MASTITIS

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MASTITIS (mastitis; grech, mastos a breast + - itis; synonym mastitis) — inflammation of a parenchyma and interstitium of a mammary gland.

80 — 85% of all cases of acute M. occur in a puerperal period at the feeding women (so-called lactic M.), 10 — 15% — at not feeding and only 0,5 — 1% are at pregnant women. According to L. N. Granat (1973), T. X. Kutusheva et al. (1976), the frequency of emergence of puerperal M. hesitates from 1,5 to 6%, and according to J. Mares et al. (1975), Marshall (V. of R. Marshall) et al. (1975) — from 3 to 20% in relation to number of childbirth. In puerperal period (see) 2/3 cases of various pyoinflammatory processes falls to the share of M. Increase in frequency of emergence of M. is explained by change of species composition of causative agents of a purulent infection, their antigenic properties and an antibiotikorezistentnost. Usually M. develops in one mammary gland; bilateral M. meets seldom. More often than puerperal M. arises at primapara women. M.'s incidence at women aged after 30 years increased that is explained by increase of number of first labor at this age.

Classification

Distinguish acute and chronic mastitis. Inflammatory process the parenchyma can preferential be surprised mammary gland (see) — parenchymatous M. or an interstitium of a mammary gland — intersticial M. Odnako to differentiate these forms on the basis a wedge, data are practically not possible especially as most often they are combined with each other. Separately allocate an inflammation of lacteal channels — galaktoforit (galactophoritis) and an inflammation of glands of a peripapillary circle — areolit (areolitis).

It is for practical purposes most acceptable a wedge, classification of acute mastitis of V. I. Struchkov (1967) which divides M. taking into account the course of inflammatory process on serous (initial) M., acute infiltrative M. abscessing M., phlegmonous M., gangrenous M. V to chronic M.' group distinguish purulent and not purulent forms. Chronic purulent M. is rather rare, it is most often a consequence of incorrectly treated acute; in exclusively exceptional cases primary and chronic M. K development to not purulent form is possible carry plazmokletochny periduktalny chronic M. Vydelyayut also specific seldom found M. — tubercular, syphilitic (see. Mammary gland ).

The etiology and a pathogeny

the Activator M. most often is staphylococcus. According to V. K. Gostishchev, at 82% of patients at crops suppurating staphylococcus it is allocated in pure form, at 11% — in associations with colibacillus and a streptococcus, at 3,4% — colibacillus in a monoculture is sowed, at 2,4% the streptococcus is allocated; seldom the pyocyanic stick, fungi meet proteas.

A source of an infection are carriers of activators and patients with the erased forms of pyoinflammatory diseases from among surrounding persons from whom microbes extend with dust particles, through objects of leaving, linen, etc. B. L. Gurtova and 3. P. Grashchenkova (1973), Loshontsi (D.Loschonzi, 1978), P.Altmann et al. attach (1975) paramount significance in M.'s emergence to an intrahospital infection.

Entrance infection atriums are most often nipple cracks. Possibly and intrakanalikulyarny penetration of an infection during the feeding by a breast or decantation of milk; less often spread of an infection hematogenous and lymphogenous in the ways from the endogenous centers of an infection meets. Existence of pathogenic bacteriums on skin and nipples of mother, and also in an oral cavity of the child not always leads to M. The favorable moments for development of a disease are weakening of an organism of mother associated diseases, decrease immunobiol. reactivity of its organism, hard proceeding childbirth, especially the first, with a large fruit, various complications of a puerperal period. The essential factor promoting M.'s disease is disturbance of outflow of milk with development of a laktostaz that is quite often observed in connection with insufficiency of lacteal channels at primapara, the wrong structure of nipples and disturbances funkts, activity of a mammary gland. At hit of microbes to expanded lacteal canals milk turns, walls of channels swell that aggravates stagnation of milk, the epithelium of channels is damaged. All this promotes penetration of microbes into fabric of gland, causing emergence and M.'s progressing

Pathological anatomy

Fig. 1. The diagrammatic representation of the most frequent localization of abscesses in a mammary gland: 1 — abscess of hypodermic cellulose of a mammary gland; 2 — subareolar abscess; 3 — intramammarny; 4 — retromammary.

