Coughing up blood refers to bleeding from the larynx and respiratory tract below the larynx and lung tissues, which is discharged by coughing or through the mouth, and its location is in the lung. Coughing up blood is a common symptom of lung cancer, about 50%-70% of lung cancer patients have the symptom of coughing up blood, and about 40% of lung cancer patients come to the clinic with coughing up blood as the first symptom.
I. Clinical manifestations
Clinically, it is characterized by coughing up blood, bright red pure blood or coughing up sputum and blood together, interspersed with foam, rapid onset, repeated attacks, and in severe cases, coughing up a lot of blood or even gushing out from the mouth. In severe cases, hemorrhagic shock can be caused, and the evidence of Qi shedding with blood can be seen in the form of white face, dripping sweat, fainting with cold limbs, and pale tongue and thin pulse. If the bleeding mass blocks the airway and causes asphyxia, the patient may die.
Patients with lung cancer coughing up blood have the following characteristics.
1. Mostly seen in men over 40 years old with long-term history of heavy smoking.
2. Early stage is mostly irritating cough.
3.Continuous or intermittent recurrent blood in sputum with bright red color, rarely seen in large coughing blood.
4.X-ray: the lung near or lung field appear mass or round shape shadow, mostly lobar or burr shape, sometimes appear obstructive pulmonary atelectasis or obstructive pneumonia. Bronchial tomography may show the phenomenon of bronchial compression.
II. Diagnosis
The amount of coughing blood can be divided into blood in sputum, mild, moderate and severe coughing blood, with small and moderate coughing blood being more common, while large coughing blood is often life-threatening to patients.
Mild: a small amount of coughing up blood, less than 100ml of blood a day, or less than 50ml of blood in one cough.
Moderate: moderate coughing up blood, bleeding in the range of 100 to 500 ml a day, or 50 to 100 ml of blood in one cough.
Severe: massive coughing of blood, bleeding volume of more than 500ml a day, or one coughing of blood of more than 100ml, pulse rate of about 100 beats/min, or an increase of 10-20 beats/min compared with that before coughing of blood, hemoglobin of less than 100g/L, or a decrease of more than 2% compared with that before coughing of blood, decrease of blood pressure, shortness of breath and cyanosis caused by coughing of blood.
III. Differential diagnosis
(a) First of all, coughing up blood must be distinguished from bleeding from the mouth, nose and pharynx or vomiting blood caused by upper gastrointestinal bleeding.
1. Nasal bleeding mostly flows from the anterior nostril, and bleeding foci can be found below the anterior nasal septum, which is not difficult to diagnose. In posterior nasal bleeding, blood can be seen flowing down from the posterior nostril along the pharyngeal wall, and the patient feels a foreign body sensation in the pharynx, and the diagnosis can be confirmed with nasopharyngoscopy.
2, vomiting blood is vomited, accompanied by epigastric discomfort, nausea, vomiting and other symptoms, blood is mostly acidic, the color is mostly dark red coffee residue-like, mixed with food residues and gastric juice, easy to coagulate into a lump, vomiting blood within a few days often discharge tar-like black stool, patients often have peptic ulcer or cirrhosis, acute erosive hemorrhagic gastritis and other medical history.
3.Coughing up blood: blood is coughing out, with itchy throat, chest tightness, coughing, etc. Blood is often weakly alkaline, bright red, often mixed with foam and sputum, and bloody sputum is still coughing out several days after bleeding, usually without black stool, and patients often have a history of lung or heart disease.
(2) Coughing up blood in lung cancer should be distinguished from coughing up blood caused by the following diseases
1. Pneumonia: About 1/4 of lung cancer appears in the form of pneumonia in early stage, which should be distinguished from general pneumonia. Cancer pneumonia has slow onset, no toxic symptoms, slow absorption of inflammation by antibiotic treatment, or recurrent pneumonia in the same area, especially segmental or lobar pneumonia, often fan-shaped distribution according to bronchial branches and accompanied by volume reduction, should be alert to obstructive pneumonia caused by lung cancer. Non-cancerous pneumonia usually starts rapidly, with chills, high fever and other toxemia symptoms, followed by cough, sputum and other respiratory symptoms, and effective antibiotic treatment, and the lesions are often rapidly absorbed and safe.
2.Inflammatory pseudotumor: chronic inflammatory mechanization in the lung can form mass-like or oval inflammatory pseudotumor, which can be easily confused with peripheral lung cancer. The inflammatory pseudotumor can occur at any age, mostly under 40 years old, more women, often asymptomatic, but sometimes also with blood in the sputum, even low-grade fever, chest pain, a few patients have a history of pneumonia. x-ray can see inflammatory pseudotumor is mostly located in the right lung, round or oval, sometimes irregular shape, but the edge is smooth, no lobar and burr, and no hilar and mediastinal lymph node enlargement, occasionally see calcification foci and translucent areas, mostly seen in the lung The lesion is benign in the long term because it often involves the pleura and is often associated with pleural thickening. 67 Gallium scan. It is helpful to identify. Sometimes it is necessary to confirm the diagnosis by open-chest exploration.
3.Chronic bronchitis: chronic bronchitis with long-term cough symptoms and occasional blood in sputum should be differentiated from lung cancer. x-ray examination mainly shows thickened texture of both lungs, usually without mass shadow or nodular shadow. Acute attacks can be relieved by antibiotic treatment. However, those who develop chronic cough with a change in nature should be highly alert to the possibility of lung cancer. Sputum exfoliative cytology examination and trans-fiberscopic biopsy can generally clarify the diagnosis.
