This document discusses pathology and methods in general and clinical pathology. It provides definitions of disease and death as basic notions in pathology. It also classifies pathogenic factors and discusses mechanisms of cellular injury, including depletion of ATP, damage to mitochondria, influx of calcium, accumulation of reactive oxygen species, and defects in membrane permeability. Autopsy and biopsy methods used in pathology are described.
At the end of the class the students will be able to,
Explain the basic concept of pathology
Describe the Cellular & tissue changes.
Describe the Infiltration and regeneration
Elaborate the inflammation and infection
Pathophysiology B Pharm 2nd semester
CONTENTS
1. Introduction
2. Course Description
3. Course Outcomes
4. Text and Reference Books
5. Syllabus
6. Question Paper Pattern
7. Evaluation Scheme
Pathophysiology is the study of causes of diseases and reactions of the body to such disease producing causes.
This course is designed to impart a thorough knowledge of the relevant aspects of pathology of various conditions with reference to its pharmacological applications, and understanding of basic pathophysiological mechanisms.
Expected outcomes
1. Describe the etiology and pathogenesis of the selected disease states
2. Name the signs and symptoms of the diseases
3. Mention the complications of the diseases.
SYLLABUS
Basic principles of Cell injury and Adaptation
Introduction, definitions, Homeostasis, Components and Types of Feedback systems, Causes of cellular injury, Pathogenesis (Cell membrane damage, Mitochondrial damage, Ribosome damage, Nuclear damage), Morphology of cell injury – Adaptive changes (Atrophy, Hypertrophy, hyperplasia, Metaplasia, Dysplasia), Cell swelling, Intra cellular accumulation, Calcification, Enzyme leakage and Cell Death Acidosis & Alkalosis, Electrolyte imbalance.
Basic mechanism involved in the process of Inflammation and Repair
Introduction, Clinical signs of inflammation, Different types of Inflammation, Mechanism of Inflammation – Alteration in vascular permeability and blood flow, migration of WBC’s, Mediators of inflammation, Basic principles of wound healing in the skin, Pathophysiology of Atherosclerosis
Cardiovascular System
Hypertension, congestive heart failure, ischemic heart disease (angina, myocardial infarction, atherosclerosis and arteriosclerosis)
Respiratory system
Asthma, Chronic obstructive airways diseases.
Renal system
Acute and chronic renal failure
Haematological Diseases
Iron deficiency, megaloblastic anemia (Vit B12 and folic acid), sickle cell anemia, thalasemia, hereditary acquired anemia, hemophilia
Nervous system
Epilepsy, Parkinson’s disease, stroke, psychiatric disorders: depression, schizophrenia and Alzheimer’s disease.
Endocrine system
Diabetes, thyroid diseases, disorders of sex hormones
Gastrointestinal system
Peptic Ulcer
Inflammatory bowel diseases,
jaundice, hepatitis (A,B,C,D,E,F) alcoholic liver disease
Diseases of bones and joints
Rheumatoid Arthritis, Osteoporosis, Gout
Principles of cancer
classification, etiology and pathogenesis of cancer
Infectious diseases
Meningitis, Typhoid, Leprosy, Tuberculosis, Urinary tract infections
Sexually transmitted diseases (STDs)
AIDS, Syphilis, Gonorrhea
#rohitkumartrivedi
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1. The subject of pathology.
Methods in the general and clinical
pathology.
Basic notions – disease/death.
Classification of the pathogenic
factors.
Radina Ivanova, MD, PhD
Associate Professor of PathologyAssociate Professor of Pathology
Medical University of SofiaMedical University of Sofia
2. Synopsis
Subject of pathological anatomy. General and
clinical pathology.
Main notions in pathology. Biopsy and
necropsy methods.
Biopsy examination in different ways of
obtaining material and tissue processing.
Cellular injuries – etiology.
General mechanisms of cellular injury –
ischemia and hypoxia.
General mechanisms of cellular injury - free
radicals injury.
4. PATHOLOGY
Hartman (19th
century)
theory of the diseases
It involves the investigation of the causes
(etiology) of disease as well as the
underlying mechanisms (pathogenesis) that
result in the presenting signs and symptoms
of the patient
to understand structural and functional changes
in cells, tissues and organs
6. Rudolph Virchow
1821-1902
The Father of
Modern Pathology
• “All diseases are the results of
visible cell abnormalities”, i.e.,
abnormal histology, i.e.,
histopathology.
