A 50 year old patient presents with a third documented episode of hemoptysis. Within six hours the bleeding stops. A portion of the right lung from a current chest CT is shown. One month ago the FEV1 was 1.5 liters. The best management for this patient is

A. bronchoscopy followed by angiography with arterial embolisation.
B. continued observation in the intensive care unit for another 48 hours and if no further bleeding occurs discharge to home on antibiotics.
C. resection of the involved area.
D. treatment with anti-fungal chemotherapy for six weeks.
E. treatment with rotating bactericidal antibiotics.

Answer C

The film demonstrates findings consistent with bronchiectasis. It is important to take a careful history and to obtain old chest radiographs. The history often points to events that suggest bronchiectasis. Discharge of this patient without definitive therapy is dangerous even if no further bleeding occurs during the current admission, as conservative therapy has failed. Prompt resection taking care to spare uninvolved lung tissue is indicated. Antibiotic therapy is appropriate for a first episode of hemoptysis associated with bronchiectasis, but not the third. There are no historical or imaging findings that suggest a fungal infection. Bronchoscopy followed by bronchial artery embolisation is an option, but one that should be reserved for patients with significant medical compromise in whom operation is contraindicated.