病理学（Pathology）－－－研究疾病的病因，发病机制，病理变化，结局和转归的基础学科．尸体剖检（Autopsy）简称尸检。活体组织检查（Biopsy）简称活检． Pathology (Pathology) - the study of the etiology of disease, pathogenesis, pathological changes, outcome and regression of the basic disciplines. Autopsy (Autopsy) referred to as autopsy. Biopsy (Biopsy) referred to as biopsy.
第一章 细胞和组织的适应与损伤 Chapter 1: Adaptation and Damage to Cells and Tissues
适应和损伤性变化都是疾病发生的基础性病理改变。 Both adaptive and injurious changes are pathologic alterations that underlie disease development.
适应：细胞和由其构成的组织，器官对内，外环境中各种有害因子（生理负荷过多／少）和刺激作用（轻度持续）而产生的非损伤性应答反应，表现为：萎缩，肥大，增生，化生 Adaptation: the non-invasive response of cells and their constituent tissues and organs to various harmful factors (physiological overload/underload) and stimuli (mild persistence) in the internal and external environments, manifested by atrophy, hypertrophy, hyperplasia, and metaplasia.
一．肥大：实质细胞，组织和器官的体积增大。 I. Hypertrophy: an increase in the size of parenchymal cells, tissues, and organs.
机制：生长因子 uarr\uparrow ，蛋白合成 uarr\uparrow Mechanism: growth factors uarr\uparrow , protein synthesis uarr\uparrow
生理性肥大 physiological hypertrophy
e．g．运动员，体力劳动者肌肉肥大，妊娠时子宫肥大 e. g. Athletes, muscle hypertrophy in manual workers, uterine hypertrophy in pregnancy
病理性肥大 pathological hypertrophy
代偿性肥大：如高血压时的心脏。 Compensatory hypertrophy: e.g., heart in hypertension.
内分泌性肥大：生长激素分泌过多导致的肢端肥大症。后果：可复性 Endocrine hypertrophy: acromegaly due to overproduction of growth hormone. Consequences: reversible
二．增生：器官或组织实质细胞的数量增多。 II. Hyperplasia: an increase in the number of parenchymal cells of an organ or tissue.
增生的原因：激素：如前列腺增生。 Causes of hyperplasia: hormones: e.g. prostate enlargement.
生长因子：如再生性增生。 Growth factors: e.g., regenerative hyperplasia.
代偿：如缺碘所致的甲状腺增生。 Compensation: e.g. thyroid hyperplasia due to iodine deficiency.
后果：可复性，修复，肿瘤性增生 Consequences: reversibility, repair, tumorigenic proliferation
三．萎缩：发育正常的实质细胞，组织和器官体积缩小。其本质是该组织，器官的实质细胞体积缩小或／和数量减少。 III. Atrophy: A reduction in the size of normally developed parenchymal cells, tissues and organs. It is essentially a reduction in the size or/and number of parenchymal cells of the tissue or organ.
萎缩的组织，器官体积常均匀性缩小，重量减轻，质地硬韧，色泽加深＂小＂，＂轻＂，＂韧＂，＂深＂光镜观察：（1）实质细胞体积缩小或／和数量减少（2）萎缩细胞胞浆内常有脂褐素增多（老年斑） Atrophied tissues, organs are often uniformly reduced in size, weight, hard and tough, deepened in color "small", "light", "tough", "darker "Light microscopic observation: (1) parenchymal cell volume or / and number of reduced (2) atrophic cell cytoplasm often lipofuscin increased (age spots)
（3）间质内纤维或／和脂肪组织增生（可能产生假性肥大）蛋白质合成减少，分解增加。电镜观察：萎缩细胞的细胞器减少，自噬泡增多。 (3) Proliferation of fibrous or/and adipose tissue in the interstitium (may produce pseudohypertrophy) Decreased protein synthesis and increased catabolism. Electron microscopy: reduced organelles and increased autophagic vesicles in atrophic cells.
分类：生理性萎缩 Classification: Physiological atrophy
病理性萎缩：营养不良性萎缩，缺血性萎缩（如脑动脉硬化导致脑萎缩）。压迫性萎缩（e．g．肾孟积水）。废用性萎缩．去神经性萎缩（小儿麻痹症）。内分泌性萎缩。 Pathological atrophy: dystrophic atrophy, ischemic atrophy (e.g. cerebral atrophy due to cerebral arteriosclerosis). Compressive atrophy (e.g., hydronephrosis). Wasting atrophy. Denervation atrophy (poliomyelitis). Endocrine atrophy.
后果：可复性，细胞消失 Consequences: reproducible, cells disappear
四。化生（metaplasia）一种分化成熟的细胞因受刺激作用而转化为另一种分化成熟细胞的过程。（只发生于同源性细胞之间），只出现于具有增生能力的组织细胞中 iv. Metaplasia (metaplasia) The process by which one type of differentiated mature cell is transformed into another type of differentiated mature cell as a result of a stimulus. (occurs only between cells of the same origin) and occurs only in tissue cells with the ability to proliferate
常见类型：鳞状上皮（复层扁平上皮）化生：常见于气管，支气管（吸烟），子宫颈，食管（返流）肠上皮化生：发生于慢性胃炎的胃粘膜化生为肠上皮。 Common types: squamous epithelium (complex flat epithelium) chemotaxis: common in trachea, bronchus (smoking), uterine cervix, esophagus (reflux) intestinal epithelial chemotaxis: occurs in chronic gastritis in which the gastric mucosa chemotaxis to intestinal epithelium.
骨组织化生：多见于间叶组织，纤维组织。 Bone tissue metaplasia: mostly in mesenchymal, fibrous tissue.
意义：1．有利于强化局部抗御环境因子刺激的能力。2．常削弱原组织本身功能。3．上皮化生可癌变。 （化生是一种对机体不利的适应性反应，应尽量消除引起化生的原因．） Significance: 1. It helps to strengthen the local resistance to the stimulation of environmental factors. 2. It often weakens the function of the original tissue itself. 3. The epithelial growths may be cancerous. (Pycnosis is an unfavorable adaptive response to the organism, and the causes of pycnosis should be eliminated as much as possible.)
细胞，组织损伤的原因： Cells, causes of tissue damage:
1 缺氧：使细胞代谢紊乱（main） 2 化学物质和药物 3 物理因素 4 生物因子（如病毒） 5营养失衡：生命必需物质的缺乏或过剩 6 内分泌因素 7 免疫反应 8 遗传变异 9 衰老 10社会—心理—精神因素：致心身疾病 11 医源性因素：致医源性疾病损伤的原理（了解）：细胞膜的破坏，线粒体的损伤，活性氧类物质（AOS）的损伤，细胞浆内高游离钙的损伤，缺血缺氧的损伤，化学性损伤，遗传变异 1 Hypoxia: disrupts cellular metabolism (MAIN) 2 Chemicals and drugs 3 Physical factors 4 Biological factors (e.g., viruses) 5 Nutritional imbalance: deficiency or excess of substances essential for life 6 Endocrine factors 7 Immune response 8 Genetic variation 9 Aging 10 Socio-psycho-psychological factors: cause psychosomatic disorders 11 Medical factors: cause Principles of injury in medical diseases (understand): disruption of cell membranes, damage to mitochondria, damage to reactive oxygen species (AOS), damage to cytoplasmic high free calcium, ischemic-hypoxic damage, chemical damage, genetic variations
缺血缺氧的损伤：钠泵功能下降，细胞吸水水肿，核糖体脱落，蛋白质合成减少，脂质沉积缺血－再灌注损伤：自由基过多，炎症，补体 Ischemic-hypoxic injury: decreased sodium pump function, cellular water uptake and edema, ribosome shedding, decreased protein synthesis, lipid deposition Ischemia-reperfusion injury: excess free radicals, inflammation, complement
损伤的形式：可逆性损伤（变性）不可逆性损伤（坏死） Forms of injury: reversible injury (degeneration) irreversible injury (necrosis)
变性（degeneration）是指细胞或细胞间质受损伤后因细胞代谢障碍所致的非致死性可逆性损伤，表现为细胞内或细胞间质内出现某些异常物质或正常物质异常蓄积，通常伴有细胞功能低下。蓄积的物质可以是：（1）过量的细胞固有成分（2）外源性，内源性物质（3）色素损伤的形态学改变 Degeneration is a non-lethal, reversible injury to cells or interstitial cells caused by impaired cellular metabolism, which is characterized by an abnormal accumulation of some abnormal or normal substances within the cells or interstitial cells, usually accompanied by cellular hypofunction. The accumulated substances can be: (1) excessive cellular intrinsic components (2) exogenous and endogenous substances (3) morphological changes of pigmentation damage.
（1）细胞水肿（cellular swelling）：细胞内水分增多导致细胞体积增大，胞浆疏松，透明浅染 (1) Cellular swelling: increased intracellular water leads to increased cell volume, loose cytoplasm, and light staining.
1）主要原因：感染，中毒，缺氧 1) Main causes: infection, poisoning, hypoxia
2）原理：能量代谢障碍，导致钠钾泵功能下降，胞内 Na+\mathrm{Na}+ 浓度高，吸水肿胀 (2) Principle: impaired energy metabolism, resulting in decreased sodium-potassium pump function, high intracellular Na+\mathrm{Na}+ concentration, and water absorption and swelling.
3）好发部位：心，肝，肾实质细胞（代谢旺盛） 3) Preferred site: heart, liver, kidney parenchymal cells (high metabolism)
4）结构特征：＂浑浊肿胀＂，切面边缘外翻隆起，似沸水淡过，空泡变性，线粒体肿胀染色淡，内质网扩张，多聚核糖体脱落 (4) Structural features: "turbid swelling", cut edges are ectopically elevated, resembling boiling water fading, vacuolar degeneration, mitochondria are swollen and pale in color, endoplasmic reticulum is dilated, and polysaccharides are detached
5）后果：可复性 5) Consequences: Reproducibility
（2）脂肪变（fatty change）甘油三酯（中性脂肪）在非脂肪细胞的细胞浆内蓄积。苏丹 III 染色为红色 (2) Fatty change (accumulation of triglycerides (neutral fats) in the cytoplasm of non-fat cells. Sudan III staining is red
1）主要原因：感染，中毒，缺氧等。 1) Main causes: infection, poisoning, hypoxia, etc.
2）结构特征：＂大黄软＂，光镜见胞内有脂质，电镜看到脂质小体 2) Structural features: "rhubarb soft", intracellular lipids seen by light microscopy, lipid vesicles seen by electron microscopy
3）好发部位：肝，心，肾实质细胞。 (3) Preferred sites: liver, heart, kidney parenchymal cells.
例：脂肪变的黄色条纹与未脂变的暗红色心肌相间，形似虎皮斑纹，称为虎斑心。 Example: The yellow streaks of fatty degeneration are interspersed with the dark red myocardium of unfatty degeneration, resembling tiger skin markings, and are called tiger heart.
脂肪肝的发生：营养不良导致载脂蛋白下降，脂肪摄入过量，脂肪酸氧化受阻（如摄入酒精） Development of fatty liver: decreased apolipoproteins due to malnutrition, excessive fat intake, impaired fatty acid oxidation (e.g., alcohol intake)
肾小管上皮细胞脂肪变：肾小管上皮细胞重吸收脂蛋白增多 Renal tubular epithelial cell steatosis: increased lipoprotein reabsorption by renal tubular epithelial cells
泡沫细胞：巨噬细胞吞噬了大量被破坏细胞释放的脂质而形成 Foam cells: formed when macrophages phagocytose large amounts of lipids released by destroyed cells
（3）玻璃样变（hyaline change）：也称透明变／透明变性，指细胞内，纤维结缔组织和血管壁等处出现均质，红染，毛玻璃样半透明的蛋白质蓄积。 (3) glassy change (hyaline change): also known as hyaline change / hyaline degeneration, refers to the intracellular, fibrous connective tissue and blood vessel walls, etc., the appearance of homogeneous, reddish-stained, hairy glass-like translucent protein accumulation.
类型：细胞内玻璃样变：即细胞浆内出现异常蛋白质形成的均质红染的近圆形小体。如肾小管上皮，浆细胞（Russell 小体），肝细胞（酒精性肝炎，Mallory 小体），神经元 Type: Intracellular vitellosis: i.e., the presence of homogeneous, reddish-stained, subcircular vesicles formed by abnormal proteins in the cell plasma. Examples include renal tubular epithelium, plasma cells (Russell's vesicles), hepatocytes (alcoholic hepatitis, Mallory's vesicles), and neurons.
纤维结缔组织玻璃样变：胶原纤维老化的表现。 Fibrous connective tissue vitellosis: a manifestation of collagen fiber aging.
细动脉壁玻璃样变 A．常见于缓进性高血压（良性高血压）和糖尿病患者 B．玻璃样变动脉壁均质红染，增厚，管腔狭窄。 Vitrified artery wall A. Common in patients with slowly progressive hypertension (benign hypertension) and diabetes mellitus B. Vitrified artery wall is homogeneously reddish-stained, thickened, and lumen narrowed.
（4）淀粉样变（amyloidosis）细胞外间质内蛋白质—粘多糖复合物沉积。HE 染色呈淡红色均质状，云雾状，遇碘呈赤褐色，同淀粉，刚果红染色呈橘红色 (4) amyloidosis (amyloidosis) deposition of protein-mucopolysaccharide complexes in the extracellular mesenchyme. HE staining is reddish homogeneous, cloudy, russet when exposed to iodine, the same as amylose, and Congo red staining is orange.
实例：原发性——多发性骨髓瘤，慢性炎症，继发性——AD，甲状腺髓样癌组织，2型糖尿病的胰岛 Examples: primary - multiple myeloma, chronic inflammation, secondary - AD, medullary thyroid cancer tissue, pancreatic islets in type 2 diabetes mellitus
（5）粘液样变（mucoid degeneration）间质内粘多糖和蛋白质的蓄积。常见于间叶组织肿瘤，风湿病，动脉粥样硬化，甲状腺激素减少。在皮下组织黏液样变时脂肪组织分界不明显 (5) mucoid degeneration (mucopolysaccharide and protein accumulation in the mesenchyme. Commonly seen in mesenchymal tumors, rheumatic diseases, atherosclerosis, thyroid hormone reduction. In the subcutaneous tissue mucoid degeneration of adipose tissue demarcation is not obvious.
（6）病理性色素沉着：有色物质在细胞内，外的异常蓄积。 (6) Pathological hyperpigmentation: abnormal accumulation of colored substances inside and outside cells.
包括：含铁血黄素（产自血红蛋白代谢衍生物，由于毛细血管破裂出血或发生溶血现象时，红细胞被巨噬细胞吞噬，以含铁血黄素的方式沉积） Includes: ferric hemoflavin (from metabolic derivatives of hemoglobin, deposited as ferric hemoflavin by macrophages as a result of phagocytosis of erythrocytes in the event of bleeding from ruptured capillaries or hemolysis).
脂褐素（老年斑） Lipofuscin (age spots)
黑色素（恶性黑色素瘤，凶险） Melanin (malignant melanoma, aggressive)
胆红素（黄疸） Bilirubin (jaundice)
（7）病理性钙化：软组织内（即除骨组织和牙齿以外的组织）固体性钙盐的异常蓄积。光镜下 HE 染色为蓝色细颗粒聚集。 (7) Pathological calcification: Abnormal accumulation of solid calcium salts in soft tissues (i.e., tissues other than bone and teeth). Light microscopic HE staining shows aggregates of fine blue particles.
（1）营养不良性钙化：继发于局部坏死或即将坏死的组织或异物的异常钙盐沉积。体内钙，磷代谢 (1) Dystrophic calcification: Abnormal calcium salt deposition secondary to localized necrosis or impending necrosis of tissue or foreign bodies. Body calcium, phosphorus metabolism
正常。（结核，脂肪坏死，斑块，瘢痕，血栓） Normal. (tuberculosis, fat necrosis, plaque, scarring, thrombosis)
（2）转移性钙化：由于全身钙，磷代谢障碍所致正常组织内的多发性钙化。 (2) Metastatic calcification: multiple calcifications in normal tissues due to systemic calcium and phosphorus metabolism disorders.
发生于细胞内的变性：细胞水肿，脂肪变性，玻璃样变性，病理性钙化，病理性色素沉着 Degeneration occurring within cells: cellular edema, lipoatrophy, vitreous degeneration, pathologic calcification, pathologic hyperpigmentation
发生于细胞外的变性：玻璃样变性，病理性钙化，病理性色素沉着 Degeneration occurring outside the cell: vitreous degeneration, pathologic calcification, pathologic hyperpigmentation
细胞死亡：细胞因受严重损伤而累及胞核时，呈现代谢停止，结构破坏和功能丧失等不可逆性变 Cell death: When cells are severely damaged and the nucleus is involved, they show irreversible changes such as metabolic arrest, structural damage and loss of function.
化。 分为：坏死和调亡 Chemistry. Divided into: necrosis and tonization
坏死（necrosis）活体内局部细胞的死亡。死亡细胞代谢停止，功能丧失，结构自溶，并引发炎症反应，是不可逆性变性。 Necrosis (necrosis) Localized cell death in the living body. Dead cells are irreversibly degenerated by metabolic arrest, loss of function, structural autolysis, and triggering an inflammatory response.
基本病变：（1）核固缩，碎裂，溶解（ghost cell）（2）胞膜破裂，细胞解体，消失（3）间质胶原肿胀，崩解，液化，基质解聚（4）坏死灶周围有炎症反应。 Basic lesions: (1) nuclear consolidation, fragmentation, and lysis (ghost cell) (2) rupture of the cell membrane, cell disintegration, and disappearance (3) swelling, disintegration, liquefaction, and matrix depolymerization of interstitial collagen (4) inflammatory reaction around the necrotic foci.
凝固性坏死：A．常见于心，肾，脾，肝等器官 B．多因缺血引起 C．肉眼观为与周围分界清楚 D．光镜观为细胞结构消失，外形和组织轮廓可辨 E．其发生可能系坏死局部酸中毒致结构蛋白和酶蛋白变性，封闭蛋白质溶解过程之故。 Coagulative necrosis: A. Commonly found in the heart, kidney, spleen, liver and other organs B. Mostly caused by ischemia C. Clearly demarcated from the surrounding area with the naked eye D. Light microscopic view of the disappearance of cellular structure, the shape and outline of the tissue can be discerned E. The occurrence of this may be due to the necrosis of the local acidosis caused by the structural proteins and enzyme proteins to denature, closed the process of proteolysis.
干酪样坏死（caseous necrosis），特殊的凝固性坏死 A．是结核病的特征性病变 B．肉眼观似奶酪或豆渣 C．光镜观细胞和组织结构均崩解破坏，消失，呈现无定形，颗粒状的红染物。 Caseous necrosis, special coagulative necrosis A. is a characteristic lesion of tuberculosis B. looks like cheese or bean curd to the naked eye C. light microscopy shows disintegration and destruction of cellular and tissue structures, disappearance of amorphous, granular, reddish-stained material.
液化性坏死：A．坏死组织呈液态；B．好发于蛋白质少，脂质多，蛋白酶多，水，磷脂多的病灶，如脑，胰腺 C．原因：化脓菌感染，嗜中性粒细胞渗出，释放水解酶，组织水解成脓肿脂肪坏死：A．酶解性：见于急性胰腺炎，形成钙皀。 B．创伤性：好发于皮下脂肪组织。 Liquefactive necrosis: A. Necrotic tissue is liquid; B. Prevalent in lesions with little protein, more lipids, proteases, water, and phospholipids, e.g., brain, pancreas C. Causes: Septic bacterial infections, neutrophilic exudation, release of hydrolases, and hydrolysis of the tissue into an abscess Fatty necrosis: A. Enzymatically resolvable: seen in acute pancreatitis, with formation of a calcareous fibres. B. Traumatic: occurs in subcutaneous adipose tissue.
纤维素样坏死：A．结缔组织和血管壁内出现细丝状，小块状或环状红染的纤维素样物。 Fibrinoid necrosis: A. The presence of filamentous, small, or ring-shaped reddish-stained fibrinoid material within connective tissue and vessel walls.
B．是结缔组织病和急进性高血压的特征性病变。 C．多系崩解的胶原纤维，免疫球蛋白或免疫复合物及纤维蛋白的混合物。 B. It is a characteristic lesion of connective tissue disease and acute hypertension. C. It is mostly a mixture of disintegrating collagen fibers, immunoglobulins or immune complexes, and fibrin.
坏疽（gangrene）身体与外界相通部位的较大范围坏死合并腐败菌感染（黑＋臭）。分类：分为干性，湿性，气性三种，其比较如下。 Gangrene (gangrene) A large-scale necrosis of the part of the body connected to the outside world combined with a putrefactive bacterial infection (black + smelly). Classification: There are three types: dry, wet, and gas, which are compared as follows.
类型 typology
好发部位 favored location
原因 rationale
病变特点 Characteristics of the lesion
全身中毒症状 systemic symptoms of poisoning
干性坏疽 gangrene
四肢（尤其下肢），体表 Extremities (especially lower extremities), body surface
A 缺血，V通畅（缺血性坏死） A Ischemia, V patency (ischemic necrosis)
干缩，黑褐色分界清楚 Dryness, dark brown well demarcated
轻或无 Light or no
湿性坏疽 wet gangrene
与体表相通的内脏，如肺．肠．子宫．胆囊 Internal organs that are connected to the surface of the body, such as the lungs. Intestines. Uterus． gallbladder
A，V 均阻塞 A, V are blocked
湿润，肿胀，黑褐或边缘分界不清楚 Moist, swollen, dark brown or poorly demarcated margins
重，明显 Heavy, obviously
气性坏疽 gas gangrene
深部肌组织－凝固性坏死 Deep muscle tissue - coagulative necrosis
创伤伴厌氧产气英膜杆梭状芽孢杆菌感染 Trauma with anaerobic gas-producing Clostridium perfringens infection
肿胀，污秽，蜂窝状，捻发音分界不清 Swelling, smudging, honeycombing, poorly demarcated by twisting and pronation
结局： 1 溶解吸收：小灶性坏死经酶解液化被淋巴管，血管吸收或被吞噬细胞吞噬。2分离，排出：形成缺损（溃疡与空洞） 3\mathbf{3} 机化（organization）：坏死组织或其它异物被肉芽组织取代，逐渐纤维化的过程。 4 包裹（encapsulation）与钙化：指仅发生较大范围坏死和异物周边的机化过程。 Endings: 1 dissolution and absorption: small foci of necrosis are enzymatically liquefied and absorbed by lymphatic vessels, blood vessels, or phagocytosed.2 separation, drainage: formation of defects (ulcers and cavities) 3\mathbf{3} Mechanization: the process by which necrotic tissue or other foreign bodies are replaced by granulation tissue and progressively fibrotic. 4 encapsulation (encapsulation) and calcification: refers to the process of mechanization that occurs only in the larger periphery of necrosis and foreign bodies.
凋亡（apoptosis）是指活体内单个细胞或小团细胞的死亡。死亡细胞的质膜不破裂，不引发死亡细胞自溶，不引发急性炎症反应。 Apoptosis (apoptosis) is the death of a single cell or a small group of cells in the living body. The plasma membrane of dead cells does not rupture, does not trigger autolysis of dead cells, and does not trigger an acute inflammatory response.
1）发生机制：与基因调节有关，也称为程序性细胞死亡 1) Mechanism of occurrence: related to gene regulation, also known as programmed cell death
2）形态特点：（1）细胞固缩。（2）染色质凝聚，DNA 分解为 180－200bp 的条段。（3）胞浆芽突及凋亡小体形成。（4）巨噬细胞吞噬凋亡小体。 (2) Morphological characteristics: (1) cell shrinkage. (2) Chromatin condensation, DNA decomposition into 180-200bp segments. (3) Cytoplasmic budding and apoptotic vesicle formation. (4) Macrophages phagocytose apoptotic vesicles.
3）生理意义：维持正常器官的大小和功能，参与器官发育和改建，但凋亡不足引起恶性肿瘤，病毒感染可以引起过度凋亡（如 HIV 使得 T cell 过度凋亡） 3) Physiological significance: maintain normal organ size and function, participate in organ development and remodeling, but insufficient apoptosis causes malignant tumors, viral infections can cause excessive apoptosis (e.g., HIV causes excessive apoptosis of T cells)
凋亡与坏死的区别：核，质，膜，炎症反应，基因调控，发生条件，生化改变（坏死的细胞器肿胀，调亡的致密，膜完整） Difference between apoptosis and necrosis: nuclear, plasma, membrane, inflammatory response, gene regulation, conditions of occurrence, biochemical alterations (necrotic organelles are swollen, tonic ones are dense, membrane is intact)
第二章 损伤的修复 Chapter II. Repair of Injuries
损伤的修复：损伤造成机体部分细胞和组织丧失后，机体对所形成的缺损进行修补恢复的过程若能完全恢复原组织的功能，则称为完全再生 Repair of damage: After the loss of part of the body's cells and tissues due to damage, the process of repairing and restoring the defects formed by the body is called complete regeneration if it can completely restore the function of the original tissue
修复的形式： Forms of restoration:
再生（regeneration）：由损伤周围的同种细胞来修复，包括生理性再生，病理性再生 Regeneration: repair by the same kind of cells around the damage, including physiological regeneration, pathological regeneration
如果完全恢复原组织的功能，则为完全再生 Regeneration is complete if it fully restores the function of the original tissue
纤维性修复：由纤维结缔组织来修复 Fibrous repair: by fibrous connective tissue
再生：按再生能力的强弱： 1 ．不稳定细胞（持续分裂细胞）：具有很强的再生能力，如表皮，呼吸道，消化道粘膜上皮，淋巴及造血细胞，间皮细胞，骨髓内细胞等。 Regeneration: According to the strength of regenerative ability: 1. Unstable cells (continuously dividing cells): strong regenerative capacity, such as epidermis, respiratory tract, digestive tract mucosal epithelium, lymphatic and hematopoietic cells, mesothelial cells, cells in the bone marrow, and so on.
2．稳定细胞：在生理情况下，这类细胞在细胞增生周期中处于静止期（G0），但受到损伤刺激时，则进入 DNA 合成前期（G1），表现出较强再生能力，如肝，胰，涎腺，内分泌腺，汗腺，皮脂腺，肾小管上皮。 2. Stable cells: Under physiological conditions, these cells are in the quiescent phase (G0) of the cell proliferation cycle, but when stimulated by injury, they enter the pre-DNA synthesis phase (G1) and show strong regenerative capacity, e.g., liver, pancreas, salivary glands, endocrine glands, sweat glands, sebaceous glands, and renal tubular epithelium.
3．永久性细胞：无再生能力或再生力极弱，如神经细胞，横纹肌细胞及心肌细胞。 3. Permanent cells: no or very weak regenerative capacity, such as nerve cells, transverse muscle cells and cardiac muscle cells.
再生的组织： Regenerated tissue:
a．被覆上皮和腺上皮：当腺体的基底膜末被破坏时，可以完全恢复，反之则难以再生，e．g．肝小叶的网状支架若坏死塌陷，则难以恢复，形成纤维结缔组织，肝硬化。 a. Covered epithelium and glandular epithelium: when the basement membrane of the glands is destroyed at the end, it can be completely restored, and vice versa, it is difficult to regenerate. e. g. The reticular scaffolding of the hepatic lobules is difficult to restore if it is necrotic and collapses, and fibrous connective tissue is formed, cirrhosis of the liver.
b．骨组织：再生能力强，骨折可完全修复 b. Bone tissue: high regenerative capacity, fractures can be fully repaired
c．血管：生芽或播种生根的方式 c. Vascularization: sprouting or rooting by seeding
d．肌组织：再生能力弱，当完全断开时，靠纤维癩痕愈合 d. Muscle tissue: weak regenerative capacity, healing by fibrous bald patches when completely disconnected
e．神经组织：中枢神经不可再生（胶质㓔痕），外周神经可以（完全）再生，是断肢再植的基础 e. Nervous tissue: central nerves are not regenerable (glial scars), peripheral nerves can be (fully) regenerated and are the basis of amputation replantation
纤维性修复 Fibrous repair
过程为：肉芽组织增生 rarr\rightarrow 溶解，吸收坏死组织及异物 rarr\rightarrow 转化成以胶原纤维为主的瘏痕组织。肉芽组织（granulation tissue）由新生薄壁的毛细血管以及增生的纤维母细胞构成，并伴有大量渗出液和炎细胞（以巨噬细胞为主），肉眼观为鲜红色，颗粒状，柔软湿润，形似鲜嫩的肉芽，＂红粒软湿＂。 The process of granulation tissue proliferation rarr\rightarrow lysis, absorption of necrotic tissue and foreign material rarr\rightarrow and transformation into collagen fiber-based scar tissue. Granulation tissue (granulation tissue) by the new thin-walled capillaries and hyperplasia of fibroblasts, with a large amount of exudate and inflammatory cells (macrophage-based), the naked eye view of bright red, granular, soft and moist, similar to the shape of the tender buds of meat, "red grains of soft and wet".
肉芽组织由三种成分构成：（1）新生的毛细血管（2）纤维母细胞（3）炎细胞。 Granulation tissue consists of three components: (1) newborn capillaries (2) fibroblasts (3) inflammatory cells.
肉芽组织的作用：（1）抗感染保护创面（2）填补创口及其它组织缺损（3）机化或包裹坏死组织，血栓及其它异物。 The role of granulation tissue: (1) anti-infection to protect the wound (2) fill the wound and other tissue defects (3) mechanization or encapsulation of necrotic tissue, thrombus and other foreign bodies.
结局：肉芽组织长出后 1 周逐渐成熟，最终转变为瘟痕组织，胶原纤维增多，纤维母细胞转为纤维细胞，此外可有少量淋巴细胞及浆细胞。 Outcome: The granulation tissue matures in 1 week and eventually transforms into plague tissue with increased collagen fibers, fibroblasts to fibroblasts, and a small number of lymphocytes and plasma cells.
縻痕（scar）组织是指肉芽组织经改建成熟形成的纤维结缔组织。由大量平行或交错分布的胶原纤维束组成。 Any tie scar (scar) tissue is the fibrous connective tissue formed by the alteration and maturation of granulation tissue. It consists of a large number of collagen fiber bundles distributed in parallel or staggered.
大体是局部呈收缩状态，原因是肉芽组织有细肌丝，有平滑肌的收缩功能，有利于创面减小对机体的影响包括两个方面： The reason for the largely localized state of contraction is that the granulation tissue has fine muscle filaments with smooth muscle contractile function, which facilitates trauma reduction The effect on the organism consists of two aspects:
1，对机体有利的一面：（1）填补并连接伤口或缺损（2）使组织器官保持其坚固性。 1, Beneficial to the organism: (1) Filling and connecting wounds or defects (2) Keeping tissues and organs in their firmness.
2，对机体不利的一面：（1）瘡痕收缩，引起器官活动受限或梗阻（2）痸痕性粘连，器官内广泛损伤导致广泛纤维化玻璃样变，可引起器官硬化（3）瘏痕组织增生过度（瘷痕体质），可形成瘢痕疮㾑。创伤愈合：是指机体遭受外力作用，皮肤等组织出现离断或缺损后的愈合过程，包括组织再生，肉芽组织增生和曒痕形成。 2, the adverse side of the body: (1) scar contraction, causing organ activity restriction or obstruction (2) scar adhesions, extensive damage in the organ leading to extensive fibrosis vitreous lesions, can cause organ sclerosis (3) excessive proliferation of scar tissue (scarred body), can form keloid sores ����������. Trauma healing: refers to the healing process after the body is subjected to external forces and the skin and other tissues become severed or defective, including tissue regeneration, granulation tissue proliferation and scar formation.
（一）皮肤创伤愈合的基本过程： (i) The basic process of skin wound healing:
1．伤口的早期变化：伤口处出现炎症反应，充血，浆液，WBC 渗出，局部红肿， 3 天后巨潄细胞出现。 1. Early changes in the wound: Inflammatory reaction in the wound, congestion, plasma, WBC exudation, localized redness and swelling, appearance of giant weezy cells after 3 days.
2．伤口收缩：伤口边缘的皮肤及皮下组织向中心移动，伤口缩小，这是由于伤口边缘处新生的肌纤维母细胞牵引作用所致。（2－3d） 2. Wound contraction: the skin and subcutaneous tissues at the wound edge move towards the center and the wound shrinks, due to the traction effect of the newborn myofibroblasts at the wound edge. (2-3d)
3．肉芽组织增生和瘢痕形成：损伤后 3 天开始出现肉芽组织，以后胶原纤维形成活跃，损伤后一个月瘢痕完全形成。 3. Granulation tissue proliferation and scar formation: granulation tissue begins to appear 3 days after the injury, then collagen fiber formation is active, and the scar is completely formed one month after the injury.
4．表皮及其他组织再生 4. Epidermal and other tissue regeneration
（2）创伤愈合的类型 (2) Types of wound healing
1．一期愈合：见于组织缺损少，创缘整齐，无感染，经粘合或缝合后创面对合严密的伤口。其特点是；愈合时间短，留下瘢痕少。 1. One-stage healing: seen in the tissue loss is small, the edge of the wound is neat, no infection, by bonding or suture after the creation of a tightly closed wound. It is characterized by short healing time and less scarring.
2．二期愈合：见于组织缺损较大，创缘不整，哆开，无法整齐对合，或伴有感染的伤口。其特点是：（1）伤口需清创（2）愈合时间长（3）形成㓔痕大。 2. Second-stage healing: seen in large tissue defects, uneven margins, do open, can not be neatly aligned, or with infection of the wound. It is characterized by: (1) the wound needs to be debrided (2) the healing time is long (3) the formation of 㓔 scar is large.
（3）影响创伤愈合的因素：年龄，营养，感染与异物，局部血液循环，神经支配，电离辐射 （二）骨折愈合的基本过程： (3) Factors affecting wound healing: age, nutrition, infection and foreign bodies, local circulation, innervation, ionizing radiation (2) Basic process of fracture healing:
1．血肿形成。 1. Hematoma formation.
2．纤维性骨痂形成：肉芽组织机化血肿，继而发生纤维化，形成纤维性骨痂，又称暂时性骨痂。 3．骨性骨疵形成。 2. Fibrous bone scab formation: granulation tissue mechanized hematoma, followed by fibrosis, the formation of fibrous bone scab, also known as temporary bone scab. 3. Bony bone defect formation.
4．骨㾐改建或再塑：改建是在破骨细胞的骨质吸收及骨母细胞新骨质形成的协调作用下完成的。骨折愈合除了需要创伤愈合的条件外，还需要断端及时正确复位，牢靠的固定，早日锻炼，恢复血供 4. Bone remodeling or remodeling: remodeling is accomplished under the coordinated action of bone resorption by osteoclasts and new bone formation by osteoblasts. In addition to the conditions of trauma healing, fracture healing also requires timely and correct repositioning of the broken end, secure immobilization, early exercise, and restoration of blood supply.
第三章 局部血液循环障碍 Chapter 3 Local circulation disorders
正常血循环的意义：保持机体内环境稳定，各器官新陈代谢和正常进行 The significance of normal blood circulation: to maintain the stability of the internal environment of the body, the metabolism of various organs and normal progress
局部性血液循环障碍表现：（1）血管内成分逸出血管外（水肿，积液，出血）（2）局部组织内循环血量的异常（充血，淤血，缺血）（3）血液内出现异常物质（血检和血管内空气，脂滴和羊水） Localized circulatory disorders: (1) escape of intravascular components from the blood vessels (edema, effusion, hemorrhage) (2) abnormalities in the amount of circulating blood in the local tissues (congestion, bruising, ischemia) (3) the presence of abnormal substances in the bloodstream (blood tests and intravascular air, lipid droplets and amniotic fluid).
一，充血（hyperemia） I. Congestion (hyperemia)
Def：器官或组织因动脉输入血量的增多而发生的充血，称为动脉性充血，简称充血。广义上说，充血是局部组织血管内血液含量增多即为充血（包括动静脉） Def: Congestion that occurs in an organ or tissue as a result of increased blood input from an artery is called arterial congestion, or simply congestion. Broadly speaking, congestion is defined as an increase in the blood content within the blood vessels of a local tissue (including arteries and veins)
特点：为主动过程，表现为局部组织或器官小动脉及毛细血管扩张，血液输入量增加。 Characteristics: An active process, manifested by dilation of small arteries and capillaries in local tissues or organs and increased blood input.
原因：神经体液因素导致舒血管神经兴奋性增高，缩血管神经兴奋性降低分类： Causes: Neurohumoral factors leading to increased excitability of the diastolic nerves and decreased excitability of the constrictor nerves Classification:
生理性充血：为适应器官和组织生理需要和代谢增强而发生的充血，称为生理性充血（进食后胃肠道粘膜充血，活动时骨骼肌充血，妊娠时子宫充血） Physiological congestion: congestion that occurs in response to the physiological needs of organs and tissues and increased metabolism is called physiological congestion (gastrointestinal mucosal congestion after eating, skeletal muscle congestion during activity, uterine congestion during pregnancy)
病理性充血：（1）炎症性充血（致炎因子使舒血管神经兴奋）（2）减压后充血（大量抽放腹水） Pathologic congestion: (1) inflammatory congestion (excitation of the vasorelaxing nerves by inflammatory factors) (2) congestion after decompression (massive evacuation of ascites)
侧支循环性充血。 Collateral circulation congestion.
病变：大体：充血的组织，器官，体积轻度增大，体表红热＂大红热旺扩＂ Lesions: gross: congested tissues, organs, mild increase in size, red heat on the surface of the body "large red heat expanding
镜下：局部细动脉及毛细血管扩张，充血 Microscopy: local dilatation of fine arteries and capillaries, congestion
结局：1．一般为短暂反应，促进局部代谢，抗炎，对机体无不良后果。2．导致血管破裂出血。 Endings: 1. Generally transient reactions, promoting local metabolism, anti-inflammatory, with no adverse consequences for the body. 2. Leads to rupture of blood vessels and hemorrhage.
二，淤血（congestion） II. Bruising (congestion)
器官或组织由于静脉回流受阻，血液淤积于毛细血管和小静脉内，称为淤血，也称静脉性充血。 Blood pooling in capillaries and small veins in organs or tissues as a result of obstruction of venous return is called bruising, or venous congestion.
特点：为被动过程 分为：全身性淤血 局部性淤血 Characteristics: passive process Divided into: generalized bruising localized bruising
淤血发生的原因： Reasons for the occurrence of bruising:
1．静脉受压：静脉受压其管腔变狭窄或闭塞，血液回流受阻而致。 1. Venous compression: venous compression narrows or occludes the lumen of the vein and impedes the return of blood.
2．静脉腔阻塞：血栓形成或肿瘤细胞瘤栓可阻塞静脉而引起淤血。 2. Venous lumen obstruction: thrombosis or tumor cell tumor embolus can block the vein and cause bruising.
3．心力衰竭：心脏不能排出正常容量的血液进入动脉，心腔内血液滞留，压力增高，阻碍了静脉的回流，造成淤血。 3. Heart failure: the heart is unable to discharge the normal volume of blood into the arteries, blood stagnation in the heart chambers, increased pressure, impeding the return of the veins, resulting in stagnation.
4．深静脉瓣膜功能不全 4. Deep vein valve insufficiency
病变： Lesions:
大体：器官肿胀，呈暗紫红色（还原血红蛋白增加），出现发绀，淤血性水肿，浆膜腔积液，淤血性出血 Gross: organs are swollen and dark purplish red (increased reduced hemoglobin), cyanosis, bruised edema, fluid in the plasma cavities, bruised hemorrhage
镜下：局部毛细血管扩张，过多的红细胞积聚。含铁血黄素细胞－吞噬血红蛋白的巨噬细胞 Microscopy: localized capillary dilatation and accumulation of excess red blood cells. Iron-containing hemosiderin cells-macrophages that phagocytose hemoglobin
结局：取定于器官／组织的性质，淤血的程度，淤血时间长短。 1．短时间淤血：后果轻微，诱因去除后可恢复正常。2．长时间淤血：发生变性，萎缩，甚至坏死。肝和肺的慢性淤血，导致组织内网状纤维胶原化和纤维组织增生，因而质地逐渐变硬，造成淤血性硬化。 Outcome: Depends on the nature of the organ/tissue, the degree of bruising, and the duration of the bruising. 1. Short-term bruising: minor consequences, return to normal after removal of the causative agent. 2. Prolonged bruising: degeneration, atrophy, or even necrosis. Chronic bruising of the liver and lungs leads to collagenization of reticular fibers and proliferation of fibrous tissue in the tissues, and thus the texture gradually hardens, resulting in bruising sclerosis.
体循环淤血及重要器官的淤血 Bruising of the circulation and vital organs
1．肺淤血（1）病因：左心衰导致肺静脉回流受阻。 1. Pulmonary stasis (1) Etiology: Left heart failure leading to obstruction of pulmonary venous return.
