BLOOD AND LYMPHATIC VESSELDr.H.Joko S.Lukito, SpPADept. Pathology AnatomyFK USU

ARTERYCONGENITAL ABNORMALITIES Especially aorta & large arteries Generally are assosiated with congenital heart disease

Ascending aorta hypoplasiaAortic arch anomalies- Aorta coarctation- Patent Ductus Arteriosus- Right Subclavian artery posterior- Aortic arch on the right- Double aortic arch

Degenerative DiseaseAtheromaArteriosclerosis

Atheroma Normal ArteriosclerosisDeposition of yellow lipid Tunica intima Generalisedmaterial in plaque under Tunica elastica degenerationthe intima Tunica media media Tunica adventitia

Degenerative Disease of the VesselArteries IschaemiaVeins/lymphatic congestive edema

Symptoms :- Functional disorders- Pain, due to :- Infarction- Trophic disorder- Skin ulceration

Arteriosclerotic disease = arterial hardening

Atherosclerotic lipid deposition under the intimaMonckeberg sclerosis calcification on tunica mediaArteriosclerosis in small arteries

PathogenesisThe developmental of focal areas of chronic endothelial injuryIncreased insudation of lipoproteins into the vessel wall, mainly LDL or modified LDL with its high cholesterol content A series of cellular interactions in the foci of injury involving ECs, monocytes/ macrophage, T lymphocytes, and SMCs of intimal or medial origin

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

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

NORMAL OF BLOOD VESSEL

ATHEROSCLEROTIC IN BLOOD VESSEL

Atheroma - Coronary heart disease - cerebrovascular accident - extremities gangrene

Major risk factor : Hypertension Hypertension Cigarette smoking Diabetes

Minor risk factor : Insufficient reguler physical activity Stress Obesity The use of oral contraceptive Hyperuricemia High carbohydrate intake Hyperhomocysteinemia

Clinical manifestation caused by ischaemic pain growth disorder skin ulceration

Arteriosclerosis complication :Blood vessel occlutionSkin ulcerationThrombosisEmbolism

2. Monckeberg sclerosis medial calsificationon tunica media + internal lamina elastica of arteries grouping Ca sedimentationAging process

elastic tissue of intima arranged like onion skin appearance Subintimal hyaline sedimentation.3. Arteriosclerosis arteriole sclerosis

INFLAMMATION OF ARTERIESAcute Infectious ArteritisEtio : - Perivascular inflammation : acute meningitis, cellulitis, pneumonia - Intravascular : septicaemia, septic embolism.

2. Periarteritis nodosa = polyarteritis = panarteritis

Clinical manifestations :- intermitten fever- malaise, lethargy- loss of body weight- peripheral neuritis- myalgia, progressive arthralgia

Male >> femaleAt all ageBody organs which are involved : kidney, brain, heart, skin, lung

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 mediaDamage of internal elastic laminaWBC infiltration in arterial wallFibroblast proliferation

Periartheritis Nodosa :The ConsequencesLuminal obliterationThrombosisAneurysmInfarct

Spesific arteritisSyphylitic arteritisTuberculosis arteritis with tubercle central necrosis surrounded by lymphocyte cells, epitheloid cells, plasma cells, and Langhans datia cells.Rheumatoid arteritis fibrinoid necrosisDatia Cells arteritis = Giant cell arteritis temporalis arteritis

Datia Cells ArteritisClinical manifestation :Fever Occurs especially in elders (>50yrs old) Temporal, occipital and skull arteries segmental inflamationLeucocytosis, BSR increasedCauses blindness in chronic inflamation (months)

Datia Cells ArteritisEtiology: unknown

Microscopic : - Inflamation reaction on media and internal elastic lamina of the vessels- Datia cells (+)- Fibrosis of the intima- Thickening of the adventitia

5. Takayasu disease = pulseless disease = Aortic arch syndromeClinical appearance :- pulseless disease- chronic and progressive- occurs especially in young women- visual disturbances- upper extremities parasthesia- lethargy (general weakness)-syncope

Takayasu diseaseMicroscopic :- pan-arteritis- thickening of the intima- coagulative necrosis- plasma cells , lymphocyte and datia cells inflitration- fibrosis- perivascular infiltration

Peripheral Arterial DiseaseI. 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

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.

