A23. Hemoptoe, hematemesis

Haemoptysis

Haemoptysis (or haemoptoe) refers to expectoration (coughing up) of blood originating from the lower respiratory tract. In most cases, haemoptysis is small and not life-threatening, originating from the pulmonary circulation. Life-threatening (also called “massive”) haemoptysis usually originates from the (higher pressure) bronchial circulation and is life-threatening due to large amounts of blood causing airway obstruction, significant gas exchange abnormality, or haemodynamic instability.

The mortality rate of life-threatening haemoptysis ranges from 7 – 30 percent.

Life-threatening haemoptysis

Etiology

• Bronchiectasis (usually cystic fibrosis-related)
• Tuberculosis
• Bronchial or lung cancer
• Aspergilloma

While these are the most common causes of life-threatening haemoptysis, any cause of non-life-threatening haemoptysis may of course be threatening to life.

Evaluation and management

Life-threatening haemoptysis should be managed initially with ABCDE and stabilisation, often involving intubation and positioning the patient in the lateral decubitus position with the bleeding side down.

Bronchoscopy is invaluable in life-threatening haemoptysis, as may allow for both diagnosis of the etiology and allow for therapeutic measures, like ablation, iced saline, topical medications, or application of balloon devices. After the patient has undergone bronchoscopy and is stable, a contrast chest CT provides complementary diagnostic information.

Bronchial artery embolization is an interventional radiological technique which iatrogenically embolises the culprit bleeding artery and may be used in cases where initial measures are insufficient to stop the bleeding.

Non-life-threatening haemoptysis

Etiology of non-life-threatening haemoptysis

• Chronic cough
• Acute bronchitis
• Bronchiectasis
• Bronchial or lung cancer
• Tuberculosis
• Pulmonary embolism
• Pulmonary vasculitis (Takayasu arteritis, ANCA-associated vascilitis, ++)
• Etc.

Evaluation and management

In non-life-threatening haemoptysis, obtaining a chest x-ray is obligatory, as it may show evidence of a tumour and tuberculosis. Further evaluation and management depend on the most likely cause, as well as the findings of the chest x-ray. Malignancy must always be ruled out.

Haematemesis

See topic B16 (acute gastrointestinal bleeding).