VESSEL Dr.H.Joko S.Lukito, SpPA Dept. Pathology Anatomy FK USU 5/15/2014 2 ARTERY CONGENITAL ABNORMALITIES Especially aorta & large arteries Generally are assosiated with congenital heart disease
1. Ascending aorta hypoplasia 2. Aortic arch anomalies - Aorta coarctation - Patent Ductus Arteriosus - Right Subclavian artery posterior - Aortic arch on the right - Double aortic arch 5/15/2014 3 Degenerative Disease 1. Atheroma 2. Arteriosclerosis
Atheroma Normal Arteriosclerosis Deposition of yellow lipid Tunica intima Generalised material in plaque under Tunica elastica degeneration the intima Tunica media media Tunica adventitia 5/15/2014 4 Degenerative Disease of the Vessel Arteries Ischaemia Veins/lymphatic congestive edema
Atherosclerotic lipid deposition under the intima Monckeberg sclerosis calcification on tunica media Arteriosclerosis in small arteries
5/15/2014 6 Pathogenesis 1. The developmental of focal areas of chronic endothelial injury 2. Increased insudation of lipoproteins into the vessel wall, mainly LDL or modified LDL with its high cholesterol content 3. A series of cellular interactions in the foci of injury involving ECs, monocytes/ macrophage, T lymphocytes, and SMCs of intimal or medial origin 5/15/2014 7
4. Proliferation of smooth muscle cells in the intima with formation of extracellular matrix by the SMCs.
Chronic endothelial injury ( hyperlipidemia, hypertension, smoking, etc) endothelial dysfunction ( increased permeability, leucocytes adhesion) monocytes adhesion and emigration smooth muscle emigration from media to intima, macrophage activation 5/15/2014 8
macrophage and smooth muscle cells - engulf lipid, macroscopically as fatty streaks smooth muscle -prolliferation, collagen and other ECM deposition , extra selluler lipid ( so called fibrous cap ) fibrofatty atheroma fibrous plaques 5/15/2014 9 NORMAL OF BLOOD VESSEL 5/15/2014 10 ATHEROSCLEROTIC IN BLOOD VESSEL 5/15/2014 11 5/15/2014 12 Atheroma - Coronary heart disease - cerebrovascular accident - extremities gangrene
Minor risk factor : Insufficient reguler physical activity Stress Obesity The use of oral contraceptive Hyperuricemia High carbohydrate intake Hyperhomocysteinemia
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Clinical manifestation caused by ischaemic pain growth disorder skin ulceration
5/15/2014 15 2. Monckeberg sclerosis medial calsification on tunica media + internal lamina elastica of arteries grouping Ca sedimentation Aging process
5/15/2014 17 Clinical manifestations : - intermitten fever - malaise, lethargy - loss of body weight - peripheral neuritis - myalgia, progressive arthralgia
Male >> female At all age Body organs which are involved : kidney, brain, heart, skin, lung 5/15/2014 18 Macroscopic finding : protruding mass 2-4 mm along the arteries specially in a. mesenteric, GIT, pancreas, kidney, striated muscle. Microscopic : Oedema with fibrinous exudate Fibrinous necrotic media Damage of internal elastic lamina WBC infiltration in arterial wall Fibroblast proliferation 5/15/2014 19 Periartheritis Nodosa : The Consequences Luminal obliteration Thrombosis Aneurysm Infarct 5/15/2014 20 Spesific arteritis 1. Syphylitic arteritis 2. Tuberculosis arteritis with tubercle central necrosis surrounded by lymphocyte cells, epitheloid cells, plasma cells, and Langhans datia cells. 3. Rheumatoid arteritis fibrinoid necrosis 4. Datia Cells arteritis = Giant cell arteritis temporalis arteritis
5/15/2014 21 Datia Cells Arteritis Clinical manifestation : - Fever - Occurs especially in elders (>50yrs old) - Temporal, occipital and skull arteries segmental inflamation - Leucocytosis, BSR increased - Causes blindness in chronic inflamation (months) 5/15/2014 22 Etiology: unknown
Microscopic : - Inflamation reaction on media and internal elastic lamina of the vessels - Datia cells (+) - Fibrosis of the intima - Thickening of the adventitia
Datia Cells Arteritis 5/15/2014 23 5. Takayasu disease = pulseless disease = Aortic arch syndrome Clinical appearance : - pulseless disease - chronic and progressive - occurs especially in young women - visual disturbances - upper extremities parasthesia - lethargy (general weakness)-syncope 5/15/2014 24 Takayasu disease Microscopic : - pan-arteritis - thickening of the intima - coagulative necrosis - plasma cells , lymphocyte and datia cells inflitration - fibrosis - perivascular infiltration
5/15/2014 25 Peripheral Arterial Disease I. Arteriosclerosis = arteriosclerosis obliterans
Clinical findings : - ischemic atrophy - cold and painful - cyanotic - extremities soft tissue gangrene from distal toes to the proximal legs - muscle spasm - claudicatio intermitten - pale lower extremities when elevated 5/15/2014 26 Pathology
- occurs in midlife and elders - luminal narrowing - thrombotic obstruction - uneven thickening of the artery, hardening but fragile - Iliac artery, femoral artery, poplitea artery, tibial artery. - complicated in diabetes mellitus, hipertension and artherosclerotic patients. 5/15/2014 27 2. Raynaud disease A vasospastic syndrome caused by freezing , restricted on fingers only.
