Morphology of cells and
tissues reversible and irreversible injury. Intracellular and
extracellular accumulation (uptake) of proteins, hydrocarbons and lipids.
(Parenchimatous and mesenchimal dystrophies)
Cells and tissue reversible changes occurs in the result of tissue or
cell metabolism disturbance and are accompanied with these substances (proteins, fats, hydrocarbons) which exists as norm intracellular or tissue
uptakes and appearance of those pathological which do not exist in the norm. These changes are named metabolic
products pathologic uptakes or dystrophies
(from Lat. dys – disturbance, trophe – nutrition). Intracellular uptake of
substances causes parenhymatous degenerations development. Parenhymatous
degenerations occurs
mostly in highly specialized cells of parenhymatous organs (kidneys, liver, heart,
cerebrum, etc.). Acquired or
congenital fermentopathies underlie parenhymatous degenerations development. These fermentopathies make a big group of storage diseases
or thesaurismoses. Latter contain a big group of storage diseases or thesaurismoses.
Causes of metabolism products abnormal uptake
1
Cell pathology. Cells are not able to utilize substances as
energy or plastic material
or release them. This is caused mostly by cells structure injury
with various factors, sometimes by congenital or acquired ferments pathology,
which participate in metabolism (fermentopathies).
2 Function disturbance of transport systems, providing both substances supply to tissues and
cells and metabolism products excretion. It is often observed under
cardiovascular collapse and pulmonary insufficiency.
3
Endocrine and nervous regulation of trophism disorders.
Mechanisms of metabolism products abnormal uptake Infiltration
is excessive penetration of metabolism products
from blood into cells and intercellular substance with their subsequent uptake due to ferment
system, providing
their metabolism, insufficiency. Substances metabolism products
abnormal uptake by way of infiltration is observed in liver, kidneys, aorta
wall.
Decomposition (phanerosis) occurs under cell and intercellular substance ultrastructures
destruction due to intoxication, hypoxia or other reasons.
Ultrastructures membranes are made of proteins, fats and hydrocarbons, so under
their destruction these substances are accumulated and stored in cells.
Distored synthesis is synthesis of those substances in cells and
tissues which are not observed in them as a norm. As an example, it’s glycogen
synthesis in nephron tubules epithelium under diabetes mellitus, alcohol hyaline synthesis
in hepatocytes.
Transformation is the creation of one kind of metabolism
products from intermediate disintegration products, which should be utilized
for proteins, fats and hydrocarbons synthesis. For example, it’s fats and
hydrocarbons components transformation into proteins under starvation, fats and
hydrocarbons components transformation
into glycogen under diabetes
mellitus.
Metabolism products abnormal uptake classification
Classification by the kind of metabolism disturbance prevail:
a) protein, b) fat, c) hydrocarbon, d) mineral
By
pathologic process localization:
a) parenchymatous (modifications in the organs parenchymatous cells - cardiomyocytes, hepatocytes, ganglionic cells of cerebrum,
etc.);
b) stromal-vascular
(modifications
in organs stroma);
c) mixed (changes in parenchyma and stroma).
Depending
on genetic factors influence:
a) congenital, b) acquired.
By
process spread:
a) general, b) local.
Morphology
of proteins abnormal uptake (proteinosis)
Occurs under proteins
metabolism disturbance. Tissues proteins form cells as plastic materials (capsule, nucleus, cytoplasm, intracellular organelles) as well as
intercellular stroma – collagen, elastic, reticulin fibers, basic intercellular substance, vessels, nerves. By proteins metabolism disturbance
development location proteinosises are divided into parenchymatous, stromal-vascular and
mixed. .
Under parenchymatous
proteinosis physical-chemical
features of intracellular proteins are violated. At the beginning grain effect occurs in
cytoplasm at the cost of protein inclusions, which is manifestation of cell
ultrastructures overstrain (hyper function).
This process is reversible. Quite often proteins disbolism is combined with Na-K-pump operation faults, which is
accompanied with natrium ions uptake and cells hydration. In case intoxication, hypoxia, inflammation
or other reasons of proteinosis increase this cause cells destructive changes
intensification. The following kinds of
parenchymatous proteinaceous degenerations (proteinosis) are recognized: hyaline-drop, hydropic (vacuolar), keratinization.
At hyaline-drop proteinosis proteins compacts and become similar to hyaline cartilage. Big hyalinoid drops of protein occur in cells cytoplasm. Sometimes
coagulation necrosis develops and cells die, organ function decreases, but
macroscopic changes are not found. This kind dystrophy is often observed in
hepatocytes under alcoholic hepatitis (Mellori bodies), in renal tubules
epithelium under nephrotic syndrome, etc.
Cytoplasmic organelle damage leads to a variety of injury patterns, most of
which are best seen by electron microscopy. Acute injuries tend to damage an
entire cell, so specific organelle damage is beside the point. However, in some
cases the damage can be cumulative over many years. Here are Mallory bodies
(the red globular material) composed of cytoskeletal filaments in liver cells
chronically damaged from alcoholism. These are a type of
"intermediate" filament between the size of actin (thin) and myosin
(thick).
Intracellular accumulations of
a variety of materials can occur in response to cellular injury. Here is fatty
metamorphosis (fatty change) of the liver in which deranged lipoprotein
transport from injury (most often alcoholism) leads to accumulation of lipid in
the cytoplasm of hepatocytes.
Hydropic or dropsy proteinosis is characterized
by intracellular fluid increase, in which
cytoplasm proteins are dissolved due to hydrolytic pigments action. Vacuoles full of cytoplasm fluid occur in cells. Further on cells
cytoplasm transforms into blisters full with fluid, intracellular organelles
destroy, cell dies off and coliquation necrosis develops. Organs also didn’t change
macroscopically. Hydropic proteinosis
often develops in liver under viral hepatitis, in kidneys under
glomerulonephritis, etc.
Sometimes cellular injury can
lead to accumulation of a specific product. Here, the red globules seen in this
PAS stained section of liver are accumulations of alpha-1-antitrypsin in a
patient with a congenital defect involving cellular metabolism and release of
this substance.
Many inherited disorders of
metabolism involving enzymes in degradation pathways can lead to accumulation
of storage products in cells, as seen here with Gaucher
disease involving spleen. The large pale cells contain an accumulated storage
product from lack of the glucocerebrosidase enzyme.
The yellow-brown granular
pigment seen in the hepatocytes here is lipochrome (lipofuscin) which
accumulates over time in cells (particularly liver and heart) as a result of
"wear and tear" with aging. It is of no major consequence, but
illustrates the end result of the process of autophagocytosis in which
intracellular debris is sequestered and turned into these residual bodies of
lipochrome within the cell cytoplasm.
Keratinization proteinosis is characterized with excessive keratin generation
on the surface of plane keratinized epithelium – hyperkeratosis,
ichthyosis.
The causes of keratinization development is chronic
inflammation, avitaminosis, skin development abnormalities. Leukoplakia which is mucous tunics epithelium pathologic keratinization, also belongs to this process and can become a source of malignant
growth.
Extracellular uptakes
Extracellular uptakes occur in the result of metabolism disturbance in
organs stroma or in vessels walls, so they are named stromal-vascular or mesenchymal proteinosis. Important attention is
paid to proteinosis developing in the result of proteins metabolism in
conjunctive tissue and are found in stroma and vessels walls. Primary
pathologic changes are developed on histion level, consisting of
microcirculation channel: basic
substance, fibers (collagen,
reticulum, elastic), cells (fibroblasts, fibrocytes, lymphocytes, labrocytes, histiocytes), nerves. Basic substance is connecting, cementing, fiber and cells are situated in it.
By chemical composition it is polymer of composite protein-hydrocarbon
molecules – mucopolysaccharides (glycosamineglycanes). The following relates to stromal-vascular proteinosis: mucoid swelling, fibrinoid swelling (fibrinoid), hyalinosis,
which are considered to be consequent stages of conjunctive tissue destruction.
Mucoid swelling – is primary disorganization of
conjunctive tissue. Causes: hypoxia,
allergy, endocrine pathologies. It often
occurs under rheumatic
and infection diseases, atherosclerosis, it is found in artery walls, cardiac valves, endocardium,
heart. Basic substance
depolymerization underlies its development. As a consequence it becomes hydrophilic, attracts liquid, vessel wall penetrability increases. Basic substance hydration, collagen
fibers swelling occurs. With vascular-tissue penetrability growth conjunctive
tissue saturates with blood plasm proteins, in first turn with albumines and
globulins. Macroscopically organ or tissue mostly doesn’t change. Microscopically phenomenon of metachromasia is observed:
glycosamineglycanes are painted with toluidine blue in red color. Described
changes in conjunctive tissue provided that the reason was eliminated are
reversible and tissue structure is rehabilitated.
This Congo red stain reveals orange-red deposits of amyloid, which is an
abnormal accumulation of breakdown products of proteinaceous material that can
collect within cells and tissues.
Fibrinoid swelling is following
stage of conjunctive tissue disorganization. Under substantial growth of
vascular-tissue penetrability fibrinogen sweats in stroma from vessels clearance, which rather quickly precipitates in strings of fibrin, collagen fibers are
destroyed (broken, fragment), conjunctive
tissue basic substance chemical composition is changed. Under fibrinoid
swelling deep and irreversible disorganization of conjunctive tissue is
observed, which is accompanied with basic substance and fibers destruction against the
background of considerable increase of balls vascular permeability. Macroscopically organ
doesn’t change, microscopically collagen
fibers become homogenous, eosinophilic,
becomes yelow when painted with
picrofuchsin, pyroninophil
and argyrophil. Consequence Fibrinoid necrosis is
developed in the final of the process. Significance – organ function disturbance under heart disease formation, joints immobility, luminal narrowing and vessel wall elasticity
decrease, organ function termination under renal insufficiency at malignant
hypertension, when fibrinoid changes as well as arterioles and cappilars
necrosis develops.
Hyalinosis is the final stage of tissue
disorganization and is characterized with uptake of collagen destruction
products, plasm proteins, polysaccharides, which merge into homogenous mass which consolidates as time passes, becomes semi-transparent
similar to hyaline cartilage, so it is
called hyaline. This is complex fibrillar protein. Hyalinosis occurs as a
consequence of fibrinoid swelling, plasmorrhagia, sclerosis, necrosis. It
develops as the result of peculiar completion of sclerosis in scarring, cardiac
valves under rheumatism (local
conjunctive tissue hyalinosis). Macroscopically fibrous
conjunctive tissue becomes dense, cartilaginous, whitish, semi-transparent. Microscopically
collagen fibers loss fibrillarity and merge into homogenous dense cartilaginous
mass, cells squeeze and atrophy.
Heart in such cases is
enlarged,
ventricular cavities are dilated, mitral valve flappers are dense, whitish
color, conjoint in between each other, considerably deformed. This kind of
hyalinosis is peculiarly expressed in rough vicious cicatrix after burns
(keloid). Consequences are
unfavorable because of considerable deterioration of organ or injured tissue
function.
Systemic hyalinosis develops
in vessels walls under hypertension disease, diabetes mellitus (vascular hyalinosis) and is
mostly expressed in kidneys, cerebrum, eye retina, pancreas.
Considering occurrence pathogenesis three kinds of vascular hyaline are
recognized: simple is observed under
hypertension disease,
atherosclerosis; lipohyaline
is developed under diabetes mellitus; complex hyaline occurs in the result of
immunopathologic disturbances and vessel wall fibrinoid disorganization
at collagenosis.
Morphology of lipids
pathological uptake (lipidosis)
Occurs as the result of fats metabolism disturbance.
Lipidosis
are divided into parenchymatous and stromal-vascular (mesenchymal) fatty
(adipose) degenerations. To reveal fats frozen sections are colored with sudan ІІІ or ІV.
Parenchymatous lipidosis are manifested
with neutral lipids (triglycerides) drops uptake in cells cytoplasm and are the results of cytoplasm fats
metabolism disturbance. Mostly they are found in myocardium, lever, kidneys.
Myocardium lipidosis is characterized with lipoproteids drops uptake in cardiac hystiocytes. As a rule it is observed under intoxications (diphtherial, alcohol, with phosphoric
compounds, arsenic, diseases of liver, kidneys,
thyrotoxicosis, etc.), long time general hypoxia (anemia, chronic pulmonary and
cardiovascular insufficiency), Under oxygen
deficiency process of oxidative phosphorylation and ATP synthesis in cardiomyocytes decreases, fatty acids beta-oxidation violates. So fats
coming into cell are not completely utilized as plastic and power material and
they accumulate in cytoplasm. Besides that under hypoxia membrane lipoprotein
complexes destruction is observed (decomposition or phanerosis). Macroscopically heart at this process enlarges in size, its chambers stretch, myocardium
becomes flaccis, of
clay-yellow color, retraction
ability of cardial muscle decreases. From myocardium side especially on
papillary muscles surface, trabeculas, it is observed yellow-grey striation– “ tiger heart”, which is caused by dystrophy. Microscopically
fat uptakes in muscular cells
groups, situated downstream cappilars venous elbow and small veins where hypoxia factor is mostly
expressed.
Liver lipidosis is characterized with fat content increase in hepatocytes. Quite often it is the result of imbalance between increased fats supply
under hyper lipidemia (alcoholism, diabetes mellitus, general obesity), their
decreased assimilation (fatty acids oxidation in mitochondrions
under hypoxia or toxic influences) and
lipids excretion decrease by liver cells under apoprotein production decrease
which transports fats in the form of lipoproteins. This is observed in case
protein insufficiency in food or under gastrointestinal disturbances, poisoning
with ethanol,
phosphor, etc., congenital defects of ferments metabolizing fats. Microscopically
first occurs saw type, then small drop and large drop degeneration. Three
stages of liver lipidosis are distinguished:
1- fat uptake in hepatocytes, 2- fat uptake with mesenchymal reaction
development, 3- fat uptake with liver fibrosis
and cirrhosis development. Fat fills all
cytoplasm and gradually pushes nucleus aside to periphery and modified hepatocytes
becomes similar to
adipocytes. Fatty degeneration prevalence in peripheral portions of
liver part confirms infiltration mechanism of its development, which is
observed under hyperlipidemia. Fatty degeneration development prevalence in
central portions of liver part is connected with decompensation mechanism and
is observed under hypoxia or intoxication.
Macroscopically liver is enlarged, loose
(of pastry
consistency), yellow or clay color.
Kidneys lipidosis is often observed under nephrotic syndrome, chronic renal insufficiency when
hyperlipidemia and lipiduria occur. Fat
excess is excreted from organism with kidneys and constipates them. Microscopically
fat occurs in proximal, distal or convoluted renal tubules epithelium
in cells basal portions. Nephrocytes lipidosis often joins
hyaline-drop degeneration and hydropic proteinosis. Macroscopically kidney
is enlarged, flaccid, cortical layer is dilated with signs of swelling, of grey color with yellow specks.