（2）病理改变：（1）大体：肺体积增大，暗红色，切面流出泡沫状红色血腥液体；慢性肺淤血，肺质地硬，棕褐色，称为肺褐色硬化。（2）镜下：急性：肺泡壁毛细血管扩张充血，肺泡间隔水肿，肺泡腔充满水肿液及出血。慢性：肺泡壁毛细血管扩张充血，肺泡壁变厚及纤维化，肺泡腔充满水肿液，出血，并见心衰细胞（heart failure cells）：含有含铁血黄素颗粒的巨噬细胞。 (2) Pathological changes: (1) Grossly: increased lung volume, dark red, cut surface outflow of foamy red bloody fluid; chronic pulmonary siltation, the lung texture is hard, brown, known as pulmonary brown sclerosis. (2) Microscopic: acute: alveolar wall capillary dilatation and congestion, alveolar septum edema, alveolar cavity filled with edema fluid and hemorrhage. Chronic: alveolar wall capillary dilatation and congestion, alveolar wall thickening and fibrosis, alveolar cavity filled with edema fluid, hemorrhage, and see heart failure cells (heart failure cells): macrophages containing ferritin-containing particles.
（3）临床体症：患者气促，缺氧，发绀，咳粉红色泡沫痰。 (3) Clinical signs: the patient was short of breath, hypoxic, cyanotic, and coughed up pink foamy sputum.
2．肝淤血 病因：右心衰导致。 2. Hepatic stasis Etiology: caused by right heart failure.
病理改变：①大体：急性：体积增大，暗红色。 慢性：槟榔肝（nutmeg liver）淤血性肝硬化 Pathologic changes: ① Gross: acute: increased size, dark red. Chronic: betel nut liver (nutmeg liver) silty cirrhosis
（2）镜下：急性期：中央静脉及肝窦出现扩张淤血，严重时肝小叶中央区发生出血和坏死，小叶外周带细胞出现脂肪样变性。 (2) Microscopic: acute stage: central vein and hepatic sinusoids appear dilated and stagnant; in severe cases, hemorrhage and necrosis occur in the central area of the liver lobules, and the cells in the peripheral band of the lobules appear steatotic degeneration.
慢性：1．小叶中央区淤血严重呈暗红色，肝细胞变性，萎缩或消失，小叶外围肝细胞出现脂肪变，这种淤血和脂肪变的改变，在肝切面上构成红黄相间的网络状图纹，形似槟榔，称为槟榔肝。 Chronic: 1. The central area of the lobules is heavily bruised in dark red, the hepatocytes are degenerated, atrophied or disappeared, and the peripheral hepatocytes of the lobules appear steatotic; this bruising and steatotic change constitutes a red and yellow network pattern on the liver section, which resembles a betel nut, and it is called betel nut liver.
2．肝细胞萎缩，坏死，网状纤维网架塌陷继而胶原化，窦周细胞（又称贮脂细胞）增生并转化成肌纤维母细胞，合成胶原纤维，最终肝脏变硬－淤血性肝硬化，也称心源性肝硬化。 2. Hepatocyte atrophy, necrosis, reticulofibrillar network collapse followed by collagenization, perisinusoidal cells (also known as lipid storage cells) proliferation and transformation into myofibroblasts, synthesis of collagen fibers, and ultimately liver hardening-silent cirrhosis, also known as cardiogenic cirrhosis.
肝门静脉受阻，将引起脾淤血，血吸虫病也会引起肝脾肿大 Obstruction of the hepatic portal vein will cause splenic stasis, and schistosomiasis will also cause hepatosplenomegaly
淤血的结局：水肿出血，萎缩变性坏死硬变，侧支循环的开放，纤维组织增生，网状组织胶原化，淤血性硬化 Outcome of bruising: edema and hemorrhage, atrophic degeneration and necrotic sclerosis, opening of collateral circulation, fibrous tissue proliferation, collagenization of reticular tissue, bruising sclerosis
三，出血：血液从血管或心腔中逸出。分类：内出血（组织间隙，体腔），外出血（体外） Third, hemorrhage: the escape of blood from a blood vessel or heart chamber. Classification: internal bleeding (tissue spaces, body cavities), external bleeding (outside the body)
按出血机制分类：破裂性出血 漏出性出血 Classification by bleeding mechanism: rupture bleeding Leakage bleeding
1）生理性出血：子宫内膜周期性出血。 1) Physiologic bleeding: cyclic bleeding from the endometrium.
2）病理性出血：创伤，血管病变，出血性疾病。 2) Pathological bleeding: trauma, vascular lesions, bleeding disorders.
病理变化：A．内出血 体腔积血：心包，胸腔，腹腔，关节腔。 血肿：组织内局限性大出血，硬膜下，皮下血肿。 Pathological changes: A. Internal hemorrhage Hematochezia in body cavities: pericardial, thoracic, abdominal, and articular cavities. Hematoma: limited hemorrhage in tissues, subdural, subcutaneous hematoma.
B．外出血（血液流出体表）鼻衄，咯血，呕血，便血，尿血，淤点，紫癜，淤斑 B. External hemorrhage (blood flowing out of the body) epistaxis, hematemesis, hematemesis, vomiting blood, blood in stool, blood in urine, bruises, purpura, bruises
结局：取决于出血的类型，出血量，出血速度，出血部位。止血／血肿／休克死亡 Ending: depends on type of bleeding, amount of bleeding, rate of bleeding, site of bleeding. Hemostasis/hematoma/death from shock
四，血栓 Four. Thrombosis.
血栓形成（thrombosis）：在活体的心脏和血管内，血液发生凝固或血液中有形成分凝聚成固体质块的过程。在凝聚过程中所形成的固体质块称为血栓。（血栓是血液在流动状态下，由于血小板活化，凝血因子激活而发生。） Thrombosis: The process by which blood coagulates or formed elements of blood coalesce into a solid mass in the heart and blood vessels of a living body. The solid mass formed during coagulation is called a thrombus. (Thrombosis occurs when blood is in a state of flow due to platelet activation and activation of coagulation factors.)
血栓形成条件：心血管内皮细胞的损伤，血流状态的改变，血液凝固性增高 Conditions for thrombosis: damage to cardiovascular endothelial cells, altered blood flow status, increased blood coagulability
（一）心血管内皮细胞的损伤 (i) Damage to cardiovascular endothelial cells
损伤原因：炎症（心内膜炎），动脉粥样硬化，心肌梗死等条件下。 Causes of injury: inflammation (endocarditis), atherosclerosis, myocardial infarction, and other conditions.
内皮细胞具有：抗凝作用（主要）促凝作用 Endothelial cells are: anticoagulant (mainly) procoagulant
1．内皮细胞的抗凝作用：（1）屏障（2）抗血小板粘集（3）抗凝血酶或凝血因子（4）促进纤维蛋白溶解。 1. Anticoagulant effects of endothelial cells: (1) barrier (2) antiplatelet adhesion (3) antithrombin or coagulation factors (4) promotion of fibrinolysis.
2．内皮细胞的促凝作用：（1）激活外源凝血过程（2）辅助血小板粘附（3）抑制纤维蛋白溶解 2. Procoagulant effect of endothelial cells: (1) activation of exogenous coagulation process (2) auxiliary platelet adhesion (3) inhibition of fibrinolysis
总结：内皮细胞的作用：（1）正常情况及内皮细胞完整时，抑制血小板粘附及抗凝。（2）内皮损伤或激活时，引起局部凝血。 Summary: Role of endothelial cells: (1) Inhibit platelet adhesion and anticoagulation under normal conditions and when endothelial cells are intact. (2) Causes localized coagulation when endothelium is damaged or activated.
3．血小板的作用：（1）粘附反应 3. Role of platelets: (1) Adhesion reaction
（2）释放反应 (2) Release reaction
（3）粘集反应 (3) Adhesion reaction
（二）血流状态的改变：指血流减慢（静脉血栓的形成，e．g。心衰，久病卧床）和产生漩涡（动脉血检，血小板的沉积）等改变，有利于血检形成。 (ii) Alteration of blood flow status: refers to changes such as slowing down of blood flow (formation of venous thrombosis, e.g. heart failure, prolonged bed-riddenness) and generation of vortices (arterial blood test, deposition of platelets), which favor the formation of blood tests.
（三）血液凝固性增加：血液中血小板和凝血因子增多，或纤维蛋白溶解系统活性降低，而出现的血液的高凝状态 (iii) Increased blood coagulability: a state of hypercoagulability of the blood due to an increase in platelets and coagulation factors in the blood or a decrease in the activity of the fibrinolytic system.
以上血栓的形成条件同时存在，相互影响 The above conditions of thrombus formation coexist and interact with each other
血栓形成的过程：血栓都是从内膜表面的血小板粘集堆开始，此后的形成过程及其组成，形态和大小决定于局部血流的速度和血栓发生的部位。 The process of thrombus formation: thrombi all start from the platelet adhesion pile on the endothelial surface, and thereafter the formation process and its composition, shape and size are determined by the speed of local blood flow and the site of thrombosis.
血栓形成的过程包括以下三个阶段：（1）血管内膜损伤处，血小板粘附，沉积，与纤维蛋白多聚体一起形成小丘。（2）血小板继续沉积，血小板堆之后产生涡流，导致下一个血小板堆的形成，多个血小板堆互相连接形成血小板小梁，其间的血液凝固，形成血栓的体部（3）混合性血栓逐渐增大阻塞血管腔，血流停止，血液凝固，形成血栓的尾部。 The process of thrombosis involves the following three stages: (1) At the endothelial injury, platelets adhere, are deposited, and together with fibrin polymers, form a mound. (2) Platelets continue to be deposited, and vortices are generated after the platelet mound, leading to the formation of the next platelet mound. Multiple platelet mounds are interconnected to form platelet trabeculae, between which the blood coagulates, forming the body of the thrombus. (3) Mixed thrombus gradually increases in size to obstruct the lumen of the vessel, and the flow of blood stops, and the blood coagulates, forming the caudal part of the thrombus.
白色血栓（pale thrombus）（1）位置：血流较快的心内膜，心腔，动脉内，静脉血栓的头部。 White thrombus (pale thrombus) (1) Location: endocardium with faster blood flow, heart chambers, intra-arterial, head of venous thrombus.
（2）病理改变：（1）大体：灰白色小结节，波浪状，表面粗糙，质实，与瓣膜或血管壁紧连。 (2) Pathologic changes: (1) Gross: small grayish-white nodules, wavy, rough surface, solid, tightly attached to the valve or vessel wall.
（2）镜下：粘集的血小板形成珊瑚状小梁，其边缘粘附着一些嗜中性粒细胞，小梁间形成少量纤维蛋白网，网眼中含一些红细胞 (2) Microscope: the adherent platelets form coral-like trabeculae with some neutrophils adhering to their edges, a small amount of fibrin mesh is formed between the trabeculae, and some erythrocytes are contained in the mesh.
混合血栓（mixed thrombus）（1）位置：多见于血流缓慢的静脉，以瓣膜囊（静脉瓣近心端）或内膜损伤处为起始点。 Mixed thrombus (mixed thrombus) (1) location: most often seen in slow-flowing veins, with the valve capsule (proximal end of the venous valve) or endothelial injury as the starting point.
（2）病理改变：（1）大体：粗糙，干燥的圆柱状，与血管壁粘着，有时可辨认出灰白与褐色相间的条纹状结构。（2）镜下：分枝状，不规则血小板小梁，其表面粘附很多的白细胞。充满小梁间纤维蛋白网的红细胞构成。 (2) Pathological changes: (1) Grossly: rough, dry cylindrical, adherent to the vessel wall, sometimes recognizable as streaks of gray and brown. (2) Microscopic: branched, irregular platelet trabeculae with many leukocytes adhering to their surface. The red blood cells that fill the fibrin network between the trabeculae constitute.
红色血栓（red thrombus） Red thrombus
（1）位置：主要见于静脉，随混合血栓逐渐增大最终阻塞管腔，局部血流停止，血液发生凝固，构成静脉血栓的尾部。 (1) Location: Mainly seen in the veins, with the gradual increase of the mixed thrombus eventually blocking the lumen, the local blood flow stops, blood coagulation occurs, constituting the tail of the venous thrombus.
（2）病理改变：（1）大体：红色，故称红色血栓。新鲜时较湿润，并有一定的弹性，与血凝块无异。经一定时间后，水分被吸收而失去弹性，变得干燥易碎。（2）镜下：血凝块。 (2) Pathologic changes: (1) Gross: red, so called red thrombus. When fresh, it is more moist and has some elasticity, which is not different from blood clot. After a certain period of time, the water is absorbed and lose elasticity, become dry and fragile. (2) Microscopic: blood clot.
透明血栓（hyaline thrombus）（1）位置：见于 DIC（弥漫性血管内凝血），发生于全身微循环小血管内。 Hyaline thrombus (1) Location: seen in DIC (diffuse intravascular coagulation), which occurs in small vessels of the systemic microcirculation.
（2）病理改变：镜下可见，故又称微血栓。主要由纤维蛋白构成。 (2) Pathological changes: visible under the microscope, so also known as microthrombosis. Mainly composed of fibrin.
血栓的结局：a．软化，溶解，吸收 b．机化（肉芽组织取代血栓），再通（脱落形成栓塞）c．钙化血栓对机体的影响：（1）有利的影响 1．止血 2．防止病原体随血液扩散。 The end of thrombus: a. Softening, dissolution, absorption b. Mechanization (granulation tissue replaces thrombus), recanalization (dislodgement to form embolus) c. Calcification Effects of thrombus on the body: (1) Favorable effects 1. Hemostasis 2. Prevention of pathogens spreading with the blood.
（2）不利的影响：（1）阻塞血管：其后果决定于器官和组织内有无充分的侧支循环。（2）栓塞，梗死。 (2) Adverse effects: (1) Obstruction of vessels: the consequences of which are determined by the presence or absence of adequate collateral circulation in organs and tissues. (2) Embolism, infarction.
（3）心瓣膜变形：心瓣膜上较大的赘生物生物机化可引起的瓣膜纤维化和变形。（4）广泛性出血 (3) Heart valve deformation: valve fibrosis and deformation caused by biomechanization of larger redundant organisms on the heart valves. (4) Extensive hemorrhage
五，栓塞（embolism）：在循环血液中出现的不溶于血液的异常物质，随血流至远处阻塞血管，这种现象称为检塞。阻塞血管的异常物质称为栓子。可见：脱落的血检检子，进入血流的脂肪滴，羊水，气体及侵入血管的肿瘤细胞团（瘤栓）。 Five, embolism (embolism): in the circulating blood appear in the blood insoluble in the abnormal material, with the blood flow to the distant blockage of blood vessels, this phenomenon is called the check plug. Abnormal substances that block blood vessels are called emboli. It can be seen as: shedding of blood test testicles, fat droplets entering the bloodstream, amniotic fluid, gas and invasion of blood vessels by tumor cell clusters (tumor embolism).
一，栓子运行的途径：栓子运行的途径与血流方向一致（静脉系统栓子－肺动脉栓塞，主动脉系统栓子－阻塞器官小动脉 e．g．脑，脾，肾，门静脉系统栓子－门脉高压） I. Pathway of emboli: emboli travel in the same direction as blood flow (venous system emboli - pulmonary embolism, aortic system emboli - obstruction of small arteries in organs e.g. brain, spleen, kidneys, portal vein system emboli - portal hypertension)
特异：1，交叉性栓塞：又称反常性栓塞（静脉的栓子流入动脉），发生于房间隔或室间隔缺损者。 2．逆行性栓塞：罕见于下腔静脉血栓（胸腹压突然升高）。 Specific: 1. Cross embolism: also known as paradoxical embolism (flow of emboli from veins into arteries), occurs in people with atrial septal or ventricular septal defects. 2, Retrograde embolism: rare in inferior vena cava thrombosis (sudden rise in chest and abdominal pressure).
二，栓塞的类型和对机体的影响 II. Types of embolism and effects on the organism
（一）血栓栓塞：血栓引起的栓塞称为血栓栓塞（thromboembolism），是栓塞中最为常见的一种 (a) Thromboembolism: Embolism caused by blood clots is called thromboembolism, which is the most common type of embolism.
1．肺动脉栓塞：血栓检子 95%95 \% 以上来自下肢深静脉（股，髂，腘静脉），少数为盆腔静脉，偶尔来自右心，检子较小，无症状，中等大小，肺出血，如有左心衰，则可能引起肺组织梗死，栓子较大，引起呼吸循环系统衰竭而死亡 1. Pulmonary artery embolism: thrombus detector 95%95 \% more than from the deep veins of the lower limbs (femoral, iliac, popliteal veins), a few for the pelvic veins, occasionally from the right heart, detector small, asymptomatic, medium size, pulmonary hemorrhage, if there is a left heart failure, it may cause infarction of the lung tissues, the embolus is large, causing respiratory and circulatory system failure and death
2．体循环动脉栓塞：来源：左心（赘生物，附壁血栓，占 80%80 \% ）大动脉（动脉粥样硬化和 A 瘤的附壁血栓）栓塞部位及后果：脾，肾，脑，心终末动脉－局灶梗死 下肢大 A，肠系膜 A－广泛梗死 上肢 A（吻合支丰富），肝 A（门静脉，肝动脉双供血）很少发生梗死 2. Arterial embolism in the circulation: source: left heart (redundancy, epiphyseal thrombus, accounting for 80%80 \% ) aorta (atherosclerosis and epiphyseal thrombus of A tumors) site of embolism and its consequences: spleen, kidneys, brain, cardiac arteries - focal infarcts, lower extremity A, mesenteric A - extensive infarcts, upper extremity A (anastomotic branches abundant), hepatic A (portal vein, hepatic A dual supply) infarcts rarely occur. （Upper limb A (anastomotic branch rich), liver A (dual portal vein, hepatic artery) infarction rarely occurs
（二）脂肪栓塞：循环血流中出现脂肪滴阻塞小血管，称为脂肪检塞。见于长骨骨折，重脂肪组织挫伤或脂肪肝挤压伤，急性胰腺炎时，脂滴被挤压入静脉进入血液循环引起脂肪栓塞。 (ii) Fat embolism: The presence of fat droplets in the circulating blood stream obstructing small blood vessels is called fat embolism. It is seen in long bone fracture, heavy adipose tissue contusion or fatty liver crush injury, and acute pancreatitis when fat droplets are squeezed into the vein and enter the circulation causing fat embolism.
（三）气体栓塞（gas embolism）：血由大量空气迅速进入血循环或溶解于液内的气体迅速游离形成 (C) gas embolism: blood is formed by the rapid entry of large quantities of air into the blood circulation or the rapid freeing of gases dissolved in the fluid.
气泡，阻塞血管所引起的栓塞。 1．空气检塞 2．减压病（又称沉箱病，潜水员病）： N_(2)\mathbf{N}_{2} An embolism caused by an air bubble that blocks a blood vessel. 1. air embolism 2. decompression sickness (also known as caisson disease, diver's disease): N_(2)\mathbf{N}_{2}
（四）羊水栓塞：在分娩过程中子宫的强烈收缩，尤其是在羊膜破裂又逢胎儿头阻塞阴道口时，可能会将羊水压入破裂的子宫壁静脉窦内，并进入肺循环，造成羊水检塞。后果：变态反应性休克（过敏），DIC，肺动脉栓塞 (iv) Amniotic fluid embolism: Strong uterine contractions during labor, especially when the amniotic membranes rupture and the fetal head obstructs the vaginal opening, may press amniotic fluid into the ruptured venous sinuses of the uterine wall and into the pulmonary circulation, resulting in an amniotic fluid embolism. Consequences: anaphylactic shock (allergy), DIC, pulmonary embolism.
栓塞对机体的影响取决于：a．栓子大小，数量 b．部位：局部——梗死全身——相应器官功能障碍，栓子性质 c ．能否建立有效的侧支循环 The effect of embolism on the organism depends on: a. Embolus size, number b. Site: localized - infarction systemic - corresponding organ dysfunction, nature of embolus c. The ability to establish effective collateral circulation
六，梗死（infarction）：器官或局部组织由于血管阻塞，血流停滞，导致缺氧而发生的坏死，称为梗死。动脉阻塞引起的梗死较多见，静脉回流中断或静脉和动脉先后受阻亦可引起梗死。 Sixth, infarction (infarction): organs or local tissues due to vascular obstruction, blood flow stagnation, resulting in hypoxia and necrosis, known as infarction. Infarction caused by arterial obstruction is more common, venous reflux interruption or venous and arterial successive obstruction can also cause infarction.
（任何引起血管管腔阻塞，导致局部组织血液循环中止和缺血的原因均可引起梗死。） (Infarction can be caused by any cause of obstruction of the lumen of a blood vessel that results in the suspension of blood circulation and ischemia in local tissues.)
（一）梗死形成的原因： (i) Causes of infarct formation:
1．血栓形成 1. Thrombosis
2．动脉栓塞 2. Arterial embolization
3．动脉痉挛 3. Arterial spasm
4．血管受压闭塞 4. Vascular compression occlusion
（二）梗死形成的条件 1．供血血管：（1）血液和心血管系统功能状态。（2）侧支循环较差的，易发生梗死，如脾，肾，心，脑。2．局部组织对缺血的敏感程度 (ii) Conditions of infarction formation 1. Blood supply vessels: (1) The functional status of blood and cardiovascular system. (2) Poor collateral circulation, prone to infarction, such as spleen, kidney, heart, brain. 2. Sensitivity of local tissues to ischemia
梗死的形态特征：（了解） Morphologic features of infarction: (understand)
1．梗死灶的形态 取决于该器官的血管分布方式 1. The morphology of the infarct depends on the vascularization of the organ.
（1）锥体形，切面上呈三角形，如脾，肾，肺等。（2）不规则地图状，如心梗。（3）节段，如肠梗死。 (1) Cone-shaped, triangular in section, e.g., spleen, kidneys, lungs. (2) Irregularly map-shaped, e.g., cardiac infarction. (3) Segmental, as in intestinal infarction.
2．梗死灶的质地 取决于坏死的类型。 2. The texture of the infarct depends on the type of necrosis.
（1）脾，肾，心的凝固性坏死，早期局部肿胀，晚期坏死组织较干燥，质地坚实。（2）脑液化性坏死。 (1) Coagulative necrosis of the spleen, kidneys, and heart, with localized swelling in the early stages and drier, firmer necrotic tissue in the later stages. (2) Liquefying necrosis of the brain.
3．梗死灶的颜色 取决于梗死灶的含血量 3. The color of the infarct depends on the blood content of the infarct.
(1)血量少时, 贫血性梗死或白色梗死 (2)血量多时, 出血性梗死或红色梗死 (1) In low blood volume, anemic or white infarction (2) In high blood volume, hemorrhagic or red infarction
梗死的类型：（根据梗死灶含血量的多少，有无细菌感染进行分类） Type of infarction: (categorized according to the amount of blood contained in the infarct focus and the presence or absence of bacterial infection)
1．贫血性梗死：见于组织结构比较致密和侧支血管细而少的器官。 1. Anemic infarction: seen in organs with dense tissue structure and fine and few collateral vessels.
特点：（1）常发生于结构致密，血管吻合枝不丰富的组织，动脉阻塞，出血很少。（2）多见于心，肾 （注意，包膜完好），脾（包膜亦梗死），脑（液化性坏死）。 Characteristics: (1) Often occurs in dense structure, vascular anastomosis branch is not rich in tissue, arterial obstruction, bleeding is rare. (2) Most common in heart, kidney (note that the pericardium is intact), spleen (pericardium is also infarcted), brain (liquefying necrosis).
（3）病理改变：（1）大体：圆雉形或不规形，黄白色，边缘有白细胞浸润带和充血出血带。 (3) Pathological changes: (1) Gross: round pheasant-shaped or irregular, yellowish-white, bordered by bands of leukocyte infiltration and congested hemorrhagic bands.
（2）镜下：凝固性坏死，原有轮廓隐约可见，后期细胞崩解，肉芽和㾊痕形成。液化性坏死，可形成空洞，脑坏死灶可形成胶质疤痕。 (2) Microscopy: coagulative necrosis, original outline faintly visible, late cell disintegration, granulation and 㾊 scar formation. Liquefying necrosis, cavities may form, and glial scars may form in foci of brain necrosis.
2．出血性梗死（1）发生条件：（1）严重淤血伴有动脉阻塞：肺，肠，卵巢。（2）组织疏松：富有弹性，易扩展，梗死区血液不易挤出（3）具有双重血供（如肺动脉和支气管动脉） 2. Hemorrhagic infarction (1) Conditions of occurrence: (1) Severe bruising with arterial obstruction: lungs, intestines, ovaries. (2) Loose tissue: elastic, easy to expand, the infarcted area of blood is not easy to extrude (3) with a dual blood supply (such as pulmonary and bronchial arteries)
（2）病理特点：（1）大体：梗死灶，圆雉形，节段性或不规则形，暗红色，无出血充血带。 (2) Pathologic features: (1) Gross: infarct foci, round pheasant-shaped, segmental or irregular, dark red, no hemorrhagic congestive bands.
（2）镜下：梗死区组织坏死，弥漫性出血。 (2) Microscopy: tissue necrosis in the infarcted area with diffuse hemorrhage.
（3）常见的类型：（1）肺出血性梗死：常见于肺下叶外周部，尤以肋膈角处多见。 (3) Common types: (1) Pulmonary hemorrhagic infarction: common in the peripheral part of the lower lobe of the lung, especially at the angle of the rib diaphragm.
肉眼：局部隆起，暗紫色，质较实，呈锥体形，切面为楔形，尖端指向肺门或血管阻塞处，基底位于胸膜面，胸膜面常有纤维素渗出。 Naked eye: localized elevation, dark purple, solid, cone-shaped, wedge-shaped in section, tip pointing to the hilum or vascular obstruction, base located on the pleural surface, pleural surface often with fibrinous exudation.
光镜：肺泡间隔结构模糊不清，肺泡腔内和组织间隙充满红细胞，周围未坏死的肺组织多有慢性淤血及水肿 Light microscopy: the structure of alveolar septa is blurred, the alveolar lumen and tissue interstices are filled with erythrocytes, and the surrounding non-necrotic lung tissues are mostly chronically bruised and edematous
左心衰竭，在肺静脉压力增高和肺淤血的情况下，单以支气管动脉的压力，不足以克服肺静脉压力增高的阻力或栓子出现时可发生。 Left heart failure, in the presence of increased pulmonary venous pressure and pulmonary stasis, can occur when bronchial arterial pressure alone is insufficient to overcome the resistance of increased pulmonary venous pressure or when emboli are present.
（2）肠出血性梗死：常见于肠套叠，扭转和绞窄性肠疝，初时肠段肠系膜静脉受压而淤血，以后受压加剧，伴有动脉受压而使血流减少或中断，肠段缺血坏死。患者腹痛，呕吐，肠梗阻，腹膜炎。 (2) Intestinal hemorrhagic infarction: common in intussusception, torsion and strangulated intestinal hernia, the mesenteric vein of the intestinal segment is compressed and bruised at the beginning, and later the compression is aggravated, accompanied by arterial compression which reduces or interrupts the blood flow, and the intestinal segment ischemic necrosis. The patient suffers from abdominal pain, vomiting, intestinal obstruction, and peritonitis.
3．败血性梗死：由含有细菌的检子阻塞血管引起。常见：急性感染性心内膜炎。 3. Septic infarction: caused by the obstruction of blood vessels by bacterial-containing checkers. Common: acute infective endocarditis.
梗死对机体的影响和结局：取决定于梗死的器官，梗死灶的大小和部位，以及有无细菌感染等因素。梗死的结局（同坏死）1．溶解，吸收 2．机化，包裹，钙化 The effect of infarction on the organism and its outcome: depends on the organ of infarction, the size and location of the infarct, and the presence or absence of bacterial infection. The outcome of infarction (same as necrosis) 1. dissolution, absorption 2. mechanization, encapsulation, calcification
了解： Understand:
1．肾梗死：腰痛，血尿，不影响肾功能 1. Renal infarction: low back pain, hematuria, without affecting renal function
2．脾梗死：脾被膜炎 rarr\rightarrow 左上腹疼痛 2. Splenic infarction: inflammation of the splenic peritoneum rarr\rightarrow Pain in the left upper abdomen
3．肺梗死：胸痛和咯血，呼吸困难 4．肠梗死：剧烈腹痛，血便，坏疽，穿孔，腹膜炎 5．心肌梗死：导致心绞痛，动脉瘤，心脏破裂，心力衰竭，猝死 3. Pulmonary infarction: chest pain and hemoptysis, dyspnea 4. Intestinal infarction: severe abdominal pain, bloody stools, gangrene, perforation, peritonitis 5. Myocardial infarction: leading to angina pectoris, aneurysm, heart rupture, heart failure, sudden death
6．脑梗死：失语，偏痽，死亡 6. Cerebral infarction: aphasia, hemiplegia, death
7．四肢，肺，肠梗死：继发腐败菌感染 坏疽 7. Infarcts of limbs, lungs, intestines: secondary infection with putrefactive organisms Gangrene
七，水肿：指组织间隙内体液增多 VII, Edema: refers to an increase in body fluids in the interstitial spaces of tissues
水肿的发病机制：1．静脉流体静压的增高 2．血浆胶体渗透压的降低 3．淋巴液回流障碍 Pathogenesis of edema: 1. Increase in venous hydrostatic pressure 2. Decrease in plasma colloid osmolality 3. Impaired lymphatic return
4．毛细血管壁通透性增加 5．水钠潴留（重吸收的增强） 4. increased permeability of capillary walls 5. water and sodium retention (enhanced reabsorption)
水肿的病理变化： 1 ．大体：组织肿胀，颜色苍白，质软，切面可呈胶冻状。（胀白肿松） Pathologic changes of edema: 1. Gross: swollen tissue, pale in color, soft, and may be jellied in section. (Swelling white swelling loose)
2．镜下：水肿液积聚于细胞和纤维结缔组织之间或腔隙中，HE 染色为透亮空 2. Microscopy: edema fluid accumulates between cells and fibrous connective tissue or in the lumen, HE staining is translucent and empty.
白区。 细胞外基质变得疏松 White areas. The extracellular matrix becomes loose
水肿对机体的影响：部位，程度，发生速度，持续时间 Effects of edema on the body: site, degree, rate of onset, duration
第四章 炎症 Chapter 4 Inflammation
炎症：具有血管系统的活体组织对损伤因子所发生的复杂防御性反应，血管反应是炎症过程的中心环节。 Inflammation: a complex defensive response to injurious agents that occurs in living tissues with a vascular system; the vascular response is central to the inflammatory process.
一，炎症的原因（一）物理性因子（高温，低温，放射性射线）（二）化学性因子 1．外源性 2．内源性（三）生物性因子：包括各种病原微生物导致的组织损伤，是最重要的炎症原因。（四）坏死组织缺氧，代谢障碍等引起的组织损伤也是炎症的原因，如梗死灶边缘的充血出血带和炎细胞浸润。（五）变态反应或异常免疫反应 First, the causes of inflammation (a) physical factors (high temperature, low temperature, radioactive rays) (b) chemical factors 1. exogenous 2. endogenous (c) biological factors: including a variety of pathogenic microorganisms caused by tissue damage, is the most important cause of inflammation. (D) necrotic tissue hypoxia, metabolic disorders and other causes of tissue damage is also a cause of inflammation, such as infarct foci edge of the congestion hemorrhagic band and inflammatory cell infiltration. (v) Metamorphic reaction or abnormal immune response
发生炎症的关键是组织损伤，是否发生组织损伤取决于致炎因子的作用和机体本身。 The key to the occurrence of inflammation is tissue damage, the occurrence of which depends on the action of inflammatory factors and the organism itself.
二，炎症局部的基本病理变化： Second, the basic pathological changes localized in the inflammation:
变质（alteration）：炎症局部组织发生的变性和坏死称为变质。是致炎因子直接作用或由局部血液循环障碍和炎症反应产物间接引起的组织损伤。 Metamorphosis (alteration): The degeneration and necrosis that occurs in the local tissues of inflammation is called metamorphosis. It is the direct action of inflammatory factors or indirectly caused by local blood circulation and inflammatory reaction products of tissue damage.
实质细胞常出现的有细胞水肿，脂肪变性，细胞凝固性坏死或液化性坏死等。 Parenchymal cells often present with cellular edema, fatty degeneration, and cellular coagulative necrosis or liquefactive necrosis.
间质成分变质包括粘液变性和纤维素样坏死等。 Degeneration of interstitial components includes mucous degeneration and fibrinoid necrosis.
渗出（exudation）：是炎症的特征性变化，炎症局部组织血管内的液体和细胞成分，通过血管壁进入间质，体腔，粘膜表面和体表的过程称为渗出，所渗出的液体和细胞总称为渗出物和渗出液。后果：炎性水肿（渗出液积聚在组织间隙），体腔积液（渗出液积聚在浆膜腔内） Exudation (exudation): is a characteristic change of inflammation, inflammation of the local tissue vascular fluid and cellular components, through the blood vessel wall into the interstitium, the body cavity, mucosal surface and the body surface of the process is called exudation, the exuded fluid and cellular total is called exudate and exudate. Consequences: inflammatory edema (accumulation of exudate in the interstitial spaces of tissues), corpora cavernosa (accumulation of exudate in the plasma membrane lumen)
渗出的重要防御作用： The important defense role of exudation:
稀释毒素，减轻损伤； Dilute the toxins and reduce the damage;
运来营养，带走废物； Transporting nutrients and taking away waste;
补体抗体，杀菌调理； Complementary antibodies, bactericidal conditioning;
淋巴引流，诱导免疫； Lymphatic drainage to induce immunity;
渗出液过多：机化粘连，压迫阻塞（e．g．肠梗阻，肺泡积液） Excessive exudate: mechanized adhesions, compression obstruction (e.g., intestinal obstruction, alveolar effusion)
注意：渗出液和漏出液的区别 Note: Difference between exudate and leakage fluid
渗出液有较高蛋白含量，较多细胞和细胞碎片，漏出液是血浆超滤的结果 Exudate has a higher protein content, more cells and cellular debris, and leakage is the result of plasma ultrafiltration
炎症的基本过程：recognition，recruitment，removal，regulation，resolution增生（proliferation） Basic processes of inflammation: recognition, recruitment, removal, regulation, resolution proliferation (proliferation)
1．实质细胞的增生：如慢性支气管炎时粘膜上皮细胞和腺体的增生。慢性肝炎中肝细胞的增生。 1. Proliferation of parenchymal cells: for example, proliferation of mucosal epithelial cells and glands in chronic bronchitis. Proliferation of hepatocytes in chronic hepatitis.
2．间质成分的增生：包括巨噬细胞，内皮细胞和纤维母细胞（慢性纤维化）等的增生。 2. Proliferation of mesenchymal components: including macrophages, endothelial cells and fibroblasts (chronic fibrosis).
意义：炎性增生具有限制炎症扩散和损伤修复的作用。 SIGNIFICANCE: Inflammatory hyperplasia has a role in limiting the spread of inflammation and repairing damage.
小结：病变的早期以变质和渗出为主，病变的后期以增生为主。但变质，渗出和增生是相互联系的。一般说来变质是损伤性过程，而渗出和增生是对损伤的防御反应和修复过程。 Summary: Metamorphosis and exudation predominate in the early stages of the lesion, and hyperplasia in the later stages of the lesion. However, metamorphosis, exudation and hyperplasia are interrelated. Generally speaking, metamorphosis is a damaging process, whereas exudation and hyperplasia are defense responses to damage and repair processes.
三，炎症的表现 Third, manifestations of inflammation
（一）急性炎症局部的共同的临床表现：红：血管扩张，充血 肿：炎性渗出 热：局部血流增多， (a) Common localized clinical signs of acute inflammation: redness: vasodilatation, congestion Swelling: inflammatory exudation Heat: increased local blood flow.
代谢增高 痛：局部张力增高，压迫或牵拉神经末梢；炎症介质的作用 功能障碍：组织损伤；炎性水肿；疼痛 Increased metabolism Pain: increased local tension, compression or pulling of nerve endings; role of inflammatory mediators Dysfunction: tissue damage; inflammatory edema; pain
（二）炎症的全身的反应：1．发热：为一种保护性反应（IL－1，TNF 作用于体温调节中枢） (ii) Systemic responses to inflammation: 1. Fever: a protective response (IL-1, TNF act on thermoregulatory centers)
外源性：细菌毒素，病毒，立克次体等致热源 内源性：白细胞产物，前列腺素 E2 Exogenous: bacterial toxins, viruses, pyrogens such as rickettsiae Endogenous: leukocyte products, prostaglandins E2
2．白细胞增高：1）炎症介质作用下的防御反应 2）白细胞总数增高及增高的白细胞分类具有临床诊断价值 2. Increased leukocytes: 1) defense response in response to inflammatory mediators 2) increased total leukocyte count and increased leukocyte classification have clinical diagnostic value
3．急性期蛋白合成增多，单核巨噬系统增生，＂核左移＂ 3. Increased protein synthesis in the acute phase, proliferation of the mononuclear macrophage system, "nuclear left shift
四，急性炎症：反应迅速，持续时间短，常常仅几天，一般不超过一个月，以渗出性病变为主。炎症细胞主要以中性粒细胞为主。 Fourth, acute inflammation: rapid response, short duration, often only a few days, usually not more than a month, with exudative lesions. Inflammatory cells are mainly neutrophils.
1，急性炎症过程中血流动力学改变 1, Hemodynamic changes during acute inflammation
（1）细动脉短暂收缩，损伤后立即出现，持续时间短 (1) Transient constriction of fine arteries, immediately after injury, of short duration
（2）微血管扩张和血液加速（红，热的原因）（化学介质组胺，NO，缓激肽作用，也有神经作用） (2) Microvascular dilatation and blood acceleration (cause of redness, heat) (chemical mediators histamine, NO, bradykinin effect, also neurological)
（3）速度减慢（血浆外溢，血液粘度增加，红细胞浓集） (3) Slowing down (plasma spillage, increased blood viscosity, erythrocyte concentration)
2，血管通透性增加：内皮细胞收缩，内皮细胞穿胞作用增强，血管内皮细胞损伤，新生毛细血管的高通透性 2, Increased vascular permeability: endothelial cell contraction, increased endothelial cell penetration, vascular endothelial cell injury, and hyperpermeability of new capillaries
3，白细胞渗出和吞噬作用 3, Leukocyte exudation and phagocytosis
1．白细胞边集（1）定义：炎症时，白细胞离开血管中心轴流，到达血管的边缘部（边流） 1. Leukocyte marginalization (1) Definition: In inflammation, leukocytes leave the central axis of vascular flow and reach the marginal portion of the vessel (marginal flow)
2．白细胞滚动和粘着：由选择素（炎症损伤导致血管内皮细胞表达选择素水平提高）介导白细胞滚动，由内皮细胞粘附分子和白细胞表面整合素介导白细胞粘附 2. Leukocyte rolling and adhesion: leukocyte rolling mediated by selectins (inflammatory injury leading to increased levels of selectin expression by vascular endothelial cells) and leukocyte adhesion mediated by endothelial cell adhesion molecules and leukocyte surface integrins
3．白细胞游出（1）定义：白细胞通过血管壁进入周围组织的过程 3. Leukocyte efflux (1) Definition: The process by which leukocytes pass through the walls of blood vessels into the surrounding tissue.
（2）特点：游出是一种主动的阿米巴样运动（变形运动），降解血管基底膜，游出的主要部位是内皮细胞连接处。所有白细胞均可游出。 (2) Characteristics: Swimming is an active amoeboid movement (metamorphosis) that degrades the vascular basement membrane; the main site of swimming is the endothelial cell junction. All leukocytes can swim out.
急性炎症和化脓性炎症时，主要游出细胞是中性粒细胞。 In acute and suppurative inflammation, the main free cells are neutrophils.
慢性炎症，以单核，巨噬细胞和淋巴细胞，浆细胞游出为主。 Chronic inflammation, dominated by monocytes, macrophages and lymphocytes, with plasma cell excursions.
病毒感染时，以淋巴细胞，单核细胞游出为主。 In viral infections, lymphocytes are predominant, with monocytes swimming out.
过敏性炎症和寄生虫感染，以嗜酸性粒细胞游出为主。 Allergic inflammation and parasitic infections, with eosinophilic excursions predominating.
红细胞经过血管壁到达周围组织是一种被动过程，称为红细胞漏出。 The passage of erythrocytes through the vessel wall to reach the surrounding tissues is a passive process called erythrocyte leakage.
