Diagnosis and management of non-lactating mastitis
Non-lactating mastitis includes two types of mastitis: plasmacytosis and granulomatous mastitis. It is a rare and specific chronic non-bacterial inflammatory type of lesion that occurs unilaterally, usually in young women, and is generally unrelated to childbirth and lactation. The disease is widespread, rapidly developing, easily misdiagnosed, with a long course (ranging from 3 months to 30 years) and poor outcome, and is globally recognized as a difficult mammary disease, often referred to as the “cancer” that does not kill.
The exact cause of this disease is unknown, but it may be related to nipple deformity (including invagination, inversion, splitting), nipple overflow, breast trauma and hormonal imbalance, etc.: nipple dysplasia, nipple invagination and inversion may cause distortion and deformation of the breast ducts; or the large ducts are originally dysplastic; or the epidermal cells naturally shed from the invaginated nipples accumulate, become moist and erosive, or even a little smelly, forming epidermal inflammation over time; or trauma. Inflammation; or trauma resulting in damage to the structural tissue of the breast; or various causes of endocrine disorders in the body, mainly estradiol, lactogen elevation caused by abnormal secretion of the duct epithelium; or degenerative lesions of the breast ducts to the accumulation of secretions and lumen narrowing. All of the above causes blockage of the duct outlet, lipid accumulation and denaturation in the large duct, stimulating the duct wall and triggering an inflammatory reaction. This inflammation is an autoimmune reaction and is not the same as the purulent inflammation caused by bacterial infection like acute mastitis.
The clinical presentation of plasmacytic mastitis is different from that of lactational mastitis.
Plasmacytoid mastitis
Plasmacytoid mastitis is a chronic non-bacterial purulent breast infection based on dilated ducts and plasma cell infiltration in the mammary gland. Because it is essentially an aseptic inflammatory reaction, bacterial infection can only occur when it breaks down or is incised, and although antimicrobial therapy is sometimes effective, it can never cure pulpy breasts. The clinical signs and symptoms are.
1. Breast lumps or abscesses (often multiple), mostly around the areola, accompanied by pain;
2, nipple discharge, most patients can squeeze out pimple-like discharge from the nipple;
3.After the abscess breaks and the fistula is formed, some patients have serious breast disfigurement;
4. Most of the patients have no obvious systemic symptoms.
Granulomatous mastitis
Granulomatous mastitis is also common in unilateral breasts and is characterized by multiple abscesses in the breast with sinus tract formation, and is characterized by an acute onset of a chronic process.
Granulomatous mastitis is granulomatous inflammation of the lobules of the breast and is generally thought to be related to abnormal lactation within the lobules, which leads to an immune metaplasia in the lobular tissue, thus inducing the disease. In general, it does not present with nipple deformities, but has a more acute and extensive onset, with multiple and scattered abscesses and sinus tracts, distant from the nipples, mostly involving the skin, and abscesses filled with beef broth-like necrotic material rather than pimple-like lipids. It may be complicated by knee osteoarthritis and erythema nodosum, and some patients have a history of dysphoria or anti-anxiety medication prior to the onset of the disease.
Diagnosis and treatment of non-lactating mastitis
Common diagnostic methods: Breast ultrasound, mammography, MRI, and bacterial culture identification are common adjuncts to diagnose non-lactating mastitis, but confirming the diagnosis requires a puncture biopsy.
Common treatment methods: The pathogenesis of this disease is complex and there is no uniform treatment method. Western hospitals mostly use surgical methods, such as abscess incision and drainage, mastectomy, subcutaneous mastectomy + prosthesis implantation, and individual hospitals try to use anti-tuberculosis treatment and hormone therapy. All of them can achieve certain effect, but after surgery, the patient’s breast shape is greatly damaged, and it is easy to recur, and some of them still develop after total breast excision.
Our treatment method
I synthesize all the treatment methods and summarize the “three-step” comprehensive treatment method of Chinese medicine for non-lactating mastitis, namely.