Congenital lipid metabolism
disturbances are manifested with systemic lipidosis and pertain to
fermentopathies (diseases of storage or uptake). The following diseases are
marked out: cerebrosine lipidosis (Gaucher's disease), sphingomyelin lipidosis (Niemann-Pick
disease), generalized gangliosidosis (Tay-Sachs disease),
generalized gangliosidosis (Norman-Landig
disease), which are accompanied with liver, spleen, marrow, nervous system and other
organs and tissues damage.
Stromal-vascular lipidosis include
neutral fat metabolism disturbance in adipose tissue and adipose depot as well
as cholesterol and its ethers in arteries walls under
atherosclerosis.
General disturbance of neutral
fats metabolism is
manifested with neutral fat stocks increase or decrease in hypodermic fat
tissue, mesentery, pericardium, marrow, etc. General uptake of neutral fat in fat depots
is called obesity. The following is
recognized: primary or idiopathic obesity the cause of which is unknown and secondary obesity which occurs under
endocrine, cerebral and hereditary diseases. By external signs obesity kinds
are as follows: upper, mid, lower and
universal symmetric. By morphologic signs hyper plastic type is marked out
characterized with fat cells (adipocytes) quantity increase in organism as well
as hypertrophic (malignant) type the basis of which is adipose cells size increase several times and
triglycerides content increase in cytoplasm several times.
Under general obesity the
important clinical attention is paid to heart injury. In this case adipose tissue grows under
pericardium, surrounding organ like
case. Lipocytes uptake in myocardium
stroma between cardiac hystiocytes,
squeezing the latter ones which causes their
atrophy. Right portion of the heart is the most injured one. Sometimes the whole thickness of right
ventricle myocardium is changed with adipose tissue, that can cause cardiac rupture or accelerate
decompensation process.
Neutral fat local uptake
is observed under Madelung's syndrome,
Dercum's disease and Weber-Krischen’s desease, as well as vacant obesity when organ atrophied portion is substituted. The essence of Dercum's disease is in painful
lipomas occurrence in subcutaneous adipose tissue of extremities and trunk.
Weber-Krischen’s disease is characterized with
recurrent nonpurulent cellulites with productive granulomatous inflammation
development around sphacelous adipose tissue.
General decrease of adipose tissue occurs under emaciation (cachexia). Tissue becomes loose, flabby, is saturated with liquid, sliming.
Cholesterol and its ethers’ metabolism imbalance is a basis of atherosclerosis development. Uptake of cholesterol fractions, lipoproteins of
various density, proteins in arteries’ walls causes formation of fat detritus (atheroma) and conjunctive tissue
enlargement (sclerosis). Hereditary cholesterol metabolism disturbance is observed under family hypercholesterolemic
xanthomatosis, manifested with xanthalasms
formation (cholesterol deposition in skin, big vessels’ walls, heart valves and other organs).
Carbohydrates
pathologic uptake
(glycogenosis) morphology
The most valuable in
carbohydrates metabolism disturbance is glycogen, glycosamineglycanes and glycoproteins. The most important in this pathology is
glycogen metabolism disturbance occurring under diabetes mellitus. In case
insulin deficiency in blood the tissues utilize sugar insufficiently causing
sugar level increase in blood (hyperglycemia), and glycogen quantity in tissues decreases. Kidneys remove sugar excess
with urine (glucosuria). In the result of glucose polymerization under its
resorption from plasma ultrafiltrate glycogen is accumulated in tubules epithelium, mesangium and membranes
of glomerule vessels. The most of it is in epithelial cells and in Henle’s loop
lumens (narrow segment). Epithelium
in these sections of nephron becomes high, with light and foamy cytoplasm. Changes in kidneys under diabetes mellitus
are finalized with sclerosis development called diabetic
glomerulosclerosis.
Hereditary (glycogenosis) occurs under deficiency of ferment which splits glycogen and the latter
accumulates in cells. These includes hepatorenal glygenosis, Pompe
disease, MacArdles and Gerce’s under which glycogen structure is not
damaged, as well as Forbes-Cori (type 3
glycogenosis) and Anderson’s disease (type 4 glycogenosis) under which this
structure is changed.
Under glycoproteins metabolism disturbance (mucins and mucoids which are the base of
mucus) mucus degeneration
develops. The typical manifestation of
it is mucoviscidosis
which is systemic disease, charactristic
of which is high viscosity of
mucus, causing development of retention
cysts and sclerosis in pancreas,
bronchi, digestive and other
glands. Besides that this degeneration
is often observed under
catarrhal inflammation of nose mucous tunic (rhinitis), mucous tunic of larynx (laryngitis), bronchi (bronchitis), stomach (gastritis), etc. Macroscopically
excess of mucus is seen on mucous tunic, and this mucous
trickles down from the surface. Microscopically
wine glass like cells appear in mucous tunic and
release mucus. Also desquamation or
cells necrosis is observed, glands’
excretory ducts are clogged with mucus which is accompanied with cysts
formation.
Glycoproteins and glycosamineglycanes uptake in organs’ stroma is accompanied with
collagen fiber as well as cartilage and adipose tissue substitute with
mucus-like mass. Damaged tissues cells
have star-like shape. This process is
called tissue sliming and it is observed under cachexias and myxedema. Carbohydrates uptake consequence
can be reversible and under process progress they become semi-transparent, looks like
mucus, colliquative necrosis
develops.
Metabolic
disease. Morphology
of pathologic accumulation of endogenous and exogenous pigments.
Morphology of mineral
metabolism disease
Importance
of the topic: metabolic disease rather often occurs in practice of clinicians and should be considered as a manifestation of general pathologic
processes. Often it occurs at endocrine
diseases, as well as at pathology of
gastrointestinal tract
and
hepatobiliary system and it reveals
through structural morphologic changes. Knowledge of issues of this topic enlarges the minds of would-be clinicians concerning the kind of changes
that underlie various pathologic processes at one or another disease.
Purpose: to study causes,
development mechanism, morphologic manifestations and consequences of
accumulation of endogenous and exogenous pigments, as well as mineral
metabolism disease.
Specific goals: 1 To learn varieties of metabolic diseases and their
development mechanisms.
2 To study causes, development mechanism,
pathogenesis and morphogenesis, morphologic presentations and consequences of
accumulation of endogenous and exogenous pigments, as well as mineral
metabolism disease.
3 To learn to differentiate various kinds of
pigment metabolic diseases and mineral metabolism diseases according to
morphologic signs.
4 To evaluate functional importance and consequences of accumulation of
endogenous and exogenous pigments, as well as mineral metabolism diseases, to
know how to diagnose their morphologic manifestations in cells and tissues.
Iron metabolic disease and metabolic disorder of
hematogenous pigments. Metabolism and pathogenic action of iron, formation of anabolic and
catabolic ferritin. Classification of hematogenous pigments.
Toxic forms of ferritin: causes and consequences of their formation.
Hemosiderosis (topical and extensive): causes, pathogenesis, morphologic characteristics and
consequences. Acquired and congenital hemochromatosis: morphologic characteristics and
consequences.
Hematoidin,
hematin, porphyrin: features and area of formation, morphologic characteristics
and consequences of their accumulation.
Bilirubin
metabolic disease: causes,
pathogenesis and anatomical pathology of hemolytic jaundice, hepatic jaundice,
obstructive jaundice. Pathogenic effect of increased
bilirubin, complications and causes of death at jaundice.
Melanin formation disorder. Causes,
pathogenesis, morphologic characteristics
of hypopigmentation (leukoderma, vitiligo, albinism) and
hyperpigmentation (common melanoderma, local melanosis, pigmented nevus).
Nucleoprotein metabolic
disease. Podagra and
gouty arthritis: classification, aetiology, pathogenesis, stage of disease and
morphologic characteristics of joints’
changes, clinical presentations, complications and consequences. Podagric nephropathy. Clinicopathologic
characteristics.
Copper metabolic disease. Hepatolenticular
degeneration (Wilson's disease).
Potassium metabolic
disease. Periodic paralysis.
Calcium metabolic
disease. Acute hypocalcemia and hypercalcemia: definition, pathogenesis, consequences and their role in thanatogenesis. Calcinosis (calcification): definition, classification, morphogenesis
of metastatic calcification, dystrophic calcification and metabolic calcinosis;
consequences, the role of calcification of organs in thanatogenesis.
Stone
formation: localization, causes, pathogenesis, types of stones, consequences
and complications of
stone formation.
Auxiliary materials for self-training to
practical lesson
Pathologic accumulation of endogenous pigments rather often is represented in
metabolic disease of complex proteins – chromoproteins, nucleoproteins,
glucoproteins and lipoproteins. Chromoproteins, or colored proteins, are
endogenous pigments, to which hematogenous, proteinogenous and lipidogenous
pigments are referred. Metabolic disease of complex proteins is observed in
parenchyma, as well as in stroma of tissues and organs.
Iron metabolic disease and metabolic disorder of hematogenous pigments
Ferritin, hemosiderin, bilirubin are referred to hematogenous pigments. There are pigments which may be accumulated in organism
at physiological conditions and at some diseases; hematoidin, hematin, porphyrin are pigments
which are formed only at pathologic processes. They are generated from hemoglobin at destruction
(hemolysis) of erythrocytes.
Ferritin is
generated from hemoglobin at intensive intravascular hemolysis of erythrocytes – catabolic form.
Anabolic form is
generated from iron absorbed in bowels . At conditions of hypoxia ferritin
is restored into an active form
(SH-ferritin) which is an adrenalin antagonist, that’s why it acts vasoparesically, i.e. as vasodilator. An active ferritin
is accumulated at incompatible blood transfusion and collapse of vessels is
observed, then a
syncope takes place.
Hemosiderin is generated from hemoglobin only in macrophages (intracellularily). It appears
outside the cell only after cell destruction. It looks like small brown seeds;
tissue acquires brown coloration at evident hemosiderosis. One can distinguish
common and topical hemosiderosis. Common hemosiderosis
is developed at intensive intravascular hemolysis of erythrocytes (incompatible blood
transfusion, hemolytic poisoning). Unconjugated hemoglobin is captured by
macrophages of unitary mononuclear phagocyte system of liver, spleen, lymph
nodes, bone marrow, thymus gland in which hemoglobin turns into hemosiderin. Listed organs acquire
brown coloring.
Topical hemosiderosis arises at areas of extravasation. Erythrocytes are
absorbed outside the vessels by macrophages, in which hemoglobin turns
into hemosiderin. An example
of topical hemosiderosis is pulmonary
hemosiderosis which is developed at
venous plethora of lungs accompanied by
diapedetic extravasations.
Hemochromatosis
is a peculiar disease closely related to common
hemosiderosis. There could be primary and secondary one. Primary (hereditary) hemochromatosis is referred to storage diseases, caused by a hereditary defect of small
intestine ferments. A secondary one is
conditioned by acquired enzymatic deficiency of systems providing food iron
metabolism.
A Prussian blue reaction is seen in this iron stain of the liver to
demonstrate large amounts of hemosiderin that are present within the cytoplasm
of the hepatocytes and Kupffer cells. Ordinarily, only a small amount of
hemosiderin would be present in the fixed macrophage-like cells in liver, the
Kupffer cells, as part of iron recycling.
The brown coarsely granular material in macrophages in this alveolus is
hemosiderin that has accumulated as a result of the breakdown of RBC's and
release of the iron in heme. The macrophages clear up this debris, which is
eventually recycled.
Bilirubin is a bile pigment
generated at destruction of hemoglobin and detachment of haem in reticulum- endothelial
(mononuclear) system. Increased bilirubin (bilirubinhemia) is evidence
of jaundice. One can distinguish hemolytic
jaundice, hepatocellular jaundice and obstructive (mechanical) jaundice.
Hemolytic jaundice arises at infectious diseases, intoxications, isoimmune and
autoimmune conflicts, massive hemorrhage, as well as erythrocytopathy and
hemoglobinopathy.
Hepatocellular jaundice arises at liver diseases of various aetiology, in
case defective hepatocytes are not able to capture bilirubin, its conjugation
to glucuronic acid and excretion are disturbed. Obstructive (mechanical)
jaundice arises at retention
of bile outflow from
liver.
These renal tubules contain large amounts of hemosiderin, as demonstrated
by the Prussian blue iron stain. This patient had chronic hematuria.
Hematoidin is a pigment which doesn’t contain iron. It is
accumulated in central areas of hemorrhage
in the distance of living tissues.
Hematin – is
an oxidized form of haem. The following pigments are referred to: malarial
pigment which is generated from hemoglobin under influence of malarial
plasmodia, muriatic hematin which is generated at hemoglobin interaction with intestinal juice
ferments and hydrochloric acid (it colours erosions and bottom of bleeding
ulcer into black and brown), as well as formalin pigment which occurs in
histologic specimen fixed by acid formalin.
The
yellow-green globular material seen in small bile ductules in the liver here is
bilirubin pigment. This is hepatic cholestasis.
The
black streaks seen between lobules of lung beneath the pleural surface are due
to accumulation of anthracotic pigment. This anthracosis of the lung is not
harmful and comes from the carbonaceous material breathed in from dirty air
typical of industrialized regions of the planet. Persons who smoke would have
even more of this pigment.
Hematoporphyrin is a pigment which
is melanin antagonist. Its small quantity is contained in blood, urine and
stool, it heightens light sensibility of skin. Excess accumulation of this
pigment is called porphyria. It could be caused by congenital defect of
porphyrin metabolism or acquired one: lead or barbiturate poisoning, avitaminosis
PP, etc. Such patients are UV hypersensitive
which causes burns, ulcers, skin atrophy and depigmentation. Bones and teeth
are coloured into brown.
Metabolic disorder
of proteinogenous pigments.
Melanin chromogenesis
disorder.
Melanin, as well as adrenochrome and pigment of enterochromaffin cell granules are referred to proteinogenous (tyrosinogenous) pigments which are tyrosine
and tryptophan
metabolic derivatives.
Melanin is a brown-black pigment which determines
color of skin, hair and eyes. Melanin chromogenesis
disorder could appear in increase or decrease of this pigment in skin. There
could be local or extensive process. There could be congenital or acquired
pathology. Extensive hypopigmentation or
hypomelanosis (albinism) appears as a result of hereditary deficiency
of tyrosinase.
Local hypomelanosis (vitiligo, leukoderma) appears as a result of disorder of neuroendocrine control of
melanogenesis at leprosy, diabetes mellitus, hyperparathyroidism, Hashimoto's
thyroiditis, syphilitic skin affection. Extensive acquired hypermelanosis
declares itself in excessive accumulation of melanin in skin (melanoderma) and
is observed at
emaciation, Addison's disease, endocrine disorders, pellagra, scurvy. Extensive
congenital hypermelanosis declares itself in spotted skin pigmentation,
hyperkeratosis and edema – pigmentary xeroderma. Local congenital
hypermelanosis is represented by birthmarks or nevus, acquired one is observed
at pregnancy, pituitary adenoma, lentigo, melanosis coli at constipation.
