Ch 3 inflammation and repair

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INFLAMMATION
AND REPAIR
CHAPTER 3
DR. ASHISH JAWARKAR, MD

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OVERVIEW
1. Definition
2. Brief introduction
3. Harmful consequences of misdirected inflammation
4. Causes
5. First step of inflammation – acute and chronic
6. Acute inflammation
1. Steps
1. Blood vessel reactions
2. Leucocyte recruitment
3. Clearing of offending agent
4. Termination of response
2. Mediators of acute inflammation
3. Morphologic patterns of acute inflammation
4. Outcomes of acute inflammation

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OVERVIEW7. Chronic inflammation
1. Causes
2. Morphological patterns of chronic inflammation
3. Mediators of chronic inflammation
4. Granulomatous inflammation
8. Systemic effects of inflammation
9. Tissue repair
1. Types
1. Repair by regeneration
2. Repair by connective tissue deposition (scar formation)
2. Factors that influence tissue repair
3. Selected examples of tissue repair
1. Skin healing
2. Healing in parenchymal organs
4. Abnormalities in tissue repair

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DEFINITION Inflammation is a response of
vascularized tissues
to infectious organisms and/or
tissue damage
that brings cells and molecules of
host defence from the circulation to
the sites where they are needed,
in order to eliminate the offending
agents.

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BRIEF INTRODUCTION
 Acute inflammation
 The initial, rapid response to infections and tissue damage is called
acute inflammation.
 It typically develops within minutes or hours and is of short duration,
lasting for several hours or a few days;
 its main characteristics are the exudation of fluid and plasma proteins
(edema) and the emigration of leukocytes, predominantly neutrophils
(also called polymorphonuclear leukocytes).
 When acute inflammation achieves its desired goal of eliminating the
offenders, the reaction subsides.
 Acute inflammation is one of the reactions of the type of host defense
known as innate immunity

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BRIEF INTRODUCTION
 Chronic inflammation
 If acute inflammation fails to clear the stimulus, the reaction can
progress to a protracted phase that is called chronic inflammation.
 Chronic inflammation is of longer duration and
 is associated with more tissue destruction, the presence of
lymphocytes and macrophages, the proliferation of blood vessels,
and the deposition of connective tissue.
 Chronic inflammation is more prominent in the reactions of
adaptive immunity

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HARMFUL
EFFECTS OF
INFLAMMATION

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HARMFUL EFFECTS OF
INFLAMMATION
 Protective inflammatory reactions to infections are often accompanied by
local tissue damage and its associated signs and symptoms (e.g., pain and
functional impairment).
 Typically, however, these harmful consequences are self-limited.
 In contrast, there are many diseases in which
 the inflammatory reaction is misdirected (e.g., against self tissues in autoimmune
diseases),
 occurs against normally harmless environmental substances (e.g., in allergies)
 Following table gives a list of some common diseases caused due to
inflammation

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CAUSES OF INFLAMMATION
1. Infections - bacterial, viral, fungal, parasitic
2. Tissue necrosis – due to ischemia, trauma, physical or chemical
injury
3. Foreign bodies
1. Exogenous - splinters, dirt, sutures
2. Endogenous - urate crystals (in the disease gout),
Cholesterol crystals (in atherosclerosis),
and lipids (in obesity-associated metabolic syndrome)
4. Immune reactions – autoimmune diseases or allergy

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FIRST STEP IN
INFLAMMATION

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FIRST STEP IN INFLAMMATION
(RECOGNITION OF
MICROBES/DAMAGED CELLS)
1. Innate immunity recognizes
foreign antigens (microbes)
through receptors on the plasma
membranes of epithelial cells,
dendritic cells, macrophages and
leucocytes
2. Recognition of tissue damage is
through factors that are released
after damage, such as – uric acid
released after DNA break down,
ATP – due to mitochondria
damage. These and such
products activate what are called
inflammasomes (cystosolic
complexes) that release IL-1. This
IL-1 is thought to be responsible
for gout and ATH.