炎症早期以中性粒细胞渗出为主，后期以单核细胞浸润为主 Inflammation is characterized by neutrophilic exudation in the early stages and mononuclear cell infiltration in the later stages
（3）炎性浸润：白细胞在炎症灶内的组织间隙中弥散分布，称为炎性浸润。浸润在组织间隙中的白细胞即为炎细胞。 (3) Inflammatory infiltration: the diffuse distribution of leukocytes in the tissue interstitium within the inflammatory foci is called inflammatory infiltration. Leukocytes infiltrated in the tissue interstitial space are inflammatory cells.
4，趋化作用：白细胞向着化学刺激物的浓度梯度做移动的现象称为趋化作用。这些化学刺激物称为趋化因子，具有特异性 4, chemotaxis: the phenomenon of leukocytes moving towards the concentration gradient of chemical stimuli is called chemotaxis. These chemical stimuli are called chemokines and have specificity
5．白细胞在局部的作用 5. Local role of leukocytes
（1）吞噬作用（识别和粘着，吞入，杀灭及降解） (1) Phagocytosis (recognition and adhesion, engulfment, killing and degradation)
（2）免疫反应 (2) Immune response
（3）组织损伤作用（脱颗粒释放活性氧自由基，溶酶体酶，前列腺素等引起组织损伤） (3) Tissue-damaging effects (release of reactive oxygen radicals from degranulation, lysosomal enzymes, prostaglandins, etc. causing tissue damage)
中性粒细胞胞外诱捕网（neutrophil extracellular traps，NETs）是细胞死亡后释出的核酸和蛋白酶，呈丝网状，具有强大的杀菌作用。 Neutrophil extracellular traps (NETs) are nucleic acids and proteases released after cell death in the form of a filamentous mesh that has a powerful bactericidal effect.
白细胞功能缺陷：（1）黏附缺陷（2）吞入和脱颗粒障碍（3）杀菌活性障碍（4）骨髓白细胞生成障碍 Defects in leukocyte function: (1) defective adhesion (2) impaired engulfment and degranulation (3) impaired bactericidal activity (4) impaired bone marrow leukopoiesis
6．炎症介质：在炎症过程中由细胞释放或体液中产生的，参与或介导炎症反应的化学物质 6. Inflammatory mediators: chemicals released by cells or produced in body fluids during the inflammatory process that participate in or mediate the inflammatory response
来源（1）细胞释放的炎症介质：血管活性胺 e．g．组胺，5－羟色胺，以脱颗粒的方式作用于血管，使细动脉扩张，血管内皮细胞收缩，细静脉通透性增强；花生四烯酸代谢产物 e．g．前列腺素，白三烯，抑制花生四烯酸代谢（抑制环氧化酶）可以缓解炎症反应；白细胞产物：活性氧代谢物，溶酶体内的蛋白酶；细胞因子 e．g．IL－1，IL－8，IFN，TNF 等；血小板激活因子；NO；神经肽 e．g．P物质 Sources (1) Inflammatory mediators released by cells: vasoactive amines e.g. histamine, 5-hydroxytryptophan, act on blood vessels in a degranulation manner, causing dilation of fine arterioles, contraction of vascular endothelial cells, and increase in permeability of fine veins; arachidonic acid metabolites e.g. prostaglandins, leukotrienes, inhibition of arachidonic acid metabolism (inhibition of cyclo-oxygenases) can alleviate inflammatory response Leukocyte products: reactive oxygen metabolites, proteases in lysosomes; cytokines e.g. IL-1, IL-8, IFN, TNF, etc.; platelet-activating factor; NO; neuropeptides e.g. Substance P
（2）体液中产生的炎症介质：激肽（激肽原 rarr\rightarrow 缓激肽，血管通透性增加，引起疼痛），补体（C3a， (2) Inflammatory mediators produced in body fluids: kinins (kininogen rarr\rightarrow bradykinin, increased vascular permeability, causes pain), complement (C3a.
C5a）和凝血与纤维蛋白溶解系统三大系统。 C5a) and the coagulation and fibrinolytic systems are three major systems.
重点掌握趋化因子：C3a，C5a，IL－1，IL－8，TNF，白三烯，细菌产物 Focus on chemokines: C3a, C5a, IL-1, IL-8, TNF, leukotrienes, bacterial products
致痛：缓激肽，前列腺素 E2 Analgesic: bradykinin, prostaglandin E2
7．急性炎症的类型 7. Types of acute inflammation
大多数为渗出性炎症，但要掌握变质性炎症：乙肝，乙脑，阿米巴肠炎，增生性炎症：伤寒，肾小球肾炎 Mostly exudative inflammation, but keep track of metaplastic inflammation: hepatitis B, BSE, amoebic enteritis, proliferative inflammation: typhoid fever, glomerulonephritis
以下详述渗出性炎 The following details exudative inflammation
（一）浆液性炎：以浆液渗出为主要特征的炎症，渗出的液体成分中含 3∼5%\mathbf{3 \sim 5 \%} 的小分子蛋白质（主要是白蛋白），少量白细胞和纤维素。部位：浆膜，粘膜和疏松结缔组织等，粘膜的浆液性炎称为浆液性卡他性炎，浆膜的浆液性炎易引起积液，e．g．感冒流涕，风湿性关节炎 (I) plasmacytitis: inflammation characterized by exudation of plasma, the exudate contains 3∼5%\mathbf{3 \sim 5 \%} small molecules of protein (mainly albumin), a small number of leukocytes and cellulose. Parts: plasma membrane, mucous membrane and loose connective tissue, etc., plasmacytitis of the mucous membrane is called plasmacytocatarrhal inflammation, plasmacytosis of the plasma membrane is prone to cause fluid retention, e.g., colds and flu, rheumatoid arthritis.
一般预后良好，少部分如喉头水肿引起窒息，胸膜腔积液和心包积液影响心肺功能 The prognosis is generally good, with a few cases such as laryngeal edema causing asphyxia, pleural effusion and pericardial effusion affecting cardiopulmonary functions
（二）纤维素性炎：以纤维蛋白原渗出为主的炎症，部位：粘膜，浆膜和肺组织。 (ii) Fibrinitis: inflammation dominated by fibrinogen exudation, site: mucous membranes, plasma membranes and lung tissue.
发生于不同部位的纤维素性炎症形态不一，可表现为： Fibrinous inflammation occurring at different sites is variable in morphology and may be manifested:
①发生于黏膜的纤维素性炎称假膜性炎：（白喉）A．咽部（鳞状上皮）黏膜为固膜 B．气管（柱状纤毛上皮）黏膜为浮膜，细菌性痢疾，在肠粘膜形成伪膜 (1) Fibrinous inflammation occurring in the mucosa is called pseudomembranous inflammation: (diphtheria) A. Pharyngeal (squamous epithelium) mucosa is solid B. Tracheal (columnar ciliated epithelium) mucosa is floating Bacterial dysentery, pseudomembrane is formed in the mucosa of the intestines
（2）发生于浆膜的纤维素性炎可因运动形式不同，表现为：A．胸膜，腹膜等呈片块状 B．风湿性心外膜炎，风湿性心包炎，心包脏壁层呈＂绒毛心＂，可形成缩窄性心包炎 (2) Fibrinous inflammation of the plasma membrane can be manifested in different forms of movement, such as: A. pleura, peritoneum, etc., in the form of a sheet B. Rheumatic epicarditis, rheumatic pericarditis, pericarditis with "choroidal heart" in the dirty pericardial wall layer, which can lead to the formation of a narrowing of the pericarditis.
（3）在肺等疏松组织可发生组织＂实变＂，疾病：大叶性肺炎 (3) Tissue "solidification" can occur in loose tissue such as lungs, disease: lobar pneumonia
结局：吸收／机化粘连 Outcome: Absorption/mechanized adhesion
（三）化脓性炎：以中性粒细胞渗出为主，并有不同程度的组织变性，坏死和脓液形成为特征。多由化脓菌感染所致。 脓性渗出物称为脓液，含脓细胞，细菌，坏死组织碎片和少量浆液。 脓细胞是指脓液中变性坏死的中性粒细胞。 (c) Pyogenic inflammation: characterized by neutrophilic exudation with varying degrees of tissue degeneration, necrosis and pus formation. It is mostly caused by pyogenic bacterial infection. The purulent exudate is called pus and contains pus cells, bacteria, necrotic tissue debris and a small amount of plasma. Pus cells are the degenerated and necrotic neutrophils in the pus.
化脓性炎症分为： Septic inflammation is divided into:
A．表面化脓和积脓 a．发生在粘膜和浆膜的化脓性炎称表面化脓，中性粒细胞向粘膜表面渗出，而深部浸润不明显。 b．化脓性炎发生于浆膜腔或空腔脏器时，脓液积存，称为积脓e．g．化脓性心包炎，流脑（化脓性脑膜炎），小叶性肺炎 A. Surface suppuration and accumulation of pus a. Suppurative inflammation occurring in the mucous membranes and plasma membranes is called surface suppuration, with neutrophils exuding to the mucosal surface, while deep infiltration is not apparent. b. Purulent inflammation occurring in the plasma membrane cavity or cavity organs, pus accumulation, called accumulation of pus e. g. Purulent pericarditis, rheumatoid meningitis (purulent meningitis), lobar pneumonia
B．蜂窝织炎：a．发生于疏松结缔组织的弥漫性化脓性炎称蜂窝织炎 b 主要由溶血性链球菌引起 c．容易扩散（透明质酸酶，链激酶，溶解周围基质）d．好发部位：皮肤，肌肉，阑尾，肠管 B. Cellulitis: a. Diffuse purulent inflammation of loose connective tissue called cellulitis b. Caused mainly by hemolytic streptococci c. Easily spreads (hyaluronidase, streptokinase, lyses the surrounding stroma) d. Preferred sites: skin, muscles, appendix, intestinal tracts
C．脓肿：a．为局限性化脓性炎症 b．造成局部组织溶解坏死，形成脓腔 c．主要由金黄色葡萄球菌 （毒素，侵袭性酶 rarr\rightarrow 坏死，血浆凝固酶 rarr\rightarrow 病变局限）引起 d．序：毛囊皮脂腺及其周围组织的脓 C. Abscess: a. A limited purulent inflammation b. Causes localized tissue lysis and necrosis, resulting in the formation of a pus cavity c. Caused primarily by Staphylococcus aureus (toxins, invasive enzymes rarr\rightarrow necrosis, plasma coagulase rarr\rightarrow lesion confinement) d. Sequence: pus in the follicular sebaceous glands and their surrounding tissue
肿 痈：多个㾔的融合，必须及时切开排脓 Carbuncle: fusion of multiple cankers, which must be incised and drained in a timely manner
（四）出血性炎 1）微血管损伤严重，渗出物含大量红细胞 2）常见于急性传染病e．g．鼠疫 (d) hemorrhagic inflammation 1) severe microvascular damage, exudate containing a large number of erythrocytes 2) common in acute infectious diseases e. g. plague
急性炎症的结局：1．痊愈 2 。迁延为慢性炎症 3．扩散到全身 The outcome of acute inflammation: 1. Healing 2. Progression to chronic inflammation 3. Spreading throughout the body
曼延扩散：1）局部曼延，经组织间隙或自然通道向周围组织或器官直接播散（可形成糜烂，溃疡，瘘管和窦道） Mantle spread: 1) Localized mantle, direct spread to surrounding tissues or organs through tissue interstitial spaces or natural channels (can form erosions, ulcers, fistulas and sinus tracts)
2）淋巴道扩散 病原微生物进入淋巴管，随淋巴液运行，可致淋巴管炎及淋巴结炎 2) Lymphatic Tract Dissemination Pathogenic microorganisms enter the lymphatic vessels and run with the lymphatic fluid, which can lead to lymphadenitis and lymph node inflammation
3）血道扩散 3) Bloodway diffusion
菌血症：细菌入血，没有在血液中繁殖，但无全身中毒症状 Bacteremia: bacteria enter the bloodstream, do not multiply in the bloodstream, but there are no signs of systemic toxicity
毒血症：细菌毒素及其代谢产物入血并引起全身中毒症状。 Toxemia: Bacterial toxins and their metabolites enter the bloodstream and cause systemic symptoms of poisoning.
败血症：细菌入血，生长繁殖，释放毒素引起全身中毒症状，血培养阳性。 Sepsis: Bacteria enter the bloodstream, grow and multiply, and release toxins causing systemic symptoms of toxicity, with positive blood cultures.
脓毒败血症：化脓菌引起的败血症，细菌随血流至全身，在全身脏器发生多发性栓塞性脓肿。 Septic sepsis: sepsis caused by septic bacteria, in which the bacteria travel throughout the body with the bloodstream and multiple embolic abscesses develop in organs throughout the body.
五，慢性炎症 V. Chronic inflammation
1．def：（1）持续几周以上，可反复发作。（2）常表现增生病变为主，浸润的炎细胞为淋巴细胞，浆细胞和巨噬细胞。 1. def: (1) It lasts for more than a few weeks and may recur. (2) Often shows predominantly proliferative lesions, infiltrating inflammatory cells as lymphocytes, plasma cells and macrophages.
发生原因：病原微生物持续存在，理化因素长期刺激，自身免疫 Causes: persistence of pathogenic microorganisms, long-term stimulation by physical and chemical factors, autoimmunity
a．炎性息肉：炎症局部粘膜上皮，腺体及肉芽组织过度增生，形成向黏膜表面突起的带蒂的炎性肿块 a. Inflammatory polyps: inflammation of the local mucosal epithelium, glands and granulation tissue overgrowth, the formation of mucosal surface protrusion of the inflammatory mass with a tip
b．炎性假瘤：炎性增生形成境界清楚的肿瘤样团块，主要发生于眼眶，肺等实性器官，为非特异性增生（有间质，有实质） b. Inflammatory pseudotumor: inflammatory hyperplasia forming a well-defined tumor-like mass, mainly occurring in solid organs such as orbits, lungs, etc., non-specific hyperplasia (interstitial and parenchymal).
2．肉芽肿性炎：以肉芽肿形成为主要特征的炎症称为肉芽肿性炎。e．g．风湿病
显微镜下由巨噬细胞及其衍生细胞（上皮样细胞，多核巨细胞）构成的境界清楚的结节状病灶，称为肉芽肿（granuloma）
肉芽肿的主要细胞成分：上皮样细胞，多核巨细胞
肉芽肿分类：感染性肉芽肿：特征为形成结核结节，中心常为干酪性坏死，周围为类上皮细胞，可见 Langhans 巨细胞，巨细胞核排列规则，位于干细胞周边，呈花环状，病因：结核等
异物肉芽肿：如手术缝线，滑石粉等引起的肉芽肿，异物周围有异物巨细胞，核排列不规则。
大：瘤细胞大；核大；核仁大。 多：瘤细胞和核多形性；核多；核仁多；核染色质多，深染；核分裂多。 怪：瘤细胞和核奇形怪状。裂：核分裂相增多，出现病理性核分裂。胞浆呈嗜碱性组织结构异型性：指肿瘤组织在空间排列方式上与其来源的正常组织的差异。（包括实质和间质之间关系杂乱，细胞排列杂乱，失极性） Large: large tumor cells; large nuclei; large nucleoli. Polymorphic: tumor cells and nuclei polymorphic; many nuclei; many nucleoli; much nuclear chromatin, deeply stained; many nuclear divisions. Odd: tumor cells and nuclei oddly shaped. Cleavage: increased nuclear schizophrenia with pathologic nuclear fission. Basophilic cytoplasm Heterogeneity of tissue structure: refers to the difference in spatial arrangement of tumor tissues from the normal tissues from which they originate. (Includes disorganized relationships between parenchyma and mesenchyme, disorganized cellular arrangement, and loss of polarity)
间变（anaplasia）：指恶性肿瘤细胞缺乏分化状态。 间变细胞：指异型性大的细胞。 Mesenchymal (anaplasia): a state of malignant tumor cells lacking differentiation. Mesenchymal: refers to cells that are highly heterogeneous.
间变性肿瘤：主要由未分化细胞构成。间变性的肿瘤细胞具有明显的多形性，即瘤细胞彼此在大小和形状上有很大的变异，异型性大。间变性肿瘤几乎都是高度恶性的肿瘤。 Mesenchymal tumors: mainly composed of undifferentiated cells. Mesenchymal tumor cells have obvious pleomorphism, i.e., the tumor cells vary greatly from each other in size and shape and are heterogeneous. Mesenchymal tumors are almost always highly malignant tumors.
多形性：瘤细胞大小，形状的变异。 pleomorphism: variation in size, shape of tumor cells.
肿瘤细胞异形性： Tumor cell heterogeneity:
瘤细胞的多形性 体大，彼此大小和形态很不一致，可出现瘤巨细胞。但分化很差时，瘤细胞较正常细胞小，圆形，大小也比较一致。 Polymorphism of tumor cells The body is large, very inconsistent with each other in size and morphology, and may appear as tumor giant cells. However, when they are very poorly differentiated, tumor cells are smaller than normal cells, round, and more uniform in size.
瘤细胞核的多形性 核肥大，核／浆比增大，核大小，形状和染色不一，并可出现巨核，双核，多核或奇异形的核。核仁肥大，数目常增多。核分裂像常增多，特别是出现病理性核分裂像时。瘤细胞胞浆的改变 由于胞浆内核蛋白体增多而多呈嗜碱性。并可因为瘤细胞产生的异常分泌物或代谢产物而具有不同特点 Tumor cell nuclear pleomorphism Nuclear hypertrophy, increased nuclear/plasma ratio, variable nuclear size, shape and staining, and may appear macronuclei, binuclei, multinuclei, or bizarrely shaped nuclei. Nucleoli are hypertrophied and often increased in number. Nucleoli are often increased, especially in the presence of pathologic nucleoli. The cytoplasm of tumor cells is basophilic due to an increase in cytoplasmic nuclear proteasomes. They may be characterized by abnormal secretions or metabolites produced by the tumor cells.
三，肿瘤的生长与扩散 III. Tumor growth and spread
1．肿瘤的生长方式： 1. Tumor growth pattern:
a．膨胀性生长：良性肿瘤多见，呈结节状，常有完整的包膜，与周围组织分界清楚，影响主要为挤压或阻塞的作用。易手术摘除，不易复发，转移 a. Expansive growth: benign tumors are common, nodular, often with complete envelope, clearly demarcated from surrounding tissues, affecting mainly the role of extrusion or obstruction. It is easy to be removed by surgery, not easy to recur and metastasize.
b．外生性生长：良，恶性肿瘤都可，多发生在体表，体腔，管道，呈乳头状，息肉状或菜花状恶性肿瘤易发生坏死脱落而形成底部高低不平，边缘隆起的恶性溃疡 b. Exogenous growth: benign, malignant tumors can be, mostly occur in the body surface, body cavity, pipe, in the form of papillary, polypoid or cauliflower-like malignant tumors are prone to necrosis and shedding and the formation of the bottom of the uneven, raised edge of the malignant ulcers.
c．浸润性生长：多数恶性肿瘤的生长方式，没有包膜，无明显界限，如树根长入泥土，不易推动；手术摘除范围广，易复发，转移 c. Infiltrative growth: most malignant tumors grow in a way that there is no envelope, no obvious boundaries, such as tree roots growing into the soil, not easy to promote; surgical removal of a wide range of easy to recur and metastasis.
影响肿瘤生长速度的因素 Factors affecting the rate of tumor growth
a．肿瘤的倍增时间：分裂繁殖成两个细胞所需时间 a. Tumor doubling time: time required to divide and multiply into two cells
b．生长分数：肿瘤细胞群体中处于增殖状态的细胞比例 b. Growth fraction: the proportion of cells in the tumor cell population that are in a proliferative state
c．肿瘤细胞生成与死亡的比例 c. Ratio of tumor cell production to death
肿瘤生成，需要诱导血管生成。VEGF，VEGFR 饥饿疗法 Tumorigenic, need to induce angiogenesis. vegf, vegfr starvation therapy
肿瘤在生长过程中，经过多代繁殖出现侵袭性增加的现象叫肿瘤的演进 The phenomenon of increased aggressiveness of a tumor that occurs through multiple generations of reproduction as it grows is called tumor evolution
肿瘤经过多代分裂，出现基因等大分子的改变，生长速度，侵袭能力，对生长信号的反应等发生改变，称为肿瘤的异质性 Tumors undergo multiple generations of divisions and show alterations in macromolecules such as genes, and changes in growth rate, invasiveness, and response to growth signals, which are called tumor heterogeneity
2．肿瘤的扩散：指恶性肿瘤不限于发生部位生长，可侵入到邻近或远处组织生长，即蔓延及转移。途径： 2. Tumor proliferation: It means that malignant tumors are not limited to the growth of the site of occurrence, but can invade to the growth of adjacent or distant tissues, i.e., spreading and metastasis. Pathway:
1）直接蔓延：指癌瘤细胞连续浸润性生长到邻近组织或器官，如肺癌侵入胸腔，子宫颈癌侵入膀 (1) Direct spread: refers to the continuous infiltrative growth of cancer cells into neighboring tissues or organs, such as invasion of lung cancer into the chest cavity, invasion of cervical cancer into the bladder.
胱或直肠。 Bladder or rectum.
浸润：指癌瘤细胞可突破基底膜长入并破坏周围组织，是恶性肿瘤的生长特点。 Infiltration: It means that cancerous tumor cells can break through the basement membrane to grow into and destroy the surrounding tissues, and it is the growth characteristic of malignant tumors.
2）转移：癌瘤细胞从原发部位（原发瘤）分离脱落侵入一定的腔道（淋巴管，血管，体腔）被带到另一部位，并生长成与原发瘤同样类型的肿瘤（转移瘤或继发瘤）。 2) Metastasis: Cancer cells are detached from the primary site (primary tumor) and invade certain cavities (lymphatic vessels, blood vessels, body cavities) to be taken to another site and grow into the same type of tumor as the primary tumor (metastasis or secondary tumor).
转移的主要途径： The main pathway of transfer:
（1）淋巴道转移：是癌的主要转移的途径 (1) Lymphatic metastasis: the main metastatic route of cancer.
（2）血道转移：是肉瘤的主要转移的途径。途径：与血栓栓塞过程相似。血道转移最常见的是肺，其次是肝，脑，骨，肾上腺。转移瘤形态上的特点是：＂多，圆，界清，癌脐＂。 (2) Hematogenous metastasis: the main route of metastasis of sarcoma. Pathway: similar to the process of thromboembolism. Hematogenous metastasis is most common in lungs, followed by liver, brain, bone and adrenal gland. The morphology of metastatic tumors is characterized by: "many, round, clear boundary, cancer umbilicus".
癌脐：位于器官表面的转移瘤，由于瘤结节中央出血，坏死而下陷，呈脐样外观。 Cancer umbilicus: a metastatic tumor located on the surface of an organ that has an umbilical appearance due to hemorrhage in the center of the tumor node, which is necrotic and sunken.
（3）种植性转移：指体腔内器官（腹腔，胸腔，脑部器官）的恶性肿瘤曼延至器官表面时，瘤细胞可以脱落，并像播种一样种植在体腔内各器官的表面，形成多数的转移瘤。胃癌破坏胃壁侵及浆膜后，种植到卵巢形成 Krukenberg 瘤。 (3) Implantation metastasis: When malignant tumors of organs in the body cavity (abdominal cavity, thoracic cavity, brain organs) extend to the surface of the organs, the tumor cells can be detached and implanted on the surface of the organs in the body cavity like sowing seeds to form most of the metastatic tumors. Gastric cancer destroys the gastric wall and invades the plasma membrane, and then implants into the ovary to form Krukenberg tumor.
3．肿瘤的分级：I 级为分化良好，属低度恶性 II级为分化中等，属中度恶性 III级为分化低的，属高度恶性。 3. Tumor grading: Grade I is well-differentiated, low malignancy, Grade II is moderately differentiated, medium malignancy, Grade III is poorly differentiated, high malignancy.
4．肿瘤的分期（TNM 分期系统）T：肿瘤原发灶，T1～T4 N：淋巴结受累，N0～N3 M：转移 4. Tumor staging (TNM staging system) T: Tumor primary focus, T1 to T4 N: Lymph node involvement, N0 to N3 M: Metastasis
5．影响 5. Impact
（一）良性肿瘤的影响：阻塞，压迫作用：如胆管，脑室肿瘤，产生过量内分泌物质，继发性改变：包括出血，坏死，感染，破裂，囊性变。 (i) Effects of benign tumors: obstruction, compressive effects: e.g., bile ducts, ventricular tumors, production of excess endocrine material, secondary changes: including hemorrhage, necrosis, infection, rupture, cystic degeneration.
（二）恶性肿瘤的影响：1．发热 2．恶病质（cachexia）：进行性严重消瘦，体力贫乏，严重贫血，多脏器衰竭综合表现。 (ii) Effects of malignant tumors: 1. fever 2. cachexia: progressive severe emaciation, physical weakness, severe anemia, and multiple organ failure.
副肿瘤综合征：不能用肿瘤的直接蔓延或向远处转移加以解释的一些病变和临床表现，一般由肿瘤产物或异常免疫反应间接引起 Paraneoplastic syndromes: lesions and clinical manifestations that cannot be explained by the direct spread of the tumor or by metastasis to distant sites, generally caused indirectly by tumor products or abnormal immune responses
异位内分泌综合征：非内分泌肿瘤分泌激素而引起内分泌症状的现象 Ectopic endocrine syndrome: a phenomenon in which a non-endocrine tumor secretes hormones that cause endocrine symptoms
四，良性与恶性肿瘤的区别（见书 P129 表）：1．组织分化程度 2．核分裂象 3．生长速度 4．生长方式 5．继发改变 6．转移 7．复发 8．对机体影响 Differences between benign and malignant tumors (see table in P129): 1. degree of tissue differentiation 2. nuclear schizophrenia 3. growth rate 4. growth pattern 5. secondary changes 6. metastasis 7. recurrence 8. effects on the body
［相对性］：指良性肿瘤与恶性肿瘤间并无绝对界限 [Relativity]: refers to the fact that there is no absolute boundary between benign and malignant tumors.
［交界性］：指肿瘤的组织形态介乎二者之间，称交界性肿瘤 [Junctional]: A tumor whose histologic pattern is intermediate between the two is called a junctional tumor.
［转化性］：良性肿瘤，可转变为恶性肿瘤，称为恶变，如结肠息肉状腺瘤可恶变为腺癌。个别的恶性肿瘤（如黑色素瘤，神经母细胞瘤），有时由于机体免疫力加强等原因，可以停止生长甚至完全自然消退。 [Transformative]: Benign tumors can be transformed into malignant tumors, which are called malignant changes, such as polypoid adenomas of the colon can be transformed into adenocarcinomas. Individual malignant tumors (e.g. melanoma, neuroblastoma), sometimes due to the strengthening of the body's immunity and other reasons, can stop growing or even completely subside naturally.
小结：良性肿瘤与恶性肿瘤的区别：良性肿瘤分化好，生长缓慢影响小，包膜完整不转移，手术切除复发少；恶性肿瘤分化差，生长迅速危害大，浸润转移易复发，灵丹妙药抓＂三早＂。 Summary: the difference between benign tumors and malignant tumors: benign tumors are well-differentiated, slow-growing and have little impact, the envelope is intact and does not metastasize, surgical resection and fewer recurrences; malignant tumors are poorly-differentiated, fast-growing and hazardous, infiltration and metastasis are prone to recurrence, and the panacea is to grasp the "three mornings".
五，肿瘤的命名 V. Naming of tumors
1．良性肿瘤：部位＋（形态）＋组织起源＋＂瘤＂（－oma） 1. Benign tumors: site + (morphology) + tissue origin + "tumor" (-oma)
2．恶性肿瘤：部位 + （形态）+ 组织起源 2. Malignant tumors: site + (morphology) + tissue origin
＂癌＂：上皮来源的恶性肿瘤：鳞状上皮起源－－－鳞状细胞癌，腺上皮－－－－腺癌 "Carcinoma": malignant tumor of epithelial origin: squamous epithelial origin - squamous cell carcinoma, glandular epithelial - --adenocarcinoma
肉瘤：来源于间叶组织的恶性肿瘤。 癌肉瘤：一个肿瘤中既有癌的结构又有肉瘤的结构 Sarcoma: a malignant tumor originating from mesenchymal tissue. Carcinosarcoma: a tumor with both cancerous and sarcomatous structures in it
特殊命名： Special Naming:
1．组织来源＋母细胞瘤＂blastoma＂：神经，髓，肾母细胞瘤为恶性 1. Tissue origin + Blastoma: Neuroblastoma, medullary and nephroblastoma are malignant.
2．组织来源＋＂瘤＂的恶性肿瘤：精原细胞瘤，生殖细胞瘤，黑色素瘤 2. Malignant neoplasms of tissue origin + "tumor": spermatogonia, germ cell tumors, melanoma
3．＂恶性＂＋组织起源＋＂瘤＂：（恶性）淋巴瘤，恶性周围神经鞘膜瘤，恶性间皮瘤 3. "Malignant" + tissue origin + "tumor": (malignant) lymphoma, malignant peripheral nerve sheath tumor, malignant mesothelioma
4．以＂病＂，＂症＂命名：白血病，恶性组织细胞增生症，组织细胞增生症 X 等。 4. Named after "disease" or "disorder": leukemia, malignant histiocytosis, histiocytosis X, etc.
5．以人名命名：Hodgkin＇s 病，Paget＇s 病，Ewing＇s 瘤，Wilm＇s 瘤 5. Named after people: Hodgkin's disease, Paget's disease, Ewing's tumor, Wilm's tumor.
6．多种成分的肿瘤：混合瘤，畸胎瘤 6. Tumors with multiple components: mixed tumors, teratomas
7．多发性良性或交界性肿瘤：神经纤维瘤病 7. Multiple benign or junctional tumors: neurofibromatosis
常见肿瘤举例 Examples of common tumors
1．上皮性肿瘤： 1. Epithelial tumors:
［良性上皮性肿瘤］ [Benign epithelial tumors]
1）乳头状瘤 来源：由覆盖上皮（鳞状上皮，尿路上皮）发生的良性肿瘤病变特点：大体：表面呈外生性生长，形成许多手指样或乳头样突起，呈菜花样或绒毛状外观。镜下：组织结构异型性明显，细胞异型性不明显肿瘤表面覆盖有增生性上皮，如鳞状上皮柱状上皮或移行上皮；乳头中心有由纤维组织与血管构成的间质。 1) papilloma Source: benign tumor lesions occurring from the overlying epithelium (squamous epithelium, uroepithelium) Characteristics: Grossly: exophytic growth on the surface, forming many finger-like or papillae-like protrusions with cauliflower-like or downy appearance. Microscopically: the histological heterogeneity is obvious, the cellular heterogeneity is not obvious tumor surface covered with proliferative epithelium, such as squamous epithelium columnar epithelium or migratory epithelium; papillae centered on the mesenchyme composed of fibrous tissue and blood vessels.
2）腺瘤：由腺上皮发生的良性肿瘤，多见于甲状腺，卵巢，乳腺，涎腺和肠等处。 2) Adenomas: benign tumors arising from the glandular epithelium, most commonly found in the thyroid, ovaries, breast, salivary glands and intestines.
类型：A．囊腺瘤；B．管状腺瘤 Type: A. Cystadenoma; B. Tubular adenoma
病变特点 大体：在粘膜面的腺瘤多呈息肉状，腺器官内的腺瘤多呈结节状，且常有包膜 Characteristics of lesions: adenomas on the mucosal surface are polypoid, adenomas in the glandular organs are nodular and often have a peripheral membrane
镜下：组织结构异型性明显，细胞异型性不明显可见大量密集的腺体，大小形状较不规则，无导 Microscopy: the tissue structure heterogeneity is obvious, cellular heterogeneity is not obvious can be seen a large number of dense glands, the size and shape of the more irregular, no guide
管，不能排出分泌产物 Tubes, unable to expel secretion products
［恶性上皮性肿瘤］：经过淋巴道转移 [Malignant epithelial tumor]: Metastasis via lymphatic channels
1）鳞状细胞癌 来源：鳞状上皮覆盖的部位，皮肤，黏膜表面病变特点：大体：鳞癌常呈乳头状，表面坏死后可形成溃疡。 1) Squamous cell carcinoma Source: squamous epithelium covered area, skin, mucous membrane surface Lesion characteristics: gross: squamous carcinoma is often papillary, and ulcers can be formed after surface necrosis.
镜下：增生的上皮突破基底膜向深层浸润，形成不规则巢状，条索状癌巢。 Microscopy: the proliferating epithelium breaks through the basement membrane and infiltrates into the deeper layers, forming irregular nested, striated cancer nests.
a．分化好的鳞癌：I ．癌巢中心可出现层状角化物，称角化珠（keratin pearl）或癌珠；II．细胞间可见细胞间桥。 a. Well-differentiated squamous carcinoma: I. Layered keratinized material called keratin pearl or cancer pearl may appear in the center of the cancer nest. Layered keratinized material, called keratin pearl or cancer pearl, may appear in the center of cancer nests; II. Intercellular bridges can be seen between cells.
b．分化差的鳞癌：I．无角化珠形成；II．细胞间桥少或无 III．癌细胞异型性明显，核分裂像多，排列紊乱。 b. Poorly differentiated squamous carcinoma: I. No keratinized bead formation; II. Few or no intercellular bridges; III. Heterogeneity of the cancer cells is obvious, with many nuclear schizophrenia and disordered arrangement.
2）腺癌：是由腺上皮发生的恶性肿瘤，多发生于柱状上皮覆盖的粘膜及各种腺器官。 2) Adenocarcinoma: It is a malignant tumor arising from glandular epithelium, mostly occurring in the mucous membrane covered by columnar epithelium and various glandular organs.
分型：腺癌 实体癌 粘液癌 Staging: adenocarcinoma, solid carcinoma, mucinous carcinoma
病变特点：A．腺癌 大体：呈息肉状，菜花状或结节状，表面坏死脱落可形成溃疡； Characteristics of lesions: A. Adenocarcinoma: polypoid, cauliflower-like or nodular, surface necrosis and shedding can form ulcers;
镜下：I．腺癌细胞常组成大小不一，形状不一腺管状结构； Microscopy: I. Adenocarcinoma cells are often composed of glandular tubular structures of different sizes and shapes;
II．细胞有不同程度的异型性，可见核分裂像，细胞排列紊乱。 II. The cells have varying degrees of anisotropy, with visible nuclear schizophrenic images and disorganized cellular arrangement.
B．粘液癌：分泌大量粘液的腺癌 大体：多呈胶冻状，故又称为胶样癌 B. Mucinous carcinoma: adenocarcinoma secreting a large amount of mucus Gross body: mostly jelly-like, so it is also called gelatinous carcinoma.
镜下：I．癌细胞分散，细胞呈印戒状，称为印戒细胞，核在一侧，胞质内充满粘液 II．细胞间可见大量粘液。 Under the microscope: I. The cancer cells are dispersed, the cells are in the shape of imprinted cells, called imprinted cells, the nucleus is on one side, and the cytoplasm is full of mucus. II. A large amount of mucus can be seen between the cells.
C．实体癌：单纯癌由癌细胞组成实体癌巢，无腺体形成。 C. Solid carcinoma: Simple carcinoma consists of solid nests of cancer cells without gland formation.
实质多，间质少，称髓样癌 实质少，间质多，称硬癌 A carcinoma with a lot of parenchyma and little mesenchyme is called medullary carcinoma A carcinoma with little parenchyma and a lot of mesenchyme is called sclerocarcinoma
3）基底细胞癌：常见老年人头面部，浸润破坏深层组织，很少发生转移 3) Basal cell carcinoma: common in the head and face of the elderly, infiltrating and destroying deep tissues, seldom metastasized.
4）尿路上皮癌：也称移行细胞癌 4) Uroepithelial carcinoma: also called migratory cell carcinoma
2．间叶组织肿瘤： 2. Tumors of mesenchymal tissue:
［良性间叶组织肿瘤］ [Benign mesenchymal tumors]
1）纤维瘤 来源：由纤维组织发生的良性肿瘤，常见于躯干及四肢皮下。 1) Fibroma Source: Benign tumors occurring from fibrous tissues, commonly found subcutaneously on the trunk and limbs.
病变特点：大体：结节状，有包膜；切面灰白色，可见编织状条纹，质硬。 Characteristics of the lesion: gross: nodular, encapsulated; grayish-white on cut surface, weave-like streaks visible, hard.
镜下：由胶原纤维及纤维细胞组成，纤维排列呈束状，束间彼此交织；其间有血管及少量疏松结缔组织。 Microscopy: composed of collagen fibers and fibroblasts, the fibers are arranged in bundles, and the bundles are intertwined with each other; there are blood vessels and a small amount of loose connective tissue in between.
2）脂肪瘤 来源：由脂肪组织发生的良性肿瘤，最常见为背，肩，颈及四肢近端的皮下组织。 2) Lipoma Source: Benign tumor arising from adipose tissue, most commonly in the subcutaneous tissue of the back, shoulder, neck and proximal extremities.
病变特点：大体：外观：扁圆形或分叶状，有包膜，肿瘤大小不一，常为单发性，质地柔软；切面：色淡黄，似正常的脂肪组织。 Characteristics of lesions: gross: appearance: flat round or lobulated, with envelope, tumors of different sizes, often solitary, soft texture; section: yellowish color, resembling normal adipose tissue.
镜下：有包膜；瘤组织结构呈大小不规则分叶，并有不均等的纤维组织间隔存在。 Microscopically: there is an envelope; the tumor tissue structure is irregularly lobulated in size and there are uneven intervals of fibrous tissue present.
3）平滑肌瘤 来源：由平滑肌细胞发生的良性肿瘤，最多见于子宫，其次为胃肠道。 3) Smooth muscle tumor Source: benign tumors arising from smooth muscle cells, most commonly seen in the uterus, followed by the gastrointestinal tract.
病变特点：大体：外观：圆形或卵圆形，有包膜，肿瘤大小不一，单发或多发，质硬；切面：灰白色编织状。 Characteristics of the lesion: gross: appearance: round or ovoid, with periosteum, tumors of different sizes, single or multiple, hard; section: grayish-white braided.
镜下：瘤组织由形态比较一致的梭形平滑肌细胞构成。细胞排列成束状，同一束内的细胞核有时排列成栅状，互相编织。核呈长杆状，两端钝圆，核分裂像少见 Microscopy: the tumor tissue consists of spindle-shaped smooth muscle cells of relatively uniform morphology. The cells are arranged in bundles, and the nuclei within the same bundle are sometimes arranged in a fenestrated pattern, interwoven with each other. The nuclei are rod-shaped with bluntly rounded ends, and nuclear schizophrenia is rare.
4）血管瘤：重点关注非恶性，但是是浸润性生长 4) Hemangiomas: focus on non-malignant, but infiltrative growths
［恶性间叶组织肿瘤］：经血道转移，实质间质分界不清（病理诊断） [Malignant mesenchymal tissue tumor]: Metastasis via the bloodstream, poorly demarcated parenchymal mesenchyme (pathologic diagnosis)
1）纤维肉瘤 来源：由纤维组织发生的恶性肿瘤常见于躯干及四肢皮下。 1) Fibrosarcoma Source: Malignant tumors arising from fibrous tissues are commonly found subcutaneously on the trunk and extremities.
病变特点：大体：外观肿瘤呈结节状或不规则形，与周围组织分界较清楚；切面：呈灰白色或灰红色，鱼肉状。 Characteristics of the lesion: gross: appearance of the tumor is nodular or irregularly shaped, with clearer demarcation from the surrounding tissues; section: grayish-white or grayish-red, fish-like.
镜下：a．细胞大小不一，有梭形或圆形，排成编织状或漩涡状 Microscopy: a. Cells vary in size, are pike-shaped or rounded, and are arranged in a braided or swirling pattern
b．分化程度可差异很大，分化好的与纤维瘤有些相似，分化差的瘤细胞异型性十分明显，核分裂像多见。 b. The degree of differentiation can vary greatly, with well-differentiated tumors somewhat similar to fibromas, and poorly differentiated tumors with very pronounced cellular anisotropy and numerous nuclear schizophrenia.
2）骨肉瘤：由骨组织发生的恶性肿瘤，常发生于四肢长骨，半数发生在股骨下端及胫骨上端。 2) Osteosarcoma: malignant tumors arising from bone tissue, often occurring in the long bones of the limbs, with half occurring in the lower end of the femur and the upper end of the tibia.
癌与肉瘤的区别 Difference between cancer and sarcoma
1．组织来源 1. Organizational sources
2．发病率 2. Morbidity
3．大体特点 4 ．组织学特点 3. General characteristics 4. Histological characteristics
5．网状纤维 5. Reticulated fibers
6．转移 6. Transfers
六，癌症的发展过程： Sixth, the course of cancer:
［癌前病变］（precancerous lesions）：指某些疾病或病变不是恶性肿瘤，但是具有癌变的潜在可能性的病变，可以是获得性的，也可以是遗传性的。 [Precancerous lesions]: Lesions that are not malignant but have the potential to become cancerous, either acquired or hereditary, in certain diseases or lesions.
