TABLE 32-1. Causes of hemoptysis | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Hemoptysis
Hemoptysis
Anthony Cultrara
Gady Har-El
Hemoptysis is the spitting or coughing of blood. It should be differentiated from hematemesis, which is the vomiting of blood. The cause of bleeding may lie anywhere in the upper or lower respiratory tract from the nose to the lungs. Blood spit up without coughing generally comes from the upper respiratory tract, including the nose, paranasal sinuses, oral cavity, and oropharynx. Blood from the larynx, trachea, and lower bronchial tree generally induces coughing. However, the entire respiratory tract must be considered in an investigation of hemoptysis, which may be acute or chronic and recurrent.
MEDICAL HISTORY AND PHYSICAL EXAMINATION
The degree of bleeding, frequency of episodes, precipitating events, and surrounding circumstances must be recorded. The amount of bleeding is difficult to assess because patients tend to overreact and exaggerate. In addition, blood may be swallowed. It is essential to differentiate spitting of blood and true coughing of blood. Complete otolaryngologic examination is necessary to rule out upper respiratory tract causes, which may be clearly evident or occult. The heart and lungs should be examined.
ANCILLARY DIAGNOSTIC TESTS
Hematologic and radiographic tests should be used selectively. A complete blood cell count may help to determine the amount of bleeding that has taken place. A platelet count and appropriate coagulation studies help to define a coagulopathy, if one exists. A family medical history may be informative, because some hematologic disorders are inherited. If suspicious lesions are found, computed tomography should be performed.
If the hemoptysis is chronic and mild, an underlying cause may not be found among as many as 20% to 30% of patients. In these circumstances, it may be reasonable to observe the patient, requesting that he or she bring in collections of coughed-up sputum and blood. The physician should be selective in evaluation of this symptom to avoid unnecessary and often expensive tests. Studies may have to be repeated. In rare instances patients may need hospitalization for observation. Fortunately, most cases of hemoptysis have an underlying cause detected with one of the usual diagnostic methods.
DIFFERENTIAL DIAGNOSIS
Hemoptysis may involve major or minor degrees of hemorrhage. It must always be investigated because it may be the first sign of serious illness. Bleeding gums are probably the leading cause of minor hemoptysis from the upper respiratory tract. This may result from vigorous tooth brushing, periodontal disease, or minor mucosal irritation. A more comprehensive list of nasal, upper airway, lower airway, and gastrointestinal bleeding is shown in Table 32-1.
