Documente Academic
Documente Profesional
Documente Cultură
INTRODUCTION
Inflammation is a local complicated vascular and cellular reaction of an individual to
an injury/irritant. The purposes of the inflammatory reaction are as follows:
a) Minimise the effect of the irritant or injury
b) Heal the damaged tissue and restore the affected animal to normal health.
It is a protective mechanism, in that protective factors such as antibodies,
complement, and phagocytic cell normally confined to the bloodstream can gain
access at localised tissue sites, to destroy foreign invaders.
An understanding of inflammation and subsequent repair and regeneration of injured
tissue is necessary for understanding many diseases and surgical processes. Most
of these will induce tissue damage (necrosis) and will involve inflammation.
Inflammation is a dynamic sequential process. While vascular and cellular responses
that make up inflammatory reaction are similar irrespective of the aetiology, these
can be modified by nature, severity and longevity of the irritant and/or by host
factors. These include the location and the type of tissue affected. The result in host
tissue therefore may not always be the same. If inflammatory reaction is successful,
healing occurs. If not successful, further tissue reaction that is harmful to the host
may occur. The initial or acute stage of inflammation is characterised by certain
clinical or cardinal signs. These are:
1) Redness
2) Swelling
3) Heat
4) Pain
5) Loss of function.
AETIOLOGY
The aetiologies of inflammation vary and include both living and non-living agents as:
Bacteria, Fungi, Viruses, Parasites, Protozoa, Immunologic injury, Trauma, Heat,
Cold, Toxins or poisons, and Irradiation.
SUMMARY OF EVENTS IN ACUTE INFLAMMATION
1. Transient vasoconstriction of arteriole (few seconds to about five minutes)
followed by an increased rate of blood flow through the terminal vascular bed. The
latter are due to dilation of all the blood vessels in the area. This includes the
opening of new capillary and venular beds.
2. Increase in the permeability of the terminal vascular bed with consequent
exudation of plasma factors into the tissues. This results in tissue swelling and
retardation of blood flow with haemoconcentration in the vascular bed.
3. The attraction to and adherence of leucocytes to the walls of the terminal vascular
bed (Margination) and subsequent migration of leucocytes and exudation of
erythrocytes into the tissue. The process that attracts cells into the tissues is
Chemotaxis.
4. Removal of any aetiological agent by leucocytes (phagocytosis). Breakdown of
necrotic tissue by phagocytes and removal by reabsorption through the lymph
vessels or into venules.
5. Repair and regeneration:
a) Replacement of dead cells by division of similar cells that escaped necrosis
(regeneration)
b) Replacement fibrosis (repair) if regeneration is not possible
c) a mixture of repair and regeneration.
VASCULAR AND CELLULAR CHANGES
The main components of the inflammatory response are fluids, plasma proteins and
cells. Together they are called EXUDATE that means they have entered the tissue
from the blood as part of an active process. This allows mechanisms of host defence
such as antibodies, complement, and phagocytic cells into the tissues to destroy
antigens.
VASCULAR CHANGES
The initial events in response to injury involve the endothelium of the small vessels,
i.e. arterioles, venules, the direct inter-communication vessels and the true
capillaries. Many true capillaries arise from the direct channels that have occasional
smooth muscle fibres in their walls. It is probable that neurogenic adjustments of the
flow of blood through the shunts help govern the flow through capillaries. The only
control that capillaries themselves have on blood flow is to respond passively to the
pressure gradient between their two ends. Apart from being a tube of endothelial
cells, these small vessels have scattered along and closely applied to them,
pericytes. The function of pericytes is not clear, but it may be supportive to the
endothelial cells.
In the first stage of the acute inflammatory response, there is:
1) Dilation of these small vessels leading to an increased blood flow (hyperaemia) in
the arterioles and capillaries. The overload of venous drainage leads to passive
congestion that also contributes to the vasodilatation.
2) Increase permeability of the small vessels compared with that operating in health.
Apart from direct damage the endothelial cells loosen their attachments to each
other. This process commences in small venules and later involves true capillaries.
The increase in permeability coupled with an increase in hydrostatic pressure due to
increased blood flow, leads to exudation of fluid and plasma factors into the tissue
spaces. This leads to swelling in the inflamed area.
