Coughing Up Blood: Causes and Next Steps for Patients

Q: Coughing Up Blood: Causes and Next Steps for Patients

Hello： Based on the above, it seems that the microvasculature of the nasal cavity, throat, or trachea is relatively fragile and can easily rupture and bleed due to increased pressure (such as from coughing, sneezing, or lifting heavy objects). <br>The bleeding is usually minimal

Coughing and sneezing with the presence of blood-tinged sputum, blood streaks, or blood spots?

The patient has a long-term history of post-nasal drip and gastroesophageal reflux, has been taking cholesterol-lowering medication for an extended period, exercises infrequently, and has slightly lower than normal blood pressure.
They have a habit of experiencing one or two dry coughs each night, mostly dry and non-productive, although when sputum is present, it is usually a small amount of yellowish mucus.
Occasionally, they feel mucus in their throat that they cannot expel.
The occurrence of coughing and sneezing with blood-tinged sputum or blood streaks has been ongoing for about three years, with an average frequency of more than half the time.
Symptoms include: 1.
After coughing, the patient immediately spits out saliva containing blood spots and streaks, with very little sputum accompanying the cough.
The presence of blood streaks and spots during coughing mostly occurs at night while sleeping, with very few occurrences during the day.
2.
After sneezing, the patient immediately spits out saliva with blood spots and streaks.
Even when unable to sneeze, saliva still shows blood-tinged sputum and spots.
3.
Typically, after coughing or sneezing, spitting three or four times results in no more blood streaks, spots, or blood-tinged sputum.
4.
Pain: Sometimes described as a dull ache, other times as a continuous sharp pain.
This occurs during normal activities such as talking, laughing, being excited, or even while lying in bed or sitting on the sofa.
There is generally no significant shortness of breath, except when the sharp pain occurs, causing the patient to hesitate to take deep breaths due to discomfort.

Medical consultation history:
- Otolaryngology: I.
The patient underwent nasal endoscopy three times, and three different doctors concluded that aside from post-nasal drip affecting nighttime cough, there is a possibility of blood being expelled through the mouth if the nasal mucosa is injured or if there is a nosebleed; otherwise, the nasal and throat examination appeared normal.
II.
Medication treatment included cough suppressants, antihistamines, and antibiotics.
III.
During medication use, the patient coughed infrequently and had no nasal drip, but symptoms recurred after stopping the medication.

- Internal Medicine: I.
Three years ago, the patient was hospitalized due to chest pain and severe hemoptysis.
The hospital arranged for two admissions for examination, hoping to collect sputum for testing; unfortunately, there was no sputum during both admissions.
X-rays, ECGs, and exercise stress tests were performed, and the results were normal, indicating no significant heart issues.

- Gastroenterology: I.
A few months ago, the patient underwent an upper endoscopy, which revealed inflammation in the esophagus and gastric antrum, but biopsy results were normal, indicating no significant gastric issues.
II.
Medication treatment included proton pump inhibitors and anti-inflammatory medications.

- Pulmonary Medicine: I.
A CT scan of the lungs was performed, and the doctor reported clean results with no lesions, indicating no significant lung issues.
The cause of chest pain may be neuralgia or pleuritis, and it could also be related to the heart.
Additionally, the doctor assessed that there was no need for bronchoscopy based on symptoms, but left the decision to the patient.
II.
Treatment medications included cough suppressants, antihistamines, and antibiotics.
Dr.
Yang, given this case, what is the most likely cause of the hemoptysis? If the patient wishes to continue seeking medical help for the coughing up of blood, which specialty should they consult? The patient is experiencing increasingly severe hemoptysis, and I would like to seek your professional knowledge and advice to help the patient recover and alleviate their suffering from this condition.
Thank you for taking the time to respond, and I wish you good health!

Li Xin, 40~49 year old female. Ask Date: 2017/04/10

Dr. Yang Wenda reply Pulmonology

Hello: Based on the above, it seems that the microvasculature of the nasal cavity, throat, or trachea is relatively fragile and can easily rupture and bleed due to increased pressure (such as from coughing, sneezing, or lifting heavy objects).
The bleeding is usually minimal and lasts for a short duration.
It is recommended to take antihistamines to reduce sneezing; however, they may cause dry mouth, so it is important to drink plenty of water.
Additionally, keep some hemostatic medications on hand.
If the sputum is red or if there is a significant amount of bleeding, it can be taken three times a day for two days.
If there is no improvement, consult a pulmonologist.
As for dietary restrictions and constitution, it is advisable to consult a traditional Chinese medicine practitioner to assess any precautions that need to be taken.

Reply Date: 2017/04/10

More Info

Coughing up blood, or hemoptysis, can be a concerning symptom that warrants thorough investigation. In the case you described, the patient has a history of post-nasal drip, gastroesophageal reflux, and a long-standing dry cough that occasionally produces blood-streaked sputum. This situation is complex and requires a multifaceted approach to diagnosis and treatment.

Possible Causes of Hemoptysis
1. Post-Nasal Drip: Given the patient's history of chronic nasal congestion and post-nasal drip, it is possible that irritation from mucus dripping down the throat could lead to minor bleeding. This could occur due to inflammation or injury to the mucosal lining of the throat or airways.

2. Gastroesophageal Reflux Disease (GERD): The reflux of stomach acid can cause irritation and inflammation of the esophagus and throat, potentially leading to bleeding. This can also contribute to chronic cough and throat discomfort.

3. Bronchial Irritation: The dry cough, especially if it is persistent, could cause irritation to the bronchial tubes. If the cough is severe enough, it may lead to small tears in the blood vessels in the airways, resulting in blood-streaked sputum.

4. Infection or Inflammation: While previous tests have ruled out significant lung pathology, infections such as bronchitis or pneumonia can cause hemoptysis. Inflammation from chronic conditions could also play a role.

5. Vascular Issues: Conditions affecting the blood vessels in the lungs or airways, such as pulmonary hypertension or arteriovenous malformations, could lead to bleeding.

6. Other Causes: Less commonly, conditions such as tumors (benign or malignant), tuberculosis, or autoimmune diseases could be responsible for hemoptysis.

Next Steps for Diagnosis
Given the persistence and worsening of symptoms, it is crucial for the patient to seek further evaluation. Here are some recommended steps:
1. Pulmonology Consultation: Since the patient has already seen multiple specialists, a referral to a pulmonologist is advisable. A pulmonologist can perform more specialized tests, such as a bronchoscopy, which allows direct visualization of the airways and the collection of samples for further analysis.

2. Imaging Studies: Although a CT scan of the chest has been performed, it may be beneficial to repeat imaging or perform additional studies to rule out any subtle abnormalities that may have been missed.

3. Further Gastroenterology Evaluation: If GERD is suspected to be a contributing factor, a gastroenterologist may recommend further evaluation, including a 24-hour pH monitoring study to assess acid reflux severity.

4. Allergy Testing: If post-nasal drip is a significant contributor, allergy testing may help identify triggers that can be managed to reduce symptoms.

5. Follow-Up on Medications: The patient should discuss with their healthcare provider the effectiveness of current medications and whether adjustments are necessary. This includes reviewing the use of antihistamines, proton pump inhibitors, and any other treatments.

Conclusion
In summary, the presence of blood in sputum is a symptom that should not be ignored, especially given its chronic nature and the potential for underlying serious conditions. A comprehensive approach involving pulmonology, gastroenterology, and possibly allergy specialists is essential for accurate diagnosis and effective management. The patient should be encouraged to advocate for themselves and seek further evaluation to ensure that all potential causes are thoroughly investigated. Early intervention can lead to better outcomes and relief from symptoms.

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