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Etiology of Hemoptysis in India Revisited

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 International Journal of Medical and Health Sciences
Journal Home Page: http://www.ijmhs.net ISSN:2277-4505

Original article

Etiology of Hemoptysis in India Revisited

Naveed Nazir Shah1, Manzoor Ahmad Wani2*, Syed Quibtiya Khursheed3, Rakesh Bhargava4, Zuber Ahmad5,
Khurshid Ahmad Dar6, Altaf Ahmad Bachh7

1
Assistant professor, Chest Diseases Hospital, Government Medical College, Srinagar,
2
Registrar, Department of General Medicine, SKIMS Medical College, Bemina,
3
Registrar, Department of General Surgery, Government Medical College, Srinagar,
4&5
Professors, Department of TB and Chest, J.N Medical College, AMU, Aligarh,
6
Lecturer, Chest diseases hospital, Government Medical College, Srinagar,
7
Lecturer, Department of Chest Medicine, SKIMS Medical College, Bemina.

ABSTRACT

Aims and Objectives: To study the changing trend in the causes of hemoptysis in India. Materials and Methods: Total of 246
patients complaining of hemoptysis were taken up for this prospective study. The study was approved by the local ethics
committee and informed consent from all patients were obtained prior to commencement of the study. All the patients were fully
investigated to find out the etiology of hemoptysis. Besides routine investigations, bronchoscopy was also done in patients, where
non bronchoscopic methods failed to reveal the cause. Other investigations like CT scan, FNAC/Biopsy was done in selective
patients. Results: The most common etiologies of hemoptysis in our study were tuberculosis[27.9%] followed by
malignancy[18.6%] and bronchiectasis[16.5%].Out of 246 patients,145 patients had mild hemoptysis [58.9%], 57 had moderate
[23.1%], 44 had severe hemoptysis [17.8%]. 32.2% patients of mild hemoptysis were diagnosed as bronchogenic carcinoma, 97%
of the patients with idiopathic hemoptysis were having mild hemoptysis. Of the 57 patients with moderate hemoptysis, 25% were
diagnosed as having bronchogenic carcinoma, 41.6% were having tuberculosis as the etiology for hemoptysis. Tuberculosis
(46.4%) and bronchiectasis (42.8%) were the most common etiologies in patients with severe hemoptysis. Conclusion: In India,
the most common cause of hemoptysis still remains tuberculosis, although the incidence has significantly decreased.

KEYWORDS: Hemoptysis, Tuberculosis, brochiectasis

INTRODUCTION

Hemoptysis is defined as expectoration of blood originating
from lungs or bronchotracheal tree[1]. The material that is
produced varies from blood tinged sputum to virtually pure
blood. Hemoptysis is a frightening symptom for the patients
and can be a manifestation of serious underlying disease.
The vast majority of hemoptysis events originate from the
bronchial arteries (90%) as compared with the pulmonary
arteries(5%)[2]. The etiology for hemoptysis varies among
different series according to time of publication, the
geographic location, and the diagnostic tests employed. In
India, first thing which comes to mind in a patient with
hemoptysis is tuberculosis and patients are often treated for
pulmonary kochs without proper evaluation.

