Learning Objectives

•Recognize and describe hemorrhage as to its size and location using proper terminology

•Outline the pathogenesis of hemorrhage

•Describe the outcome of hemorrhagic lesions

HEMORRHAGE

Circulatory Disturbances 4: Hemorrhage

Shannon Martinson, Feb 2017

http://people.upei.ca/smartinson/ VPM 152 General Pathology

Edema

Hyperemia and congestion

Shock

Hemorrhage

Thrombosis and embolism

Infarction

CIRCULATORY DISTURBANCES

Altered hemostasis

Altered Blood flow

• Escape of blood from the cardiovascular system Hemorrhage

Internal External

HEMORRHAGE

Causes

Trauma

Sepsis, viruses, or toxins

Abdominal neoplasia

Coagulation disorders

Platelet disorders

Congestion (capillary hemorrhage)

HEMORRHAGE

Causes

Trauma

Sepsis, viruses, or toxins

Abdominal neoplasia

Coagulation disorders

Platelet disorders

Congestion (capillary hemorrhage)

HEMORRHAGE

Causes

Trauma

Sepsis, viruses, or toxins

Abdominal neoplasia

Coagulation disorders

Platelet disorders

Congestion (capillary hemorrhage)

HEMORRHAGE

Causes

Trauma

Sepsis, viruses, or toxins

Abdominal neoplasia

Coagulation disorders

Platelet disorders

Congestion (capillary hemorrhage)

HEMORRHAGE

www.merckvetmanual.com

Causes

Trauma

Sepsis, viruses, or toxins

Abdominal neoplasia

Coagulation disorders

Platelet disorders

Congestion (capillary hemorrhage)

HEMORRHAGE

Causes

Trauma

Sepsis, viruses, or toxins

Abdominal neoplasia

Coagulation disorders

Platelet disorders

Congestion (capillary hemorrhage)

HEMORRHAGE

Significance

HEMORRHAGE

Location:

Brain

Pericardium

Volume and rate:

↑worse -

Hemorrhagic shock

• Blood accumulation beneath / above the dura Subdural / Epidural

hemorrhage

Compresses the brain

HEMORRHAGE

• Heart failure due to massive accumulation of fluid/blood in the pericardial sac

Cardiac Tamponade

HEMORRHAGE

Compresses the atria and ventricles - restricts diastolic cardiac filling

• Hemorrhage from a tear in blood vessel or heart Hemorrhage by

Rhexis

HEMORRHAGE

HEMORRHAGE

• Hemorrhage from a tear in blood vessel or heart Hemorrhage by

Rhexis

Results in moderate to marked hemorrhage

HEMORRHAGE

• Hemorrhage from a tear in blood vessel or heart Hemorrhage by

Rhexis

• Bleeding from a small defect Hemorrhage by

Diapedesis

HEMORRHAGE

HEMORRHAGE

• Bleeding from a small defect Hemorrhage by

Diapedesis

• RBCs passing through a wall in inflammation or vasculitis

• RBCs entering alveoli with lung congestion

HEMORRHAGE

• Bleeding from a small defect Hemorrhage by

Diapedesis

• Increased tendency to hemorrhage from usually insignificant injuries

Hemorrhagic Diathesis

HEMORRHAGE

Seen in a wide variety of clinical disorders: Platelet disorders and Coagulation deficiency

• Extravascular 3D blood clot

• Hemorrhage enclosed within a tissue Hematoma

HEMORRHAGE

Splenic hematoma

Photos: Dr R Lofstedt, AVC

HEMORRHAGE

• Extravascular 3D blood clot

• Hemorrhage enclosed within a tissue Hematoma

Ovarian hematoma

• Blood in the pericardial sac Hemopericardium

Can lead to cardiac tamponade

HEMORRHAGE

• Blood in the thorax (pleural cavity) Hemothorax

HEMORRHAGE

• Blood in the abdomen (peritoneal cavity) Hemoabdomen

(Hemoperitoneum)

HEMORRHAGE

• Blood in the joint spaces Hemarthrosis

HEMORRHAGE

• Coughing blood from the lungs or airways Hemoptysis

HEMORRHAGE

• Bleeding from the nose Epistaxis

HEMORRHAGE

• Vomiting up blood Hematemesis

HEMORRHAGE

• Presence of fresh blood in the stool Hematochezia

• Presence of tarry blood in the stool Melena

• Pinpoint (~1-2 mm) hemorrhages

• Most common in the skin, mucosa, serosa Petechia(e)

HEMORRHAGE

• 3 mm – 1 cm hemorrhages

• Most common in the skin, mucosa, serosa Purpura

HEMORRHAGE

• Hemorrhages larger than 1 cm

• Often blotchy and irregular

Ecchymosis

(Ecchymoses)

HEMORRHAGE

• Hemorrhage which looks like red paint was applied with a brush

Paint brush hemorrhage

HEMORRHAGE

HEMORRHAGE

• Areas of hemorrhage larger than ecchymoses and contiguous

Suffusive hemorrhage

• Areas of hemorrhage larger than ecchymoses and contiguous

Suffusive hemorrhage

HEMORRHAGE

• Refer to petechiae and ecchymoses that are associated with the death struggle (terminal hypoxia)

Agonal hemorrhage

HEMORRHAGE

• Arrest of hemorrhage occurs as a result of hemostasis

• Resolution depends on the amount of hemorrhage

Resolution of Hemorrhage

• A small amount can be resorbed

1. Resorption

• Larger amounts require breakdown and removal of RBCs by macrophages

• Hemoglobin pigment broken down sequentially

• Connective tissue organization occurs in large hematomas

2. Organization

HEMORRHAGE

Hemoglobin Bilirubin Hemosiderin

Resolution of Hemorrhage

HEMORRHAGE

Blue-Green Yellow-Brown Red - Blue

• Center contains fibrin and RBCs that are phagocytosed by macrophages

• Outside is composed of vascularized fibrous tissue

Organizing hematoma

HEMORRHAGE

Aural hematoma http://criticalcaredvm.com

REVIEW

Coelomic cavity of male turkey with ruptured aorta – which term is correct for this lesion?

• Hemorrhage by diapedesis

• Hemorrhage by rhexis

• Hemarthrosis

• Petechiae

• Hemoptysis

REVIEW

What is your diagnosis?

• Hemothorax

• Hydrothorax

• Chylothorax

• Hemopericardium

• Hydropericardium

Morphologic Diagnosis and Speculate on cause...

• Hydroperitoneum - Ruptured small intestine

• Ascites - Left Heart Failure

• Hydroperitoneum - Liver Failure

• Ascites - Right heart failure

Morphologic Diagnosis and Speculate on cause... REVIEW

REVIEW

What type of hemorrhage is this?

• Ecchymoses

• Paintbrush hemorrhage

• Purpura

• Petechiae

• Suffusive hemorrhage

This aortic rupture could have resulted in which of the following?

• Hemothorax

• Cardiac tamponade

• Cor pulmonale

• Hemoptysis

• Hemopericardium

REVIEW