A23. Hemoptoe, hematemesis

Haemoptysis

Definition and epidemiology

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 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

  • Acute bronchitis
  • Bronchiectasis
  • Bronchial or lung cancer
  • Tuberculosis
  • Pulmonary embolism
  • Pulmonary vasculitis
  • 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

Definition and epidemiology

Haematemesis refers to vomiting blood and is one of the two presentations of acute upper GI tract bleeding, the other being melena. Upper GI tract bleeding refers to bleeding proximal to the ligament of Treitz. The blood may be outright red, which suggests a larger bleeding, or coffee-ground coloured, which suggests a smaller bleeding.

Haematemesis may be significant, causing haemodynamic instability.

Etiology

  • Peptic ulcer
  • Oesophageal varices
  • Arteriovenous malformations
  • Malignancy
  • Oesophageal (Mallory-Weiss) tear

Evaluation and management

As always, stabilisation and ABCDE is essential and is the first step. Intubation may be necessary to protect the airway.

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.

Treatment

Several pharmacological therapies are important in the management of acute upper GI tract bleeding:

  • IV PPI – in all cases – to reduce bleeding of any underlying peptic ulcer
  • Erythromycin – to improve vision for endoscopy
  • Somatostatin or an analogue – in cases with suspected oesophageal varices or cirrhosis
  • IV antibiotics – in cases with suspected oesophageal varices or cirrhosis

Endoscopy allows thermal coagulation, band ligation, application of haemoclips, and/or injection of epinephrine as measures to stop bleeding. If endoscopy fails to stop the bleeding, interventional radiological techniques (like transarterial embolization) should be tried.

The following are indications for surgical treatment:

  • Failure of endoscopy and interventional radiology to stop the bleeding
  • Perforation
  • Persistent haemodynamic instability

When the underlying cause is determined, treatment should be directed at it.


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