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Probability diagnosis

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Pregnancy

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Physiological

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Intraduct papilloma

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Lactation/lactation cysts

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Mammary dysplasia

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Serious disorders not to be missed

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Infection:

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  • acute mastitis/discharging breast abscess

  • areolar abscess (infected gland of Montgomery)

  • tuberculosis abscess

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Cancer:

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  • intraduct carcinoma

  • invasive carcinoma

  • Paget disease of nipple

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Other:

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  • hyperprolactinaemia

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Pitfalls (often missed)

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Mammary duct ectasia

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Drugs (e.g. chlorpromazine, metoclopramide, OCP, cimetidine, opiates, amphetamines, CCBs, tricyclic antidepressants, phenothiazine)

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Rarities:

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  • mammary duct fistula

  • mechanical stimulation

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Masquerades checklist

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Drugs (as above)

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Endocrine: hyperprolactinaemia, hypothyroidism

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Key history

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Family history of breast disease and past history including previous breast lumps, pain or nipple discharge. Note association with pregnancy, postpartum and lactation. Investigate drug intake including OTC preparations and illicit drugs especially opioids.

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Key examination

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  • Careful examination of the breast, particularly the nipples and ductal area

  • Examine associated lymph node regions

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Key investigations

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Select from:

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  • pregnancy test

  • swab of any purulent discharge

  • cytology of discharge

  • prolactin level

  • excision biopsy of discharging duct area.

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Discuss imaging (e.g. mammography, ultrasound, galactography) with consultant

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Diagnostic tips

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  • If the discharge is bilateral then serious breast disease is unlikely—consider mammary dysplasia and pregnancy.

  • Bloodstained discharge is caused by intraduct papilloma (commonest) and intraduct carcinoma.

  • Green-grey discharge: consider mammary dysplasia and mammary duct ectasia.

  • Yellow discharge: intraduct carcinoma (serous), mammary dysplasia and pus from a breast abscess.

  • Milky-white discharge (galactorrhoea): lactation, lactation cysts, hyperprolactinaemia and drugs.

  • Consider malignancy in women with a new breast discharge (>40 years) and bloody discharge.

  • Nipple discharge in a male is always abnormal.

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