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 Acute inflammation
 Steps
 Blood vessel reactions
 Leucocyte recruitment
 Clearing of offending agent
 Termination of response
 Mediators of acute inflammation
 Morphologic patterns of acute inflammation
 Outcomes of acute inflammation

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STEPS IN
ACUTE
INFLAMMATION

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STEPS IN ACUTE INFLAMMATION
Blood vessel
reactions
1
Leucocyte
recruitment
2
Phagocytosis
and Clearing of
offending agent
3
Termination of
response
4

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1. BLOOD VESSEL REACTIONS
 The vascular reactions of acute inflammation consist of
 changes in the flow of blood
 Changes in the permeability of vessels
 both designed to maximize the movement of plasma
proteins and leukocytes out of the circulation and into the
site of infection or injury.

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1. BLOOD VESSEL
REACTIONS
 A. CHANGES IN FLOW OF
BLOOD
 Vasodilatation
 Stasis and accumulation of
leucocytes, principally
neutrophils along the
endothelium

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1. BLOOD VESSEL
REACTIONS
 B. INCREASED
VASCULAR
PERMEABILITY
 Endothelial
contraction/retraction
 Endothelial injury
 Transcytosis

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2. LEUCOCYTE RECRUITMENT AT
SITE OF INJURY
 The journey of leukocytes from the vessel lumen to the site
of injury can be divided into sequential phases
A. In the lumen: margination, rolling, and adhesion to endothelium.
B. Migration across the endothelium and vessel wall
C. Migration in the tissues toward a chemotactic stimulus

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A. Margination, rolling, and adhesion to endothelium
 Margination
 white cells assume a peripheral
position along the endothelial
surface
 Rolling
 Subsequently, leukocytes adhere
transiently to the endothelium,
detach and bind again, thus rolling
on the vessel wall (Selectins)
 Adhesion
 The cells finally come to rest at
some point where they adhere
firmly (Integrins)
2. LEUCOCYTE RECRUITMENT AT SITE OF INJURY
L selectin

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B. Migration across the endothelium and vessel wall
(diapedesis)

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C. Migration in the tissues toward a chemotactic stimulus
(Chemotaxis)

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 Phagocytosis involves three
sequential steps
1. recognition and attachment of
the particle to be ingested by the
leukocyte;
2. engulfment, with subsequent
formation of a phagocytic vacuole;
and
3. killing or degradation of the
ingested material (by ROS and
other lysosomal enzymes)
3. PHAGOCYTOSIS &
KILLING OF
OFFENDING
AGENT

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 Neutrophilic lysosomes contain two types of granules
 Smaller specific (or secondary) granules contain lysozyme,
collagenase, gelatinase, lactoferrin, plasminogen activator,
histaminase, and alkaline phosphatase.
 The larger azurophil (or primary) granules contain myeloperoxidase,
bactericidal factors (lysozyme, defensins), acid hydrolases, and a
variety of neutral proteases (elastase, cathepsin G, nonspecific
collagenases, proteinase 3).
 Acid proteases degrade bacteria and debris
 Neutral proteases are capable of degrading various extracellular
components, such as collagen, basement membrane, fibrin, elastin, and
cartilage
3. PHAGOCYTOSIS & KILLING OF
OFFENDING AGENT

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4. TERMINATION OF RESPONSE
1. Removal of mediators of inflammation - mediators of
inflammation are produced in rapid bursts, only as long as the
stimulus persists, have short half-lives, and are degraded after
their release.
2. Short half life of inflammatory cells – inflammatory cells die
by apoptosis within a few hours after leaving the blood.
3. Stop signals - These include antiinflammatory cytokines,
including transforming growth factor-β (TGF-β) and IL-10, from
macrophages and other cells.

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 LEUCOCYTE MEDIATED TISSUE INJURY
 Collateral damage: As part of a normal defence reaction against
infectious microbes, when adjacent tissues suffer collateral damage.
 Difficult to eradicate infections: In some infections that are difficult to
eradicate, such as tuberculosis and certain viral diseases, the
prolonged host response contributes more to the pathology than does
the microbe itself.
 Autoimmunity: When the inflammatory response is inappropriately
directed against host tissues, as in certain autoimmune diseases.
 Allergy: When the host reacts excessively against usually harmless
environmental substances, as in allergic diseases, including asthma.
4. TERMINATION OF RESPONSE

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MEDIATORS OF
ACUTE
INFLAMMATION

