Surgery Flashcards
(88 cards)
Define mastitis:
Mastitis is the inflammation of the breast tissue, which can be with or without an infection. When associated with lactation in postpartum women, the condition is specified as puerperal mastitis. Alternatively, mastitis can be seen in women who are not breastfeeding.
What is the cause of non-infectious mastitis:
Mastitis unrelated to pregnancy and breastfeeding is typically due to obstruction of the ducts from cellular debris. This can result in a local inflammatory response in non-infectious mastitis.
What is the cause of infectious mastitis:
In infectious mastitis, bacteria from the skin can then enter the ducts, causing inflammation and may progress to peri-areolar abscesses. The most common causative pathogen is Staphylococcus aureus.
Name some risk factors for non-lactational mastitis:
Cigarette smoking
Nipple rings
Diabetes mellitus
Immunocompromise
Signs and symptoms of non-lactational mastitis
Localised symptoms: Painful, tender, red, and hot breast.
Systemic symptoms: Fever, rigours, myalgia, fatigue, nausea, and headache.
Additional information: The condition is usually unilateral and tends to present within the first week postpartum.
In some cases, mastitis may develop into a breast abscess, manifesting as a fluctuant, tender mass with overlying erythema.
What is the investigation for non-lactational mastitis
Ultrasound: Utilised to identify a potential abscess, appearing as a collection of pus.
Additional information: Early referral to secondary care is vital if an abscess is suspected.
What is the management for non-lactational mastitis:
Provide analgesia to manage symptoms (i.e. paracetamol, ibuprofen)
Warm and cold compresses may also help.
Antibiotics may be considered if acute pain, severe symptoms or symptoms lasting more than 12-24 hours, fever or positive cultures
Flucloxacillin or clindamycin for those with penicillin allergy
Treatment is indicated for 10-14 days.
In cases where the condition does not improve, consider intravenous antibiotics (i.e. vancomycin) or ultrasound to evaluate for the presence of a breast abscess.
Patients may also benefit from antifungal therapy (i.e. nystatin) for concomitant nipple candidiasis
Name some complications of mastitis:
Breast abscess
Recurrence:
More common if treatment is delayed or too short in duration
What is pueperal mastitis?
Puerperal mastitis is a condition characterised by inflammation and potential infection of the breast tissue, typically associated with lactation in postpartum women.
What causes pueperal mastitis?
Puerperal mastitis is often caused by milk stasis or blocked milk ducts. Milk stasis may occur due to inadequate milk removal, either from poor breastfeeding techniques or infrequent feeding. This can result in an inflammatory response and a potential secondary bacterial infection. The bacteria enter the breast tissue, often through a cracked or sore nipple. Staphylococcus aureus is the most common bacterial pathogen implicated in infectious cases.
Name some risk factors for pueperal mastitis?
Difficulties feeding
Reduced milk clearance from the breast
This may be related to weaning, bottle feeding, mastalgia, or infant preference for one breast or another.
Occlusion of milk ducts
Damage to the nipple (i.e. fissures, cracks or sores)
Injuries to the breast (i.e. tight clothing, seat belts)
Maternal stress
Previous history of mastitis
Cigarette smoking
Presence of breast implants
Shaving or plucking of hairs around the nipples
Signs and symptoms of pueperal mastitis?
Puerperal mastitis typically presents within one week of birth with the following symptoms:
Painful, tender, red, and hot breast. It is typically unilateral.
Systemic symptoms: Fever, rigours, myalgia, fatigue, nausea, and headache.
Potential complications: In some cases, a breast abscess may develop, which presents as a fluctuant, tender mass with overlying erythema.
Some patients may have associated axillary lymphadenopathy.
There is a severe deep burning breast pain
What are the investigations for pueperal mastitis?
Clinical evaluation: Puerperal mastitis is primarily diagnosed based on clinical symptoms and breast examination.
Ultrasonography: This may be used in cases where an abscess is suspected.
Cultures:
Not routinely indicated
Used if severe, recurrent or the presentation is abnorm
What is the conservative management for pueperal mastitis?
Most women improve with conservative management:
Analgesia: Over-the-counter pain relievers and anti-inflammatories can help manage pain and inflammation.
Avoid wearing a bra at night
Continued breastfeeding or pumping: To promote milk flow and prevent stasis. The mother should be reassured that this poses no risk to the baby.
Consider an assessment of breastfeeding by a specialist to determine if feeding pattern or positioning could be improved to reduce the risk of recurrence.
It is recommended to breastfeed 8-12 times per day to aid clearance.
Advise on methods to facilitate milk removal, e.g. manual expression.
What is the further management for puerperal mastitis?
Antibiotic therapy may be used for women who do not improve after 24 hours of conservative management if they have signs of systemic upset or if there are breaks in the skin around the nipple.
Flucloxacillin or clarithromycin are typically the first line.
Treatment is often used for 10-14 days.
The choice of antibiotic may be guided by culture results if available.
Surgical management (incision and drainage or needle aspiration):
This may be required in severe cases where a breast abscess has developed.
A sample of the fluid should be sent off for culture to enable sensitivities of the bacteria to be determined to tailor antibiotic treatment.
What are the complications of pueperal mastitis?
Abscesses are seen in approximately 1 in 20 women with puerperal mastitis.
Sepsis
Candida of the nipple:
This can occur after puerperal mastitis is treated with antibiotics.
It presents with painful and itchy nipples, with flaky and cracked skin around the areola.
The baby may, in turn, develop candida of the mouth or tongue following continued feeding.
If this develops, both mother and baby require oral antifungal treatment (e.g. miconazole).
Define breast cysts:
Breast cysts are fluid-filled sacs within the breast tissue that can be palpated as a lump
Signs and symptoms of breast cysts:
The aetiology of breast cysts is not fully understood but hormonal fluctuations are believed to play a significant role. Clinically, they may be asymptomatic or present with pain and tenderness, particularly in the premenstrual phase. On physical examination, they typically feel round or oval and smooth with distinct edges.
What are the investigations for breast cysts:
Diagnosis usually involves ultrasound imaging which distinguishes cysts from solid masses. Fine needle aspiration (FNA) may also be performed for therapeutic and diagnostic purposes; clear fluid aspiration without residual mass generally confirms the diagnosis of a simple cyst.
What is the management for breast cysts:
If symptomatic, treatment options include watchful waiting, oral contraceptives to regulate hormonal imbalances, or surgical excision in case of persistent or recurrent cysts. It’s important to note that breast cysts do not increase the risk of breast cancer.
Define fibroadenomas:
Fibroadenomas are benign tumours that consist of a mixture of fibrous and epithelial tissue. They originate from the lobules, the milk-producing glands in the breast. They are a common cause of breast lumps, particularly in women under the age of 40 years.
Causes of fibroadenomas:
The exact cause of fibroadenomas is unclear. However, they seem to be influenced by reproductive hormones, as they often enlarge during pregnancy or in times of hormone replacement therapy (HRT) use and shrink after menopause. They are also associated with Cowden’s syndrome.
They consist of fibrous and epithelial tissue.
What are simple fibroadenomas:
These are 1-3 cm in diameter and consist of uniform-appearing cells.
These are not associated with an increased risk of breast cancer.
The majority of fibroadenomas are considered to be simple.
What are complex fibroadenomas?
These are typically larger in size and are not as homogenous under the microscope. They may contain popcorn calcifications or cysts.
These are associated with a small increased risk of breast cancer.