(1) Health education: The doctor introduces the characteristics of non-lactating mastitis, clinical manifestations, course of the disease, prognosis and disease precautions to the patient;
(2) evidence-based treatment: using the holistic view of Chinese medicine and the view of evidence-based treatment, each patient is physically identified and all clinical manifestations are comprehensively analyzed to develop an individualized plan. Liver meridian with heat: Lactic Kang Chai and Scutellaria Tang (Chai Hu, Scutellaria baicalensis, Gardenia jasminoides, Soapberry, Dandelion, Yinhua, Qingpi, Curcuma longa, Pierced gourd, Whole guavas, Coix seeds) is used. Cold clotting and blood stasis: apply Yang He Tang (Warming Yang and dispersing cold, resolving stasis and dispersing nodules) together with Decongestant Pill plus reduction (Shu Di, Deer Antler Gum, Cinnamon, White Mustard Seed, Zhe Bei, Xuan Shen, Oyster). The residual toxin has not been cleared: adopt Lactic Kang Qi Ling Tang (on the basis of Lactic Kang Chai Scutellaria Tang, remove Scutellaria, Gardenia and Curcuma, and add products that support and disperse the knots: Astragalus, Poria, Angelica dahurica and Zhaobei). If there is more lipid-like secretion in the pus of the papilla or fistula, add Lulutong, Wang Bu Liuxing, Leucaena, and raw hawthorn; if there is a lump, add red peony, Chuanxiong, and Angelica; if there is constipation, add raw rhubarb. The above herbs are decocted in water and taken in two doses daily for 8 weeks.
(3) Combined with external treatment: each external treatment method is applied once a day for 10-15 days as a course of treatment, and the next course of treatment is performed after 3 days of rest, during hospitalization. Hoop permeation method: use Ruyi Jinhuang San (Angelica dahurica, Atractylodes macrocephala, Chen Pi, Rhubarb, Glycyrrhiza glabra, Hou Pu, Huang Bai, Jiang Huang, Sheng Tian Nan Xing, Smallpox Powder) plus alum ice liquid (our hospital’s own medicine) to make a paste and put it on the red and swollen parts, the external application range is larger than the lesion range, the thickness of the dressing should be about 0.5cm, add TDP lamp irradiation for 30 minutes/time, ultrasonic permeation for 30 minutes/time; Needle pushing plus cotton pad method: use The needle channel left by Bard’s puncture needle is used to push and squeeze with manipulation to discharge the plasma and pus, and then cotton or gauze is folded into a block to pad the affected dressing and wrapped with pressure. Incision and drainage method: Gauze strips are used for drainage, that is, gauze strips with or without rubberized muscle-generating ointment (made of elephant skin, blood surplus, turtle nail, dioscorea, angelica, gypsum, stove glycol, beeswax) are made into oiled gauze strips and inserted into the bottom of the pus cavity or sinus tract with vascular forceps. Surgical excision method: surgical removal of the mass or lesioned segment.
Prognosis
Non-lactating mastitis is prone to fistula formation, which can be prolonged and can last for years or even decades. The author’s “three-step” comprehensive treatment, health education is conducive to the patient’s correct understanding of disease regression, prognosis, and can actively cooperate with the system treatment, through more communication with patients to eliminate fear and depression, improve treatment confidence. In Chinese medicine, the nipple belongs to the liver, and the breast belongs to the stomach. If the nipple is sunken and deformed, and if it is stagnant due to liver qi, blood stasis, and lumps, and if the stagnation turns into heat, then the heat can cause the flesh to rot and become pus. Professor Lu Deming believes that the internal treatment is often based on the evidence of heat in the liver meridian and the evidence of residual toxicity not yet cleared. Accordingly, the author treats the symptoms of hepatic heat with self-prepared Lvkang Chaiqin Tang, which dredges the liver and clears heat, and eliminates swelling and dissipates nodules; he treats the symptoms of hepatic heat with Yanghe Tang from the “Complete Collection of Surgical Evidence” and the “Medical Heart Enlightenment” Scrofula Pill with addition and reduction to warm the yang and disperse the cold and dissolve the stasis and disperse the nodules; he treats the late fistula, sinus tract and sores that do not close with Lvkang Qiling Tang, which helps to disperse nodules and clear residual toxins. During the external treatment, we make full use of the Bard needle to puncture the biopsy needle channel and push out the fluid, pus and necrotic tissue from the diseased area several times, which can effectively avoid surgical incision and drainage and achieve the purpose of drainage. Combined with the special features of Chinese medicine (Chinese medicine hoops, ultrasound, TDP light irradiation, cotton padding and pressure bandaging), the treatment can significantly enhance the efficacy of plasmacytoid mastitis and maintain the appearance of the patient’s breast to a greater extent.