Adrenochrome is an adrenalin oxidation
product. It occurs in the form of granules in cells of medullary
substance of adrenal glands.
Pigment of enterochromaffin cell granules occurs in cells of diffuse endocrine system:
enterochromaffin cells of stomach, bowels, B and C cells of thyroid gland,
cells of juxtaglomerular apparatus of kidney, cells of Langans’s islands of
pancreas. It is considered to be a serotonin analog. Carcinoids or tumors made
of above mentioned cells possess a significant serotonin activity. In such
cases patients get carcinoid syndrome.
Here
is anthracotic pigment in macrophages in a hilar lymph node. Anthracosis is
nothing more than accumulation of carbon pigment from breathing dirty air.
Smokers have the most pronounced anthracosis. The anthracotic pigment looks
bad, but it causes no major organ dysfunction.
Metabolic disorder of lipidogenous pigments
Lipofuscin and lipochromes are referred to lipidogenous
pigments.
Lipofuscin is a pigment of goldish colour. Its perinuclear
location is an evidence of active metabolic processes. Its accumulation
(lipofuscinosis) at the periphery of a cell is an evidence of activity decrease
of respiratory ferments in a cell. Lipofuscinosis is occurred at aging,
cachexy. The organs are colored into brown – brown atrophy of myocardium,
liver.
Lipochrome colours lipocytes, adrenal gland cortex, blood serum, yellow body
of ovary into yellow. At pathologic
conditions the quantity of lipochromes is increased in fatty tissue at diabetes
mellitus, lipidic-vitaminous metabolic disorder, drastic
emaciation.
Metabolic disorder of nucleoproteids
It
could be often observed at excessive formation of uric acid and its salts which
determines development of podagra, urolithiasis, uric acid infarct. At most
cases pathology is determined by congenital
purine metabolic disorder. Over-use of animal proteins, kidney diseases
are of a significant importance for disease pathogenesis. Uric acid sodium deposits
in joints (synovial membrane, articular cartilages of hands and feet), synovial
membranes of tendon with necrosis areas developed, granulomatosis giant-cell
reaction, painful arthroliths, deformation of joints are typical for podagra
and gouty arthritis. Podagric nephropathy – uric acid salt deposits in ducts and gathering
tubes with obstruction of their lumens and inflammatory, sclerotic and atrophic changes – arises as
complication.
Copper metabolic
disorder
It
could be most often observed at hereditary hepatolenticular
degeneration or Wilson's disease. Copper accumulation is observed in liver, brain,
kidneys, pancreas,
Potassium metabolic disorder cornea – typical green-brown Kaiser- Fleischer ring
at the periphery of cornea. Dystrophic and sclerotic changes are the result of
copper accumulation in organs.
It
could declare itself in
increase of potassium in blood and tissues which is observed at Addison’s
disease as result of affection of adrenal glands.
Decrease of potassium causes periodic paralysis – fit of weakness and motor paralysis
development.
Calcium metabolic
disorder
It
could declare itself in
increase or decrease of calcium concentration in blood (hypocalcemia and
hypercalcemia). Calcium metabolic
disorder results in development of calcifications (calcinosis) –
calcium salts deposits in intercellular substance or cells, that’s why
calcifications are divided into intercellular and extracellular ones. According
to development mechanism there are metastatic, dystrophic, metabolic calcifications.
Calcifications also could be systemic or local.
Metastatic
calcifications are more often systemic and appear at hypercalcemia caused by the following:
-
disorder of endocrine control of calcium metabolism
(hyperproduction of parathyroid hormone, calcitonin deficiency),
excessive vitamin D content;
-
intensive calcium excretion
from bones (multiple fractures, myelomatosis, tumor deposits of bones,
osteomalacia, hyperparathyroidic osteodystrophy);
-
disorder of calcium
excretion from organism (colonic involvement, chronic dysentery, mercuric
chloride poisoning, kidney diseases: polycystic renal disease, chronic
nephritis).
Most often there are calcium salts deposits in lungs, mucous coat of stomach, kidneys,
miocard, walls of arteries.
This is dystrophic
calcification in the wall of the stomach. At the far left is an artery with
calcification in its wall. There are also irregular bluish-purple deposits of
calcium in the submucosa. Calcium is more likely to be deposited in tissues
that are damaged.
Here
is so-called "metastatic calcification" in the lung of a patient with
a very high serum calcium level (hypercalcemia).
Dystrophic calcifications or petrifications are
of local character and result in calcium salts deposits formation in necrosis
areas or areas of severe dystrophic changes of tissues (tuberculosis, gumma,
infarction, atherosclerosis of vessel wall, mitral valve at endocarditis, dead
parasites).
Change of physicochemical composition
of tissues and local increase in phosphatase activity determine their
development, there is no hypercalcemia observed at the
same time.
Metabolic calcinosis appears at
instability of buffer systems of organism (calcium gout, interstitial
calcinosis). Consequences of calcifications
are unfavorable in most cases.
Stone formation is appearance of solid concrements in caval organs
or excretory ducts of glands. Stones appear
in biliary and urinary tracts, excretory ducts of pancreas and salivary glands,
bronchi and bronchiectasis, as well as in vessels and bowels. Stone formation
is caused by acquired or hereditary metabolic diseases (metabolic disorders of
carbohydrates, fats, nucleoproteins, minerals). Among local factors there are secretion disorder,
secretion congestion, inflammation. Depending on localization and form of organ
in which stones appear there are solitary, multiple, round, oval stones, stones
with processes, cylindrical, smooth and shaggy stones.
Cholelithic disease and urolithiasis, pressure bedsore, perforation of
organs, fistulas, inflammation of walls of caval
organs, jaundice, hydronephrosis are the consequences
of stone formation.
Cells and
tissues damage and death. Necrosis and apoptosis.
Pathologic anatomy of organ deficiency.
Fundamentals of
thanatology.
Death, definition, signs of
death
Critical alteration of specialized cells. Definition, etiology and consequences.
Molecular mechanisms of cells critical alteration. Concepts of endogenous metabolic
catastrophe: cells biological combustion
insufficiency, cell acidotic alteration,
plasma membrane transportaion mechanisms injury, activation of cytoplasm lipid peroxidation
and cell membranes, injury with
free radicals and nitrogen oxide excess,
catastrophic increase of free calcium in cell, cell injury with transmitters
excess, abnormal proteins accumulation
in cell. Critical injury of cell with external factors:
external physics-chemical factors, pathogenic
infects (ultramicrobs,
Rickettsias, bacteria, fungi).
Kinds of specialized cells death in organism.
Cell
necrosis: definition, terms and phases of
development, morphologic characteristic of coagulation necrosis
and cells necrosis, their consequences.
Pathogenic
inductive apoptosis: definition, molecular mechanisms, term of
development, microscopic manifestation, consequences.
Immune destruction of cells. Immune destruction of cells in organism conditions and designation. Phagocytosis: definition, main
cells-phagocytes, phagocytosis mechanisms and microscopic manifestation. Immune cells killing: definition, cytotoxical cells, mechanisms and microscopic
manifestations, consequences. Cells destruction with activated complement: definition, mechanisms and microscopic manifestations.
Pathological anatomy of organ insufficiency.
Autoimmune (lymphocytic) destruction of all specialized structures of organ: definition, stages of development, clinical-morphological
characteristics, consequences.
Postishemic-markfusional
organs injury: definitions, morphogenesis peculiarities, clinical-morphologic characteristics, consequences.
Necrosis of organ or its portion. Morphologic types of tissues
necrosis (colliquative, coagulative): definition, causes, pathological anatomy. Organ necrosis: definition, causes, development stages (ore-necrotic,
necrosis and tissues destruction). Post necrotic transformation of organ’s sphacelus (necrosis
demarcation and encapsulation, regeneration, infection
and inflammation, formation of ulcer, cyst, sequester,
sclerosis/gliosis foci,
calcinosis foci).
Clinical-morphological classification of organ necrosis basic kinds.
Infarction: definition, morphogenesis, pathological anatomy of main types,
consequences. Gangrene: definition, morphogenesis, pathological anatomy of dry, wet and anaerobic,
consequences. Morphologic
characteristics of infarction, gangrene. Decubitus:
definition, trophoneurotic necrosis morphogenesis, consequences. Noma: definition, morphogenesis, pathological anatomy, consequences. Morphogenesis, pathological anatomy of liver toxic necrosis and enzymatic pancreatonecrosis. Sequester: definition, morphogenesis, pathological anatomy, consequences.
Fundamentals of thanatology.
Human being
birth and death. Organism death from biological,
social and medical positions: idea of
natural, violent death and death from diseases (untimely
and sudden). Intrauterine
death definition.
Thanatogenesis. Cause, molecular-metabolic and structural
mechanisms of vital parts activity cessation under natural course of disease. Immidiate consequences of heart, lungs, cerebrum,
kidneys and liver work cessation.
Clinical-pathological characteristics of the main periods of thanatogenesis. Modern acknowledged periods of thanatogenesis: critical period, apparent death, post reanimation period, natural
death. Consequences of
vital parts activity cessation.
Critical and
agonal periods of disease: definition,
clinical-pathological features, consequences.
Clinical
death: definition, features and terms of
development, idea of cardiopulmonary
reanimation and its consequences.
Post
reanimation period: definition, molecular and clinical-pathological
anatomy features of vital parts injury and their functions recovery.
Natural death: definition, immediate (main) causes and development terms under natural clinical course and under sudden
death of a person. Precursory and delayed signs of natural death and resuscitated
patient. Morphological
characteristic of cadaveric changes. Basic reasons and morphological
signs of intrauterine
fetal death and neonate death.
Critical alteration of specialized cells is manifested with their death being the final result of their damage. The
most often cell’s death is caused by acute hypoxia or ischemia; physical factors (mechanical trauma, burns, frostbites, radiation, electric shock); chemical substances and medicines; infections, intoxications, immune reactions and other conditions.
Mechanisms
of cells damage
Mechanisms of cells damage are
extremely various. Under ischemia damage
develops in the result of oxygen scarcity in tissues and its free radicals creation causing lipids peroxidation and cellular breakdown. Critical damage can develop under calcium homeostasis disturbance. Under
cytolemma hyperpermeability free calcium ions concentration grows causing
activation of numerous ferments’ damaging cell: phospholipase,
protease, ATPase, endonuclease.
ATP content decrease causes cytolemmas damage and induces cell death.
Types of
specialized cells death.
Three basic types of
specialized cells death in organism are recognized: ischemic or hypoxic, toxic and
damage with oxygen free radicals. Hypoxic and ischemic damage occurs in the
result of arterial
flow cessation. Herewith oxidative phosphorilation is ceased and ATP formation
is terminated,
anaerobic glycolysis enhances, lactic acid, inorganic phosphate
accumulates, intracellular pH decreases,
chromatin consenses, cell becomes
dropsical, membrane structures destruct. Cell damage by free radicals is caused
by membranes
lipids peroxidation, autocatalytic
reactions development, oxic proteopepsis, DNA damage. Toxic damage occurs under
chemical substances action on cell membrane or intracellular organelles.
Two types of local death exists: necrosis and
apoptosis. Necrosis (from Greek nekros – dead) which is local death, death is characterized with cells death in living
body. Specific cells, a group of cells, the portion of the organ, organ in full
can be subject to death.
Cells necrosis
Cell necrosis is cell death under the influence of extreme negative
exogenic and endogenic factors and it is manifested with considerable cells
edema or cellular breakdown, cytoplasmic proteins denaturation and coagulation, cell
organelles breakdown. Three
stages are differentiated in necrosis
development: pre-necrotic, necrotic and
post necrotic. Pre-necrotic stage is characterized with severe degenerative changed which are
ended with necrosis. At necrosis stage the following is broken-down and
decomposed (kariorrhexis, kariolysis), cellular cytoplasm (plasmorrhexis,
plasmolysis) and intercellular substance – fibrinoid necrosis.
In the post necrotic stage
necrosis products are subject to autolysis, meaning dilation or dispersion or organization. Macroscopically
necrosis region differs from surrounding living tissues. Its of dirty black color in skin and bowels
and whitish yellow in the other organs (myocardium, liver, kidneys, spleen).
By etio-pathogenetic principle the following direct necrosis is differentiated: traumatic, toxic and the following indirect ones: trophoneurotic, allergic, vascular.
Microscopic signs of necrosis:
Cell nucleus change: karyopyknosis, karyorrhexis,
kariolysis.
Cell cytoplasm chang: plasma coagulation, plasmorrhesis, plasmolysis.
Intracellular substance change: mucoid swelling, fibrinoid swelling, fibers disintegration.
Necrosis classification by etiology: trophoneurotic, toxic, traumatic, vascular,
allergic.
Trophoneurotic necrosis occurs under central nervous system and peripheral nerves injury. Traumatic necrosis occurs in the result of physical, electrical, chemical, thermal trauma direct
action. Toxic necrosis
occurs in the result
of toxins, mostly of bacterial origin influence on tissues. Allergic necrosis develops on condition of
tissues hypersensitivity (sensibilization).
Vascular (ischemic) necrosis
occurs in the result of tissues blood supply significant decrease or
termination.
Clinicopathologic classification of the
main types of organs’ and tissues’ necrosis
The following types of necrosis are
differentiated: coagulation, colliquative, infarction, gangrene, decubitus,
sequester.
Coagulation (dry) necrosis is
characterized with
sphacelus portion deaquation and induration. It includes cheesy (caseation) necrosis
under tuberculosis, lues,
lymphogranulomatosis as well as cereous
myonecrosis under abdominal and
flea-borne typhus, cholera, fibrinoid necrosis under allergic and lymphocytic diseases, malignant hypertension as well as adiponecrosis which is distributed into
ferment, which occurs under pancreatitis
and non-ferment caused by trauma.
Colliquative (wet) necrosis is characterized with necrotic tissue rarefication and fusion in the result of hydrolytic processes
activation. It is developed in tissues rich with moisture, for example in
cerebrum.
Infarction is necrosis
caused by blood supply deficiency. Occurs in the result of thrombosis,
embolism, long term arteriostenosis and long term, functional overexertion of
organ in hypoxia conditions. By its shape infarction could be wedge-like
(spleen, lung, kidneys)
and irregular shape (heart, cerebrum). By its
appearance it is distributed into white (ischemic), which the most often is found
in cerebrum, spleen; red (hemorrhagic) which occurs in lungs, bowel,
amphiblestrodes; white with
hemorrhagic crown – in heart, kidneys. Infarction
form and appearance depends on the features of organ’s vascular system, types of
vessels branching, anastomosis development, structural-functional features of the organ (for detail see the theme of circulatory disturbances).