Inflammatory process can be limited to an inflammation of lacteal channels, a cut is followed by release of milk with impurity of pus, or an inflammation of glands of a peripapillary circle. Upon transition of process to fabric of gland and its progressing phases of a serous and purulent inflammation can consistently be observed, it is frequent with the expressed destructive changes. Process comes to an end with a reparative phase. In a phase of a serous inflammation fabric of gland is impregnated with serous liquid, accumulation of leukocytes around vessels is noted. During the progressing of inflammatory process serous treatment is replaced by diffusion purulent infiltration of a parenchyma of a mammary gland with the small centers of purulent fusion which in the subsequent merge, forming abscesses. The last owing to the sharp thinning of interlobular partitions caused by inflammatory process and increase in the secretory device during a lactation can merge, break in hypodermic cellulose or in retromammary space. The most frequent localization of abscesses at M. is shown in the figure 1. In rare instances at purulent M. owing to involvement in inflammatory process of vessels and their thrombosing there comes the necrosis of certain sites of gland, the gangrenous form M develops. After opening and emptying of an abscess at a gangrenous form M. and removals of sequesters of tissue of mammary gland process of proliferation begins. Granulyatsionny fabric is formed, and then there occurs scarring.

Formation of small abscesses with the expressed induration of surrounding fabrics is the cornerstone of chronic purulent M. At plazmokletochny M. infiltrates with a large number of the wandering plasmocytes around lacteal channels come to light.

A clinical picture

the Initial form of acute M. should be distinguished from acute stagnation of milk which often precedes inflammatory process. However the basis the opinion of S. B. Rafalkes who recommends to consider any nagrubaniye of mammary glands proceeding with temperature increase, a serous form M is on the practical level not deprived. At acute stagnation of milk the feeling of weight and tension in iron appears, a cut gradually amplifies. In one or several segments according to stagnation consolidation with a clear boundary, mobile, painless is palpated; milk is emitted freely, decantation painless and gives relief. The general state suffers a little. Body temperature is increased slightly, a wedge, blood test normal, at a research of a secret of a mammary gland of deviations is not defined.

At penetration into gland of pyogenic microbes in 2 — 4 days serous M. Zabolevaniye develops begins sharply with a fever, temperature increase, perspiration, weakness, weakness, sharp a mammary gland pains. Gland is increased, its palpation is painful, infiltrate is defined indistinctly. Decantation of milk is painful and does not give relief. The quantity of leukocytes in blood increases to 10 — 12 thousand in 1 mkl, ROE is accelerated to 20 — 30 mm/hour. At absence or the wrong treatment in 2 — 3 days the initial form M. can pass in infiltrative, edges the wedge, signs of an inflammation, weight of the general condition of the patient is characterized by bigger expressiveness. At a palpation of gland inflammatory infiltrate decides on a dermahemia over it more accurately.

Fig. 2. Mammary glands of the patient at right-hand purulent mastitis: the right mammary gland is deformed due to protrusion of infiltrate, the left gland normal.

Serous M.'s transition in infiltrative, and then in purulent happens quickly, within 4 — 5 days, and is characterized by strengthening of the general and local symptoms of an inflammation, more expressed symptoms of intoxication. Temperature keeps constantly on high figures or accepts gektichesky character. The dermahemia of the struck gland amplifies, infiltrate in iron increases (fig. 2), there is a fluctuation in one of its sites, before everything — over superficially located abscesses.

At phlegmonous M. fervescence to 40 ° quite often is followed by a fever; the mammary gland sharply increases, skin becomes edematous, brilliant, hyperemic, with a cyanotic shade. Early there is regional lymphadenitis. Critical condition of patients is observed at a gangrenous form M.: temperature increases to 40 — 41 °, pulse becomes frequent to 120 — 130 in 1 min.; the mammary gland is sharply increased, skin edematous, with the bubbles filled with hemorrhagic contents with sites of a necrosis. Puffiness extends to surrounding fabrics. A leukocytosis — to 30 thousand in 1 mkl blood with a deviation to the left and toxic granularity of leukocytes; in urine protein is defined.

