Problems in Family Practice Hemoptysis Gibbe H. Parsons, MD and Glen A. Lillington, MD Davis, California Hemoptysis is an alarming symptom that should not be dis­ missed lightly. A thorough evaluation will lead to the correct diagnosis in 80 to 90 percent of cases. Surgery is occasionally necessary where life-threatening hemorrhage is present but, more commonly, appropriate therapy can only be determined when the etiology is discovered, thus mandating a careful, thorough diagnostic search. Hemoptysis, the coughing up of blood, is a In contrast to hematemesis, the blood is startling symptom which usually brings the patient coughed up and not vomited, is often frothy as it is promptly to the physician and results in well- mixed with air and sputum, and is usually (but not deserved apprehension on the part of both.1 always) bright red. In hematemesis the blood may The first task of the physician is to determine be dark red or brownish in color, due to hemoglo­ that, in fact, the blood has originated from the bin conversion to hematin by gastric acid. Hemop­ airway (larynx, trachea, bronchi) or lungs, and tysis may be preceded by a gurgling noise as the does not represent bleeding from the mouth, blood is moved by air flow in large bronchi or the nasopharynx, or gastrointestinal tract. In the trachea. The pH of the blood in hemoptysis is pediatric age group the vast majority of children usually alkaline, whereas the pH of vomited blood brought to the physician by the parent for spitting is more likely acidic. Following an episode of up blood have a source of bleeding outside the hemoptysis, the sputum may be blood-tinged for lower respiratory tract, for example epistaxis. several days, whereas vomited blood, unless it is Sometimes the patient with true hemoptysis can aspirated, is not associated with blood-tinged describe a sensation of fluid in an area of the chest sputum. Actual observation by the physician of immediately prior to hemoptysis. When this oc­ the sputum is often helpful because occasionally curs, it helps to localize the point of origin to a oxidation of inhaled bronchodilators will result in specific side and region in the tracheobronchial a brownish-red color which can impart a tree, but this is not invariably reliable. homogeneous pink color to the expectorated material. The majority of diseases that affect the pulmo­ nary system can result in hemoptysis, thus the list of possible etiologies is lengthy and will not be From the Department of Internal Medicine, Section of Pul­ reviewed in its entirety here. Nevertheless, a di­ monary Medicine, University of California, Davis, School of Medicine, Davis, California. Requests for reprints should be vision of the more common causes of hemoptysis addressed to Dr. Gibbe H. Parsons, Section of Pulmonary by age, ie, children vs adults, may be of use (Ta­ Medicine, UCD Professional Building, 4301 X Street, Sac­ ramento, CA 95817. bles 1 and 2). 0094-3509/78 !01 -0353$01.75 ® 1978 Appleton -Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 7, NO. 2: 353-359, 1978 353 HEMOPTYSIS Table 1. Some Causes of Hemoptysis in Chil­ dren Aspirated foreign body Bronchiectasis with Agammaglobulinemia Cystic fibrosis Necrotizing pneumonia Pulmonary hemosiderosis Congenital heart disease Hemoptysis in Children Idiopathic pulmonary hemosiderosis, which is As children under the age of six years rarely an uncommon disease, occurs predominantly in expectorate sputum even with extensive coaching, children and young adults, is associated with dif­ the presence of hemoptysis may not be apparent fuse recurrent alveolar hemorrhage, and char­ unless the amount of hemorrhage is large. When a acteristically presents with expectoration of pink child does present with hemoptysis, a common frothy sputum, diffuse parenchymal infiltrates on etiology is an aspirated foreign body. This diag­ chest roentgenogram, and iron deficiency anemia. nosis is especially likely if coughing is pronounced Congenital heart disease of various types as and if unilateral wheezing is present. Nonopaque well as other congenital pulmonary vascular ab­ foreign bodies resulting in “ asthma” and recurrent normalities may cause hemoptysis in children. hemoptysis have been reported in children refrac­ tory to the usual pharmacologic management of Hemoptysis in Adults asthma. Therefore, persistent wheezing that may Hemoptysis is a more frequent complaint in be generalized in association with hemoptysis adults than in children, and the list of possible should suggest the diagnosis of an aspirated etiologies is considerably longer. These etiologies foreign body. can be grouped into five categories: infections, Bronchiectasis, an abnormal dilatation of neoplastic diseases, cardiovascular diseases, im­ bronchi usually