Haematuria, haemoptysis and goitre

Haematuria: first steps

• Visible versus non-visible (dipstick 1+ or more, confirmed on repeat).
• Exclude red urine without red cells: beetroot, rifampicin, porphyria, myoglobinuria (rhabdomyolysis: dipstick positive, no red cells on microscopy) and haemoglobinuria (intravascular haemolysis: free haemoglobin appears in urine once haptoglobin is saturated). Also exclude menstruation, UTI (treat and retest), exercise, recent catheterisation.
• Timing in the stream: initial (urethra, prostate), terminal (bladder neck and trigone: stones, schistosomiasis), total (bladder or above).

Causes by site

• Urothelial carcinoma risk: smoking (the biggest), aromatic amines (aniline and azo dyes, rubber and tyre factories, leather, paint), cyclophosphamide, phenacetin, schistosomiasis (squamous type). Factory workers with painless haematuria are classic.
• Renal cell carcinoma: haematuria, loin pain and a flank mass (the classic triad, now uncommon), fever, weight loss, polycythaemia from erythropoietin (Hb 18), hypercalcaemia, left varicocele from renal vein invasion.

Glomerular haematuria and pulmonary–renal syndromes

• Clues to a glomerular source: dysmorphic red cells, red cell casts, proteinuria, hypertension, raised creatinine, cola-coloured urine; refer to nephrology for biopsy.

Investigating non-glomerular haematuria

• Painless visible haematuria in an adult (for example a 62-year-old smoker) needs urgent urology: flexible cystoscopy plus CT urography, urine culture and cytology, renal function, PSA after counselling. Ultrasound replaces CT in younger, low-risk patients.
• Fever and hypotension after cystoscopy or other urinary instrumentation: Gram-negative bacteraemia (*E. coli*, *Klebsiella*, *Proteus*) with endotoxin-driven septic shock; blood cultures and IV antibiotics.
• Clot retention: three-way catheter and bladder irrigation.

Haemoptysis

• True haemoptysis is bright red, frothy and mixed with sputum; haematemesis is dark, acidic and may contain food; pseudohaemoptysis comes from the nose or mouth.

• Post-partum or post-operative PE: a week after delivery or several days after laparotomy, sudden pleuritic pain, breathlessness and haemoptysis with S1Q3T3: CT pulmonary angiography.
• Massive haemoptysis (roughly 200–600 mL in 24 hours, or any amount compromising the airway) kills by asphyxiation, not blood loss. Lie the patient bleeding side down to protect the good lung; oxygen, reverse clotting problems, tranexamic acid, secure the airway (large tube, selective intubation of the good lung), then CT angiography and bronchial artery embolisation: the bleeding usually comes from the high-pressure bronchial (systemic) arteries. Rigid bronchoscopy or resection if it persists.
• Investigations: chest X-ray, CT, sputum for AFB and GeneXpert, cytology, bronchoscopy, clotting, urinalysis and creatinine (pulmonary–renal syndromes).

Goitre: mechanisms and types

• Why iodine deficiency enlarges the thyroid: too little iodine means less T4 and T3; the pituitary responds with more TSH, which drives follicular cell hyperplasia and hypertrophy, so the gland enlarges to keep the patient euthyroid. Iodine deficiency is the commonest cause of goitre worldwide and is endemic in the northern mountain valleys of Pakistan (Gilgit-Baltistan, Chitral). Cycles of stimulation and involution produce a multinodular goitre, with nodules that may become autonomous.
• Jod-Basedow effect: giving large doses of iodine to a long-standing nodular goitre with autonomous nodules can provoke hyperthyroidism. Prevention is universal salt iodisation.

• Medullary carcinoma shows nests of cells in an amyloid stroma (from calcitonin) and raises calcitonin; check RET and exclude phaeochromocytoma before surgery.

Assessing a goitre

• A thyroid swelling moves up on swallowing because the gland is enclosed in pretracheal fascia attached to the larynx; a thyroglossal cyst also moves with tongue protrusion.
• Retrosternal goitre: breathlessness lying flat (orthopnoea), stridor, Pemberton sign (facial plethora when the arms are raised), SVC obstruction.
• Malignancy clues: rapid growth, hard fixed nodule, hoarseness (recurrent laryngeal nerve), cervical nodes, previous neck irradiation, MEN 2 family history, extremes of age, male sex.
• Tests: TSH first, then free T4 or T3 and antibodies; ultrasound with FNAC (Bethesda categories); isotope scan if TSH is low (a hot nodule is rarely malignant; cold nodules carry a higher risk though most are benign); CT for retrosternal extent; laryngoscopy before surgery to document vocal cord function.
• Thyroidectomy indications: suspected or proven cancer, compression (dysphagia, stridor), retrosternal goitre, toxic goitre unsuitable for drugs or radioiodine, cosmesis.

After thyroidectomy

Remember Iodine shortage drives TSH, TSH drives follicular growth, and the gland enlarges to keep the patient euthyroid.

Exam trap In massive haemoptysis lie the patient bleeding side down; death is from asphyxiation.

Exam trap Painless visible haematuria in an adult needs cystoscopy and CT urography; a neck haematoma after thyroidectomy needs the wound opened at the bedside.

How FCPS asks about this

• Painless haematuria in a smoker or tyre-factory worker: urothelial carcinoma; cystoscopy and CT urography.
• Haematuria with flank mass and high Hb: renal cell carcinoma secreting erythropoietin.
• Haemoptysis plus haematuria: Goodpasture (linear IgG) or GPA (c-ANCA, saddle nose).
• Red urine without red cells: myoglobin or haemoglobin after haptoglobin saturation.
• Endemic goitre in Gilgit: TSH-driven follicular hyperplasia; salt iodisation prevents it.
• Massive haemoptysis: bronchial artery bleeding; embolisation.
• Thyroid lump: moves with swallowing; TSH first, then ultrasound and FNAC; hot nodules are rarely malignant.