In modern the wedge, practice is noted a number of features of lactic M.: 1) later beginning, preferential after an extract of the woman from a maternity home (the so-called overdue, delayed M.), and at 10 — 15% of patients the first symptoms of a disease appear in 4 weeks after the delivery; 2) dominance of infiltrative and purulent forms M. which, on a nek-eye to data, are observed in 2/3 cases and proceed in the form of a diffusion or nodal form. The diffusion form with development of the expressed infiltrate and treatment of fabrics by pus (as bee cells) without accurate abscessing is more often observed. At a nodal form the isolated roundish infiltrate is formed; 3) heavier and long current of purulent forms M.; 4) a possibility of development along with typiforms of acute M. of the erased subclinical forms which are characterized by weak expressiveness and even lack of separate signs of inflammatory process, discrepancy a wedge, manifestations of true weight of defeat.

At hron, purulent M.'s current the wedge, manifestations are expressed unsharply. Increase in a mammary gland and its moderate morbidity, sometimes regional lymphadenitis with subfebrile, and from time to time — high temperature is noted; at a superficial arrangement of the inflammatory centers the dermahemia appears. Plazmokletochny M. has the subacute beginning. Appear a diffuse hyperemia, hypostasis and a dermatalgia are closer to a nipple and a peripapillary circle, subfebrile temperature, increased axillary limf. nodes. The hyperemia, hypostasis and a dermatalgia pass in several days. According to the site of a hyperemia there is dense, without clear boundary, a painful infiltrate, retraction of a nipple and serous allocations from it are sometimes noted; are palpated increased axillary limf. nodes.

Complications

M.'s Current can become complicated limfangiity (see), lymphadenitis (see) and it is rare sepsis (see). After opening (especially spontaneous) abscess milk fistulas which are closed independently, but for a long time can sometimes be formed.

The diagnosis

the Diagnosis is based on characteristic data a wedge, inspections. Bacterial, a research of pus, milk (and from a region and healthy mammary gland) is carried out, and at high temperature and a fever — a blood analysis. The electro-thermometry of skin shows more high temperature (on 1 — 2 °) over the center of defeat in comparison with surrounding sites or on other (healthy) gland.

Acute M. sometimes reminds a mastitopodobny and rozhepodobny form of cancer (see. Mammary gland). At chronic (especially plazmokletochny) M. it is necessary to exclude existence of a breast cancer what in addition apply rentgenol to. methods of a research (see. Mammography , the Mammary gland), tsitol, a research of punctate from infiltrates (see. Cytologic research ), termografiya (see), obligatory gistol, the research of remote fabrics, etc.

Treatment

Treatment is conducted taking into account a form M.: at initial forms (i.e. in the absence of a purulent inflammation) this complex conservative treatment, at purulent — an operative measure. At emergence of signs of stagnation of milk creation of rest to gland is provided for what it is given sublime situation with the help of retaining bandages or a brassiere which shall support, but not squeeze gland. Apply physiotherapeutic procedures to improvement of emptying of gland, suck away milk a milk pump; feedings by a breast do not stop, appoint oxytocin and Nospanum. At serous and infiltrative M. apply antibiotics (semi-synthetic Penicillin, aminoglycosides, cephalosporins, Makrolida), streptocides (in combination with antibiotics), infusional therapy (see) with administration of plasma substitutes, Haemodesum, proteinaceous drugs, saline solutions; use also the means increasing protective forces of an organism (gamma-globulin, etc.). Some clinics apply retromammary novocainic blockade with antibiotics and proteolytic enzymes. For blockade use 70 — 80-ml 0,5% of solution of novocaine, 500 000 PIECES of Monomycinum of a pla of Kanamycinum and 10 mg of trypsin or chymotrypsin. At stagnation of milk apply magnetic field of VCh and UVCh in a slaboteplovy dosage 10 — 20 min. to improvement of emptying of gland daily, radiation by visible and infrared beams 20 min. 2 times a day, on a course prior to 10 — 15 procedures. At a serous form M. apply electric field of UVCh or microwave in a slaboteplovy dosage 10 — 15 min. to calling of involution of process, ultrasound in intensity of 0,2 — 0,4 W/cm 2 5 — 6 min., UF-radiation of gland (2 — 3 biodoses), novocaine electrophoresis (2% solution for 70% alcohol) 20 — 30 min. in combination with microwaves or ultrasound on 8 — 10 influences. At an infiltrative form M. apply the same physical. factors, as at an initial form, but the power and intensity of influence increase. After opening of abscess and removal of pus apply ultrasound, electric field, UVCh or microwaves to stimulation of growth of granulations; for stimulation of epithelization - UF-radiations in suberythema and small erythema doses. All procedures are carried out after emptying of gland. At bilateral process impact on glands is carried out in one day serially. Sometimes at a heavy current of M. recommend suppression of a lactation the drugs inhibiting secretion of prolactin, a combination of drugs of estrogen with androgens.

