Nonneoplastic Conditions

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Atherosclerosis: very common and affects the elastic arteries (aorta, carotid, iliac) and large and medium-sized muscular arteries (coronary and popliteal). The vessels show intimal thickening and lipid accumulation producing atheromatous plaques, which may become complicated by calcification, focal rupture or gross ulceration. Debris can be discharged into the bloodstream forming microemboli. Haemorrhage may occur into a plaque or a thrombus may form on the surface, potentially occluding the vessel. With the formation of atheromatous plaques the adjacent media atrophies and aneursymal dilatation may occur.

Hyaline arteriolosclerosis: occurs in the elderly with an increased incidence in hypertension and diabetes. There is thickening of the walls with deposition of pink homogenous material and narrowing of the lumen. Hyperplastic arteriolosis is characteristic of, but not limited to, malignant hypertension.

Vasculitis: inflammation of the walls of blood vessels due to immune-mediated inflammation or to invasion of the wall by pathogenic organisms.

Giant cell arteritis (temporal arteritis): a granulomatous arteritis affecting the aorta and major branches especially the extracranial branches of the carotid artery (temporal, vertebral and ophthalmic arteries). Most commonly there is a granulomatous inflammation of the inner half of the media centred on the internal elastic lamina. Up to 40% of patients with good clinical evidence of cranial arteritis have a negative temporal artery biopsy. The diagnostic histological findings are often also only found focally within an involved segment.

Takayashu arteritis (pulseless disease): a rare granulomatous vasculitis of the aortic arch, its branches and the pulmonary arteries. Morphological changes may be indistinguishable from giant cell arteritis, but the clinical profile differs with the patient usually being female and under the age of forty years but elderly in giant cell arteritis.

Polyarteritis nodosa: a relatively uncommon condition causing necrotising fibrinoid vasculitis of small-to-medium-sized arteries particularly in the kidneys, heart, liver and gastrointestinal tract. Vessel necrosis, thrombosis, rupture and aneurysms occur with fibrous repair resulting in mural nodularity.

Microscopic polyarteritis (leukocy to clastic vasculitis): involves arterioles, capillaries and venules. It affects skin, mucous membranes, lungs, brain, heart, gastrointestinal tract, kidneys and muscle in isolation or various combinations. It is much more common than polyarteritis nodosa and may be precipitated by drugs or infections.

Kawasaki syndrome: a rare arteritis, which affects the large, medium and small arteries (often coronary arteries). Eighty per cent are less than four years old and 20% develop cardiovascular sequelae.

Wegener's granulomatosis: a focal necrotizing or granulomatous vasculitis involving small and medium sized vessels, most prominent in the lungs or upper airways, and associated with a focal or necrotizing (often crescentic) glomerulitis.

Aneurysm: an abnormal widening of a blood vessel wall. In a true aneurysm the walls make up the boundary; in a false aneurysm the boundary is made of haematoma or fibrous tissue.

Abdominal aortic aneurysms: the most common site for atherosclerotic aneurysms, usually below the renal arteries, above the bifurcation of the aorta. Aneurysms less than 5 cm diameter rarely rupture, while about 50% of those more than 5 cm suffer fatal rupture within a ten-year period. Operative mortality after rupture is approximately 50% but 5% prior to it. A small minority are inflammatory in type, with a thick cuff of surrounding fibrous tissue, and associated with obstruction of the ureters.

Dissecting aneurysms: blood enters the wall of the aorta and dissects between layers. It affects two groups of patients - males predominantly between the age of 40 and 60 years with a history of hypertension, and a younger group with an abnormality of the connective tissue, e.g., Marfan's syndrome. Histological examination shows cystic medial degeneration with elastic tissue fragmentation. Surgery involves plication of the aortic wall (65-75% of patients with dissection survive).

Syphilitic aneurysms: obliterative endarteritis affects the vasa vasorum leading to a thoracic aortitis and subsequent aneurysmal dilatation of the thoracic aorta and the aortic annulus. These are now rare in developed countries.

Berry aneurysms occur in the circle of Willis of the brain, due to congenital defects in the vessel wall, and are an important cause of sudden subarachnoid haemorrhage in young adults.

Mycotic aneurysm occurs in the arterial wall secondary to damage caused by sepsis. They are rare in developed countries. Polyarteritis nodosa may be associated with multiple microaneurysms. Kawasaki disease causes arteritis and aneurysm of the coronary arteries.

Varicose veins: abnormally dilated, tortuous veins due to prolonged intraluminal pressure or loss of support of the vessel wall. They affect a wide range of patients but particularly obese females over 50 years of age. There is also a familial tendency. Varicosities also occur in the oesophagus secondary to portal hypertension in association with liver cirrhosis. Haemorrhoids are varicose dilatations of the haemorrhoidal plexus of veins at the anorectal junction.

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