Epistaxis vs hematemisis vs hemoptysis

This is a very basic doubt among the health care workers around the world.

1. Approach to hemoptysis and epistaxis By – Shubham kamde

2. Hemoptysis Hemoptysis is the expectoration of blood from the respiratory tract. The first step in evaluation is to ascertain whether the bleeding is coming from the respiratory tree or instead originating from the nasal cavities (i.e., epistaxis ) or the gastrointestinal tract (i.e., hematemesis ) as the therapies for these etiologies will be significantly different. Massive or life-threatening hemoptysis (>400 mL of blood in 24 h or >150 mL at one time) requires emergent intervention.

3. Anatomy and Physiology Hemoptysis can arise from anywhere in the respiratory tract; from the glottis to the alveolus. Most commonly, bleeding arises from the bronchi or medium sized airways, but a thorough evaluation of the entire respiratory tree is often necessary. The lungs are supplied with a dual circulation. The pulmonary arteries arise from the right ventricle to supply the pulmonary parenchyma in a low-pressure circuit. The bronchial arteries arise from the aorta and carry blood under high systemic pressure to the airways, blood vessels and visceral pleura.

4. ETIOLOGY Infections Most blood-tinged sputum and small-volume hemoptysis is due to viral bronchitis. Patients with chronic bronchitis are at risk for bacterial superinfection with organisms such as Streptococcus pneumoniae , Haemophilus influenzae , or Moraxella catarrhalis , increasing airway inflammation and potential for bleeding. Similarly, patients with bronchiectasis are prone to hemoptysis with exacerbations of disease. Due to recurrent bacterial infection, bronchiectatic airways are dilated, inflamed, and highly vascular, supplied by the bronchial circulation. In several case series, bronchiectasis is the leading cause of massive hemoptysis and subsequent death.

5. History A history of repeated small haemoptysis , or blood- streaking of sputum, is highly suggestive of lung cancer. Fever, night sweats and weight loss suggest tuberculosis. Pneumococcal pneumonia often causes ‘rusty’- coloured sputum but can cause frank haemoptysis , as can all suppurative pneumonic infections, including lung abscess . pulmonary thromboembolism is a common cause of haemoptysis and should always be considered.

6. Physical examination Finger clubbing suggests lung cancer or bronchiectasis; other signs of malignancy, such as cachexia, hepatomegaly and lymphadenopathy, should also be sought. Fever, pleural rub and signs of consolidation occur in pneumonia or pulmonary infarction; a minority of patients with pulmonary infarction also have unilateral leg swelling or pain suggestive of deep venous thrombosis. Rashes, haematuria and digital infarcts point to an underlying systemic disease, such as a vasculitis, which may be associated with haemoptysis .

7. Diagnostic Studies complete blood count to assess for infection, anemia, or thrombocytopenia, coagulation parameters. Chest imaging is necessary for every patient. chest computed tomography (CT) with contrast should be obtained to better identify masses, bronchiectasis , and parenchymal lesions.

8. INTERVENTION IN MASSIVE OR LIFE THREATNING HEMOPTYsis protect the non bleeding lung - Protecting the airway and nonbleeding lung is paramount in the management of massive hemoptysis because asphyxiation can happen quickly. If the side of bleeding is known, the patient should be positioned with the bleeding side down to use gravitational advantage to keep blood out of the nonbleeding lung. locate the site of bleeding - A chest radiograph, if it shows new opacities, can be helpful in localizing the side or site of bleeding, although this test is not adequate by itself. CT angiography helps by localizing active extravasation . Flexible bronchoscopy may be useful to identify the side of bleeding. control the bleeding - a flexible bronchoscope can be used to suction clot and insert a balloon catheter or bronchial blocker that occludes the involved airway. Rigid bronchoscopy , done by an interventional pulmonologist or thoracic surgeon, may allow therapeutic interventions of bleeding airway lesions such as photocoagulation and cautery

9. EPISTAXIS - Bleeding from inside the nose is called epistaxis Nose is richly supplied by both the external and internal carotid systems, both on the septum and the lateral walls.

10. Anterior VS posterior epistaxis Anterior Epistaxis When blood flows out from the front of nose with the patient in sitting position. Posterior Epistaxis Mainly the blood flows back into the throat. Patient may swallow it and later have a “coffee- coloured ” vomitus . This may erroneously be diagnosed as haematemesis .

11. Local Causes - Nose 1 . Trauma - Finger nail trauma, injuries of nose, intranasal surgery , fractures of middle third of face and base of skull , hard-blowing of nose, violent sneeze. 2. Infections - (a ) Acute: Viral rhinitis, nasal diphtheria, acute sinusitis. (b) Chronic: All crust-forming diseases, e.g. atrophic rhinitis , rhinitis sicca , tuberculosis , syphilis septal perforation , granulomatous lesion of the nose, e.g. rhinosporidiosis . 3. Foreign bodies - (a ) Nonliving: Any neglected foreign body, rhinolith . (b) Living: Maggots , leeches. 4. Neoplasms of nose and paranasal sinuses . - ( a) Benign: Haemangioma , papilloma . (b) Malignant: Carcinoma or sarcoma . 5. Atmospheric changes - High altitudes, sudden decompression (Caisson disease). 6. Deviated nasal septum.

12. General Causes Cardiovascular system - Hypertension , arteriosclerosis, mitral stenosis , pregnancy (hypertension and hormonal). Disorders of blood and blood vessels - Aplastic anaemia , leukaemia , thrombocytopenic and vascular purpura , haemophilia , Christmas disease, scurvy, vitamin K deficiency and hereditary haemorrhagic telangectasia . Liver disease - Hepatic cirrhosis (deficiency of factor II, VII , IX and X). Kidney disease - Chronic nephritis. Drugs - Excessive use of salicylates and other analgesics (as for joint pains or headaches), anticoagulant therapy (for heart disease). Mediastinal compression - Tumours of mediastinum (raised venous pressure in the nose). Acute general infection - Influenza , measles, chickenpox, whooping cough, rheumatic fever, infectious mononucleosis , typhoid, pneumonia, malaria and dengue fever. Vicarious menstruation - ( epistaxis occurring at the time of menstruation).

13. Site of epistaxis 1. Little’s area - In 90% cases of epistaxis , bleeding occurs from this site. 2. Above the level of middle turbinate - Bleeding from above the middle turbinate and corresponding area onthe septum is often from the anterior and posterior ethmoidal vessels (internal carotid system). 3. Below the level of middle turbinate - Here bleeding is from the branches of sphenopalatine artery. It may be hidden, lying lateral to middle or inferior turbinate and may require infrastructure of these turbinates for localization of the bleeding site and placement of packing to control it. 4. Posterior part of nasal cavity - Here blood flows directly into the pharynx. 5. Diffuse - Both from septum and lateral nasal wall. This is often seen in general systemic disorders and blood dyscrasias . 6. Nasopharynx .

14. managment 1. Mode of onset. Spontaneous or finger nail trauma. 2. Duration and frequency of bleeding. 3. Amount of blood loss. 4. Side of nose from where bleeding is occurring. 5. Whether bleeding is of anterior or posterior type. 6. Any known bleeding tendency in the patient or family. 7. History of known medical ailment (hypertension, leukaemia , mitral valve disease, cirrhosis and nephritis). 8 . History of drug intake (analgesics, anticoagulants, etc.).