensation).
3. The amoun9 of bIood Ioss: f less than 500 ml,
no effect unless it is repeated will lead to
anaemia. f massive (more than 750 ml), it is
serious & may lead to hypovolemic shock. f
moderate (500-750ml) , will result in rapid fall in
blood pressure.
$hock (Cardiovascular Collapse)
t is an acu9e circuIa9ory faiIure due to inadequate
circulating blood volume Ieading 9o hypoperfusion
of 9issues and ceIIuIar hypoxia.
lthough the hypoxic and metabolic effects of
hypoperfusion ini9iaIIy cause only reversibIe
ceIIuIar injury, persis9ence of 9he shock
even9uaIIy cause irreversibIe 9issue injury and
can lead to death of the patient.
Classification of $hock
1.Cardiogenic Shock: myocardial infarction (intrinsic damage)
haemopericardium (extrinsic pressure)
pulmonary embolism (obstruction to the outflow)
2.HypovoIaemic Shock: haemorrhage (blood loss)
severe vomiting, diarrhea or burns (fluid loss)
3.Sep9ic Shock: systemic microbial infection (septicemia) results in
vasodilatation, diminished myocardial contractility,
widespread endothelial injury, thrombosis &DC
4.Neurogenic Shock: severe injury, pain or emotional disturbance
(generalized vasodilatation)
5.AnaphyIac9ic Shock: allergic reaction (systemic vasodilatation)
Pathologic Findings in $hock
ungs: adult respiratory distress syndrome
astrointestinal tract: widespread mucosal ischaemia resulting in multiple
haemorrhagic erosions or ulcerations
Kidney: tubular necrosis
iver : centrilobular congestion &necrosis
Brain : ischaemia with focal haemorrhages & oedema
drenals : haemorrhage & cortical necrosis
Pathologic findings are similar to those seen in DC:
Widespread micro9hrombi
MuI9ipIe foci of ischaemic necrosis
Haemorrhage
MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances
. n old woman underwent mastectomy & axillary lymph node clearance for left
breast carcinoma. Postoperatively she developed marked swelling of her left
arm, which was not tender, not painful& not red. The possible diagnosis is:
a. nflammation of subcutaneous tissue of her arm.
b. Phlebothrombosis in arm veins.
c. ymphedema.
d. Congestive heart failure.
2. 23 year old pregnant woman (with uncomplicated pregnancy) develops
sudden dyspnea with cyanosis& hypotension just after her vaginal delivery.
Which of the following findings is most likely to be present in the peripheral
pulmonary arteries?
a. mniotic fluid
b. Fat globules
c. as bubbles
d. Thromboemboli
MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances
3. 5 year old dentist works in a clinic notices at the end of the day that her legs
&feet were swollen, although there was no swelling at the beginning of the day.
There was no pain or redness. The liver &renal function tests were normal.
Which of the following mechanisms that best explains this case?
a. ncreased hydrostatic pressure
b. ymphatic obstruction
c. Hypoproteinemia
d. nflammation of subcutaneous tissue
. 78 year old man had fracture neck femur. He was hospitalized, operated upon
&fixation of the fracture was done. 2 weeks later his legs were swollen, painful
on movement &tender. Which of the following complications is most likely to
occur after these events? { hat is your diagnosis first?}
a. angrenous necrosis of the foot
b. Haematoma of the tigh
c. Pulmonary thromboembolism
d. Fat embolism
MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances
5. young female had multiple fractures due to a car accident. The fractures was
stabilized surgically. fter day she suddenly complained of dyspnea (difficulty
in breathing) Which of the following complication is the most likely cause of this?
a. Congestive heart failure
b. Fat embolism
c. Pulmonary oedema
d. Pulmonary infarction
6. The pathophysiology involved in lower limb oedema in right side heart failure is :
a. Decreased osmotic pressure
b. ymphatic obstruction
c. ncreased vascular permeability
d. ncreased hydrostatic pressure
MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances
7. ower limb oedema in liver cirrhosis is due to:
a. Decreased osmotic pressure
b. ymphatic obstruction
c. ncreased vascular permeability
d. ncreased hydrostatic pressure
8.ower limb oedema in a case of filariasis is due to:
a. Decreased osmotic pressure
b. ymphatic obstruction
c. ncreased vascular permeability
d. ncreased hydrostatic pressure
.Oedema in nephrotic syndrome is due to :
a. Decreased osmotic pressure
b. ymphatic obstruction
c. ncreased vascular permeability
d. ncreased hydrostatic pressure
MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances
0. The most common site of origin of thrombotic pulmonary emboli is:
a. Deep leg veins
b. umen of left ventricle
c. umen of right ventricle
d. Mesenteric veins
. The most common site of origin of thrombotic lower limb arterial emboli is:
a. Deep leg veins
b. umen of right atrium
c. Mesenteric veins
d. therosclerosis in the aorta
2. . The most common site of origin of thrombotic lower limb arterial emboli is:
a. Deep leg veins
b. umen of right atrium
c. Mesenteric veins
d. therosclerosis in the aorta
MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances
3. 55 year old man had left ventricular wall infarction.Three days later he
develops breathelessness (dyspnea). The most likely microscopic changes
to be present in the lungs are:
a. Congestion of alveolar capillaries and numerous neutrophils in alveoli
b. Congestion of alveolar capillaries with transudate in alveoli
c. Fibrosis of alveolar walls with haemosiderin- laden macrophages in alveoli
. young diver descended in deep sea. fter 30 minutes he ascended
rapidly because he forgot to get his camera. He soon experienced difficulty
in breathing, severe headache, pain in muscles &joints. These symptoms
are due to :
a. Fat globules in arterioles
b. Disseminated intravascular coagulopathy
c. Venous thrombosis
d. Tissue nitrogen emboli
MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances MuI9ipIe Choice Ques9ions on CircuIa9ory Dis9urbances
5. n old woman fell and stroke her back of her head. Over the next 2 hours
she becomes increasing sleepy. head CT scan shows an accumulation of a
fluid beneath the dura, compressing the left cerebral hemisphere. Which of
the following terms describes this collection of fluid?
a. Haematoma
b. Purpura
c. Petechia
d. Ecchymosis
6.The following are characteristics of wet gangrene except :
a. The affected limb is swollen, oedematous , tense skin with blebs
b. The fluid is minimal ,the proliferation of the organisms is excessive & the
putrefaction is slow
c. t develops in internal organs as lung , intestine, and uterus
d. t develops in lower limbs of diabetics