常见的癌前病变有：粘膜白斑；慢性子宫颈炎伴子宫颈糜烂；乳腺纤维囊性病；结肠／直肠的息肉状腺瘤；慢性萎缩性胃炎及胃溃疡；慢性溃疡性结肠炎；皮肤慢性溃疡；肝硬化 Common precancerous lesions include: mucosal leukoplakia; chronic cervicitis with cervical erosion; fibrocystic breast disease; polypoid adenomas of the colon/rectum; chronic atrophic gastritis and gastric ulcers; chronic ulcerative colitis; chronic ulcers of the skin; and cirrhosis of the liver.
［非典型性增生（异型增生）］指上皮组织内出现异型性细胞增生，波及／未波及全层上皮。属癌前病变。 [Atypical hyperplasia (heterogeneous hyperplasia)] refers to the appearance of heterogeneous cellular proliferation in the epithelial tissue, affecting/not affecting the entire epithelial layer. It is a precancerous lesion.
轻度（I 级）：异型性细胞增生，累及上皮层下部的 1//31 / 3 。 中度（II 级）：异型性细胞增生，累及上皮层下部的 2//32 / 3 。重度（III 级）：异型性细胞增生，累及上皮 2//32 / 3 以上但尚未达到全层。 Mild (grade I): heterogeneous cellular proliferation involving 1//31 / 3 the lower part of the epithelium. Moderate (grade II): heterogeneous cellular proliferation involving the lower part of the epithelial layer 2//32 / 3 . Severe (grade III): heterogeneous cellular hyperplasia involving more than but not all of the epithelial 2//32 / 3 layer.
［原位癌］（carcinoma in situ）上皮组织异型性细胞增生波及全层上皮，但未突破基底膜向深层浸润 ［Carcinoma in situ: Heterogeneous cell proliferation of epithelial tissue affecting the entire epithelial layer without breaking through the basement membrane and infiltrating into the deeper layers.
上皮内瘤变：上皮非典型增生和原位癌的总称 Intraepithelial neoplasia: a general term for atypical hyperplasia and carcinoma in situ of the epithelium
（正确识别癌前病变，非典型性增生及原位癌是防止肿瘤发生发展及早期诊断肿瘤的重要环节） (Proper identification of precancerous lesions, atypical hyperplasia and carcinoma in situ is an important part of preventing tumor development and early diagnosis of tumors)
七，肿瘤的分子基础（了解） VII. Molecular basis of tumors (understanding)
八，环境致瘤因素 VIII. Environmental tumorigenic factors
1．化学物质：多环芳烃（油烟，香烟，酒精，尾气），芳香胺（氨基偶氮染料），亚硝胺，真菌毒素（黄曲霉素），烷化剂酰化剂金属元素（直接致癌因素） 1. Chemical substances: polycyclic aromatic hydrocarbons (oil smoke, cigarettes, alcohol, exhaust fumes), aromatic amines (amino azo dyes), nitrosamines, mycotoxins (aflatoxins), alkylating agents acylating agents metallic elements (direct carcinogens)
2．物理因素：紫外线，电离辐射 2. Physical factors: ultraviolet light, ionizing radiation
3．生物因素：肿瘤病毒（HPV，EBV，HBV），细菌，寄生虫 3. Biological factors: tumor viruses (HPV, EBV, HBV), bacteria, parasites
第六章 心血管系统疾病 Chapter VI. Diseases of the cardiovascular system
一，动脉粥样硬化（atherosclerosis，AS）： I. Atherosclerosis (AS):
一种与血脂异常及血管壁成分改变有关的动脉疾病。（好发于大动脉，中动脉，壁变厚，硬化，弹性下降） A disease of the arteries associated with dyslipidemia and changes in the composition of blood vessel walls. (Prevalent in large arteries, middle arteries, wall thickening, hardening, loss of elasticity)
病变特征：脂质沉积于动脉内膜 rarr\rightarrow 灶性纤维性增厚＋粥样板块（粥瘤）rarr\rightarrow 动脉壁变硬 rarr\rightarrow 管腔狭窄 Characteristics: lipid deposition in intima rarr\rightarrow focal fibrous thickening + atheromatous platelets (atheroma) rarr\rightarrow arterial wall stiffening rarr\rightarrow lumen narrowing
1．危险因素 1. Risk factors
a．高脂血症：与 AS 发病密切相关的血浆胆固醇主要成分为 LDL，其中小颗粒致密低密度脂蛋白 （sLDL）是判断冠心病的最佳指标，脂蛋白 a（Lp a）在血浆浓度与 AS 发病率呈正相关 a. Hyperlipidemia: the main component of plasma cholesterol closely related to the development of AS is LDL, of which small dense low-density lipoprotein (sLDL) is the best indicator of coronary heart disease, and the plasma concentration of lipoprotein a (Lp a) is positively correlated with the incidence of AS.
b．高血压：独立危险因素，主要是引起内皮细胞的损伤 b. Hypertension: independent risk factor, mainly causing endothelial cell damage
c．糖尿病，高胰岛素血症，甲减，肾病综合征 c. Diabetes mellitus, hyperinsulinemia, hypothyroidism, nephrotic syndrome
d．遗传，年龄，性别 d. Heredity, age, gender
2．发病机制：损伤应答学说 2. Pathogenesis: the damage response theory
内皮损伤 rarr\rightarrow 脂质沉积 rarr\rightarrow LDL 氧化修饰 rarr\rightarrow 单核细胞，平滑肌细胞吞噬 LDL／ox－LDL，形成泡沫细胞 Endothelial damage rarr\rightarrow Lipid deposition rarr\rightarrow LDL oxidative modification rarr\rightarrow Monocytes, smooth muscle cells phagocytosis of LDL/ox-LDL, formation of foam cells rarr\rightarrow 平滑肌细胞分泌胶原蛋白，形成纤维帽 rarr\rightarrow 释放细胞因子引起白细胞粘附，促进炎症反应 rarr\rightarrow 泡沫细胞变性坏死，形成淡黄色粥糜样坏死物 rarr\rightarrow 后期可能发生营养不良性钙化 rarr\rightarrow Smooth muscle cells secrete collagen, forming a fibrous cap rarr\rightarrow Release of cytokines induces leukocyte adhesion and promotes an inflammatory response rarr\rightarrow Foam cells degenerate and necrose, forming a yellowish atheromatous necrotic mass rarr\rightarrow Dystrophic calcification may occur in later life
3．病理变化 3. Pathological changes
a．早期病变——脂纹（fatty streak）肉眼：动脉内膜面稍隆起的黄色斑点或条纹 a. Early lesions - fatty streak Naked eye: slightly elevated yellow spots or streaks on the intima-media surface of arteries
光镜：内皮下大量泡沫细胞聚集 + SMC（平滑肌细胞）+ 细胞外基质 泡沫细胞：圆形，体积较大，胞浆内大量小空泡 Light microscopy: large aggregates of foam cells in the subendothelium + SMC (smooth muscle cells) + extracellular matrix Foam cells: round, large in size, large number of small vacuoles in the cytoplasm
结局：病因消除可完全消退，属可逆性变化 Ending: the elimination of the cause of the disease can be completely subsided, is reversible changes
b．纤维斑块（fibrous plaque） b. Fibrous plaque
肉眼：早期为淡黄／灰黄色不规则隆起的斑块，后期胶原纤维 uarr+\uparrow+ 玻璃样变，瓷白色蜡烛油样。 Naked eye: early yellowish/grayish-yellow irregularly elevated plaques, late collagen fibers uarr+\uparrow+ vitreous, porcelain-white candle oil-like.
光镜：表层（纤维帽）：大量胶原纤维＋SMC 下层：泡沫细胞 + SMC＋脂质＋炎细胞 Light microscopy: surface layer (fibrous cap): numerous collagen fibers + SMC Lower layer: foam cells + SMC + lipids + inflammatory cells
c．粥样斑块（atheromatous plaque）——粥瘤（atheroma） c. Atheromatous plaque - atheroma
肉眼：黄色斑块＋大量黄色粥糜样物 Naked eye: yellow plaques + large amount of yellow porridge-like material
光镜：玻璃样变性的纤维帽，大量粉红无定形坏死物质和脂质十胆固醇结晶＋有时钙化，无中心粒细胞！中膜萎缩变薄，底部，周边：肉芽组织＋泡沫细胞＋淋巴细胞浸润 Light microscopy: glassy degenerated fibrous cap, large amounts of pink amorphous necrotic material and lipid ten cholesterol crystals + sometimes calcification, no centrocytes! Atrophic thinning of the mesentery, base, periphery: granulation tissue + foam cells + lymphocyte infiltration
d．继发性病变：（1）斑块内出血：新生血管破裂 rarr\rightarrow 血肿 rarr\rightarrow 狭窄，堵塞 d. Secondary lesions: (1) intraplaque hemorrhage: neovascularization rarr\rightarrow hematoma rarr\rightarrow stenosis, occlusion
（2）斑块破裂：粥瘤性溃疡 rarr\rightarrow 栓子 rarr\rightarrow 栓塞 (2) Plaque rupture: atheromatous ulcer rarr\rightarrow embolus rarr\rightarrow embolization
（3）血栓形成：内皮细胞损伤＋粥瘤性溃疡 rarr\rightarrow 血栓 (3) Thrombosis: endothelial cell injury + atheromatous ulcer rarr\rightarrow Thrombus
（4）钙化：纤维帽及粥瘤灶钙盐沉着 (4) Calcification: Calcium salt deposits in the fibrous cap and atheroma foci
（5）动脉瘤形成：动脉管壁局限性扩张 rarr\rightarrow 动脉瘤 (5) Aneurysm formation: limited dilatation of the arterial wall rarr\rightarrow Aneurysm
二，冠状 A 䉼样硬化症 CAS II, Coronary A sclerosis CAS
部位：左冠状 A\mathbf{A} 前降支 >> 右主干 >> 左旋支，左主干 >> 后降支。病变呈节段性受累。 Sites: left coronal A\mathbf{A} anterior descending branch >> right main stem >> levator ani, left main stem >> posterior descending branch. The lesion has a segmental involvement.
病变：斑块性病变，心壁侧，呈新月形，管腔呈偏心性狭窄。 Lesion: plaque lesion, lateral to the heart wall, crescent-shaped, with eccentric narrowing of the lumen.
冠状 A 性心脏病（冠心病）（CHD）：冠状 A 狭窄等变化所致的缺血性心脏病。病因：冠状 A 粥样硬化 Coronary A heart disease (coronary heart disease) (CHD): ischemic heart disease caused by changes such as coronary A stenosis. Causes: Coronary A atherosclerosis
主要临床表现 Main clinical manifestations
（一）心绞痛：类型： (i) Angina pectoris: types:
1．稳定型心绞痛 1. Stable angina
2．不稳定型心绞痛 2. Unstable angina
3．变异型心绞痛 3. Variant angina
（二）心肌梗死 病因：1．冠状动脉血栓形成 (ii) Myocardial infarction Causes: 1. Coronary artery thrombosis
2．冠状动脉痉挛 2. Coronary artery spasm
3．冠状动脉䉼样斑块内出 3. Coronary artery 䉼-like plaques within the outlet
血 4．心脏负荷过重 5．出血，休克 Blood 4. cardiac overload 5. hemorrhage, shock
1．类型（1）心内膜下心肌梗死（薄层梗死）：部位：心室壁内侧心肌 1//31 / 3 ，波及肉柱和乳头肌病变：多发性，小灶性坏死，或环状梗死，分布左心室四周，厚度不及心肌的一半。 1. Types (1) subendocardial myocardial infarction (thin-layer infarction): site: ventricular wall of the inner myocardium 1//31 / 3 , affecting the sarcomere and papillary muscle lesions: multiple, small foci of necrosis, or annular infarction, the distribution of the left ventricle around the thickness of less than half of the thickness of the myocardium.
（2）透壁性心肌梗死（区域性心肌梗死）病变：累及心室壁全层或深达室壁 2//32 / 3 以上 (2) Transmural myocardial infarction (regional myocardial infarction) lesions: involving the entire ventricular wall or reaching deep into the ventricular wall 2//32 / 3 above
" 部位: 与闭塞的冠状 A 支供血区一致 病灶: 较大, "2.5cm\text { 部位: 与闭塞的冠状 A 支供血区一致 病灶: 较大, } 2.5 \mathrm{~cm}
常见的梗死好发部位：最常见一一左前降支供血区：左室前壁，心尖部，室间隔前 2//32 / 3 及前内乳头肌 Common sites of infarction: the most common one is the left anterior descending feeder: left ventricular anterior wall, apical region, anterior septum and anterior internal papillary muscle.
其次是右冠状动脉供血区：左室后壁，室间隔后 1//31 / 3 及右心室，并可累及窦房结 The second area is the right coronary artery: the posterior wall of the left ventricle, the posterior septum and the right ventricle, and the sinus node.
再次为左旋支供血区：左室侧壁，膈面及左房，并可累及房室结 Reassertion of the left spinous branch: left ventricular lateral wall, diaphragmatic surface and left atrium, with involvement of the AV node
2．病理变化： 2. Pathological changes:
（1）发展过程：（1）梗死 < 6h:<6 \mathrm{~h}: 肉眼无变化。（2）梗死 > 6h:>6 \mathrm{~h}: 坏死灶心肌呈苍白色 (1) Progression: (1) Infarction < 6h:<6 \mathrm{~h}: no change by the naked eye. (2) Infarction > 6h:>6 \mathrm{~h}: Necrotic foci of myocardium pale in color
（3）梗死 8∼9h8 \sim 9 \mathrm{~h} 后：呈土黄色。光镜：心肌早期凝固性坏死 + 间质水肿 + 出血 + 中性粒细胞浸润（炎症反应） (3) Post-infarction 8∼9h8 \sim 9 \mathrm{~h} : yellowish color. Light microscopy: early coagulative myocardial necrosis + interstitial edema + hemorrhage + neutrophilic infiltration (inflammatory response)
（4）梗死 4 天后：充血出血带。光镜：带内血管充血，出血＋中性粒细胞浸润 uarr\uparrow 。心肌细胞肿胀，空泡变 rarr\rightarrow 核溶解消失 rarr\rightarrow 肌纤维呈空管状 (4) 4 days after infarction: congested hemorrhagic band. Light microscopy: vascular congestion within the band, hemorrhage + neutrophilic infiltration uarr\uparrow . Myocytes are swollen and vacuolated rarr\rightarrow Nucleolysis has disappeared rarr\rightarrow Myofibers are tubular.
（5）梗死 1 ∼2\sim 2 周后：边缘区出现肉芽组织（6）梗死 2∼82 \sim 8 周：梗死灶机化及瘏痕形成 (5) After 1 ∼2\sim 2 week of infarction: granulation tissue in the marginal zone (6) After 2∼82 \sim 8 week of infarction: mechanization of the infarcted foci and formation of an injury mark
3．合并症 3. Comorbidities
器质性（1）心脏破裂 Organic (1) heart rupture
（2）室壁瘤 病变：梗死心肌或瘡痕组织局限性向外膨隆 rarr\rightarrow 可继发附壁血栓，心律紊乱及左心衰竭。 (2) Ventricular wall tumor Lesion: limited outward expansion of infarcted myocardium or scar tissue rarr\rightarrow Can be followed by epiphyseal thrombus, rhythm disturbances and left heart failure.
（3）附壁血栓形成 (3) Appendage thrombosis
（4）乳头肌功能失调或断裂：常见二尖瓣乳头肌缺血坏死，造成二尖瓣脱垂或关闭不全其他（功能性）：心律失常：传导系统受累＋MI rarr\rightarrow 电生理紊乱，急性左心室衰竭：心脏收缩失调三，高血压（Hypertention）：以体循环动脉血压持续高于正常水平为主要表现的疾病。（高血压是一种体征） (4) papillary muscle dysfunction or rupture: common ischemic necrosis of the mitral papillary muscle, resulting in mitral valve prolapse or closure of the other (functional): arrhythmia: conduction system involvement + MI rarr\rightarrow electrophysiological disorders, acute left ventricular failure: cardiac contractile dysfunction III, hypertension (Hypertention): a disease in which the arterial blood pressure of the physical circulation remains persistently higher than the normal level. Hypertension: a disease characterized by persistently higher than normal blood pressure in the arteries of the body circulation. (Hypertension is a sign)
原发性高血压：是一种原因未明的，以体循环动脉血压 uarr\uparrow 为主要表现的独立性全身性疾病，以全身细动脉硬化为基本病变，常引起心，脑，肾及眼底病变及相应的临床表现，旧称高血压病。 Primary hypertension: It is an independent systemic disease of unknown cause, with arterial blood pressure uarr\uparrow in the body circulation as the main manifestation, and with systemic arteriosclerosis as the basic lesion, often causing heart, brain, kidney and fundus pathology and the corresponding clinical manifestations, which was formerly known as hypertensive disease.
【诊断标准】：成人收缩压 >= 140mmHg(18.4kPa)\geqslant 140 \mathrm{mmHg}(18.4 \mathrm{kPa}) 和／或舒张压 >= 90mmHg(12.0kPa)\geqslant 90 \mathbf{m m H g}(12.0 \mathrm{kPa})类型和病理变化 Diagnostic Criteria]: Adult systolic >= 140mmHg(18.4kPa)\geqslant 140 \mathrm{mmHg}(18.4 \mathrm{kPa}) and/or diastolic >= 90mmHg(12.0kPa)\geqslant 90 \mathbf{m m H g}(12.0 \mathrm{kPa}) type and pathologic changes.
1．缓进型高血压：良性高血压 多见（95\％），中，老年人为多，病程长，进展缓。 1. Slow-onset hypertension: benign hypertension is common (95\%), mostly in middle-aged and elderly people, with a long course and slow progress.
【病理变化】 [Pathological changes]
（1）第一期（功能紊乱期） (1) Phase I (dysfunctional period)
全身细小动脉间歇性痉挛，伴高级神经功能失调，无器质性病变，无明显症状，仅有血压 uarr\uparrow ，常有波动，可有头昏，头痛。 Intermittent spasm of small arteries throughout the body, with high-level nerve dysfunction, no organic lesions, no obvious symptoms, only blood pressure uarr\uparrow , often fluctuating, may have dizziness, headache.
（2）第二期（动脉病变期） (2) Stage II (arterial lesion stage)
细动脉硬化：主要特征病变 Fine arteriosclerosis: the main characteristic lesion
部位：肾入球 A，脾中心 A，视网膜 A－最常见 病变：细 A\mathbf{A} 壁玻璃样变（透明变性） Site: glomerulus A, splenic center A, retina A - most common lesion: A\mathbf{A} wall vitreous degeneration (hyaline degeneration)
镜检：细 A 管腔变小，内皮下间隙区 rarr\rightarrow 均质状，红染无结构玻璃样物，管壁增厚。 Microscopic examination: small lumen of fine A tubules with rarr\rightarrow homogeneous subendothelial interstitial areas, red-stained unstructured vitreous material, and thickened tubular walls.
肌型小动脉硬化：部位：肾小叶间 A，弓形 A，脑的小 A Myocardial small arteriosclerosis: site: renal interlobular A, arcuate A, small A of the brain
病变：内膜胶原及弹性纤维 uarr\uparrow ，中膜平滑肌细胞增生，肥大，血管壁增厚，管腔狭窄，大动脉无明显变化或粥样硬化
（3）第三期（内脏病变期）
心脏 rarr\rightarrow 高血压性心脏病 代偿：心脏向心性肥大 失代偿：离心性肥大
肾脏：原发性颗粒性固缩肾（细动脉性肾硬化）
病理变化：肉眼：双侧肾体积减小，重量减轻，质地变硬，表面均匀弥漫细颗粒状，切面肾皮质变薄，肾孟周围脂肪组织增生（原因：部分萎缩坏死，部分代偿性增生肥大）
镜下：入球 A\mathbf{A} 玻璃样变＋肌型小 A\mathbf{A} 硬化，肾小球纤维化和玻璃样变，肾小管萎缩，消失
间质：纤维结缔组织增生＋淋巴细胞浸润
脑病变：脑血管硬化
【脑水肿】：脑血管硬化及痉挛 rarr\rightarrow 中枢神经功能障碍
【脑软化】表现：多发，微小梗死灶 结局：无严重后果。坏死组织被吸收 rarr\rightarrow 胶质㓔痕修复
【脑出血】：最严重，致命并发症
视网膜病变：病变：视网膜中央 A 发生细小 A 硬化 眼底血管迂曲，反光增强，动静脉交叉处静脉受压；视乳头水肿，视网膜渗出，出血，表现：视力 darr\downarrow
2．急进型高血压／恶性高血压：舒张压显著升高，> 130mmHg>130 \mathrm{mmHg} 青中年多，进展迅速，易发肾衰竭。常原发，可继发
病理变化：以肾为主，也可出现于脑和视网膜，细小动脉管壁纤维素样坏死
增生性小动脉硬化：内膜增厚，平滑肌细胞增生肥大，胶原增生，管壁同心圆洋葱皮状增厚，管腔狭窄。
坏死性细动脉炎：内膜，中膜纤维素样坏死，可见核碎裂和炎细胞浸润
入球小 A 受累，肾小球毛细血管丛节段性坏死 并发症：微血栓，出血和微梗死。
四，风湿病（rheumatism）：与 A 组乙型溶血性链球菌感染有关的主要侵犯全身结缔组织的变态反应性（自身免疫性）疾病，形成特征性风湿性肉芽肿，常常累及心脏和关节（咬住心脏，舔过关节）
发病机制：抗原抗体交叉反应（糖蛋白 C\mathbf{C} 抗原和蛋白质 M\mathbf{M} 抗原）
临床表现：发热，关节疼痛，皮疹，皮下结节，抗 O 抗体升高
（1）病变部位：心包脏层 (1) Location of the lesion: the visceral layer of the pericardium
（2）病变特点：渗出性炎（纤维素／浆液） (2) Characteristics of the lesion: exudative inflammation (fibrin/plasma)
纤维素渗出为主：绒毛心（干性心包炎）浆液渗出为主：心包积液（湿性心包炎） Fibrin exudate predominant: chorioallantoic heart (dry pericarditis) Plasma exudate predominant: pericardial effusion (wet pericarditis)
后期：渗出纤维素溶解吸收 darr rarr\downarrow \rightarrow 机化粘连 rarr\rightarrow 缩窄性心包炎。 Posterior: exudative fibrin lysis and absorption darr rarr\downarrow \rightarrow Mechanized adhesions rarr\rightarrow Constrictive pericarditis.
（二）风湿性关节炎：浆液性炎 (ii) Rheumatoid arthritis: plasma inflammation
病变：滑膜充血，肿胀，关节腔浆液渗出 + 不典型风湿性肉芽肿性，胶原纤维有潻液样变和纤维素样坏死，部位：大关节，表现：游走性多关节炎（炎症表现），结局：可吸收消退，关节不变形。 （三）皮肤病变 Lesions: synovial membrane congestion, swelling, joint cavity plasma exudation + atypical rheumatoid granulomatous, collagen fibers with supplements and fibrinoid necrosis, site: large joints, manifestation: wandering polyarthritis (inflammatory manifestations), outcome: resorptive regression, joints are not deformed. (iii) Skin lesions
环形红斑：非特异性渗出性炎，淡红色环状红晕，微隆起，中央色泽正常，具诊断意义。 Circumscribed erythema: nonspecific exudative inflammation, light red circumscribed erythema, slightly elevated, with a normal-colored center, diagnostic.
皮下结节 部位：四肢大关节附近伸侧面皮下 表现：圆形倩圆结节（ 0.5∼2cm0.5 \sim 2 \mathrm{~cm} ），活动，无痛。形态：中央纤维素样坏死 外周增生纤维母细胞 + 组织细胞 + 淋巴细胞浸润（风湿性肉芽肿病变，有风湿小体）。 结局：可自行消退或留小㾊痕。 Subcutaneous nodules Location: subcutaneous on the extensor surfaces of the extremities near the large joints Presentation: round sinusoidal nodules ( 0.5∼2cm0.5 \sim 2 \mathrm{~cm} ), mobile, painless. Morphology: central fibrinoid necrosis peripheral proliferative fibroblast + histiocyte + lymphocyte infiltrate (rheumatoid granulomatous lesion with rheumatoid bodies). Ending: may resolve spontaneously or leave small 㾊 marks.
（四）风湿性动脉炎，部位：小动脉常见，如冠状 A，肾 A，肠系膜 A，脑 A，肺 A病变：血管壁纤维素样坏死 土淋巴细胞，单核细胞浸润，风湿小体。 (d) Rheumatoid arteritis, site: small arteries are common, e.g., coronary A, renal A, mesenteric A, cerebral A, pulmonary A lesions: fibrinoid necrosis of vessel wall soil lymphocytes, mononuclear cell infiltration, rheumatoid vesicles.
后期：血管壁纤维化 rarr\rightarrow 增厚 rarr\rightarrow 管腔狭窄 rarr\rightarrow 闭塞。 Posterior: vessel wall fibrosis rarr\rightarrow thickening rarr\rightarrow lumen narrowing rarr\rightarrow occlusion.
（五）风湿性脑病：纹状体，锥体外系 (v) Rheumatic encephalopathy: striatum, extrapyramidal system
五，感染性心内膜炎：是由病原微生物经过血道直接侵袭心内膜（心瓣膜）引起的炎症性疾病。常常伴有赘生物形成 Fifth, infective endocarditis: an inflammatory disease caused by pathogenic microorganisms directly attacking the endocardium (heart valves) through the bloodstream. It is often accompanied by the formation of redundant organisms
1．亚急性感染性心内膜炎（亚急性细菌性心内膜炎） 1. Subacute infective endocarditis (subacute bacterial endocarditis)
特点：毒力相对弱的病原微生物引起（草绿色链球菌）＋已有病变的瓣膜 Characteristics: caused by a relatively virulent pathogenic microorganism (Streptococcus oxysporus) + pre-existing diseased valve
赘生物呈污秽灰黄色，质松脆，易破碎，脱落 Superfluous organisms are dirty grayish-yellow in color, brittle, easily broken, and detached
赘生物组成：纤维蛋白，血小板，炎细胞，坏死物，细菌团。 Superfluous composition: fibrin, platelets, inflammatory cells, necrotic material, bacterial clusters.
病变：栓塞梗死（无菌性梗死），最常见于脑，皮下小动脉炎一欧式小结，肾小球肾炎，败血症 Lesions: embolic infarction (aseptic infarction), most commonly cerebral, subcutaneous small arteritis I eurocystic, glomerulonephritis, sepsis
2，急性感染性心内膜炎：a．起病急，多为金葡菌，化脓链球菌 b．多发生于正常心内膜，常单独侵犯主动脉瓣或二尖瓣 c．赘生物大而脆，易脱落，检塞早（含菌的栓子），败血性梗死 d．瓣膜毁损严重，迅速穿孔破裂，心衰出现早 e．病程短，可在数日或数周内死亡。 2, acute infective endocarditis: a. the onset of disease is acute, most of the aureus, streptococcus pyogenes b. most occur in the normal endocardium, often alone infringement of the aortic valve or mitral valve c. redundant organisms are large and brittle, easy to dislodge, the check is early (containing bacteria embolus), septic infarction d. valve destruction is serious, rapid perforation rupture, heart failure early e. the course of the disease is short, can be in a few days or a few weeks to death.
六，心瓣膜病：各种原因造成心瓣膜器质性病变，导致心功能不全和全身血循环障碍。 Sixth, heart valve disease: various causes of heart valve organic lesions, resulting in cardiac insufficiency and systemic blood circulation disorders.
原因：风湿性心内膜炎反复发作。其它：感染性心内膜炎，主动脉粥样硬化，梅毒 Causes: recurrent episodes of rheumatic endocarditis. Other: infective endocarditis, aortic coarctation, syphilis
部位：多见于二尖瓣，次为主动脉瓣 Site: Most common in mitral valve, followed by aortic valve
联合瓣膜病：两个以上瓣膜（如二尖瓣和主动脉瓣）同时或先后受累。 Combined valve disease: simultaneous or sequential involvement of two or more valves (e.g., the mitral and aortic valves).
1．二尖瓣狭窄：常常由风湿性心内膜炎引起 1. Mitral stenosis: often caused by rheumatic endocarditis
临床表现：心尖区舒张期隆隆样杂音 左心房扩大，呼吸困难，紫绀，血性泡沫痰（肺淤血）颈静脉扩张，肝脾肿大，下肢水肿，体腔积液。 Clinical manifestations: diastolic rumbling murmur in the apical region, enlarged left atrium, dyspnea, cyanosis, bloody frothy sputum (pulmonary stasis) jugular venous dilatation, hepatosplenomegaly, lower extremity edema, body cavity effusion.
心脏三大一小：左房，右室，右房肥大扩张，左室轻度缩小 X 线：梨形心 Three large and three small heart sizes: left atrium, right ventricle, right atrium hypertrophied and dilated, left ventricle mildly reduced X-ray: pear-shaped heart
2．二尖瓣关闭不全：临床表现：心尖区全收缩期吹风样杂音 XX 线：左右心房，心室均肥大扩张．球形心 2. Mitral valve closure insufficiency: Clinical manifestations: apical area full systolic blowing murmur XX line: left and right atria, ventricles are hypertrophied and dilated. Spherical heart
3．主动脉瓣关闭不全（由风湿性心内膜炎，亚急性感染性心内膜炎，主动脉粥样硬化引起）：舒张期主动脉血返流 rarr\rightarrow 左室肥大，扩张 rarr\rightarrow 心衰 3. Aortic valve insufficiency (caused by rheumatic endocarditis, subacute infective endocarditis, aortic atherosclerosis): diastolic aortic regurgitation rarr\rightarrow left ventricular hypertrophy, dilatation rarr\rightarrow heart failure
4．主动脉瓣狭窄：左室排血受阻 rarr\rightarrow 左室肥厚，扩张 rarr\rightarrow 左房 rarr\rightarrow 右室 rarr\rightarrow 右房肥大，靴形心 4. Aortic stenosis: left ventricular drainage blocked rarr\rightarrow Left ventricular hypertrophy, dilatation rarr\rightarrow Left atrium rarr\rightarrow Right ventricle rarr\rightarrow Right atrial hypertrophy, boot-shaped heart
第七章 呼吸系统疾病 Chapter VII. Diseases of the respiratory system
肺实质：肺内支气管的各级分支＋肺泡。 肺间质：结缔组织及血管，淋巴管，神经。 Lung parenchyma: branches of the bronchial tubes in the lungs at all levels + alveoli. Interstitium: connective tissue and blood vessels, lymphatics, nerves.
A，肺炎（pneumonia）肺组织炎症性疾病的统称，以急性渗出性炎症为主。 A, Pneumonia (pneumonia) A collective term for inflammatory diseases of the lung tissue, with acute exudative inflammation predominating.
细菌性肺炎最为常见：大叶性肺炎，小叶性肺炎，军团菌性肺炎 Bacterial pneumonia is the most common: lobar pneumonia, lobular pneumonia, legionella pneumonia
一，大叶性肺炎（lobar pneumonia）：由肺炎链球菌引起的以肺泡内弥漫性纤维素渗出为主的炎症（纤维素性炎），病变累及一个肺段或整个大叶（段及以上）。 I. Lobar pneumonia (lobar pneumonia): inflammation caused by Streptococcus pneumoniae with diffuse fibrinous exudation in the alveoli (fibrinous inflammation), with lesions involving one lung segment or the entire lobe (segments and above).
临床特征：起病急，恶寒，高热，胸痛，咳嗽，咳铁锈色痰，呼吸困难伴肺实变征及 WBC 增高。病程约一周。多见于青壮年。 Clinical features: acute onset, chills, high fever, chest pain, cough, rust-colored sputum, dyspnea with signs of solid changes in the lungs and increased WBC. Duration of the disease is about one week. Most common in young adults.
1．病因及发病机制 病原菌：肺炎链球菌为主 机体：抵抗力下降—受寒，醉酒，感冒，麻醉，疲劳等。 1. Etiology and pathogenesis Pathogenic organisms: Streptococcus pneumoniae is the main organism: decreased resistance - cold, drunkenness, cold, anesthesia, fatigue.
病变发生迅速，以肺泡毛细血管通透性 uarr\uparrow 为特点：渗出；病菌迅速蔓延一肺段，肺叶病变。 Lesions occur rapidly and are characterized by alveolar capillary permeability uarr\uparrow : exudation; rapid spread of the disease to one lung segment and lobar lesions.
2．病理变化及病理临床联系 性质：纤维素性炎 部位和范围：一般单侧，左肺或右肺下叶常见。病变分期－－－四期： 2. pathological changes and pathoclinical associations Nature: fibrinous inflammation Location and extent: usually unilateral, common in the left or right lower lobe of the lung. Staging of the lesion - stage IV:
（1）充血水肿期：1－2日 (1) Congestion and edema phase: 1-2 days
1）病变：大体：肿大，暗红色 1) Lesions: gross: enlarged, dark red color
镜下：肺泡壁毛细血管扩张，充血；肺泡腔大量浆液性渗出物，细菌；少量 RBC，中性粒细胞 Microscopy: dilated capillaries in alveolar walls, congestion; large amount of plasma exudate in alveolar lumen, bacteria; few RBCs, neutrophils
2）病理临床联系：细菌毒素入血 + 细菌入血释放毒素 rarr\rightarrow 中毒症状：寒战，高热，肌肉酸痛肺泡腔大量渗出物 + 炎细胞浸润 rarr\rightarrow 咳嗽 肺泡腔大量浆液性渗出物 + 少量 RBC rarr\rightarrow 咳淡红色痰 2) Pathologic-clinical associations: bacterial toxins in blood + bacteria in blood releasing toxins rarr\rightarrow Symptoms of poisoning: chills, high fever, muscle aches massive exudate in alveolar space + inflammatory cell infiltrate rarr\rightarrow Cough massive plasma exudate in alveolar space + small amount of RBCs rarr\rightarrow Cough pale red sputum
（2）红色肝样变期（Red hepatization）实变早期：2～4日 (2) Red hepatization (Red hepatization) Early stage of solid changes: 2 to 4 days
1）病变：镜下：肺泡壁——毛细血管扩张，充血 1) Lesions: microscopic: alveolar wall - capillary dilation, congestion
肺泡腔一大量红细胞，细菌，少量 N,MN, ~ M ；纤维蛋白原渗出 rarr\rightarrow 纤维素（呈粗的条索状，片团状分布， Alveolar lumen a large number of erythrocytes, bacteria, a small number of N,MN, ~ M ; fibrinogen exudation rarr\rightarrow Fibrin (in the form of thick cords, clumps of flakes.
意义在于有利于巨噬细胞吞噬细菌，防止细菌进一步扩散） (The significance of this is that it facilitates the phagocytosis of bacteria by macrophages and prevents the further spread of bacteria)
大体：肺肿大，重量增加，暗红，质实如肝—原因：血管扩张充血＋渗出物＋肺泡腔大量 RBC 渗出 Gross: enlarged lungs, increased weight, dark red, solid as liver - Cause: vasodilatation congestion + exudates + massive RBC exudates from alveolar cavities
2）病理临床联系：肺泡腔大量 RBCrarr\mathrm{RBC} \rightarrow 巨噬细胞吞噬，崩解—含铁血黄素：铁锈色痰； 2) Pathologic-clinical associations: alveolar cavities heavily RBCrarr\mathrm{RBC} \rightarrow phagocytosed by macrophages, disintegration-containing ferritin: rust-colored sputum;
大量 RBC，纤维素，少量 Nrarr\mathrm{N} \rightarrow 肺实变 rarr\rightarrow 缺氧：紫绀，呼吸困难；肺实变征：查体，X－ray，高热稽留浆液性渗出物（培养基）rarr\rightarrow 病菌繁殖 rarr\rightarrow 血菌 (+)(+) Large amounts of RBCs, fibrin, small amounts Nrarr\mathrm{N} \rightarrow Lung solid changes rarr\rightarrow Hypoxia: cyanosis, dyspnea; signs of lung solid changes: exam, x-ray, hyperthermia auditory plasma exudate (cultures) rarr\rightarrow Bacterial colonization rarr\rightarrow Hematobacteria (+)(+)
（3）灰色肝样变期（Gray hepatization）实变晚期，5～6日 (3) Gray hepatization (Gray hepatization) Late solid phase, 5-6 days
1）病变：镜下：肺泡壁——毛细血管受压，贫血 肺泡腔一一大量中性粒细胞，纤维蛋白量多，呈丝网状－－纤维素网；纤维素丝经肺泡间孔互相连接 1) Lesions: microscopic: alveolar wall - capillary compression, anemia alveolar lumen a large number of neutrophils, high amount of fibrin, filamentous mesh - fibrin network; fibrin filaments interconnect each other through interalveolar pores
大体：肺呈灰白色，肺肿胀；肺实变 Gross: grayish-white lungs, lung swelling; pulmonary solidity
2）病理临床联系：坏死脱落细胞 + 渗出液 + 纤维素 rarr\rightarrow 刺激 rarr\rightarrow 咳嗽 2) Pathologic-clinical associations: necrotic decidual cells + exudate + fibrin rarr\rightarrow irritation rarr\rightarrow coughing
中性粒细胞坏死 + 渗出液 + 坏死脱落上皮细胞 rarr\rightarrow 脓性痰 巨噬细胞 uarr rarr\uparrow \rightarrow 病菌阴性 Neutrophil necrosis + exudate + necrotic exfoliated epithelial cells rarr\rightarrow Purulent sputum Macrophages uarr rarr\uparrow \rightarrow Negative for germs
纤维素开始溶解＋机体适应 rarr\rightarrow 缺氧症状减轻 中性粒细胞＋纤维素 rarr\rightarrow 肺实变 -x 线，体征 Fibrin begins to dissolve + organism adapts rarr\rightarrow Hypoxic symptoms reduced Neutrophils + fibrin rarr\rightarrow Lung solid lesions - x-ray, physical signs
（4）溶解消散期 第7－10日 (4) Dissolution and dissipation period Days 7-10
1）病变：镜下：巨噬细胞 uarr\uparrow ，中性粒细胞变性坏死 rarr\rightarrow 渗出物（主要为纤维素）溶解（中性粒细胞释放的蛋白水解酶） 1) Lesions: microscopic: macrophages uarr\uparrow , neutrophils degenerate and necrotic rarr\rightarrow exudate (mainly fibrin) lysis (protein hydrolases released by neutrophils)
大体：质地变软，切面颗粒外观渐消失，可有脓样混浊液体 渗出物被溶解 rarr\rightarrow 肺体积缩小 Gross: texture softens, granular appearance fades in section, may have purulent cloudy fluid Exudate is lysed rarr\rightarrow Lungs decrease in size
渗出物主要为纤维素，RBC 较少 rarr\rightarrow 肺灰白色 渗出物被溶解 rarr\rightarrow 经淋巴管吸收或咳出 rarr\rightarrow 肺实变 （持续时长 3－4 周，故复查周期为一个月左右） Exudate mainly fibrin, less RBCs rarr\rightarrow Lung grayish-white Exudate dissolved rarr\rightarrow Absorbed through lymphatics or coughed up rarr\rightarrow Lung solid (lasts 3-4 weeks, so review cycle is about a month)
2）病理临床联系：咳嗽，渗出物 + 坏死的中性粒细胞 rarr\rightarrow 咳痰 2) Pathologic-clinical associations: cough, exudate + necrotic neutrophils rarr\rightarrow coughing up sputum
3．结局及并发症 3. Outcome and complications
（1）痊愈：大叶性肺炎通常为急性渗出性炎症，故肺组织常无坏死，肺泡壁结构未遭破坏 rarr\rightarrow 结构和功能恢复痊愈 (1) Cured: lobar pneumonia is usually an acute exudative inflammation, so the lung tissue is often not necrotic, and the alveolar wall structure has not been damaged rarr\rightarrow Structure and function restored and cured.
（2）并发症：a．中毒性休克 b．肺脓肿及脓（气）胸：金黄色葡萄球菌 c．败血症或脓毒败血症：严重感染 d．胸膜炎 e．肺肉质变（pulmonary carnification）：灰肝期，中性粒细胞渗出过少 rarr\rightarrow 蛋白溶解酶不足 rarr\rightarrow 渗出物不能及时溶解吸收 rarr\rightarrow 肉芽组织长入 rarr\rightarrow 机化 rarr\rightarrow 病变呈褐色肉样。 (2) Complications: a. Toxic shock b. Pulmonary abscess and pus (pneumothorax): Staphylococcus aureus c. Septicemia or septicemia: severe infection d. Pleurisy e. Pulmonary carnification: gray liver stage, with too little neutrophil exudate rarr\rightarrow Insufficient proteolytic enzymes rarr\rightarrow Exudate can't be absorbed in time. Lysis and absorption rarr\rightarrow Granulation tissue grows in rarr\rightarrow Mechanization rarr\rightarrow Lesion is brown and fleshy.
