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

Gastrointestinal (GI) bleeding can range from occult (no symptoms, only found on occult blood test) to severe and life-threatening. It may manifest as haematemesis, haemodynamic instability, melena, or haematochezia.

Haematemesis refers to vomiting of fresh blood, clotted blood, or coffee grounds-like material. Haematochezia refers to fresh or clotted blood per rectum and is typically a sign of lower GI tract bleeding, while melena refers to passage of black tarry stool and is typically a sign of upper GI tract bleeding. However, large (> 1L) upper GI bleeding may cause haematochezia as well.

Haematemesis mostly occurs in large bleedings.

Acute GI bleeding requires hospitalisation and urgent assessment and treatment. Mortality is high, 5 – 20%. Upper GI bleeding is 5x more frequent than lower GI bleeding.

Gastrointestinal bleeding can be occult, meaning that blood is present in the stool but not visible to the naked eye. Occult, chronic, or intermittent GI bleeding can be a sign of gastrointestinal cancer.

Variceal bleeding has a higher mortality than non-variceal upper GI bleeding, but the latter also has a high mortality rate, up to 15%. 70% of cases stop bleeding spontaneously, while the remaining either rebleed in 1 – 3 days or continuously bleed. These bleedings most frequently originate from ulcers.

Etiology

Upper GI bleeding (mostly haematemesis):

Variceal bleeding
- Due to portal hypertension, mostly due to cirrhosis
Non-variceal upper GI bleeding

Melena:

Haematochezia:

Diverticulosis (most common cause overall)
Inflammatory bowel disease
Infectious colitis (inflammatory diarrhoea)
Colorectal cancer
Angiodysplasia

The most important risk factors for ulcer bleeding are:

NSAID and aspirin use
H. pylori infection
Alcohol
Anticoagulants and antiplatelets

Clinical features

If acute GI bleeding is suspected, the first evaluation should assess for features of severe bleeding and haemodynamic instability.

Signs of severe but partially compensated bleeding:
- Postural hypotension
- Tachycardia
- Signs of vasoconstriction
Signs of haemorrhagic shock
- Pulse rate (bpm) > systolic blood pressure (mmHg)

Elevation of serum urea can be present in upper GI bleeding, due to proteins in the blood being metabolised to urea.

Diagnosis and evaluation

Acute GI bleeding

In case upper GI bleeding is suspected, due to haematemesis or signs of haemodynamic instability, urgent upper endoscopy is indicated. Colonoscopy is the investigation of choice for haematochezia. Both colonoscopy and upper endoscopy allow for both diagnosis and, in some cases, treatment of the bleeding.

Obtaining the patient’s bleeding parameters, medication list, and previous history are important to determine the source. As examples, anticoagulants can be reversed, known cirrhosis increases the likelihood of the source being oesophageal varices, and so on.

Aspiration of gastric contents through a nasogastric tube allows for quick differentiation between upper and lower GI bleeding. The aspirate is bloody in case of upper bleeding and clear in case of lower.

The Blatchford scoring system may be used to assess the risk of an upper GI bleeding requiring intervention. It’s based on vital parameters, comorbidities, lab tests, and clinical features. It’s used to identify patients who are low-risk (score ≤1) and can be treated outpatient.

Occult, chronic, or intermittent GI bleeding

Occult, chronic, or intermittent melena and haematochezia warrants investigation for malignancy, usually beginning with colonoscopy. As part of colorectal cancer screening or to investigate suspected melena or haematochezia, one can test the stool for blood. This can be accomplished with faecal occult blood tests.

Treatment

In case of acute bleeding, urgent assessment and stabilisation are crucial. If the patient is haemodynamically unstable they must be stabilised first. This involves monitoring, replacing lost fluids, and blood transfusion. Blood transfusion is indicated at haemoglobin level < 70 g/L, with a target of 70 – 90 g/L. Intubation may be necessary to protect the airway.

Then, we should determine the source of the bleeding, stop it, treat the underlying condition, and prevent recurrent bleeding. This may include terlipressin for varices.

Upper endoscopy is the main tool in the evaluation of acute upper GI bleeding, as it allows for both diagnosis and treatment of the underlying cause. It should be performed as soon as possible when the patient is haemodynamically stable. Administering erythromycin prior to endoscopy is useful, as its prokinetic properties help remove residual blood and gastric content.

If there is active bleeding, a non-bleeding visible vessel, or an adherent clot to the ulcer, endoscopic therapy with IV PPI is indicated. If there is a flat spot or clean based ulcer, no endoscopic therapy is necessary, only oral PPI. Endoscopic haemostasis may be achieved with:

Electrocoagulation
Heat
Laser
Clipping
Banding
Injection of adrenaline, sclerosing agents, or fibrin glue

Surgical treatment

Surgical therapy is indicated if endoscopic therapy fails, if the ulcer is large (> 2 cm), if there is perforation, or if the bleeding is so large that the patient requires many units of blood (4 – 6). However, > 90% of gastrointestinal bleedings are managed without surgery.

Surgical options depend on the underlying cause and include:

Bleeding ulcer
- Oversewing the ulcer
- Vagotomy
- Pyloroplasty
Perforation
- Bowel resection
Lower GI bleeding
- Segmental colectomy/hemicolectomy