Int J Med Health Sci. Jan 2016,Vol-5;Issue-1 9

The main aim of present study was to revisit the various
etiologies of hemoptysis using bronchoscopic and non
bronchoscopic methods, and to define the characteristics
associated with different etiologies.
MATERIALS AND METHODS
The present study was conducted on patients, attending the
Outpatient Department (OPD) and those who were admitted
in the wards (IPD) of Department of Tuberculosis and Chest
Diseases, Jawaharlal Nehru Medical College Hospital,
Aligarh Muslim University, Aligarh, India for 3 year
duration. Total of 246 patients complaining of hemoptysis
were taken up for this prospective study. The study was
approved by the local ethics committee and informed
consent from all patients were obtained prior to
commencement of the study.
Detailed clinical history was recorded and the patients were
thoroughly examined with a detailed reference to the general
physical examination pertaining to the respiratory diseases.
The complaints which were evaluated in detail included
hemoptysis (amount, time of onset in relation to duration of
other symptoms), cough, sputum production, chest pain,
dyspnoea, fever, weight loss, anorexia, hoarseness of voice,
dysphagia, and symptoms suggestive of malignancy. History
of cigarette smoking, cardiopulmonary disease, hematuria
and symptoms of nasal, oropharyngeal, laryngeal disease, or
gastrointestinal disease were noted, if any. The presenting
quantity of hemoptysis was estimated as best as possible
from the patient’s history, and was classified arbitrarily
according to the severity into mild(<30ml/day),
moderate(30-200ml/day), or severe(>200ml/day) depending
upon the amount of bleeding.
Baseline routine laboratory investigations including
hemogram, ESR, KFT,ABG was done in all patients.
Patients were asked to collect sputum in sterile wide
mouthed vials after rinsing the mouth with plain water in the
morning to bring out first cough sample, which was then
sent to the laboratory on at least 3 consecutive days for (a)
Cytopathological examination to look for malignant cells (b)
Sputum for acid fast bacilli by Ziehl Nelson technique and
(c) Sputum smear and culture for bacteria, and fungus. Chest
Roentgenography (Posteroanterior view and Right or left
lateral view) was done in all patients.
Fibreoptic bronchoscopy(FOB) was done in 157 patients.
FOB was done using Olympus (BF Te2e) model in an
endoscopy room or bedside. Medical records were analyzed
for the quantity and duration of hemoptysis, prior diagnostic
procedures, timing of FOB (in relation to hemoptysis),
endoscopic findings and results of any accessory
procedures. Although attempt was made to perform the
procedure as soon as possible, FOB was performed up to 10
days following the initial event because of technical
problems. For the purpose of this study, a definitive (or
endoscopic) diagnosis for hemoptysis was made if FOB
revealed a specific bleeding lesion, endobronchial mass, or
positive and specific microbiology, cytology or histology.
Int J Med Health Sci. Jan 2016,Vol-5;Issue-1
An endoscopic diagnosis of bronchitis was made on account
of presence of generalized inflammation of the airways
(redness and swelling of mucosa), indistinct cartilage rings,
presence of small diverticula in the bronchial mucosa and
dilatation of the mucous gland ducts in the bronchial wall. A
non-bleeding abnormality was not considered a definitive
lesion but was consistently recorded. The influence of FOB
was determined by noting whether or not changes in the
clinical diagnosis and management of the hemoptysis
occurred, based on results of each FOB. A final diagnosis
for the hemoptysis was based on the definitive diagnosis
and/or review of subsequent historical, radiological,
surgical, or autopsy information, if sufficient to establish a
probable cause of bleeding. CT scan/ CT guided FNAC or
biopsy, percutaneus FNAC or biopsy was done in selected
patients.
RESULTS
Out of the total of 246 patients with hemoptysis, chest
roentgenogram was interpreted as normal or with non-
localizing abnormalities in 48. Four of them did not give
consent for bronchoscopy. Of the remaining 198 patients
with localizing findings on the chest roentgenogram,
diagnosis was made in 141 by non-bronchoscopic measures.
Sixty of these patients were having persistent hemoptysis
and were planned for therapeutic bronchoscopy. Fifty seven
patients with abnormal roentgenogram not diagnosed by
non-bronchoscopic techniques were planned up for
bronchoscopy. Hence, a total 157 patients underwent
fibreoptic bronchoscopy. In none of the patients was there
an abnormality of clotting, or a bleeding source found on
otolaryngologic examination. Out of 246 patients with
hemoptysis, 157 patients underwent bronchoscopy.
The age of the patients ranged between 23 to 85 years. The
mean age of the patients was 58.76 years. Out of 246
patients , 178 were males [72.3%], 68 [27.7%] females. 150
were smokers[60.9%], 96 were nonsmokers. Among
smokers, 90% were males. The most common etiologies of
hemoptysis in our study[Table 1] were tuberculosis[27.9%]
followed by malignancy[18.6%] and bronchiectasis[16.5%].
Other less common causes were bronchitis, pneumonia, lung
abscess and congestive heart failure [table 1].
145 patients had mild hemoptysis[58.9%], 57 had moderate
[23.1%], 44 had severe hemoptysis [17.8%]. 32.2% patients
of mild hemoptysis were diagnosed as bronchogenic
carcinoma, 97% of the patients with idiopathic hemoptysis
were having mild hemoptysis. Of the 57 patients with
moderate hemoptysis, 25% were diagnosed as having
bronchogenic carcinoma, 41.6% were having tuberculosis as
the etiology for hemoptysis. Tuberculosis (46.4%) and
bronchiectasis (42.8%) were the most common etiologies in
patients with severe hemoptysis. FOB was done in 157
patients and bleeding site was localized in 76 patients.
10
 Table 1: Final diagnosis in patients who presented with hemoptysis.
Causes Number(%) Patients in which FOB was done
Bronchitis 19(7.8%) 15(78.9%)
Malignancy 45(18.6%) 39(86.7%)
Tuberculosis (active) 45(18.6%) 24(53.3%)
Tuberculosis (inactive) 22(9%) 9(40.9%)
Bronchiectasis 40(16.5%) 25(62.5%)
Pneumonia 12(4.9%) 4(13.3%)
Congestive Heart Failure 8(3.3%) -
Lung abscess 8(3.3%) 3(37.5%)
Aspergilloma 5(2%) 2(40%)
Pseudohemoptysis (Bleeding from upper respiratory 2(0.8%) 2(100%)
tract)
Idiopathic 32(13.3%) 32(100%)
TOTAL 242(100%) 157(64.8%)

