Case 6: Haemoptysis Flashcards
what is haematemesis
vomiting blood
what is melena
black tarry stool indicating GI bleed
what is epistaxis
nose bleed
4 most possible diagnoses if experiencing haemoptysis
lung cancer (if smoker)
PE
infection (pneumonia or TB)
vasculitis
2 good questions to ask for suspicion of lung cancer
do they smoke
have they noticed the ends of their fingers becoming swollen
2 good questions to ask for suspicion of PE
do they suddenly feel more breathless
do they have acute chest pain
2 good questions to ask for suspicion of infection (pneumonia or TB)
are they producing lots of sputum
do they have fever
2 good questions to ask for suspicion of vasculitis
any nose bleeds or haematuria
any purpuric rash
what is the most common type of lung cancer
NSCLC (80-85%)
what is the less common type of lung cancer
SCLC (15-20%)
main subtypes of NSCLC
adenocarcimoma
squamous cell
large cell
adenocarcinoma is more commonly seen in which subtype of people
non smokers and women
squamous cell carcinomas are normally more related with what
smokers
what type of lung cancer grows and spreads more rapidly
SCLC
most people with SCLC normally present at what stage of the disease
stage 4
which type of lung cancer is more chemotherapy responsive
SCLC (but this generally carries a poorer prognosis due to late detection of the disease)
what are the 2 indications for suspected lung cancer referral
chest x-ray findings that suggest lung cancer
aged over 40 with unexplained haemoptysis
what testing is usually done with rapid access lung cancer clinics
straight to CT approach
this is followed by timely radiology report and then physician review
what may happen to the patient when intravenous contrast is injected
hot flush
why are patients kept in the clinic 15 minutes following the contrast injection
in case of an allergic reaction
most patients feel a warming sensation
what mild reaction may happen after injection of contrast
nausea and vomiting in 5%
what moderate reaction may happen after injection of contrast
hives and swelling in 1%
is anaphylaxis common following contrast injection
no severe reactions are rare in 0.1%
what different manifestations can lung cancer have
paraneoplastic manifestation
what are paraneoplastic manifestations
symptoms that develop when a malignant tumor causes changes in your body that aren’t directly caused by the cancer itself
the tumour may secrete a hormone or protein that affects a particular body system
how can lung cancer cause lambert-eaton syndrome
can cause autoantibodies that block ach being released in muscle synapses
lambert-eaton syndrome symptoms
muscle weakness
how can lung cancer cause syndrome of inappropriate antidiuretic hormone secretion (SIADH)
there is release of anti-diuretic hormone causing low sodium
symptoms of SIADH
nausea
vomiting
confusion
in severe cases seizures
how can lung cancer cause hypertrophic osteoarthropathy
there is new bone forming in the periosteum in the lower forearms and lower legs
symptoms of hypertrophic osteoarthropathy
pain and marker clubbing
how can lung cancer cause cushing’s syndrome
ectopic secretion of ACTH by small cell tumour
hyperparathyroidism
what does the TNM stand for
T= primary tumour
N= regional lymph node involvement
M= distant metastasis
symptoms of cushing’s syndrome
hypertension
weight gain
these paraneoplastic manifestations are more common with which type of lung cancer
SCLC
which test confirms SIADH
raised urinary sodium >30
when a lung tumour is found on CT what further investigation is done
confirm diagnosis of cancer with biopsy
confirm stage of the disease
assess patients fitness and wishes
what does the ECOG performance status scale assess
it assess the patients functioning in terms of their ability to care for themself, daily activity, and physical ability (walking, working, etc)
what must you not do before a PET scan
do strenuous exercise for 24hrs before
eat within 6hrs before
what tracer is injected before PET scan
flurodeoxyglucose (FDG) - similar to naturally occurring glucose so the body uses it in similar way
what does a PET scan show
areas which use high amounts of glucose glow on scan
cancer tumours use more glucose
what are two possible complications of CT guided lung biopsy