History of pathology
• Morgagni, 1761- founder of pathological anatomy
• Bishat, 1800 – founder of pathological histology
7. PATHOLOGY
GENERAL
fundamental cellular and tissue responses
to pathologic stimuli.
E.g.. Inflammation, cancer, ageing.
SYSTEMIC
particular responses of specialized organs
E.g.. Goiter, pneumonia, breast cancer.
9. What is Disease?
dis + ease (not at ease…)
Disease
“Expression of discomfort due to structural or
functional abnormality”
Health
Complete physical, mental and social well being,
not merely absence of disease…
10. What is Disease?
Disease
A condition of impaired dynamic equilibrium of the
organism with the environment
Biologic processes in which the function and structure of the
organs are abnormal
Health
A condition of dynamic equilibrium of the organism with the
environment
Homeostasis – internal equilibrium of different organs and
systems
11. Disease Types:
Inflammatory / Neoplastic / Degenerative
Acute / Chronic
Acute – short days to weeks.
Chronic – long, months to years.
Congenital / Familial / Acquired
Genetic / Environmental
Mild / Moderate / Severe
13. Etiology: What is the cause?
Environmental agents
Physical
Chemical
Nutritional
Infections
Immunological
Psychological
Genetic Factors
Multifactorial:Multifactorial:
Diabetes,Diabetes,
HypertensionHypertension
CancerCancer
14. One agentOne agent One diseaseOne disease - Malaria- Malaria
Several agentsSeveral agents One diseaseOne disease -- DiabetesDiabetes
One agentOne agent Several diseasesSeveral diseases - Smoking- Smoking
Disease
Disease
Disease
DiseaseDisease
15. Pathogenesis
Development (underlying mechanisms)
“Sequence of events in the cells and tissues to a
stimulus/pathogen” starting from the initial
stimulus to the ultimate expression of disease.”
16. Morphology
To render diagnoses, pathologists identify:
changes in the gross or microscopic appearance
(morphology) of cells and tissues
Other changes (molecular)
17. Clinical Significance
Patient Signs and symptoms are related to
underlying pathology…
Prognosis of disease depends on inside
pathology
Is he going to recover or die soon?
Guided therapy
What treatment is suitable for this patient?
18. Outcome of disease
Restitutio ad integrum (recovery)
Substitutio (not fully recovery,
chronic disease)
Death
19. What is death?
Clinical death-minutes
medical term for cessation of blood
circulation and breathing
cardiopulmonary resuscutation
Biological death
irreversible cessation of circulatory and
respiratory functions and of all functions of
the entire brain (areflexia)
20. Late signs of death
Algor mortis -cooling of the body after death
Depends on body temperature at the time of death and
environmental temperature
Livor mortis –discoloration
the red-purple discoloration caused by the settling of the
blood in the dependent portions of the body due to gravity
Rigor mortis
the stiffening of the muscles after death due to chemical
changes in the muscle fibers (depletion of ATP, lowered pH)
The decomposition of a body – several stages
2-3 days -green staining on the right side of the abdomen,
smell
21. Methods in the general and
clinical pathology
Autopsy
hospital (pathologo-anathomic)
performed by pathologists in hospitalized patients who
died of natural causes
forensic
investigate the death in cases of violence or presumed
violence
Biopsy
histological
cytological
22. Autopsy
Aims
to identify the cause of death
to clarify cases without clinical diagnosis or in those in
which the patient death was unexpected
recognition of the effect of the treatment in the evolution
of the disease.
recognition of new diseases and of new lesion patterns
source of information, allowing the making of precise
statistics on the most frequent diseases
material for the residents, students and staff learning
material for scientific research.
28. 1. Hypoxia
= or oxygen deficiency
an extremely important and common cause of cell
injury and death.
should be distinguished from ischemia ( a loss of
blood supply in a tissue due to impeded arterial flow
or reduced venous drainage).
Reasons for oxygen deprivation
Ischemia
inadequate oxygenation of the blood (pneumonia)
reduction in the oxygen-carrying capacity of the
blood (anemia)
carbon monoxide (CO) poisoning (CO forms a stable
complex with hemoglobin that prevents oxygen
binding.)
29. 2. Chemical Agents
An enormous number of chemical substances can
injure cells
Concentrated glucose or salt
Oxygen at sufficiently high partial pressures
Poisons and potentially toxic agents (air pollutants,
insecticides, CO, ethanol)
Therapeutic drugs
if used excessively or inappropriately
30. Pathogenic factors
3. Physical Agents
Trauma, extremes of temperatures, radiation, electric
shock, sudden changes in atmospheric pressure
4. Infectious Agents
Viruses, tapeworms, rickettsiaes, bacteria, fungi,
protozoas.
