History

Fact Explanation
Green, black, dirty white nipple discharge Dilatation of large lactiferous ducts that fill up with a stagnant brown or green secretion. [1] Usually occurs spontaneously and is usually intermittent. [2]
Tenderness of nipple and surrounding breast Peri-ductal mastitis or abscess formation due to bacterial infection of the stagnant fluid. [1]
Reddeness of the nipple and surrounding breast Discharge of the stagnant fluid onto the surrounding skin creates an irritant reaction. [1]
Nipple inversion Fibrosis develops in a setting of chronic inflammation [1] causes shortening of the duct and the nipple [2] causing a slit like nipple retraction.
Breast lump Over time the continuity of the duct epithelium is broken leading to leaking of lipoid material[2] that forms a chronic indurated mass that appears beneath the areola. [1]
Mammillary duct fistula With recurrent abscesses fistula formation of the ducts may occur [2]
Enlarged axillary lymph nodes [3] Reactive lymphadenopathy due to inflammation and abscess formation in the breast.
References
  1. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher J K. Bailey and Love's Short Practice of Surgery. 23rd edition (International students) London. Arnold 2000.
  2. ABRAMSON DJ. Mammary duct ectasia, mammillary fistula and sub areolar sinuses. Annals of Surgery. Lippincott Williams and Wilkins. February 1969, Vol- 169(2) 217-226 [viewed 8 March 2014]. Available from DOI:10.1097/00000658-196902000-00007
  3. PETERSEN L, GRAVERSEN HP, ANDERSEN JA, DYREBORG U, BLICHERT-TOFT M. The duct ectasia syndrome. A prospective clinical study of patients with breast diseases. Ugeskr Laeger. May 1993, vol- 155(20) 1545-9 [viewed 8 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8316986

Examination

Fact Explanation
Nipple discharge Characteristically black, brown or green colored. May be offensive due to bacterial growth. [1]
Nipple retraction Manifest as transverse slit like retraction [2] 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. [2]
Mammillary fistula Rupture of a peri ductal abscess on to the skin will cause a fistula. [2]
Sub areolar lump Indurated mass forms due to leakage of lipoid material from a lactiferous duct. [3]
References
  1. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher J K. Bailey and Love's Short Practice of Surgery. 23rd edition (International students) London. Hodder Arnold 2000.
  2. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William E G. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th edition. Hodder Arnold 2005.
  3. ABRAMSON DJ. Mammary duct ectasia, mammillary fistula and sub areolar sinuses. Annals of Surgery. Lippincott Williams and Wilkins. February 1969, Vol- 169(2) 217-226 [viewed 8 March 2014]. Available from DOI:10.1097/00000658-196902000-00007

Differential Diagnoses

Fact Explanation
Breast carcinoma Nipple retraction in Breast CA differs in that it is circumferential as opposed to the transverse slit retraction seen in duct ectasia. [1] Other differentiating factors are blood stained nipple discharge, presence of hard irregular breast lump and hard immobile axillary nodes. [2]
Breast abscess Commonly seen in the lactating breast due to Staphylococcal infections. [1] Will have features of acute inflammation and cellulitis of the overlying skin. [1] Breast lump will be tender and cystic.
Tuberculosis of the breast Extremely rare presentation in developed countries. Has multiple chronic abscesses and sinuses. [1]
Bacterial mastitis Common in the lactating breast. The affected segment of the breast will show features of acute inflammation and cellulitis. [1]
Hyperprolactinemia Usually such physiological discharges are multi ductal in origin. [3] Nature of the discharge is milky white and non purulent. Possibility of a pituitary adenoma must be entertained.
References
  1. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher J K. Bailey and Love's Short Practice of Surgery. 23rd edition (International students) London. Arnold 2000.
  2. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William E G. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th edition. Hodder Arnold 2005.
  3. BLAND Kirby I, COPELAND III Edward M. The Breast: Comprehensive Management of Benign and Malignant Diseases. 4th edition. Elsevier 2010

Investigations - for Diagnosis

Fact Explanation
Culture and antibiogram of the nipple discharge To identify causative pathogens and prescription of appropriate antibiotics. [1] In duct ectasia 60% will have anaerobic growth. [2]
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. [3]
Ductography To identify the nature, extent and location of intra-ductal lesions. [1]
Mammogram Essential in the triple assessment of a breast lump. Should be performed if the patient is above 35 years.[1] 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. [1]
Ultrasound scan Alternative to mammogram in younger patients with dense breast tissue. Combined use increases the sensitivity and specificity of breast cancer diagnosis. [4]
References
  1. BLAND Kirby I, COPELAND III Edward M. The Breast: Comprehensive Management of Benign and Malignant Diseases. 4th edition. Elsevier 2010
  2. WALKER AP , EDMISTON Jr C.E., KREPEL CJ, CONDON RE. A prospective study of the microflora of nonpuerperal breast abscess. Arch Surgery . Vol 23 908-911[viewed 8 March 2013] Available from: PMID1988 3382358
  3. LEIS Jr HP, PiILNIK S, DURSI J, Nipple discharge. Int Surg. 1973 vol- 58 162-165 [viewed 8 March 2014] Available from: PMID 4735022
  4. DUJIM LE., GUIT GL , ZAAT JO, KOOMEN AR ,WILLEBRAND D. Sensitivity, specificity and predictive values of breast imaging in the detection of cancer. British Journal of Cancer 1997 vol- 76(3) 377–381 [viewed on 8 March 2014]. Available from PMCID: PMC2224070

Management - General Measures

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. [1]
References
  1. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher J K. Bailey and Love's Short Practice of Surgery. 23rd edition (International students) London. Hodder Arnold 2000.

Management - Specific Treatments

Fact Explanation
Hadfields Procedure [1] Involves radical sub-areolar duct excision. This completely removes the dilated ducts thereby alleviating symptoms. [2]
Microdochectomy Appropriate for single duct discharge without any mass and negative mammogram. [3]
References
  1. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher J K. Bailey and Love's Short Practice of Surgery. 23rd edition (International students) London. Hodder Arnold 2000.
  2. RICHARDS T, HUNT A, UMEH H. Nipple Discharge? A sign of breast cancer. The Annals of Surgery. Royal College of Surgeons England. March 2007 vol 89(2) 124-126. [viewed March 8 2014]. Available from : doi: 10.1308/003588407X155491
  3. BURTON S, LI WY, HIMPSON R, SULIEMAN S, BALL A. Microdochectomy in women aged over 50 years. The Annals of Surgery. Royal College of Surgeons England. January 2003. vol - 85(1) 47–49 [viewed 8 March 2014]. Available from: PMC1964348