Young women
Etiology : blood vessels spasm
5/15/2014 28 Clinical findings - distal fingers paleness - tingling/ numbness and hot - cyanotic and alternate reddening - can progress to ichaemic necrotic fingers 5/15/2014 29 II. Scleroderma = Progressive Systemic Sclerosis - A systemic disease - Especially effected the skin - Fibrosis in the internal organ - 30-50 years old - Female >> 5/15/2014 30 III. Buerger disease = Thromboangitis obliterans (Wini Warter ) young male , heavy smokers persistent painful legs, cause by distal arterial obstruction and occlusion persistent ischemia of 1 or more toes superficial thrombophlebitis 5/15/2014 31 Macroscopic : Wire like blood vessels (hardening)
Blood vessels occluded by yellow/ grayish mass due to thrombosis
Perivascular fibrosis
5/15/2014 32 Microscopic : - thrombus filled lumen - intact elastic lamina - lymphocyte infiltration of media & adventitia - widening of vasa vasorum - fibrosis of adventitia - granulomatous focal with datia cell or supurative milier focal 5/15/2014 33 Aneurysm local abnormal dilatation of the artery due to wall defect.
5/15/2014 36 Complication : - rupture - hemorrhage - compression to other organ - erosion 5/15/2014 37 Veins Inflamation Acute phlebitis :
Purulent phlebitis : Abcess, meningitis, pneumonia Non Purulent phlebitis : dermatitis, rheumatoid fever, drug allergy, rheumatoid arthritis 5/15/2014 38 Microscopic : - Inflamation cell infiltration - oedema - hyperemia - blood vessel wall destruction 5/15/2014 39 Vein Obstruction Abnormalities 1. Phlebothrombosis Vein thrombosis without regional blood vessel destruction. 2. Thrombophlebitis Thrombosis cause vessel wall destruction. 5/15/2014 40 3. V. Cava Superior Obstruction due to : bronchogenic Carcinoma mediastinal lymphoma Aortic aneurysm causing : cyanotic and congestion of cephalic v, neck and upper extremities v. 4. Vena Cava Inferior Obstruction due to : liver tumor and renal cell Ca. aneurysm ascites and inflamation 5/15/2014 41 5. Portal vein Obstruction due to : thrombosis intrahepatic diseases splenectomy polycytemia vera
6. Varicose vein = Varix abnormal vein dilation which restricted due to intraluminal pressure increament and loss of surrounding tissue support. 5/15/2014 42 Etio : hereditary weakness vein obstruction intraabdominal pressure >> elderly people standing too much, hard work vein inflammation chronic constipation 5/15/2014 43 Portal hypertension hemorrhoid oesophageal varices
Frequently on superficial vein of lower extremities. 5/15/2014 44 HEART DISEASES
All of myocardium disorders due to a. coronary insuffisience - arterisclerosis 99% - rheumatica - sifilis - arteritis - polyarteritis 5/15/2014 48 Variant of coronary heart disease : 1. Arteriosclerotic heart disease 2. Angina pectoris 3. Myocardial infarction
Influenced by : 1. Flow of a. coronary 2. Sensitivity myocardium toward ischaemia 3. O2 concentration of blood 5/15/2014 49 Condition associated to CHD : 1. Hypertension 2. Obesity 3. Hypercholesterolemia 4. Smoking 5. DM
5/15/2014 50 Ad.1. Coronary insufficiency due to : a. Aortitis luetica b. Granulation tissue of proximal a. coronary c. A. coronaria aneurysm d. Buerger disease e. Polyarteritis nodosa/ Rheumatica 5/15/2014 51 Ad.2. Activity of myocardial influenced by : a. Hyperthyroid b. Pregnancy c. Hypermetabolic, febris d. Exercise
Ad.3. O2 concentration : a. Severe anemia b. Erytrocyte disorders, polycythemia c. Cyanosis 5/15/2014 52 Predisposition factors : 1. Lipoprotein serum , soft drink, obesity, alkohol 2. Increased blood pressure 3. Increased blood glucose 4. Stress 5. Lack of exercise 6. Smoking 7. Uric acid serum 5/15/2014 53 1. Arterioscerotic Heart disease Arterioscerotic of a. coronary & myocardial fibrosis diffuse & sometimes with valve fibrosis.
