REPAIR, FIBROSIS & HEALING (pp. 29-34)
How much necrosis/tissue damage occurs (CT
1. Repair
o Process by which lost or necrotic cells are replaced by vital
cells
o Stimuli that induce death in some cells can trigger activation
of proliferative pathways in others
o Involves regeneration and/or fibrosis
a. Regeneration
- Replacement of cells by those of an identical type
- 2 Requirements:
i. Tissue capable of parenchymal regeneration
ii. Maintenance of the architectural (CT)
framework/ basement membranes (eg.
hepatocytes and renal tubular cells)
- E.g. parvoviral enteritis
i. necrosis of intestinal epithelium (crypts)
ii. regeneration of epithelium = recovery
iii. Note: not all animals survive; rate ~5%
- Regeneration begins early in the inflammatory
process
- Mediators (interleukins, chemokines, etc.) often
both pro-inflammatory and pro-repair
- Cells to replace must be differentiated
i. A cells I well-differentiated if it looks like the
mature adult cell.
ii. Has tendency to be benign
iii. If it looks undifferentiated, it may be
malignant (tumor).
Normal and injured mucosa, nasal conchae, rats. Normal ciliated
epithelium composed of tall columnar cells with numerous cilia.
b. Fibrosis
- When replacement by original tissue is impossible
- See increase in fibrous CT within the tissue
- Fibroblasts synthesize collagen and proteoglycans
- New blood vessels are necessary:
neovascularization
- Granulation tissue: term for the particular
arrangement of
i. Fibroblasts
ii. Collagen
iii. Neovascularization
o Regeneration vs. Fibrosis: the achievement of normality at
the end of a repair process depends on:
a. The ability of the host to eliminate the inciting agent
b.
framework, basement membranes)
c. How much fo the exudate is removed/resolved.
d. The ability of the injured tissue cells to regenerate
(labile or stable vs permanent)
o Because there are so many requirements for a return to
normality, some degree of scarring is more common than
complete resolution for most significant lesions.
2. Tissue Proliferative Capacity
o Repair capability of tissues varies with the organ system; ie.
Different cell types have varying regenerative ability:
a. Labile (continuously dividing cells)
- Usually repairs by regeneration
- Continuously dividing (>1.5% of these cells are in
mitoses) & dying
- After injury, see rapid regeneration if:
i. Architecture not severely altered
ii. Enough stem cells remain viable
- E.g. epithelium of skin and mucous membranes
(eg. gut), lymphoid cells (in the intestine),
haematopoietic cells
b. Stable (quiescent) cells
- Repair by regeneration or fibrosis
- ‘inactive, but can divide’
- Low level of replication (<1.5% of normal adult
cells in mitosis)
- Cells in this category generally have long life spans
and are capable of rapid division in following tissue
damage.
- E.g. hepatocytes, renal tubular epithelium,
endothelial cells, mesenchymal cells (fibroblasts),
smooth muscle cells, epithelial cells of liver,
kidney, lung; endocrine organs
- Need intact BM for renal tubules or hepatocytes to
regenerate
- Glomeruli do not regerate.
c. Permanent (nondividing) cells
- Repair by fibrosis
- Cells don’t divide; no regenerative ability
- 0% are in mitoses
- Can only regenerate portions of the cell (eg. axonal
regeneration)
- E.g. Neurons (now found able to divide), cardiac
muscle cells, lens epithelium
3. Fibrosis (Repair by Connective Tissue Proliferation)
o Repair begins within 24 hours of occurrence of the injury
o First events:
 a. Fibroblasts migrate to the site of injury/inflammation
b. Induction of fibroblast and endothelial cell proliferation
c. Within 3-5 days, see granulation tissue (fibroblasts +
collagen + neovascularization)
d. Over weeks to months: gradual increase in collagen and
regression of vessels (scar)
o Four components of repair by fibrosis:
a. Angiogenesis (neovascularization)
1. Proteolysis of parent vessel basement membrane and
ECM: allows formation of capillary sprouts
2. Migration & chemotaxis of endothelial cells to angiogenic
stimulus: via endothelial integrins binding to fibrin and
fibronectin
3. Proliferation of endothelial cells: esp. VEGF secreted by
macrophages, platelets, endothelium and fibroblasts
4. Maturation into capillary tubes with recruitment and
proliferation of supporting pericytes & smooth muscle
cells
5. New vessels are leaky.
In angiogenesis from preexisting vessels, endothelial cells from these
vessels become motile and proliferate to form capillary sprouts.
