Hemoptysis

Hemoptysis is defined as coughing or spitting up blood. Blood can originate from any anatomic site that communicates with the mouth (the “aerodigestive” tract): the mouth, sinuses, nasopharynx, oropharynx, esophagus, stomach, airways, or lung parenchyma. History often differentiates source, as may exam, but hemoptysis—no matter how small—always warrants attention.

Differential Diagnosis

• Think anatomically and physiologically of why we bleed and the source of the blood
• Upper airway
  –Nose bleed
  –Chronic sinus disease
  –Postoperative bleeding
  –Dental disease
  –Trauma (including CNS)
• Digestive tract
  –Esophageal varices
  –Gastric bleeding (unlikely to come from intestine; that is, distal to antrum)
  –Oral ulcers/trauma
• Lower airways
  –Tracheobronchial tree bronchiectasis (e.g., with CF)
  –Bronchial erosion (e.g., from tracheotomy tube)
  –Wegener granulomatosis
• Parenchyma
  –Pulmonary hemorrhage
  –Pulmonary tuberculosis
  –Lung abscess
  –Hemorrhagic fevers (rare in U.S.)
  –Paragonimiasis (a trematode infection)
  –Lung contusion from trauma
  –Primary pulmonary hemosiderosis
  –Swyer-James syndrome
• Cardiovascular causes
  –Pulmonary embolism
  –Multiple pulmonary telangiectasia (e.g., Osler-Weber-Rendu)
  –Ruptured arteriovenous fistula
  –Mitral stenosis
• Bleeding disorders (may present from any source)
  –Hemophilia, leukemia, and other blood dyscrasias
  –Increased consumption of coagulation factors (e.g., disseminated vascular coagulation)
• The most common source of blood originating in the lower airways is from small bronchial lesions secondary to inflammation from infection

Workup and Diagnosis

• History
  –Recent surgery such as sinus surgery, tonsillectomy, transbronchial biopsy
  –Recent trauma
  –Recent respiratory disease (e.g., choking episode suggests FB, fever and productive cough suggest infection)
  –Chronic illness suggests bronchiectasis, CF, chronic infection (e.g., TB)
  –Chest pain associated with cough suggests tracheal disease (i.e., tracheitis)
  –Association with gagging or emesis suggests Mallory-Weiss tear
  –Association with liver or spleen disease suggests varices or decreased platelets

• Physical exam
  –Careful ENT evaluation for an upper airway source of bleeding
  –Bleeding in other sites suggests bleeding disorder (e.g., joints, skin)
  –Examine whole patient for signs of systemic disease
• Labs
  –Blood work may help: PT/PTT and CBC for anemia and/or thrombocytopenia
• Flexible nasopharyngoscopy or bronchoscopy to evaluate airways
• Chest X-ray to evaluate pulmonary hemorrhage
• MRI may diagnose ectopic blood vessel in chest

Treatment

• The patient may need blood, packed red cells, or blood products emergently
• Diagnosis-specific therapy (e.g., FB removal)
• Therapy for bronchiectasis is aimed at treatment of underlying endobronchial infection
• Cauterization of bleeding vessels is more useful in the upper airway
• Digestive tract: Antacids, reduce portal hypertension, surgically repair source of bleeding
• It is a life-threatening surgical emergency if a large blood vessel bleeds into the trachea from tracheotomy tube-related erosions
• Consider gel-foam or metal coil injection into the bronchial circulation for chronic bleeding caused by bronchiectasis

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: Sore Throat (In A Page: Pediatric Signs and Symptoms)

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