There are two phases of vascular permeability. An immediate transient phase lasting
less than one hour is followed by a prolonged phase which last 3-4 hours or longer if
the stimulus persists. A third phase which is delayed in onset, but last for several
days has also been described. Sunburn is an example of this phase.
CELLULAR RESPONSE
An early manifestation of inflammation is the phenomenon by which platelets and
leucocytes adhere to endothelium (Margination). Many cells may eventually line the
endothelium (Pavementing). There is a slowing of the blood flow and sludging of red
cells in the terminal vascular bed. This is due to:
1] Haemoconcentration consequent to loss of fluid to extravascular tissues.
2] Increased resistance to flow associated with adherence of cells to each other and
to the endothelium.
Migration of leucocytes into the tissues is accomplished by a pseudopodia into the
intercellular junction of the endothelial cells, enlarging the opening and squeezing
through. This allows the passive extravasation of red cells. All leucocytes have
similar migration capacity. Chemotaxis is the process by which leucocytes are
attracted to sites in injured tissue.
Neutrophils and eosinophils are usually first and move through fibrin and past tissue
cells to their destination. Accumulation may reach a peak in about four hours,
although this will vary as to the stimulus. They have been called microphages but
pathologist does not commonly use the term. They are more frequently called
polymorphs or granulocytes. Monocytes become macrophages in the tissues.
Red cells have no amoeboid capabilities, but may take advantage of the holes
created. Leakage of blood (haemorrhage) from the damaged small vessels into the
extravascular tissue spaces gives the appearance of a bruise. A large extravascular
clot is called haematoma or haematocyst.
PHAGOCYTOSIS
Phagocytosis is the process by which particulate matter in taken into the cell, usually
by invagination of the cell membrane to form a vacuole containing the particle
(Phagosome). It is probably the most important defence system available to animals,
and while it does occur without antibody it is enhanced by opsonin. Opsonins are
mainly antibodies, and complement components (C3b fragment), but other serum
components such as polypeptides and basic poly-amino acids have been described
as playing a role. Opsonin improved the efficiency of phagocytosis. Factors favoring
phagocytosis apart from opsonin include higher body temperature, and enmeshment
of the antigen (e.g., bacteria) within the inflammatory exudate.
The phagosome merges with lysosomes to form a phagolysosome, in which the
particle is exposed to the digestive enzymes of the lysosomes and the normally
dormant oxygen consuming pathways. The enzymes break down carbohydrates and
proteins but not fat. Undigested material is called a residual body (Figure 14). In
phagocytosis, contact of neutrophils with the stimuli results to the activation of an
oxygen consuming pathway. This "Respiratory Burst" is characterised by a two- to
three- fold increase in oxygen consumption, the production of hydrogen peroxide
(H2O2), an increase in the activity of the hexose monophosphate shunt, and the
generation of superoxide anion (O2-). The reaction between O2- and H2O2
produces a bactericidal hydroxyl radical. The oxygen dependent mechanism is a
major cause of microbial death. This is due to the activities of the H2O2 acting either
alone or with myeloperoxidase, the hydroxyl radical, the superoxide anion and
singlet oxygen (O2). Oxygen-independent agents include lysozyme, lactoferrin,
phospholipase, and granule-associated cationic proteins.
Some agents are resistant to digestion and remain inside the phagocytic cells for
prolonged period and are protected from other defence mechanisms, and from the
action of antibacterial drugs. Infection may spread because of migration via the
lymphatics of the phagocytes containing the organism. The release of lysosomal
enzymes from the cells apart from having a chemotactic effect may influence clotting
mechanisms and act as pyrogens (fever-inducing agent).
MEDIATORS OF INFLAMMATION
The alterations in blood flow, vascular permeability and the cellular response at the
site of injury are controlled and influenced by chemical mediators of both tissue and
Exudates are fluids and cells that have accumulated in tissue spaces during
inflammation. Accordingly, the exudate has certain characteristics. It will contain
protein, have inflammatory cells, may have bacteria, and depending on the degree of
damage, erythrocytes and globulins. The latter usually includes fibrinogen, and lead
to clotting. The fluid portions of the exudate will:
[a] Dilute the toxic substances at the site of injury and neutralise toxins
[b] Provide a suitable nutrient environment for sustaining the leucocytes that quickly
invade the area
[c] Form a fibrin net from the fibrinogen released. This will help opposing surfaces
of the wound to adhere together, and localise the bacteria (if present) by
enveloping them in a fibrillar meshwork.