Regardless of the initiating mechanism, vessel maturation
(stabilization) involves the recruitment of pericytes and smooth
muscle cells to form the periendothelial layer.
- Blood vessels make healing possible.
b. Migration and proliferation of fibroblasts
- Due to growth factors produced by activated
endothelial cells and activated leukocytes (esp.
macrophages)
- Main growth factors:
i. PDGF: Platelet Derived Gorwth Factor
ii. TGF-β: Transforming Growth Factor Beta
iii. FGF: Fibroblast Growth Factor
c. Deposition of extracellular matrix (ECM)
- Fibroblasts synthesize ECM (especially collagen);
starts from 3-5 days and continues onward.
- Main growth factors involved:
i. PDGF: Platelet Derived Gorwth Factor
ii. TGF-β: Transforming Growth Factor Beta
d. Maturation and reorganization of fibrous tissue
- Development of granulation tissue & subsequent
scar tissue formation
- In well organized granulation tissue, fibroblasts
and collagen fibers run in bundles perpendicular to
long thin blood vessels of the neovascularization.
4. Wound Healing
o Process of fibrous replacement and regeneration (various
amounts of each)
o Results in: restoration of tissue continuity, with or without
function.
o Steps in wound healing (regardless of etiology):
a. Induction of acute inflammatory response by initial
injury (necrosis)
b. Parenchymal cells regenerate (if possible)
c. Migration and proliferation
- CT cells: fibroblasts and endothelial cells
- Parenchymal cells
d. Synthesis of ECM (collagen/ proteoglycans)
e. Remodeling of parenchymal cells: restore function
f. Remodeling of connective tissue: wound strength
o Factors that can impair wound healing
a. Infection
b. Nutrition
c. Glucocorticoids
d. Mechanical factors
e. Poor perfusion
f. Foreign bodies
g. Amount & type of tissue injured
h. Location of injury
o Two main ways in which cutaneous wound will be resolved:
a. Cutaneous wound healing by First Intention (primary
union)
- Possible when tissue elements in close proximity/
close apposition in a wound (eg. surgical wound)
- A primary union where regeneration predominates
over fibrosis
24 hours Neutrophils migrate into fibrin clot
Basal epidermal cells at edges of incision increase
mitotic activity
24-48 hours Epithelial cells migrate and proliferate
Deposition of basement membrane
Day 3 Macrophages replace neutrophils
Fibroblasts and collagen fibers at margin (vertical)
Epithelial cells continue to proliferate
Day 5 Neovascularization peaks as granulation tissue fills
space
Collagen fibers bridge wound (horizontal)
Day 14 Fibroblasts and collagen accumulation continue
Decreased leukocytes and edema
Blanching occurs as vascular channels regress
No more neutrophils, macrophages, growth factors,
regressing blood vessels
4 weeks Scar (fibroblasts and collagen)
Few inflammatory cells
Tensile strength increases with time

b. Cutaneous wound healing by Second Intention
(secondary union)
- Where there is poor apposition (eg. ragged cuts)
- usually develops in more extensive injuries
- More complex repair process
i. More inflammation (fibrin and leukocytes)
ii. More granulation tissue
iii. Contraction due to myofibroblasts
iv. Usu. result in an irregular scar (which
generally contracts)
- Minimize by: tissue transplant
1. Healing in Specific Tissues
o Wound Strength
a. If not sutured: at 1 week, ~10% wound strength and
increases to ~70-80% at 2 months; then doesn’t get
much better.
b. If sutured: immediate wound strength is ~70%; note
sutures are usu. removed on day 10.
o Granulation Tissue
- Gross: Pink, soft, granular tissue on wound surface
that bleeds easily
- Histologically: see proliferation of new small blood
vessels and fibroblasts (characteristic features)
- Composed of four recognizable zones:
a. Zone of necrotic debris and fibrin: superficial area of
variable thickness
b. Zone of macrophages (clean-up) and in-growing
capillaries: angiogenesis
c. Zone of proliferating capillaries and fibroblasts:
- Budding young blood vessels grow from more
mature vessels in the deeper zone up into the
wound
- These vessels grow perpendicular to the surface of
defect.
d. Zone of mature fibrous connective tissue:
- Oldest portion of the healing process (mature
collagenous scar)
o Exuberant Granulation Tissue (Proud Flesh)
- Esp. with horses; due to:
a. Severe and prolonged tissue injury
b. Loss of tissue framework (BM’s)
c. Large amounts of exudate
- Hypertrophic scar: precludes epithelization
- Humans can also get, eg. keloid
- Keloid: excessive amount of scar tissue that grows
beyond the boundaries of the original wound and
does not regress
o Consequences of granulation/fibrosis
a. Loss of functional parenchymal tissue
b. Alteration of physical properties of tissue, eg.