Gangrene is death of
tissues contacting with air (bowel,
extremities). Under the influence of air
ferric sulphide is formed from hemoglobin, and this ferric sulphide colors
necrotic portion in black. Dry and wet gangrenes are differentiated. Dry occurs mostly in the result of
insufficient arterial blood supply. Necrotic portion dries up, densifies,
mummifies. Wet gangrene occurs in the cases when lymph and
black blood outflow is disrupted or when
necrosis portion is subject to putrefactive mycronychia action. Necrotic portion
is hydropic, diluted, of dirty black color with very unpleasant smell. Anaerobic
gangrene development is based also on blood outflow disrupted. It is caused
by a group of anaerobic activators. During that gases squeeze microvasculature
structures.
Decubitus is a kind of gangrene. It is caused by blood supply and nervous trophism
disturbance of subiculum in the place of squeezing (sacral
bone, bladebones, calx) under seriously ill patient long term decubitus, for example,
cerebrovascular accident.
Sequestrum is sphacelus which is not
subject for autolysis for a long time. As a rule sequestra are observed in
bones under osteomyelitis.
Demarcation line of red color
with a tinge of yellow occurs surrounding necrotic
portion. This is reactive inflammation
characterized with vascular distention in living tissue, edema, leukocytic
infiltration, macrophages
incipiency. Lytic ferments of
heterophilic leukocytes
expedite dead zymolyte maceration and resolution similar to the
one observed under wet necrosis, for example in cerebrum with cisterns formation and cyst buildup or
rejection (autoamputation) of external necrotic body parts. In
favorable cases mesenhymal origin cells proliferation starts around necrotic
portion, spacelous aggregate either grow with conjunctive tissue (organization) or encrust with it (encapsulation) or are subject to calcification (petrification). Sometimes necrotic portion purulence is observed with abscess
formation.
Apoptosis
Apoptosis is genetically
programmed death of unnecessary or defective cells in living body and the
following causes these cells destruction in the process of embryogenesis and physiologic involution:
cutaneous epithelium, white and red corpuscles
extinction. Herewith
chromatin condensation and fragmentation in cells is observed. In case
apoptosis decrease neoplastic process is
developed and in case apoptosis increase – atrophy. Apoptosis differs from
necrosis in:
- inflammation
absence,
- only several
cells or their groups are involved in the process,
- cell
membrane is saved,
- cellular
breakdown is done not by activated
hydrolytic ferments, but in participation of special
calcium-magnesium dependent
endonucleases which cut nucleus into numerous fragments,
- formed cells
fragments (apoptosis corpuscles) phagocytized
by parenchymatous or stromal cells which are situated nearby.
Apoptosis
morphogenesis develops in several stages:
- chromatin
condensation and margination, nucleus
becomes fragmented,
- intracellular
organelles condensation and cells
shrinkage,
- apoptosis
corpuscles formation,
- apoptosis
corpuscles phagocytosis with parenchymatous cells or macrophages .
Under
histological investigation apoptosis cells are round or oval particles with
intensively colored cytoplasm and dark fragments of nucleus
chromatin.
Fundamentals of thanatology
Thanatology is doctrine of organism dying starting from initial signs up
to full corruption of the body. In the course of dying organism stays in
terminal (critical) condition and is capable for reversible development
occur prior to death coming. Herewith progressive functions decrement of
various organism’s systems is observed, first of all respiratory depression as well as blood flow
organs depression occurs, organism’s homeostatic systems incoordination has
place:
pulmonary edema, arrhythmia, paroxysm,
respiration disturbance, constrictors paralyses, etc. Hypoxia and blood
circulation disturbance
cause pathologic changes in organs and tissues, which
are called moribund state. Blood
circulation directed to support functions of cerebrum causes microcirculation
disturbance on periphery resulting in parenhymal organs structure and
functions failure. Energy metabolism switches to anaerobic glycolysis causing lactic acid accumulation, acidosis, hypoxia intensifies. Biologically active substances come into
blood causing microcirculation channel paresis and paralysis, increase of
vascular permeability, blood clotting, stasis occurrence, clots formation. Terminal condition development
and signs depend on pathological process caused death agony. In case dying is
going on, terminal condition can be divided into several stages: pre-agony,
terminal pause, agony,
apparent death, natural death.
During pre-agony stage arterial tension gradually decreases, inhibition of
sensorium and electric activity of cerebrum. Tachycardia passes into bradycardia,
trunkal reflex disturbance occur. In terminal phase temporary breath holding is
observed, and periodic asystolia changes bradycardia. Agony is characterized with sudden activation
of bulbar centers on
the background of cerebral cortex full shutdown. Such disintegration of vegetal
centers is accompanied with temporary and short time arterial tension increase, sinus
automatism initiation and respiratory
movements intensification. Apparent
death is characterized with the deepest inhibition of central nervous system
which expands also on spinal bulb with blood circulation termination and
apnea.
Death, types, signs, postmortem
changes
Depending on the causes the following
types of death are recognized: natural (physiologic) death from age and organism depreciation, violent
death from trauma or other negative influence on
organism which ends with death and from
diseases. Depending on reversible or irreversible changes in organism apparent
death and natural death are specified.
Apparent death is characterized with apnea,
blood circulation termination and lasts for 5-6 minutes until cerebral cells death. Apparent
death is reversible process of dying. Reversibility depends on the stage of
hypoxic changes in cerebrum. Natural death is manifested with
irreversible changes development and autolytic processes beginning in all
the organs. It has characteristic signs
and postmortem changes in tissues: dead body cooling, postmortem rigidity, mummification, blood relocation, postmortem lividity, cadaveric disintegration. In case death
process in fast, it is observed liquid
blood in the heart and vessels caused by fibrinolysis, postmortem face lividity, ecchymosis in conjunctiva, intensive and wide spread cadaveric lividity, urine, fecal matter discharge as well as red mucus presence in respiratory passages, considerable
venous plethora of internal organs, hemicardia engorgement, punctuate hemorrhage on heart, lungs
surface.
In
case agony comes prior to death dense blood clots are observed in the
heart and vessels – red
in case of short term agony and yellowish-white or white under long term agony. Following basic vital functions of organism
termination, early and late signs of natural death gradually develop in
organism. Early signs are as follows: cadaveric
lividity (occur in 30 –60
minutes post mortem), cadaveric rigidity (occurs in 2-4 hours), cooling (every
hour of death gives 1 degree dead body
temperature decrease, desiccation of specific parts of skin and mucous coats (the most clearly it can be seen on opened eye
sclera – Lyarshe
spots) and
autolysis. Late signs of natural death occur on 2-3 day
port mortem. They are
ruining (putrefaction, dead
body damage by plants, animals) and preserving
(grave
wax, mummification, turfy tannage, etc.). Putrefaction
occurs with microorganisms participation and is characterized with dead body
organic substances destruction. This is
accompanied with gases formation, tissues mollities and dilution. First signs
of putrefaction occur in large bowel in 24-36 hours, abdominal wall derma turns green because of sulfgemoglobin
accumulation.
Autopsy.
Autopsy procedure and methods in medical and preventive treatment
facilities
Dead body stays in the ward
for two hours after the fact of natural death is established by in-patient hospital’s
physician. Surname, name, father’s name, date and time of death, department are
to be written on the hip with brilliant green. Usually rubber-coated label on
which above mentioned passport data is written is fixed to the arm. The latter
method is better to use in those medical and preventive treatment facilities in
which sporadic death cases occur.
Under body lift
and its further examination it’s necessary to keep all moral-ethical and
professional requirements. Ethical
requirements include medical secrecy keeping regarding everything revealed at
autopsy (thanatopsy). It’s also should
be taken in mind that dead body serving for science has relatives and
family. For example, Professor V.Gruberg required
from students and those working in autopsy room to take off hats, as "hats wearing does
not correspond the credit of the room". It’s advised to warn junior health professionals of the fact that cadaveric
hypostasis can disfeature the face in case body stays dorsum upwards. It should be kept in mind that after natural
death fact is etsbalished it’s necessary to close eyes, fasten up lower jaw, to cover the body with
clean linen, etc. Simultaneously with
diseased body completely filled-in medical records should be submitted to
mortuary.
Prior to deceased
body autopsy anatomist studies all the data regarding patient’s life, disease
and death which can be found in medical card of hospital patient, asks attending doctor missed facts relating
to course of disease and dying.
Sometimes it’s useful to clarify some data from relatives, especially in case
patient’s short term stay in the hospital. The following should be carefully
investigated: laboratory, tolls and
other methods of investigations, methods of treatment, medicines potions taken by patient,
diagnosis written on title page of medical records as well as all working
diagnosis written in log books. All this circumstances study pursues one more
important aim – to exclude or to find out medicolegal aspect.
It’s desirable
that anatomist examining all necessary data independently formulated diagnosis
which can differ of attending doctor diagnosis. Doing this, as P.Kalitiyevskyi
mentions, anatomist in a certain manner puts her/himself in the position
of attending doctor, which is really important
for mutual understanding between anatomist and clinician.
There is certain algorithm in autopsy fulfillment:
1 To carry out autopsy in day light as artificial lighting changes color
transfer.
2 To put
on gown and rubberized apron and oversleeves.
It’s advisable to use anatomical gloves. This will ensure contagious
diseases prevention, as well as cadaveric alkaloid penetration through possible
defects of skin.
3 External examination of
diseased body. The following should be
established: sex, body-type, nutrition, state of integumentum, existence of death signs, eruptions,
hematomas, wounds, ulcerations, edema, etc. It’s desirable that
attending doctor could confirm passport data of diseased.
4 Main incision.
It’s necessary to watch to prevent it coming through after surgical sections, cicatrix and other
defects.
5 Detailed
examination of cavities establishing the position and interlocation of organs,
presence of joints, exudates, transudate, foreign objects,
etc.
6 Organs’ withdrawal
from the cavities and their investigations (size, weight, color, consistency, shape, etc.) with simultaneous necropsy taking and, depending on
tasks set for anatomist, material for bacteriologic, serologic, biochemical and virology
investigations. Sometimes X-ray examination of bones is done.
7 Short summary
incorporating paragnosis, the cause of death, possible discrepancies between clinical diagnosis and
paragnosis, accessory matters clarification which are of interest for clinicians.
8 Cadaver toilette.
9 Autopsy records keeping.
First autopsy
methods were described in details by R.Virhov. Later on it was improved by Kiary, L’Etule, O.Abrykosov,
G.Shore. methods
of two last ones are the most widely used in anatomists’ practice.
O.Abrikosov offers
to investigate organs by cavities. First organs of cervix and thoracic cavity
are removed in totality. Then separately intestinal tract, liver, stomach and dodecadactylon
in one set, urinary tracts and genital organs in totality.
G.Shore suggested
organs full evisceration method, which means removal of cervix, thoracic cavity, abdominal cavity
and small pelvis as single total complex. This method is rather convenient to
be used under investigation of those deceased bodies who
died of after surgery complications. In this cases it’s reasonable to search in
details field of operation area, namely state of surgical sutures, vessels,
exudates presence and character, correctness of surgery fulfillment.
Autopsy recording
Autopsy recoding should be done in autopsy document –
records of post mortem examination (autopsy). It consists of the following parts: passport, descriptive, paragnosis and clinical autopsy epicrisis. Passport portion includes data regarding
deceased’ surname, name and father’s name, his/her age, address, number of
in-patent’s observation records,
profession and specialty, the
date of admission to the hospital and date of death, diagnosis. Autopsy records should contain also brief
extract from observation records regarding features of etiology, clinical
implications, tools and laboratory
results, methods of treatment. Take into
consideration that it’s advisable to indicate specialty instead of writing
“retired”, as well as characteristic features of disease which made it possible
to make diagnosis mentioned in
clinics.
There are various procedures to fill-in descriptive
part. At present there is a tendency to
simplify it, to go apart from classical form of presentation. It’s unacceptable to use general terms, for
example "atherosclerosis", "adenoma", "pneumosclerosis", etc. instead of pathologic signs or to compare the
size of pathologic changes with such objects as
English walnut, pea, egg instead of accurate statement of dimensions. It
should be remembered that autopsy records is legal document in which minor
changes, which, to the opinion of anatomist, are not critical could be of first
priority under further examination.
Moreover it’s not feasible to use autopsy records in which the character of pathologic changes is
only emphasized. This way often causes mistakes, which are hard to correct.
Making pictures and audio tape recording are also considered to be ancillary
methods of recording. The basic requirement imposed to descriptive part of
records is sufficient completeness and distinctness combined in case possible
with briefness of presentation.
The following forms of pathologicoanatomic changes
registration are widely used in autopsy practice:
Ø by anatomic systems of organism;
Ø by the way of autopsy fulfillment;
Ø by preliminary defined place of system injury in
conformance with peculiarities of the case,
and further on - by the way of other
systems examination.
It’s always
recommended to start descriptive part from body appearance description,
registration of nutrition, status of skin integuments, mucus tunic, eyes, hair,
nails, character of edema, etc. These
features are sometimes sufficient to assume this or that pathology
presence. It’s advisable to make records
immediately following autopsy and do not
defer that on the next day, it’s better
to make records at dictation by stages of autopsy carrying out or using voice recorder.
Pathologoanatomic
diagnosis formulation follows descriptive part of records, based on macroscopic
diagnostics and in case necessary using express-methods. Diagnosis formulation
is advised to be done in attending doctors presence
prior to the body toilette.
Hemodynamic Disorders, Thromboembolic Disease, and Shock
The health of cells and organs critically depends on an unbroken
circulation to deliver oxygen and nutrients and to remove wastes. However, the
well-being of tissues also requires normal fluid balance; abnormalities in
vascular permeability or hemostasis can result in injury even in the setting of
an intact blood supply. This chapter will describe major disturbances involving
hemodynamics and the maintenance of blood flow, including edema, hemorrhage,
thrombosis, embolism, infarction, and shock. Normal fluid homeostasis
encompasses maintenance of vessel wall integrity as well as intravascular
pressure and osmolarity within certain physiologic ranges. Changes in
vascular volume, pressure, or protein content, or alterations in endothelial
function, all affect the net movement of water across the vascular wall. Such
water extravasation into the interstitial spaces is called edema and has
different manifestations depending on its location. In the lower extremities,
edema mainly causes swelling; in the lungs, edema causes water to fill alveoli,
leading to difficulty in breathing. Normal fluid homeostasis also means
maintaining blood as a liquid until such time as injury necessitates clot
formation. Clotting at inappropriate sites (thrombosis) or migration
of clots (embolism) obstructs blood flow to tissues and leads to cell
death (infarction). Conversely, inability to clot after vascular injury
results in hemorrhage; local bleeding can compromise regional tissue
perfusion, while more extensive hemorrhage can result in hypotension (shock)
and death.
Some of the failures of fluid homeostasis reflect a primary pathology
in a discrete vascular bed (e.g., hemorrhage due to local trauma) or in
systemic coagulation (thrombosis due to hypercoagulability disorders); others
may represent a secondary manifestation of some other disease process.