contd : myocardium fiber atrophy and contain lipochrom = Brown atrophy so that cor becomes : small normal swelling (in DC)
Valve abnormalities : mitral valve fibrosis chorda tendinea fibrosis calcification 5/15/2014 55 Clinical Manifestation : asymptomatic old age with angina pectoris mitral / aortic murmur damage myocardium on ECG heart congestive arrhythmia and myocardium infarction 5/15/2014 56 ANGINA PECTORIS
Is the clinical symptom markedly temporary paroxysmal pain attack in substernal or precordial and commonly arise after exercise and disappear in rest. Myocardium damage not appear normal at ECG 5/15/2014 57 Basic : Myocardium hypoxia due to : coronary arteriosclerosis myocardium luetica polyarthritis nodosa aortic valve insufficience Anemia
Hypoxia caused by : small arteri occlution arteri spasm While exercising paroxysmal myocardium hypoxia 5/15/2014 58 MYOCARDIUM INFARCT ( MCI ) Coronary insufficiency due to :
coronary arteriosclerotic 99 % thrombosis and embolism disease of vessels narrowing ostium due to syphilis arteriosclerose and hypotension. 5/15/2014 59 MCI Predilection : right a. coronary 40 % left anterior a. coronary 40 % left ventricle
Morphology : Restricted on central myocardium Myocardium : epicardium + endocardium becomes thick ( 3 4 cm). Zahn Infarction, subendocardial small lesion 5/15/2014 60 Myocardium Infarct Progressivity : < 12 hours : vague or pale 18 - 24 hours : clearly anemic, brown-gray, stable muscle consistency. 2 4 days : well defined necrotic tissue border surround by hyperaemic area, soft, yellow in colour, due to fatty changes 4 10 days : progressive fatty degeneration, central nekrosis, soft , haemorrhage (grayish yellow), well -defined border 6 weeks : fibrosis 5/15/2014 61 Microscopic : blood vessel ischaemic coagulative necrosis in myocardium cell interstitial edema haemorrhage / haemosiderin pigment neutrophyl exudation fibrosis 5/15/2014 62 Complication : Pericarditis fibrinosa / haemorrhagica Mural Thrombosis embolism Rupture infarction heart tamponade fibrosis and aneurysm 5/15/2014 63 Lab : Nekrosis coagulativa enzyme dehidrogenase glutamic oxaloacetic transaminase
12 24 hours SGOT Leukositosis BSR LDH C Reactive Protein 5/15/2014 64 Clinical Manifestation : Sudden and deep pain on substernal and precordial. Pain referred to left back , arm to fingers and chin. Pressed feeling, sweating , nausea, vomit Loss of energy Blood vessel to shock Dyspnoe
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Cyanotic Heart arrhythmia ECG : - Q abnormal - ST elevation - T inverted Death rate : male >> 2 x female
Incidence : Male : 33- 35 years Female : after menopause 5/15/2014 66 HYPERTENSIVE HEART DISEASE Markedly by left ventricle hypertrophy due to continous systemic hypertensive.