（二）小叶性肺炎（lobular pneumonia）化脓菌引起，以肺小叶为病变单位的急性化脓性炎。常以细支气管为中心，又称支气管肺炎。常是某些疾病的并发症。常见小儿和年老体弱者，肺小叶临床表现：发热，咳嗽，粘液脓性痰，呼吸困难和肺部散在湿罗音。 (B) lobular pneumonia (lobular pneumonia) caused by Pseudomonas aeruginosa, acute suppurative inflammation of the lung lobules as the lesion unit. Often centered on the fine bronchi, also known as bronchopneumonia. It is often a complication of certain diseases. Commonly found in children and the elderly and infirm, the clinical manifestations of pulmonary lobules: fever, cough, mucopurulent sputum, dyspnea and scattered wet rhonchi in the lungs.
1．病因和发病机制： 1. Etiology and pathogenesis:
1）病原：细菌（化脓菌：肺炎链球菌，葡萄球菌等），病毒，霉菌 1) Pathogens: Bacteria (Pseudomonas: Streptococcus pneumoniae, Staphylococcus, etc.), viruses, molds
2）机体抵抗力 darr\downarrow 2) Organismal resistance darr\downarrow
两种特殊情况：坠积性肺炎，吸入性肺炎 Two special cases: crashing pneumonia, aspiration pneumonia
2．病理变化及病理临床联系 特征：肺组织急性化脓性炎，多以细支气管为中心，中心粒细胞浸润。病变从细支气管 rarr\rightarrow 周围或末梢肺组织 rarr\rightarrow 形成以肺小叶为单位，灶状散布的炎症灶。 2. Pathological changes and pathological and clinical associations Characteristics: acute purulent inflammation of the lung tissue, mostly centered on the fine bronchioles, with central granulocytic infiltration. Lesions from the rarr\rightarrow peripheral or terminal lung tissue rarr\rightarrow formation of lung lobules as a unit, focally scattered foci of inflammation.
1）病理变化 大体：肺内多发性，散在分布，斑片状实变病灶，两肺各叶，背侧，下叶较多病灶多为小叶范围（ d0.5-1cm\mathbf{d} \mathbf{0 . 5 - 1 c m} ），不规则，切面致密，灰黄色，脓性渗出物 1) Pathologic changes Grossly: multiple, scattered, patchy solid lesions in the lungs, each lobe of the lungs, dorsal, lower lobe more foci mostly lobular in extent ( d0.5-1cm\mathbf{d} \mathbf{0 . 5 - 1 c m} ), irregular, dense, grayish-yellow, purulent exudate on the cut surface
镜下：病灶中央或周围有细支气管 细支气管管壁：充血，水肿， N 为主的炎细胞浸润 Microscopy: fine bronchi in or around the center of the lesion Fine bronchial walls: congestion, edema, N-dominant inflammatory cell infiltrate
管腔：脓性渗出物，纤维蛋白较少，病灶周肺泡腔有大量浆液， N,\mathrm{N}, ~ 纤维蛋白较少。 Lumen: purulent exudate, less fibrin, perifocal alveolar lumen with large amounts of plasma, N,\mathrm{N}, ~ less fibrin.
重者融合成片或累及全叶 rarr\rightarrow 融合性支气管肺炎（confluent bronchopneumonia） In severe cases, it fuses into patches or involves the whole lobe rarr\rightarrow Confluent bronchopneumonia
2）临床表现：常为原发疾病掩盖。 炎症＋脓性渗出物 rarr\rightarrow 咳嗽，咳痰（粘液脓性痰）X－ray－－－不规则小片状，斑点状模糊阴影 2) Clinical manifestations: often masked by primary disease. Inflammation + purulent exudate rarr\rightarrow Coughing, coughing up sputum (mucopurulent sputum) X-ray - irregular small flakes, speckled fuzzy shadows
3．结局及并发症：1）痊愈：及时治疗，渗出物完全吸收 3. Outcome and complications: 1) Cured: timely treatment, complete absorption of exudate
2）并发症：危险性比大叶性肺炎大得多，可有呼衰，心衰，败血症，脓胸，支气管扩张等。 2) Complications: the danger is much greater than that of lobar pneumonia, and there can be expiratory failure, heart failure, sepsis, septic chest, bronchodilatation, and so on.
（1）病因：上呼吸道病毒感染向下蔓延所致的肺部炎症，病毒－－流感病毒，腺病毒，麻疹病毒，巨细胞病毒等，单一或混合感染（多种病毒＋继发细菌）。常常通过飞沫传播 (1) Causes: inflammation of the lungs due to downward spread of viral infections of the upper respiratory tract, viruses - influenza virus, adenovirus, measles virus, cytomegalovirus, etc., single or mixed infections (multiple viruses + secondary bacteria). Often spread by droplets
（2）病理变化及病理临床联系 病理变化：间质性炎症，充血水肿 (2) Pathologic changes and pathologic-clinical associations Pathologic changes: interstitial inflammation, congestion and edema
变质性炎：肺泡壁上皮细胞变性坏死 Metaplasia: degeneration and necrosis of alveolar wall epithelial cells
两大病理损伤：透明膜，包涵体 Two major pathologic injuries: hyaline membrane, inclusion bodies
一般肺泡腔无渗出，若有，则为浆液纤维素性渗出物，均匀红染——透明膜 Generally no exudation from alveolar cavities, if any, plasma-fibrinous exudate, uniformly red-stained - hyaline membrane
病毒包涵体（viruses inclusions）：圆形或椭圆形，约红细胞大小，嗜酸性，周围常有一清晰的透明晕 部位：上皮细胞／多核巨细胞内，胞核一巨细胞病毒，腺病毒，胞浆一呼吸道合胞病毒，胞核和胞浆都有 意义：诊断病毒性肺炎的重要依据 Viruses inclusions: round or oval, about the size of a red blood cell, eosinophilic, often surrounded by a clear halo Location: in epithelial cells/polynuclear giant cells, cytomegalovirus, adenovirus, cytoplasmic respiratory syncytial viruses, both cytomegalovirus and cytomegalovirus Significance: Important in the diagnosis of viral pneumonia.
多核巨细胞（giant cells ）：支气管和肺泡上皮增生 rarr\rightarrow 多核巨细胞 Giant cells: bronchial and alveolar epithelial hyperplasia rarr\rightarrow Giant cells
病理与临床联系：炎症－－－剧烈咳嗽 渗出－－－缺氧，呼吸困难（注意：无痰）＝病毒－－－中毒症状。 Pathologic and clinical links: inflammation - severe coughing exudation - hypoxia, dyspnea (note: no sputum) = viral --Toxicity symptoms.
三，间质性肺炎：管壁，小叶间隔，肺泡隔等肺间质的炎症。多由支原体感染引起。（阿奇霉素） Third, interstitial pneumonia: inflammation of the interstitium of the lungs such as the walls of the tubes, the interlobular septa, and the alveolar septa. Mostly caused by mycoplasma infection. (Azithromycin)
B，慢性阻塞性肺疾病（chronic obstructive pulmonary diseases，COPD）一组慢性可逆性／不可逆性气道阻塞，呼气阻力增加，肺功能不全为共同特征的疾病统称。 B, chronic obstructive pulmonary diseases (chronic obstructive pulmonary diseases, COPD) a group of chronic reversible/irreversible airway obstruction, increased expiratory resistance, pulmonary insufficiency as a common feature of the disease collectively.
包括慢性支气管炎，肺气肿，支气管扩张，支气管哮喘。 This includes chronic bronchitis, emphysema, bronchiectasis, and bronchial asthma.
一，慢性支气管炎（chronic bronchitis）气管，支气管粘膜及其周围组织的慢性非特异性炎，以支气管粘膜，粘膜下增生为主要病变。临床表现－－咳，痰，喘，> 3m//>3 \mathrm{~m} / 年，> 2y>2 \mathrm{y} 。 First, chronic bronchitis (chronic bronchitis) trachea, bronchial mucosa and its surrounding tissues of chronic non-specific inflammation, bronchial mucosa, submucosal hyperplasia as the main lesion. Clinical manifestations - cough, sputum, wheezing, > 3m//>3 \mathrm{~m} / years, > 2y>2 \mathrm{y} .
（一）病因和发病机制：1．感染：病毒，细菌 rarr\rightarrow 粘膜上皮损伤，防御 darr2\downarrow 2 ．吸烟：粘膜上皮损伤，防御 darr,M\downarrow, \mathrm{M} 吞噬 darr3\downarrow 3 ．大气污染和气候变化：有害气体，寒冷 4 ．过敏因素 (I) Etiology and pathogenesis: 1. Infection: viruses, bacteria rarr\rightarrow Mucosal epithelial damage, defense darr2\downarrow 2 ． Smoking: mucosal epithelial damage, defense darr,M\downarrow, \mathrm{M} phagocytosis darr3\downarrow 3 ． Air pollution and climate change: harmful gases, cold 4. Allergic factors
（二）病理变化：早期：累及气管，大中支气管 晚期：细小支气管炎及其周围炎 (ii) Pathologic changes: Early stage: involvement of trachea, large and medium-sized bronchi Late stage: fine bronchitis and its periphery
镜下：1，粘膜上皮损伤与修复：纤毛粘连，倒伏，脱失；上皮细胞变性，坏死；再生，鳞化； Microscopy: 1, Mucosal epithelial damage and repair: cilia adherence, inversion, loss; epithelial cell degeneration, necrosis; regeneration, squamization;
杯状细胞 uarr\uparrow 。修复时可伴有鳞状上皮化生 Cup cells uarr\uparrow . Repair may be accompanied by squamous epithelial hyperplasia
2，腺体增生，肥大及粘液腺化生，后期腺体可萎缩 2, Glandular hyperplasia, hypertrophy and mucous glandular chemosis, later the gland can atrophy
3，支气管壁的慢性炎症损害：充血，淋巴，浆细胞浸润；平滑肌束断裂，萎缩；软骨变性，萎缩， 3, Chronic inflammatory damage to the bronchial wall: congestion, lymphoid, plasma cell infiltration; smooth muscle bundles fracture, atrophy; cartilage degeneration, atrophy, and
钙化或骨化；细支气管炎和周围炎。 Calcification or ossification; fine bronchitis and periostitis.
大体：粘膜上皮及支气管壁损害 rarr\rightarrow 支气管粘膜粗糙，充血，水肿 腺体病变 rarr\rightarrow 粘性或脓性分泌物 （三）病理与临床联系：支气管粘膜炎症 rarr\rightarrow 咳嗽 Gross: mucosal epithelial and bronchial wall damage rarr\rightarrow Bronchial mucosa rough, congested, edematous Glandular lesions rarr\rightarrow Viscous or purulent secretions (c) Pathologic and clinical associations: bronchial mucosal inflammation rarr\rightarrow Coughing
杯状细胞，粘液腺体，分泌物 uarr rarr\uparrow \rightarrow 咳痰（白色粘液泡沫痰／脓性痰－－急性期） Cup cells, mucous glands, secretions uarr rarr\uparrow \rightarrow Coughing up sputum (white mucous foamy sputum/purulent sputum - acute phase)
支气管狭窄／痉挛＋渗出物 rarr\rightarrow 阻塞 rarr\rightarrow 喘，罗音，哮鸣音 慢性萎缩性支气管炎 rarr\rightarrow 无痰。 Bronchial stenosis/spasm + exudates rarr\rightarrow Obstruction rarr\rightarrow Wheezing, rhonchi, rales Chronic atrophic bronchitis rarr\rightarrow No sputum.
（四）结局及并发症：1．痊愈 (iv) Outcome and complications: 1. Cured
2．并发症：（1）慢性阻塞性肺气肿（2）支气管扩张症（3）支气管肺炎（4）肺癌 2. Complications: (1) chronic obstructive pulmonary emphysema (2) bronchiectasis (3) bronchopneumonia (4) lung cancer
二，支气管哮喘：内，外因素（遗传等）引发呼吸道过敏反应 rarr\rightarrow 以弥漫性细支气管痉挛为特征的支气管慢性炎性疾病。 Second, bronchial asthma: endogenous and exogenous factors (genetic, etc.) trigger respiratory allergic reactions rarr\rightarrow Chronic inflammatory disease of the bronchial tubes characterized by diffuse spasm of the fine bronchial tubes.
临床表现：发作性喘息十哮鸣音的呼气性呼吸困难等。 慢性疾病，可视为慢性阻塞性细支气管炎的一种特殊类型。 Clinical manifestations: episodes of wheezing ten croupy expiratory dyspnea and so on. Chronic disease, can be regarded as a special type of chronic obstructive fine bronchitis.
（一）病因和发病机制：遗传因素＋过敏（过敏原反复接触，感染，冷空气，烟雾等）因素： (i) Etiology and pathogenesis: genetic + allergic (repeated exposure to allergens, infections, cold air, smoke, etc.) factors:
（1）抗原 rarr B\rightarrow B 细胞 rarr\rightarrow 浆细胞 IgE uarr rarr\uparrow \rightarrow 肥大，嗜碱性粒细胞致敏 -+ 过敏原 rarr\rightarrow 释放组胺，缓激肽等 rarr\rightarrow 气管平滑肌收缩 rarr\rightarrow 速发型哮喘反应 (1) Antigens rarr B\rightarrow B Cells rarr\rightarrow Plasma cells IgE uarr rarr\uparrow \rightarrow Mast, basophilic sensitization -+ Allergens rarr\rightarrow Release of histamine, bradykinin, etc. rarr\rightarrow Contraction of tracheal smooth muscle rarr\rightarrow Rapid-onset asthma response
（2）PAF，花生四烯酸代谢产物，水解酶 rarr\rightarrow 嗜酸性，中性粒细胞趋化因子 rarr\rightarrow 嗜酸性，N,MN, ~ M 细胞浸润 rarr\rightarrow 释放炎症介质 rarr\rightarrow 组织损伤 rarr\rightarrow 迟发型哮喘反应 (2) PAF, arachidonic acid metabolite, hydrolase rarr\rightarrow eosinophilic, neutrophil chemotactic factor rarr\rightarrow eosinophilic, N,MN, ~ M cellular infiltration rarr\rightarrow release of inflammatory mediators rarr\rightarrow tissue damage rarr\rightarrow delayed asthmatic response
（二）病理变化 镜下：1，粘膜上皮损害，杯状细胞 uarr\uparrow (ii) Pathologic changes Microscopy: 1, mucosal epithelial damage, cup-shaped cells uarr\uparrow
2，粘膜基底膜 uarr\uparrow ，玻变，粘液腺增生 2, Mucosal basement membranes uarr\uparrow , glassy lesions, mucous gland hyperplasia
3，管壁平滑肌：肥大，嗜酸性及单核细胞浸润 4，粘液栓：Charcot－Leyden 结晶等大体：粘膜基底膜 uarr+\uparrow+ 平滑肌肥大 + 粘液栓 + 炎症 rarr\rightarrow 细支气管狭窄，痉挛 rarr\rightarrow 肺含气量 uarr rarr\uparrow \rightarrow 肺膨胀，柔软，有弹性症 rarr\rightarrow 粘膜充血，水肿 rarr\rightarrow 管腔狭窄。 3, Tubular wall smooth muscle: hypertrophy, eosinophilic and mononuclear cell infiltration 4, Mucus plugs: Charcot-Leyden Crystallization et al. Gross: mucosal basement membrane uarr+\uparrow+ Smooth muscle hypertrophy + Mucus plugs + Inflammation rarr\rightarrow Fine bronchial stenosis, spasticity rarr\rightarrow Lung air-containing capacity uarr rarr\uparrow \rightarrow Lungs distended and Soft, elastosis rarr\rightarrow Mucosal congestion, edema rarr\rightarrow Lumen narrowing.
支气管粘膜杯状细胞 uarr+\uparrow+ 粘液腺增生 rarr\rightarrow 分泌物 uarr+\uparrow+ 痉挛 rarr\rightarrow 粘／脓性分泌物—粘液栓 Bronchial mucosal cuprocytes uarr+\uparrow+ Mucous gland hyperplasia rarr\rightarrow Secretion uarr+\uparrow+ Spasm rarr\rightarrow Mucous/purulent secretion-mucus plugs
（三）病理与临床联系：粘膜肿胀 + 粘液栓 rarr\rightarrow 细支气管狭窄 + 痉挛 rarr\rightarrow 呼气性呼吸困难，哮鸣。 (c) Pathologic and clinical associations: mucosal swelling + mucus plugs rarr\rightarrow fine bronchial stenosis + spasm rarr\rightarrow expiratory dyspnea, croup.
（四）结局及并发症： (iv) Outcome and complications:
1．缓解 1. Mitigation
2．并发症：胸廓变形，肺气肿，气胸。 2. Complications: thoracic deformation, emphysema, pneumothorax.
三，支气管扩张症（bronchiectasis）以支气管的持久性扩张为特征的慢性疾病，常因分泌物潴留继发化脓性炎症。（肺内小支气管壁及弹性成分破坏使得管腔持久性扩张的慢性呼吸道疾病，扩张支气管因分泌物潴留而继发化脓性炎症。） Bronchiectasis is a chronic disease characterized by persistent dilatation of the bronchial tubes, often followed by purulent inflammation due to secretion retention. (Chronic respiratory disease characterized by persistent dilatation of the lumen of the small bronchial tubes in the lungs due to destruction of their walls and elastic components, with suppurative inflammation secondary to secretion retention in the dilated bronchioles.)
病变特点一支气管的慢性化脓性炎。 部位一好于肺段及以下小支气管。 Characteristics of the lesion I chronic suppurative inflammation of the bronchi. Site I Prefers lung segments and small bronchi below.
临床表现一慢性咳嗽，大量脓痰或反复咯血症状。男性多见。 Clinical manifestations a chronic cough, a large amount of purulent sputum or recurrent hemoptysis symptoms. It is more common in males.
（一）病因：1．感染：支气管壁炎症损伤，弹力 darr\downarrow ，周围肺组织纤维化；肿瘤／异物吸入：支气管不完全阻塞，支气管壁回弹力 darr\downarrow ，吸入腐蚀性气体，霉菌等 (A) Etiology: 1. Infection: inflammatory damage to the bronchial wall, elasticity darr\downarrow , fibrosis of the surrounding lung tissue; tumor/foreign body inhalation: incomplete obstruction of the bronchial tubes, bronchial wall elasticity darr\downarrow , inhalation of corrosive gases, mycobacteria and so on.
2．先天性发育缺陷和遗传因素：胰腺囊性纤维化十肺囊性纤维化一支扩 2. Congenital developmental defects and genetic factors: cystic fibrosis of the pancreas and cystic fibrosis of the lungs with an expanded
（二）病理变化：大体：部位－－肺段支气管，左下叶多见。支气管－－柱或囊状扩张；多 rarr\rightarrow 蜂窝肺；管腔－－粘膜粗糙，充血，水肿，血性或脓性分泌物；壁 uarr\uparrow 周围肺－－萎缩，纤维化，肺气肿； (ii) Pathologic changes: gross: site - bronchi of lung segments, left lower lobe more common. Bronchioles - columnar or cystic dilatation; multiple rarr\rightarrow honeycomb lungs; lumen - rough mucosa, congestion, edema, bloody or purulent secretions; wall uarr\uparrow Peripheral lungs - - Atrophy, fibrosis, emphysema;
镜下：1，粘膜上皮损害：上皮细胞变性，坏死，脱落，溃疡形成；增生，鳞化 Microscopic: 1, mucosal epithelial damage: epithelial cell degeneration, necrosis, detachment, ulcer formation; hyperplasia, squamousness
2．支气管壁的损害：萎缩，断裂，纤维化 3．支气管周围组织：淋巴组织，纤维组织增生，纤维化 （三）病理与临床联系：慢性炎，腺体 uarr\uparrow ，感染 rarr\rightarrow 咳嗽，咳痰（脓性痰）血管壁损害 rarr\rightarrow 咯血四，肺气肿（pulmonary emphysema）：呼吸性细支气管以远的末梢肺组织因弹性 darr\downarrow ，残气量 uarr\uparrow 而呈持久的扩张十肺泡隔破坏，容积 uarr\uparrow 的一种病理状态。 2. bronchial wall damage: atrophy, fracture, fibrosis 3. peribronchial tissue: lymphoid tissue, fibrous tissue hyperplasia, fibrosis (3) Pathological and clinical links: chronic inflammation, glands uarr\uparrow , infection rarr\rightarrow coughing, coughing up sputum (purulent sputum) vascular wall damage rarr\rightarrow haemoptysis emphysema: a pathological condition in which the terminal lung tissues remote from the respiratory bronchi are persistently dilated due to elasticity and residual air volume , and the alveolar septa are destroyed, with a volume of uarr\uparrow .
（一）病因和发病机制 (i) Etiology and pathogenesis
类型及病理变化特点 Types and characteristics of pathological changes
类型：1，肺泡性肺气肿：（1）腺泡（小叶）中央型（最常见）（2）腺泡周围型（3）全腺泡型（1＋2）肺大泡（bulla of lung）：局灶性肺泡破坏，融合形成的大囊泡。直径 > 2cm>2 \mathrm{~cm} ，多为单个孤立的囊泡，位于胸膜下。 Types: 1, alveolar emphysema: (1) alveolar (lobular) central type (most common) (2) periaqueductal type (3) whole-alveolar type (1 + 2) bulla of lung: focal alveolar destruction, fusion of the formation of large vesicles. Diameter > 2cm>2 \mathrm{~cm} , mostly a single isolated vesicle, located in the subpleura.
2，间质性肺气肿：气体进入肺间质 2, Interstitial emphysema: gas enters the interstitium of the lungs
镜下：1．肺泡扩张，肺泡孔扩大，间隔变窄断裂，囊腔形成 2．肺毛细血管受压数量减少，小动脉内膜纤维化 3．肺小动脉内膜纤维性增厚，小气道周围慢性炎 Microscopically: 1. alveolar dilatation, enlargement of alveolar pores, narrowing and fracture of septa, cystic lumen formation 2. reduction in the number of compressed pulmonary capillaries, fibrosis of the lining of small arteries 3. fibrous thickening of the lining of small pulmonary arteries, chronic inflammation of the periphery of small airways
大体：体积大（钝圆，压痕），弹性差（柔软），色灰白，切面蜂窝状。 Major: large (bluntly rounded, indented), poorly elastic (soft), grayish color, cut surface honeycombed.
（二）病理与临床联系： (ii) Pathological and clinical links:
（1）呼气性呼吸困难：胸闷头痛，紫绀等缺氧症状。 (1) Expiratory dyspnea: chest tightness, headache, cyanosis and other hypoxic symptoms.
（2）桶状胸：重度，胸廓前后径增大；胸廓呈过吸气状态：肋间隙增宽，肋骨上抬，叩诊过清音，胸透肺透明度增加。 (2) Barrel chest: severe, with increased anterior and posterior thoracic diameters; the thorax is hyperextracted: widening of the intercostal space, elevation of the ribs, hyperextracted sounds on percussion, and increased transparency of the lungs on chest X-ray.
（三）并发症：1．慢性肺源性心脏病，右心衰竭 2．自发性气胸，皮下气肿：肺大泡破裂 rarr\rightarrow 大量气体进入胸腔 rarr\rightarrow 大面积肺萎陷 肺门区 rarr\rightarrow 纵隔气肿 rarr\rightarrow 皮下气肿 3 。急性肺感染 （Complications: 1. Chronic pulmonary heart disease, right heart failure 2. Spontaneous pneumothorax, subcutaneous emphysema: rupture of large pulmonary alveoli rarr\rightarrow large amount of gas into the thoracic cavity rarr\rightarrow large pulmonary atrophy pulmonary hilar area rarr\rightarrow mediastinal emphysema rarr\rightarrow subcutaneous emphysema 3. Acute lung infection
C，慢性肺源性心脏病（chronic cor pulmonale）（肺心病）：肺，胸廓畸形或肺血管病变 rarr\rightarrow 肺动脉高压 rarr\rightarrow 右心肥厚，扩张为特征的心脏病。 C, chronic cor pulmonale (pulmonary heart disease): heart disease characterized by pulmonary, thoracic deformities or pulmonary vascular lesions rarr\rightarrow pulmonary hypertension rarr\rightarrow hypertrophy and dilatation of the right heart.
（一）病因和发病机制：肺动脉高压 (i) Etiology and pathogenesis: pulmonary hypertension
1．慢性阻塞性肺疾患 rarr\rightarrow 肺小动脉，毛细血管床减少，闭塞 rarr\rightarrow 肺动脉高压 rarr\rightarrow 肺心病 1. Chronic obstructive pulmonary disease (COPD) rarr\rightarrow Decreased number of small pulmonary arteries and capillary beds, occlusion rarr\rightarrow Pulmonary hypertension rarr\rightarrow Pulmonary heart disease (CHD)
2．肺的通气和换气功能障碍 rarr\rightarrow 低氧血症：缺氧 rarr\rightarrow 肺动脉压 uarr\uparrow 3．肺内血管分流 rarr\rightarrow 肺动脉压 uarr\uparrow 2. Ventilation and ventilation dysfunction of the lungs rarr\rightarrow Hypoxemia: hypoxia rarr\rightarrow Pulmonary artery pressure uarr\uparrow 3. Intrapulmonary vascular shunting rarr\rightarrow Pulmonary artery pressure uarr\uparrow
4．胸廓运动障碍性疾病，肺血管疾病 4. Thoracic dyskinesias, pulmonary vascular diseases
（二）病理变化：（病因在肺，病变在心） (ii) Pathological changes: (cause in the lungs, lesions in the heart)
肺：肺小 A 病变：管壁厚 uarr\uparrow ，硬 uarr\uparrow ，管腔狭窄—肌化—炎症 rarr\rightarrow 纤维化，血栓形成和机化，无肌细动脉肌化 Lung: lung small A lesion: thick wall uarr\uparrow , hard uarr\uparrow , luminal narrowing-myositis-inflammation rarr\rightarrow fibrosis, thrombosis and mechanization, no muscular arteriolar myositis
右心：大体：右心肥大，扩张 rarr\rightarrow 横位心 rarr心\rightarrow 心 尖钝圆，肥厚，右室内乳头肌，肉柱，室上峬增粗 Right heart: gross: right heart hypertrophy, dilated rarr\rightarrow transverse heart rarr心\rightarrow 心 apex bluntly rounded, hypertrophied, right intraventricular papillary muscle, meatus column, coarsening of supraventricular segments
肺动脉瓣下 2 cm 处室壁厚度 > 5mm>5 \mathrm{~mm}（诊断标准）肺动脉圆雉膨隆 Ventricular wall thickness 2 cm below the pulmonary valve > 5mm>5 \mathrm{~mm} (diagnostic criterion) Pheasant bulge of the pulmonary artery
镜下：心肌细胞肥大，增宽，核大染色深 肌纤维萎缩，肌浆溶解，横纹消失 间质水肿，胶原纤维增生。 Microscopy: cardiomyocyte hypertrophy, widening, large deeply stained nuclei myofibrillar atrophy, sarcoplasmolysis, loss of transverse striations interstitial edema, collagen fiber hyperplasia.
（三）病理与临床联系：肺病史，心脏病症状，右心衰的表现。 (c) Pathologic and clinical links: pulmonary history, cardiac symptoms, manifestations of right heart failure.
右心衰竭：气促，心跳 uarr\uparrow ，紫绀，呼吸困难，肝大，下肢水肿等。缺氧 +CO 2 潴留 rarr\rightarrow 肺性脑病 D，肺间质疾病 Right heart failure: shortness of breath, heart rate uarr\uparrow , cyanosis, dyspnea, hepatomegaly, and lower extremity edema. Hypoxia +CO 2 retention rarr\rightarrow Pulmonary encephalopathy D, interstitial lung disease
一，肺尘埃沉着症（尘肺）有害粉尘微粒沉积于肺 rarr\rightarrow 肺组织病变（粉尘结节 + 纤维化），包括硅肺，煤肺，石棉肺。 I. Pneumoconiosis (pneumoconiosis) Harmful dust particles deposited in the lungs rarr\rightarrow Lung tissue lesions (dust nodules + fibrosis), including silicosis, coal lung, and asbestosis.
1．肺硅沉着症（矽肺，硅肺）：长期吸入游离大量二氧化硅 SiO_(2)\mathrm{SiO}_{2} 粉尘微粒而引起的以硅结节形成和肺广泛纤维化为病变特征的尘肺 1. Pulmonary silicosis (silicosis, silicon lung): pneumoconiosis characterized by the formation of silica nodules and extensive fibrosis of the lungs caused by long-term inhalation of large amounts of free silica SiO_(2)\mathrm{SiO}_{2} dust particles.
（一）病因：硅尘 SiO_(2)\mathrm{SiO}_{2} 的吸入，直径 1－2 mum\mu \mathrm{m} 大小的硅尘微粒致病力最强 (i) Causes: Inhalation of silica dust SiO_(2)\mathrm{SiO}_{2} , silica dust particles with a diameter of 1-2 mum\mu \mathrm{m} size are the most pathogenic.
（二）病理变化及病理临床联系 基本病变：肺，肺门 LN\mathbf{L N} 硅结节＋弥漫性肺纤维化， X\mathbf{X} 线特点：致密条索状阴影，肺及肺门淋巴结内硅结节形成——硅肺特征性病变 (ii) Pathological changes and pathoclinical associations Basic lesion: lung, hilar LN\mathbf{L N} silicone nodules + diffuse pulmonary fibrosis, X\mathbf{X} line features: dense striated shadows, formation of silicone nodules in the lungs and hilar lymph nodes - characteristic lesions of silicone lungs
（1）硅结节（silicotic nodule）：圆或卵圆形，灰白，质硬，有砂砾感，界清，直径 2∼5mm2 \sim 5 \mathrm{~mm} ；中央缺血，氧 rarr\rightarrow 坏死 rarr\rightarrow 硅肺性空洞 (1) Silicotic nodule: round or ovoid, grayish, hard, gritty, well defined, 2∼5mm2 \sim 5 \mathrm{~mm} in diameter; central ischemia, oxygen rarr\rightarrow necrosis rarr\rightarrow Silicotic cavity
三个阶段：1）细胞性结节：巨噬细胞聚集在局部吞噬硅尘 2）纤维性结节：纤维细胞 + 纤维母细胞＋胶原纤维 3）玻璃样结节：玻璃样变的胶原纤维呈同心圆状排列，似洋葱皮样，中央有闭塞的小血管，巨噬细胞，周围纤维母细胞。 Three stages: 1) cellular nodules: macrophages gather locally to phagocytose silica dust 2) fibrous nodules: fibroblasts + fibroblasts + collagen fibers 3) vitreous nodules: vitreous degeneration of collagen fibers arranged in concentric circles resembling onion skin, with occluded small blood vessels in the center, macrophages, and peripheral fibroblasts.
（2）弥漫性肺纤维化 (2) Diffuse pulmonary fibrosis
（3）胸膜，肺门淋巴结的病变 (3) Lesions of pleura, hilar lymph nodes
（三）并发症： (iii) Complications:
1．肺结核 1. Tuberculosis
2．肺感染 2. Lung infections
3．慢性肺原性心脏病 3. Chronic pulmonary heart disease
4．肺气肿和自发性气胸 4. Emphysema and spontaneous pneumothorax
2．肺石棉沉着症（石棉肺）长期吸入石棉粉尘引起的肺间质和胸膜纤维化为主要病变的疾病。咳嗽，咳痰，气急和胸胀痛等，晚期－肺功能障碍和肺心病的症状和体征，痰内可检见石棉小体。 （一）病理变化：肉眼：肺缩小，变硬，蜂窝状改变。 胸膜：脏层（下叶）显著增厚，壁层纤维斑，纤维化，胸膜腔闭锁，甚为灰白色的纤维瘢痕包裹。 2. Pulmonary asbestosis (asbestosis) is a disease in which long-term inhalation of asbestos dust causes fibrosis of the interstitium and pleura as the main lesion. Cough, sputum, shortness of breath and chest pain, etc., advanced stage - symptoms and signs of pulmonary dysfunction and pulmonary heart disease, asbestos microsomes can be detected in sputum. （Pathologic changes: naked eye: lungs are shrunken, hardened and honeycombed. Pleura: significant thickening of the dirty layer (lower lobe), fibrous mottling of the wall layer, fibrosis, atresia of the pleural cavity, or even grayish-white fibrous scarring.
胸膜斑（pleural plaques）：发生于壁层胸膜上凸出的局限性纤维㓔痕斑块，质硬，呈灰白色，半透明，状似软骨。常位于两侧中，下胸壁，呈对称性分布。 Pleural plaques (pleural plaques): occur in the wall pleura protruding from the confined fibrous 㓔 scar plaques, hard, grayish-white, translucent, cartilage-like. Often located on both sides of the middle and lower chest wall, symmetrically distributed.
镜下：早期 脱屑性间质性肺炎：肺泡腔内大量脱落的肺泡上皮和 M 聚积。间质内 L，M 浸润＋纤维结缔组织增生。 Microscopy: Early desquamative interstitial pneumonia: large aggregates of desquamative alveolar epithelium and M in the alveolar lumen. Interstitial L,M infiltrate + fibrous connective tissue proliferation.
晚期：肺组织弥漫性纤维化：多数肺泡闭塞，纤维组织填充。细支气管和小血管管壁纤维性增厚，管腔狭窄闭塞。增生的纤维组织间可见石棉小体，异物巨细胞。 Advanced stage: diffuse fibrosis of lung tissue: most alveoli are occluded and filled with fibrous tissue. Fibrous thickening of the walls of fine bronchial tubes and small blood vessels, with narrowing and occlusion of the lumen. Asbestos microsomes, foreign body giant cells are seen between the proliferating fibrous tissues.
石棉小体：铁蛋白包裹的石棉纤维，分节，棒状，哑铃形 。诊断石棉肺的重要依据。 Asbestos microsomes: ferritin-coated asbestos fibers, segmented, rod-shaped, dumbbell-shaped . Important in the diagnosis of asbestosis.
（二）并发症：1．恶性肿瘤：恶性胸膜间皮瘤 ，肺癌等 (ii) Complications: 1. malignant tumors: malignant pleural mesothelioma, lung cancer, etc.
2．肺结核 2. Tuberculosis
3．肺源性心脏病 3. Pulmonary heart disease
E，急性呼吸窘迫综合征（acute respiratory distress syndrome，ARDS），又称成人呼吸窘迫综合征（adult respiratory distress syndrome），休克肺，弥漫性肺泡损伤，创伤性湿肺 E, Acute respiratory distress syndrome (ARDS), also known as adult respiratory distress syndrome, shock lung, diffuse alveolar injury, traumatic wet lung
概念：肺内，外严重疾病引起的以肺毛细血管弥漫性损伤，通透性增加为基础；以肺水肿，透明膜形成和肺不张为主要病理变化；以进行性呼吸窘迫和难治性低氧血症为特征的急性呼吸衰竭综合征。 Concept: Acute respiratory failure syndrome caused by severe intrapulmonary and extrapulmonary diseases based on diffuse damage to the pulmonary capillaries and increased permeability; with pulmonary edema, hyaline membrane formation and pulmonary atelectasis as the main pathological changes; characterized by progressive respiratory distress and refractory hypoxemia.
（一）病因：多，严重感染，创伤，肺严重疾患等。 (i) Etiology: multiple, severe infections, trauma, severe lung disorders, etc.
（二）病理变化： (ii) Pathological changes:
肉眼：肺湿润，肿胀，暗红色，重量 uarr\uparrow ，弹性 darr\downarrow ，散在出血点，散在实变区，斑及斑片状略凹陷的肺萎陷区。
镜下：肺水肿：间质和肺泡腔内大量蛋白质液体
透明膜形成：肺间质毛细血管扩张，充血，点状出血，灶状坏死。局灶性肺萎陷。
微血管：透明血栓和白细胞栓塞。后期 II 型肺泡细胞及肺间质的纤维母细胞大量增生，透明膜机化，纤维化——弥漫性肺泡内和肺间质纤维化。
二，新生儿呼吸窘迫综合征（NRDS）新生儿出生后已出现短暂（数分钟至数小时）的自然呼吸，继而发生进行性呼吸困难，发绀，呻吟等急性呼吸窘迫症状和呼吸衰竭。
病因：与肺（主要是肺泡）发育不全，缺乏肺表面活性物质有关。关键期：胎龄 22 周－出生
病理变化 大体：肺组织质地坚实，色暗红，含气少。
镜下：透明膜－－在呼吸性细支气管壁，肺泡管和肺泡壁上贴附一层均匀红染的透明膜。
F，呼吸系统常见肿瘤
一，鼻咽癌：鼻咽部上皮组织发生的恶性肿瘤 Nasopharyngeal carcinoma: malignant tumors occurring in the epithelial tissues of the nasopharynx
鼻血，鼻塞，耳鸣，颈部淋巴结肿大好发部位：鼻咽顶部。 Nosebleeds, nasal congestion, tinnitus, swollen lymph nodes in the neck Preferred site: top of the nasopharynx.
病因：EB 病毒，环境致癌因素 Causes: EBV, environmental carcinogens
病理类型：1，大体类型：结节型（最常见），菜花型，粘膜下型，浸润型，溃疡型 Pathologic types: 1, generalized types: nodular (most common), cauliflower, submucosal, infiltrative, ulcerative
2，组织学类型：起源：柱状上皮储备细胞（多）鳞状上皮基底细胞（少） 2, Histologic type: origin: columnar epithelial reserve cells (many) squamous epithelial basal cells (few)
（1）角化性鳞状细胞癌：高分化性鳞癌，癌巢，角化珠（2）腺癌 (1) Keratinizing squamous cell carcinoma: highly differentiated squamous carcinoma, carcinoma nests, keratinizing beads (2) Adenocarcinoma
扩散及转移： Diffusion and metastasis:
a，直接曼延 rarr\rightarrow 颅内（上），中耳（外），鼻腔及眼眶（前），颈椎（后） a, direct Manganian rarr\rightarrow intracranial (upper), middle ear (outer), nasal and orbital (anterior), cervical spine (posterior)
b，淋巴道为主，早，颈深上淋巴结 c，血道：肝，肺，骨多见，较少，晚。 b, Lymphatic tracts predominate, early, deep upper cervical lymph nodes c, Blood tracts: liver, lungs, bone more often, less often, late.
病理与临床联系：（1）头痛，鼻塞，回缩性涕血，耳鸣，颈部肿块（乳突尖下方或胸锁乳突肌上 Pathologic and clinical associations: (1) headache, nasal congestion, retractile runny blood, tinnitus, neck mass (below the tip of the mastoid process or on the sternocleidomastoid muscle)
份前缘）（2）颅神经受损症状和体征 (share anterior margin) (2) Signs and symptoms of cranial nerve damage
二，肺癌（carcinoma of the lung）咳嗽，咳痰，痰中带血，咯血，胸痛，肺部块影等 Carcinoma of the lung: coughing, coughing up sputum, blood in sputum, hemoptysis, chest pain, lung mass shadow, etc.
病因：吸烟，空气污染，职业因素，分子遗传学改变 Etiology: smoking, air pollution, occupational factors, molecular genetic changes
病理变化： Pathological changes:
大体：中央型（最常见，以鳞状细胞癌，小细胞癌多见，发生于段以上大支气管，向周围肺组织浸润扩展，吸烟者，中老年男性多发）周围型（以腺癌多见，段以下支气管发生，近胸膜周边肺组织形成圆形或结节状癌结节，界限较清楚，但无包膜，无吸烟史，女性多发）弥漫型（罕见，多为腺癌） General: central type (most common, squamous cell carcinoma, small cell carcinoma, occurs in the large bronchial tubes above the segment, infiltrates and expands to the surrounding lung tissues, smokers, middle-aged and old men are more common) peripheral type (adenocarcinoma is more common, occurs in the bronchial tubes below the segment, and forms rounded or nodular cancerous nodules in the lung tissues around the periphery of the near-pleural area, the boundaries are clearer, but there is no peritoneum, no history of smoking, women are more common) diffuse type (rare, adenocarcinoma is most often found) Diffuse (rare, mostly adenocarcinoma)
组织学类型： 1 鳞状细胞癌：最常见，大支气管，中央型 Histologic types: 1 Squamous cell carcinoma: most common, large bronchial, central type
2 腺癌：女性多，较小支气管，周围型，常常通过血道转移 2 Adenocarcinoma: more female, smaller bronchioles, peripheral type, often metastasizes through blood channels
隐性肺癌：肺内无明显肿块，影像学检查阴性，痰或支气管分泌物中找到癌细胞，手术切除标本经病理检查证实为支气管粘膜原位癌或早期浸润癌 Occult lung cancer: there is no obvious mass in the lung, imaging examination is negative, cancer cells are found in sputum or bronchial secretion, and the surgical resection specimen is confirmed to be bronchial mucosal carcinoma in situ or early invasive carcinoma by pathological examination.