Thus, pulmonary edema due to increased hydrostatic pressure may be a terminal
complication of ischemic or valvular heart disease. Similarly, shock may be the
fatal sequela of infection. Overall, disturbances in normal blood flow are
major sources of human morbidity and mortality; thrombosis, embolism, and
infarction underlie three of the most important causes of pathology in Western
society-myocardial infarction, pulmonary embolism, and cerebrovascular accident
(stroke). Thus, the hemodynamic disorders described in this chapter are
important in a wide spectrum of human disease.
Edema
Approximately 60% of lean
body weight is water; two thirds of this water is intracellular, and the
remainder is found in the extracellular space, mostly as interstitial fluid
(only about 5% of total body water is in blood plasma). The term edema
signifies increased fluid in the interstitial tissue spaces. In addition,
depending on the site, fluid collections in the different body cavities are
variously designated hydrothorax, hydropericardium, and hydroperitoneum
(the last is more commonly called ascites). Anasarca is a severe
and generalized edema with profound subcutaneous tissue swelling
Inflammation |
Acute inflammation |
Chronic inflammation |
Angiogenesis |
In general, the opposing effects of vascular hydrostatic pressure and
plasma colloid osmotic pressure are the major factors that govern movement of
fluid between vascular and interstitial spaces. Normally the exit of fluid into
the interstitium from the arteriolar end of the microcirculation is nearly
balanced by inflow at the venular end; a small residuum of excess interstitial
fluid is drained by the lymphatics. Either increased capillary pressure or
diminished colloid osmotic pressure can result in increased interstitial fluid.
As extravascular fluid accumulates, the increased tissue hydrostatic pressure
and plasma colloid osmotic pressure eventually achieve a new equilibrium, and
water reenters the venules. Any excess interstitial edema fluid is typically
removed by lymphatic drainage, ultimately returning to the bloodstream via the
thoracic duct .clearly, lymphatic obstruction (e.g., due to scarring or tumor) will also
impair fluid drainage and result in edema. Finally, a primary retention of
sodium (and its obligatory associated water) in renal disease also leads to
edema.
Increased Hydrostatic Pressure. Local increases in hydrostatic pressure may result from impaired
venous outflow. For example, deep venous thrombosis in the lower
extremities leads to edema, which is restricted to the affected leg. Generalized
increases in venous pressure, with resulting systemic edema, occur most
commonly in congestive heart failure affecting right ventricular cardiac
function.
Although increased venous hydrostatic
pressure is important, the pathogenesis of cardiac edema is more complex
Congestive heart failure is associated with reduced cardiac output and,
therefore, reduced renal perfusion. Renal hypoperfusion, in turn, triggers the
renin-angiotensin-aldosterone axis, inducing sodium and water retention by the
kidneys (secondary aldosteronism). This process is putatively designed
to increase intravascular volume and thereby improve cardiac output (via the
Frank-Starling law) with restoration of normal renal perfusion. If the failing
heart cannot increase cardiac output, however, the extra fluid load results
only in increased venous pressure and eventually edema.1
Unless cardiac output is restored or renal water retention is reduced (e.g., by
salt restriction, diuretics, or aldosterone antagonists), a cycle of renal
fluid retention and worsening edema ensues. Although discussed here in the
context of edema in congestive heart failure, salt restriction, diuretics, and
aldosterone antagonists may also be used to manage generalized edema arising
from a variety of other causes
Reduced Plasma Osmotic Pressure. Reduced plasma osmotic pressure can result from excessive loss or reduced
synthesis of albumin, the serum protein most responsible for maintaining
colloid osmotic pressure. An important cause of albumin loss is the nephrotic
syndrome characterized by a leaky glomerular capillary wall and generalized
edema. Reduced albumin synthesis occurs in the setting of diffuse liver
pathology (e.g., cirrhosis, or as a consequence of protein malnutrition (In each
case, reduced plasma osmotic pressure leads to a net movement of fluid into the
interstitial tissues and a resultant plasma volume contraction. Predictably,
with reduced intravascular volume, renal hypoperfusion with secondary
aldosteronism follows. The retained salt and water cannot correct the plasma
volume deficit because the primary defect of low serum proteins persists. As
with congestive heart failure, edema precipitated by hypoproteinemia is
exacerbated by secondary salt and fluid retention.
Lymphatic Obstruction. Impaired lymphatic drainage and
consequent lymphedema is usually localized; it can result from
inflammatory or neoplastic obstruction. For example, the parasitic infection filariasis
often causes massive lymphatic and lymph node fibrosis in the inguinal region.
The resulting edema of the external genitalia and lower limbs is so extreme
that it is called elephantiasis. Cancer of the breast may be treated by
removal or irradiation (or both) of the breast and the associated axillary lymph
nodes. The resection of the lymphatic channels as well as scarring related to
the surgery and radiation can result in severe edema of the arm. In carcinoma
of the breast, infiltration and obstruction of superficial lymphatics can cause
edema of the overlying skin, giving rise to the so-called peau d'orange (orange
peel) appearance. Such a finely pitted appearance results from an accentuation
of depressions in the skin at the site of hair follicles.
Sodium and Water Retention. Sodium and water retention are clearly contributory factors in several
forms of edema; however, salt retention may also be a primary cause of edema.
Increased salt, with the obligate accompanying water, causes both increased
hydrostatic pressure (owing to expansion of the intravascular fluid volume) and
diminished vascular colloid osmotic pressure. Salt (and water) retention may
occur with any acute reduction of renal function, including glomerulonephritis
and acute renal failure
Morphology.
Edema is most easily recognized grossly; microscopically, edema fluid generally
manifests only as subtle cell swelling, with clearing and separation of the
extracellular matrix elements. Although any organ or tissue in the body may be
involved, edema is most commonly encountered in subcutaneous tissues, the
lungs, and the brain. Severe, generalized edema is called anasarca
Pulmonary edema is a common clinical problem most typically seen in the setting of left
ventricular failure but also occurring in renal failure, acute respiratory distress
syndrome , pulmonary infections, and hypersensitivity reactions. The lungs are
two to three times their normal weight, and sectioning reveals frothy,
blood-tinged fluid representing a mixture of air, edema fluid, and extravasated
red blood cells.
Edema of the brain may be localized (e.g., owing to abscess or neoplasm) or may be
generalized, as in encephalitis, hypertensive crises, or obstruction to the
brain's venous outflow. Trauma may result in local or generalized edema
depending on the nature and extent of the injury. With generalized edema, the
brain is grossly swollen, with narrowed sulci and distended gyri, showing signs
of flattening against the unyielding skull
Hyperemia and Congestion
The terms hyperemia
and congestion both indicate a local increased volume of blood in a
particular tissue. Hyperemia is an active process resulting from
augmented tissue inflow because of arteriolar dilation, as in skeletal muscle
during exercise or at sites of inflammation. The affected tissue is redder
because of the engorgement of vessels with oxygenated blood. Congestion
is a passive process resulting from impaired outflow from a tissue. It
may occur systemically, as in cardiac failure, or it may be local, resulting
from an isolated venous obstruction. The tissue has a blue-red color (cyanosis),
particularly as worsening congestion
leads to accumulation of deoxygenated
hemoglobin in the affected tissues
Congestion and edema commonly occur
together, primarily since capillary bed congestion can result in edema due to
increased fluid transudation. In long-standing congestion, called chronic
passive congestion, the stasis of poorly oxygenated blood also causes
chronic hypoxia, which can result in parenchymal cell degeneration or death,
sometimes with microscopic scarring. Capillary rupture at these sites of
chronic congestion may also cause small foci of hemorrhage; breakdown and
phagocytosis of the red cell debris can eventually result in small clusters of
hemosiderin-laden macrophages
Morphology. The cut surfaces of hyperemic or
congested tissues are hemorrhagic and wet. Microscopically, acute pulmonary
congestion is characterized by alveolar capillaries engorged with blood;
there may be associated alveolar septal edema and/or focal intra-alveolar
hemorrhage. In chronic pulmonary congestion, the septa are thickened and
fibrotic, and the alveolar spaces may contain numerous hemosiderin-laden
macrophages (heart failure cells). In acute hepatic congestion,
the central vein and sinusoids are distended with blood, and there may even be
central hepatocyte degeneration; the periportal hepatocytes, better oxygenated
because of their proximity to hepatic arterioles, experience less severe
hypoxia and may only develop fatty change. In chronic passive congestion of
the liver, the central regions of the hepatic lobules are grossly red-brown
and slightly depressed (owing to a loss of cells) and are accentuated against
the surrounding zones of uncongested tan liver (nutmeg liver)
). Microscopically, there is evidence of
centrilobular necrosis with loss of hepatocytes dropout and hemorrhage,
including hemosiderin-laden macrophages In severe, long-standing hepatic
congestion (most commonly associated with heart failure), there may even be
grossly evident hepatic fibrosis (cardiac cirrhosis). Because the central
portion of the hepatic lobule is the last to receive blood, centrilobular
necrosis can also occur whenever there is reduced hepatic blood flow (including
shock from any cause); there need not be previous hepatic congestion
Hemorrhage
Hemorrhage generally
indicates extravasation of blood due to vessel rupture. As described
previously, capillary bleeding can occur under conditions of chronic
congestion, and an increased tendency to hemorrhage from usually insignificant
injury is seen in a wide variety of clinical disorders collectively called hemorrhagic
diatheses However, rupture of a large artery or vein is almost always due
to vascular injury, including trauma, atherosclerosis, or inflammatory or neoplastic
erosion of the vessel wall. Hemorrhage may be manifested in a variety of
patterns, depending on the size, extent, and location of bleeding.
ü Hemorrhage may be external or may be enclosed
within a tissue; accumulation of blood within tissue is referred to as a hematoma.
Hematomas may be relatively insignificant (a bruise) or may be sufficiently
large as to be fatal (e.g., a massive retroperitoneal hematoma resulting from
rupture of a dissecting aortic aneurysm;
ü Minute 1- to 2-mm hemorrhages into skin,
mucous membranes, or serosal surfaces are denoted as petechiae (and are
typically associated with locally increased intravascular pressure, low
platelet counts (thrombocytopenia), defective platelet function (as in
uremia), or clotting factor deficits.
ü Slightly larger (≥3 mm) hemorrhages
are called purpura. These may be associated with many of the same
disorders that cause petechiae and may also occur secondary to trauma, vascular
inflammation (vasculitis), or increased vascular fragility (e.g., in
amyloidosis).
ü Larger (>1 to 2 cm) subcutaneous
hematomas (i.e., bruises) are called ecchymoses and are
characteristically seen after trauma but may be exacerbated by any of the
aforementioned conditions. The erythrocytes in these local hemorrhages are
degraded and phagocytosed by macrophages; the hemoglobin (red-blue color) is
then enzymatically converted into bilirubin (blue-green color) and eventually
into hemosiderin (gold-brown color), accounting for the characteristic
ü color changes in a hematoma.
ü Large accumulations of blood in one or
another of the body cavities are called hemothorax, hemopericardium,
hemoperitoneum, or hemarthrosis (in joints). Patients with extensive
hemorrhage occasionally develop jaundice from the massive breakdown of red
cells and systemic release of bilirubin.
The clinical significance of hemorrhage
depends on the volume and rate of bleeding. Rapid loss of up to 20% of the
blood volume or slow losses of even larger amounts may have little impact in
healthy adults; greater losses, however, may result in hemorrhagic
(hypovolemic) shock (discussed later). The site of hemorrhage is also
important; bleeding that would be trivial in the subcutaneous tissues may cause
death if located in the brain because the skull is unyielding and bleeding
there can result in increased intracranial pressure and herniation Finally,
loss of iron and subsequent iron-deficiency anemia become a consideration in
chronic or recurrent external blood loss (e.g., peptic ulcer or menstrual
bleeding). In contrast, when red cells are retained, as in hemorrhage into body
cavities or tissues, the iron can be reused for hemoglobin synthesis.
THROMBOSIS
Pathogenesis. Three
primary influences predispose to thrombus formation, the so-called Virchow
triad: (1) endothelial injury; (2) stasis or turbulence of blood flow; and
(3) blood hypercoagulability
Endothelial Injury. This is the dominant influence;
endothelial injury by itself can lead to thrombosis. It is particularly
important for thrombus formation occurring in the heart or in the arterial
circulation, where the normally high flow rates might otherwise hamper clotting
by preventing platelet adhesion or diluting coagulation factors. Thus, thrombus
formation within the cardiac chambers (e.g., following endocardial injury due
to myocardial infarction), over ulcerated plaques in atherosclerotic arteries,
or at sites of traumatic or inflammatory vascular injury (vasculitis) is
largely due to endothelial injury. Clearly, physical loss of endothelium will
lead to exposure of subendothelial ECM, adhesion of platelets, release of
tissue factor, and local depletion of PGI2 and PAs. However, it is
important to note that endothelium need not be denuded or physically disrupted
to contribute to the development of thrombosis; any perturbation in the dynamic
balance of the pro- and antithrombotic effects of endothelium can influence
local clotting Thus, dysfunctional endothelium may elaborate greater
amounts of procoagulant factors (e.g., platelet adhesion molecules, tissue
factor, PAI) or may synthesize less anticoagulant effectors (e.g.,
thrombomodulin, PGI2, t-PA). Significant endothelial dysfunction (in
the absence of endothelial cell loss) may occur due to the hemodynamic stresses
of hypertension, turbulent flow over scarred valves, or bacterial endotoxins.
Even relatively subtle influences, such as homocystinuria,
hypercholesterolemia, radiation, or products absorbed from cigarette smoke may
initiate endothelial injury.
Alterations in Normal Blood Flow. Turbulence contributes to arterial
and cardiac thrombosis by causing endothelial injury or dysfunction as well as
by forming countercurrents and local pockets of stasis; stasis is a
major factor in the development of venous thrombi.Normal blood flow is laminar such
that the platelets flow centrally in the vessel lumen, separated from the
endothelium by a slower-moving clear zone of plasma. Stasis and turbulence
therefore (1) disrupt laminar flow and bring platelets into contact with the
endothelium; (2) prevent dilution of activated clotting factors by fresh
flowing blood; (3) retard the inflow of clotting factor inhibitors and permit
the build-up of thrombi; and (4) promote endothelial cell activation,
predisposing to local thrombosis, leukocyte adhesion, and a variety of other
endothelial cell effects
Turbulence and stasis clearly contribute
to thrombosis in a number of clinical settings. Ulcerated atherosclerotic
plaques not only expose subendothelial ECM, but are also sources of turbulence.
Abnormal aortic and arterial dilations called aneurysms cause local
stasis and are favored sites of thrombosis Myocardial infarctions not only have
associated endothelial injury, but also have regions of noncontractile
myocardium, adding an element of stasis in the formation of mural thrombi.
Mitral valve stenosis (e.g., after rheumatic heart disease) results in left
atrial dilation. In conjunction with atrial fibrillation, a dilated atrium is a
site of profound stasis and a prime location for thrombus development. Hyperviscosity
syndromes (such as polycythemia; cause small vessel stasis; the deformed
red cells in sickle cell anemia cause vascular occlusions, with the
resulting stasis predisposing to thrombosis.
