Duct Ectasia - Clinicals, Diagnosis, and Management

Breast

Clinicals - History

Fact Explanation
Green, black, dirty white nipple discharge Dilatation of large lactiferous ducts that fill up with a stagnant brown or green secretion. Usually occurs spontaneously and is usually intermittent. Green, black, dirty white nipple discharge
Dilatation of large lactiferous ducts that fill up with a stagnant brown or green secretion. Usually occurs spontaneously and is usually intermittent.
Tenderness of nipple and surrounding breast Peri-ductal mastitis or abscess formation due to bacterial infection of the stagnant fluid. Tenderness of nipple and surrounding breast
Peri-ductal mastitis or abscess formation due to bacterial infection of the stagnant fluid.
Reddeness of the nipple and surrounding breast Discharge of the stagnant fluid onto the surrounding skin creates an irritant reaction. Reddeness of the nipple and surrounding breast
Discharge of the stagnant fluid onto the surrounding skin creates an irritant reaction.
Nipple inversion Fibrosis develops in a setting of chronic inflammation causes shortening of the duct and the nipple causing a slit like nipple retraction. Nipple inversion
Fibrosis develops in a setting of chronic inflammation causes shortening of the duct and the nipple causing a slit like nipple retraction.
Breast lump Over time the continuity of the duct epithelium is broken leading to leaking of lipoid material that forms a chronic indurated mass that appears beneath the areola. Breast lump
Over time the continuity of the duct epithelium is broken leading to leaking of lipoid material that forms a chronic indurated mass that appears beneath the areola.
Mammillary duct fistula With recurrent abscesses fistula formation of the ducts may occur Mammillary duct fistula
With recurrent abscesses fistula formation of the ducts may occur
Enlarged axillary lymph nodes Reactive lymphadenopathy due to inflammation and abscess formation in the breast. Enlarged axillary lymph nodes
Reactive lymphadenopathy due to inflammation and abscess formation in the breast.

Clinicals - Examination

Fact Explanation
Nipple discharge Characteristically black, brown or green colored. May be offensive due to bacterial growth. Nipple discharge
Characteristically black, brown or green colored. May be offensive due to bacterial growth.
Nipple retraction Manifest as transverse slit like retraction due to shortening of duct and nipple in a setting of chronic inflammation. Nipple retraction
Manifest as transverse slit like retraction due to shortening of duct and nipple in a setting of chronic inflammation.
Breast tenderness Chronic low grade infection of the peri-areolar area. Can progress to abscess formation when it is known as peri ductal mastitis. Breast tenderness
Chronic low grade infection of the peri-areolar area. Can progress to abscess formation when it is known as peri ductal mastitis.
Mammillary fistula Rupture of a peri ductal abscess on to the skin will cause a fistula. Mammillary fistula
Rupture of a peri ductal abscess on to the skin will cause a fistula.
Sub areolar lump Indurated mass forms due to leakage of lipoid material from a lactiferous duct. Sub areolar lump
Indurated mass forms due to leakage of lipoid material from a lactiferous duct.

Investigations - Diagnosis

Fact Explanation
Culture and antibiogram of the nipple discharge To identify causative pathogens and prescription of appropriate antibiotics. In duct ectasia 60% will have anaerobic growth. Culture and antibiogram of the nipple discharge
To identify causative pathogens and prescription of appropriate antibiotics. In duct ectasia 60% will have anaerobic growth.
Occult blood of nipple discharge Positive in 64%, this does not include or exclude the possibility of cancer but indicated intra ductal pathology. Warrants further investigation to exclude malignancy. Occult blood of nipple discharge
Positive in 64%, this does not include or exclude the possibility of cancer but indicated intra ductal pathology. Warrants further investigation to exclude malignancy.
Ductography To identify the nature, extent and location of intra-ductal lesions. Ductography
To identify the nature, extent and location of intra-ductal lesions.
Mammogram Essential in the triple assessment of a breast lump. Should be performed if the patient is above 35 years. This should precede cytological investigation of a breast lump. Mammogram
Essential in the triple assessment of a breast lump. Should be performed if the patient is above 35 years. This should precede cytological investigation of a breast lump.
Fine Needle Aspiration Cytology (FNAC) Needed in the triple assessment of a breast lump. An indurated mass in duct ectasia reveals foamy macrophages and inflammatory cells. Fine Needle Aspiration Cytology (FNAC)
Needed in the triple assessment of a breast lump. An indurated mass in duct ectasia reveals foamy macrophages and inflammatory cells.
Ultrasound scan Alternative to mammogram in younger patients with dense breast tissue. Combined use increases the sensitivity and specificity of breast cancer diagnosis. Ultrasound scan
Alternative to mammogram in younger patients with dense breast tissue. Combined use increases the sensitivity and specificity of breast cancer diagnosis.

Management - Supportive

Fact Explanation
Antibiotic therapy The commonest infective organism is Staphylococcus aureus. Therefore treatment with flucloxacillin and addition of metronidazole to cover anaerobic organisms can be prescribed. Antibiotic therapy
The commonest infective organism is Staphylococcus aureus. Therefore treatment with flucloxacillin and addition of metronidazole to cover anaerobic organisms can be prescribed.

Management - Specific

Fact Explanation
Hadfields Procedure Involves radical sub-areolar duct excision. This completely removes the dilated ducts thereby alleviating symptoms. Hadfields Procedure
Involves radical sub-areolar duct excision. This completely removes the dilated ducts thereby alleviating symptoms.
Microdochectomy Appropriate for single duct discharge without any mass and negative mammogram. Microdochectomy
Appropriate for single duct discharge without any mass and negative mammogram.

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