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MEDIATORS OF ACUTE INFLAMMATION
 The mediators of inflammation are the substances that initiate and
regulate inflammatory reactions.
 Some chief mediators with their actions is summarised below. We will
discuss them in detail in slides that follow -
1. Vasoactive amines - mainly histamine and serotonin:
 vasodilation and increased vascular permeability
2. Arachidonic acid metabolites (prostaglandins and leukotrienes):
 several forms exist and are involved in vascular reactions, leukocyte chemotaxis, and
other reactions of inflammation; antagonized by lipoxins
3. Cytokines:
 proteins produced by many cell types; usually act at short range; mediate multiple
effects, mainly in leukocyte recruitment and migration; principal ones in acute
inflammation are TNF, IL-1, and chemokines
INTRODUCTION

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4. Complement system proteins:
 Activation of the complement system by microbes or antibodies
leads to the generation of multiple breakdown products, which are
responsible for leukocyte chemotaxis, opsonization, and
phagocytosis of microbes and other particles, and cell killing
5. Kinins:
 produced by proteolytic cleavage of precursors; mediate vascular
reaction, pain
INTRODUCTION

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 Histamine
 Richest sources of histamine are the mast cells that are normally
present in the connective tissue adjacent to blood vessels
 Released by mast cells in response to variety of stimuli such as –
 Heat, cold or trauma
 Hypersensitivity (allergy)
 Anaphylatoxins (C3a and C5a)
 Histamine causes dilation of arterioles and increases the permeability
of venules
 Its vasoactive effects are mediated mainly via binding to receptors,
called H1 receptors, on microvascular endothelial cells
A. VASOACTIVE AMINES – HISTAMINE AND SEROTONIN

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 Serotonin
 Serotonin (5-hydroxytryptamine) is a preformed vasoactive
mediator present in platelets and certain neuroendocrine cells
 It is also a vasoconstrictor
A. VASOACTIVE AMINES – HISTAMINE AND SEROTONIN

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B. ARACHIDONIC ACID METABOLITES – PROSTAGLANDINS AND
LEUKOTRIENES
 The lipid mediators prostaglandins and leukotrienes are
produced from arachidonic acid (AA) present in membrane
phospholipids

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Cytokines
 Cytokines are proteins produced by many cell types
(principally activated lymphocytes, macrophages, and
dendritic cell, but also by endothelial, epithelial, and
connective tissue cells) that mediate and regulate immune
and inflammatory reactions
 Following table summarises some chief cytokines involved
in inflammation and their actions

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C. Cytokines

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 Chemokines are a family of small (8 to 10 kD) proteins that act
primarily as chemo attractants for specific types of leukocytes
 Role of chemokines
 In acute inflammation
 stimulate leukocyte attachment to endothelium
 stimulate migration (chemotaxis) of leukocytes
 Maintenance of tissue architecture
 Some chemokines are produced constitutively in tissues and are sometimes
called homeostatic chemokines.
 These organize various cell types in different anatomic regions of the tissues,
such as T and B lymphocytes in discrete areas of the spleen and lymph nodes
D. Chemokines

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 The complement system is a collection of soluble proteins and
membrane receptors that function mainly in host defence
against microbes and in pathologic inflammatory reactions
 The system consists of more than 20 proteins, some of which are
numbered C1 through C9
 Complement proteins are present in inactive forms in the plasma,
and many of them are activated to become proteolytic enzymes that
degrade other complement proteins, thus forming an enzymatic
cascade
 The critical step in complement activation is the proteolysis of the
third (and most abundant) component, C3
E. Complement system

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E. Complement system

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MORPHOLOGIC
PATTERNS OF ACUTE
INFLAMMATION

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MORPHOLOGIC PATTERNS OF ACUTE
INFLAMMATION
1. SEROUS INFLAMMATION
2. FIBRINOUS INFLAMMATION
3. PURULENT INFLAMMATION
4. ULCERS

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1. Serous inflammation
 Serous inflammation is marked by the exudation of cell poor fluid into
spaces created by cell injury or into body cavities lined by the peritoneum,
pleura, or pericardium.
 Typically, the fluid in serous inflammation is not infected by destructive
organisms and does not contain large numbers of leukocytes (which tend to
produce purulent inflammation, described later).
 In body cavities the fluid may be derived from the plasma (as a result of
increased vascular permeability) or from the secretions of mesothelial cells
(as a result of local irritation); accumulation of fluid in these cavities is called
an effusion. (Effusions also occur in noninflammatory conditions, such as
reduced blood outflow in heart failure, or reduced plasma protein levels in
some kidney and liver diseases.)
 The skin blister resulting from a burn or viral infection represents
accumulation of serous fluid within or immediately beneath the damaged
epidermis of the skin
INFLAMMATION