Hypercoagulability. Hypercoagulability contributes less
frequently to thrombotic states but is nevertheless an important component in
the equation. It is loosely defined as any alteration of the coagulation
pathways that predisposes to thrombosis. The causes of hypercoagulability may
be primary (genetic) and secondary (acquired) disorders
Morphology.
Thrombi may develop anywhere in the cardiovascular system: within the cardiac
chambers; on valve cusps; or in arteries, veins, or capillaries. They are of
variable size and shape, depending on the site of origin and the circumstances
leading to their development. Arterial or cardiac thrombi usually begin at a
site of endothelial injury (e.g., atherosclerotic plaque) or turbulence (vessel
bifurcation); venous thrombi characteristically occur in sites of stasis. An
area of attachment to the underlying vessel or heart wall, frequently firmest
at the point of origin, is characteristic of all thromboses. Arterial thrombi
tend to grow in a retrograde direction from the point of attachment, whereas
venous thrombi extend in the direction of blood flow (i.e., toward the heart).
The propagating tail may not be well attached and, particularly in veins, is
prone to fragmentation, creating an embolus
When
formed in the heart or aorta, thrombi may have grossly (and microscopically)
apparent laminations, called lines of Zahn; these are produced by alternating
pale layers of platelets admixed with some fibrin and darker layers containing
more red cells. Lines of Zahn are significant only in that they imply
thrombosis at a site of blood flow; in veins or in smaller arteries, the
laminations are typically not as apparent, and, in fact, thrombi formed in the
sluggish flow of venous blood usually resemble statically coagulated blood
(similar to blood clotted in a test tube). Nevertheless, careful evaluation
generally reveals irregular, somewhat ill-defined laminations
These are "lines of Zahn" which are the
alternating pale pink bands of platelets with fibrin and red bands of RBC's
forming a true thrombus.
When arterial thrombi arise in heart
chambers or in the aortic lumen, they usually adhere to the wall of the
underlying structure and are termed mural thrombi. Abnormal myocardial
contraction (arrhythmias, dilated cardiomyopathy, or myocardial infarction) leads
to cardiac mural thrombi , while ulcerated atherosclerotic plaque and aneurysmal dilation are the
precursors of aortic thrombus formation
Arterial thrombi are usually occlusive; the most common sites,
in descending order, are coronary, cerebral, and femoral arteries. The thrombus
is usually superimposed on an atherosclerotic plaque, although other forms of
vascular injury (vasculitis, trauma) may be involved. The thrombi are typically
firmly adherent to the injured arterial wall and are gray-white and friable,
composed of a tangled mesh of platelets, fibrin, erythrocytes, and degenerating
leukocytes.
Here is the anterior surface of the heart
with the left anterior descending coronary artery opened longitudinally. This
is coronary thrombosis, one of the complications of atherosclerosis. The
occlusive dark red thrombus is seen within the lumen of the coronary artery.
This produces an acute coronary syndrome.
Here is a closer view of the gross
appearnace of a coronary thrombosis. The thrombus occludes the lumen and
produces ischemia and/or infarction of the myocardium. Atherosclerosis is an
ongoing process that takes years to decades for clinically apparent problems to
appear.
A coronary thrombosis is seen microscopically
occluding the remaining small lumen of this coronary artery. Such an acute
coronary thrombosis is often the antecedent to acute myocardial infarction.
Venous
thrombosis, or phlebothrombosis, is almost invariably occlusive;
the thrombus often creates a long cast of the vein lumen. Because these thrombi
form in a relatively static environment, they tend to contain more enmeshed
erythrocytes and are therefore known as red, or stasis, thrombi.
Phlebothrombosis most commonly affects the veins of the lower extremities (90%
of cases). Less commonly, venous thrombi may develop in the upper extremities,
periprostatic plexus, or the ovarian and periuterine veins; under special
circumstances, they may be found in the dural sinuses, the portal vein, or the
hepatic vein. At autopsy, postmortem clots may be confused for venous thrombi.
Postmortem clots are gelatinous with a dark red dependent portion where red
cells have settled by gravity and a yellow chicken fat supernatant resembling
melted and clotted chicken fat; they are usually not attached to the underlying
wall. In contrast, red thrombi are firmer, almost always have a point of
attachment, and on transection reveal vague strands of pale gray fibrin
Under special circumstances, thrombi may form on heart valves. Bacterial or
fungal blood-borne infections may establish a foothold, leading to valve damage
and the development of large thrombotic masses, or vegetations (infective
endocarditis; Sterile vegetations can also develop on noninfected valves in
patients with hypercoagulable states, so-called nonbacterial thrombotic
endocarditis Less commonly, noninfective, verrucous (Libman-Sacks)
endocarditis attributable to elevated levels of circulating immune
complexes may occur in patients with systemic lupus erythematosus.
Fate
of the Thrombus. If
a patient survives the immediate effects of a thrombotic vascular obstruction,
thrombi undergo some combination of the following four events in the ensuing
days to weeks
(organization) and
may eventually become recanalized; that is, may reestablish vascular
flow, or may be incorporated into a thickened vascular wall.
Propagation and embolization are discussed further below. As for dissolution,
activation of the fibrinolytic pathways can lead to rapid shrinkage and even
total lysis of recent thrombi. With older thrombi, extensive fibrin
polymerization renders the thrombus substantially more resistant to
proteolysis, and lysis is ineffectual. This is important because therapeutic
infusions of fibrinolytic agents such as t-PA (e.g., for pulmonary
thromboemboli or coronary thrombosis) are likely to be effective for only a
short time after thrombi form
Older thrombi tend to become organized. This refers to the ingrowth
of endothelial cells, smooth muscle cells, and fibroblasts into the fibrin-rich
thrombus. In time, capillary channels are formed, which may anastomose to
create conduits from one end of the thrombus to the other, re-establishing, to
a limited extent, the continuity of the original lumen. Although the channels
may not successfully restore significant flow to many obstructed vessels, such recanalization
can potentially convert the thrombus into a vascularized mass of connective
tissue). With time and contraction of the mesenchymal cells (and particularly
for smaller thrombi), the connective tissue may be incorporated as a
subendothelial swelling of the vessel wall; eventually, only a fibrous lump may
remain to mark the original thrombus site. Occasionally, instead of organizing,
the center of a thrombus undergoes enzymatic digestion, presumably as a result
of the release of lysosomal enzymes from trapped leukocytes and platelets. This
is particularly likely in large thrombi within aneurysmal dilations or the
cardiac chambers. If bacterial seeding occurs, such a degraded thrombus is an
ideal culture medium, resulting, for example, in a so-called mycotic
aneurysm
Venous
Thrombosis (Phlebothrombosis). The great preponderance
of venous thrombi occur in either the superficial or the deep veins of the leg.
Superficial venous thrombi usually occur in the saphenous system, particularly
when there are varicosities. Such thrombi may cause local congestion, and
swelling, pain, and tenderness along the course of the involved vein but rarely
embolize. Nevertheless, the local edema and impaired venous drainage do
predispose the involved overlying skin to infections from slight trauma and to
the development of varicose ulcers. Deep thrombi in the larger leg
veins at or above the knee (e.g., popliteal, femoral, and iliac veins) are
more serious because they may embolize. Although they may cause local pain and
distal edema, the venous obstruction may be rapidly offset by collateral bypass
channels. Consequently, deep vein thromboses are entirely asymptomatic in
approximately 50% of affected patients and are recognized only in retrospect
after they have embolized
Deep
venous thrombosis may occur with stasis and in a variety of hypercoagulable
states as described earlier Cardiac failure is an obvious reason for stasis in
the venous circulation. Trauma, surgery, and burns usually result in reduced
physical activity, injury to vessels, release of procoagulant substances from
tissues, and/or reduced t-PA activity. Many factors act in concert to
predispose to thrombosis in the puerperal and postpartum states. Besides the
potential for amniotic fluid infusion into the circulation at the time of
delivery, late pregnancy and the postpartum period are also associated with
hypercoagulability. Tumor-associated procoagulant release is largely
responsible for the increased risk of thromboembolic phenomena seen in
disseminated cancers, so-called migratory thrombophlebitis or Trousseau
syndrome. Regardless of the specific clinical setting, advanced age, bed
rest, and immobilization increase the risk of deep venous thrombosis,
particularly in those who have inherited susceptibility reduced physical
activity diminishes the milking action of muscles in the lower leg and so slows
venous return
Arterial and Cardiac Thrombosis. Atherosclerosis is a major
initiator of thromboses, related to the associated abnormal vascular flow and
loss of endothelial integrity Cardiac mural thrombi can arise in the setting of
myocardial infarction related to dyskinetic contraction of the myocardium as
well as damage to the adjacent endocardium Rheumatic heart disease may
result in atrial mural thrombi due to mitral valve stenosis, followed by left
atrial dilation; concurrent atrial fibrillation augments atrial blood stasis.
In addition to the local obstructive consequences, cardiac and arterial (in
particular, aortic) mural thrombi can also embolize peripherally. Virtually any
tissue may be affected, but the brain, kidneys, and spleen are prime targets
because of their large flow volume.
While we clearly understand a number of
conditions that predispose to thrombosis, the phenomenon remains somewhat unpredictable.
It continues to occur at a distressingly high frequency in healthy, ambulatory
individuals without apparent provocation or underlying patholog
DISSEMINATED INTRAVASCULAR COAGULATION
(DIC)
DIC is an acute, subacute,
or chronic thrombohemorrhagic disorder occurring as a secondary complication in
a variety of diseases. It is characterized by activation of the coagulation
sequence that leads to the formation of microthrombi throughout the
microcirculation of the body, often in a quixotically uneven distribution.
Sometimes the coagulopathy is localized to a specific organ or tissue. As a
consequence of the thrombotic diathesis, there is consumption of platelets,
fibrin, and coagulation factors and, secondarily, activation of fibrinolytic
mechanisms. Thus, DIC can present with signs and symptoms relating to
tissue hypoxia and infarction caused by the myriad microthrombi or as a
hemorrhagic disorder related to depletion of the elements required for
hemostasis (hence, the term "consumption coagulopathy" is sometimes
used to describe DIC). Activation of the fibrinolytic mechanism aggravates the
hemorrhagic diathesis
Etiology and Pathogenesis. At the outset, it must be emphasized that
DIC is not a primary disease. It is a coagulopathy that occurs in the course of
a variety of clinical conditions. In discussing the general mechanisms
underlying DIC, it is useful to briefly review the normal process of blood
coagulation and clot removal. Clotting can be initiated by either of two
pathways: (1) the extrinsic pathway, which is triggered by the release
of tissue factor ("tissue thromboplastin"), and (2) the intrinsic
pathway, which involves the activation of factor XII by surface contact
with collagen or other negatively charged substances. Both pathways, through a
series of intermediate steps, result in the generation of thrombin, which in
turn converts fibrinogen to fibrin. Once activated at the site of injury,
thrombin further augments local fibrin deposition through feedback activation
of the intrinsic pathway and inhibition of fibrinolysis. Remarkably, as excess
thrombin is swept away in the blood from sites of tissue injury it is converted
to an anticoagulant. Upon binding a surface protein called thrombomodulin
on intact endothelial cells, thrombin becomes capable of
activating protein C, an inhibitor of the
pro-coagulant factors V and VIII. Other important clot-inhibiting factors
include the activation of fibrinolysis by plasmin and the clearance of
activated clotting factors by the mononuclear phagocyte system and the liver.
These and additional checks and balances normally ensure that just enough
clotting occurs at the right place and time.From this brief review, it should be clear
that DIC could result from pathologic activation of the extrinsic and/or
intrinsic pathways of coagulation or impairment of clot-inhibiting influences.
Since the latter rarely constitute primary mechanisms of DIC, we focus our
attention on the abnormal initiation of clotting
Acute intravascular hemolysis, snakebite, giant hemangioma, shock, heat
stroke, vasculitis, aortic aneurysm, liver disease
Two
major mechanisms trigger DIC: (1) release of tissue factor or thromboplastic
substances into the circulation and (2) widespread injury to the endothelial
cells. Tissue
thromboplastic substances can be derived from a variety of sources, such as the
placenta in obstetric complications and the granules of leukemic cells in acute
promyelocytic leukemia. Mucus released from certain adenocarcinomas can also
act as a thromboplastic substance by directly activating factor X, independent
of factor VII. In gram-negative sepsis (an important cause of DIC), bacterial
endotoxins cause activated monocytes to release interleukin-1 and TNF, both of
which increase the expression of tissue factor on endothelial cell membranes
and simultaneously decrease the expression of
thrombomodulin.72 The
net result is a shift in balance toward procoagulation
Endothelial injury, the other major trigger, can initiate DIC
by causing release of tissue factor, promoting platelet aggregation, and
activating the intrinsic coagulation pathway. TNF is an extremely important
mediator of endothelial cell inflammation and injury in septic shock. In
addition to the effects previously mentioned, TNF up-regulates the expression
of adhesion molecules on endothelial cells and thus favors adhesion of
leukocytes, which in turn damage endothelial cells by releasing oxygen-derived
free radicals and preformed proteases. Even subtle endothelial injury can
unleash procoagulant activity by enhancing membrane expression of tissue
factor. Widespread endothelial injury may be produced by deposition of
antigen-antibody complexes (e.g., systemic lupus erythematosus), temperature
extremes (e.g., heat stroke, burns), or microorganisms (e.g., meningococci,
rickettsiae).
. The initiating factors in these
conditions are often multiple and interrelated. For example, particularly in
infections caused by gram-negative bacteria, released endotoxins can activate
both the intrinsic and extrinsic pathways by producing endothelial cell injury
and release of thromboplastins from inflammatory cells; furthermore, endotoxins
inhibit the anticoagulant activity of protein C by suppressing thrombomodulin
expression on endothelium. Endothelial cell damage can also be produced
directly by meningococci, rickettsiae, and viruses. Antigen-antibody complexes
formed during the infection can activate the classical complement pathway, and
complement fragments can secondarily activate both platelets and granulocytes.
Endotoxins as well as other bacterial products are also capable of directly
activating factor XII. In massive trauma, extensive surgery, and severe
burns, the major mechanism of DIC is believed to be the release of tissue
thromboplastins. In obstetric conditions, thromboplastins derived from
the placenta, dead retained fetus, or amniotic fluid may enter the circulation.
However, hypoxia, acidosis, and shock, which often coexist with the surgical
and obstetric conditions, also cause widespread endothelial injury. Supervening
infection can complicate the problems further. Among cancers, acute
promyelocytic leukemia and carcinomas of the lung, pancreas, colon, and stomach
are most frequently associated with DIC. These tumors release of a variety of
thromboplastic substances, including tissue factors, proteolytic enzymes,
mucin, and other undefined tumor products
The consequences of DIC are twofold.
