(临床诊断学) 仁济临床医学院诊断学教研室 An Introduction to Clinical Diagnostics



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Chapter 7 Hemoptysis

Hemoptysis is the expectoration of blood from the airway below larynx. When patients complain of coughing up blood, the nose, mouth and upper respiratory tract must be searched carefully by the mirror examination to rule out the possibility that blood may come from those areas.

Although the quantity of blood produced may vary in quantity from streaks and flecks in the sputum to massive hemorrhages, even minimal bleeding may be an early indicator of the presence of serious bronchopulmonary disease. Hemorrhages of even moderate degree may be life threatening.

In approximately one-half of patients with hemoptysis, the standard chest roentgenogram shows no abnormalities or only minimal nonspecific changes. Hemoptysis may be the initial or the sole symptom of bronchopulmonary disease, and the determination of its cause is a common diagnostic problem.

Etiology

1. Bronchial disease:


Hemoptysis may occur in bronchiectasis (TB or non-TB), chronic bronchitis, endobronchial tuberculosis disease, bronchogenic carcinoma. It can be seen in the benign bronchogenic tumor, broncholithiasis, foreign body, bronchogenic nonspecific ulceration. The inflammatory processes leads to the increase of permeability of capillary and rupture of vessels in the bronchial mucosa. Blood-streaked sputum occasionally occurs in the course of acute bronchitis.

2. Lung diseases:


The sputum of pneumococcal pneumonia is classically described as "rusty" in appearance. Pulmonary tuberculosis was formerly the most common cause of hemoptysis and is still an important etiology. Pulmonary tuberculosis may cause the expectoration of frank blood from pulmonary cavity. Lung abscess may be associated with putrid smelling sputum and expectoration of blood. Hemoptysis occurs in approximately 25% of patients with pulmonary embolism and infarction. Pulmonary fungi and parasite infection may also serve as the sources of hemoptysis.

3. Cardiovascular diseases:

Pink,frothy sputum is frequently associated with acute pulmonary edema. Blood-streaked sputum may occur with acute pulmonary congestion when the classic findings of acute pulmonary are not fully developed. The blood comes from pulmonary capillaries, which have ruptured under high intravascular pressure. Hemoptysis due to mitral stenosis is frequently induced by physical exercise, by sexual intercourse, or in the presence of excitement. The blood comes from a break in the pulmonary veins which have ruptured under very high pressure. The bleeding is due to rupture of endobronchial vessels that form collateral channels between the bronchial veins and pulmonary venous system. Episodes of pulmonary hemorrhage of this type tend to subside as the veins adapt to the high pressure and as pulmonary arteriolar disease develops. Many pulmonary emboli do not lead to pulmonary infarction, and when they do, frank hemoptysis occurs in the minority of instances. Despite this, when hemoptysis occurs in a patient with heart failure, pulmonary infarction is likely. The bloody sputum usually appears within a few hours to a day after the embolus and is due to necrosis and hemorrhage into the alveoli.

hemoptysis is also associated with congenital cardiac disease and aortic aneurysms..


4. Constitutional diseases:


Blood spitting may also occur in the patients suffering from certain blood dyscrasias, such as hemophilia, leukemia, and infectious disease, connective tissue disease.

Clinical manifestations


  1. The patient’s age.

Hemoptysis is often seen in pulmonary tuberculosis, bronchiectasis, and rheumatic heart disease (mitral stenosis) for most youth. Cancer is now the disease that patients think of when they expectorate blood, just as it was tuberculosis 50 years ago. If an elder people complain of coughing up sputum tinged with blood or streaks of blood in sputum, especially in the male patient with long history of smoking, the possibility of suffering cancer must be taken into account. If the patient is in close contact with tuberculosis suffer, the pulmonary tuberculosis should be considered. The diagnosis of paragonimialsis may be suspected in the man with the history of eating raw or improperly cooked crabs or crayfish.

Epidemic hemorrhagic fever, leptospirosis also can cause hemoptysis, they are endemic

diseases.

2. The amount of coughing up blood

Hemoptysis can be classified into three groups according to the amount of coughing blood, massive, moderate and minimal. Massive hemoptysis may be defined in various ways, but is usually taken to include cases in which there is expectoration of 500 ml or more with 24-hour period. Massive hemoptysis often occurs in the patients with pulmonary tuberculosis cavity, chronic lung abscess or bronchiectasis. Minimal means the amount of coughing up blood less than 100 ml, and moderate is between them.

3. Color and character.

When a patient gives a history of “coughing blood,” it is necessary to ascertain the exact nature of the sputum. The sputum must be examined both grossly and microscopically. It is useful to determine whether the material that is coughed up contains large volumes of liquid blood, which indicates brisk bleeding, or whether it contains smaller quantities of dark or clotted blood, which would indicate slow bleeding from low-pressure vessels or subsiding bleeding. Brisk bleeding, for example, is commonly associated with specific focal ulceration of the bronchus, such as bronchogenic carcinoma, a foreign body, bronchiectasis, or a bleeding aortic aneurysm. Slow bleeding strongly suggests venous bleeding which is more likely to be the result of increased in blood flow through the bronchial venous system such as may occur as a result of mitral stenosis or bronchiectasis.

Accompanying Symptom


1.Hemoptysis with fever: Pulmonary tuberculosis, pneumonia, lung abscess and leptospirosis, epidemic hemorrhagic fever, bronchogenic carcinoma.

2. Hemoptysis with chest pain: Lobar pneumonia, pulmonary infarction, and pulmonary tuberculosis cancer.

3. Hemoptysis with putrid sputum: lung abscess, cavitious tuberculosis, and bronchiectasis.

4. Hemoptysis with irritating cough: bronchogenic carcinoma, mycoplasma pneumonia.

5. Hemoptysis with skin and mucosa bleeding: hematologic disease, epidemic hemorrhagic fever, rheumatism, leptospirosis.

6. Hemoptysis with jaundice: leptospirosis, lobar pneumonia, pulmonary infarction.


The distinction between hemoptysis and hematemsis




Hemoptysis

hematemesis




History:

T.B, bronchiectasis

Ulcer, cihrrosis




Presymptom:

Cough, chest discomfortable

Vomit, nausea, epigastric discomfort




mode of expectoration:

blood spitting

vomiting





color of blood:

bright red

dark red and black




Material mixed with blood




mixed with air bubble and sputum

contain food debrits gastric juice

pH




alkaline

acid

melena




No

occasionally swallowed



Yes

may continue for several days





Chapter 8 Cyanosis

Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from and increased amount of reduced hemoglobin or of abnormal hemoglobin pigments in the blood perfusing these areas.


Mechanism

In general, unsaturated oxygen of arterial blood is 1 vol/100ml, unsaturated oxygen in venous blood is 6 vol/100 ml, and in capillary the unsaturated oxygen probably in the mean value of arteral and venous blood (1+6/3=3.5 vol/100 ml). When fully saturated with oxygen, each gram of hemoglobin binds 1.34 ml of oxygen. Cyanosis becomes apparent at a mean capillary concentration of 5 gm/100 ml reduced hemoglobin (or blood unsaturated oxygen 6.7 vol/100 ml).

Since it is the absolute quantity of reduced hemoglobin in the blood that is responsible for casnosis the higher the total hemoglobin content, the greater the tendency toward cyanosis; thus patients with marked polycythemia become cyanotic at higher levels of arterial oxygen saturation than patients with normal hemotocric values, and cyanlsis may be absent in patients with severe anemia despite marked arterial desaturation.




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