3 腺鳞癌：较少，鳞癌十腺癌 3 Adenosquamous carcinoma: less frequent, squamous ten adenocarcinomas
4 小细胞癌： 10-20%10-20 \% ，肺癌中恶性程度最高，与吸烟有明确关系，对放化疗敏感，肺门周围结节，淋巴结转移，是一种可产生多种异位激素的异源性神经分泌功能的肿瘤。形似裸核，燕麦细胞癌 （Oat cell carcinoma） 4 Small cell carcinoma: 10-20%10-20 \% , the most malignant of the lung cancers, with a clear relationship to smoking, sensitive to radiotherapy, periportal nodules, lymph node metastases, a tumor that can produce a variety of ectopic hormones of heterogenic neurosecretory function. Oat cell carcinoma, resembling a naked nucleus.
5 大细胞癌：恶性度高。 6 肉瘤样癌：少，高恶性。 7 类癌 8 唾液腺癌 5 Large cell carcinoma: highly malignant. 6 Sarcomatoid carcinoma: rare, highly malignant. 7 Carcinoid tumor 8 Salivary gland carcinoma
临床表现：咳嗽，胸痛，痰中带血等症状，压迫，阻塞和浸润导致 肺萎陷，肺气肿，血性胸水，支气管食管瘘，交感神经麻痹综合征（Horner 综合征），异位激素综合征 Clinical manifestations: cough, chest pain, blood in sputum, etc., compression, obstruction and infiltration leading to pulmonary atrophy, emphysema, hemorrhagic pleural fluid, bronchoesophageal fistula, sympathetic paralysis syndrome (Horner syndrome), ectopic hormone syndrome
副肿瘤综合征（paraneoplastic syndrome）：指除肿瘤及其转移灶直接引起的症状外，伴随发生的由肿瘤引起的一系列异位激素性和代谢性症状综合征。如：肺性骨关节病，高血钙，高血糖，类癌综合征（支气管痉挛，陈发性心动过速，水样腹泻，皮肤潮红）。 Paraneoplastic syndrome: In addition to the symptoms directly caused by the tumor and its metastatic foci, a series of ectopic hormonal and metabolic syndromes caused by the tumor may occur. For example: pulmonary osteoarthropathy, hypercalcemia, hyperglycemia, carcinoid syndrome (bronchospasm, tachycardia, watery diarrhea, skin flushing).
第八章 消化道疾病 Chapter VIII. Diseases of the digestive tract
一，Barrett 食管：慢性反流性食管炎 rarr\rightarrow 食管黏膜修复过程中，食管下段（食管贲门交界处的齿状线 2 cm 以上）粘膜的鳞状上皮被化生的腺上皮取代称之。 I, Barrett's esophagus: chronic reflux esophagitis rarr\rightarrow The replacement of the squamous epithelium of the mucosa of the lower esophagus (more than 2 cm above the dentate line at the junction of the esophagus and cardia) by the metaplastic glandular epithelium in the process of esophageal mucosal restoration is termed.
二，胃炎（gastritis）胃粘膜的炎性病变 Second, gastritis (gastritis) inflammatory lesions of the gastric mucosa
（一）急性胃炎 (i) Acute gastritis
1．病因：理化因素及微生物感染，非类固醇类抗炎药，过度饮酒，腐蚀性化学剂，严重应急和休克，细菌感染。 1. Etiology: physical and chemical factors and microbial infections, non-steroidal anti-inflammatory drugs, excessive alcohol consumption, corrosive chemicals, severe emergencies and shock, bacterial infections.
2．类型：（1）急性刺激性胃炎或单纯性胃炎 2. Types: (1) Acute irritant gastritis or simple gastritis
（2）急性腐蚀性胃炎 (2) Acute corrosive gastritis
（3）急性出血性胃炎 (3) Acute hemorrhagic gastritis
（4）急性感 (4) Acute sensation
染性胃炎：急性蜂窝织炎性胃炎 Infectious gastritis: acute cellulitis gastritis
（二）慢性胃炎：胃粘膜的慢性非特异性炎症。 (ii) Chronic gastritis: chronic non-specific inflammation of the gastric mucosa.
1．病因：（1）幽门螺旋杆菌感染（2）长期慢性刺激（饮酒，吸烟）（3）自身免疫（4）含胆汁的十二指肠液反流。 1. Etiology: (1) Helicobacter pylori infection (2) long-term chronic irritation (alcohol consumption, smoking) (3) autoimmunity (4) bile-containing duodenal fluid reflux.
分型：A 型（自身免疫性）：罕见，常伴恶性贫血，好发部位一胃体，胃底。 Types: Type A (autoimmune): Rare, often accompanied by pernicious anemia, preferred site a gastric body, gastric fundus.
B 型（单纯性萎缩性）：常见，好发部位一胃窦黏膜。 Type B (simple atrophic): common, with a predominant site in the mucosa of the gastric antrum.
类型 typology
病因 etiology
发病机制 pathogenesis
HP检出率\％ HP detection rate\%
A
??
自身免疫 autoimmunity
6-166-16
B
HP
细菌感染 bacterial infection
90
C
Bile Reflux, Alcohol, NSAIDS
胆汁反流，酒
精，NSAIDS
胆汁反流，酒
精，NSAIDS| 胆汁反流，酒 |
| :--- |
| 精，NSAIDS |
化学损伤 chemical damage
10
类型 病因 发病机制 HP检出率\％
A ? 自身免疫 6-16
B HP 细菌感染 90
C "胆汁反流，酒
精，NSAIDS" 化学损伤 10| 类型 | 病因 | 发病机制 | HP检出率\％ |
| :--- | :--- | :--- | :--- |
| A | $?$ | 自身免疫 | $6-16$ |
| B | HP | 细菌感染 | 90 |
| C | 胆汁反流，酒 <br> 精，NSAIDS | 化学损伤 | 10 |
【肉眼形态】（胃镜观察）：（1）正常粘膜橘红色 rarr\rightarrow 暗灰色或灰绿色； [Naked eye morphology] (gastroscopic observation): (1) Normal mucosa orange-red rarr\rightarrow dark gray or gray-green;
②萎缩区胃粘膜明显变薄，周围正常粘膜隆起，两者界限明显；（3）粘膜下血管清晰可见。 (2) The gastric mucosa in the atrophic area is obviously thinned, the surrounding normal mucosa is elevated, and the boundary between the two is obvious; (3) the submucosal blood vessels are clearly visible.
【组织形态】1．病变处胃粘膜变薄，腺上皮萎缩，腺体 darr\downarrow ，数目 darr\downarrow 或囊性扩张；纤维组织 uarr\uparrow 2．固有层 L，浆细胞浸润。 [Histomorphology] 1. Gastric mucosa thinned at lesion, glandular epithelium atrophied, glands darr\downarrow , number darr\downarrow or cystic dilatation; fibrous tissue uarr\uparrow 2. lamina propria L, plasma cell infiltration.
2．类型：（1）慢性浅表性胃炎 好发部位：胃窦，胃体粘膜，弥漫性／灶状，粘膜充血水肿红白相间花斑状，渗出物，点状出血／糜烂，组织学：粘膜层内淋巴细胞，浆细胞浸润，粘膜固有腺体完整。结局：痊愈，慢萎 2. Types: (1) Chronic superficial gastritis Site of occurrence: gastric antrum, gastric body mucosa, diffuse/focal, mucosal congestion and edema red-white florid, exudate, punctate hemorrhage/erosions, histology: lymphocyte and plasma cell infiltration in the mucosal layer, mucosal intrinsic glands intact. Outcome: healed, slow atrophy
（2）慢性萎缩性胃炎（chronic atrophic gastritis）特点：胃粘膜萎缩变薄，腺体数量减少＋肠化，皱襞减少，粘膜下血管可见，固有层 L，浆细胞浸润。＂癌前病变＂ (2) Chronic atrophic gastritis (chronic atrophic gastritis) Characteristics: atrophy and thinning of the gastric mucosa, reduction in the number of glands + intestinalization, reduction of folds, visible submucosal vessels, lamina propria L, plasma cell infiltration. "precancerous lesions
常见肠上皮化生：胃粘膜上皮 rarr\rightarrow 肠型上皮细胞，可出现异型增生 Common intestinal epithelial hyperplasia: gastric mucosal epithelium rarr\rightarrow intestinal-type epithelial cells, which may show heterogeneous hyperplasia
完全性（I）：小肠型化生：吸收细胞，杯状细胞，潘氏细胞 Complete (I): small intestinal-type metaplasia: absorptive cells, cupped cells, Penn cells
不完全性（II）大肠型化生：柱状细胞，杯状细胞，II a 胃型，IIb 结肠型（癌变率高） Incomplete (II) colorectal type of metaplasia: columnar cells, cup cells, II a gastric type, IIb colonic type (high carcinogenicity)
静止性萎缩性胃炎：以淋巴，浆细胞浸润为主 活动性萎缩性胃炎：中性粒细胞浸润为主。假幽门腺化生：胃底，体区腺体的主，壁细胞消失，代之以粘液分泌细胞 Resting atrophic gastritis: predominantly lymphoid, plasma cell infiltration Active atrophic gastritis: predominantly neutrophilic infiltration. Pseudopyloric glandular metaplasia: disappearance of the main, mural cells of the glands in the fundus, body region of the stomach, replaced by mucus-secreting cells
【分级】 轻度：胃固有腺体减少正常量的 1//31 / 3 以内者，中度：减少 1//3-2//31 / 3-2 / 3 者，重度：减少 2//32 / 3 以上。 [Grading] Mild: reduction of gastric intrinsic glands within 1//31 / 3 of normal, moderate: reduction of 1//3-2//31 / 3-2 / 3 , severe: reduction of 2//32 / 3 or more.
【伴随病变】（1）上皮化生：（1）幽门腺化生（假幽门腺化生） [Accompanying lesions] (1) Epithelial hyperplasia: (1) Pyloric glandular hyperplasia (pseudo-pyloric glandular hyperplasia)
（2）肠上皮化生（肠化）：病变区黏膜表面上皮呈绒毛样突起，增生上皮内出现杯状 C，吸收 C临床病理联系：1．胃粘膜萎缩，腺体 darr\downarrow ，壁，主细胞 darr rarr\downarrow \rightarrow 胃液，胃酸 darr rarr\downarrow \rightarrow 食欲下降，上腹不适或疼痛，消化不良 (2) intestinal epithelial hyperplasia (enterochemistry): the surface epithelium of the mucosa in the lesion area is villous, and cup-shaped C appears in the hyperplastic epithelium, and absorbs C. Clinicopathological associations: 1. atrophy of the gastric mucosa, glands darr\downarrow , wall, master cell darr rarr\downarrow \rightarrow gastric juice, gastric acid darr rarr\downarrow \rightarrow loss of appetite, epigastric discomfort or pain, indigestion
A 型 ：壁细胞 darr rarr\downarrow \rightarrow 内因子 darr//\downarrow / 缺乏 rarr\rightarrow B12 吸收障碍 rarr\rightarrow 恶性贫血 肠化 rarr\rightarrow 细胞异常增生 rarr\rightarrow 癌变 Type A: Mural cells darr rarr\downarrow \rightarrow Endokinesis darr//\downarrow / Deficiency rarr\rightarrow Impaired absorption of B12 rarr\rightarrow Pernicious anemia Enterocytosis rarr\rightarrow Abnormal cellular proliferation rarr\rightarrow Carcinogenesis
（3）慢性肥厚性胃炎：好发部位：胃底，胃体 临床表现：消化不良，反酸，疼痛，粘膜肥厚皱襞加深似脑回，腺体肥大增生腺管延长 (3) Chronic Hypertrophic Gastritis: Prevalent sites: gastric fundus, gastric body Clinical manifestations: indigestion, acid reflux, pain, mucosal hypertrophy and deepening of folds like the cerebral gyrus, glandular hypertrophy and hyperplasia glandular duct lengthening
（4）疣状胃炎：部位：胃窦部，多灶性糜烂，中心凹陷的疣状突起病灶 (4) Verrucous gastritis: site: gastric antrum, multifocal erosions, warty raised foci with depressed center
三，消化性溃疡病：以胃，十二指肠粘膜形成慢性溃疡为特征的常见病。 Third, peptic ulcer disease: a common disease characterized by the formation of chronic ulcers in the mucosa of the stomach and duodenum.
1．反复发作，慢性经过，与胃液自我消化有关 1. Recurrent, chronic, related to self-digestion of gastric juices
肠腺，又称肠隐窝（intestinal crypt）：是小肠上皮在线毛根部下陷至固有层而形成的管状腺，开口于相邻绒毛之间 Intestinal gland, also known as intestinal crypt: a tubular gland formed by the root of the on-line hairs of the small intestinal epithelium sinking down into the lamina propria, opening between adjacent villi
五，消化系统肿瘤 V. Tumors of the digestive system
1．食管癌：食管粘膜上皮／腺体发生的恶性肿瘤 1. Esophageal cancer: malignant tumors of the mucosal epithelium/glands of the esophagus
病因： Etiology:
饮食因素：硝酸盐和亚硝酸盐，二级胺，亚硝胺合成增加，维生素缺乏（核黄素，VitA，叶酸）环境因素：钼缺乏 Dietary factors: nitrates and nitrites, secondary amines, increased nitrosamine synthesis, vitamin deficiencies (riboflavin, VitA, folic acid) Environmental factors: molybdenum deficiency
遗传因素 genetic factor
【病理变化】：好发于食管中段，下段次之，上段较少。可分为早期癌和中晚期癌。 [Pathological changes]: Prevalent in the middle part of the esophagus, followed by the lower part and less frequent in the upper part. It can be categorized into early-stage cancer and middle-late-stage cancer.
a．早期癌：多为原位癌或粘膜内癌 a. Early-stage cancer: mostly carcinoma in situ or intramucosal cancer
镜下：病变较局限，仅累及粘膜层或粘膜下层，未侵及肌层，无淋巴结转移。 Microscopically: the lesion is relatively limited, involving only the mucosal layer or submucosal layer, without invading the muscular layer, without lymph node metastasis.
b．中，晚期癌：病变不局限粘膜或粘膜下层，侵犯肌层，转移（浸润，淋巴，血道）virchow 淋巴结 b. Intermediate, advanced cancer: lesions not limited to the mucosa or submucosa, invasion of the muscularis propria, metastasis (infiltration, lymphatic, hematogenous) virchow Lymph nodes
肉眼：分四型（1）髓质型（2）草伞型（3）溃疡型（4）缩窄型 Naked eye: four types (1) medullary (2) herbaceous umbrella (3) ulcerated (4) narrowing type
镜下：组织学类型（1）鳞状细胞癌：最常见（2）腺癌（与 Barrett 食管有关）（3）小细胞癌（4）腺鳞癌 Microscopy: histologic types (1) squamous cell carcinoma: most common (2) adenocarcinoma (associated with Barrett's esophagus) (3) small cell carcinoma (4) adenosquamous carcinoma
2．胃癌（carcinoma of stomach）：胃粘膜上皮和腺上皮发生的恶性肿瘤，消化道最常见的恶性肿瘤之一，好发部位：胃窦部小弯侧，病因：饮食，遗传与环境，诱因：严重睡眠不足，饮食不规律，压力和紧张 2. Carcinoma of stomach: malignant tumor of gastric mucosal epithelium and glandular epithelium, one of the most common malignant tumors of gastrointestinal tract, site of incidence: small curvature of gastric antrum, etiology: diet, heredity and environment, triggers: severe sleep deprivation, irregular diet, stress and tension.
（一）病理变化 (i) Pathological changes
1．早期胃癌：癌组织浸润仅限于粘膜层及粘膜下层者，无论其面积大小和是否有淋巴结转移。起源于胃腺颈部和胃小凹底部的干细胞，肠上皮化生：大肠型化生 1. Early gastric cancer: the infiltration of cancerous tissue is limited to the mucosal layer and submucosal layer, regardless of the size of its area and whether there are lymph node metastases. Stem cells originating from the neck of gastric glands and the bottom of gastric notch, intestinal epithelial hyperplasia: colon type hyperplasia
2．进展期胃癌 2. Progressive gastric cancer
1）定义：癌组织浸润到粘膜下层以下者，或称中晚期胃癌。 1) Definition: Those whose cancerous tissues have infiltrated below the submucosal layer, or known as intermediate or advanced gastric cancer.
2）肉眼分型： 2) Naked eye typing:
（1）息肉型或䓥伞型：癌组织向粘膜表面生长，呈息肉状或䓥状，突入胃腔内。 (1) Polypoid or umbrella type: the cancerous tissue grows towards the mucosal surface in the form of a polyp or umbrella, protruding into the gastric lumen.
（2）溃疡型：癌组织坏死脱落 rarr\rightarrow 溃疡，呈血状，边缘隆起，如火山口。 (2) Ulcerative type: necrotic shedding of cancerous tissue rarr\rightarrow ulcers, blood-like, with elevated margins, like craters.
（3）浸润型：癌组织向胃壁内呈局限或弥漫浸润，胃壁增厚变硬，胃的形状似皮革制成的囊袋 rarr\rightarrow革囊胃 (3) Infiltrative type: the cancer tissue infiltrates into the stomach wall in a limited or diffuse manner, the wall of the stomach becomes thickened and hardened, and the shape of the stomach resembles a leather pouch rarr\rightarrow Leather Pouch Stomach
（二）组织学分型：乳头状腺癌，腺癌，黏液腺癌，印戒细胞癌，未分化癌 (ii) Histologic typing: papillary adenocarcinoma, adenocarcinoma, mucinous adenocarcinoma, indolent cell carcinoma, undifferentiated carcinoma
（三）扩散：直接，淋巴道，血道，种植性转移（krukenberg 瘤） (iii) Spread: direct, lymphatic, blood, implantation metastases (krukenberg tumors).
结直肠癌：大肠粘膜和腺体发生的恶性肿瘤，好发部位：直肠 >> 乙状结肠 >> 盲，升，降，横结肠病因：饮食，遗传，慢性肠病 Colorectal cancer: malignant tumors of the mucosa and glands of the large intestine, site of origin: rectum >> sigmoid colon >> blind, ascending, descending, transverse colon etiology: diet, heredity, chronic bowel disease
发病机制：黏膜上皮被二次打击 Pathogenesis: a second blow to the mucosal epithelium
分类：（1）早期大肠癌：指癌组织局限于粘膜层及粘膜下层，一般无淋巴结转移，5－10\％的粘膜下层癌可伴局部淋巴结转移。 Classification: (1) Early stage colorectal cancer: the cancerous tissues are confined to the mucous membrane layer and submucosa, generally without lymph node metastasis, while 5-10\% of the submucosa cancers may be accompanied by local lymph node metastasis.
（2）中晚期大肠癌：隆起型 溃疡型 浸润型 胶样型 (2) Intermediate and advanced colorectal cancer: elevated, ulcerated, invasive, and colloid.
隆起型－多位于右半结肠 Bulging type-mostly located in the right half of the colon
溃疡型－易感染，出血 Ulcerated-prone to infection, bleeding
浸润型－多发于左侧结肠，累及肠管全周，易致肠腔狭窄，梗阻 Infiltrative type-mostly in the left side of the colon, involving the whole periphery of the intestinal tube, easy to cause intestinal lumen narrowing, obstruction
胶样型－含大量粘液 Gummy - contains a lot of mucus
组织学类型：与胃癌类似（1）腺癌（为主）：乳头状腺癌 管状腺癌 粘液腺癌 印戒细胞癌 Histologic type: similar to gastric cancer (1) adenocarcinoma (predominant): papillary adenocarcinoma tubular adenocarcinoma mucinous adenocarcinoma impression cell carcinoma
（2）未分化癌 (2) Undifferentiated carcinoma
（3）腺鳞癌 (3) Adenosquamous carcinoma
（4）鳞状细胞癌 (4) Squamous cell carcinoma
第九章 肝脏，胆道，胰腺疾病 Chapter 9 Diseases of the Liver, Biliary Tract, and Pancreas
一，肝脏疾病 I. Liver disease
1．肝损伤的基本病变：可逆性损伤（细胞水肿－气球样变，羽毛状变性－胆汁性肝硬化，淤胆性肝硬化，肝脂肪变），坏死和凋亡（发生在汇管区周围的肝细胞和有炎症的汇管区之间，破坏肝小叶周边的界板，点状坏死，碎片状坏死，桥接坏死，亚大块坏死，大块坏死，凋亡－嗜酸小体），炎细胞浸润，再生，纤维化 1. Basic lesions of liver injury: reversible injury (cellular edema - ballooning, feathery degeneration - biliary cirrhosis, silty cirrhosis, hepatic steatosis), necrosis and apoptosis (occurring between hepatocytes around the confluent zone and the inflamed confluent zone, disruption of the periportal plate around the liver lobules, punctate necrosis, fragmentary necrosis, bridging necrosis, submassive necrosis, massive necrosis, apoptosis - eosinophilic vesicles), inflammatory cell infiltration, regeneration, fibrosis
羽毛状坏死：坏死肝细胞肿大，细胞质疏松呈网状，核消失，多见于胆汁性肝硬化 Feathery necrosis: necrotic hepatocytes are enlarged, cytoplasm is loose and reticular, and the nucleus disappears, mostly seen in biliary cirrhosis
桥接坏死：相邻肝小叶的肝细胞坏死，形成汇管区－汇管区，汇管区－小叶中心，小叶中心－小叶中心的连续的肝细胞坏死 Bridging necrosis: hepatocellular necrosis of adjacent liver lobules, forming a succession of confluent zone-confluent zone, confluent zone-lobular center, and lobular center-lobular center
嗜酸性小体：肝细胞皱缩，嗜酸性变，核固缩，凋亡 Eosinophilic vesicles: hepatocyte crumpling, eosinophilic degeneration, nuclear consolidation, apoptosis
2．病毒性肝炎（Viral hepatitis）是指由一组肝炎病毒引起的以肝实质细胞的变性，坏死为主要病变的传染病。肝炎病毒：甲，乙，丙，丁，戊，己六种，血清两对半 2. Viral hepatitis refers to a group of hepatitis viruses caused by the degeneration of liver parenchymal cells, necrosis as the main lesions of infectious diseases. Hepatitis viruses: A, B, C, D, E, F six kinds, serum two halves
基本病理变化： Basic pathological changes:
毛玻璃样肝细胞：HBsAg Hairy glass-like hepatocytes: HBsAg
携带者，无症状感染，急性肝炎，暴发性肝炎，慢性肝炎 Carrier, asymptomatic infection, acute hepatitis, fulminant hepatitis, chronic hepatitis
病毒性肝炎：普通型（急性，慢性）重型：急性 亚急性 Viral hepatitis: generalized (acute, chronic) Severe: acute Subacute
a．急性（普通型）肝炎 a. Acute (common) hepatitis
四期：潜伏期，黄疸前期，黄疸期，恢复期 Four phases: incubation, pre-jaundice, jaundice, recovery
临床表现：（1）肝大，肝区疼痛或压痛；（2）血清谷丙转氨酶 uarr\uparrow（3）黄疸，全身乏力，恶心，食欲下 Clinical manifestations: (1) hepatomegaly, pain or tenderness in the liver region; (2) serum ghrelin uarr\uparrow (3) jaundice, generalized fatigue, nausea, and decreased appetite.
降，低热，头痛，肝肿大 Drop, low-grade fever, headache, hepatomegaly.
病变：【大体】：肝体积 uarr\uparrow ，被膜紧张，质软，淤胆，黄绿色 Lesions: [Gross]: Liver volume uarr\uparrow , peritoneum tense, soft, silty, yellowish green
【镜下】：细胞肿胀，肝细胞凋亡，点状坏死，小灶状坏死，汇管区轻度炎细胞浸润，Kupffer细胞增生肥大，胆汁淤积 [microscopic]: cell swelling, hepatocyte apoptosis, punctate necrosis, small foci of necrosis, mild inflammatory cell infiltration in the confluent area, hyperplasia and hypertrophy of Kupffer cells, cholestasis
结局：1．痊愈：半年～1年可恢复 2．转为慢性 Endings: 1. Cured: half a year to one year to recover 2. Turned chronic
b．慢性（普通型）肝炎：指有肝炎症状，血清病毒抗原阳性或生化改变持续 6 个月以上，肝脏有 b. Chronic (generalized) hepatitis: refers to the presence of hepatitis symptoms, positive serum viral antigens or biochemical changes lasting more than 6 months, and the liver has
炎症和坏死 Inflammation and necrosis
病变：轻度慢性肝炎，中度慢性肝炎，重度慢性肝炎 Lesions: mild chronic hepatitis, moderate chronic hepatitis, severe chronic hepatitis
毛玻璃样肝细胞 def：LM：肝 C 浆内充满嗜酸性细颗粒状物质（含大量 HBsAg），呈线状／小管状积存在内质网池，不透明似毛玻璃样，常见于 HBSAg 携带者及慢性肝炎患者肝组织。 Hepatocytes with gross glass def: LM: Hepatic C plasma filled with eosinophilic fine granular material (containing large amounts of HBsAg), accumulated in the endoplasmic reticulum pools in a linear/tubular fashion, opaque and gross-glass like, commonly found in liver tissues of HBSAg carriers and patients with chronic hepatitis.
分级： Grading:
c．暴发性肝炎：起病急，病情凶险，急性或亚急性肝功能衰竭 c. Burst Hepatitis: acute onset, aggressive condition, acute or subacute hepatic failure
（1）急性重型肝炎：起病急，发展迅猛，病死率高。 (1) Acute Severe Hepatitis: acute onset, rapid development, high mortality rate.
病理变化：【大体】肝体积 darr darr\downarrow \downarrow（左叶），重量 darr\downarrow ，质柔软，被膜皱缩。切面呈黄或红褐色（急性黄色／红色肝萎缩）。 Pathologic changes: [Gross] Liver volume darr darr\downarrow \downarrow (left lobe), weight darr\downarrow , soft, pericardium wrinkled. The cut surface is yellow or reddish brown (acute yellow/red hepatic atrophy).
【镜下】：（1）坏死：严重，广泛。肝索解离，溶解 rarr\rightarrow 多个小叶／大块坏死。（2）小叶中央开始坏死 rarr\rightarrow 四周，残留肝 C 少，肝 C 再生不明显。 [microscopic]: (1) Necrosis: severe, extensive. Hepatic cords dissociate and dissolve rarr\rightarrow multiple lobules/massive necrosis. (2) Necrosis begins in the center of the lobules rarr\rightarrow around the periphery, with little residual hepatic C and little hepatic C regeneration.
（2）亚急性重型肝炎 (2) Subacute severe hepatitis
病理变变：【大体】：肝缩小，被膜皱缩，呈黄绿色（亚急性黄色肝萎缩）。 Pathologic changes: [Gross]: Hepatic shrinkage, periosteum crumpling, yellowish-green color (subacute yellow hepatic atrophy).
【镜下】：亚大块坏死＋肝 C 结节状再生；原小叶结构丧失；小叶内外炎细胞 uarr\uparrow 。周边小胆管增生 + 胆汁淤积 rarr\rightarrow 胆栓。 [microscopic]: submassive necrosis + nodular regeneration of liver C; loss of original lobular architecture; inflammatory cells inside and outside the lobule uarr\uparrow . Peripheral bile duct hyperplasia + cholestasis rarr\rightarrow bile thrombus.
结局：坏死后性肝硬化。 Outcome: postnecrotizing cirrhosis.
3．酒精性肝病 3. Alcoholic liver disease
病理变化：脂肪肝 rarr\rightarrow 酒精性肝炎 rarr\rightarrow 酒精性肝硬化 Pathologic changes: fatty liver rarr\rightarrow Alcoholic hepatitis rarr\rightarrow Alcoholic cirrhosis
原因：乙醇代谢产生 NADH，促进脂质合成，肝内脂肪堆积，乳酸堆积，耗氧量增大，形成脂肪肝，后续坏死，纤维化 Causes: Ethanol metabolism produces NADH, which promotes lipid synthesis, intrahepatic fat accumulation, lactic acid buildup, increased oxygen consumption, formation of fatty liver, subsequent necrosis, and fibrosis.
酒精性肝炎：肝细胞脂肪变性，水肿，酒精透明小体（Mallory 小体）：细胞角蛋白中间丝，是变 Alcoholic hepatitis: hepatocyte steatosis, edema, Mallory vesicles: cytokeratin intermediate filaments that are variable
性肝细胞质内的嗜酸性包涵体，灶性肝细胞坏死伴中性粒细胞浸润，纤维化 Eosinophilic inclusion bodies in the cytoplasm of sexual hepatocytes, focal hepatocellular necrosis with neutrophilic infiltration, fibrosis
4．肝硬化（liver cirrhosis）多种原因 rarr\rightarrow 肝 C\mathbf{C} 变性，坏死，纤维组织 uarr+\uparrow+ 肝 C\mathbf{C} 结节状再生 rarr\rightarrow 肝小叶结构及血液循环改建 rarr\rightarrow 肝脏变形，变硬 rarr\rightarrow 肝硬化。 4. Cirrhosis (liver cirrhosis) Multiple causes rarr\rightarrow Liver C\mathbf{C} Degeneration, necrosis, fibrous tissue uarr+\uparrow+ Liver C\mathbf{C} Lumpy regeneration rarr\rightarrow Liver lobule structure and blood circulation alteration rarr\rightarrow Liver deformation, hardening rarr\rightarrow Cirrhosis.
病因：酒精，饮食，病毒性肝炎，中毒（如砷） Etiology: alcohol, diet, viral hepatitis, poisoning (e.g. arsenic)
发病机制：肝细胞的变性坏死及慢性炎症是诱导肝纤维化的前提，肝内弥漫性纤维结缔组织增生，肝细胞结节状再生形成不具有正常结构的假小叶 Pathogenesis: degeneration and necrosis of hepatocytes and chronic inflammation are the prerequisites for the induction of hepatic fibrosis, diffuse fibrous connective tissue proliferation in the liver, and nodular regeneration of hepatocytes to form pseudolobules that do not have a normal structure
假小叶：广泛增生的纤维结缔组织分割原来的肝小叶并包绕成大小不等，圆／椭圆形的肝细胞团，或纤维结缔组织包绕再生的肝细胞结节 Pseudolobules: extensive proliferation of fibrous connective tissue dividing the original hepatic lobules and encircling them to form round/elliptical clusters of hepatocytes of varying sizes, or fibrous connective tissue encircling regenerating nodules of hepatocytes
临床病理类型： Clinicopathologic Type:
a．门脉性肝硬化（portal cirrhosis）：最多见（酒精性肝硬化）。病理变化：【大体】：早－中期：肝体积正常／略大，质稍硬。 后期：肝体积 darr\downarrow ，重量 darr\downarrow 质硬。弥漫性小结节（ < 1.0cm<\mathbf{1 . 0 c m} ），大小相近，薄层纤维包绕，结节黄褐色（脂肪变）或黄绿色（淤胆）。镜下：（1）假小叶（pseudolobule）；（2）假小叶周纤维组织 uarr+\uparrow+ 慢性炎 C 浸润，小胆管淤胆。 b．坏死后性肝硬化（postnecrotic cirrhosis）： a. Portal cirrhosis: most common (alcoholic cirrhosis). Pathologic changes: [Gross]: early-middle stage: liver volume normal/slightly large, slightly hard. Later stages: liver volume darr\downarrow , weight darr\downarrow , hard. Diffuse nodules ( < 1.0cm<\mathbf{1 . 0 c m} ), similar in size, surrounded by thin layers of fibers, yellowish-brown (steatosis) or yellowish-green (bile sludge) nodules. Microscopically: (1) pseudolobule; (2) peripseudolobule fibrous tissue uarr+\uparrow+ chronic inflammatory C infiltrate, small bile ducts sludge bile. b. postnecrotic cirrhosis (postnecrotic cirrhosis):
1）病因：乙，丙型亚重肝转变而来；药物及化学物质中毒引起。 1) Etiology: B, C sub-heavy liver transformation; drug and chemical poisoning caused.
2）病变：大结节型和大小结节混合型肝硬化 2) Lesions: macronodular and mixed size nodular cirrhosis
【大体】：肝体积不对称性 darr\downarrow ，重量 darr\downarrow ，质地 uarr\uparrow 变硬。 结节较大且大小不等；结节间纤维条索宽大。 结节呈黄绿或黄褐色。 [Gross]: asymmetry of liver volume darr\downarrow , weight darr\downarrow , texture uarr\uparrow hardness. The nodules are large and unequal in size; the fibrous bands between the nodules are wide. Nodules yellowish green or yellowish brown.
【镜下】：肝小叶结构破坏，假小叶和纤维间隔形成，肝细胞排列紊乱，变性，中央静脉偏位或者缺如，肝细胞淤胆，纤维间隔宽窄不一，炎细胞浸润，小胆管或假胆管再生，淤胆 [microscopic]: structural destruction of hepatic lobules, formation of pseudolobules and fibrous septa, disorganization and degeneration of hepatocytes, deviation or absence of central vein, hepatocyte sludge, fibrous septa of varying widths, inflammatory cell infiltration, regeneration of small bile ducts or pseudobile ducts, sludge
c．胆汁性肝硬化 c. Biliary cirrhosis
临床病理联系： Clinicopathologic links:
（1）门脉高压症 1）临床表现：（1）脾肿大（2）胃肠淤血（3）腹水（4）侧支循环形成所致并发症：食管下段 V 丛曲张：破裂 rarr\rightarrow 引起大呕血（三腔二囊管）。 直肠 VV（痔 V）丛曲张：破裂 rarr\rightarrow 便血 rarr\rightarrow 贫血 脐周及腹壁 V 曲张：rarr\rightarrow＂海蛇头＂。 (1) Portal hypertension 1) Clinical manifestations: (1) splenomegaly (2) gastrointestinal stasis (3) ascites (4) complications due to the formation of collateral circulation: lower esophageal V plexus varices: rupture rarr\rightarrow causing hematemesis (three-lumen, two-bladder tube). Rectal VV (hemorrhoidal V) plexus varices: rupture rarr\rightarrow Hematochezia rarr\rightarrow Anemia Periaqueductal and abdominal wall V varices: rarr\rightarrow "head of the sea serpent".
（2）肝功能不全：（1）睪丸萎缩，男子乳腺发育症：雌激素灭活 darr rarr\downarrow \rightarrow 雌激素 uarr\uparrow（2）出血倾向，凝血因子生成不足，蜘蛛状血管痣（3）肝肾综合征（4）黄疸（5）肝性脑病（肝昏迷） (2) Liver insufficiency: (1) testicular atrophy, gynecomastia: estrogen inactivation darr rarr\downarrow \rightarrow estrogen uarr\uparrow (2) hemorrhagic tendency, insufficient production of clotting factors, sideroblastic nevus (3) hepatorenal syndrome (4) jaundice (5) hepatic encephalopathy (hepatic coma)
5．原发性肝癌：由肝细胞或肝内胆管上皮细胞发生的恶性肿瘤，简称肝癌。 5. Primary hepatocellular carcinoma: malignant tumors occurring in the epithelial cells of hepatocytes or intrahepatic bile ducts, referred to as hepatocellular carcinoma.
临床：腹痛，腹水，黄疸，肝脏肿大 AFP（甲胎蛋白）阳性 Clinical: abdominal pain, ascites, jaundice, liver enlargement AFP (alpha-fetoprotein) positive
病因：1．病毒性肝炎：HBV，HCV Causes: 1. Viral hepatitis: HBV, HCV
霉菌及其毒素 4．亚硝胺类化合物 Molds and their toxins 4. Nitrosamines
病理变化 pathological changes
1．肉眼类型： 1. Naked eye type:
1）早期肝癌—小肝癌（small liver cancer）：单个癌结节直径 < 3cm<3 \mathrm{~cm} 或结节数目不超过两个，其直径的总和 < 3cm<3 \mathrm{~cm} ，界清，灰白色质软，切面无出血坏死 1) Early stage liver cancer-small liver cancer: diameter of a single cancer nodule < 3cm<3 \mathrm{~cm} or the number of nodules does not exceed two, the sum of its diameter < 3cm<3 \mathrm{~cm} , clear boundary, gray-white texture and soft, and no hemorrhage and necrosis on the cut surface.
2）中晚期肝癌：（1）巨块型（右叶多见，单个实性肿块，> 5cm>5 \mathrm{~cm} ）（2）多结节型（最常见，合并较重的肝硬化，多个大小不等的结节）（3）弥漫型（少见，微小结节弥漫分布全肝） 2) Intermediate and advanced hepatocellular carcinoma: (1) macromassive type (common in the right lobe, single solid mass, > 5cm>5 \mathrm{~cm} ) (2) multinodular type (most common, combined with severe cirrhosis, multiple nodules of varying sizes) (3) diffuse type (rare, diffuse distribution of microscopic nodules throughout the liver)
2．组织学类型：（1）肝细胞癌：高分化：排列成小梁状（板状），假腺管型和腺泡型，瘤细胞间有丰富的血窦，低分化：实体型／硬化型，核浆比例增大，癌细胞内出现胆汁 2. Histological types: (1) Hepatocellular carcinoma: highly differentiated: arranged in trabecular (plate-like), pseudo-glandular ductal and glandular vesicular types, with abundant blood sinusoids between tumor cells; lowly differentiated: solid/sclerotic type, with increased nucleoplasmic ratio and the appearance of bile in the cancer cells.
（2）肝内胆管细胞癌：由肝内胆管上皮发生的癌，多为腺癌或单纯 (2) Intrahepatic cholangiocellular carcinoma: carcinoma arising from the epithelium of the intrahepatic bile ducts, mostly adenocarcinoma or simple carcinoma.
（3）混合细胞型肝癌 (3) Mixed cell type liver cancer
第十章 淋巴造血系统疾病 Chapter X. Diseases of the lymphohematopoietic system
一，淋巴结良性增生 I. Benign hyperplasia of the lymph nodes
由病原微生物感染，化学药物，外来的毒物，异物，机体代谢产物等导致的肉芽肿形成，急性化脓性炎症，淋巴细胞，组织细胞，树突状细胞增生引起的淋巴结肿大 Granuloma formation caused by pathogenic microbial infections, chemical drugs, foreign poisons, foreign bodies, metabolic products of the body, etc., acute suppurative inflammation, lymphocyte, histiocyte, dendritic cell hyperplasia caused by enlarged lymph nodes
二，淋巴瘤概述 II. Overview of Lymphoma
1．def：淋巴瘤（lymphoma）也称恶性淋巴瘤，起源：淋巴结或结外淋巴组织的淋巴细胞及其前体细胞，其中 B 细胞源性约 80%80 \% ，NK 细胞，组织细胞罕见，T 细胞源性约 20%20 \% 1. def: lymphoma, also known as malignant lymphoma, origin: lymphocytes and their precursor cells in lymph nodes or extra-nodal lymphoid tissues, of which B-cell origin is about 80%80 \% , NK-cells, histiocytes are rare, and T-cell origin is about 20%20 \% .
2．发病原因：是被阻断在 B 细胞和 T 细胞分化过程中某一阶段淋巴细胞的单克隆性增生所致。 2. Pathogenesis: It is caused by the monoclonal proliferation of lymphocytes that are blocked at a certain stage in the process of B-cell and T-cell differentiation.
3．临床表现：无痛性 LN 肿大 ( > 2cm)(>2 \mathrm{~cm}) ，发热，盗汗；免疫功能低下，感染等，属免疫系统肿瘤，免疫功能缺陷易见，故常合并感染，自身免疫病 3. Clinical manifestations: painless LN enlargement ( > 2cm)(>2 \mathrm{~cm}) , fever, night sweats; immunocompromise, infections, etc., are immune system tumors, immune deficiency is easy to see, so often combined with infections, autoimmune diseases.
三，霍奇金淋巴瘤 III, Hodgkin's lymphoma
1．病变多始于一个或一组淋巴结，原发于结外罕见，好发部位：颈，锁骨上 LN\mathbf{L N} ，次为纵隔，腹膜后 LN。 组织起源：B 细胞 1. The lesions mostly start in one or a group of lymph nodes, with a rare primary in the extranodal area, preferred sites: neck, supraclavicular LN\mathbf{L N} , followed by mediastinum, retroperitoneal LN. Tissue of origin: B cells.
2．病理改变：肉眼观：LN 肿大 rarr\rightarrow 粘连 rarr\rightarrow 大肿块。切面灰白鱼肉状，可见黄白色坏死灶。 2. Pathologic changes: Naked eye view: LN enlarged rarr\rightarrow adherent rarr\rightarrow large mass. Grayish-white fish-like, yellowish-white necrotic foci can be seen on the cut surface.
