Broncholithiasis is a disease of the respiratory tract caused by the presence of calcified exogenous or endogenous foreign bodies (bronchitis) in the bronchi. It is manifested by paroxysmal cough with hemoptysis and coughing up concretions, recurrent inflammatory processes of the respiratory tract, bronchial obstruction. The main diagnostic methods are radiation examination of the chest organs, bronchoscopy. Conservative therapy with antibiotics and expectorants in combination with bronchosanation is prescribed. If necessary, surgical intervention is performed.
ICD 10
J98.0 Bronchial diseases not classified elsewhere
Meaning
Broncholithiasis is rare and accounts for 0.1-0.2% of all diseases of the bronchopulmonary system. In Europe, this pathology in 50-80% of patients is associated with tuberculosis of the bronchi and (or) intra-thoracic lymph nodes. In the USA, the main cause of bronchitis is histoplasmosis. Concretions are found in various parts of the tracheobronchial tree, but in most cases they are located in large – lobular and segmental bronchi. Localization of the pathological process in the right parts of the respiratory system is observed 2.5-3 times more often than in the left. The majority (40-50%) of bronchitis detected during bronchoscopy belongs to the category of transmural.
Broncholithiasis causes
The occurrence of the disease is caused by concretions appearing in the airways. They consist mainly of calcium salts, can be of different sizes, have spurs and protrusions. By origin, these formations are divided into endogenous and exogenous. Bronchitis of external origin are aspirated foreign bodies that have undergone ossification. This also includes calcified endobronchial infectious granulomas and fungal colonies. Endogenous concretions are formed when the contents of a calcified lymph node break into the bronchus, calcification of which is the outcome of granulomatous infections – tuberculosis, histoplasmosis, coccidiosis.
Pathogenesis
Most often, broncholithiasis develops as a result of petrifications entering the bronchial lumen from a calcified lymph node located nearby. Under the influence of nonspecific inflammation or activation of a specific process, its capsule is partially destroyed. Respiratory movements and cardiac pulsation cause compression of the lymph node and perforation of the bronchus by its ossified contents. Petrifications fall into the bronchial lumen or remain embedded in the wall of the organ.
In addition to petrificates, caseous masses enter the airways from the lymph nodes, which subsequently become overgrown with calcium salts and turn into bronchitis. The ossification of foreign bodies and mushroom balls also occurs. The bronchial wall is injured during perforation, damaged by the sharp edges of endobronchial concretions. The integrity of blood vessels of various calibers is violated, which leads to the occurrence of hemoptysis or pulmonary bleeding. Bronchitis can partially or completely obstruct the bronchus, cause a vent swelling of the corresponding section of the lung or its atelectasis.
Classification
Depending on the localization in modern pulmonology, right-, left- or bilateral broncholithiasis is detected. There are single and multiple concretions that cause partial or complete obturation of the bronchial lumen. Of great clinical and diagnostic importance is the endoscopic classification of the disease, according to which broncholithiasis is divided into three types:
- Endobronchial. The concretions are completely located in the lumen of the bronchi. They can reach large sizes (up to 1.5 cm), are often mobile, become overgrown with granulations and provoke the development of purulent endobronchitis.
- Transmural. It is characterized by partial penetration of bronchitis into the bronchus by the type of “tip of the iceberg”. Its main part is located outside the organ and is closely soldered to the underlying tissues. Such a concretion is stationary, granulations are usually absent.
- Intramural. Bronchitis is found soldered into the thickness of the bronchial wall. It dramatically deforms and stenoses the corresponding segment of the tracheobronchial tree.
Broncholithiasis symptoms
In some cases, the disease can be asymptomatic for a long time. However, more often the pathology is manifested by a prolonged dry or productive cough. A pathognomonic sign is the presence of concretions in the sputum secreted, but this symptom is rarely observed. The process of migration of petrificates into the bronchi from calcified lymph nodes is accompanied by bronchial colic. The patient experiences sharp intense pain in the corresponding half of the chest. Cough appears or increases and changes. He becomes paroxysmal, the paroxysm ends with hemoptysis.
Violation of the drainage function of the bronchi due to obstruction of the lumen by concretions provokes the occurrence of secondary purulent-inflammatory diseases of the respiratory system. Purulent bronchitis, pneumonia, and lung abscess develop and recur. The manifestation of suppurative or inflammatory process is accompanied by febrile or hyperthermic fever, increased cough. Sputum turns yellow-green, sometimes with an unpleasant putrid smell. There are symptoms of general intoxication, shortness of breath. The disease can also occur under the mask of asthmatic bronchitis with characteristic attacks of shortness of breath, dry cough.
