Haemostasias,

Haemorrhage, Hyperemia
and Congestion
 HAEMOSTASIS

Def: It is a state of balance, through which the

body control bleeding and prevent thrombosis.
Mechanisms include:
- Intact Blood Vessel: Through a negative charge
of the endothelium, which repels negatively
charged platelets. when they are injured, they
constrict and prevent bleedings.
- Normal Platelets:
Normal in count and function: Platelets are responsible for the
formation of primary haemostatic plugs, normal count is (150-400)
thousand/cu.mm, normal functions include adhesion, aggregation, and
release. Thus, any change in the number or abnormality in function
results in bleeding or thrombosis
- Normal Coagulation Factors:
These are inactive proteins, when trauma occurs it will be activated in
a cascade manner (each one activate the other ). from factor I to factor
XIII, there are two pathways for activation, intrinsic or extrinsic,
ending in a common pathway and fibrin formation
- Normal Fibrinolytic System:
Fibrinolytic factors are proteins that prevent propagation of
thrombus formation (localizations of thrombus in one site).
Plasminogen is the main fibrinolytic factor. The absence of
these factors results in excessive thrombosis.
- Natural Inhibitors:
Like Protein S, C, antithrombin III, which inactivate the
active coagulation factor, so prevent further thrombosis, lack of
these inhibitors result in thrombosis
 HEMORRHAGE
Hemorrhage or (bleeding) is the escape of blood from the blood
vessels (artery, vein, capillary or heart) due to trauma, inflammation,
neoplasia or abnormal haemostasis.
Classification of Bleeding:
1- According to the Affected Vessels:
• Cardiac Bleeding: caused by penetrating wounds or rupture of the
ventricle as a result of myocardial infarction.
• Arterial Bleeding: caused by trauma or rupture of an aneurysm.
• Capillary Bleeding: caused by trauma or surgery, it also occurs in
diseases characterized by weakness of vessel walls e.g., Ehlers–
Danlos syndrome, vitamin C deficiency. and platelet disorders e.g.,
idiopathic thrombocytopenic purpura.
• Venous Bleeding: commonly caused by trauma or surgery.
2-According to the Site Bleeding:
• External Bleeding: bleeding outside the body or
extravasations into tissues with swelling, which is
called a hematoma.
• Internal Bleeding: Intra-cavitary, i.e., intraperitoneal
or intracranial bleeding that is not visible.
• Local Bleeding: Caused by trauma, inflammation,
neoplastic infiltration of blood vessels.
• Generalized Bleeding: caused by 1) clotting factor
deficiency, like hemophilia, DIC 2) platelet count
and functional abnormalities.
Important Terminology of bleeding:
Petechiae, Purpura, and Ecchymoses: All the three terms
refer to subcutaneous hemorrhages and mucosae.
• Petechiae: Pinpoint hemorrhages: smaller than one mm
• Purpura: measuring on (1 mm - 1 cm) in diameter
• Ecchymoses: larger than on1 cm.
Note that petechiae become confluent and give purpura or
ecchymoses. Moreover, the term purpura is used in several
diseases characterized by subcutaneous hemorrhages like
Thrombotic thrombocytopenic purpura (PTT) and
Henoch-Schonlein purpura
Hematoma:
Hematoma is a grossly visible extravasated blood in the
tissues. Firstly it is red, then as the blood is deoxygenated, it
becomes bluish, and as the RBCs are lysed and biliverdin is
formed, it gets greenish. Then biliverdin will be converted to
bilirubin which will give it a yellowish colour. After that, the
remnants of the RBC may be resorbed and the tissue resumes
its normal color, but sometimes iron pigment is formed and
taken up by macrophages and degraded into hemosiderin,
which gives the tissues a brownish color.
Colour of Mechanism
hematoma
Blueish Deoxygenation of hematoma
Greenish Lysis of RBCs and bilivirdin getting out

Yellowish Bilivirdin converted to bilirubin

Brownish Iron pigment from macrophages

Hemorrhages into Body Cavities:
such hemorrhages are named by combining the prefixes hem or
hemato (from Greek haima, ‘‘blood’’) and the anatomic site involved.
Accordingly,
Hematopericardium, hematothorax, and hemarthrosis can be easily
be understood as denoting bleeding into the pericardial, pleural, or
intraarticular space, respectively. Other terms are not so obvious, for
example, hematocephalus denotes accumulation of blood into the
ventricles of the brain and hematocolpos signifies accumulation of
blood in vagina in cases of imperforate hymen.
Hematuria: Hematuria is the appearance of blood in urine,
it may be classified as microscopic i.e., detectable by
microscope or macroscopic if visible to the naked eyes.
Hematuria may be a sign of renal or urinary tract lesions.
Hematemesis: Hematemesis is vomiting of blood, it is a
sign of ruptured esophageal varices, ulcer of the stomach and
duodenum.
Hemoptysis: bloody stained sputum, associated with
cough
 CONGESTION & HYPEREMIA
Definition: Both of them are local increase in volume of blood
in a particular tissue or organ with the following criteria
Hyperemia Congestion
Active process Passive process
Arteriolar dilatation Venous obstruction
Red color tissue Tissue is blue-red
Oxygenated blood Deoxygenated blood is
accumulated in the organ accumulated
Muscle exercise is an Heart failure and lung
example congestion
HYPEREMIA:
Hyperemia is an active process
resulting from an increased blood flow
into a tissue, due to arteriolar
vasodilatation. It commonly occurs in
exercising skeletal muscles or acute
inflammation. Affected tissue becomes
red, as there is engorgement with
oxygenated blood.
CONGESTION:
Congestion is a passive process resulting
from impaired outflow of blood in a tissue. It
occurs systemically as in cardiac failure or
locally as in isolated venous obstruction.
Affected tissue appears blue-red due to
accumulation of deoxygenated blood. In
long-standing congestion (also called
chronic passive congestion states), poorly
oxygenated blood causes hypoxia which
results in parenchyma cell degeneration or
cell death.
 Findings in Congested Organs:
Pulmonary Congestion:
Passive accumulation of blood in the lung due to left heart failure,
mitral stenosis...etc.
• In the acute type of congestion: Gross changes: include, heavy
firm dark lung and cut surface shows frothy hemorrhagic fluid on
squeezing. Microscopic changes: include, alveolar capillaries
engorged with blood, and septal edema.
• in chronic pulmonary congestion: Gross findings include brown
indurations of the lung. Microscopic findings include thickened &
fibrotic beaded alveolar septa, alveolar spaces contain hemosiderin-
laden macrophages (cardiac failure cells). Chronic pulmonary
congestion may result in pulmonary hypertension.
Hepatic Congestion:
• Acute Hepatic Congestion: Both central vein & sinusoids are distended ,
fatty changes in the middle zone, while peripheral hepatocytes are normal
because they are better oxygenated.
• Chronic Hepatic Congestion: gross changes including depressed central zone
with fatty changes. Liver appears red brown (nutmeg liver) i.e. similar to the cut
surafece of nutmeg seeds, portal zone is red, because of better oxygenation.
Microscopical changes include appearance of haemosiderin laden
macrophages.
in longstanding hepatic congestion, as in right sided cardiac failure, there is
fibrosis and loss of architecture called cardiac cirrhosis.