learning objectivespeople.upei.ca/smartinson/...and_congestion-17_sam.pdf · •know where...
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Learning Objectives
• Define congestion and hyperemia
• Differentiate between the two with regard to:
• Mechanisms / underlying causes
• Appearance (gross and histologic)
• Effects
• Differentiate between the 2 types of hyperemia
• Know where congestion occurs with right and left heart failure
• Be able to differentiate acute and chronic pulmonary congestion (gross and histology)
• Know the consequences of chronic pulmonary congestion
• Be able to recognize and describe hepatic congestion (acute vs chronic) and know under what condition it occurs
• What does the term shock mean and what are the 3 main categories?
HYPEREMIA AND CONGESTION
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Circulatory Disturbances 2: Hyperemia and Congestion
Shannon Martinson, January 2017
http://people.upei.ca/smartinson/ VPM 152 General Pathology
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Edema
Hyperemia and congestion
Shock
Hemorrhage
Thrombosis and embolism
Infarction
CIRCULATORY DISTURBANCES
Altered Blood flow
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Hyperemia and congestion indicate a local increase in blood within a tissue
• Active engorgement of vascular beds due to increased arteriolar flow Hyperemia
• Passive engorgement of vascular beds due to decreased outflow of blood Congestion
ALTERATIONS IN BLOOD FLOW & PERFUSION
Image - Robbins and Cotran PBD 8th Ed, 2010
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• Active process
• Increased blood entering tissue via arterial flow
• Oxygenated (red) Hyperemia
ALTERATIONS IN BLOOD FLOW & PERFUSION - HYPEREMIA
• Response to stimulus → Can be physiologic or pathologic Image - Robbins and Cotran PBD 8th Ed, 2010
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Physiologic Hyperemia
Digestion
Exercise
Dissipate heat
Neurovascular (blushing)
ALTERATIONS IN BLOOD FLOW & PERFUSION - HYPEREMIA
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• Due to an underlying pathologic process → INFLAMMATION
• Arteriolar dilation in response to inflammatory stimuli / mediators
• Often accompanied by edema!
ALTERATIONS IN BLOOD FLOW & PERFUSION - HYPEREMIA
Pathologic Hyperemia Chantal Albert AVC ‘2007
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Gross Findings • Red colouration of the tissue • Swelling, warmth (in the living…)
ALTERATIONS IN BLOOD FLOW & PERFUSION - HYPEREMIA
One of the cardinal signs of inflammation is reddening = “rubor”
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Histology Findings • Capillaries +/-
arterioles are dilated and filled with blood
• Often accompanied by edema
• May see inflammation!
ALTERATIONS IN BLOOD FLOW & PERFUSION - HYPEREMIA
Effect of hyperemia – hastens movement of metabolites into an area and flushes catabolites from the area
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• Passive process
• Decreased outflow of blood
• Deoxygenated blue (dark red - blue) Congestion
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
• Passive engorgement of vascular beds due to decreased/
obstructed venous return Image - Robbins and Cotran PBD 8th Ed, 2010
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Gross Appearance
• Dark red to blue / black depending on degree of stagnation of blood
• Tissues might be cooler than normal (living animal)
• Cut surfaces ooze blood and are often wet due to accompanying edema
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
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Chronic Congestion • Hypoxia (O2)
• Cellular atrophy
• Cellular degeneration / necrosis
Histopathology
Acute Congestion • Engorged capillaries
• +/- Edema
Effect of congestion • Leads to hypoxia and accumulation of catabolites
• Cellular degeneration / necrosis • Interference with normal tissue function • May get thrombosis of congested veins • +/- proliferation of connective tissue if chronic
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
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Two factors used to define types of congestion
1. Duration
• Acute (sudden)
• Chronic (longer-term)
2. Extent
• Localized – Change is confined to a discrete area
• Generalized – Indicates systemic change (eg heart failure)
Acute localized
congestion
Acute generalized congestion
Chronic generalized congestion
Chronic localized
congestion
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
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Intestinal torsion
Localized congestion
• Local obstruction to venous drainage
• Such as when and organ twists
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
Splenic torsion (with GDV)
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ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
Generalized congestion
• Can be acute:
• Sudden death due to heart
failure or euthanasia with
barbiturates
• Blood accumulates in lung,
spleen and liver
• More often chronic!