Complications
Broncholithiasis is very often complicated by hemoptysis. This condition develops when the bronchial wall or granulations are injured by the sharp edges of the concretion. The most formidable life–threatening complication is pulmonary hemorrhage (sometimes massive). Cases of lightning-fast death of patients with broncholithiasis with a breakthrough of blood into the respiratory tract through a fistula formed between the bronchus and the pulmonary artery are described. Recurrent pneumonia, abscesses, bronchiectasia are next in frequency. Prolonged injury to the wall of the tracheobronchial tube with bronchitis sometimes provokes tumor growth.
Diagnostics
Pulmonologists take part in the diagnostic search for suspected broncholithiasis, and with concomitant tuberculosis – phthisiologists. During the survey, special attention is paid to clarifying the presence in the anamnesis of granulomatous infections, aspiration of foreign objects. Auscultation allows you to detect a weakening or strengthening of breathing in the projection of the secondary inflammatory process of the lung, listen to dry and wet wheezes characteristic of an infectious exacerbation. The main methods of detecting this pathology are:
- Radiation studies of the lungs. Broncholithiasis is difficult to detect on a chest X-ray. Indirect signs of the disease are atelectasis of a segment or lobe, a site of linear fibrosis, the presence of single or multiple petrified lymph nodes in the area of the roots of the lungs. With dynamic X-ray examination, it is possible to determine the disappearance of one or more calcinates. Bronchitis itself is well visualized using bronchography and CT of the respiratory organs.
- Endoscopic methods. With bronchoscopy, it is possible to see grayish-yellow concretions present in the lumen or embedded in the wall of the tracheobronchial tube or “feel” them with the help of special devices. Stones overgrown with granulations or deforming the bronchial wall should be differentiated from tumors. In this case, a biopsy is indicated.
- Laboratory tests. Laboratory diagnostics is of an auxiliary nature. During the period of exacerbation of the secondary purulent-inflammatory process in the peripheral blood, leukocytosis, a shift to the left of the leukocyte formula, acceleration of ESR is determined. Sputum examination helps to identify the activation of a specific process. Sometimes concretions are found in the pathological bronchial secretions.
Broncholithiasis treatment
The tactics of patient management depends on the number of bronchitis, their localization and mobility, the presence of complications. Cases of spontaneous healing of patients with broncholithiasis, when single mobile endobronchial pebbles coughed up with sputum, are described. To patients with small, few bronchitis, a wait-and-see tactic can be applied with regular monitoring and rehabilitation of the tracheobronchial tree. It is mandatory to prescribe antibacterial therapy during the exacerbation of the infectious process. Patients with an active form of tuberculosis are treated with anti-tuberculosis drugs.
Complicated by hemoptysis, occlusion of the respiratory tract broncholithiasis is an indication for surgical intervention. A few mobile stones located endobronchially can be extracted using a bronchoscope. Bronchotomy is performed to remove intra- and transmural concretions. With significant scarring of the bronchi, bronchiectasis, suppurative processes, lung resection, frontal or pneumonectomy is performed.
Prognosis and prevention
The prognosis with timely detection and adequate therapy of the disease is favorable. After bronchoscopic extraction of concretions, economical lung resections, complete recovery occurs. Without treatment, there is always a risk of massive pulmonary hemorrhage. Long-term suppurative processes, bronchostenosis gradually lead to chronic respiratory failure. Prevention of broncholithiasis is reduced to complete and timely treatment of granulomatous infections, monitoring of patients who have undergone tuberculosis or histoplasmosis.
Literature
- Acute airway obstruction secondary to bilateral broncholithiasis. Hodgson NC, Inculet RI. Chest. 2000 Apr;117(4):1205-7. link
- Broncholithiasis with recurrent lithoptysis: a case report. Bircan A, Onur D, Yılmaz A. Med Princ Pract. 2014;23(1):83-5. link
- Broncholithiasis: rare but still present. Nollet AS, Vansteenkiste JF, Demedts MG. Respir Med. 1998 Jul;92(7):963-5. link
- Broncholithiasis: A Review. Alshabani K, Ghosh S, Arrossi AV, Mehta AC. Chest. 2019 Sep;156(3):445-455. link
