Investigation of hemoptysis (summary)

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This is a basic article for medical students and other non-radiologists.

Hemoptysis is the coughing up of frank blood or blood-stained mucus/pus from the lungs and it is an important indicator of pathology. Careful assessment of history, clinical examination and investigations will help elicit the source of hemoptysis.

Reference article

This is a summary article; read more in our article on hemoptysis.

Summary

  • history
    • differentiate between hemoptysis, pseudohaemoptysis and hematemesis 
      • hemoptysis - typically bright red, frothy sputum
        • volume, frequency, fresh/altered blood
      • pseudohaemoptysis - source other than lower respiratory tract
        • e.g. upper airway bleed initiates cough reflex
    • investigate for other symptoms of pathology
      • respiratory - cough, sputum, wheeze, shortness of breath
      • constitutional - fever, weight loss, fatigue, night sweats
  • etiology (with typical associations)
  • investigations: hemoptysis always requires investigation

Radiographic features

Chest x-ray

A chest x-ray is strongly recommended in patients over 40 presenting with unexplained hemoptysis. Smokers are at especially high risk for lung cancer which may appear as a new or enlarged focal lesion. Other signs of malignancy include effusion, mediastinal lymphadenopathy and consolidation. Chest x-ray can also give clues to tuberculosis (patchy consolidation/cavitation), pneumonia (opacification) and pulmonary edema (Kerley lines / batwing opacification). It is of minimal diagnostic use in pulmonary embolism, bronchiectasis and vasculitis due to absent or variable signs on radiographs.

CT

CT is the imaging modality of choice in many of the conditions described above. It can help differentiate the etiology of a lesion or opacification seen on x-ray. It will generally show the same findings but with increased detail.

CT pulmonary angiography is the gold standard of diagnosis in pulmonary embolism and a high-resolution CT is key in bronchiectasis diagnosis. CT is a better option for investigating pulmonary manifestations of Goodpasture syndrome and granulomatosis with polyangiitis.

Medical student radiology curriculum