First, there is widespread deposition of fibrin within the
microcirculation. This can lead to ischemia of the more severely affected or
more vulnerable organs and to a hemolytic anemia resulting from
fragmentation of red cells as they squeeze through the narrowed
microvasculature (microangiopathic hemolytic anemia). Second, a hemorrhagic
diathesis can dominate the clinical picture. This results from consumption
of platelets and clotting factors as well as activation of plasminogen. Plasmin
can not only cleave fibrin, but also digest factors V and VIII, thereby
reducing their concentration further. In addition, fibrinolysis leads to the
formation of fibrin degradation products, which inhibit platelet aggregation
and fibrin polymerization and have antithrombin activity. All these influences
lead to the hemostatic failure seen in DIC
Morphology. In general, thrombi are found in the
following sites in decreasing order of frequency: brain, heart, lungs, kidneys,
adrenals, spleen, and liver. However, no tissue is spared, and thrombi are
occasionally found in only one or several organs without affecting others. In giant
hemangiomas, for example, thrombi are localized to the neoplasm, where they are
believed to form due to local stasis and recurrent trauma to fragile blood
vessels. The affected kidneys can reveal small thrombi in the glomeruli that
may evoke only reactive swelling of endothelial cells or, in severe cases,
microinfarcts or even bilateral renal cortical necrosis. Numerous fibrin
thrombi may be found in alveolar capillaries, sometimes associated with
pulmonary edema and fibrin exudation, creating "hyaline membranes"
reminiscent of acute respiratory distress syndrome . In the central nervous
system, fibrin thrombi can cause microinfarcts, occasionally complicated by
simultaneous hemorrhage. Such changes are the basis for the bizarre neurologic
signs and symptoms sometimes observed in DIC. The manifestations of DIC in the
endocrine glands are of considerable interest. In meningococcemia, fibrin
thrombi within the microcirculation of the adrenal cortex are the likely basis
for the massive adrenal hemorrhages seen in Waterhouse-Friderichsen syndrome
Similarly, Sheehan postpartum pituitary necrosis is a form of DIC complicating
labor and delivery. In toxemia of pregnancy the placenta exhibits widespread
microthrombi, providing a plausible explanation for the premature atrophy of
the cytotrophoblast and syncytiotrophoblast encountered in this condition
The
bleeding manifestations of DIC are not dissimilar to those encountered in the
hereditary and acquired disorders affecting the hemostatic mechanisms discussed
earlier
Embolism
An
embolus is a detached intravascular solid, liquid, or gaseous mass that is
carried by the blood to a site distant from its point of origin. Almost all emboli represent some part of
a dislodged thrombus, hence the commonly used term thromboembolism. Rare
forms of emboli include droplets of fat, bubbles of air or nitrogen,
atherosclerotic debris (cholesterol emboli), tumor fragments, bits of
bone marrow, or even foreign bodies such as bullets. However, unless otherwise
specified, an embolism should be considered to be thrombotic in origin.
Inevitably, emboli lodge in vessels too small to permit further passage,
resulting in partial or complete vascular occlusion. The potential consequence
of such thromboembolic events is the ischemic necrosis of distal tissue, known
as infarction. Depending on the site of origin, emboli may lodge
anywhere in the vascular tree; the clinical outcomes are best understood from
the standpoint of whether emboli lodge in the pulmonary or systemic
circulations.
The capillary loops of this glomerulus
contain fat globules in a patient with fat embolism syndrome
PULMONARY THROMBOEMBOLISM
Pulmonary
embolism has an incidence of 20 to 25 per 100,000 hospitalized patients. Although the rate of fatal pulmonary emboli
(as assessed at autopsy) has declined from 6% to 2% over the last quarter
century, pulmonary embolism still causes about 200,000 deaths per year in the
United States. In more than 95% of instances, venous emboli originate from deep
leg vein thrombi above the level of the knee as described previously. They are
carried through progressively larger channels and usually pass through the
right side of the heart into the pulmonary vasculature. Depending on the size
of the embolus, it may occlude the main pulmonary artery, impact across the
bifurcation (saddle embolus), or pass out into the smaller, branching
arterioles Frequently, there are multiple emboli, perhaps sequentially or as a
shower of smaller emboli from a single large mass; in general, the patient
who has had one pulmonary embolus is at high risk of having more. Rarely,
an embolus may pass through an interatrial or interventricular defect to gain
access to the systemic circulation (paradoxical embolism).
Multiple
emboli over time may cause pulmonary hypertension with right heart failure
The
main pulmonary trunk and pulmonary arteries to the right and to the left lung
are seen here opened to reveal a large "saddle" pulmonary
thromboembolus. Patients with such an embolus will have a high mortality rate.
Here is another large pulmonary
thromboembolus seen in cross section of this lung. The typical source for such
thromboemboli is from large veins in the legs and pelvis.
Pulmonary emboli can be classified by size as
small, medium, and large. Small ones may be clinically inapparent. Medium-sized
ones may not kill the patient, but may lead to pulmonary infarction. Large ones
can be life-threatening. Recurrent pulmonary embolization can reduce pulmonary
vascular flow and cause pulmonary hypertension.
This is the microscopic appearance of a pulmonary embolus
(PE) in a major pulmonary artery branch. The layering of the RBC's and the
lighter pink fibrin enmeshing leukocytes and platelets occurred in the vein in
which the thrombus originally formed.
This
pulmonary embolus is adherent to the pulmonary arterial wall. If the patient
survives, the thromboembolus will organize and, for the most part, be removed.
SYSTEMIC THROMBOEMBOLISM
Systemic thromboembolism refers to emboli
traveling within the arterial circulation. Most (80%) arise from intracardiac
mural thrombi, two thirds of which are associated with left ventricular wall
infarcts and another quarter with dilated and fibrillating left atria (e.g.,
secondary to mitral valve disease;. The remainder originate from aortic
aneurysms, thrombi on ulcerated atherosclerotic plaques, or fragmentation of a
valvular vegetation with a small fraction due to paradoxical emboli; 10%
to 15% of systemic emboli are of unknown origin. In contrast to venous emboli,
which tend to lodge primarily in one vascular bed (the lung), arterial emboli
can travel to a wide variety of sites; the point of arrest depends on the
source of the thromboembolus and the volume of blood flow through the
downstream tissues. The major sites for arteriolar embolization are the lower
extremities (75%) and the brain (10%), with the intestines, kidneys, spleen,
and upper extremities involved to a lesser extent. The consequences of systemic
emboli depend on the extent of collateral vascular supply in the affected
tissue, the tissue's vulnerability to ischemia, and the caliber of the vessel
occluded; in general, arterial emboli cause infarction of tissues downstream of
the obstructed vessel
FAT EMBOLISM
Microscopic fat globules may be found in
the circulation after fractures of long bones (which have fatty marrow) or,
rarely, in the setting of soft tissue trauma and burns. Presumably the fat is
released by marrow or adipose tissue injury and enters the circulation by
rupture of the marrow vascular sinusoids or of venules. Although traumatic fat
embolism occurs in some 90% of individuals with severe skeletal injuries less
than 10% of such patients have any clinical findings. Fat embolism syndrome
is characterized by pulmonary insufficiency, neurologic symptoms, anemia,
and thrombocytopenia. Symptoms typically begin 1 to 3 days after injury,
with sudden onset of tachypnea, dyspnea, and tachycardia. Neurologic symptoms
include irritability and restlessness, with progression to delirium or coma.
Patients may present with thrombocytopenia, presumably caused by platelets
adhering to the myriad fat globules and being removed from the circulation;
anemia may result as a consequence of erythrocyte aggregation and hemolysis. A
diffuse petechial rash in nondependent areas (related to rapid onset of
thrombocytopenia) is seen in 20% to 50% of cases and is useful in establishing
a diagnosis. In its full-blown form, the syndrome is fatal in up to 10% of
cases
The rounded clear holes seen in the small
pulmonary arterial branch in this section of lung are characteristic for fat
embolism. Fat embolism syndrome is most often a consequence of trauma with long
bone fractures. It can also be seen with extensive soft tissue trauma, burn
injuries, severe fatty liver, and very rarely with orthopedic procedures.
An Oil Red O stain demostrates the fat
globules within the pulmonary arterioles. The globules stain reddish-orange.
The cumulative effect of many of these gobules throughout the lungs is similar
to a large pulmonary embolus, but the onset of dyspnea is usually 2 to 3 days
following the initiating event, such as blunt trauma with bone fractures.
The pathogenesis of fat emboli syndrome
probably involves both mechanical obstruction and biochemical injury.
Microemboli of neutral fat cause occlusion of the pulmonary and cerebral
microvasculature, aggravated by local platelet and erythrocyte aggregation;
this is further exacerbated by release of free fatty acids from the fat
globules, causing local toxic injury to endothelium. Platelet activation and
recruitment of granulocytes (with free radical, protease, and eicosanoid
release; complete the vascular assault. Because lipids are dissolved out of
tissue preparations by the solvents routinely used in paraffin embedding, the
microscopic demonstration of fat microglobules (i.e., in the absence of
accompanying marrow) typically requires specialized techniques, including
frozen sections and fat stains
From several days to a week following the
event initiating fat embolism syndrome, there may be loss of consciousness from
lesions evidenced by the "brain purpura" as shown here. Numerous
petechial hemorrhages are produced by fat emboli to the brain, particularly in
the white matter. Subsequent to this there can be brain edema with herniation.
With cerebral
fat embolism syndrome, there is loss of consciousness. Note the multitude of petechial
hemorrhages here, most in white matter. Cerebral edema and herniation may
follow. Overall, few persons with a history of trauma will develop fat
embolism, but it is difficult to predict which patients will.
AIR EMBOLISM
Gas bubbles within the circulation can
obstruct vascular flow (and cause distal ischemic injury) almost as readily as
thrombotic masses can. Air may enter the circulation during obstetric
procedures or as a consequence of chest wall injury. Generally, in excess of
100 cc is required to have a clinical effect; the bubbles act like physical
obstructions and may coalesce to form frothy masses sufficiently large to
occlude major vessels
A
particular form of gas embolism, called decompression sickness, occurs
when individuals are exposed to sudden changes in atmospheric pressure. Scuba
and deep sea divers, underwater construction workers, and individuals in
unpressurized aircraft in rapid ascent are all at risk. When air is breathed at
high pressure (e.g., during a deep sea dive), increased amounts of gas
(particularly nitrogen) become dissolved in the blood and tissues. If the diver
then ascends (depressurizes) too rapidly, the nitrogen expands in the tissues
and bubbles out of solution in the blood to form gas emboli
The
rapid formation of gas bubbles within skeletal muscles and supporting tissues
in and about joints is responsible for the painful condition called the
bends (so named in the 1880s because afflicted individuals characteristically
arched their backs in a manner reminiscent of a then popular women's fashion
called the Grecian Bend). Gas emboli may also induce focal ischemia in a
number of tissues, including brain and heart. In the lungs, edema, hemorrhages,
and focal atelectasis or emphysema may appear, leading to respiratory distress,
the so-called chokes. Treatment of gas embolism requires placing the
individual in a compression chamber where the barometric pressure may be
raised, thus forcing the gas bubbles back into solution. Subsequent slow
decompression theoretically permits gradual resorption and exhalation of the
gases so that obstructive bubbles do not re-form
A
more chronic form of decompression sickness is called caisson disease
(named for the pressurized vessels used in the construction of the base of the
Brooklyn Bridge in New York; workers digging in these vessels suffered both
acute and chronic forms of decompression sickness). In caisson disease,
persistence of gas emboli in the skeletal system leads to multiple foci of
ischemic necrosis; the more common sites are the heads of the femurs, tibia,
and humeri
AMNIOTIC
FLUID EMBOLISM
Amniotic
fluid embolism is a grave but fortunately uncommon complication of labor and
the immediate postpartum period (1 in 50,000 deliveries). It has a mortality
rate of 20% to 40%, and as other obstetric complications (e.g., eclampsia,
pulmonary embolism) have been better managed, amniotic fluid embolism has
become an important cause of maternal mortality. The onset is characterized by
sudden severe dyspnea, cyanosis, and hypotensive shock, followed by seizures
and coma. If the patient survives the initial crisis, pulmonary edema typically
develops, along with (in half the patients) DIC, owing to release of
thrombogenic substances from amniotic fluid.
The
underlying cause is the infusion of amniotic fluid or fetal tissue into the
maternal circulation via a tear in the placental membranes or rupture of
uterine veins. The classic findings are therefore the presence in the pulmonary
microcirculation of squamous cells shed from fetal skin, lanugo hair, fat from
vernix caseosa, and mucin derived from the fetal respiratory or
gastrointestinal tract. There is also marked pulmonary edema and changes of diffuse
alveolar damage as well as systemic fibrin thrombi indicative of DIC.
An
infarct is an area of ischemic necrosis caused by occlusion of either the
arterial supply or the venous drainage in a particular tissue. Infarction involving different organs is
a common and extremely important cause of clinical illness. In the United
States, more than half of all deaths are caused by cardiovascular disease, and
most of these are attributable to myocardial or cerebral infarction. Pulmonary
infarction is a common complication in a number of clinical settings, bowel
infarction is frequently fatal, and ischemic necrosis of the extremities
(gangrene) is a serious problem in the diabetic population
Nearly
99% of all infarcts result from thrombotic or embolic events, and almost all result
from arterial occlusion. Occasionally, infarction may also be caused by other
mechanisms, such as local vasospasm, expansion of an atheroma owing to
hemorrhage within a plaque, or extrinsic compression of a vessel (e.g., by
tumor). Other uncommon causes include twisting of the vessels (e.g., in
testicular torsion or bowel volvulus), compression of the blood supply by edema
or by entrapment in a hernia sac, or traumatic rupture of the blood supply.
Although venous thrombosis may cause infarction, it more often merely induces
venous obstruction and congestion. Usually, bypass channels rapidly open after
the thrombosis, providing some outflow from the area, which, in turn, improves
the arterial inflow. Infarcts caused by venous thrombosis are more likely in
organs with a single venous outflow channel, such as the testis and ovary
Morphology. Infarcts are classified on the basis of
their color (reflecting the amount of
hemorrhage)
and the presence or absence of microbial infection. Therefore, infarcts may be
either red (hemorrhagic) or white (anemic) and may be either septic
or bland.
White (anemic) infarcts occur with arterial occlusions in solid
organs with end-arterial circulation (such as heart, spleen, and kidney), where
the solidity of the tissue limits the amount of hemorrhage that can seep into
the area of ischemic necrosis from adjoining capillary beds
Most
infarcts tend to be wedge-shaped, with the occluded vessel at the apex and the
periphery of the organ forming the base when the base is a serosal surface,
there is often an overlying fibrinous exudate. The lateral margins may be
irregular, reflecting the pattern of vascular supply from adjacent vessels. At
the outset, all infarcts are poorly defined and slightly hemorrhagic. The
margins of both types of infarcts tend to become better defined with time by a
narrow rim of hyperemia attributable to inflammation at the edge of the lesion
In
solid organs, the extravasated red cells from the limited hemorrhage are lysed.
