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Chronic inflammation, Wound healing - Pathology - Nursing
- 1. Chronic inflammation, Wound healing Dr.Salman Ansari(MBBS) Tutor, Dept. of Pathology Kanachur Institute of Medical Sciences
- 2. ● Chronic inflammation ●Wound healing
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- 4. Chronic inflammation Definition: Inflammationof prolonged duration(weeks or months) in which inflammation, tissue damage and healing occurs at same time It may occur: after an acute inflammation which did not resolve. E.g: acute osteomyelitis → chronic osteomyelitis It may begin as an insidious, low-grade chronic response without any inflammatory reaction
- 5. Causes - Persistent infections- by microbes which are hard to eradicate. E.g: Mycobacterium tuberculosis - Immune-mediated diseases: E.g: autoimmune diseases, allergic reactions - Prolonged exposure to toxic agents. E.g: silicosis due to silica particles
- 6. Morphology Chronic inflammation ischaracterised by: - Infiltration by mononuclear cells: macrophages, lymphocytes and plasma cells - Tissue destruction - Healing by fibrosis
- 7. Chronic granulomatous inflammation -Special pattern of of chronic inflammation - Can be due to infectious and non-infectious causes - Seen in: tuberculosis, fungal infections - involves immune reactions - Microscopic feature: presence of granuloma - Granuloma is formed from macrophages and T-cells - Macrophages transform into epithelium-like cells, called epithelioid cells - Epithelioid cells may fuse with each other to form Langhan’s giant cell SN
- 8. Granuloma Definition: defined asa type of chronic inflammation characterised by microscopic aggregation of macrophages which are transformed into into epithelium-like(epithelioid) cells and surrounded by a rim of lymphocytes - Old granulomas also have a layer of fibroblasts as the outermost layer SN
- 9. Components of granuloma Epithelioidcells: - They are modified macrophages which look like epithelial cells - Elongated nucleus Giant cells: - Epithelioid cells fuse to form giant cells - The nuclei are shaped like a horse-shoe Epithelioid cells Giant cells
- 11. Types of granuloma Foreignbody granuloma. E.g: around sutures, talc Immune granuloma. E.g: tuberculosis
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- 13. Healing Definition: Healing isthe process of replacement of dead tissue by living tissue Divided into Regeneration Repair
- 14. Regeneration “Process by whichlost/damaged tissue is completely replaced by tissue of similar type.” Occurs in tissues which have regenerative cells. E.g: skin epithelium, hematopoietic cells
- 15. Repair “Process in whichlost/damaged tissue is replaced by fibrous tissue(scar).” E.g: healed myocardial infarction
- 16. Granulation tissue - First24-72 hours: Fibroblasts and vascular endothelial cells multiply and form a special type of tissue called “granulation tissue” - Granulation tissue: Gross: pink, soft, granular on the surface of the healing wound Micro: - formation of new blood vessels, called angiogenesis - proliferation of fibroblasts SN
- 17. - Granulation tissuegrows into the incision/wound - If it is healing by secondary intention, the amount of granulation tissue will be more - By 5-7 days: the wound is filled by granulation tissue
- 21. Types of healing Cutaneoushealing Healing of fracture Healing by primary union Healing by secondary union LE
- 22. Cutaneous wound healing 1)Healing by primary union or healing by first intention: Definition: Healing of sterile, surgical wounds - Simplest type of cutaneous wound healing - Minimal disruption of epithelial basement membrane - Edges of wound are approximated by surgical sutures - Minimal scarring LE
- 23. Stages of healingby first intention LE First 24 hours - Blood clots in the space between the suture wound margins - Neutrophils at the margins - Epithelial cells at the edges multiply and migrate across the wound Day 2 - Macrophages begin to appear - Surface epithelial continuity is established and is thin Day 3-7 - Granulation tissue begins to form - Surface epithelium is of normal thickness - Collagen deposited Day 10-14 - Wound gains 10% strength of normal skin - Fibroblasts multiply with collagen deposition Weeks to months - Collagens deposition and wound achieves maximal 80% of tensile strength of normal skin
- 27. Healing by secondaryunion or second intention Definition: “Healing of large wounds and infected wounds” - Healing in such wounds is more complicated - There is more tissue loss in these wounds LE