5. Immunologic Reactions
autoimmune reactions against one's own tissues
allergic reactions against environmental substances in
genetically susceptible individuals
31. Pathogenic factors
6. Nutritional Imbalances
Nutritional deficiencies - protein-calorie insufficiency,
specific vitamin deficiencies
Excesses of nutrition
obesity –DM
diets rich in animal fat - atherosclerosis
7. Genetic Defects
congenital malformations associated with Down
syndrome, sickle cell anemia
deficiency of functional proteins -enzymes in inborn
errors of metabolism
8. Aging
alterations in replicative and repair abilities of individual
cells and tissues
32. Cellular responses to stress and
pathogenic factors
Normal cells have a
fairly narrow range of
function or steady state
Homeostasis
Excess physiologic or
pathologic stress may
force the cell to a new
steady state
Adaptation
Too much stress
exceeds the cell’s
adaptive capacity
Injury
33. Cell injury
Reversible/Irreversible
Reversibility depends
on the type, severity
and duration of injury
Cell death is the result
of irreversible injury
Responses of the heart to different types of
stress:
• Hypertension – hypertrophy (adaptation)
• Ischemia
•incomplete occluded coronary artery – cell injury
•complete or prolonged occlusion – cell death
34. Mechanisms of cell injury
1. Depletion of ATP
2. Damage to Mitochondria
3. Influx of Calcium
4. Accumulation of Oxygen-Derived Free Radicals (Oxidative Stress)
5. Defects in Membrane Permeability
5. Damage to DNA and Proteins
35. 1. Depletion of ATP
ATP - the energy store of cells
required for almost all
synthetic and degradative
processes within the cell
membrane transport, protein
synthesis, lipogenesis
The major causes of ATP
depletion
reduced supply of oxygen and
nutrients,
mitochondrial damage,
toxins (e.g., cyanide).
36. 2. Damage to Mitochondria
Mitochondria -critical players in cell
injury and death.
Mitochondria can be damaged by
↑ cytosolic Ca2+,
reactive oxygen species (ROS)
oxygen deprivation (hypoxia, toxins).
Two major consequences of
mitochondrial damage:
loss of mitochondrial membrane potential and
pH changes, resulting in failure of oxidative
phosphorylation and progressive depletion of
ATP
leakage of cytochrome c and other proteins
into the cytosol and death by apoptosis.
37. 3. Influx of Calcium
Increased cytosolic Ca++
activates a number of enzymes,
with potentially deleterious cellular
effects
induction of apoptosis by direct
activation of caspases and by
increasing mitochondrial
permeability
Increase in cytosolic Ca++
by:
increased influx across the
plasma membrane
ischemia and certain toxins
release of Ca2+ from the
intracellular stores
38. 4. Accumulation of Oxygen-Derived Free
Radicals (Oxidative Stress)
Free radicals have an unpaired electron in their outer orbit
cause autocatalytic reactions (molecules that react with free radicals
are in turn converted into free radicals, thus propagating the chain of
damage)
Oxidative stress – a condition called in ↑ production of
ROS or ↓ degradation - an excess of free radicals
Generated by:
Absorption of radiant energy
Oxidation of endogenous and exogenous compounds
Oxidation of exogenous compounds
39. 4. Accumulation of Oxygen-Derived Free
Radicals (Oxidative Stress)
Reactions relevant for
cell injury by ROS
Lipid peroxidation
damage to cellular and
organellar membranes
Protein cross-linking and
fragmentation due to
oxidative modification of
amino acids and proteins
DNA damage due to
reactions of free radicals
with thymine
40. 5. Defects in Membrane Permeability
The plasma membrane can be
damaged by:
ischemia,
various microbial toxins,
lytic complement components,
physical and chemical agents.
The most important sites of
membrane damage during cell injury
are:
Mitochondrial membrane damage
Plasma membrane damage
leads to loss of osmotic balance and influx
of fluids and ions, as well as loss of cellular
contents.
Injury to lysosomal membranes
leads to leakage of their enzymes into the
cytoplasm and enzymatic digestion of cell
components, necrosis.
41. 6. Damage to DNA and Proteins
Damage to DNA and
proteins in:
radiation injury
oxidative stress,
inherited mutations
Cells have mechanisms
that repair damage to DNA
if this damage is too
severe to be corrected the
cell initiates its suicide
program and dies by
apoptosis.