Operational treatment

At acute and hron, purulent M. operation is shown. Operation is carried out under anesthetic, only at the small superficially located abscesses it is possible to use the infiltration anesthesia added with retromammary novocainic blockade. The puncture method of treatment which in due time was widely practicing so by Hie as well as small cuts section puncture ooze, it is necessary to consider vicious and it is not recommended to undertake it. At operational treatment of acute M. preference shall be given to wide and rather deep cuts of a mammary gland which would allow to remove considerably all nekrotizirovanny fabrics and to liquidate all accumulations of pus. It is necessary to remember that features of an anatomic structure of a mammary gland, poorly expressed tendency of its fabrics to restriction of inflammatory process and their high reactivity cause tendency to a recurrence and M.'s progressing that is of particular importance at insufficiently considerably executed operation.

Intramammarny abscesses open with radiarny cuts. The cavity of an abscess is inspected a finger, divide crossing points. Pus is deleted, the cavity of an abscess is washed out solution of hydrogen peroxide, drained. Then edges of a section part with hooks and at good lighting examine an abscess cavity, pressing on gland. If the message of an abscess with other deep located abscess is found, then the opening, from to-rogo arrives pus, expand with a packer. Excise the nekrotizirovanny fabrics not only sequestered, but also connected with fabric of gland, which are hanging down in an abscess cavity. If conditions for drainage are adverse (the big sizes a cavity, purulent flow), then do additional radiarny cuts. Cavities of abscesses drain by means of rubber tubes or strips of glove rubber. If there are several intramammarny abscesses, each of them is opened with a separate section and carry out active aspiration of contents (see. Aspiration drainage ).

Retromammary and the deep-located intramammarny abscesses open from the lower semi-oval section of Bardengeyer: on the lower transitional fold cut skin, hypodermic cellulose and get into retromammary space, otslaivy to iron from a big pectoral muscle. At the same time intramammarny abscesses open behind. Enter tampons into a cavity of an abscess, drainage tubes, sew up a wound to drainages. Such method of opening of abscesses allows to avoid crossing of intra lobular lacteal channels, provides good conditions for outflow of pus and an otkhozhdeniye of nekrotizirovanny fabrics, yields good cosmetic result as after recovery there is a hardly noticeable hem which is covered with the hanging gland. Some authors at the localized acute M.'s forms and especially at chronic M. excise a suppurative focus within healthy fabrics and put a deaf stitch, leaving a thin drainage for introduction of antibiotics. Also active complex therapy is shown.

Treatment of wounds after opening of an abscess is carried out taking into account a phase of a wound process (see. Wounds, wounds ). Use secondary seams (see) reduces terms of treatment and improves cosmetic results of operation.

To postoperative complications can give leaving in iron of small abscesses, nekrotizirovanny fabrics, insufficient drainage of an abscess cavity. These defects of operation are fraught with danger of continuation of purulent process that is the reason of repeated operative measures.

