HYPEREMIA AND CONGESTION
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1 HYPEREMIA AND CONGESTION 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?
2 Circulatory Disturbances 2: Hyperemia and Congestion Shannon Martinson, January VPM 152 General Pathology
3 CIRCULATORY DISTURBANCES Edema Hyperemia and congestion Shock Altered Blood flow Hemorrhage Thrombosis and embolism Infarction
4 ALTERATIONS IN BLOOD FLOW & PERFUSION Hyperemia and congestion indicate a local increase in blood within a tissue Hyperemia Active engorgement of vascular beds due to increased arteriolar flow Congestion Passive engorgement of vascular beds due to decreased outflow of blood Image - Robbins and Cotran PBD 8 th Ed, 2010
5 ALTERATIONS IN BLOOD FLOW & PERFUSION - HYPEREMIA Hyperemia Active process Increased blood entering tissue via arterial flow Oxygenated (red) Response to stimulus Can be physiologic or pathologic Image - Robbins and Cotran PBD 8 th Ed, 2010
6 ALTERATIONS IN BLOOD FLOW & PERFUSION - HYPEREMIA Physiologic Hyperemia Digestion Exercise Dissipate heat Neurovascular (blushing)
7 ALTERATIONS IN BLOOD FLOW & PERFUSION - HYPEREMIA Pathologic Hyperemia Chantal Albert AVC 2007 Due to an underlying pathologic process INFLAMMATION Arteriolar dilation in response to inflammatory stimuli / mediators Often accompanied by edema!
8 ALTERATIONS IN BLOOD FLOW & PERFUSION - HYPEREMIA Gross Findings Red colouration of the tissue Swelling, warmth (in the living ) One of the cardinal signs of inflammation is reddening = rubor
9 ALTERATIONS IN BLOOD FLOW & PERFUSION - HYPEREMIA Histology Findings Capillaries +/- arterioles are dilated and filled with blood Often accompanied by edema May see inflammation! Effect of hyperemia hastens movement of metabolites into an area and flushes catabolites from the area
10 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Congestion Passive process Decreased outflow of blood Deoxygenated blue (dark red - blue) Passive engorgement of vascular beds due to decreased/ obstructed venous return Image - Robbins and Cotran PBD 8 th Ed, 2010
11 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION 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
12 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Histopathology Acute Congestion Engorged capillaries +/- Edema Chronic Congestion Hypoxia ( O 2 ) Cellular atrophy Cellular degeneration / necrosis 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
13 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Two factors used to define types of congestion Chronic localized congestion Chronic generalized congestion Acute localized congestion Acute generalized 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)
14 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Intestinal torsion Splenic torsion (with GDV) Localized congestion Local obstruction to venous drainage Such as when and organ twists
15 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Generalized congestion 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 Can be acute: Sudden death due to heart failure or euthanasia with barbiturates Blood accumulates in lung, spleen and liver More often chronic!
16 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION LEFT sided heart failure Congestion and edema of the lungs
17 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION RIGHT sided heart failure Systemic congestion Liver especially Generalized edema (dependent SQ edema, ascites)
18 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION 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 Cor pulmonale Right heart failure resulting from pulmonary disease
19 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Pulmonary congestion Usually due to LEFT heart failure Lungs are red (congestion), wet (edema) and heavy Gross Histology
20 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Chronic pulmonary congestion When chronic lungs may have brown tan areas reflecting hemosiderin accumulation Histology Gross PBVD, Zachary, 2017
21 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Consequences of Chronic Pulmonary Congestion Histology 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
22 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Hepatic Congestion Most often due to right heart failure Less often secondary to pulmonary hypertension and cor pulmonale
23 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Hepatic Congestion Gross appearance: Liver is enlarged and dark brown with rounded edges
24 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Hepatic Congestion Gross appearance: Cut surface may have a reticular / zonal pattern (= nutmeg liver)
25 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Hepatic Congestion
26 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Histopathology: Acute hepatic congestion Hepatic Congestion Zone 1 - relatively normal Zone 2 - fatty change (partial hypoxia) Zone 3 - congested sinusoids, hepatocyte degeneration/necrosis
27 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Histopathology: Acute hepatic congestion Hepatic Congestion Zone 1 - relatively normal Zone 2 - fatty change (partial hypoxia) Zone 3 - congested sinusoids, hepatocyte degeneration/necrosis
28 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Histopathology: Chronic hepatic congestion Hepatic Congestion In zone 3 Hemosiderin within macrophages (kupffer cells) Hepatocyte loss &/or atrophy and dilated sinusoids Increased connective tissue around central veins
29 ALTERATIONS IN BLOOD FLOW & PERFUSION - CONGESTION Hyperemia/Congestion vs Hemorrhage Congestion / Hyperemia RBCs are within the blood vessels (*) Hemorrhage RBCs are outside vessels ( ) * *
30 ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK Shock Systemic hypotension due to reduced cardiac output or reduced blood volume 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 Cardiovascular collapse 3 Categories of Shock 1. Cardiogenic Shock 2. Hypovolemic Shock 3. Vasogenic Shock
31 ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK 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
32 ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK 2. Hypovolemic shock Decreased circulating blood volume May result from Blood loss from hemorrhage (internally or externally) Fluid loss Vomiting Diarrhea Burns
33 ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK 3. Vasogenic shock Maldistribution of blood Due to decreased peripheral vascular resistance pooling of blood in peripheral tissues Results from vasodilation Anaphylactic shock Release of vasoactive amines Neurogenic shock Occurs with severe CNS damage Loss of ANS signals to arteriolar smooth muscle Septic shock* Release of chemical mediators associated with inflammation
34 ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK 3. Vasogenic shock Pathogenesis Septic shock* Release of chemical mediators associated with inflammation Microbial substances are released from bacteria (LPS) Activation / endothelial cells and stimulation of WBCs to release cytokines Vasodilation, coagulation activation (DIC), complement activation
35 ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK Three stages of shock: 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
36 ALTERATIONS IN BLOOD FLOW & PERFUSION - SHOCK 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
37
38 REVIEW QUESTIONS How would you describe this change What s your morphologic diagnosis?
39 REVIEW QUESTIONS What do these two findings tell you about the lungs? Possible cause?
40 REVIEW QUESTIONS What is your morphologic diagnosis? Possible cause?
41 REVIEW QUESTIONS Give 3 morphologic diagnoses Possible cause?
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