镜下：LN 结构破坏，瘤组织内细胞类型多样化，由肿瘤细胞和非肿瘤细胞组成 Microscopy: structural disruption of the LN, diverse cell types within the tumor tissue, composed of tumor cells and non-tumor cells
3．瘤细胞： R-S\mathrm{R}-\mathrm{S} 细胞：双核，分叶，对称，大，红染的瘤巨细胞，核仁周围有空晕，由于核对称，故也称镜影细胞，其中具有以上特征，但为单核的细胞，称为霍奇金细胞 3. Tumor cells: R-S\mathrm{R}-\mathrm{S} Cells: binucleated, lobulated, symmetric, large, reddish-stained tumor giant cells with empty halos around the nuclei, also known as mirror cells due to symmetrical nuclei, and cells that have the above characteristics but are uninucleated are known as Hodgkin's cells.
变异：陷窝细胞，爆米花细胞，木乃伊细胞，多核瘤巨细胞 Mutations: trap cells, popcorn cells, mummy cells, multinucleated tumor giant cells
4．分类：经典型：淋巴细胞为主型（预后好），混合细胞型（R－S 细胞和霍奇金细胞多），淋巴细胞消减型（大量 R－S 细胞，预后差），结节硬化型（见陷窝细胞） 4. Classification: Classic: lymphocyte-dominant (good prognosis), mixed cell type (many R-S cells and Hodgkin cells), lymphocyte-absent (many R-S cells, poor prognosis), nodular sclerosis (see trapped cells).
结节性淋巴细胞为主型：淋巴细胞多，瘤细胞少，常见 LH 细胞（爆米花细胞），预后最好 Nodular lymphocyte-dominant: many lymphocytes, few tumor cells, common LH cells (popcorn cells), best prognosis
四，非霍奇金淋巴瘤 IV, Non-Hodgkin's lymphoma
1．概述：占全部淋巴瘤的 80%∼90%80 \% \sim 90 \% ，淋巴结多发，结外组织亦有（不确定性），扩散不连续，组织学分类复杂（成人多患大 B 细胞淋巴瘤，儿童青少年多患急淋母白血病／淋巴瘤和 Burkitt 淋巴瘤），临床表现多样：无痛性 LN\mathbf{L N} 肿大，发热，盗汗；免疫功能低下，感染等 1、Overview:accounting for 80%∼90%80 \% \sim 90 \% of all lymphomas, lymph nodes and extra-nodal tissues (uncertainty), discontinuous spread, complex histological classification (adults tend to suffer from large B-cell lymphoma, and children and adolescents tend to suffer from acute gonorrheal leukemia/lymphoma and Burkitt's lymphoma), with a variety of clinical manifestations: painless LN\mathbf{L N} enlargement, fever, night sweats, immune deficiency, infections, and so on. immunocompromise, infections, etc.
病因：EBV 感染，B 细胞起源多，常有染色体易位和基因突变 Etiology: EBV infection, many B-cell origins, often with chromosomal translocations and gene mutations
2．滤泡性淋巴瘤 follicular lymphoma：好发年龄：中年，好发部位：腹股沟 LN，组织起源：淋巴滤泡中心 B 细胞，性质：惰性，中度恶性，病变特点：瘤细胞呈结节状增生 2. follicular lymphoma: age of prevalence: middle-aged, site of prevalence: inguinal LN, tissue origin: lymphoid follicle-centered B cells, nature: inert, moderately malignant, lesion characteristics: nodular proliferation of tumor cells
临床特点：反复无痛性多个 LN 肿大，预后尚好 Clinical features: recurrent painless enlargement of multiple LNs, good prognosis
3．Burkitt 淋巴瘤：好发年龄：青少年，好发部位：颌，面，预骨等，组织起源：滤泡中心 B 细胞，性质：高度恶性，病变特点：弥漫性淋巴细胞浸润，高分裂指数和高凋亡，瘤细胞直接散在分布吞噬有核碎片的巨噬细胞，呈满天星图像，标记：c－myc 易位，临床特点：巨大肿块，侵袭性强 Burkitt's lymphoma: age of prevalence: adolescents, site of prevalence: jaw, face, pre-bone, etc., tissue origin: follicular center B cells, nature: highly malignant, lesion characteristics: diffuse lymphocyte infiltration, high divisional index and high apoptosis, tumor cells are directly scattered distribution of phagocytosis of nucleated fragments of macrophages, in the shape of a starry sky image, marker: c-myc translocation, clinical features: huge mass, aggressive
4．弥漫性大 B 细胞淋巴瘤：成人中最常见，形态变化范围大。BCL6 基因重排或突变组织学：核大，核仁大，核空亮 4. Diffuse large B-cell lymphoma: most common in adults, with a wide range of morphologic variations. histology of BCL6 gene rearrangements or mutations: large nuclei, large nucleoli, and hollow nuclei
5．浆细胞淋巴瘤：多发性骨髓瘤 5. Plasma cell lymphoma: multiple myeloma
五，髓系肿瘤 V. Medullary Tumors
1．def：髓系肿瘤是骨髓造血干细胞克隆性增生形成的恶性肿瘤，常常表现为白血病 1. def: myeloid neoplasms are malignant tumors formed by clonal proliferation of bone marrow hematopoietic stem cells, often manifested as leukemias
2．基本特点：白血病是造血系统最常见的恶性肿瘤，是青少年中发病最高的恶性肿瘤，瘤细胞破坏骨髓，进入周围血液，浸润肝，脾，淋巴结等器官，贫血，出血，感染是主要症状 2. Basic features: leukemia is the most common malignant tumor of the hematopoietic system, and is the malignant tumor with the highest incidence in adolescents. Tumor cells destroy the bone marrow, enter the peripheral bloodstream, infiltrate the liver, spleen, lymph nodes and other organs, and anemia, hemorrhage, and infection are the main symptoms.
3．病因：电离辐射，药物，化学物质，遗传，病毒 3. Causes: ionizing radiation, drugs, chemicals, genetics, viruses
4．急性髓系白血病（Acute myeloid leukemia）：瘤细胞分化停滞在较早阶段，多为原始细胞和早期幼稚细胞 4. Acute myeloid leukemia: tumor cell differentiation stagnates at an early stage, mostly primitive cells and early naive cells.
5．慢性髓系白血病（Chronic myeloid leukemia）：瘤细胞分化停滞在较晚阶段，多为中晚幼细胞和成熟细胞，慢性髓系白血病伴 BCR－ABL－1 阳性，是骨髓增生性肿瘤最常见类型。遗传特征是形成 BCR－ABL－1 融合基因，该融合基因定位于 Ph 费城染色体，为 22 号染色体长臂易位到 9 号染色体长臂 5. Chronic myeloid leukemia (CML): the differentiation of tumor cells is stagnated at a late stage, mostly middle and late juvenile and mature cells, CML with BCR-ABL-1 positivity is the most common type of myeloproliferative neoplasms. It is characterized by the formation of a BCR-ABL-1 fusion gene, which is localized on the Ph Philadelphia chromosome and is a translocation from the long arm of chromosome 22 to the long arm of chromosome 9.
6．髓肉瘤：幼稚造血细胞在骨髓以外的器官或组织内增生形成的包块。 6. Myelosarcoma: a mass formed by the proliferation of naive hematopoietic cells in organs or tissues other than bone marrow.
第十一章 泌尿系统疾病 Chapter XI Diseases of the Urinary System
肾脏功能：排泄代谢产物，毒物；调节机体水和电解质含量；维持酸碱平衡；产生内分泌激素（肾素，促红细胞生成素，前列腺素） Kidney functions: excretion of metabolites, toxins; regulation of body water and electrolyte levels; maintenance of acid-base balance; production of endocrine hormones (renin, erythropoietin, prostaglandins)
肾脏基本结构功能单位－－－－肾单位（nephron）：肾单位 == 肾小球 + 肾小管 Basic Structural Functional Units of the Kidney ---- renal unit (nephron): renal unit == glomerulus + tubule
滤过膜：毛细血管有孔内皮，带负电 基膜一内，外疏松层及中间致密层 足细胞裂孔膜 Filtration membrane: capillary perforated endothelium, negatively charged Basement membrane an inner, outer lax layer and an intermediate dense layer Adequate cellular lacunar membrane
抗体介导的免疫损伤（抗原抗体反应）是肾小球损伤的主要原因 Antibody-mediated immune injury (antigen-antibody reaction) is the main cause of glomerular injury
一，肾小球肾炎：一类与多种原因有关的原发于肾脏的独立疾病，肾为唯一或主要受累脏器，以肾小球病变为主的变态反应性炎症性疾病。 First, glomerulonephritis: a class of independent diseases related to a variety of causes originating in the kidneys, the kidneys are the only or the main organs involved, with glomerulopathy as the main allergic inflammatory disease.
临床表现一蛋白尿，血尿，水肿，高血压及肾衰 Clinical manifestations a proteinuria, hematuria, edema, hypertension and renal failure
发病机制：致肾小球损伤的主要原因：抗原一抗体复合物（IC） Pathogenesis: the main cause of glomerular injury: antigen-antibody complex (IC)
a．循环免疫复合物性肾炎：可溶性 Ag （非肾小球性）+Ab 在循环血流中形成 ICrarrG\mathrm{IC} \rightarrow \mathrm{G} 内沉积 rarrG\rightarrow \mathrm{G}损伤（结合补体，引起 III 型超敏反应） a. Circulating immune complex nephritis: soluble Ag (non-glomerular)+Ab forms ICrarrG\mathrm{IC} \rightarrow \mathrm{G} in circulating blood streams and deposits rarrG\rightarrow \mathrm{G} damage (binds complement, causing type III hypersensitivity)
沉积部位：（1）系膜区（2）内皮细胞与基膜之间，构成内皮下沉积物（3）基膜和足细胞之间 Sites of deposition: (1) thylakoid region (2) between endothelial cells and basement membrane, constituting subendothelial deposits (3) between basement membrane and podocytes
b．原位免疫复合物性肾炎：Ab＋肾小球固有／植入性 AgrarrIC\mathrm{Ag} \rightarrow \mathrm{IC} 沉积 rarrG\rightarrow \mathrm{G} 损伤 b. Immunocomplex nephritis in situ: Ab + glomerular intrinsic/implantation AgrarrIC\mathrm{Ag} \rightarrow \mathrm{IC} deposits rarrG\rightarrow \mathrm{G} damage
（1）抗肾小球基膜肾炎： Ab+\mathrm{Ab}+ 肾小球基膜 AgquadIF\mathrm{Ag} \quad \mathrm{IF} ：抗体沿基膜沉积 rarr\rightarrow 特征性的连续的线形 (1) Antiglomerular basement membrane nephritis: Ab+\mathrm{Ab}+ glomerular basement membrane AgquadIF\mathrm{Ag} \quad \mathrm{IF} : antibody deposition along the basement membrane rarr\rightarrow Characteristic continuous linear pattern
荧光 原因：感染使基膜结构发生改变病原微生物与 GBM 成分具有共同抗原性 Fluorescence Reason: Infection changes the structure of the basement membrane Pathogenic microorganisms have common antigenicity with GBM components.
（2）Heymann 肾炎：Heymann Ag rarrAb+\rightarrow \mathrm{Ab}+ 肾小管上皮刷状缘，足细胞小凹 rarrIC\rightarrow \mathrm{IC} 上皮下沉积 IF：沿基膜弥漫颗粒状分布 IC 或补体的沉积 rarr\rightarrow 不连续的颗粒状荧光 (2) Heymann nephritis: Heymann Ag rarrAb+\rightarrow \mathrm{Ab}+ Brush border of renal tubular epithelium, pedunculated cellular dimples rarrIC\rightarrow \mathrm{IC} Subepithelial deposits IF: Diffuse granular distribution along basement membrane Deposits of IC or complement rarr\rightarrow Discontinuous granular fluorescence
（3）抗体与植入抗原的反应：定位于肾小球 (3) Antibody reaction with implanted antigen: localization in the glomerulus
基本病理变化 Basic pathological changes
1．肾小球细胞增生：系膜细胞，内皮及上皮细胞 +N,M+\mathrm{N}, ~ \mathrm{M} 及 L 浸润 1. Glomerular cell proliferation: thylakoid cells, endothelial and epithelial cells +N,M+\mathrm{N}, ~ \mathrm{M} and L infiltrate
2．基膜增厚，系膜基质 uarr\uparrow ，基膜断裂：GBM 本身增厚或蛋白样物质的沉积 rarr\rightarrow 基底膜 uarr rarr\uparrow \rightarrow 通透性 uarr rarr\uparrow \rightarrow 代谢 darr rarr\downarrow \rightarrow 血管祥或肾小球硬化，原因：免疫复合物沉积 2. Basement membrane thickening, thylakoid matrix uarr\uparrow , basement membrane fracture: thickening of the GBM itself or deposition of protein-like material rarr\rightarrow Basement membrane uarr rarr\uparrow \rightarrow permeability uarr rarr\uparrow \rightarrow metabolism darr rarr\downarrow \rightarrow vascularization or glomerulosclerosis due to: immune complex deposition
3．炎性渗出和坏死：N，纤维素渗出＋血管壁纤维素样坏死＋血栓形成 3. Inflammatory exudation and necrosis: N, fibrin exudation + fibrinoid necrosis of vessel wall + thrombosis
4．玻璃样变和硬化：肾小球内出现均质红染物质堆积 4. Vitrification and sclerosis: accumulation of homogeneous reddish-stained material in the glomeruli
5．肾小管和间质的改变：上皮变性，管型改变等，间质：水肿，炎细胞浸润 5. Renal tubular and interstitial changes: epithelial degeneration, tubular changes, etc., interstitial: edema, inflammatory cell infiltration
（重点！）临床表现： (Emphasis added!) Clinical manifestations:
（1）急性肾炎综合征：起病急，血尿，轻中度蛋白尿（ < 3.5g//d<3.5 \mathrm{~g} / \mathrm{d} ），水肿，高血压。重者肾小球滤过率 darr rarr\downarrow \rightarrow 氮质血症。原因往往是急性增生性肾小球肾炎 (1) Acute nephritis syndrome: acute onset, hematuria, mild to moderate proteinuria ( < 3.5g//d<3.5 \mathrm{~g} / \mathrm{d} ), edema, and hypertension. Severe glomerular filtration rate darr rarr\downarrow \rightarrow azotemia. The cause is often acute proliferative glomerulonephritis
（2）急进性肾炎综合症：起病急，进展快，急性肾炎综合征的表现＋少尿，无尿＋氮质血症 rarr\rightarrow 快速进展为急性肾功能衰竭。原因往往是急进性肾小球肾炎 (2) Acute progressive nephritis syndrome: acute onset, rapid progression, acute nephritis syndrome manifestations + oliguria, anuria + azotemia rarr\rightarrow Rapid progression to acute renal failure. The cause is often acute progressive glomerulonephritis
（3）肾病综合症：＂三高一低＂：高蛋白尿，高度水肿，高脂血症，低蛋白血症 (3) Nephrotic syndrome: "three highs and one low": high proteinuria, high degree of edema, hyperlipidemia, hypoproteinemia
（4）无症状性血尿或蛋白尿：持续发作的血尿，轻度蛋白尿，常由 IgA 肾病引起 (4) Asymptomatic hematuria or proteinuria: persistent episodes of hematuria, mild proteinuria, often caused by IgA nephropathy
（5）慢性肾炎综合症：多尿，夜尿，低比重尿，高血压，贫血，氮质血症和尿毒症。起病缓，渐发展为慢性肾功能不全。 (5) Chronic nephritis syndrome: polyuria, nocturia, hypospadias, hypertension, anemia, azotemia and uremia. It starts slowly and gradually develops into chronic renal insufficiency.
主要病理类型 Main types of pathology
（一）急性弥漫性增生性肾小球肾炎：以弥漫性肾小球系膜细胞和内皮细胞增生为主要病变伴 N ， M 浸润的一种急性肾炎。又称毛细血管内增生性肾小球肾炎；链球菌感染（A 组乙型溶血性链球 (I) Acute diffuse proliferative glomerulonephritis: an acute nephritis characterized by diffuse glomerular mesangial cell and endothelial cell proliferation with N and M infiltration. Also known as intracapillary proliferative glomerulonephritis; streptococcal infection (group A hemolytic streptococcus B).
菌）后肾炎。儿童多见，发病急 预后良好 (Bacteria) Post nephritis. Common in children, rapid onset, good prognosis.
发病机制：循环免疫复合物介导，C3 沉积 Pathogenesis: Circulating immune complex-mediated, C3 deposition
病理改变：大体：双侧肾肿大，包膜紧张，表面充血，光滑 rarr\rightarrow 大红肾 Pathologic changes: Gross: bilateral enlarged kidneys, tense peritoneum, congested surface, smooth rarr\rightarrow Large red kidneys
表面与切面散在粟粒大 Surface and cut surface scattered with corn grain size
小的出血点 rarr\rightarrow 蚤咬肾 Small hemorrhages rarr\rightarrow flea-bitten kidneys
LM：1．病变呈弥漫分布 2．肾小球体积增大， G 内 C 数目 uarr3\uparrow 3 3．系膜 C 与内皮 C 显著增大，肿胀 rarr\rightarrow 肾小球缺血状 4．肾小球内多数炎细胞浸润 5．严重病例毛细血管内血栓形成，管壁纤维素样坏死6．球囊腔内纤维素渗出及红细胞漏出 7．肾小管上皮变性，管型 8．间质充血，水肿，少量炎细胞浸润 LM: 1. Diffuse distribution of lesions 2. Increased glomerular volume, number of C in G uarr3\uparrow 3 3. Significantly enlarged thylakoid C and endothelial C, swelling rarr\rightarrow glomerular ischemia 4. Majority of inflammatory cells infiltrate the glomerulus 5. Intracapillary thrombosis and tubular wall fibrinoid necrosis in severe cases 6. Fibrinoid exudates from the lumen of the globular capsule and erythrocyte leakage 7. Tubular epithelium degeneration, tubular pattern 8. Tubular pattern 8. Interstitial congestion, edema, small amount of inflammatory cell infiltration
EM：1．系膜 C，内皮 C 增生，肿胀 2．上皮下驼峰状，小丘状电子致密物沉积 EM: 1. thylakoid C, endothelial C hyperplasia, swelling 2. subepithelial hummocky, hillocky electron-dense deposits
IF：呈颗粒状荧光，主要成分为 IgG，IgM，C3 IF: granular fluorescence, mainly composed of IgG, IgM, C3
临床病理联系：急性肾炎综合征 Clinicopathologic link: acute nephritic syndrome
1．尿的变化：（1）少尿或无尿： G 内细胞增生，肿胀 rarr\rightarrow 毛细血管管腔狭窄，闭塞 rarrG\rightarrow \mathrm{G} 缺血 rarrGFR\rightarrow \mathrm{GFR}darr rarr\downarrow \rightarrow 尿量 darr\downarrow（2）血尿，蛋白尿：GBM 受损，通透性 uarr rarr\uparrow \rightarrow RBC，血浆蛋白漏出（3）管型尿 1. Changes in urine: (1) oliguria or anuria: cell proliferation in G, swelling rarr\rightarrow narrowing of capillary lumen, occlusion rarrG\rightarrow \mathrm{G} ischemia rarrGFR\rightarrow \mathrm{GFR}darr rarr\downarrow \rightarrow urine volume darr\downarrow (2) hematuria, proteinuria: impaired GBM, permeability uarr rarr\uparrow \rightarrow RBCs, plasma protein leakage (3) tubulointerstitial urine
2．水肿：（1）GFR darr rarrNa+\downarrow \rightarrow \mathrm{Na}+ ， H 2 O 渚留（2）变态反应 rarr\rightarrow 全身毛细血管通透性 uarr\uparrow 2. Edema: (1) GFR darr rarrNa+\downarrow \rightarrow \mathrm{Na}+ , H 2 O islet (2) Metamorphosis rarr\rightarrow Systemic capillary permeability uarr\uparrow
3．高血压：（1）GFR darr rarrNa+H2O\downarrow \rightarrow \mathrm{Na}+\mathrm{H} 2 \mathrm{O} 渚留 rarr\rightarrow 血容量 uarr\uparrow（2）肾组织缺血 rarr\rightarrow 肾素血管紧张素 IIuarr rarr\mathrm{II} \uparrow \rightarrow 细小 A 收缩 rarr\rightarrow 血压 uarr\uparrow 3. Hypertension: (1) GFR darr rarrNa+H2O\downarrow \rightarrow \mathrm{Na}+\mathrm{H} 2 \mathrm{O} islet retention rarr\rightarrow blood volume uarr\uparrow (2) renal tissue ischemia rarr\rightarrow renin angiotensin IIuarr rarr\mathrm{II} \uparrow \rightarrow fine A contraction rarr\rightarrow blood pressure uarr\uparrow
预后：多数良好，少量转变为急进性肾小球肾炎／慢性肾炎 Prognosis: mostly favorable, with a small number of changes to acute glomerulonephritis/chronic nephritis
（二）急进性（新月体性）肾小球肾炎：一组病情快速发展的 GN，病理学特征为肾小球囊壁层上皮增生，新月体形成一一肾小囊壁层上皮细胞＋渗出的单核细胞，临床表现为急进性肾炎综合征。好发年龄：中，青年为主 (b) Acute (crescentic) glomerulonephritis: a group of GN with rapid progression of the disease, characterized by epithelial hyperplasia of the glomerular capsule wall layer, crescentic formation of epithelial cells of the wall layer of the glomerular capsule layer + exudative mononuclear cells, and the clinical manifestation of an acute nephritic syndrome. Prevalent age: middle-aged and young people
发病机制：原位免疫复合物，循环免疫复合物，抗中性粒细胞抗体引起滤过膜损伤，引起纤维蛋白原漏出，壁层上皮细胞增生 Pathogenesis: In situ immune complexes, circulating immune complexes, and anti-neutrophil antibodies cause damage to the filtration membrane, resulting in fibrinogen leakage and mural epithelial cell proliferation
病变特点：肾小球内大量新月体形成 Characteristics of the lesion: massive crescent formation in the glomerulus
临床特点：病变严重，进展快，血尿，少尿，无尿，高血压，氮质血症 Clinical features: severe lesions, rapid progression, hematuria, oliguria, anuria, hypertension, azotemia
I型为抗肾小球基底膜性疾病。在 GBM 内出现 IgG 和 C3 的线状沉积。部分病例出现肺出血－肾炎综合征（肺泡与基底膜有交叉抗原）。 Type I is an antiglomerular basement membrane disease. Linear deposits of IgG and C3 are seen within the GBM. Some cases present with pulmonary hemorrhage-nephritis syndrome (alveoli are cross-antigenic with the basement membrane).
II 型为循环免疫复合物性疾病（我国常见） Type II is a circulating immune complex disease (common in our country).
III 型为免疫反应缺乏型 Type III is immune-deficient
病理变化：大体：双侧肾体积增大，苍白，皮质内散在点状出血（大白肾） Pathologic changes: gross: bilateral kidneys increased in size, pale, scattered punctate hemorrhages in the cortex (large white kidneys)
光镜： 1 ．大部分肾小球 (50%(50 \% ）内有新月体形成。壁层上皮细胞 uarr\uparrow ，堆积成层，单核细胞，中性粒细胞，淋巴细胞浸润 + 纤维素（细胞性新月体，细胞一纤维性新月体，纤维性新月体） Light microscopy: 1. Crescent formation in most glomeruli (50%(50 \% ). Mural epithelial cells uarr\uparrow , stacked in layers, monocytes, neutrophils, lymphocyte infiltration + fibrils (cellular crescent, cellular-a-fibrillar crescent, fibrillar crescent)
早期：壁层上皮 Cuarr+Mrarr\mathrm{C} \uparrow+\mathrm{M} \rightarrow 细胞性新月体 成纤维 Crarr\mathrm{C} \rightarrow 纤维 uarr rarr\uparrow \rightarrow 细胞－纤维性新月体晚期：纤维化 rarr\rightarrow 纤维性新月体 Early stage: mural epithelium Cuarr+Mrarr\mathrm{C} \uparrow+\mathrm{M} \rightarrow cellular crescent Fibroblastic Crarr\mathrm{C} \rightarrow fibrous uarr rarr\uparrow \rightarrow cell-fibrous crescent Late stage: fibrotic rarr\rightarrow fibrous crescent
2．增生的上皮 C 间可见 RBC，N 和纤维素性渗出物 3．可见毛细血管壁发生纤维素样坏死和出血 4．系膜细胞和内皮细胞轻度增生 5．部分肾小球纤维化，玻璃样变 6．肾小管上皮变性，萎缩至消失 2. RBCs, N, and fibrinous exudate are seen between the C of the hyperplastic epithelium 3. Fibrinous necrosis and hemorrhage of the capillary wall are seen 4. Mild proliferation of tethered cells and endothelial cells 5. Partial glomerular fibrosis and vitrification 6. Degeneration of the tubular epithelium with atrophy and loss of the tubular epithelium
EM：（1）GBM 致密物沉积，BM 外侧，膜内或内侧（2）GBM 厚薄不均，裂孔或缺损 EM: (1) GBM dense material deposits, outside of BM, inside or inside of membrane (2) GBM uneven thickness, cracks or defects
（3）新月体内，可见纤维蛋白条索 (3) Inside the crescent, fibrin streaks are visible
IF：（1）连续线形荧光（I）（2）颗粒状荧光（不规则）（II）（3）很少或不见荧光（III） IF: (1) continuous linear fluorescence (I) (2) granular fluorescence (irregular) (II) (3) little or no fluorescence (III)
临床病理联系：急进性肾炎综合征 Clinicopathologic link: acute progressive nephritic syndrome
1．血尿，蛋白尿，显著水肿 2．少尿，无尿 rarr\rightarrow 氮质血症 rarr\rightarrow 肾衰 3.G3 . G 受压，缺血 rarr\rightarrow 肾素 uarr rarr\uparrow \rightarrow高血压 1. hematuria, proteinuria, significant edema 2. oliguria, anuria rarr\rightarrow azotemia rarr\rightarrow renal failure 3.G3 . G stress, ischemia rarr\rightarrow renin uarr rarr\uparrow \rightarrow hypertension
肺出血肾炎综合征（Goodpasture＇s syndrome）特点：肺出血＋新月体性肾小球肾炎发病年龄：多见于青壮年，男＞女 临床表现：反复咯血＋血尿，蛋白尿，少尿等 Pulmonary hemorrhage nephritis syndrome (Goodpasture's syndrome) Characteristics: pulmonary hemorrhage + crescentic glomerulonephritis Age of onset: most common in young adults, male>female Clinical manifestations: repeated hemoptysis + hematuria, proteinuria, oliguria and so on.
（三）膜性肾小球病（膜性肾病）：是引起成人肾病综合征最常见原因。 (c) Membranous glomerulopathy (membranous nephropathy): it is the most common cause of adult nephrotic syndrome.
病变特点：肾小球毛细血管壁弥漫性增厚，肾小球基膜侧上皮细胞出现含免疫球蛋白的电子致密沉积物 Characteristics of the lesion: diffuse thickening of the glomerular capillary wall and the appearance of electron-dense deposits containing immunoglobulin in the epithelial cells on the side of the glomerular basement membrane
病因和发病机制：原位免疫复合物型肾炎 Etiology and pathogenesis: in situ immune complex nephritis
上皮细胞抗原：原位 IC，C5b－C9 膜攻击复合体激活上皮细胞和系膜细胞，但无中性粒细胞，单核细胞浸润 Epithelial cell antigen: IC in situ, C5b-C9 Membrane attack complex activates epithelial and lineage cells but no neutrophils, monocyte infiltration
病理变化：大体：肾肿大，色苍白 rarr\rightarrow 大白肾 Pathologic changes: gross: enlarged kidneys, pale rarr\rightarrow Large white kidneys
LM：1．肾小球毛细血管壁均匀，弥漫性增厚 2．六胺银染色：GBM 示钉突形成，梳齿状（虫蚀状）3．肾小球毛细血管壁增厚 rarr\rightarrow 管腔狭窄，闭塞 4．肾小管上皮变性，管型 LM: 1. uniform, diffuse thickening of glomerular capillary wall 2. silver hexamine staining: GBM shows nail formation, combing (worm-eaten) 3. thickening of glomerular capillary wall rarr\rightarrow tubular lumen narrowing, occlusion 4. tubular epithelial degeneration, tubular pattern
EM：1．GBM 外侧（上皮下）多数小丘状突起 2．GBM 钉状突起插入小丘状突起之间 EM: 1. GBM lateral (subepithelial) majority of hillock-like projections 2. GBM nail-like projections inserted between hillock-like projections
3．钉状突起与 GBM 垂直相连 4．钉状突起包绕沉积物，融合 rarr\rightarrow GBM 呈＂虫蚀状＂ 3. Spikes are vertically connected to the GBM 4. Spikes encircle the sediment, fusing rarr\rightarrow the GBM in a "worm-like" pattern
IF：沿 GBM 表面呈颗粒状荧光。IgG，C3 IF: granular fluorescence along the GBM surface. IgG, C3
临床表现：肾病综合征＂三高一低＂：高度蛋白尿；高度水肿；高脂血症；低蛋白血症 Clinical manifestations: nephrotic syndrome "three highs and one low": high proteinuria; high edema; hyperlipidemia; hypoproteinemia
（四）微小病变性肾小球肾炎（脂性肾病，足突病）病变特点：弥漫性脏层上皮细胞足突消失，肾小管上皮细胞内有脂质沉积 小儿肾病综合征的最常见原因 (iv) Microscopic lesion glomerulonephritis (lipoid nephropathy, podocytosis) Characteristics of the lesion: diffuse loss of epithelial cell podocytosis in the visceral layer and lipid deposition in the epithelial cells of the renal tubules The most common cause of nephrotic syndrome in pediatric patients
发病机制：无免疫复合物沉积，细胞免疫：T 细胞功能异常，肾小球滤过膜阴离子丧失，足细胞损伤 Pathogenesis: no immune complex deposition, cellular immunity: abnormal T-cell function, glomerular filtration membrane anion loss, podocyte injury
临床：肾病综合征；皮质激素治疗效果好，高度选择性蛋白尿 Clinical: nephrotic syndrome; effective corticosteroid therapy, highly selective proteinuria
病理变化：大体：肾脏肿胀，苍白，切面皮质因肾小管上皮细胞内脂质沉着而出现黄白色条纹 Pathologic changes: gross: kidneys are swollen and pale, with yellowish-white streaks in the cut cortex due to lipid deposits in tubular epithelial cells
LM：G 仅有轻度节段性增生；肾小管上皮脂类沉积，脂质空泡，透明管型 LM:G Mild segmental hyperplasia only; tubular epithelial lipid deposits, lipid vacuoles, hyaline tubular pattern
EM ：弥漫性 G 脏层上皮足突消失；内质网 uarr\uparrow（足突病） EM : Diffuse loss of epithelial peduncles in the stratum G; endoplasmic reticulum uarr\uparrow (pedunculopathy)
（五）弥漫性膜增生性肾小球肾炎 (v) Diffuse membranoproliferative glomerulonephritis
病理特征：肾小球基膜增㫗，系膜细胞增生和基质增多 Pathologic features: glomerular basement membrane hyperplasia, thylakoid cell proliferation and stromal increase
I 型（内皮下和系膜区）：循环免疫复合物型肾炎 Type I (subendothelial and tethered areas): circulating immune complex nephritis
II 型（GBM 内）：补体替代途径异常，C3Nef 自身抗体 Type II (within GBM): Abnormalities in the complement replacement pathway, C3Nef autoantibodies
系膜增生和系膜基质增多，基膜明显增厚，PASM：双轨状 Thylakoid hyperplasia and increased thylakoid stroma with marked thickening of the basement membrane, PASM: double-tracked
临床表现：儿童和青年，肾病综合征＋血尿，无症状性蛋白尿 Clinical presentation: children and young adults, nephrotic syndrome + hematuria, asymptomatic proteinuria
（六）IgA 肾病：发病年龄：儿童及青少年多见 (vi) IgA nephropathy: age of onset: common in children and adolescents
临床病理联系：复发性镜下或肉眼血尿，轻度蛋白尿，急性肾炎综合征 Clinicopathologic associations: recurrent microscopic or gross hematuria, mild proteinuria, acute nephritic syndrome
病变特点：LM：肾小球系膜增生，IgA 在系膜区沉积，局灶性节段性增生／硬化，新月体 Lesion characteristics: LM: glomerular mesangial hyperplasia, IgA deposition in the mesangial area, focal segmental hyperplasia/sclerosis, crescents
发病机制：病毒，细菌等刺激呼吸道或消化道 IgA\operatorname{IgA} 产生过多，清除异常 Pathogenesis: Viruses, bacteria, etc. irritate the respiratory or digestive tract IgA\operatorname{IgA} producing excessive amounts and eliminating them abnormally.
EM：系膜区电子致密物沉积（IgA） EM: electron dense matter deposition (IgA) in the thylakoid region
（七）慢性肾小球肾炎（弥漫性硬化性 GN）不同 GN 发展的终末阶段 病变特点：大量肾小球玻璃样变和硬化，慢性肾炎综合征 (vii) Chronic glomerulonephritis (diffuse sclerosing GN) End stage of development of different GNs Characteristics of lesions: massive glomerular vitreous degeneration and sclerosis, chronic nephritic syndrome
病理改变：肉眼：继发性颗粒性固缩肾 Pathologic changes: naked eye: secondary granular consolidation of the kidney
LM：（1）大量 G 纤维化，玻变，相互靠近，残余 G 肥大（2）部分肾小管萎缩，纤维化，消失；部分肾小管上皮增生，管型（3）间质内小 A 硬化，管壁增厚（4）间质纤维组织明显增生，炎细胞浸润 LM: (1) a large number of G fibrosis, glass change, close to each other, residual G hypertrophy (2) some renal tubules atrophy, fibrosis, disappearance; some renal tubular epithelial hyperplasia, tubular pattern (3) small A sclerosis in the mesenchyme, thickening of the tubular wall (4) interstitial fibroblastic tissue markedly hyperplasia, inflammatory cell infiltration
临床病理联系：（1）肾对尿的浓缩功能降低 rarr\rightarrow 多尿，夜尿，尿比重 darr\downarrow Clinicopathologic associations: (1) Reduced renal concentration of urine rarr\rightarrow Polyuria, nocturia, urine specific gravity darr\downarrow
（2）大量肾单位纤维化 rarr\rightarrow 肾缺血 rarr\rightarrow 肾素分泌 uarr rarr\uparrow \rightarrow 高血压 rarr\rightarrow 左心室肥大，心力衰竭 (2) Fibrosis of a large number of renal units rarr\rightarrow Renal ischemia rarr\rightarrow Renin secretion uarr rarr\uparrow \rightarrow Hypertension rarr\rightarrow Left ventricular hypertrophy, heart failure
（3）大量肾单位破坏 rarr\rightarrow 代谢废物潴留 rarr\rightarrow 氮质血症 rarr\rightarrow 肾衰 (3) Massive destruction of renal units rarr\rightarrow Metabolic waste retention rarr\rightarrow Azotemia rarr\rightarrow Renal failure
预后极差 The prognosis is very poor.
二，肾孟肾炎：是一种由化脓性细菌感染引起的，以肾小管，肾孟，肾间质为主的化脓性炎症性 Second, renal mononephritis: it is a kind of purulent inflammatory disease caused by purulent bacterial infection, mainly in the renal tubule, renal mononephritis and renal interstitium.
疾病。性质：化脓性炎症 年龄：任何年龄 分类：急性肾孟肾炎；慢性肾孟肾炎 Disease. Nature: purulent inflammation Age: any age Classification: acute nephromonephritis; chronic nephromonephritis
临床表现：1．急性感染的全身症状：发热，寒战，乏力 2 。膀胱－尿道刺激症状：尿频，尿急，尿痛，腰酸，腰痛 3 尿常规异常：菌尿，脓尿，蛋白，管型尿 Clinical manifestations: 1. Systemic symptoms of acute infection: fever, chills, malaise 2 . Bladder-urethral irritation symptoms: urinary frequency, urinary urgency, urinary pain, lumbago, lumbago 3 Abnormal urine routine: bacteriuria, pus, protein, tubular urine
感染途径：1．血行（下行性）感染：金黄色葡萄球菌，常由败血症／感染性心内膜炎引起，病变多为双肾受累 Infection route: 1. Bloodstream (downstream) infection: Staphylococcus aureus, often caused by sepsis/infective endocarditis, lesions are mostly bilateral kidney involvement
2．上行性感染（最常见）：大肠杆菌最常见，尿液排出受阻，膀胱功能障碍引起，单侧受累（多见） 2. Ascending infections (most common): E. coli most common, obstructed urinary drainage, caused by bladder dysfunction, unilateral involvement (most common)
1．急性肾孟肾炎：细菌引起肾小管，肾孟，肾间质化脓性炎 1. Acute nephronephritis: bacterial-induced septic inflammation of renal tubules, nephrons and interstitium.
病变 大体：肾肿大，充血，表面散在小脓肿 Lesions Gross: enlarged, congested kidneys with small abscesses scattered on the surface
光镜：（1）肾孟粘膜充血，水肿，大量中性粒细胞浸润（2）肾间质化脓性炎（3）肾小管腔充满脓细胞，细菌（4）血源性感染者，间质小脓肿临床病理联系：1．起病急，发热，寒战，WBC uarr\uparrow 等全身症状 2 。尿的改变：脓尿，菌尿，蛋白尿，管型尿等 3 ．膀胱刺激症状：尿频，尿急，尿痛等 Light microscopy: (1) renal Membranous mucosa congestion, edema, a large number of neutrophil infiltration (2) renal interstitial septic inflammation (3) renal tubular lumen is filled with pus cells, bacteria (4) hematogenous infections, interstitial small abscess clinicopathological associations: 1. Sharp onset of disease, fever, chills, WBC uarr\uparrow and other systemic symptoms 2. Urinary changes: pyuria, bacteriuria, proteinuria, tubular urine, etc. 3. Bladder irritation symptoms: urinary frequency, urinary urgency, urinary pain, and so on
并发症：急性坏死性乳头炎（肾乳头坏死），肾孟积脓，肾周围脓肿 Complications: acute necrotizing papillitis (necrosis of the renal papillae), pus in the renal corpuscle, perinephric abscesses
预后：痊愈慢性肾孟肾炎 Prognosis: cured Chronic Bengal Nephritis
2．慢性肾孟肾炎：肾小管－间质的慢性炎症 2. Chronic nephromonephritis: chronic tubulo-interstitial inflammation of the kidney
病变特点：大体：1．慢性间质性炎症，纤维化和疤痕形成，肾孟肾盏的纤维化和变形 2 。肾小管间质活动性炎 rarr\rightarrow 肾组织纤维化，瘏痕形成 rarr\rightarrow 肾孟，肾盏变形 3 。病变分布不均，呈不规则灶状或片状瘢痕性固缩肾 Characteristics of the lesion: broadly: 1. Chronic interstitial inflammation, fibrosis and scar formation, fibrosis and deformation of the renal corpuscles and calyces 2 . Active tubulointerstitial inflammation rarr\rightarrow Fibrosis of renal tissue, scar formation rarr\rightarrow Renal孟, renal calyx deformation 3 . Uneven distribution of lesions, irregular foci or patches of scarred consolidated kidneys
LM：（1）瘏痕区肾间质破坏，肾间质，肾孟粘膜纤维组织增生（2）间质大量炎细胞浸润 LM: (1) interstitial destruction of the kidney in the area of the injury scar, interstitium, and fibrous tissue proliferation of the mucosa of the renal meninges (2) massive infiltration of inflammatory cells in the interstitium
（3）小血管管壁增厚，管腔狭窄（4）部分肾小管萎缩，坏死，纤维化，部分管腔扩张，管型（5）病变区肾小球多萎缩，纤维化，玻变（6）部分肾单位代偿性肥大 (3) Thickening of the wall of small blood vessels and narrowing of the lumen (4) Atrophy, necrosis, and fibrosis of some renal tubules, dilatation of some lumens, and tubular pattern (5) Much atrophy of glomeruli in the lesion area, fibrosis, and glassy changes (6) Compensatory hypertrophy of some renal units
临床病理联系：1．脓尿，低钠，低钾血症，代谢性酸中毒 quad2\quad 2 。肾小管浓缩功能 darr rarr\downarrow \rightarrow 多尿，夜尿 Clinicopathologic associations: 1. Pyuria, hyponatremia, hypokalemia, metabolic acidosis quad2\quad 2 . Renal tubular concentrating function darr rarr\downarrow \rightarrow Polyuria, nocturia
三，肾细胞癌（肾腺癌）：来源：起源于肾小管的腺癌 III, Renal cell carcinoma (renal adenocarcinoma): origin: adenocarcinoma originating in the renal tubules
病理变化：大体：上极最多，单个圆形，分界清，有假包膜，呈多彩性 Pathologic changes: gross: uppermost pole most numerous, single rounded, well demarcated, pseudo-enveloped, colorful
镜下：根据癌细胞形态和排列分为：透明细胞癌。乳头状癌。嫌色细胞癌 Microscopically: according to the morphology and arrangement of the cancer cells, they are classified as: clear cell carcinoma. Papillary carcinoma. smoky cell carcinoma
1．透明细胞癌：最常见，癌细胞体积大，多角形，胞浆丰富，几乎呈透明状，胞界清楚，癌细胞排列成实性巢状或条索状 1. Clear cell carcinoma: the most common, the cancer cells are large, polygonal, rich in cytoplasm, almost transparent, with clear cell boundaries, and the cancer cells are arranged in solid nests or cords.