related to chronic or recurrent in­ munologic diseases, and miscellaneous (Table 2). fection and bronchial obstruction, is seen in chil­ dren with agammaglobulinemia or related im­ munologic deficiency states, with cystic fibrosis, Infections or following infections such as pertussis. Bron­ Chronic bronchitis is one of the most frequent chiectasis is associated with proliferation of bron­ causes of mild hemoptysis. A history of chronic chial blood vessels that commonly rupture, result­ productive cough, usually with a history of ciga­ ing in hemoptysis. rette smoking, is present. Caution is advised in Cystic fibrosis does not commonly give rise to attributing hemoptysis to chronic bronchitis as hemoptysis until the obstructive pulmonary dis­ more serious diseases, such as lung cancer, also ease and bronchiectasis associated with it is pro­ occur predominantly in cigarette smokers. nounced. In such cases, hemoptysis may first ap­ Bronchiectasis, if it is symptomatic, is accom­ pear in adolescence after many years of recurrent panied by hemoptysis in about 50 percent of cases. or chronic pulmonary infections. Chronic bronchitis and bronchiectasis were the Lower respiratory tract infections, especially major causes of hemoptysis in adults in one recent necrotizing pneumonias, may result in hemop­ study.2 Bronchography establishes a diagnosis of tysis. Thus, Klebsiella, staphylococcal, and bronchiectasis in most cases. Unlike bronchiec­ Pseudomonas pneumonias, when they occur in tasis of the lower lobes that usually is symptomatic children, may cause hemoptysis. with chronic production of copious amounts of 354 THE JOURNAL OF FAMILY PRACTICE, VOL. 7, NO. 2, 1978 HEMOPTYSIS purulent sputum, the upper lobe bronchiectasis Table 2. Some Causes of Hemoptysis in Adults that is a common consequence of healed apical tuberculosis is often “dry,” without sputum pro­ Infections duction. Both varieties may cause hemoptysis, Chronic bronchitis and in “dry” bronchiectasis it may be the only Bronchiectasis symptom. Lung abscess Lung abscess, frequently due to an indolent Pulmonary tuberculosis anaerobic infection especially in patients who Bacterial pneumonias have had seizures or unconsciousness with aspi­ Parasitic and fungal pneumonias Neoplastic Diseases ration, has become a major cause of hemoptysis in Bronchogenic carcinoma adults. It should be noted that lung abscess is Bronchial adenoma usually a roentgenographic diagnosis and does not Metastatic carcinoma in lung define the etiology. Not uncommonly, the bleed­ Cardiovascular Diseases ing actually originates from a tumor or foreign Pulmonary infarction body beyond which the abscess develops. Bron­ Mitral stenosis choscopy is always indicated in cases of lung Pulmonary Arteriovenous Fistula abscess to exclude these two possibilities and es­ Telangiectatic bronchial wall vessels tablish the etiology. Major hemoptysis occurs in Immunologic Diseases about five percent of cases of lung abscess and is Collagen vascular disease one clear indication for surgical resection. Systemic lupus erythematosus Wegener granulomatosis Pulmonary tuberculosis was, in the past, a very Periarteritis nodosa common cause of hemoptysis in adults, being the Goodpasture syndrome leading etiologic factor in several reported stud­ Miscellaneous ies.3 Aneurysms of bronchial vessels within tuber­ Thoracic trauma culosis cavities, named after Rasmussen who orig­ Broncholith inally described them in 1868, are a cause of mas­ Bullae and cysts sive hemoptysis. Bronchiectasis resulting from the Iatrogenic causes healing of tuberculosis contributes to the fre­ Excessive anticoagulation quency of bleeding. Although the incidence of Idiopathic causes tuberculosis is declining, hemoptysis is still the presenting symptom in this disease in some cases. This accentuates the need for adequate sputum examination for the tubercle bacillus in all cases of Neoplastic Diseases hemoptysis. Hemoptysis occurs in over 50 percent of cases Bacterial pneumonias are occasionally as­ of bronchogenic carcinoma at some time in the sociated with mild hemoptysis, particularly in nec­ course of the disease. The bleeding is usually not rotizing pneumonias. A slowly clearing pneumonia profuse, but the seriousness of this disease de­ or recurrent pneumonia in one segment or lobe mands a thorough diagnostic evaluation. A normal suggests an obstructing lesion and is an indication chest roentgenogram does not exclude this diag­ for further diagnostic work-up. nosis even though hemoptysis is usually a late Hemoptysis is an occasional manifestation in a symptom of lung cancer rather than an early one. number of parasitic and fungal pneumonias. In With fiberoptic bronchoscopy and adequate current practice, the presence of a mycetoma sputum cytologic