The released hemoglobin remains in the tissue in the form of hemosiderin within
macrophages; this can microscopically identify sites of previous infarction but
does not grossly impart any significant color to the tissue. White infarcts
resulting from arterial occlusions typically become progressively more pale and
sharply defined with time By comparison, in spongy organs the hemorrhage is too
extensive to permit thelesion ever to become pale Over the course of a few
days, it does, however, become more firm and brown, as the extensive bleeding
progressively degrades into hemosiderin pigmentThe dominant histologic
characteristic of infarction is ischemic coagulative necrosis It is
important to recall that if the vascular occlusion has occurred shortly
(minutes to hours) before the death of the patient, no demonstrable histologic
changes may be evident; if the patient survives even 12 to 18 hours, the only
change present may be hemorrhage
An
inflammatory response begins to develop along the margins of infarcts within a
few hours and is usually well defined within 1 or 2 days. Inflammation at these
sites is incited by the necrotic material; given sufficient time, there is
gradual degradation of the dead tissue with phagocytosis of the cellular debris
by neutrophils and macrophages. Eventually the inflammatory response is
followed by a reparative response beginning in the preserved margins In stable
or labile tissues, some parenchymal
Infarction
of the brain can result from thrombosis, though most cases occur following
embolization, involving cerebral arteries, often the circle of Willis. Cerebral
infarction typically results in liquefactive necrosis, as shown here with
beginning cystic resolution of the infarct.
An
inflammatory response begins to develop along the margins of infarcts within a
few hours and is usually well defined within 1 or 2 days. Inflammation at these
sites is incited by the necrotic material; given sufficient time, there is
gradual degradation of the dead tissue with phagocytosis of the cellular debris
by neutrophils and macrophages. Eventually the inflammatory response is
followed by a reparative response beginning in the preserved margins In stable
or labile tissues, some parenchymal regeneration may occur at the periphery
where the underlying stromal architecture has been spared. However, most
infarcts are ultimately replaced by scar tissue .The brain is an exception to these
generalizations; as with all other causes of cell death, ischemic injury in the
central nervous system results in liquefactive necrosis.
Infarction
of many internal organs leads to a "pale" infarct from loss of hte
blood supply, resulting in coagulative necrosis. Shown here is a myocardial
infarction from occlusion of a major coronary artery, here the left anterior
descending artery.
Infarction of many internal organs leads to a
"pale" infarct with a wedge-shaped gross appearance (conical in 3
dimensions) from occlusion of a branching blood supply. Here are splenic
infarcts in a patient with infective endocarditis. Portions of the vegetations
have embolized to the spleen. These infarcts are typical of ischemic infarcts:
they are based on the capsule, pale, and wedge-shaped. The remaining splenic
parenchyma appears dark red.
Here are petechial hemorrhages seen on
the epicardium of the heart. Petechiae (pinpoint hemorrhages) represent
bleeding from small vessels and are classically found when a coagulopathy is
due to a low platelet count. They can also appear following sudden hypoxia
Septic infarctions may develop when
embolization occurs by fragmentation of a bacterial vegetation from a heart
valve or when microbes seed an area of necrotic tissue. In these cases, the
infarct is converted into an abscess, with a correspondingly greater
inflammatory response. The eventual sequence of organization, however, follows
the pattern already described
Shock
Shock,
or cardiovascular collapse, is the final common pathway for a number of
potentially lethal clinical events, including severe hemorrhage, extensive
trauma or burns, large myocardial infarction, massive pulmonary embolism, and
microbial sepsis. Regardless of the underlying pathology, shock gives rise
to systemic hypoperfusion caused by reduction either in cardiac output or in
the effective circulating blood volume. The end results are hypotension,
followed by impaired tissue perfusion and cellular hypoxia. Although the
hypoxic and metabolic effects of
hypoperfusion initially cause only reversible
cellular injury, persistence of shock eventually causes
irreversible tissue injury and can culminate in
the death of the patient
Shock may be grouped into three general
categories The mechanisms underlying cardiogenic and hypovolemic shock are
fairly straightforward, essentially involving low cardiac output. Septic
shock, by comparison, is substantially more complicated and is discussed in
further detail below.
Septic shock is caused by
systemic microbial infection. Most commonly, this occurs in the setting of
gram-negative infections (endotoxic shock), but it can also occur with
gram-positive and fungal infections.
Less commonly, shock may occur in the setting
of anesthetic accident or spinal cord injury (neurogenic shock), owing
to loss of vascular tone and peripheral pooling of blood. Anaphylactic shock,
initiated by a generalized IgE-mediated hypersensitivity response, is
associated with systemic vasodilation and increased vascular permeability. In
these instances, widespread vasodilation causes a sudden increase in the
vascular bed capacitance, which is not adequately filled by the normal
circulating blood volume. Thus, hypotension, tissue hypoperfusion, and cellular
anoxia result.
PATHOGENESIS OF SEPTIC SHOCK
Three Major Types of Shock
Type of Shock |
Clinical Examples |
Principal Mechanisms |
Cardiogenic |
||
|
Myocardial infarction |
Failure of myocardial pump owing to
intrinsic myocardial damage, extrinsic pressure, or obstruction to outflow |
|
Ventricular rupture |
|
|
Arrhythmia |
|
|
Cardiac tamponade |
|
|
Pulmonary embolism |
|
Hypovolemic |
||
|
Hemorrhage |
Inadequate blood or plasma volume |
|
Fluid loss, e.g., vomiting, diarrhea,
burns, or trauma |
|
Septic |
||
|
Overwhelming microbial infections |
Peripheral vasodilation and pooling of
blood; endothelial activation/injury; leukocyte-induced damage; disseminated
intravascular coagulation; activation of cytokine cascades |
|
Endotoxic shock |
|
|
Gram-positive septicemia |
|
|
Fungal sepsis |
|
|
Superantigens |
|
Septic shock, with a 25% to 50% mortality
rate, ranks first among the causes of mortality in intensive care units and is
estimated to account for over 200,000 deaths annually in the United States.
Moreover, the reported incidence of sepsis syndromes has increased dramatically
in the past two decades, owing to improved life support for high-risk patients,
increasing use of invasive procedures, and growing numbers of immunocompromised
hosts (secondary to chemotherapy, immunosuppression, or human immunodeficiency
virus infection). Septic shock results from spread and expansion of an
initially localized infection (e.g., abscess, peritonitis, pneumonia) into the
bloodstream
Most cases of septic shock (approximately
70%) are caused by endotoxin-producing gram-negative bacilli, hence the term endotoxic
shock. Endotoxins are bacterial wall lipopolysaccharides (LPSs) that are
released when the cell walls are degraded (e.g., in an inflammatory response).
LPS consists of a toxic fatty acid (lipid A) core and a complex
polysaccharide coat (including O antigens) unique to each bacterial species.
Analogous molecules in the walls of gram-positive bacteria and fungi can also
elicit septic shock
All
of the cellular and resultant hemodynamic effects of septic shock may be
reproduced by injection of LPS alone. Free LPS attaches to a circulating
LPS-binding protein, and the complex then binds to a cell-surface receptor
(called CD14), followed by binding of the LPS to a signal-transducing protein
called mammalian Toll-like receptor protein 4 (TLR-4). (Toll is a Drosophila
protein involved in fly development; a variety of molecules with homology to
Toll [i.e., "Toll-like"] participate in innate immune responses to
different microbial components Signals from TLR-4 can then directly activate
vascular wall cells and leukocytes or initiate a cascade of cytokine mediators,
which propagates the pathologic state. Engagement of TLR-4 on endothelial cells
can lead directly to down-regulation of natural anticoagulation mechanisms,
including diminished synthesis of tissue factor pathway inhibitor (TFPI) and
thrombomodulin. Engagement of the receptor on monocytes and macrophages (even
at doses of LPS as minute as 10 picograms/ml) causes profound mononuclear cell
activation with the subsequent production of potent effector cytokines such as
IL-1 and TNF Presumably, this series of responses helps to isolate organisms
and to trigger elements of the innate immune system to efficiently eradicate
invading microbes. Unfortunately, depending on the dosage and numbers of
macrophages that are activated, the secondary effects of LPS release can also
cause severe pathologic changes, including fatal shock.
Activation
of the coagulation system, culminating in DIC
The
hypoperfusion resulting from the combined effects of widespread vasodilation,
myocardial pump failure, and DIC induces multiorgan system failure affecting
the liver, kidneys, and central nervous system, among others. Unless the
underlying infection (and LPS overload) is rapidly brought under control, the
patient usually dies. Of note, mice lacking LPS-binding protein, CD14, or the
mammalian TLR-4 are protected against the effects of LPS. Clinical efforts to
take advantage of these insights and induce pharmacologic blockade of the same
pathways (e.g., soluble CD14 or antibodies to LPS-binding protein) have yet to
bear fruit. Antibodies or antagonists to IL-1 or TNF (or their receptors), or
pharmacologic inhibitors of various other secondary mediators (e.g., nitric
oxide or prostaglandins) have some efficacy in animal models of septic shock,
but they have not shown significant clinical benefit in human disease. Indeed
such failure of "anti-inflammatory" therapy in human shock has caused
some investigators to challenge the model presented hereInstead, it has been
argued that in later stages, sepsis is associated with a state of
immunosuppression (rather than uncontrolled inflammation). These observations
may dictate different forms of therapy, but this remains to be tested.
An interesting group of bacterial proteins called superantigens also
cause syndromes similar to septic shock. These include toxic shock syndrome
toxin-1, produced by staphylococci and responsible for the toxic shock
syndrome. Superantigens are polyclonal T-lymphocyte activators that induce
systemic inflammatory cytokine cascades similar to those occurring downstream
in septic shock. Their actions can result in a variety of clinical
manifestations ranging from a diffuse
rash to vasodilation, hypotension, and death
Stages of Shock.
Shock is a progressive disorder that, if uncorrected, leads to death. Unless
the insult is massive and rapidly lethal (e.g., a massive hemorrhage from a
ruptured aortic aneurysm), shock tends to evolve through three general (albeit
somewhat artificial) phases. A brief discussion here can help to integrate the
sequential pathophysiologic and clinical events in the progression of shock.
These have been documented most clearly in hypovolemic shock but are common to
other forms as well:
An irreversible
stage that sets in after the body has incurred cellular and tissue injury
so severe that even if the hemodynamic defects are corrected, survival is not
possible
In
the early nonprogressive phase of shock, a variety of neurohumoral
mechanisms help maintain cardiac output and blood pressure. These include
baroreceptor reflexes, release of catecholamines, activation of the
renin-angiotensin axis, antidiuretic hormone release, and generalized
sympathetic stimulation. The net effect is tachycardia, peripheral
vasoconstriction, and renal conservation of fluid. Cutaneous
vasoconstriction, for example, is responsible for the characteristic coolness
and pallor of skin in well-developed shock (although septic shock may initially
cause cutaneous vasodilation and thus present with warm, flushed skin).
Coronary and cerebral vessels are less sensitive to this compensatory
sympathetic response and thus maintain relatively normal caliber, blood flow,
and oxygen delivery to their respective vital organs
If
the underlying causes are not corrected, shock passes imperceptibly to the
progressive phase, during which there is widespread tissue hypoxia. In the
setting of persistent oxygen deficit, intracellular aerobic respiration is
replaced by anaerobic glycolysis with excessive production of lactic acid. The
resultant metabolic lactic acidosis lowers the tissue pH and blunts the
vasomotor response; arterioles dilate, and blood begins to pool in the
microcirculation. Peripheral pooling not only worsens the cardiac output, but
also puts endothelial cells at risk for developing anoxic injury with
subsequent DIC. With widespread tissue hypoxia, vital organs are affected and
begin to fail; clinically the patient may become confused, and the urine
output declines
Unless
there is intervention, the process eventually enters an irreversible stage.
Widespread cell injury is reflected in lysosomal enzyme leakage, further
aggravating the shock state. Myocardial contractile function worsens in part
because of nitric oxide synthesis. If ischemic bowel allows intestinal flora to
enter the circulation, endotoxic shock may be superimposed. At this point, the
patient has complete renal shutdown owing to acute tubular necrosis and despite
heroic measures, the downward clinical spiral almost inevitably culminates in
death
Morphology. The cellular and tissue changes induced by
shock are essentially those of hypoxic injury since shock is characterized by failure
of multiple organ systems, the cellular changes may appear in any tissue.
Nevertheless, they are particularly evident in brain, heart, lungs, kidneys,
adrenals, and gastrointestinal tract subendocardial hemorrhage and/or contraction
band necrosis Although the cardiac changes are not diagnostic of shock
(they may also be seen in the setting of cardiac reperfusion after irreversible
injury, or after administration of catecholamines), they are usually much more
extensive in the setting of shock. The kidneys typically exhibit
extensive tubular ischemic injury (acute tubular necrosis; therefore
oliguria, anuria, and electrolyte disturbances constitute major clinical
problems. The lungs are seldom affected in pure hypovolemic shock
because they are resistant to hypoxic injury. When shock is caused by bacterial
sepsis or trauma, however, changes of diffuse alveolar damage (may appear, the
so-called shock lung. The adrenal changes in shock are those seen
in all forms of stress; essentially, there is cortical cell lipid depletion.
This does not reflect adrenal exhaustion but rather conversion of the
relatively inactive vacuolated cells to metabolically active cells that utilize
stored lipids for the synthesis of steroids. The gastrointestinal tract
may suffer patchy mucosal hemorrhages and necroses, referred to as hemorrhagic
enteropathy. The liver may develop fatty change and, with severe
perfusion deficits, central hemorrhagic necrosis
The brain may develop so-called ischemic encephalopathy, discussed in The heart may undergo focal or widespread coagulation necrosis or may exhibitWith the exception of neuronal and myocyte loss, virtually all of these tissue changes may revert to normal if the patient survives. Unfortunately, most patients with irreversible changes owing to severe shock succumb before the tissues can recover
The
prognosis varies with the origin of shock and its duration. Thus, 80% to 90% of
young, otherwise healthy patients with hypovolemic shock survive with
appropriate management, whereas cardiogenic shock associated with extensive
myocardial infarction and gram-negative shock carry mortality rates of up to
75%, even with the best care currently available.
Small fibrin thrombi from widespread activation of
the coagulation system with disseminated intravascular coagulopathy (DIC) can be
seen in capillary loops in this glomerulus, highlighted by a fibrin stain.
Laboratory findings with DIC include decreased platelets, diminished
fibrinogen, prolonged prothrombin time, elevated partial thromboplastin time,
and elevated D-dimer. Consumption of coagulation factors with generation of
fibrin split products, along with platelet consumption, leads to these
findings.