Dieulafoy's disease of the bronchial tree: a case report / Doença de Dieulafoy da árvore brônquica: relato de caso

ABSTRACT CONTEXT: Dieulafoy's disease of the bronchial tree is a very rare condition. Few cases have been reported in the literature. It can be asymptomatic or manifest with massive hemoptysis. This disease should be considered among heavy smokers when recurrent massive hemoptysis is present amid otherwise normal findings. The treatment can be arterial embolization or surgical intervention. CASE REPORT: A 16-year-old girl was admitted to the emergency department due to hemoptysis with an unknown lesion in the bronchi. She had suffered massive hemoptysis and respiratory failure one week before admission. Fiberoptic bronchoscopy revealed a lesion in the bronchus of the right lower lobe, which was suspected to be a Dieulafoy lesion. Segmentectomy of the right lower lobe and excision of the lesion was carried out. The outcome for this patient was excellent. CONCLUSION: Dieulafoy's disease is a rare vascular anomaly and it is extremely rare in the bronchial tree. In bronchial Dieulafoy's disease, selective embolization has been suggested as a method for cessation of bleeding. Nevertheless, standard anatomical lung resection is a safe and curative alternative.

RESUMO CONTEXTO: A doença de Dieulafoy da árvore brônquica é uma condição muito rara, poucos casos foram descritos na literatura. Pode ser assintomática ou manifestar-se com hemoptise maciça. Esta doença deve ser considerada em fumadores pesados quando eles têm recorrentes hemoptises maciças sem outros achados anormais. O tratamento pode ser tanto embolização arterial como intervenção cirúrgica. RELATO DE CASO: Uma menina de 16 anos foi admitida no Serviço de Urgências devido a hemoptise com uma lesão nos brônquios de origem desconhecida. Havia sofrido hemoptise maciça e insuficiência respiratória uma semana antes da admissão. A broncoscopia de fibra óptica relevou lesão no brônquio do lobo inferior direito, com suspeita de ser lesão de Dieulafoy. Foi realizada uma segmentectomia do lobo inferior direito com excisão da lesão. O resultado da paciente foi excelente. CONCLUSÃO: A doença de Dieulafoy é uma anomalia vascular rara, sendo extremamente rara na árvore brônquica. Na doença de Dieulafoy bronquial, embolização seletiva tem sido sugerida como método para cessação do sangramento; no entanto, a habitual resseção anatômica do pulmão é uma alternativa segura e curativa.

Electrocauterio y broncoscopia flexible como primera medida en la obstrucción central de la vía aérea y hemoptisis asociada / Electrocautery and bronchoscopy as a first step for the management of central airway obstruction and associated hemoptysis

Background: Central airway obstruction caused by malignant or benign lesions, associated in some cases with hemoptysis, is a condition with high morbidity and mortality. The use of electrocautery by flexible bronchoscopy is an initial treatment option with immediate improvement of obstruction symptoms. It is as effective as Nd: YAG laser. Aim: To describe the usefulness of electrocautery in the management of central obstruction of the airway and hemoptysis. Material and Methods: A retrospective, descriptive study of patients referred for management of central airway obstruction or associated hemoptysis. Diagnoses, symptoms (dyspnea, cough, and hemoptysis) and radiology before and after the procedures were analyzed. Results: Eighteen patients aged 59 ± 12 years (66% males) were evaluated, registering 25 endoscopic procedures. Three conditions were found: partial or complete airway obstruction, hemoptysis and post lung transplant bronchial stenosis. Seventy two percent presented with dyspnea, 61% with cough and 33% with hemoptysis. Sixty six percent of patients had airway obstruction caused by malignant metastatic lesions. After electrocautery, 17 patients (94.4%) improved their symptoms and achieved complete airway clearing. Three patients had significant bronchial stenosis after lung transplant achieving subsequent clearing after electrocautery. Conclusions: Electrocautery during flexible bronchoscopy is an effective and safe procedure for the management of central airway obstruction and associated hemoptysis.

Fibrinógeno-trombina como tratamiento puente en un caso de hemoptisis masiva / Fibrinogen-thrombin as bridge therapy in massive hemoptysis

Se presenta el caso de una paciente joven con hemoptisis masiva por tuberculosis que no pudo ser controlada de forma efectiva con la inserción de un catéter Fogarty por un fibrobroncoscopio. Ante esto y el alto riesgo de asfixia o desangramiento, se decidió infundir fibrinógeno-trombina a través de un catéter, introducido por el fibrobroncoscopio; con esto se logró controlar el sangrado, intubarla con un tubo orotraqueal de doble luz y estabilizarla para remitirla a otra institución, donde fue sometida a lobectomía y se le proporcionó tratamiento antituberculoso. La infusión de fibrinógeno-trombina podría considerarse como una opción terapéutica transitoria, de tipo puente, mientras se practica el manejo definitivo.