Fibrin acts as a physical barrier to confine and prevent the spread of the irritant. It
also provides a scaffold that enables the leucocytes to move towards and
phagocytose the bacteria or other foreign material that may be present.
Subsequently, it allows capillary loops and fibroblast to invade during the process of
healing and repair.
TYPES OF INFLAMMATORY EXUDATES
1.SEROUS EXUDATE - primarily a clear fluid, low in protein (mainly albumin) which
exudes from serosal or mucosal surfaces because of mild irritation. Such an exudate
can also be located within body organs. Neutrophils can be present in considerable
number, in which case there will be whitish appearance to the exudate. The initial
exudate in many inflammatory reactions is serous.
2.FIBRINOUS EXUDATE - exudation of a fluid rich in fibrinogen which will clot to
form a yellowish gel. Usually occurs with severe vascular injury and is seen more
commonly on mucosal and serosal surfaces such as intestine, pleura, peritoneum,
and synovial membranes. Fibrinous pneumonia is also an example.
Because fibrin is chemotactic large number of neutrophils are usually present.
Where two opposing surfaces have a fibrinous exudate between them, the
organisation of the fibrin leads to adhesion. Viewed microscopically the fibrin may
appear as solid clumps or long delicate strands. In severe mucosal damage where
the epithelium is lost the fibrin that accumulates may become adhered to the
remaining mucosa. A diphtheritic membrane or pseudomembrane is formed. The
term diphtheritic applies to fibrous organisation of any fibrinous or necrotic exudate
on a mucosal surface.
3.HAEMORRHAGIC EXUDATE - haemorrhage is prominent and therefore such an
exudate occurs where the blood supply is abundant, and there is severe damage to
the terminal vascular bed. The term must not be confused with haemorrhage alone,
which can occur without any inflammatory reaction.
4.CATARRHAL OR MUCUPURULENT EXUDATE - occur on mucous membranes
and mucosal surfaces of the alimentary, respiratory, and reproductive tracts.
Characterised by the outpouring of large amounts of mucous that is accompanied by
neutrophils, tissue debris, fibrin and sometimes red blood cells. Other signs of
inflammation are present in the underlying mucosa.
phagocytic like neutrophils but are more prominent in certain inflammatory reactions
such as in parasitic infections and in allergic reactions. Antigen-antibody complexes
attract eosinophils when arrested in the tissues. The antigens of parasites because
of their bulk persist longer and attract eosinophils. Apart from parasitic disease, the
presence of eosinophils in an inflammatory reaction in great number is not
consistent. They are found in some granulomas (e.g., eosinophilic granulomas in
cats), in eosinophilic myositis, and in the meninges of pigs with salt poisoning. They
also have some neutralising effect against histamine, but it is probably not a major
role.
3.BASOPHILS - similar in form and function to the tissue mast cells. Circulatory
numbers in the blood are very low. Basophils play a role in hypersensitivity reactions.
4.LYMPHOCYTES - they are not phagocytic, and do not ordinarily migrate during the
acute phase of inflammation, but may be many in the more chronic phase
particularly where there is mucous membrane involvement. Lymphocytes are
associated with the host's immune response and are often present in lesions around
small blood vessels where they form a cuff.
5.PLASMA CELLS - tend to be found in areas of more chronic inflammation and are
usually present along with lymphocytes, macrophages and fibroblast. The formation
of mature plasma cells from lymphocytes (B-cells) requires 4-5 days. The nucleus is
displaced to one side and the cytoplasm has a clear halo on one side of the nucleus.
It produces antibodies and their presence in an inflammatory reaction usually reflects
a subacute or chronic process. Plasma cells are also found in high number in lymph
tissue that is producing antibody to any antigen.
6.MONOCYTES (MACROPHAGES) - less common in blood than neutrophils.
