Surgery Flashcards
Mastitis and breast abscess - Definition & Presentation
Mastitis is defined as inflammation of the breast with or without infection
Lactational mastitis occurs in breastfeeding individuals and is usually caused by a blocked milk duct or a bacterial infection entering the breast tissue
Non-lactational mastitis occurs in individuals who are not breastfeeding and can result from various factors, such as trauma, infections, autoimmune disorders
Both can be due to infection.
A breast abscess is a localised area of infection with a walled-off collection of pus. It may or may not be associated with mastitis
Presentations:
- Fever
- Decreased lactation output
- Breast warmth
- Breast Tenderness
- Breast Firmness
- Breast Swelling
- Flu-like symptoms
- Breast Pain
- Sometimes nipple discharge
Mastitis and breast abscess - Aetiology & Risk Factors
Infectious mastitis and breast abscesses are usually caused by bacteria colonising the skin –> Staphylococcus aureus are most common
Breast infections may sometimes be polymicrobial (up to 40% of abscesses)
Non-infectious mastitis may result from underlying duct ectasia (dilation/distention), and sometimes by a foreign material (i.e. nipple piercing or implants)
Risk factors:
- Female sex
- Age >30
- Poor breastfeeding technique
- Lactation
- Nipple Injury
- Shaving/plucking areola hair
Mastitis and breast abscess - Differentials
1) Breast engorgement
–> Engorgement usually occurs on the third to fifth post-partum day.
–> There may be bilateral generalised breast pain, firmness, erythema, warmth, and a mild fever (milk fever), but there is usually no oedema.
–> Relieved by frequent emptying of the breasts (e.g., breastfeeding)
2) Nipple Sensitivity
–> Usually no evidence of nipple trauma, features of breast inflammation, or fever
–> Nipple sensitivity with breastfeeding usually subsides once suckling begins, whereas pain from trauma or infection persists or increases
3) Galactocele
–> A milk retention cyst may cause a tender palpable breast lump, but there are usually no sharp shooting pains and no signs of breast inflammation or systemic illness
4) Fibrocystic Breasts
–> Painful breast tissue before menses that improves during menstruation
–> Lumps are palpated mainly in the upper outer quadrant.
–> A non-bloody nipple discharge may be reported
5) Mastodynia
–> Mastalgia may be cyclic or non-cyclic with menstruation
–> There should be no symptoms or signs of breast inflammation
Mastitis and breast abscess - Investigations
1st Order:
1) Breast Ultrasound -> Find underlying abscess
2) Diagnose needle aspiration drainage -> Infection?
3) Cytology of nipple discharge if present or from fine-needle aspiration -> Infection or malignancy?
4) Milk, aspirate, discharge or biopsy tissue for culture and sensitivity
5) Histopathological examination of biopsy tissue
Consider:
1) Pregnancy test
2) Blood culture & sensitivity -> Bacteria?
3) Mammogram
4) Milk for leukocyte counts & bacteria quantification
5) FBC -> Leukocytosis?
6) Tuberculin skin test -> Rule out TB
Mastitis and breast abscess - Management
Acute:
1) Lactational Mastitis:
–> If due to blocked duct and no signs of infections
-> Milk removal via breast feeding or milk pump + analgesia if necessary
-> paracetamol: 500-1000 mg orally every 4-6 hours when required
–> If symptoms lasting more than 12-24 hours; fever or any other signs of systemic infection; or positive microbiology studies, but MRSA ruled out
-> Antibiotics: Cloxacillin: 250-500 mg orally four times daily, for 10-14 days
-> + milk removal
–> If MRSA is confirmed
-> Non-beta-lactam antibiotic: Clindamycin: 300-450 mg orally four times daily, for 10-14 days
-> + Milk removal
2) Non-lactational Mastitis:
–> If MRSA excluded
-> Differentiating between infectious and non-infectious non-lactational mastitis is difficult, so antimicrobial therapy is always the initial treatment
-> Cloxacillin: 250-500 mg orally four times daily, for 10-14 days
-> Then switch to appropriate therapy for underlying cause if needed
–> If MRSA is confirmed
-> Non-beta-lactam antibiotic
-> Clindamycin: 300-450 mg orally four times daily
3) Breast Abscess:
–> If MRSA is ruled out
-> Surgical intervention: Drain w/ needle aspiration
-> Intravenous/oral antibiotic w/ activity against methicillin-sensitive staphylococci
-> Dicloxacillin: 500 mg orally four times daily, 7-10 days
-> Intravenous Vancomycin if more severe
–> If MRSA is confirmed
-> Surgical intervention: Drain w/ needle aspiration
-> Non-beta-lactam
-> Clindamycin: 300-450 mg orally four times daily
Ongoing:
–> Breast abscess post acute intervention
-> further surgical intervention if there is still infected tissue
Mastitis and breast abscess - Prognosis & Complications
When treated promptly and appropriately, most breast infections, including abscess, will resolve without serious complications