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 With greater increase in vascular permeability, large molecules
such as fibrinogen pass out of the blood, and fibrin is formed
and deposited in the extracellular space.
 A fibrinous exudate is characteristic of inflammation in the lining
of body cavities, such as the meninges, pericardium and pleura.
 Conversion of the fibrinous exudate to scar tissue (organization)
within the pericardial sac leads to obliteration of the pericardial
space.
2. Fibrinous inflammation
INFLAMMATION

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 Purulent inflammation is characterized by the production of
pus, an exudate consisting of neutrophils, the liquefied
debris of necrotic cells, and edema fluid
 Abscesses are localized collections of purulent
inflammatory tissue caused by suppuration buried in a tissue,
an organ, or a confined space
3. Purulent inflammation (Abscess)
INFLAMMATION

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 An ulcer is a local defect, or excavation, of the surface of an
organ or tissue that is produced by the sloughing
(shedding) of inflamed necrotic tissue
 Ulcerations are best exemplified by peptic ulcer of the stomach
or duodenum, in which acute and chronic inflammation coexist.
 During the acute stage there is intense polymorphonuclear
infiltration and vascular dilation in the margins of the defect.
 With chronicity, the margins and base of the ulcer develop
fibroblastic proliferation, scarring, and the accumulation of
lymphocytes, macrophages, and plasma cells.
4. Ulcers
INFLAMMATION

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OUTCOMES OF
ACUTE
INFLAMMATION

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OUTCOMES OF ACUTE INFLAMMATION

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CHRONIC INFLAMMATION
 Causes
 Morphological patterns of chronic inflammation
 Mediators of chronic inflammation
 Granulomatous inflammation

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CAUSES OF
CHRONIC
INFLAMMATION

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CAUSES
 Persistent infections –
 by microorganisms that are difficult to eradicate, such as mycobacteria and
certain viruses, fungi, and parasites. These organisms often evoke an immune
reaction called delayed-type hypersensitivity. The inflammatory response
sometimes takes a specific pattern called a granulomatous reaction
 Autoimmunity –
 Autoantigens evoke a self-perpetuating immune reaction that results in chronic
tissue damage and inflammation; examples of such diseases are rheumatoid
arthritis and multiple sclerosis
 Allergy –
 Immune responses against common environmental substances are the cause of
allergic diseases, such as bronchial asthma
 Prolonged exposure to toxic agents -
 Eg silicosis, atherosclerosis

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MORPHOLOGIC
PATTERNS
1. Infiltration with mononuclear
cells, which include macrophages,
lymphocytes, and plasma cells
2. Tissue destruction, induced by the
persistent offending agent or by the
inflammatory cells
3. Attempts at healing by connective
tissue replacement of damaged
tissue, accomplished by
angiogenesis (proliferation of small
blood vessels) and, in particular,
fibrosis
ACUTEVSCHRONICINFLAMMATION

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MEDIATORS OF
CHRONIC
INFLAMAMATION

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MEDIATORS OF CHRONIC INFLAMMATION
 Macrophages
 Lymphocytes
 Eosinophils
 Mast cells
 Neutrophils

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Macrophages
 Cells derived from monocytes – part of
mononuclear phagocyte system
 Examples
 normally diffusely scattered in most
connective tissues.
 liver (where they are called Kupffer cells),
 spleen and lymph nodes (called sinus
histiocytes),
 central nervous system (microglial cells), and
 lungs (alveolar macrophages)

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 The dominant cells in most chronic inflammatory reactions
are macrophages, which contribute to the reaction by
 secreting cytokines and growth factors that act on various
cells,
 by destroying foreign invaders and tissues,
 and by activating other cells, notably T lymphocytes
Macrophages

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 There are two major pathways of macrophage activation,
called classical and alternative
Macrophages
Produced by T
lymphocytes