Although they arrive at the site of inflammation later than the polymorphs
(granulocytes), they start to emigrate simultaneously. Their movement is slower but
they are responsive to chemotactic influences. They are much longer-lived than the
polymorphs. Their numbers are augmented by local mitotic proliferation of histiocytes
(a histiocyte is a macrophage present in tissues which is derived from blood
monocytes made in the bone marrow). The macrophages are more efficient than the
polymorph at phagocytizing fibrin and cellular debris from the site of inflammation in
preparation for repair. They process many antigens before transferring them to
lymphocytes for antibody production. If antigens are readily broken down the
macrophages do not persist. If difficulty in this process is encountered then the
macrophages will persist in the lesion. They respond to a variety of stimuli, such as
antigen-antibody complexes, complement, and bacterial and neutrophil products also
immune and non-immune stimuli. Macrophages may divide in tissue to form other
macrophages or may form epithelioid or giant cells.
7.EPITHELIOID CELLS - formed from macrophages with similar appearance, but lie
closer together and take the shape and arrangements similar to prickle cells in the
epidermis. The cytoplasm is eosinophilic and the cell membrane is indistinct. They
do not appear to phagocytize but probably work at destruction of the irritant by
secretion. It is common in many granulomatous types of inflammatory reactions (see
later).
involved in keloid formation and the predisposing factors remain unknown. The other
deviation in wound healing is the formation of excessive amount of granulation tissue
that protrudes above the levels of the injury. This has been called EXUBERANT
GRANULATION or PROUD FLESH.
Scarring is an inevitable consequence of all repair except in the ideal situation in
which an entire parenchymal injury permits perfection of regenerative activity and
reconstitution of the original architecture. Fibroblasts are the workhorses of scar
formation, and the collagen is their essential product that ultimately provides the
tensile strength in the healing of soft tissue wound.
The acquisition of tensile strength follows a sigmoid curve. The first phase has been
described as the catabolic phase when there may be destruction of collagen. The
second phase (also called anabolic, proliferative or collagen phase) involves
deposition of collagen and stabilisation. As the collagen matures, polymerisation of
collagen results, and contraction of the scar tissue follows. The strength of the scar
tissue formed thus depends on the degree of maturation of collagen laid down during
repair.
Artery - arteritis
Bile Ducts - cholangitis
Bladder - cystitis
Blood Vessel - vasculitis
Bone - osteitis
Bone marrow - osteomyelitis
Brain - encephalitis
Bursa - bursitis
Caecum - typhlitis
Colon - colitis
Cornea - keratitis
Dura mater- pachymeningitis
Ear - otitis
Endocardium - endocarditis
Eustachian tube - eustachitis
Eye - ophthalmitis
Eyelid blepharitis
Fascia - Fasciitis
Fat - steatitis
Gallbladder - cholecystitis
Glans penis - balanitis
Heart - carditis
Intestine - enteritis
Iris - iritis
Meninges - meningitis
Mouth - stomatitis
Muscle (skeletal) - myositis
Myocardium - myocarditis
Nasal cavity rhinitis
Nerve - neuritis
Ovary - oophoritis
Oviduct - salpingitis
Pancreas - pancreatitis
Pericardium - pericarditis
Peritoneum - peritonitis
Pleura - pleuritis
Prepuce - posthitis
Renal glomeruli - glomerulitis
Renal pelvis - pyelitis
Salivary gland - sialadenitis
Sinus - sinusitis
Skin - dermatitis
Spermatic cord - funiculitis
Spinal nerve root - radiculitis
Spleen - splenitis
Stomach - gastritis
Testicle - orchitis
Tongue - glossitis
Joints - arthritis
Kidney - nephritis
Lacrimal gland - dacryoadenitis
Ligaments - desmitis
Lip - cheilitis
Liver - hepatitis
Lung - pneumonitis
Lymph nodes - lymphadenitis
Lymph vessels - lymphangitis
Trachea - tracheitis
Tympanum - tympanitis
Uterus - metritis
Vagina - vaginitis
Vas deferens - vasitis
Vein - phlebitis
Vertebra - spondylitis
Vessels - vasculitis