2. Raynaud diseaseA vasospastic syndrome caused by freezing , restricted on fingers only.

Young women

Etiology : blood vessels spasm

Clinical findings- distal fingers paleness- tingling/ numbness and hot - cyanotic and alternate reddening- can progress to ichaemic necrotic fingers

II. Scleroderma = Progressive Systemic SclerosisA systemic diseaseEspecially effected the skinFibrosis in the internal organ30-50 years old Female >>

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

Macroscopic : Wire like blood vessels (hardening)

Blood vessels occluded by yellow/ grayish mass due to thrombosis

Perivascular fibrosis

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

Aneurysmlocal abnormal dilatation of the artery due to wall defect.

Etiology : - artheriosclerosis- syphilis , bacterial or fungal infection- congenital- trauma

Clinical form of aneurysm :- sacculer- fusiform- cylindric- dissecans- circoid / racemosus

Favorite localization :- aortic arch- abdominal aorta- popliteal artery- femoral artery- carotid artery or subclavia artery

Complication :- rupture- hemorrhage- compression to other organ - erosion

VeinsInflamation Acute phlebitis :

Purulent phlebitis : Abcess, meningitis, pneumoniaNon Purulent phlebitis : dermatitis, rheumatoid fever, drug allergy, rheumatoid arthritis

Microscopic : - Inflamation cell infiltration - oedema - hyperemia - blood vessel wall destruction

Vein Obstruction AbnormalitiesPhlebothrombosisVein thrombosis without regional blood vessel destruction.ThrombophlebitisThrombosis cause vessel wall destruction.

V. Cava Superior Obstructiondue to : bronchogenic Carcinoma mediastinal lymphoma Aortic aneurysmcausing : cyanotic and congestion of cephalic v, neck and upper extremities v.Vena Cava Inferior Obstructiondue to : liver tumor and renal cell Ca. aneurysm ascites and inflamation

5. Portal vein Obstruction due to : thrombosis intrahepatic diseases splenectomy polycytemia vera

Varicose vein = Varix abnormal vein dilation which restricted due to intraluminal pressure increamentand loss of surrounding tissue support.

Etio : hereditary weakness vein obstruction intraabdominal pressure >> elderly people standing too much, hard work vein inflammation chronic constipation

Portal hypertension hemorrhoid oesophageal varices

Frequently on superficial vein of lower extremities.

HEART DISEASES

1. Coronary heart disease 80%2. Hipertensive heart disease 9%3. Rheumatic heart disease 2-3%4. Congenital heart disease 2%5. Bacterial endocarditis 1-2%6. Sifilitik heart disease 1%7. Cor pulmonale 1%8. Another heart disease 5%

Coronary heart disease

All of myocardium disorders due to a. coronary insuffisience - arterisclerosis 99%- rheumatica- sifilis- arteritis- polyarteritis

Variant of coronary heart disease :Arteriosclerotic heart disease Angina pectorisMyocardial infarction

Influenced by :Flow of a. coronarySensitivity myocardium toward ischaemiaO2 concentration of blood

Condition associated to CHD : Hypertension Obesity Hypercholesterolemia Smoking DM

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

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

Predisposition factors :Lipoprotein serum , soft drink, obesity, alkoholIncreased blood pressureIncreased blood glucoseStressLack of exercise SmokingUric acid serum

Arterioscerotic Heart diseaseArterioscerotic of a. coronary & myocardial fibrosis diffuse & sometimes with valve fibrosis.

Morphologic : Arterioscerotic muscle ischaemia myocardial fibrosis as diffuse grey plaque ...

contd :myocardium fiber atrophy and contain lipochrom = Brown atrophy so that cor becomes : smallnormalswelling (in DC)

Valve abnormalities : mitral valve fibrosischorda tendinea fibrosiscalcification

Clinical Manifestation :

asymptomaticold age with angina pectorismitral / aortic murmurdamage myocardium on ECGheart congestivearrhythmia and myocardium infarction

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 appearnormal at ECG

Basic : Myocardium hypoxia due to :coronary arteriosclerosismyocardium lueticapolyarthritis nodosaaortic valve insufficienceAnemia

Hypoxia caused by : small arteri occlutionarteri spasmWhile exercising paroxysmal myocardium hypoxia

MYOCARDIUM INFARCT ( MCI )Coronary insufficiency due to :

coronary arteriosclerotic 99 %thrombosis and embolismdisease of vesselsnarrowing ostium due to syphilis arteriosclerose and hypotension.