4.Lung abscess: cancerous cavity secondary to infection should be differentiated from primary lung abscess. The former has symptoms of lung cancer first, such as chronic cough and recurrent bloody sputum, and then fever, cough and other symptoms of secondary infection, etc. X-ray shows that the cancerous mass is mostly eccentric cavity with thick wall and uneven inner wall, mostly without fluid plane. If the mass occurs at the edge of the lung lobe, it is often confined by the lobe space and does not cross the lobe, and there is a phenomenon of pushing the lobe between the lobes. Primary lung abscesses have a rapid onset and severe toxic symptoms, often with chills, high fever, cough, and coughing up large amounts of purulent sputum. x-rays show large uniform inflammatory shadows with thin-walled cavities and fluid levels, and smooth interior walls. Chronic lung abscess shrinks due to fibrosis and scar formation, there is a pulling phenomenon on the interlobular fissure, and there are more fibrous striated changes around the lung abscess, and there are often irregular distorted thin strip shadows in the adjacent lung tissue, or adhesions with pleural thickening. Leukocytes and neutrophils increase in the acute phase.
5, pulmonary aspergillosis: most of pulmonary aspergillosis is secondary to tuberculosis cavitation, bronchiectasis, lung abscess or pulmonary cyst. It is characterized by: (1) clinically recurrent blood in sputum or coughing up blood, while other signs and symptoms are mild. (2) X-rays show that varicoceles are found in the upper lobe and rarely in the lower lobe. A half-moon shaped translucent band can be seen between the bacteriophage and the wall of the cavity, and it can move with the change of the patient’s position. (3) Sputum microscopy with Aspergillus spores and multiple cultures with pathogenic Aspergillus. Pathological biopsy helps in the diagnosis.
6, pneumocystis: mainly prevalent in the livestock areas, to young and strong farmers and herders are common, sputum with blood or coughing up blood, cyst rupture after coughing up a lot of blood and can cough up pink skin-like corneal membrane, may have liver or other parts of the cyst signs, cyst antigen intradermal test complement binding test and sputum examination can help confirm the diagnosis.
7.Pulmonary tuberculosis
(1) Tuberculosis bulb: It should be differentiated from peripheral type lung cancer. Tuberculosis globules are mostly seen in young patients and are usually asymptomatic. The lesions are mostly located at the sites of tuberculosis predilection, namely the middle part of the upper lobe and the anterior part of the upper and lower lobes of the lung. The lesions have a fibrous envelope and are therefore well-defined, with high endoplasmic density, often with spots, which may be concentric rings, subenvelope annular or arcuate calcifications, and speckled small nodular calcifications surrounded by fibrous nodular or infiltrative satellite lesions, often unchanged for many years. If cavities are formed, they are mostly central cavities with regular walls, thin, rarely exceeding 3 CM in diameter, and may be positive for tuberculin skin test.
(2) Cornular tuberculosis: It should be differentiated from diffuse fine bronchial-alveolar carcinoma, in which patients with cornular tuberculosis are younger and have fever and other symptoms of systemic toxicity, but respiratory symptoms are not obvious. In the middle and lower lung fields, nodular disseminated lesions of different sizes with clear borders and deeper densities can be seen, progressively developing and expanding. Systemic symptoms are not obvious, while progressive dyspnea may be present. Sputum exfoliated cells can be clearly diagnosed by fibrinoscopic lung biopsy.
(3) Other tuberculous lesions: infiltrative lesions and lobar opacities of pulmonary tuberculosis are differentiated from obstructive pneumonia opacities of lung cancer. Infiltrative lesions of pulmonary tuberculosis are mostly seen above and below the clavicle, often located in the posterior segment of the upper lobe tip, and usually take 6 to 12 months to form, with no mass in the root of the corresponding lobe, no obstruction of the lumen, and often more extensive pleural thickening and adhesions around the lesion, while cancerous pulmonary dysplasia progresses rapidly, mostly forming dysplasia within 2 to 3 months, and the lumen is often completely obstructed, with masses often visible in the root of the corresponding lobe and few pleural adhesions, and bronchoscopy Bronchoscopy and sputum cytology are helpful for diagnosis.
(4) Pulmonary hilar lymph node tuberculosis can be easily confused with central lung cancer. Pulmonary hilar lymph node tuberculosis is usually seen in children and young people, with fever, night sweats and other toxic symptoms, and is often strongly positive for tuberculin and effective with anti-tuberculosis drugs. Lung cancer, on the other hand, is common in adults above middle age, with rapid development and more obvious respiratory symptoms, and sputum exfoliative cell examination and fibrinoscopy help diagnose it.
8.Malignant tumor: Lung malignant tumor is a mixed benign tumor, with cartilage as the main structure, in addition to connective tissue, fat, glands, bone and lymphatic tissue. This tumor can occur at any age, but most of them are young and middle-aged. X-ray features include subpleural lesions in the periphery of the lung, with clear and smooth borders, uniform density of the mass, and sometimes calcified spots within the mass. In a few cases, the tumor tissue is composed of more fatty tissue, and low-density areas can be seen in the mass, and some of the masses are lobulated, with multiple small nodules at the edges, sometimes with lamellar calcifications, and typically in the shape of “popcorn”, which should be investigated surgically if it is difficult to identify.