- 28. Features of healingby secondary intention: - severe inflammatory reaction - formation of abundant granulation tissue - more deposition of collagen - large scar formation - wound contraction occurs - - Wound contraction occurs due to myofibroblasts which contract and decrease the dermal edges of the wound and reduce the surface area of the wound
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- 32. Factors that affectwound healing Local factors Systemic factors
- 33. Local factors - infection:causes delay in wound healing - mechanical factors: movement of wounded area results in delayed healing - foreign bodies: sutures or pieces of steel, glass, bone etc delay healing - Location: delayed if wound is over a bone with little tissue in between. E.g: skin over anterior tibia - Blood supply: good blood supply results in faster healing. E.g: face
- 34. Systemic factors: - Nutrition:protein deficiency, vitamin C deficiency inhibits collagen synthesis and slows healing - Age: faster in young - Metabolic status: delayed in Diabetes mellitus - Circulatory status: poor blood supply(arteriosclerosis) or venous abnormalities(e.g: varicose veins) results in poor healing - Hormones: steroids inhibit collagen synthesis & delay wound healing
- 35. Complications of woundhealing: 1) Inadequate granulation tissue formation: poor scar formation can lead to - dehiscence: rupture of wound - due to increased abdominal pressure or stress from vomiting, coughing - ulceration: due to poor new blood vessel formation and can lead to non-healing ulcer. E.g: wounds in varicose veins - incisional hernia: due to weak scar
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- 38. 2) Excessive scarformation: can result in: - hypertrophic scar: excessive collagen deposition leads to a raised scar at the site of the wound, called a hypertrophic scar - develops after thermal injury or traumatic injury - keloid: if the scar grows beyond the boundaries of the original wound - exuberant granulation: pyogenic granuloma(proud
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- 42. Exuberant granulation tissueor “Proud flesh”
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- 44. 3) “contracture”: decreasein the size of a wound is called contraction. Excessive contraction is called "contracture" and results in deformity and reduced mobility
- 46. 4) wound infection 5)pigmentation of wound area
- 47. Healing of fracture ●Takes about 6-8 weeks in total ● 3 phases LE 1) Inflammatory phase ↓ 2) Repair phase ↓ 3) Remodelling phase
- 48. 1) Inflammatory phase -Rupture of blood vessels leads to hemorrhage and hematoma formation at site of fracture - Inflammatory cells(neutrophils, macrophages) arrive at fracture site - Blood clots and forms fibrin mesh work - New blood vessels form(“neovascularistion”) occurs and fibroblasts multiply - formation of granulation tissue between the fracture fragments - Osteoblasts enter granulation tissue and deposit woven bone(weak) - Formation of soft tissue callus or pro-callus - Pro-callus is granulation tissue which contains bone or cartilage,
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- 50. 2) Reparative phase -Formation of lamellar bone - Woven bone is replaced by lamellar bone - Lamellar bone is stronger than woven bone and is made of parallel collagen fibres - Ossification occurs(cartilage is replaced by woven bone) - Calcification of callus occurs, which is now called “bony callus” - Stiffness and strength of callus increases - By 2-3 weeks, controlled weight-bearing can be tolerated
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- 53. 3) Remodelling phase -Starts a few weeks after callus has sealed the bone ends - Compact bone formation occurs - Remodelling occurs till original bone shape and strength is reached
- 55. & soft callusformation
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- 58. Causes of delayedfracture healing Local factors General factors - Excessive movement of bone during healing - Infection at fracture side - Severe local soft tissue injury - Wide separation of fracture ends - Extensive necrosis of fracture bone - Poor blood supply - Old age - Poor general health - Use of steroids
- 59. Complications of fracturehealing ● Delayed union of fracture ● Non-union of fracture ● False joint(“pseudo-arthrosis”): false joint associated with abnormal movements at site ● Malunion: when fracture heals with a deformity
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- 64. For notes, scan: References: ● Dr.Purnima S. Rao - Textbook of Pathology and Genetics for Nursing ● Dr. Ramadas Nayak - Textbook of Pathology for Allied Health Sciences Questions: [email protected] For PPT, scan: