5/15/2014 1

BLOOD AND LYMPHATIC

VESSEL
Dr.H.Joko S.Lukito, SpPA
Dept. Pathology Anatomy
FK USU
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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
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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
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Degenerative Disease of the Vessel
Arteries Ischaemia
Veins/lymphatic congestive edema

Symptoms : - Functional disorders
- Pain, due to :
- Infarction
- Trophic disorder
- Skin ulceration
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Arteriosclerotic disease
= arterial hardening

Atherosclerotic lipid deposition under
the intima
Monckeberg sclerosis calcification on
tunica media
Arteriosclerosis in small arteries

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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
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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
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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
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NORMAL OF BLOOD VESSEL
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ATHEROSCLEROTIC IN BLOOD VESSEL
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Atheroma - Coronary heart disease
- cerebrovascular accident
- extremities gangrene

Major risk factor :
Hypertension
Hypertension
Cigarette smoking
Diabetes
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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

Arteriosclerosis complication :
1. Blood vessel occlution
2. Skin ulceration
3. Thrombosis
4. Embolism


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2. Monckeberg sclerosis medial
calsification
on tunica media + internal lamina elastica of
arteries grouping Ca sedimentation
Aging process




elastic tissue of intima arranged like onion
skin appearance
Subintimal hyaline sedimentation.
3. Arteriosclerosis arteriole
sclerosis
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INFLAMMATION OF ARTERIES
1. Acute Infectious Arteritis
Etio : - Perivascular inflammation : acute
meningitis, cellulitis, pneumonia
- Intravascular : septicaemia,
septic embolism.

2. Periarteritis nodosa = polyarteritis
= panarteritis

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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
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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
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Periartheritis Nodosa :
The Consequences
Luminal obliteration
Thrombosis
Aneurysm
Infarct
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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

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

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

Young women

Etiology : blood vessels spasm

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Clinical findings
- distal fingers paleness
- tingling/ numbness and hot
- cyanotic and alternate reddening
- can progress to ichaemic necrotic fingers
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II. Scleroderma
= Progressive Systemic Sclerosis
- A systemic disease
- Especially effected the skin
- Fibrosis in the internal organ
- 30-50 years old
- Female >>
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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
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Macroscopic :
Wire like blood vessels (hardening)

Blood vessels occluded by yellow/ grayish
mass due to thrombosis

Perivascular fibrosis

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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
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Aneurysm
local abnormal dilatation of the artery due
to wall defect.

Etiology :
- artheriosclerosis
- syphilis , bacterial or fungal infection
- congenital
- trauma
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Clinical form of aneurysm :
- sacculer
- fusiform
- cylindric
- dissecans
- circoid / racemosus

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

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Complication :
- rupture
- hemorrhage
- compression to other organ
- erosion
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Veins
Inflamation
Acute phlebitis :

Purulent phlebitis : Abcess, meningitis,
pneumonia
Non Purulent phlebitis : dermatitis,
rheumatoid fever, drug allergy, rheumatoid
arthritis
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Microscopic :
- Inflamation cell infiltration
- oedema
- hyperemia
- blood vessel wall destruction
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Vein Obstruction Abnormalities
1. Phlebothrombosis
Vein thrombosis without regional blood
vessel destruction.
2. Thrombophlebitis
Thrombosis cause vessel wall
destruction.
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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
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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.
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Etio :
hereditary weakness
vein obstruction
intraabdominal pressure >>
elderly people
standing too much, hard work
vein inflammation
chronic constipation
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Portal hypertension hemorrhoid
oesophageal varices

Frequently on superficial vein of lower
extremities.
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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%
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1. Coronary heart disease

All of myocardium disorders due to a.
coronary insuffisience
- arterisclerosis 99%
- rheumatica
- sifilis
- arteritis
- polyarteritis
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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
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Condition associated to CHD :
1. Hypertension
2. Obesity
3. Hypercholesterolemia
4. Smoking
5. DM

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

Morphologic :
Arterioscerotic muscle ischaemia
myocardial fibrosis as diffuse grey
plaque ...
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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
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Clinical Manifestation :
asymptomatic
old age with angina pectoris
mitral / aortic murmur
damage myocardium on ECG
heart congestive
arrhythmia and myocardium infarction
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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
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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
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MYOCARDIUM INFARCT ( MCI )
Coronary insufficiency due to :

coronary arteriosclerotic 99 %
thrombosis and embolism
disease of vessels
narrowing ostium due to syphilis
arteriosclerose and hypotension.
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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
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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
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Microscopic :
blood vessel ischaemic coagulative
necrosis in myocardium cell
interstitial edema
haemorrhage / haemosiderin pigment
neutrophyl exudation
fibrosis
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Complication :
Pericarditis fibrinosa / haemorrhagica
Mural Thrombosis embolism
Rupture infarction heart tamponade
fibrosis and aneurysm
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Lab :
Nekrosis coagulativa
enzyme dehidrogenase
glutamic oxaloacetic transaminase

12 24 hours
SGOT
Leukositosis
BSR
LDH
C Reactive Protein
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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
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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

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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
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Muscle hyperthrophy caused by :
activity >> anoxia myocard weakness
hypertension coronary arteriosclerosis
myocardium anoxia.
hypertension damage renal blood
vessel Renin NaCl + H2O retention
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Morfology :
left ventricle wall >> ( 2,5 cm )
heart weight >>
without other heart disorders
microscopic : normal cardiac muscle
thickened arterial wall
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Clinical manifestation :
Compensatory stadium : asymptom
Hypertensive symptom :
headache, palpitation, retinopathy
Left decompensatio cordis :
dyspnoe, cough, hemoptysis
Coronary arteriosclerose symptom
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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.
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Rheumatic fever is the collagen disease,
can occur in :
joint,
heart,
skin,
serous,
lung blood vessel

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Incidence :
age 5 15 years 90 %
Low economics
Overcrowded area, poor sanitation
Low nutrition
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Rheumatic Inflammation Changes:

mucoid degeneration
fibrinoid necrosis
hyaline collagen degeneration
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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
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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

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mitral, aortic valve : fibrotic vegetation,
calcification
tricuspidale valve : stenosis
Chorda tendinea : shorten and thicken
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Clinical Manifestation :

Major Criteria of J ones:
1. Polyarthritis migrans 85 %
2. Carditis 65 %
3. Chorea sydenham
4. Subcutaneous nodule
5. Erythema marginatum
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Minor Criteria of J ones
1. Leucocytosis
2. BSR
3. ASTO
4. Fever
5. Arthralgia
6. Prolonged PR interval
7. Erythema
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Cause of death :
1. Decompensatio cordis
2. Brain/ renal thromboembolism
3. Bacterial Endocarditis
4. Mitral stenosis
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COR PULMONALE
The right ventricle hypertrophy, due to
pulmonale disorders :
Etiology :
1. Acute massive pulmonary embolism,
so that dilatation right ventricle
2. Chronic 1. Pulmonary disease
2. Chronic pulmonary disease
3. Thorax abnormalities
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Ad.1. - Diffuse big/small arteries trombosis
- Embolism
- Diffuse vasculitis
- Fibrosis : - sarcoidosis
- radiation
- asbestosis
- berryliosis
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Ad.2. - Emphysema
- Chronic bronchitis
- Pulmonary fibrosis due to TBC
- Sarcoidosis
- Severe pneumonia
- Pulmonary resection
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Ad.3. Thickness pleura bilateral
- Neuro abnormalities :
Poliomyelitis
Myasthenia gravis
Muscle distrophy
Kyphoscoliosis

Clinical Manifestation :
- dyspnoe - dilatation of vein
- oedema - ascites
- hydrothorax - hepatosplenomegaly
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CONGENITAL HEART DISEASE
Etiology :
- Unknown
- Genetics
- Infection virus rubella, lues, toxoplasma
- Drug teratogenic thalidomide, cortison,
busulfan
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1. Rogers disease
= ventricle septal sefect
Manifest in IV-VII weeks
Macros : - defect, mmcm
- right ventricle >>
- thickening endocardium
parallel of defect
Clinically : - hard systole murmur =
machinary murmur
- pulmonary hypertension
- tardive cyanosis
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Death because of : - right disease
- endocarditis


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2. Atrium Septal Defect
Over IV weeks
Defect of foramen ovale
Clinically : - cyanotic right sided overload
- hypertrophy right ventricle
- pulmonary hypertension
- systolic murmur

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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

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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
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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
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COARCTATIO AORTA

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

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PERICARDIUM

Fluid in cavum pericardium

1. Hydropericardium
Normal : 30-50cc, serous
50cc - D.C,
- Chronic kidney disease
- Hypoproteinemia
chronic pericard adhesion
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2. Hemopericardium
Blood >> pericardium, because :
Trauma
Rupture of muscle infark myocard
rupture of aorta
malignant tumor
rupture of a. coronary
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PERICARDITIS
Usually secundairy of : - hematogen
- lymphogen
-
percontuinitatum
Classification of pericardium based of
etiology :
Tuberculosis pericarditis
Bacterialis pericarditis
Rheumatica pericarditis

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

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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


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

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Pathogenesis
1. Heart anomalies MCI
Acute rheumatica
Surgical trauma

2.Pulmonary disease Tuberculosis
Carcinoma
Pneumonia
Empyema
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Complications :
1. Constrictive pericarditis
2. Obliterative, focal/diffuse pericarditis
3. V. cava compression
- ascites
- hepatosplenomegaly
4. DC

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Clinical manifestations :
pain
congesion & edema
static dermatitis
cellulitis
chronic ulceration

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Complications :
inflammation
perforated of vein
thrombosis
ulceration + dermatitis

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Lymph
Acute lymphagitis because of pyogen
process
Chronic lymphagitis because of filariasis
Non inflammatory lymphedema because
of neoplasm
Operative

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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
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Endothelioma Hemangioma
Proliferative of endothel
Pericytoma Hemangioma
Proliferative of suportive tissue

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Glomangioma + Glomus Tumor
Small, under the skin / nail
Maligna
Angiosarcoma

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Kaposis Sarcoma

Subcutaneus plaque or verucosus
It contains : - endothelial proliferation
extravascular hemorrhage
anaplastic fibroblast proliferation
granulation like inflammatory reaction
Very painfull tumor

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Virus pericarditis
Carcinomatosa pericarditis
MCI because of pericarditis
Secundair of : - parasit
- fungal
Idiopathic

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