Resolution of mastitis after 2-3 days of appropriate antibiotic therapy is expected among most patients
Non-lactational abscesses can be multifactorial and have a greater risk of becoming chronic
Mastitis may recur with delayed therapy, inappropriate therapy, uncorrected poor breastfeeding technique, nipple candidiasis, an underlying breast condition, and in Staphylococcus carriers
Complications:
1) Cessation of breastfeeding
2) Sepsis
3) Scarring
4) Breast Hypoplasia if done in infancy
5) Extra-mammary skin infection -> if due to Staphylococcus aureus
6) Rupture of abscess can lead to Fistula
Chance of these are low
Breast Cyst - Definition & Presentation
A fluid-filled sac that can develop within the breast tissue
Common and can affect women of all ages
Usually benign
Presentations:
-> Usually doesn’t present w/ symptoms
-> Can present w/:
- Lump
- Pain/Tenderness
- Cyst size can change throughout menstrual cycle
- Change in breast tissue texture -> Lumpy/rope-like
- Nipple discharge when cyst is pressed
- Skin changes if cyst grows and stretches the skin - dimpling/puckering
Breast Cyst - Aetiology & Risk Factors
Exact cause is not fully understood
Potential risk factors:
- Hormonal Fluctuations -> especially Progesterone & oestrogen changes -> Menstrual cycle
- Hormone Replacement Therapy (HRT)
- Aging -> menopausal women more likely
- Trauma or Injury
- Genetic
Breast Cyst - Differentials
1) Fibrocystic breasts
-> common non-cancerous condition characterized by the presence of lumpy, tender breast tissue
-> It can cause cysts, breast pain, and generalized breast lumpiness
2) Fibroadenoma
-> benign tumour
-> feels like a firm, rubbery lump and is movable under the skin
-> Common in young women
3) Intraductal Papilloma
-> small, wart-like growth in a milk duct of the breast
-> can cause bloody nipple discharge and may be felt as a lump
4) Fat Necrosis
-> occurs when there is damage to fatty tissue in the breast
-> can be caused by injury or surgery.
-> can form a lump that might be mistaken for a cyst or tumour
5) Mastitis
-> infection of the breast tissue that results in breast pain, swelling, warmth, and redness
-> can sometimes cause the formation of an abscess, which could be mistaken for a cyst
6) Breast Cancer
-> can present as a lump, changes in the skin or nipple, or nipple discharge
Breast Cyst - Investigations
- Breast exam: access size, texture, shape
Typically diagnosed through imaging studies:
- Ultrasound, CT scans, or MRIs
- Fine-needle aspiration, to confirm the presence of a cyst and analyse its contents
- Biopsy lump if present
Breast Cyst - Management
No treatment is necessary for simple breast cysts that don’t cause symptoms.
Many cysts disappear without treatment
If cyst persists, feels firmer or there are skin changes, then it can be accessed and treated:
- Fine-needle Aspiration: drains the cyst. May need to be done multiple times if recurrent
- Birth control pills (oral contraceptives) to regulate your menstrual cycles may help reduce the recurrence of breast cysts –> Only recommended for severe symptoms
- Surgery (unusual)
Breast Cyst - Prognosis & Complications
Breast Cysts DO NOT increase chance of breast cancer
Very common condition that is usually very benign and unnoticeable
- Could potentially becoming infected leading to an abscess
- Can sometimes be painful
- Small risk of bleeding/infection from Needle Aspiration (rare)
- Can reoccur
- Can mask other breast changes, i.e. tumours
Anaphylaxis - Definition & Presentation
Anaphylaxis is a severe, generalised or systemic hypersensitivity reaction, characterised by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes
Presentations:
- acute onset
- airway swelling
- inspiratory stridor and hoarse voice
- SOB
- agitation, anxiety, and a sense of impending doom
Anaphylaxis - Aetiology & Risk Factors
Exposure to allergen in pre-sensitised individuals is the cause of immune-mediated anaphylaxis
Common allergens include:
- foods
- drugs
- insect stings
Anaphylaxis - Differentials
1) Septic shock
-> No allergy Hx/allergen exposure
-> Slower onset
-> Fever
2) Cardiogenic shock
-> risk factors for coronary artery disease
-> Hx angina episodes
-> elevated CK & Troponin, abnormal ECG
3) Hypovolaemic shock
-> Acute Hx major fluid loss (blood, vomit, diarrhoea, heat exposure)
-> increased Thirst, decreased urine output
-> Anaphylaxis is a form of hypovolaemic shock secondary to intravascular fluid shifts, so to differentiate must find a cause other than allergy for hypovolaemia
4) Vasovagal reaction
-> hypotension, with pallor, weakness, nausea, vomiting, and diaphoresis
->May be differentiated by the lack of cutaneous manifestations, the absent allergic history, and the presence of bradycardia instead of the tachycardia
–> Hard to tell apart
5) Asthma/Acute COPD exacerbation
-> Made better by Salbutamol
-> No allergy Hx/allergen exposure