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 Microbes and other environmental antigens activate T
lymphocytes, which amplify and propagate chronic
inflammation
 There are three subsets of CD4+ T cells that secrete different types
of cytokines and elicit different types of inflammation.
 TH1 cells produce the cytokine IFN-γ, which activates macrophages by
the classical pathway.
 TH2 cells secrete IL-4, IL-5, and IL-13, which recruit and activate
eosinophils and are responsible for the alternative pathway of
macrophage activation.
 TH17 cells secrete IL-17 and other cytokines, which induce the
secretion of chemokines responsible for recruiting neutrophils (and
monocytes) into the reaction.
Lymphocytes

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Lymphocytes

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 Eosinophils are abundant in immune reactions mediated by IgE
and in parasitic infections
 Mast cells release mediators, such as histamine and
prostaglandins
 Neutrophils play a part in acute on chronic reactions –
 In osteomyelitis, a neutrophilic exudate can persist for many
months.
 Neutrophils are also important in the chronic damage induced in
lungs by smoking
Eosinophils, Mast cells and Neutrophils

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GRANULOMATOUS
INFLAMMATION

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GRANULOMATOUS
INFLAMMATION
 Granulomatous inflammation is a form
of chronic inflammation characterized
by collections of activated
macrophages, often with T
lymphocytes, and sometimes
associated with central necrosis
 The activated macrophages may
develop abundant cytoplasm and begin
to resemble epithelial cells, and are
called epithelioid cells.
 Some activated macrophages may
fuse, forming multinucleate giant
cells (Langhan’s)
 This is a type of immune granuloma –
produced when infecting agent is difficult to
eradicate

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FOREIGN BODY
GRANULOMA
 incited by relatively inert
foreign bodies
 foreign body granulomas
form around materials such
as talc (associated with
intravenous drug abuse)
sutures, or other fibres that
are large enough to
preclude phagocytosis by a
macrophage

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SYSTEMIC
EFFECTS OF
INFLAMMATION

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SYSTEMIC
EFFECTS OF
INFLAMMATION
Fever: cytokines (TNF, IL-1) stimulate
production of prostaglandins in hypothalamus
Production of acute-phase proteins: C-
reactive protein, others; synthesis stimulated
by cytokines (IL-6, others) acting on liver cells
Leucocytosis: cytokines (colony-stimulating
factors) stimulate production of leukocytes
from precursors in the bone marrow
In some severe infections, septic shock: fall
in blood pressure, disseminated intravascular
coagulation, metabolic abnormalities; induced
by high levels of TNF and other cytokines

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Tissue Repair Repair V/S
Regeneration
Concept of
Regeneration
Repair
Skin wound healing
Abnormalities in
tissue repair

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Repair Vs Regeneration
 Regeneration
 some tissues are able to replace the damaged components and
essentially return to a normal state; this process is called regeneration
 Tissues whose cells retain the capacity to proliferate, for example, in
the rapidly dividing epithelia of the skin and intestines, and the liver can
undergo regeneration
 Repair (scar formation)
 If the injured tissues are incapable of complete restitution, or if the
supporting structures of the tissue are severely damaged, repair
occurs by the laying down of connective (fibrous) tissue

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Concept of Regeneration
 Regeneration of the liver is a classic example
of repair by regeneration.
 It is triggered by cytokines and growth factors
produced in response to loss of liver mass and
inflammation.
 In different situations, regeneration may occur
by
1. proliferation of surviving hepatocytes or
2. repopulation from progenitor cells (stem cells),
these progenitor cells have been called oval
cells because of the shape of their nuclei. Some
of these progenitor cells reside in specialized
niches called canals of Hering

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Repair (by connective tissue deposition;
Scar formation)
 Scar formation is a response that “patches” rather than restores
the tissue
 The term scar is most often used in connection to wound healing
in the skin, but may also be used to describe the replacement of
parenchymal cells in any tissue by collagen, as in the heart after
myocardial infarction

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Steps in repair
1. Angiogenesis
 Angiogenesis is the formation of new blood
vessels, which supply nutrients and oxygen
needed to support the repair process
2. Formation of granulation tissue
 Migration and proliferation of fibroblasts and
deposition of loose connective tissue, together with
the vessels and interspersed leukocytes, form
granulation tissue.
 The term granulation tissue derives from its pink,
soft, granular gross appearance, such as that seen
beneath the scab of a skin wound.
3. Remodelling of connective tissue
 Maturation and reorganization of the connective
tissue produce the stable fibrous scar

