Ziarnina to tkanka, która powstaje wskutek jednego z procesów gojenia uszkodzonych tkanek. Gojenie przez ziarninowanie jest dłuższe niż w przypadku rychłozrostu i może się wiązać z powikłaniami.
Ziarninowanie to proces odbudowy uszkodzonej tkanki przez angiogenezę (odrost naczyń mikrokrążenia w fazie proliferacji) oraz napływ i podział fibroblastów w miejscu zranienia. Napływ komórek jest możliwy dzięki obecności enzymów proteolitycznych (MMP1, MMP2), które upłynniają środowisko rany, oraz kwasu hialuranowego, który utrzymuje silnie uwodnione środowisko ułatwiające proliferację i odbudowę tkanek. Powstająca nowa, miękka, ale niedojrzała tkanka łączna wypełniająca ubytek jest nazywana ziarniną. W wypełnionym ziarniną ubytku makrofagi, dzięki uwalnianym czynnikom chemotaktycznym, umożliwiają odrost nerwów i odtwarzanie receptorów skóry w trakcie epitelizacji.
Gojenie w mechanizmie ziarninowania występuje w przypadku ran, w których nie doszło do pierwotnego zamknięcia. Tkankę ziarninową stopniowo pokrywają narastające na ranę komórki skóry i naskórka. Następnie ziarnina i nadmiar naczyń krwionośnych w wypełnionym ubytku przekształca się w bladą tkankę łączną z dużą zawartością włókien kolagenowych. Dochodzi do obkurczenia i zmniejszenia powierzchni rany, a następnie do wytworzenia blizny. Blizna powstała w wyniku gojenia przez ziarninowanie jest większa i bardziej widoczna niż przy gojeniu przez rychłozrost.
Jak pielęgnować rany ziarninujące?
Ziarnina i nowo tworzący się nabłonek to tkanki bardzo delikatne i podatne na uszkodzenia. Z tego względu bardzo istotne jest, by zapewnić ranie ochronę przed czynnikami zewnętrznymi. Wzrastająca tkanka wymaga również odpowiedniej wilgotności – zarówno wysychanie rany, jak i jej nadmierne sączenie mogą opóźniać proces gojenia. Tworząca się ziarnina powinna mieć również zapewnione odpowiednie warunki fizyczne (temperatura, pH, dostęp tlenu), ponieważ są one konieczne do prawidłowej migracji komórek w łożysku rany.
Leczenie miejscowe zmierzające do zapewnienia ranie optymalnych warunków gojenia powinno obejmować dobór właściwego opatrunku (z uwzględnieniem najważniejszych cech rany: lokalizacji, charakteru, głębokości i powierzchni, ilości wysięku, obecności zakażenia i stanu skóry otaczającej ranę) oraz stosowanie strategii T.I.M.E.R.S., która wzmacnia naturalne procesy regeneracyjne i eliminuje agresywne działania terapeutyczne, które mogłyby hamować proliferację rany.
Jakie powikłania mogą się wiązać z ziarniną i jak je leczyć?
W przypadku kiedy nowo tworząca się tkanka ulega nadmiernemu rozrostowi, występuje zjawisko zwane przerostem ziarniny lub wybujałą ziarniną. Przyczyną nadmiernego rozrostu ziarniny mogą być np. powtarzalne uszkodzenia łożyska rany, spowodowane jego niewystarczającym zabezpieczeniem. Przerost ziarniny uniemożliwia prawidłowe narastanie naskórka na ranę.
Wybujałą ziarninę można leczyć różnymi metodami. Pierwsza z nich to elektrokoagulacja wykonywana przez chirurga w poradni chirurgicznej. Stosowane są również laseroterapia oraz krioterapia. Do zmniejszenia rozrośniętej ziarniny można zastosować również roztwory azotanu srebra lub jodopowidon.
Inne zaburzenie związane z procesem ziarninowania to spowolnienie lub zahamowanie narastania tkanki ziarninowej, co wydłuża proces gojenia rany. Spowolnienie ziarninowania może być efektem niedoboru kwasu hialuranowego i nadmiernego przesuszenia tkanek. W przypadku zaburzeń ziarninowania tkanka narastająca w łożysku rany może być pokryta maziowatym nalotem, blada lub niebieskawa, o gąbczastej fakturze. Może to być spowodowane anemią lub schorzeniami towarzyszącymi takimi jak przewlekła niewydolność nerek i wątroby, otyłość, cukrzyca, a także zaburzeniami pracy układu krążenia. Przyczyną zaburzeń ziarninowania może być także nieprawidłowa pielęgnacja rany (np. stosowanie zbyt agresywnych metod oczyszczania lub nieodpowiednio dobrany opatrunek).
Źródła:
K. Skórkowska-Telichowska, A. Bugajska-Prusak i in., „Fizjologia i patologia przewlekle niegojących się owrzodzeń oraz sposoby ich miejscowego leczenia w świetle współczesnej wiedzy medycznej”, „Dermatologia Praktyczna” 2009, 5, 15-29.
A. Kurzyk, „Angiogeneza — możliwości, problemy, perspektywy”, „Postępy Biochemii” 2015, 61 (1): 2.
P. Mrówka, E. Głodkowska- Mrówka, „Regeneracja i reparacja uszkodzeń tkanek”, [w:] A. M. Badowska-Kozakiewicz, „Patofizjologia człowieka”, Warszawa 2013.
J. Skóra, J. Biegus i in., „Molekularne podstawy angiogenezy”, „Postępy Higieny i Medycyny Doświadczalnej” 2006; 60: 410-415.
Przeczytaj także: Czy warto stosować manualny drenaż limfatyczny w terapii ran trudno gojących się?
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