Generalized congestion occurs with pathology of the heart or lung • Left heart failure → pulmonary congestion • Right heart failure → systemic congestion • 1◦ Pulmonary disease → can cause RHF → systemic congestion
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• LEFT sided heart failure
• Congestion and edema of the lungs
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
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RIGHT sided heart failure
•Systemic congestion – Liver especially
•Generalized edema (dependent SQ edema, ascites)
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
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Primary pulmonary disease • Lung disease → damage of pulmonary vascular bed → increased resistance /pulmonary hypertension →
RIGHT heart failure
• Generalized edema (SQ, ascites) and hepatic congestion; +/- pleural effusion
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
• Right heart failure resulting from pulmonary disease Cor pulmonale
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Histology
•Pulmonary congestion
•Usually due to LEFT heart failure
•Lungs are red (congestion), wet (edema) and heavy
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
Gross
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ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
•Chronic pulmonary congestion
•When chronic →lungs may have brown – tan areas reflecting hemosiderin accumulation
PBVD, Zachary, 2017
Gross
Histology
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Consequences of Chronic Pulmonary Congestion
1. Intra-alveolar hemorrhages • “Heart failure cells”
2. Pulmonary Edema • Interferes with gas exchange
3. Interstitial Fibrosis
4. Pulmonary Hypertension • ↑ Pressure in pulmonary artery • +/- Cor pulmonale
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
Histology
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• Hepatic Congestion • Most often due to right heart failure • Less often secondary to pulmonary hypertension and cor pulmonale
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
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• Hepatic Congestion • Gross appearance:
• Liver is enlarged and dark brown with rounded edges
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
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• Hepatic Congestion • Gross appearance:
• Cut surface may have a reticular / zonal pattern (= nutmeg liver)
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
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ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
Hepatic Congestion
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Zone 1 - relatively normal Zone 2 - fatty change
(partial hypoxia)
Zone 3 - congested sinusoids, hepatocyte degeneration/necrosis
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
Hepatic Congestion Histopathology: Acute hepatic congestion
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ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
Zone 1 - relatively normal Zone 2 - fatty change
(partial hypoxia)
Zone 3 - congested sinusoids, hepatocyte degeneration/necrosis
Histopathology: Acute hepatic congestion
Hepatic Congestion
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In zone 3
• Hemosiderin within macrophages (kupffer cells)
• Hepatocyte loss &/or atrophy and dilated sinusoids
• Increased connective tissue around central veins
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
Hepatic Congestion Histopathology: Chronic hepatic congestion
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Congestion / Hyperemia – RBCs are within the blood vessels (*)
Hyperemia/Congestion vs Hemorrhage
*
*
Hemorrhage – RBCs are outside vessels ( )
ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION
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• Systemic hypotension due to reduced cardiac output or reduced blood volume Shock
• Results in impaired tissue perfusion • Brain and heart especially • Tissue hypoxia
• Final common pathway for: • Microbial sepsis • Severe hemorrhage • Trauma or burns • Myocardial damage • Severe pulmonary embolism
ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK
Cardiovascular collapse
3 Categories of Shock
1. Cardiogenic Shock
2. Hypovolemic Shock
3. Vasogenic Shock
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1. Cardiogenic shock
• Failure of the heart to adequately pump the blood
• Can result from: • Myocardial infarction • Arrhythmias • Cardiomyopathy • Valvular disease • Obstruction of blood
flow from the heart
ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK
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2. Hypovolemic shock • Decreased circulating blood volume • May result from
• Blood loss from hemorrhage (internally or externally)
• Fluid loss • Vomiting • Diarrhea • Burns
ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK
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3. Vasogenic shock
• Maldistribution of blood • Due to decreased peripheral
vascular resistance → pooling of blood in peripheral tissues
• Results from vasodilation
• Release of vasoactive amines
Anaphylactic shock
• Occurs with severe CNS damage
• Loss of ANS signals to arteriolar smooth muscle
Neurogenic shock
• Release of chemical mediators associated with inflammation
Septic shock*
ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK
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Microbial substances are released from bacteria (LPS)
Activation / endothelial cells and stimulation of WBCs to release cytokines
Vasodilation, coagulation activation (DIC), complement activation…
Pathogenesis
ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK
3. Vasogenic shock
• Release of chemical mediators associated with inflammation
Septic shock*
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Three stages of shock: 1 2 3
Compensated
• Reflex compensation
• ↑HR, peripheral vasoconstriction
• Perfusion of vital organs
Progressive
• Tissue hypoperfusion
• Worsening circulatory and metabolic imbalances
Irreversible
• Severe cell/tissue injury
• Survival is not possible
ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK
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LESIONS OF SHOCK
Pulmonary congestion & edema
Hepatic congestion
Heart - hemorrhage and necrosis
Brain - neuronal cell death
Kidneys - acute tubular necrosis
Blood vessels - endothelial damage (thrombosis / DIC)
Adrenal glands - hemorrhage
GI Tract – congestion and hemorrhage
Skeletal muscle - pallor
ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK
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REVIEW QUESTIONS
How would you describe this change
What’s your morphologic diagnosis?
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What do these two findings tell you about the lungs?
•Possible cause?
REVIEW QUESTIONS
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REVIEW QUESTIONS
What is your morphologic diagnosis?
Possible cause?
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REVIEW QUESTIONS
Give 3 morphologic diagnoses
Possible cause?