C46-14 Spontaneous Bulla Hemorrhage in COPD on Anticoagulation: A Case of Bleeding That Healed Itself

Abstract Introduction Spontaneous hemorrhage within an emphysematous bulla is a rare complication, typically resulting from rupture of fragile neovascular structures within thin bulla walls. Anticoagulant therapy, infection, or elevated intrathoracic pressure can precipitate bleeding. We present a case of bullar hemorrhage managed conservatively and considerations for longitudinal anticoagulation management. Case Report A 65-year-old current smoker with severe COPD (FEV1 19%, DLCO 32%). chronic oxygen dependence, atrial fibrillation, and prior pulmonary embolism on warfarin therapy presented after experiencing an episode of massive hemoptysis. Chest X-ray revealed a new patchy consolidation in the left mid and lower lung. Warfarin and aspirin were discontinued, and intravenous vitamin K was administered. CT angiography of the chest revealed an 11.8 cm hyperdense lesion within a large anterior left-upper-lobe bulla, consistent with acute intrabullar hematoma, with surrounding consolidation and ground-glass opacities. No clear hypertrophied vessels were identified as a target for intervention. After a multidisciplinary discussion, the patient was not deemed to be a surgical candidate due to poor pulmonary reserve. He was conservatively managed using nebulized tranexamic acid, antibiotics, and cough suppression and was discharged home. Serial imaging performed 3 months after the initial episode noted a marked decrease in size of the bulla with partial resorption of the hematoma and resolution of surrounding ground glass opacities. A left atrial appendage closure device was placed six months following the index event to mitigate his stroke risk with atrial fibrillation. Unfortunately, pulmonary embolism reoccurred 3 years following the initial hemoptysis event, and he was able to tolerate initiation of apixaban without recurrence of bleeding. Discussion Non-traumatic bleeding into emphysematous bullae is a rare complication. Chronic inflammation from smoking, vascular remodeling, and mechanical stress weaken the wall of the bulla, predisposing fragile neovascular capillaries to rupture. Bleeding typically arises from the low-pressure pulmonary circulation and is usually self-limiting. This is due to spontaneous tamponade and containment within the bulla, and therefore, they respond well to conservative management. Management of bleeding associated with anticoagulation can be challenging and should incorporate a careful assessment of bleeding and clotting risk. Optimization of stroke risk with the left atrial appendage occlusion device permitted discontinuation of chronic anticoagulation. When thromboembolism later recurred, anticoagulation with apixaban was deemed reasonable due to the resorption of the bulla, reduction of chronic inflammation with smoking cessation, and the lower bleeding risk associated with apixaban. This case emphasizes individualized anticoagulation strategies, balancing hemorrhagic and thrombotic risk. This abstract is funded by: None