44. General mechanism of cellular injury
in hypoxia and ischemia
↓ intracellular generation of ATP
failure of many energy-
dependent cellular systems
ion pumps
depletion of glycogen stores,
with accumulation of lactic acid
and lowering the intracellular
pH
reduction in protein synthesis
If hypoxia continues, worsening
ATP depletion causes further
deterioration
If oxygen is restored, all of these
disturbances are reversible.
If ischemia persists, irreversible
injury and necrosis ensue.
Editor's Notes
Literally translated, pathology is the study (logos) of suffering (pathos).
ATP, the energy store of cells, is produced mainly by oxidative phosphorylation of adenosine diphosphate (ADP) during reduction of oxygen in the electron transport system of mitochondria. In addition, the glycolytic pathway can generate ATP in the absence of oxygen using glucose derived either from the circulation or from the hydrolysis of intracellular glycogen. The major causes of ATP depletion are reduced supply of oxygen and nutrients, mitochondrial damage, and the actions of some toxins (e.g., cyanide). Tissues with a greater glycolytic capacity (e.g., the liver) are able to survive loss of oxygen and decreased oxidative phosphorylation better than are tissues with limited capacity for glycolysis (e.g., the brain). High-energy phosphate in the form of ATP is required for virtually all synthetic and degradative processes within the cell, including membrane transport, protein synthesis, lipogenesis, and the deacylation-reacylation reactions necessary for phospholipid turnover. Depletion of ATP to less than 5% to 10% of normal levels has widespread effects on many critical cellular systems (Fig. 1-17).
The activity of the plasma membrane energy-dependent sodium pump is reduced, resulting in intracellular accumulation of sodium and efflux of potassium. The net gain of solute is accompanied by iso-osmotic gain of water, causing cell swelling and dilation of the ER.There is a compensatory increase in anaerobic glycolysis in an attempt to maintain the cell's energy sources. As a consequence, intracellular glycogen stores are rapidly depleted, and lactic acid accumulates, leading to decreased intracellular pH and decreased activity of many cellular enzymes.Failure of the Ca2+ pump leads to influx of Ca2+, with damaging effects on numerous cellular components, described below.Prolonged or worsening depletion of ATP causes structural disruption of the protein synthetic apparatus, manifested as detachment of ribosomes from the rough endoplastic reticulum (RER) and dissociation of polysomes into monosomes, with a consequent reduction in protein synthesis. Ultimately, there is irreversible damage to mitochondrial and lysosomal membranes, and the cell undergoes necrosis.
The plasma membrane can be damaged by:
ischemia,
various microbial toxins,
lytic complement components,
a variety of physical and chemical agents.
Several biochemical mechanisms may contribute to membrane damage
Decreased phospholipid synthesis. The production of phospholipids in cells may be reduced whenever there is a fall in ATP levels, leading to decreased energy-dependent enzymatic activities. The reduced phospholipid synthesis may affect all cellular membranes including the mitochondria themselves, thus exacerbating the loss of ATP.Increased phospholipid breakdown. Severe cell injury is associated with increased degradation of membrane phospholipids, probably due to activation of endogenous phospholipases by increased levels of cytosolic Ca2+.
ROS. Oxygen free radicals cause injury to cell membranes by lipid peroxidation, discussed earlier.
Cytoskeletal abnormalities. Cytoskeletal filaments serve as anchors connecting the plasma membrane to the cell interior. Activation of proteases by increased cytosolic Ca2+ may cause damage to elements of the cytoskeleton.
Lipid breakdown products. These include unesterified free fatty acids, acyl carnitine, and lysophospholipids, catabolic products that are known to accumulate in injured cells as a result of phospholipid degradation. They have a detergent effect on membranes. They also either insert into the lipid bilayer of the membrane or exchange with membrane phospholipids, potentially causing changes in permeability and electrophysiologic alterations.
The most important sites of membrane damage during cell injury are:
Mitochondrial membrane damage - decreased production of ATP, culminating in necrosis, and release of proteins that trigger apoptotic death.
Plasma membrane damage - leads to loss of osmotic balance and influx of fluids and ions, as well as loss of cellular contents. The cells may also leak metabolites that are vital for the reconstitution of ATP, thus further depleting energy stores.
Injury to lysosomal membranes results in leakage of their enzymes into the cytoplasm and activation of the acid hydrolases in the acidic intracellular pH of the injured (e.g., ischemic) cell. Lysosomes contain RNases, DNases, proteases, glucosidases, and other enzymes. Activation of these enzymes leads to enzymatic digestion of cell components, and the cells die by necrosis