Incidence : Female >> 2x male Middle age and old age Genetically inherited
Etiology : Hypertensive occur if arterial peripheral resistence
5/15/2014 67 Peripheral resistence increased due to : vasoconstriction blood vessel arteriole, small arteries. diffuse organic blood vessel disease
Hypertensive hyperthrophy myocardium coronary arteriosclerotic Peripheral resistence heart will compensate cardiac output to normal hyperthrophy myocardium swelling left ventrikel dilatation 5/15/2014 68 Muscle hyperthrophy caused by : activity >> anoxia myocard weakness hypertension coronary arteriosclerosis myocardium anoxia. hypertension damage renal blood vessel Renin NaCl + H2O retention 5/15/2014 69 Morfology : left ventricle wall >> ( 2,5 cm ) heart weight >> without other heart disorders microscopic : normal cardiac muscle thickened arterial wall 5/15/2014 70 Clinical manifestation : Compensatory stadium : asymptom Hypertensive symptom : headache, palpitation, retinopathy Left decompensatio cordis : dyspnoe, cough, hemoptysis Coronary arteriosclerose symptom 5/15/2014 71 RHEUMATIC HEART DISEASE Rheumatic fever is the non supurative systemic inflammation disease. Associated with streptococcus beta haemolitycus group A infection and the immunology reaction with febrile attack and prolonged remission. 5/15/2014 72 Rheumatic fever is the collagen disease, can occur in : joint, heart, skin, serous, lung blood vessel
mucoid degeneration fibrinoid necrosis hyaline collagen degeneration 5/15/2014 75 Etiology: Rheumatic fever arise after 1 - 4 weeks , after infected by streptococcus ( Pharyngitis, Tonsilitis, Scarlatina ) Antigen- antibody reaction causing focal allergic necrosis. markedly by ASTO level 5/15/2014 76 5/15/2014 77 Morphology : Specific disorders and pathognomonic : Aschoff body focus fibrinoid degeneration surrounded by inflammation cell infiltration. Focus can be found in : - heart, - Synovial joint, - fascia tendon. Vegetation nodule can be found in skin, subcutis 1 -4 cm Subcutaneous nodule
5/15/2014 90 2. Atrium Septal Defect Over IV weeks Defect of foramen ovale Clinically : - cyanotic right sided overload - hypertrophy right ventricle - pulmonary hypertension - systolic murmur
5/15/2014 91 5/15/2014 92 3. Lutembachers disease ASD + Stenosis mitral, right & left ventricle dilatation, hypertrophy right ventricle
4. Tetralogi Fallot a. Defect septum interventricle b. Dextroposed overriding aorta c. Stenosis pulmonal valve d. Right ventricle hypertrophy
5/15/2014 93 Clinical manifestation : cyanosis from newborn clubbing of the finger growing disorder
Bad Prognose, cause of death : - Right DC - Endocarditis bacterialis - Brain abcess - Respiratory Tr. Infection 5/15/2014 94 5/15/2014 95 5. Eisenmenger Complex Variant of Tetralogi Fallot without Stenosis Pulmonalis
6. Patent Ductus Arteriosus From ductus Botalli connected with a. pulmonale & aorta - Ductus Botalli be closed at 1-2 yrs after borned - The blood flow from aorta to a. Pulmonalis, that caused decreased blood in circulation - Right ventricle hypertrophy 5/15/2014 96 5/15/2014 97 COARCTATIO AORTA
Aortic Stenosis left ventricle hypertrophy proximal dilatation, blood >> headache distal vasoconstriction pale of extremity & cold
5/15/2014 98 5/15/2014 99 PERICARDIUM
Fluid in cavum pericardium
1. Hydropericardium Normal : 30-50cc, serous 50cc - D.C, - Chronic kidney disease - Hypoproteinemia chronic pericard adhesion 5/15/2014 100 2. Hemopericardium Blood >> pericardium, because : Trauma Rupture of muscle infark myocard rupture of aorta malignant tumor rupture of a. coronary 5/15/2014 101 PERICARDITIS Usually secundairy of : - hematogen - lymphogen - percontuinitatum Classification of pericardium based of etiology : Tuberculosis pericarditis Bacterialis pericarditis Rheumatica pericarditis
5/15/2014 102 Morphologi : - dilatation of vein & irregularity, ectasion - valves thickening - different of wall thickned - elastic tissue changed by fibrotic
5/15/2014 103 Classification of pericardium based of etiology : Tuberculosis pericarditis Bacterialis pericarditis Rheumatica pericarditis Uremic pericarditis Virus pericarditis Carcinomatosa pericarditis MCI because of pericarditis Secundair of : - parasit - fungal Idiopathic
5/15/2014 109 Lymph Acute lymphagitis because of pyogen process Chronic lymphagitis because of filariasis Non inflammatory lymphedema because of neoplasm Operative
5/15/2014 110 Vessel & Lymph Tumors Benign Capillary Hamangioma Tumor capsul (-), vessel proliferation (+), separated by fibrous tissue, ussually at skin & mucosa Cavernosum Hemangioma = Cystic hygroma Large vessel lumen cystic 5/15/2014 111 Endothelioma Hemangioma Proliferative of endothel Pericytoma Hemangioma Proliferative of suportive tissue
5/15/2014 112 Glomangioma + Glomus Tumor Small, under the skin / nail Maligna Angiosarcoma
5/15/2014 113 Kaposis Sarcoma
Subcutaneus plaque or verucosus It contains : - endothelial proliferation extravascular hemorrhage anaplastic fibroblast proliferation granulation like inflammatory reaction Very painfull tumor
5/15/2014 114 Virus pericarditis Carcinomatosa pericarditis MCI because of pericarditis Secundair of : - parasit - fungal Idiopathic