DISCUSSION
Different parts of the world have reported different
etiological patterns of hemoptysis. In developed countries,
tuberculosis is becoming less important cause of bleeding
from the lungs, but in our country tuberculosis still remains
the most common cause.
Of all the patients in our study, tuberculosis was the most
common etiology of hemoptysis in 27.6% cases followed by
malignancy in 18.6% and bronchiectasis in 16.5%.
Bronchitis was the etiological factor in only 7.8% cases. In
previous studies conducted between 1930-1960,
bronchiectasis, tuberculosis and
malignancy were the most common causes of hemoptysis[3-
10]. Recent studies showed a change in the trend in causes
of hemoptysis[11-18]. Tuberculosis decreased to 7% in
contrast to 13-61% in previous studies[6-8].
The rate of occurrence of bronchogenic carcinoma remained
similar. However the incidence of infective pathologies like
tuberculosis and bronchiectasis remains high in developing
countries like ours accounting for the difference in the
etiologies of hemoptysis in our studies compared with other
recent studies. Causes of hemoptysis in various studies is
shown in Table 2.

Table 2: Causes of hemoptysis by percentage in various studies

Cause
Study
Carcinoma Bronchiectasis Bronchitis Tuberculosis Abscess Pneumonia Infarction Cardiac Unknown
Jackson and
Diamond[3] 20 32 17 * 12 6 - - 8
(n=436)
Heller[4]
2 7 15 39 1 3 1 2 16
(n=413)
Abbott[5]
21 21 2 22 6 2 2 1 4
(n=497)
Levitt[6]
(n=717) 12 15 - 47 5 1 - 7 5
Moersch[7]
(n=200) 24 27 9 6† 5 3† 1 1† 8

Saunders &
Smith[8] 3† 37 12 2§ 2 - - 9 18
(n=100)
Pursel &
Lindskog[9] 19 23 5 13 3 5 3 - 15
(n=105)

Int J Med Health Sci. Jan 2016,Vol-5;Issue-1 11

Lyons[10]
(n=200) 12 21 - 61 4 - - - 2

Gong Jr. &

Salvatierra[11] 24 40 - 3 - 3 2 4 11
(n=129)
Johnston &
Reisz[21] 19 1 37 7 2 5 1 1 3
(n=148)
Santiago[22]
(n=264) 29 0.5 23 6 - 11 - - 22
Alaou[23]
(n=291) 34 15 3.5 19 - 7 - - 3
Knott-
Craig[24] 51
5 - 73 - 4 - - 8
(all had TB)
(n=120)
McGuinness
[25] (n=57) 12 25 5 16 - 12 - - 19
Domoua[26]
(n=142) 4.2 11.2 - 49.3 - 13.3 - - -
Hirshberg[27]
(n=208) 19 20 18 1 - 16 - - 8
Abal[28]
(n=52) - 21.2 5.8 15.4 - - - - 25
Fidan[29]
(n=108) 34.3 25 - 17.6 - 10.2 - - -
Unsal[30]
(n=143) 18.9 22.4 5.6 11.2 - 4.9 - - 13.2
Present study
18.6 16.5 7.8 27.6 3.3 4.9 - 3.3 13.2
†
*Excluded from study, Selection criteria biased against inclusion of patients with this diagnosis.

Although tuberculosis is still the most common cause in our with hemoptysis had inactive tuberculosis.This suggests
study, the incidence has markedly decreased in comparison that even if the patient of pulmonary tuberculosis who is on
with other studies from India in the past[19]. This decrease treatment or who has completed ATT presents with
in the incidence of tuberculosis can be attributed to better hemoptysis again, we should not think that patient is not
and newer tuberculosis control programme, in which both responding or the infection is drug resistant.
the diagnosis and the treatment is free and directly observed,
what is called as Directly Observed Treatment, Short-course
(DOTS)[20]. The incidence of bronchiectasis in our study CONCLUSION
was 16.5% which is almost same to that of many other We conclude that pulmonary tuberculosis still remains the
studies from developing countries[19].Johnston & Reiz[21] most common cause in India, although the frequency has
found bronchitis to be the most common cause and a significantly decreased. Hemoptysis even if mild should be
dramatic decrease in bronchiectasis, 1% as compared to 7- extensively evaluated as malignancy is the second most
37% in previous studies[3-10]. common cause in our setting.
In our study malignancy was the second most common
cause (18.6%). Many other studies has also shown
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Int J Med Health Sci. Jan 2016,Vol-5;Issue-1 13

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