2．乳头状癌：呈现高分化腺癌，癌细胞排列成乳头状结构 2. Papillary carcinoma: presenting a highly differentiated carcinoma with the cancer cells arranged in a papillary structure.
3．嫌色细胞癌：癌细胞胞浆弱嗜碱性，核周常有空晕，细胞呈实性片状排列，预后较好 3. Smoky cell carcinoma: the cytoplasm of cancer cells is weakly basophilic, there is often a halo around the nucleus, and the cells are arranged in solid sheets, the prognosis is better.
临床病理联系：1．无痛性肉眼血尿 2．肾区肿块 3．异位内分泌肿瘤 Clinicopathologic associations: 1. painless hematuria of the naked eye 2. renal mass 3. ectopic endocrine tumor
转移：肺，骨 Metastasis: lung, bone
肾母细胞瘤：小儿腹腔内最常见的原发性的恶性肿瘤 Nephroblastoma: the most common primary malignant tumor of the pediatric abdominal cavity
病理变化：大体：多发生在单侧肾脏的上下极，单个，巨大球形，边界清，切面呈多彩性。 Pathological changes: gross: mostly in the upper and lower poles of unilateral kidneys, single, huge spherical, clear borders, colorful in section.
光镜：三种主要成分：1．未分化肾母细胞 2．原始上皮细胞成分，排列成胚胎性小管和小球样结 Light microscopy: three main components: 1. undifferentiated nephroblasts 2. primitive epithelial cell components arranged in embryonic tubules and goblet-like junctions
构 3．梭形细胞间质 Organization 3. Spindle-shaped interstitial cells
膀胱移行细胞癌：部位：膀胱侧壁和膀胱三角区 临床病理联系：无痛性血尿 Migratory cell carcinoma of the bladder: site: lateral bladder wall and bladder triangle Clinicopathologic association: painless hematuria
第十四章 生殖系统和乳腺疾病 Chapter 14 Diseases of the Reproductive System and the Mammary Gland
一，子宫颈鳞状上皮内病变 SIL 及子宫颈癌 I. Squamous Intraepithelial Lesion of the Cervix SIL and Cervical Cancer
1．病因 1. Etiology
HPV 感染：高危型 16,18 型 HPV infection: high-risk type 16,18
2．子宫颈上皮内瘤变（Cervical intraepithelial neoplasia，CIN）：宫颈上皮层内的不典型增生＋原位癌 2. Cervical intraepithelial neoplasia (CIN): atypical hyperplasia + carcinoma in situ in the epithelial layer of the uterine cervix
CIN I级 < 1//3<1 / 3 不典型增生 rarr\rightarrow LSIL CIN grade I < 1//3<1 / 3 Atypical hyperplasia rarr\rightarrow LSIL
CIN II级 1／3－2／3 不典型增生 rarr\rightarrow HSIL CIN grade II 1/3-2/3 atypical hyperplasia rarr\rightarrow HSIL
CIN III级 > 2//3>2 / 3 重度不典型增生＋原位癌 rarr\rightarrow HSIL CIN grade III > 2//3>2 / 3 severe atypical hyperplasia + carcinoma in situ rarr\rightarrow HSIL
3．子宫颈鳞状上皮内病变（squamous intraepithelial lesion，SIL）：子宫颈上皮部分被不同程度异型性细胞所取代，表现为出现凹空细胞或鳞状上皮细胞大小形态不一，核大深染，核浆比例增大，核分裂像增多，细胞极性紊乱。 3. Squamous intraepithelial lesion (SIL): the epithelium of the uterine cervix is partially replaced by heterogeneous cells of varying degrees, which are characterized by the appearance of hollow cells or squamous epithelial cells of varying sizes and morphologies, with large and deeply stained nuclei, increased nucleoplasma ratio, increased nuclear schizophrenic images, and disorganized cellular polarity.
4．临床病理联系：碘液染色试验：＋正常 一异常 醋酸试验 白色：异常 4. Clinicopathologic connection: iodine staining test: + normal - abnormal Acetic acid test white: abnormal
5．子宫颈鳞状细胞癌 5. Squamous cell carcinoma of the uterine cervix
a．早期浸润癌 microinvasive carcinoma／微小浸润性鳞状细胞：浸润深度＜基底膜下 5 mm ，浸润宽度 < 7mm<7 \mathrm{~mm} ，无血管浸润及淋巴结转移 a. Early invasive carcinoma microinvasive carcinoma/microinvasive squamous cell: depth of infiltration <5 mm below basement membrane, width of infiltration < 7mm<7 \mathrm{~mm} , no vascular infiltration and lymph node metastasis.
b．浸润型鳞状细胞癌：浸润深度超过基底膜下 5 mm ，分为角化型鳞癌，非角化型鳞癌，非角化型小细胞癌 b. Invasive squamous cell carcinoma: the depth of infiltration is more than 5 mm below the basement membrane, and it is divided into keratinized squamous carcinoma, non-keratinized squamous carcinoma and non-keratinized small cell carcinoma.
c．扩散： 3 种，最常见为淋巴道，最先侵犯子宫旁淋巴结 c. Dissemination: 3 types, most commonly lymphatic, first invading the para-uterine lymph nodes.
二，滋养层细胞疾病（gestational trophoblastic diseases，GTD）：来源于胎盘滋养细胞的增生性疾病共同特征：滋养层细胞异常增生 hCGuarr uarr\mathrm{hCG} \uparrow \uparrow Second, gestational trophoblastic diseases (GTD): proliferative disorders originating from placental trophoblast cells Common feature: abnormal proliferation of trophoblast cells hCGuarr uarr\mathrm{hCG} \uparrow \uparrow
1．葡萄胎 Hydatidiform mole：完全／部分性葡萄胎 1. Hydatidiform mole: complete/partial hyperemesis gravidarum
完全：全部或部分线毛水肿，囊泡形成，形如葡萄，大小不等。有恶变可能 Complete: total or partial thread hair edema, vesicle formation, grape-like in shape, varying in size. Possibility of malignant transformation
部分：尚存部分胎儿结构 Partial: some fetal structures remain
特点：绒毛间质水肿，戗毛间质血管消失／少数无功能血管，滋养层细胞不同程度增生 Characteristics: chorionic interstitial edema, loss of impaction interstitial vasculature/few non-functional vessels, trophoblast cells proliferated to varying degrees
2．侵蚀性葡萄胎 invasive mole：交界性肿瘤水泡状组织侵入子宫肌壁／阴道阔韧带，滋养层细胞侵入肌层，增生显著，腔内多少不等的水泡状物 2. Erosive staphylococcus invasive mole: junctional tumor blister-like tissue invades the myometrial wall/vaginal broad ligament, trophoblast cells invade the myometrium, proliferation is significant, and blisters in the lumen vary in amount.
3．绒毛膜上皮癌 choriocarcinoma 3. Choriocarcinoma
大体：癌结节单个或多个，肿瘤部位不定，出血坏死明显，暗红色或紫蓝色结节 Gross: single or multiple cancerous nodules, variable tumor location, marked hemorrhagic necrosis, dark red or purplish-blue nodules
镜下：滋养层细胞高度增生，异型性明显 无绒毛和水泡状结构（与侵袭性葡萄胎不同之处）癌组织自身内无间质，无血管 Microscopy: trophoblast cells are highly proliferated, with marked heterogeneity No villi or blister-like structures (as opposed to invasive staphylococcus) No mesenchyme within the cancerous tissue itself, no blood vessels
转移：侵袭破坏血管能力强，极易发生血道转移，以肺和阴道壁最多见。 Metastasis: Strong ability to invade and destroy blood vessels, highly susceptible to bloodway metastasis, most common in the lungs and vaginal wall.
三，乳腺癌 Carcinoma of the Breast Carcinoma of the Breast
病因：雌激素长期作用（月经初潮早，闭经晚，生育晚，长期服用雌激素）家族遗传倾向：BRCA1基因（抑癌基因）突变，环境 Etiology: long-term effects of estrogen (early menarche, late amenorrhea, late childbearing, long-term use of estrogen) familial predisposition: mutations in BRCA1 gene (oncogene), environment
起源：终末导管－小叶单元上皮，多发生于外上象限，其次乳腺中央区 Origin: Terminal ductal-lobular unit epithelium, mostly in the upper outer quadrant, followed by the central mammary area
1．非浸润性癌：导管内癌，小叶原位癌 1. Non-invasive carcinoma: intraductal carcinoma, lobular carcinoma in situ
2．浸润性癌：非特异性浸润性癌（最常见，肉眼观：GIFT），浸润性小叶癌（最易转移，癌细胞单行串珠样或细条索样浸润于纤维间质中） 2. Invasive carcinoma: non-specific invasive carcinoma (most common, visualization: GIFT), invasive lobular carcinoma (most likely to metastasize, with single rows of bead-like or fine-stranded cells infiltrating the fibrous interstitium)
3．其他类型癌，如小管癌是恶性程度最低的扩散： 3 种，最常见为淋巴道转移 3. Other types of cancer, such as tubular cancer, are the least malignant spreading: 3 types, most commonly lymphatic metastases
分子亚型与预后： Molecular subtypes and prognosis:
传染病是由病原微生物通过一定的传播途径进入易感人群的个体所引起的一组疾病，并能在人群中引起局部和广泛的流行。 Infectious diseases are a group of diseases caused by pathogenic microorganisms that enter susceptible individuals through certain routes of transmission and can cause localized and widespread epidemics in the population.
传染病三个基本环节：传染源，传播途径和易感人群。 There are three basic components of infectious disease: the source of infection, the means of transmission, and the susceptible population.
一．结核病（tuberculosis）由结核杆菌引起的一种慢性肉芽肿性疾病。除牙齿，毛发，指甲外，全身各器官均可发生，但以肺结核最为多见。 典型病变—结核结节形成和干酪样坏死结核病的基本病变： I. Tuberculosis is a chronic granulomatous disease caused by Mycobacterium tuberculosis. It can occur in all organs of the body except teeth, hair and nails, but is most common in the lungs. Typical lesions - tuberculosis nodule formation and caseous necrosis The basic lesions of tuberculosis:
■ 渗出为主的病变 条件：早期或机体免疫力低下，菌量多，毒力强或变态反应较强时。病变特点：浆液性或浆液纤维素性炎 ▪ Exudate-predominant lesions Conditions: early stage or when the organism is immunocompromised, with high bacterial loads, virulence, or a high degree of metaplasia. Characteristics of lesions: plasma or plasma-fibrinous inflammation
早期（24h）局部嗜中性粒细胞浸润，后为巨噬细胞。在渗出液和巨噬细胞中可查见结核杆菌。好发部位：肺，浆膜，滑膜和脑膜等处 转归：可完全吸收不留痕迹，或转变为以增生为主或以坏死为主的病变。 Early (24h) localized neutrophilic infiltration followed by macrophages. Mycobacterium tuberculosis can be found in the exudate and macrophages. Prevalent sites: lungs, plasma membrane, synovium and meninges etc. Regression: may be completely absorbed and leave no trace, or transformed into a predominantly hyperplastic or necrotic lesion.
■ 增生为主的病变 条件：菌量少，毒力较低或人体免疫反应较强时。 ■ Proliferation-dominant lesions Conditions: when the bacterial load is low, virulence is low, or the body's immune response is strong.
病变特点：增生为主的变化，形成具有诊断价值的结核结节（tubercle） Characteristics of the lesion: hyperplasia-predominant changes, formation of tuberculous nodules with diagnostic value (tubercle)
典型结核结节组成：中央：干酪样坏死 Typical tuberculous nodule composition: center: caseous necrosis
周围：呈放射状排列的类上皮细胞＋Langhans 巨细胞＋纤维母细胞＋淋巴细胞 Periphery: radially arranged epithelioid cells + Langhans giant cells + fibroblasts + lymphocytes
■ 坏死为主的病变 条件：菌量多，毒力强，机体抵抗力低或变态反应强；以渗出或增生为主的病变均可继发干酪样坏死。 ■ Necrosis-predominant lesions Conditions: high bacterial load, high virulence, low body resistance or high metaplasia; exudative or hyperplastic-predominant lesions can all be followed by caseous necrosis.
病变特点：干酪样坏死（caseous necrosis）大体：结核坏死灶由于含脂质较多呈淡黄色，均匀细淢，质地较实，状似奶酪。 镜下：细胞坏死，崩解，为红染无结构的颗粒状物。 Characteristics of lesions: caseous necrosis (caseous necrosis): tuberculosis necrosis foci are yellowish due to the high lipid content, uniformly fine moat, solid texture, like cheese. Microscopy: cell necrosis, disintegration, for red staining structureless granular material.
肺结核病 tuberculosis
原发性肺结核病：指机体初次感染结核杆菌而发生的肺结核病。 Primary tuberculosis: tuberculosis that occurs when the organism is first infected with Mycobacterium tuberculosis.
病理特征：原发综合征（primary complex）初次感染结核杆菌出现的病变 Pathologic features: primary complex (primary complex) first infection with Mycobacterium tuberculosis lesions
肺内原发病灶＋淋巴管炎＋肺门淋巴结结核 X 线呈哑铃状。 Primary lesion in the lung + lymphadenitis + hilar lymph node tuberculosis X-ray is dumbbell shaped.
支气管播散：干酪性肺炎 淋巴道播散：广泛淋巴结结核 血道播散：全身粟粒性结核病继发性肺结核病 特点：病变多开始于肺尖部，而且右肺多见 Bronchial spread: caseous pneumonia Lymphatic spread: extensive lymph node tuberculosis Hematogenous spread: systemic granulomatous tuberculosis Secondary tuberculosis Characteristics: lesions begin in the apical region of the lungs and are more common in the right lungs
病变的类型： Type of lesion:
1．局灶性肺结核：是继发性肺结核病的早期病变。属非活动性结核病，常无自觉症状。 1. Focal tuberculosis: It is the early lesion of secondary tuberculosis. It is inactive tuberculosis and often has no conscious symptoms.
X 线：肺尖部有单个或多个结节状病灶，多位于肺尖，右肺多见。 镜下：病变以增生为主，中央为干酪样坏死 X-ray: single or multiple nodular lesions in the apices of the lungs, mostly located in the apices, more common in the right lung. Microscopy: the lesions are predominantly hyperplastic with a central caseous necrosis
2．浸润性肺结核：临床上最常见的类型，属于活动性肺结核病，多由局灶型肺结核发展而来。临床：低热，疲乏，盗汗，咳嗽和咯血等。 X 线：锁骨下可见边缘模糊的云絮状阴影 病变：渗出＋干酪样坏死＋炎症包绕 2. Infiltrative tuberculosis: the most common clinical type, belonging to active tuberculosis, mostly developed from focal tuberculosis. Clinical: low-grade fever, fatigue, night sweats, cough and hemoptysis. X-ray: subclavian cloudy shadow with fuzzy edges Lesions: exudate + caseous necrosis + inflammation encapsulation
3．慢性纤维空洞性肺结核：属开放性肺结核，多由浸润型肺结核形成急性空洞的基础上发展而来。临床表现：发热，盗汗，咳嗽，咳痰，咯血，呼吸困难，气短 3. Chronic fibro-cavitary tuberculosis: open tuberculosis, mostly developed on the basis of acute cavities formed by infiltrative tuberculosis. Clinical manifestations: fever, night sweats, cough, sputum, hemoptysis, dyspnea, shortness of breath.
X 线：见一侧或两侧上，中肺一个或多个厚壁空洞互相重叠成蜂窝状 X-ray: one or more thick-walled cavities in one or both upper and middle lungs overlapping each other in a honeycomb pattern
病变特点：大体：肺内有一个或多个厚壁空洞。多位于肺上叶，壁厚可达 1 cm 以上。 Characteristics of the lesion: Grossly: one or more thick-walled cavities in the lungs. Mostly located in the upper lobes of the lungs, the wall thickness can be more than 1 cm.
镜下：内层：干酪样坏死物（大量结核杆菌）中层：结核性肉芽组织 外层：纤维结缔组织病变空洞与支气管相通，成为结核病的传染源，故此型又称开放性肺结核 Microscopy: inner layer: caseous necrotic material (large number of tubercle bacilli) middle layer: tuberculous granulation tissue outer layer: fibrous connective tissue lesions cavities and bronchial tubes are connected to the source of tuberculosis infection, so this type is also known as open tuberculosis
并发症：咯血，气胸或脓气胸，喉结核，肠结核，肺心病 Complications: hemoptysis, pneumothorax or pyothorax, laryngeal tuberculosis, intestinal tuberculosis, pulmonary heart disease
4．干酪性肺炎 临床表现：起病急，病情危重，中毒症状明显，病死率高，故有＂百日疼＂或＂奔马疼＂之称 4. Caseous pneumonia Clinical manifestations: acute onset, critical condition, obvious symptoms of poisoning, high mortality rate, so there is a "hundred days of pain" or "galloping horse pain" called
5．结核球或结核瘤（tuberculoma） 5. Tuberculosis nodules or tuberculoma
大体：直径 2∼5cm2 \sim 5 \mathrm{~cm} ，有纤维包裹的孤立的境界分明的干酪样坏死灶。单个或多个。 X 片上有时很难与周围型肺癌相鉴别。 Gross: isolated well-defined foci of caseous necrosis 2∼5cm2 \sim 5 \mathrm{~cm} in diameter, with fibrous encapsulation. Single or multiple. Sometimes difficult to distinguish from peripheral lung cancer on X-ray.
镜下：结节中央为干酪样坏死，可见钙盐沉积，周围为玻璃样变的结缔组织，内层可见结核性肉芽组织结构。 Microscopically: the nodule is centrally caseous necrotic with visible calcium salt deposits, surrounded by vitreous degeneration of the connective tissue, with tuberculous granulation tissue structures visible in the inner layers.
结核球由于其纤维包膜的存在，抗㾤药不易发挥作用，且有恶化进展的可能。 Due to the presence of its fibrous envelope, tuberculosis balls are not easily acted upon by antituberculosis drugs and have the potential to deteriorate and progress.
6．结核性胸膜炎 湿性结核性胸膜炎，干性（增生性）结核性胸膜炎 6. Tuberculous pleurisy Wet tuberculous pleurisy, dry (proliferative) tuberculous pleurisy
肺结核病血源播散所致病变：急性全身粟粒性结核病，慢性全身性粟粒性结核病，急性肺粟粒性结核病，慢性肺粟粒性结核病，肺外结核病 Lesions due to hematogenous dissemination of tuberculosis: acute systemic granulomatous tuberculosis, chronic systemic granulomatous tuberculosis, acute pulmonary granulomatous tuberculosis, chronic pulmonary granulomatous tuberculosis, extrapulmonary tuberculosis
肺外结核病 extrapulmonary tuberculosis
（一）肠结核病 发生于回盲部 溃疡型：典型的肠结核溃疡，多呈环形，其长轴与肠腔长轴垂 (i) Intestinal tuberculosis (TB) occurring in the ileocecal region Ulcerative type: typical TB ulcers of the intestines, mostly circular in shape, with their long axis perpendicular to that of the intestinal lumen.
直。 增生型—较少见 Straight. Proliferative - less common
（二）结核性腹膜炎 湿性——结核性浆液性渗出引起大量腹水为特征 临床：腹痛，腹胀，腹泻和结核中毒症状 (ii) Tuberculous peritonitis Wet - tuberculous plasmacytosis exudate causing large amounts of ascites characterized Clinical: abdominal pain, abdominal distension, diarrhea and symptoms of tuberculosis toxicity
干性——大量纤维素性渗出物，机化后引起腹腔脏器的广泛粘连。临床：肠梗阻，腹部扪及包块 Dry - large amount of fibrinous exudate, which when machined causes extensive adhesions to the abdominal organs. Clinical: intestinal obstruction, abdominal palpation of a mass
（三）结核性脑膜炎 镜下：蛛网膜下腔内炎性渗出物组成：浆液＋纤维素＋巨噬细胞＋淋巴细胞 (III) Tuberculous meningitis: microscopy: composition of inflammatory exudate in the subarachnoid space: plasma + fibrin + macrophages + lymphocytes
（四）泌尿生殖系统结核病 (iv) Tuberculosis of the genitourinary system
（五）骨与关节结核病 坏死物液化后在骨旁形成结核性＂脓肿＂，由于局部并无红，热，痛，故又称＂冷脓肿＂ (e) Tuberculosis of bones and joints A tuberculous "abscess" is formed next to the bone after liquefaction of the necrotic material, which is also known as "cold abscess" because of the lack of local redness, heat and pain.
（六）淋巴结结核病 (vi) Tuberculosis of the lymph nodes
二．伤寒：是由伤寒杆菌引起的急性传染病。 II. Typhoid: It is an acute infectious disease caused by the typhoid bacillus.
病变特征：全身单核巨噬细胞系统细胞的增生。 部位：以回肠末端淋巴组织，肠系膜淋巴结的病变最为突出。 Characteristics of the lesion: proliferation of cells of the mononuclear macrophage system throughout the body. Sites: The most prominent lesions are in the lymphoid tissue of the terminal ileum, and in the mesenteric lymph nodes.
临床主要表现：持续高热，相对缓脉，脾肿大，皮肤玫瑰疹及中性，嗜酸性粒细胞 darr\downarrow 。 The main clinical manifestations: persistent high fever, relatively bradypnea, splenomegaly, skin roseola and neutrophils and eosinophils darr\downarrow .
病理变化：伤寒杆菌引起的炎症是以巨噬细胞增生为特征的急性增生性炎。 PATHOLOGICAL CHANGES: The inflammation caused by S. typhi is an acute proliferative inflammation characterized by macrophage proliferation.
伤寒细胞：增生活跃时巨噬细胞胞浆内每吞啫有伤寒杆菌，红细胞和细胞碎片，以吞噬红细胞的作用尤为明显。这种巨噬细胞称～。 Typhoid cells: When hyperplastic, the cytoplasm of the macrophage is permeated with typhoid bacilli, erythrocytes, and cellular debris, with phagocytosis of erythrocytes being particularly pronounced. This macrophage is called ~.
伤寒小结：伤寒细胞常聚集成团，形成小结节称伤寒肉芽肿或伤寒小结（typhoid nodule），是伤寒的特征性病变，具有病理诊断价值。 Typhoid nodule: typhoid cells often gather into clusters, forming small nodules called typhoid granuloma or typhoid nodule (typhoid nodule), is a characteristic lesion of typhoid fever, with pathological diagnostic value.
临床病理联系：1．肠道病变（1）髓样肿胀期（2）坏死期（3）溃疡期 Clinicopathologic associations: 1. Intestinal lesions (1) medullary swelling stage (2) necrotic stage (3) ulcerative stage
溃疡特点：外形与淋巴小结的分布及形态一致，呈圆或椭圆形，溃疡的长径与肠管纵轴平行，此为伤寒溃疡的特点 Characteristics of ulcers: the shape is consistent with the distribution and morphology of lymph nodes, round or oval, and the longitudinal diameter of the ulcer is parallel to the longitudinal axis of the intestinal canal, which is a characteristic of typhoid ulcers
（4）愈合期：由于病灶的长径与肠管纵轴相平行，故不致肠狭窄。 (4) Healing phase: Since the longitudinal diameter of the lesion is parallel to the longitudinal axis of the intestinal canal, there is no intestinal stenosis.
并发症：肠穿孔，肠出血，支气管肺炎 Complications: intestinal perforation, intestinal hemorrhage, bronchopneumonia
三．细菌性痢疾：简称菌痢，是由痢疾杆菌所引起一种假膜性肠炎。 III. Bacterial dysentery: referred to as bacillary dysentery, is caused by dysentery bacillus a pseudomembranous enteritis.
（1）病变多局限于结肠，以大量纤维素渗出形成假膜为特征，假膜脱落伴有不规则浅表溃疡形成。 (1) The lesions are mostly confined to the colon and are characterized by the formation of a pseudomembrane by exudation of a large amount of cellulose, which is dislodged accompanied by the formation of irregular superficial ulcers.
（2）临床主要表现为腹痛，腹泻，里急后重，粘液脓血便。 (2) The main clinical manifestations are abdominal pain, diarrhea, urgency, and mucus, pus, and blood in the stool.
1．急性细菌性痢疾（1）初期：粘液分泌元进，粘膜充血，水肿，中性粒细胞和巨噬细胞浸润。可见点状出血。 1. Acute bacillary dysentery (1) Initial stage: mucus secretion, mucosal congestion, edema, neutrophil and macrophage infiltration. Punctate hemorrhage can be seen.
（2）后期：粘膜浅表坏死，在渗出物中有大量纤维素，并与坏死组织，炎症细胞和红细胞及细菌一起形成特征性的假膜，呈㻖皮状。假膜脱落，形成大小不等，形状不一的＂地图状＂溃疡。 (2) Late stage: superficial necrosis of the mucosa, a large amount of cellulose in the exudate, and with necrotic tissue, inflammatory cells and erythrocytes and bacteria to form a characteristic pseudomembrane, in the form of 㻖 skin. Pseudomembrane detachment, the formation of different sizes and shapes of "map-like" ulcers.
（3）愈合期：渗出物和坏死组织逐渐被吸收，排出，经周围健康组织再生缺损得以修复。 (3) Healing period: exudate and necrotic tissue are gradually absorbed and discharged, and the defect is repaired by regeneration of the surrounding healthy tissue.
2．慢性细菌性痢疾：病程 >> 二个月以上者 2. Chronic bacillary dysentery: duration of illness >> more than two months
病理改变：（1）肠道病变此起彼伏，原有溃疡尚未愈合，新的溃疡又形成。因此新旧病灶同时存在。 （2）组织的损伤修复反复进行，慢性溃疡边缘不规则，粘膜常过度增生 rarr\rightarrow 息肉。 PATHOLOGICAL CHANGES: (1) The intestinal lesions come one after the other, with new ulcers forming before the original ulcers have healed. Thus old and new lesions coexist. (2) Repeated damage repair of tissues, chronic ulcers with irregular edges, mucosa often overgrown rarr\rightarrow polyps.
3．中毒型细菌性痢疾 3. Toxic bacillary dysentery
五．梅毒：是由梅毒苍白螺旋体引起的慢性传染病，是性传播疾病中危害性较严重的一种，其危害性仅次于 AIDS V. Syphilis: a chronic infectious disease caused by the syphilitic spirochete, is a more serious form of sexually transmitted diseases, second only to AIDS.
病理变化：1．增生性动脉内膜炎和小血管周围炎 灶性闭塞性动脉内膜炎：动脉管壁增厚，管腔狭窄。血管周围炎：围管性的 L，M，浆细胞浸润，浆细胞恒定出现。 Pathologic changes: 1. Proliferative endarteritis and perivascular inflammation of small vessels Focal occlusive endarteritis: thickening of the arterial wall and narrowing of the lumen. Perivasculitis: peritubular L, M, plasma cell infiltration, constant presence of plasma cells.
2．树胶样肿（gumma）又称梅毒瘤（syphiloma）是第三期梅毒的特征性病变 2. Gumma, also known as syphiloma, is a characteristic lesion of stage III syphilis.
镜下结构颇似结核结节，中央为凝固性坏死，形态类似干酪样坏死，但坏死不如干酪样坏死彻底，弹力纤维尚保存。外层有淋巴细胞和浆细胞浸润，而上皮样细胞和郎罕巨细胞较少．绝少钙化 Microscopically, the structure is quite similar to that of tuberculosis nodules, with coagulative necrosis in the center, similar to caseous necrosis, but the necrosis is not as complete as that of caseous necrosis, and the elastic fibers are still preserved. The outer layer is infiltrated by lymphocytes and plasma cells, while epithelioid cells and Langham's giant cells are rare. Calcification is rare.
后天性梅毒：一，二期梅毒称早期梅毒，有传染性。三期梅毒又称晚期梅毒，因常累及内脏，故又称内脏梅毒。 Acquired syphilis: Stage I and II syphilis are called early syphilis and are infectious. Stage III syphilis is also known as late syphilis, because it often involves the internal organs, so it is also known as visceral syphilis.
第一期梅毒：主要是硬性下疸的形成，有大量梅毒螺旋体，传染性极强 Stage 1 syphilis: mainly the formation of sclerosing jaundice, with a large number of syphilitic spirochetes, extremely contagious
第二期梅毒：硬下疳发生 3∼43 \sim 4 周后，引起全身皮肤，粘膜广泛的梅毒疹和全身性非特异性淋巴结肿大。 Stage 2 syphilis: the chancre occurs 3∼43 \sim 4 weeks after the onset of the chancre, causing a widespread syphilitic rash on the skin and mucous membranes and generalized nonspecific lymph node enlargement.
第三期梅毒：常发生于感染 4∼54 \sim 5 年后，病变累及内脏，特别是心血管和中枢神经系统．有特征性 Stage 3 syphilis: usually occurs 4∼54 \sim 5 years after infection and involves internal organs, especially the cardiovascular and central nervous systems. Characteristic
的树胶肿形成 Gummy formation
六．艾滋病（AIDS ）：又称获得性免疫缺陷综合征 VI. AIDS: also known as Acquired Immunodeficiency Syndrome
由 HIV 感染所致的慢性传染病；通过性接触或血及血液制品传播； Chronic infectious disease caused by HIV infection; transmitted through sexual contact or blood and blood products;
病毒主要侵犯和破坏 CD4＋T 细胞，造成机体细胞免疫功能缺陷； The virus mainly invades and destroys CD4+ T cells, causing defects in the body's cellular immunity;
表现：全身淋巴结肿大，发热，乏力，食欲不振，体重减轻，腹河，盗汗 Presentation: generalized lymph node enlargement, fever, fatigue, loss of appetite, weight loss, abdominal river, night sweats
AIDS 的病理变化：全身淋巴组织的变化，机会感染，恶性肿瘤（Kaposi 肉瘤） Pathologic changes in AIDS: changes in systemic lymphoid tissue, opportunistic infections, malignant tumors (Kaposi's sarcoma).
七．阿米巴病：由溶组织内阿米巴原虫感染引起的一种寄生虫病，主要累及结肠，也可移行到肝，脑，肺及肛周皮肤，泌尿，生殖等器官，临床上常出现腹痛，腹泄等症状，故常称为阿米巴痢疾。 VII. Amebiasis: a parasitic disease caused by ameba protozoa infection in the dissolved tissues, mainly involving the colon, but also can migrate to the liver, brain, lungs and perianal skin, urinary, reproductive and other organs, clinically, often abdominal pain, abdominal discharge and other symptoms, so it is often referred to as amoebic dysentery.
（一）肠阿米巴病 好发部位：以盲肠，升结肠 主要病变：肠壁组织液化性坏死并形成溃疡及肠出血，穿孔。烧瓶状溃疡，口小底大，边缘潜行的溃疡，邻近者可形成窦道，形成大片溃疡及肠出血，肠穿孔。 (A) intestinal amebiasis Prevalent parts: cecum, ascending colon Main lesions: intestinal wall tissue liquefaction necrosis and the formation of ulcers and intestinal bleeding, perforation. Flask-shaped ulcers, small mouth and large base, the edge of the ulcer submerged, adjacent to the formation of sinus tracts, the formation of large ulcers and intestinal hemorrhage, intestinal perforation.
临床表现：轻度腹河，腹痛，大便含粘液，血液及坏死组织，暗红色果酱样大便，可出现肠梗阻症状。 Clinical manifestations: mild abdominal river, abdominal pain, stools containing mucus, blood and necrotic tissue, dark red jam-like stools, and symptoms of intestinal obstruction may occur.
（二）肠外阿米巴病 (ii) Parenteral amebiasis
1．阿米巴肝脓肿：途径：肠壁小 vv－肠系膜 v－门 v－肝 大体：脓肿壁呈破絮状外观。 1. Amebic liver abscess: pathway: intestinal wall small vv - mesentery v-portal v-hepatic large body: abscess wall has a ragged flocculent appearance.
镜下：脓肿壁见未彻底溶化坏死组织及少许炎细胞，边缘活组织中可见滋养体。周围可有肉芽组织及纤维包裏形成。2．肺脓肿 3．脑脓肿 Microscopy: the wall of the abscess shows incompletely dissolved necrotic tissue and a few inflammatory cells, and trophoblasts can be seen in the biopsy at the edge. There may be granulation tissue and fibrous envelope formation around the abscess. 2. lung abscess 3. brain abscess
八．血吸虫病：由血吸虫寄生于人体所引起的地方性寄生虫病。 病理特点：形成血吸虫虫卵结节 VIII. Schistosomiasis: endemic parasitic disease caused by schistosomes parasitizing the human body. Pathological characteristics: the formation of schistosome eggs nodules
临床表现：发热，腹泻，肝肿大，晚期可致肝硬化（干线型肝硬变）及门脉高压。 Clinical manifestations: fever, diarrhea, hepatomegaly, advanced cirrhosis (dry-line liver cirrhosis) and portal hypertension.
感染阶段：尾蚴 感染方式：经皮肤感染 寄生部位：成虫主要寄生于肠系膜下静脉血管内中间宿主：钉螺 Stage of infection: caecilians Mode of infection: transdermal Parasites: adult worms mainly parasitize in the blood vessels of the inferior mesenteric vein Intermediate host: nail snails
主要致病虫期：虫卵导致的免疫反应 Main pathogenic stages: immune response due to eggs
虫卵引起的变化：部位：主要为乙状结肠，直肠壁及肝 Changes caused by eggs: Site: mainly sigmoid colon, rectal wall and liver
（1）急性虫卵结节：肉眼：灰黄色，粟粒及绿豆大小结节。 (1) Acute worm egg nodules: naked eye: grayish-yellow, corn and mung bean-sized nodules.
镜下：中央见 1∼21 \sim 2 个成熟虫卵，虫卵卵壳上见嗜酸性棒状体，为抗原抗体复合物。 Microscopy: 1∼21 \sim 2 a mature worm egg is seen in the center and eosinophilic rods are seen on the egg shell as antigen-antibody complexes.
虫卵周围为无结构颗粒状坏死物质及大量嗜酸性粒细胞浸润叫做啫酸性脓肿。 A structureless granular necrotic material surrounded by worm eggs and infiltrated by a large number of eosinophils is called a gelatinous abscess.
（2）慢性虫卵结节：急性虫卵结节十天后，毛蚴死亡，坏死物质被吸收，虫卵破裂或钙化，其周围除类上皮细胞外，出现异物巨细胞和淋巴细胞，形态上似结核结节，称为假结核结节。 (2) Chronic worm-egg nodules: after ten days of acute worm-egg nodules, the trichinae die, the necrotic material is absorbed, the worm-eggs rupture or calcify, and in addition to epithelioid-like cells, foreign giant cells and lymphocytes appear around them, which morphologically resemble tuberculous nodules and are known as pseudotuberculous nodules.
干线型肝硬变：见于血吸虫病时，硬变的肝脏表面有散在的浅沟纹，将肝表面划分成大小不等及不整形微突之分区，严重者可形成粗大突起结节。切面上，沿门静脉分枝增生的纤维组织呈树枝状分布，故有干线型肝硬变之称。 Stem line type hepatic cirrhosis: seen in schistosomiasis, the surface of the cirrhotic liver has scattered shallow grooves, dividing the surface of the liver into different sizes and shapeless microtuberculous partitions, and in severe cases, coarse protruding nodules can be formed. On the cut surface, the fibrous tissue proliferating along the portal vein branches is distributed in the form of dendrites, so it has the name of trunk type liver cirrhosis.
九．流行性脑脊髓膜炎：由脑膜炎双球菌感染引起的脑脊髓膜的急性化脓性炎。 IX. Epidemic cerebrospinal meningitis: acute suppurative inflammation of the cerebrospinal membrane caused by meningococcal infection.
主要临床表现：高热，头痛，频繁呕吐，皮肤粘膜淤点和脑膜刺激征，重者可有败血症休克及脑实质损害。脑脊液呈化脓性改变。 Main clinical manifestations: high fever, headache, frequent vomiting, skin and mucous membrane bruises and signs of meningeal irritation, septic shock and brain parenchyma damage in severe cases. Cerebrospinal fluid shows purulent changes.
累及人群：多为儿童及青少年 Involvement: mostly children and adolescents
病理变化：上呼吸道感染期：粘膜充血，水肿 败血症期：粘膜游斑 脑膜炎症期 Pathologic changes: upper respiratory tract infection stage: mucosal congestion, edema Septicemia stage: mucosal free spots Meningitis stage
病理学改变：大体：脑脊膜血管高度充血，蛛网膜下腔充满灰黄色脓性渗出物。 Pathologic changes: gross: cerebrospinal vessels are highly congested and the subarachnoid space is filled with gray-yellow purulent exudate.
镜下：蛛网膜下腔增宽，其中有大量中性粒细胞及纤维蛋白渗出和单核细胞，淋巴细胞浸润。 Microscopy: widening of the subarachnoid space, which is infiltrated with large numbers of neutrophils and fibrin exudates and monocytes, lymphocytes.
临床表现：颎内压升高，脑膜刺激症和颅神经麻痹。 CLINICAL PRESENTATIONS: Elevated intra-blaze pressure, meningeal irritation, and cranial nerve palsy.
临床病理联系：1．发热。 2．神经系统症状：a．颅内压升高症状：头痛，喷射性呕吐 b．月㐫膜刺 Clinicopathologic associations: 1. Fever. 2. Neurologic symptoms: a. Symptoms of elevated intracranial pressure: headache, projectile vomiting b. Lunar 㐫 membranous spikes
激症状：颈项强直。 c．颎神经麻痹 d．脑脊液的变化：压力上升，混浊不清 Radical symptoms: cervical rigidity. c. Blaze nerve palsy d. Changes in cerebrospinal fluid: increased pressure, cloudiness
十．流行性乙型脑炎：是乙型脑炎病毒感染引起的以脑实质（灰质，基底核，视丘）炎症为主要病变的中枢神经系统的急性传染病。 变质性炎临床特点：急性起病，高热，嗜睡，抽搐，昏迷 传播媒介为蚊 X. Epidemic encephalitis B: it is an acute infectious disease of the central nervous system caused by encephalitis B virus infection with inflammation of the brain parenchyma (gray matter, basal nuclei, optic thalamus) as the main lesion. Metaplasia clinical features: acute onset, high fever, lethargy, convulsions, coma Vector for mosquitoes
病理变化：大体：脑膜充血，脑水肿明显，脑回宽，脑沟变窄。切面见粟粒或针尖大小的软化灶。镜下：A．血管变化和炎症反应：血管扩张，小灶出血；淋巴细胞套 L 为主的炎细胞围绕血管呈袖套状浸润。 PATHOLOGICAL CHANGES: Grossly: meningeal congestion, marked cerebral edema, wide cerebral gyrus, narrowed sulcus. Foci of softening of corn or pinpoint size are seen on section. Microscopy: A. Vascular changes and inflammatory reaction: vasodilatation, small foci of hemorrhage; lymphocytes set L as the main inflammatory cells around the blood vessels in a cuff-like infiltration.
B．神经元变性，坏死：少突胶质细胞环绕一神经元，则称为卫星现象（satellitosis）。 B. Neuronal degeneration, necrosis: When oligodendrocytes surround a neuron, the phenomenon is called satellitosis.
嗜神经细胞现象（neuronophagia）：小胶质细胞及血源性巨噬细胞侵入变性坏死的神经细胞内。 Neuronophagia: invasion of microglia and blood-borne macrophages into degenerating necrotic nerve cells.
C．脑软化灶形成：软化灶为圆形，卵圆形 ，边界清楚，镂空筛网状，为灶性神经组织的坏死液化所致，对本病的诊断具有一定的特征性 C. Cerebral soft foci formation: soft foci are round, ovoid, with clear boundaries, hollow sieve-like, caused by necrosis and liquefaction of focal neural tissues, which is characteristic for the diagnosis of this disease.
D．胶质细胞增生：在小血管或坏死的神经细胞附近，小胶质细胞增生明显，形成小胶质细胞结节临床病理联系：1．嗜睡和昏迷 D. Glial cell proliferation: in the vicinity of small blood vessels or necrotic nerve cells, microglia proliferate markedly, forming microglial cell nodules Clinicopathologic associations: 1. Drowsiness and coma