MCIPredilection :right a. coronary 40 %left anterior a. coronary 40 %left ventricle

Morphology :Restricted on central myocardiumMyocardium : epicardium + endocardium becomes thick ( 3 4 cm).Zahn Infarction, subendocardial small lesion

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 changes4 10 days : progressive fatty degeneration, central nekrosis, soft ,haemorrhage (grayish yellow), well -defined border6 weeks : fibrosis

Microscopic :blood vessel ischaemic coagulative necrosis in myocardium cellinterstitial edemahaemorrhage / haemosiderin pigmentneutrophyl exudationfibrosis

Complication :Pericarditis fibrinosa / haemorrhagicaMural Thrombosis embolismRupture infarction heart tamponadefibrosis and aneurysm

Lab : Nekrosis coagulativa enzyme dehidrogenase glutamic oxaloacetic transaminase

12 24 hoursSGOT Leukositosis BSR LDH C Reactive Protein

Clinical Manifestation :Sudden and deep pain on substernal and precordial.Pain referred to left back , arm to fingers and chin.Pressed feeling, sweating , nausea, vomitLoss of energyBlood vessel to shockDyspnoe

CyanoticHeart arrhythmiaECG : - Q abnormal- ST elevation - T invertedDeath rate : male >> 2 x female

Incidence : Male : 33- 35 years Female : after menopause

HYPERTENSIVE HEART DISEASEMarkedly 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

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

Muscle hyperthrophy caused by :activity >> anoxia myocard weaknesshypertension coronary arteriosclerosis myocardium anoxia.hypertension damage renal blood vessel Renin NaCl + H2O retention

Morfology :left ventricle wall >> ( 2,5 cm )heart weight >>without other heart disordersmicroscopic : normal cardiac musclethickened arterial wall

Clinical manifestation :Compensatory stadium : asymptomHypertensive symptom : headache, palpitation, retinopathyLeft decompensatio cordis : dyspnoe, cough, hemoptysisCoronary arteriosclerose symptom

RHEUMATIC HEART DISEASERheumatic 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.

Rheumatic fever is the collagen disease, can occur in : joint, heart, skin, serous,lung blood vessel

Incidence : age 5 15 years 90 %Low economicsOvercrowded area, poor sanitation Low nutrition

Rheumatic Inflammation Changes:

mucoid degenerationfibrinoid necrosishyaline collagen degeneration

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

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 cmSubcutaneous nodule

mitral, aortic valve : fibrotic vegetation, calcificationtricuspidale valve : stenosisChorda tendinea : shorten and thicken

Clinical Manifestation :

Major Criteria of Jones:1. Polyarthritis migrans 85 %2. Carditis 65 %3. Chorea sydenham4. Subcutaneous nodule5. Erythema marginatum

Minor Criteria of JonesLeucocytosisBSR ASTO FeverArthralgiaProlonged PR intervalErythema

Cause of death :Decompensatio cordisBrain/ renal thromboembolismBacterial EndocarditisMitral stenosis

COR PULMONALEThe right ventricle hypertrophy, due to pulmonale disorders :Etiology :Acute massive pulmonary embolism, so that dilatation right ventricleChronic 1. Pulmonary disease 2. Chronic pulmonary disease 3. Thorax abnormalities

Ad.1. - Diffuse big/small arteries trombosis - Embolism - Diffuse vasculitis - Fibrosis : - sarcoidosis - radiation - asbestosis - berryliosis

Ad.2. - Emphysema - Chronic bronchitis - Pulmonary fibrosis due to TBC - Sarcoidosis - Severe pneumonia - Pulmonary resection