This article presents the case of a young woman with massive hemoptysis (1,000 mL in 6 hours) due to tuberculosis, which could not be controlled by insertion of a Fogarty catheter through a fiber-optic bronchoscope. Because of asphyxia and persistent bleeding risk we instilled fibrinogen-thrombin through a fiber-optic bronchoscope inserted catheter, achieving bleeding cessation and permitting the placing of a double-lumen oro-tracheal tube. Later on, the patient underwent lobectomy and anti-tuberculosis treatment. The fibrinogen-thrombin could be considered as a bridge, transitory measure for massive hemoptysis, while definitive treatment could be established.

Massive life-threatening hemoptysis from pulmonary hydatid cysts: a 13 - year experience from an endemic area

Echinococcosis is a parasitic disease often seen in sheep and cattle raised in countries with unsanitary conditions. The disease is encountered endemically in northwest of Iran. Life-threatening hemoptysis due to a pulmonary hydatid cyst is a rare condition. This study assessed the prevalence and treatment of this condition. Materials and In a retrospective study, between 1993 and 2005, 520 patients with pulmonary hydatid cysts were operated at the Imam Khomeini Hospital in Tabriz, Iran. Ten [1.9%] cysts exhibited life-threatening hemoptysis [Group II]. The remaining 510 patients with pulmonary hydatid cyst were studied [Group I] and compared with group II. Ten patients were included in group II, with a mean follow - up of 2.5 years. Four [40%] cases were males and six [60%] were females. The age ranged between 8 and 46 [mean 27.90 +/- 13.86] years. The most common symptoms were cough [100%], massive hemoptysis [100%], respiratory distress [100%], and chest pain [90%]. The amount of hemoptysis was between 600 and 1400 ml [mean 840 +/- 249.66] a day. The origin of bleeding in six [60%] was from the cyst in the right lung and in four [40%] from the left lung. Bronchoscopy revealed the site of bleeding in all 10 patients, and the lobe in seven [70%]. Chest x-ray and CT scan showed patchy infiltration in one or both lungs and a ruptured hydatid cyst in eight cases. Lobectomy was the most frequent applied procedure [100%]. Two [20%] cases died due to blood aspiration and respiratory distress syndrome, one in the 3rd and the other in the 4th postoperative day. The postoperative hospital stay ranged between 7 and 25 [mean 11.30 +/- 6.56] days. Two and a half years follow-up of patients was good. There was no recurrence. There were significant differences between the two groups In terms of complications and mortality [X2 =102.39, df=1, p<0.0005] and [X2 = 5.82, df=1, p<0.16]. Massive life-threatening hemoptysis due to pulmonary hydatid cysts must be managed as an urgent clinical entity. It has serious symptoms, serious post-operative complications and a high mortality rate.

Surgical treatment of complicated pulmonary hydatid cyst

Hydatid disease is caused by an infection with the cestode, Echinococcus granulosus and is endmic in Iran. Medical therapy and surgical management are two main treatments. The purpose of this study is to represent our ten-year experience in surgical management of patients with complicated pulmonary hydatid disease including cysts ruptured into the pleural space or bronchi, multiplicity, hemoptysis, large size cysts and coexistence with liver cysts. Medical records of 109 patients, who underwent surgery for the treatment of pulmonary hydatid disease in Masih Daneshvari Hospital from December 1995 to October 2005, were reviewed. Among these patients, we selected our study group in accordance with the following criteria: 1] Cyst rupture into the pleural space or bronchi, 2] Occupying more than two third of the hemithorax in radiological studies, 3] Multiple cysts, 4] Massive hemoptysis, and 5] Synchronous pulmonary and liver cysts. Among the 109 patients with pulmonary hydatid cyst, 82 patients [59% male and 41% female] met the above mentioned criteria. The mean age of patients was 31.7 years [range 9-80 yrs]. The cyst diameter was determined by radiological imaging. The mean diameter was 6.23 cm, and 13 patients had giant cysts [occupying more than 2/3 width of the hemithorax]. In this study group 55 patients had ruptured hydatid cysts, 29 had multiple cysts, 11 had significant hemoptysis and 15 had synchronous pulmonary and liver cysts. All patients had undergone surgery with or without previous medical therapy. Our procedure of choice was thoracotomy, cystectomy and closure of the bronchial openings before irrigating the cavity with silver nitrate [0.5%] soaked sponge. Pulmonary resection was done in 8 patients due to the irreversible parenchymal damage. Post operative complications occurred in 16 [19%] patients including residual pleural space in 8, broncho-pleural fistula in 2, pleural effusion in 1, pulmonary embolism in 1, osteomyelitis of sternum in 1, laceration of diaphragm in 1, and inability to access the liver hydatid cyst after thoracotomy and post operative pulmonary insufficiency necessitating mechanical ventilation also in 1 patient. One patient died because of sepsis [she had been operated on for combined pulmonary and liver hydatid disease]. In the 1 to 60 months follow up period, 2 recurrences occurred. Although post operative complications occurred in 19% of our patients, all were treated by conservative managements. This rate of complications was acceptable among patients with complicated hydatid disease. Our procedure of choice is draining the cyst; closing all the bronchial openings in the pericyst and leaving the pericyst cavity open into the pleural space

