Inversion of nipple

Q) Simple nipple inversion is seen in?

a) Duct ectasia

b) Puberty

c) Peri ductal fibrosis

d) Carcinoma breast

Answer free

b

Inversion of nipple  is  seen in a lot of conditions, both benign and malignant. Common causes are 

  1. Duct ectasia
  2.  After breast Surgery
  3. Fat necrosis
  4. Mondor disease
  5. Chronic peri ductal mastitis
  6. Carcinoma breast 

Rapid unilateral development of inversion of nipple is a dangerous sign and warrants further diagnosis. Further circumferential retraction is also sign of carcinoma.

Simple nipple inversion occurring at puberty  or retracted nipple is of unknown cause and is bilateral in 25%. Mostly No treatment is required for this and condition resolves spontaneously during pregnancy and lactation.

Suction pumps and cosmetic surgery can also help.

Inversion of nipple associated with malignancy may be with or without the presence of lump. Associated discharge from the nipple can point to the diagnosis.

Ref - Bailey 801

Grading of benign nipple inversions for management

In grade I, the nipple is easily pulled out manually and maintains its projection quite well.  It has minimal fibrosis  thus, manual traction and a single, buried purse-string suture are enough for the correction.

Grade II (majority)  the nipples can be pulled out but cannot maintain projection and tend to go back again. These nipples are thought to have moderate fibrosis beneath the nipple.

In grade III, to which the least number of inverted-nipple cases belong, the nipple can hardly be pulled out manually. Severe fibrosis made it impossible to reach optimal release of the fibrotic band with the preservation of the ducts.

Ref https://www.ncbi.nlm.nih.gov/pubmed/10654681

 

 

Spontaneous fistula closure

Q) Adverse factor for spontaneous fistula closure:

a) Tract <1cm

b)Transferrin > 200

c) Location in esophagus

d) First surgery done in the same institution

Answer free

a) Tract less than 1 cm

Spontaneous fistula closure

Short-turnover  protein (prealbumin,  retinol-binding  protein,  transferrin)  levels should  be  measured  at  least  weekly  to  assess  the  adequacy of  protein  delivery. An  ongoing  catabolic  state  will adversely  affect  short-turnover  protein  levels,  even  with maximal  protein  delivery.

Failure  of  an  enterocutaneous  fistula  to  close  spontaneously  is associated with acronym FRIENDS): 

the  presence  of  a foreign  body  within  the  tract  or  adjacent  to  it,  previous radiation  exposure  of  the  site,  ongoing  inflammation (most  commonly  from  Crohn  disease)  or  infection  that contributes  to  a  catabolic  state,  epithelialization  of  the fistula  tract  (particularly  if  the  fistula  tract  is  less  than 2  cm  long),  neoplasm,  distal  intestinal  obstruction,  and  pharmacologic  doses  of  steroids. 

Fistulas  associated  with  a concurrent  pancreatic  fistula  also  have  a  low  rate  of  spontaneous  closure,  as  do  those  occurring  in  the  presence  of  malnutrition  or  adjacent  infection.

In general,  anatomic  locations  that  are  favorable  for  closure  are  the  oropharynx,  esophagus,  duodenal  stump,  pancreas,  biliary  tree,  and  jejunum.