Ad.3. Thickness pleura bilateral - Neuro abnormalities :PoliomyelitisMyasthenia gravisMuscle distrophyKyphoscoliosis

Clinical Manifestation :- dyspnoe- dilatation of vein- oedema- ascites- hydrothorax- hepatosplenomegaly

CONGENITAL HEART DISEASEEtiology :UnknownGeneticsInfection virus rubella, lues, toxoplasmaDrug teratogenic thalidomide, cortison, busulfan

Rogers disease= ventricle septal sefectManifest in IV-VII weeksMacros : - defect, mmcm - right ventricle >> - thickening endocardium parallel of defect Clinically : - hard systole murmur = machinary murmur - pulmonary hypertension - tardive cyanosis

Death because of : - right disease - endocarditis

2. Atrium Septal DefectOver IV weeksDefect of foramen ovaleClinically : - cyanotic right sided overload - hypertrophy right ventricle - pulmonary hypertension - systolic murmur

3. Lutembachers disease ASD + Stenosis mitral, right & left ventricle dilatation, hypertrophy right ventricle

4. Tetralogi FallotDefect septum interventricleDextroposed overriding aortaStenosis pulmonal valveRight ventricle hypertrophy

Clinical manifestation : cyanosis from newborn clubbing of the finger growing disorder

Bad Prognose, cause of death :Right DCEndocarditis bacterialisBrain abcessRespiratory Tr. Infection

5. Eisenmenger ComplexVariant 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

COARCTATIO AORTA

Aortic Stenosis left ventricle hypertrophy proximal dilatation, blood >> headache distal vasoconstriction pale of extremity & cold

PERICARDIUM

Fluid in cavum pericardium

1. HydropericardiumNormal : 30-50cc, serous50cc - D.C, - Chronic kidney disease - Hypoproteinemia chronic pericard adhesion

2. Hemopericardium Blood >> pericardium, because : TraumaRupture of muscle infark myocardrupture of aorta malignant tumorrupture of a. coronary

PERICARDITISUsually secundairy of : - hematogen - lymphogen - percontuinitatum Classification of pericardium based of etiology :Tuberculosis pericarditisBacterialis pericarditisRheumatica pericarditis

Morphologi : - dilatation of vein & irregularity, ectasion - valves thickening - different of wall thickned - elastic tissue changed by fibrotic

Classification of pericardium based of etiology :Tuberculosis pericarditisBacterialis pericarditisRheumatica pericarditisUremic pericarditisVirus pericarditisCarcinomatosa pericarditisMCI because of pericarditisSecundair of : - parasit - fungal Idiopathic

Classification from inflammatory exudate : 1. Serousa pericarditis 2. Seurofibrinos pericarditis 3. Fibrinous pericarditis 4. Suppurative pericarditis

Pathogenesis1. Heart anomalies MCI Acute rheumatica Surgical trauma

2.Pulmonary disease Tuberculosis Carcinoma Pneumonia Empyema

Complications :Constrictive pericarditisObliterative, focal/diffuse pericarditisV. cava compression -ascites -hepatosplenomegaly4. DC

Clinical manifestations : paincongesion & edemastatic dermatitiscellulitischronic ulceration

Complications : inflammationperforated of veinthrombosisulceration + dermatitis

LymphAcute lymphagitis because of pyogen processChronic lymphagitis because of filariasisNon inflammatory lymphedema because of neoplasmOperative

Vessel & Lymph TumorsBenignCapillary HamangiomaTumor capsul (-), vessel proliferation (+), separated by fibrous tissue, ussually at skin & mucosaCavernosum Hemangioma = Cystic hygromaLarge vessel lumen cystic

Endothelioma HemangiomaProliferative of endothelPericytoma HemangiomaProliferative of suportive tissue

Glomangioma + Glomus TumorSmall, under the skin / nailMalignaAngiosarcoma

Kaposis Sarcoma

Subcutaneus plaque or verucosusIt contains : - endothelial proliferationextravascular hemorrhageanaplastic fibroblast proliferationgranulation like inflammatory reactionVery painfull tumor

Virus pericarditisCarcinomatosa pericarditisMCI because of pericarditisSecundair of : - parasit - fungalIdiopathic

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