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Skin wound healing
 This is a process that involves both epithelial regeneration and the formation of
connective tissue scar
 Based on the nature and size of the wound, the healing of skin wounds is said to
occur by first or second intention
1. Healing by First Intention
 When the injury involves only the epithelial layer, the principal mechanism of repair is
epithelial regeneration
 One of the simplest examples of this type of wound repair is the healing of a clean,
uninfected surgical incision approximated by surgical. The incision causes only focal
disruption of epithelial basement membrane continuity and death of relatively few
epithelial and connective tissue cells.

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Skin wound healing
2. Healing by Second Intention
 When cell or tissue loss is more extensive, such as in large
wounds, abscesses, ulceration, and ischemic necrosis (infarction)
in parenchymal organs, the repair process involves a combination
of regeneration and scarring

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Healing by first intention
Steps
 1st 24 hours –
 Wounding causes the rapid activation of coagulation pathways, which results in the
formation of a blood clot on the wound surface. As dehydration occurs at the external
surface of the clot, a scab covering the wound is formed.
 Neutrophils are seen at the incision margin. They release proteolytic enzymes that
begin to clear the debris.
 Epithelial cell proliferation starts at the edge of the wound
 3-7 days –
 Neutrophils have been largely replaced by macrophages, and granulation tissue
progressively invades the incision space
 Collagen fibers and fibroblasts are now evident at the incision margins.
 Epithelial cell proliferation continues, forming a covering approaching the normal
thickness of the epidermis.

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Healing by first intention
Steps
 Weeks –
 The epidermis recovers its normal thickness
 The process of “blanching” begins, accomplished by increasing
collagen deposition within the incisional scar and the regression of
vascular channels
 By the end of the first month, the scar comprises a cellular connective
tissue largely devoid of inflammatory cells and covered by an
essentially normal epidermis. However, the dermal appendages
destroyed in the line of the incision are permanently lost.
 The tensile strength of the wound increases with time due to collagen
cross linking

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Healing by second intention
Steps
 Secondary healing differs from primary healing in several respects:
 The fibrin clot is larger, and there is more exudate and necrotic debris in the
wounded area.
 Inflammation is more intense because large tissue defects have a greater
volume of necrotic debris, exudate, and fibrin that must be removed.
 Larger defects require a greater volume of granulation tissue to fill in the gaps
and provide the underlying framework for the regrowth of tissue epithelium. A
greater volume of granulation tissue generally results ina greater mass of scar
tissue.
 Wound contraction generally occurs in large surface wounds. The contraction
helps to close the wound by decreasing the gap between its dermal edges and
by reducing the wound surface area. Contraction is mediated by a network of
myofibroblasts, which are modified fibroblasts exhibiting many of the
ultrastructural and functional features of contractile smooth muscle cells.

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Abnormalities in tissue repair
 Complications in tissue repair can arise from abnormalities in
any of the basic components of the process, including
1. Dehiscence and Ulceration
 Dehiscence - Dehiscence or rupture of a wound occurs most
frequently after abdominal surgery and is due to increased
abdominal pressure
 Ulceration - Wounds can ulcerate because of inadequate
vascularization during healing. For example, lower extremity
wounds in individuals with atherosclerotic peripheral vascular
disease

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Abnormalities in tissue repair
2. Excessive formation of the repair components
 Hypertrophic scar - accumulation of excessive amounts of collagen may give
rise to a raised scar known as a hypertrophic scar
 Keloid - if the scar tissue grows beyond the boundaries of the original wound
and does not regress, it is called a keloid
 Exuberant granulation - consisting of the formation of excessive amounts of
granulation tissue, which protrudes above the level of the surrounding skin and
blocks reepithelialisation (proud flesh)
 Desmoids, or aggressive fibromatoses - Exuberant proliferation of fibroblasts,
these neoplasms lie in the interface between benign and malignant
3. Contractures
 Exaggeration of process of contraction during healing is prone to develop in
palms and soles and thorax. Contractures are commonly seen after serious
burns and can compromise the movement of joints.

Ch 3 inflammation and repair

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