- skin with a scar is more prone to tearing
- pulmonary fibrosis decreases compliance and thus
increases workload for respiration.
a. Liver
- Healing can vary from complete parenchymal
regeneration to extensive scar formation (or in
between)
- Depends on how much damage to the CT framework
(insult, location, extend, chronicity)
- If the insult is mild: regeneration with minimal fibrosis/
alteration of morphology
- If insult is severe: fibrosis will be abundant and will
result in morphologic and functional alterations.
 as they establish contact with other epithelial cells, mitosis
stops and cells differentiate into type 1 pneumocytes.
o Alveolar injury with ruptured BM
- will result in fibrosis/scarring
- mesenchymal cells from alveolar septa proliferate and
differentiate into fibroblasts and myofibroblasts.
d. Heart
- Healing occurs by granulation tissue & scarring, as
myocardial cells are permanent cells, unable to proliferate.
e. Brain
- Fibroblasts and glial cells proliferate along vasculature
- Neurons are permanent cells: can’t
proliferate/regenerate
- Astrocytes & fibroblasts proliferate: form fibrous
network
- Microglial cells are phagocytic: clean up debris
- When neuropil (neuroparenchyma) is punctured by sterile
instrument: lesion heals by astrocytic gliosis and fibrosis
- Lesion fills with fibrous core derived from
meninges and perivascular adventitia.
- Astrocytes: stimulated by edema and ischemia; less
b. Kidney vulnerable to injury than nerve cells
- has variable regenerative capacity - So if astrocytes are not destroyed during injury,
- cortical tubules: maximal they form a branching network around the
- medullary tubules: minimal wounded neuropil.
- Microglial cells: migratory, actively phagocytic cells of the
- glomeruli: none
nuropil.
- See excellent tubular epithelial regeneration in cases of f. Bone
mild injury (ie no destruction of BM) - Stages in fracture healing:
- Tubular regeneration requires intact BMs 1-2 days Hematoma: extensive blood clot forms in
- If there is destruction of ECM framework (along with subperiosteal and soft tissue, and in marrow
tubular epithelial necrosis), it will result in repair with cavity. Bone at the fracture site is jagged
scar formation with incomplete regeneration. Up to 7 days Inflammatory phase: neovascularization and
Right: cortical tubules with
beginning organization of blood clot
tubulorrhexis (destruction of Week 1 to Reparative phase: formation of a callus of
BM): epithelial cells have no many weeks cartilage and woven bone near fracture site.
platform to proliferate on. Jagged edges of the original cortex have
Macrophages and fibroblasts been remodeled and eroded by osteoclasts.
infiltrate and proliferate. Marrow space is revascularized and contains
Fibrous CT replaces & reactive woven bone, as does the periosteal
surrounds, sometimes
area.
suffocates the surviving ones
which become atrophied. Several weeks Remodeling phase: cortex is revitalized,
Left: cortical tubules without to months reactive bone may be lamellar or woven.
tubulorrhexis: surviving tubular New bone is organized along stress lines and
cells flatten (squamoid mechanical forces.Extensive osteoclastic and
appearance) & migrate into osteoblastic cellular activity is maintained.
necrotic area along the BM. Eventually the woven bone is replaced by
Mitoses frequent, occasional
lamellar bone.
clusters of epithelial cells
project into the lumen. Within - Soft callus: organizing fibrocellular tissue before
a week, flattened cells are calcification, provides some anchorage bw the
more cuboidal and ends of fractured bones but offers no structural
differentiated cytoplasmic elements appear. Tubular morphology and rigidity for weight bearing
function normal by 3-4 weeks. - Hard callus: hard bony tissue that develops around
c. Lung the edges of fractured bone during healing; as it
o Alveolar Injury with intact BM mineralizes the stiffness and strength of the callus
- See regeneration if alveolar exudate (eg. fibrin, cell debris) increases to the point that controlled weight
is cleared by neutrophils and macrophages bearing can be tolerated.
- If inflammatory cells fail to lyse the alveolar exudate,
exudate is organized by granulation tissue and intra-
alveolar fibrosis results.
- Alveolar type 2 pneumocytes: cells responsible for
regeneration (they are the alveolar stem cells)
- After injury, type 2 pneumocytes migrate to denuded
areas and undergo mitosis to generate cells with features
intermediate bw those of type 1 and type 2 pneumocytes;