Surgical management of tuberculous broncholithiasis

Broncholithiasis is often seen after chronic granulomatosis diseases such as tuberculosis and histoplasmosis and leads to a wide spectrum of signs and symptoms; including hemoptysis which often needs surgical management. The goal of this study is evaluation of surgery in patients with tuberculous broncholithiasis presenting with hemoptysis. In this study, all patients with tuberculous broncholithiasis whom had been operated on between 1991 and 2005 and their follow-up period was at least 6 months and at most 9 years were included and studied in regard to age, sex, clinical symptoms, diagnostic methods, type of surgical procedure, complications, and mortality rate. Overall, 5 patients were studied; [M/F=2/3, mean age=31 years], 40% with severe and 60% with mild to moderate and recurrent hemoptysis. Lesion was at the left lung in 80% and at the right lung in 20% of patients. In 60% of patients some degrees of bronchiectasis were seen, in 80% the lesion was visible in bronchoscopy and endoscopic removal of lesion failed in all cases. Sixty percent of patients underwent pulmonary resections and in 40% broncholithectomy was done. In follow-up, patients with pulmonary resection have had no problem till now, but in patients with broncholithectomy due to the late occurrence of bronchiectasis, re-operation and pulmonary resection were unavoidable. No mortality was reported in our patients. Regarding the risks of hemoptysis, excellent results of surgery and possible occurrence of late bronchiectasis after broncholithectomy, the results of our study showed that the procedure of choice for these lesions is pulmonary resection distal to lesion and saving as much of parenchyma as possible. Broncholithectomy should be done only in patients in whom pulmonary resection is not technically possible. But because of very low occurrence of this complication, further studies are required in this regard

Parallel Technique of Endobronchial Balloon Catheter Tamponade for Transient Alleviation of Massive Hemoptysis

Endobronchial balloon tamponade is an alternative method that can be used to control massive hemoptysis. Several different techniques have been used for this purpose. We describe a new parallel method, in which biopsy forceps introduced through a bronchoscope channel is used to grasp a balloon catheter. As the bronchoscope is advanced to the bleeding site, the balloon catheter is pulled into position, and subsequently inflated. There are several advantages of this technique. It needs no specialized catheter or guide wire, the procedure is relatively easy to perform, and applicable to other purposes such as introduction of an additional suction catheter.

Hemoptisis de mediana gravedad de causa poco frecuente: bronquiectasia seca y unica / Un frequent cause of severe hemoptysis: dry bronchiectasia

Se presenta un caso de hemoptisis de mediana gravedad de causa poco frecuente: la llamada "bronquiectasia seca, única, hemoptizante", ocurrida en un paciente sin ningún antecedente respiratorio y con radiología torácica convencional prácticamente normal. Se llegó al diagnóstico certero preoperatorio por broncofibroscopia y broncografía selectiva. Se efectuó la resección pulmonar más económica adecuada al caso: bisegmentectomía anterior apicoposterior del lóbulo superior izquierdo. El paciente curó. Se hacen consideraciones sobre el diagnóstico y tratamiento de las hemoptisis en general y se comenta con más detalle el manejo actual de las de gravedad mediana y mayor

Hemorragia tuberculosa incontrolável: uma urgência cirúrgica / Uncontrolled tuberculosis hemorrhage: a surgical emergency

O trabalho apresentado, focaliza uma entidade clínico-patológica designada Hemoptise Tuberculosa Incoercível, frente ao tratamento clínico convencional indicado. É analisada a dominante do quadro clínico, caracterizado por hemoptises maciças incontroláveis, repetidas e persistentes. Dentre os exames complementares, valorizamos a importante contribuiçäo da radiologia, o emprego PEEP e os aspectos anátomo-patológicos mais característicos da lesäo. Säo tecidas consideraçöes acerca do tratamento cirúrgico, enfatizando a terapia resseccionalista como única condiçäo viável à cura desta entidade mórbida

Hemoptise maciça / Massive hemoptysis

Estudo sobre hemoptise maciça, analisando a etiologia, patogênese e abordagem terapêutica. O enfoque atual está no que se refere às técnicas mais recentes usadas no diagnóstico e controle do sangramento

Hemoptise maciça / Massive hemoptysis

Os autores revisam a literatura e relatam parte de sua experiência sobre o tratamento da hemoptise maciça. Adotam um conceito menos matemático e mais fisiológico para o sangramento maciço, enfatizando a necessidade de se estabelecer uma rotina que possa ser executada rápida e eficientemente. Destacam o papel da embolizaçäo seletiva das artérias brônquicas, especialmente para os casos näo cirúrgicos. Propöem a cirurgia de ressecçäo pulmonar com a única forma definitiva de tratamento