pneumothorax
haemoptysis
what may patients get whilst taking pembrolizumab (an immunotherapy agent)
immunotherapy related pneumonitis
symptoms of immunotherapy related pneumonitis
dry cough
shortness of breath
relatively normal inflammatory markers
when does immunotherapy related pneumonitis typically come about
around 3 months into immunotherapy treatment
how is immunotherapy related pneumonitis treated
steroids
intravenous methylprednisolone in severe disease
oral prednisolone in milder disease
(immunotherapy is withheld during treatment)
what is pleural effusion
buildup of fluid in the pleural space
common examination finding of pleural effusion
reduced chest expansion
reduced breath sounds
dull percussion
finger clubbing
clinical signs of right sided pleural effusion
dull percussion note
reduced breath sounds
reduced vocal resonance
clinical signs of right sided pneumothorax
hyper-resonant percussion note
absent breath sounds
no/reduced vocal resonance
clinical signs of right sided pneumonia
dull percussion note
bronchial breathing
increased vocal resonance
transudate vs exudate
exudates= fluids, cells or other cellular substances that are slowly discharged from blood vessels usually from inflamed tissues
transudates= fluids that pass through a membrane or squeeze through tissue or in the extracellular space of tissues
description of exudates
local process
caused by factors which change the formation and absorption of pleural fluid
high pleural fluid protein usually above 30 and raised LDH
description of transudates
generalised process
caused by factors that alter hydrostatic pressure, pleural permeability, and oncotic pressure
low pleural fluid protein usually less than 30 and low/normal LDH
exudative causes of pleural effusion
vascular- PE
infective- pneumonia and TB
inflammatory- pancreatitis
traumatic- haemothorax (blood in pleural space and often associated with rib fractures)
autoimmune- rheumatoid arthritis
metabolic- uraemia
iatrogenic- drug related (amiodarone, methotrexate, sodium valporate, nitrofurantoin- as these are oesinophil rich)
environmental- asbestos related
neoplastic- primary pleural malignancy (mesothelioma) or metastatic cancer from many solid organ tumour most commonly breast and lung
transudative causes of pleural effusion
cardiac- congestive heart failure commonly presents with bilateral effusion (less common with unilateral disease)
renal- chronic kidney disease results in generalised fluid overload and classically bilateral effusions, nephrotic syndrome is a form of glomerulonephritis which presents with low serum albumin and reduced oncotic pressure and generalised oedema
hepatic- liver cirrhosis (chronic alcohol abuse or fatty liver disease), usually causes a right sided effusion often termed hepatic hydrothorax
investigation findings for pnueumonia/TB
positive sputum for AFB (acid-fast bacillus)
fever and nigh sweats
investigation findings for mesothelioma
asbestos exposure
chest pain and weight loss
investigation findings for PE
acute pleuritic pain
CTPA showing saddle embolus
investigation findings for pancreatitis
abdominal pain
raised serum lipase
investigation findings for metastatic breast cancer
ER positive adenocarcinoma in pleural fluid
investigation findings for cardiac failure
pedal oedema
raised JVP
investigation findings for liver cirrhosis
jaundice
ascites
what is mesothelioma
malignant tumour of the mesothelium
where do the majority of mesothelioma cases arise
90% arise in the pleura but it can also develop in the peritoneum, pericardium and testes
what is the strongest risk factor for mesothelioma
asbestos exposure
high risk occupations for mesothelioma
shipyard workers
construction workers
boiler engineers
(can also be at home in family for example washing the asbestos covered clothes)
classic presentation of mesothelioma
shortness of breath
chest pain
pleural effusion
does mesothelioma commonly metastasise
it can metastasis but more commonly progresses locally
3 main subtypes of mesothelioma
sarcomatoid
epitheliod
mixed
which type of mesothelioma has a poorer prognosis
sarcomatoid
is there a cure for mesothelioma
no
treatment for mesothelioma
treatments are supportive not curative such as chemotherapy and radiotherapy
surgery not gone