At not purulent (plazmokletochny) M. if the diagnosis is confirmed cytologic, short-term antiinflammatory treatment by salve dressings, antibiotics is admissible, it is occasionally admissible roentgenotherapy (see). If within 2 weeks conservative treatment is inefficient, the sectoral resection of a mammary gland with an urgent gistol, a research of remote fabrics is necessary.

The forecast and Prevention

the Forecast at timely begun M.'s treatment favorable.

Prevention is begun in clinics for women long before childbirth. A basis of preventive actions is increase in body resistance of the pregnant woman to adverse influences of childbirth and a puerperal period. The important place is taken by sanitation of the endogenous centers of an infection, training of women, especially primapara, to rules of feeding of the child a breast, to care of mammary glands (see. Pregnancy , Puerperal period ), hardening of an organism, immunization by staphylococcal anatoxin, UF-radiation etc. Special attention needs to be paid to the pregnant women from group of «high risk» of M.'s development i.e. having in M.'s anamnesis, a purulent infection of various localization and also with mastopathy (see), anomaly of development of mammary glands, a nipple, with complications pregnancies (see). The prevention of patrimonial traumatism, blood loss, a labor pain relief, fight against stagnation of milk, processing of nipples before feeding of the child a breast, prevention and timely treatment of nipple cracks (see. Mammary gland ) enter a complex of preventive actions. Considering value of a hospital infection in M.'s development, a dignity. - epid, allocate to the mode of hospitals in prevention of pyoinflammatory diseases of newborns and women in childbirth extremely important place. Early detection and sanitation of bacillicarriers, careful performance a dignity first of all concern to them. - a gigabyte. requirements at care of women in labor, regular wet cleaning, airing of chambers, use of germicidal lamps etc. (see. Intrahospital infections ).

Mastitis of newborns

Mastitis of newborns is observed in the first weeks of life and often the nagrubaniye of mammary glands when segments of gland increase several times matches the period fiziol.

Etiology and pathogeny. Infection of giperplazirovanny ferruterous elements leads to their inflammation. An infestant most often is staphylococcus. Infection, as a rule, occurs in the contact way. At development of purulent process in iron in segments one or several abscesses are formed. Because of an underdevelopment of the capsule of gland inflammatory process is seldom limited to one segment and passes to surrounding fabrics, peripapillary a circle, skin and hypodermic cellulose.

Clinical picture. The disease begins sharply. The mammary gland increases, condensed, local temperature increases, there is a hyperemia and a swelling peripapillary a mug, and in 1 — 2 days — fluctuation. The palpation of gland is painful. The general condition of the child worsens: there is a slackness, loss of appetite, body temperature increases. In the absence of treatment inflammatory process can progressively extend.

Complications — full death of tissue of mammary gland and development of phlegmon of a thorax.

Treatment can be conservative and operational. In a stage of inflammatory infiltration locally apply the warming compresses, salve dressings, dry heat, UVCh. Under the influence of early the begun treatment process can undergo involution.

During the abscessing operational treatment is shown. Cuts over the site of fluctuation make in the radiarny direction from a peripapillary circle. Length of a section no more than 1 — 1,5 cm. The wound for days is drained a thin rubber strip, imposing for 2 — 3 hours a bandage with hypertensive solution of sodium chloride, replacing it then ointment. Carry out UVCh-therapy, appoint antibiotics of a broad spectrum of activity. In uncomplicated cases on 3 — the 5th days the general state improves, temperature is normalized, to 7 — to the 8th day infiltrate resolves and the wound heals. In case of M.'s complication by phlegmon of a thorax and development of sepsis treatment is carried out by the principles accepted at these diseases (see. Sepsis , Phlegmon ).

Forecast at M. favorable is more often. However at considerable fusion of gland in the subsequent at girls asymmetry in development of gland, an obliteration of lacteal channels can be noted that in the future can affect a lactation.


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V. K. Gostishchev, B. L. Gurtova, P. I. Tolstykh; T. V. Krasovskaya (it is put. hir.).

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