What is the approach to evaluating and managing a patient with brown emesis?

Approach to Brown Emesis Evaluation and Management

Brown emesis is most likely coffee-ground emesis indicating upper gastrointestinal bleeding that requires prompt evaluation and management to reduce morbidity and mortality.

Diagnostic Considerations

Brown or coffee-ground emesis represents partially digested blood in the stomach, suggesting upper gastrointestinal bleeding that has had time to be altered by gastric acid. This differs from fresh hematemesis (bright red blood) but still requires thorough evaluation 1.

Initial Assessment

• Hemodynamic status: Check pulse, blood pressure, and orthostatic vital signs
• Severity indicators: Recent research shows that coffee-ground emesis may be just as concerning as bloody emesis with similar rates of:
  • Tachycardia (pulse ≥100 beats/min in 37% of cases)
  • Hypotension (systolic BP ≤100 mm Hg in 12% of cases)
  • Anemia (hemoglobin ≤100 g/L in 27% of cases) 2
• Warning sign: Concurrent melena significantly worsens outcomes (composite endpoint of transfusion, intervention, or mortality increases from 27.1% to 59.1%) 2

Differential Diagnosis

Common causes of upper GI bleeding presenting as brown emesis include:

• Peptic ulcer disease (35-50%)
• Gastroduodenal erosions (8-15%)
• Esophagitis (5-15%)
• Varices (5-10%)
• Mallory-Weiss tears (15%)
• Upper GI malignancy
• Vascular malformations (1%) 1

Management Algorithm

1. Initial Stabilization

• Secure airway if needed
• Establish IV access (two large-bore IVs)
• Volume resuscitation with crystalloids
• Blood product transfusion if hemodynamically unstable or significant anemia
• Consider proton pump inhibitor infusion for suspected peptic ulcer disease 1

2. Risk Stratification

• Assess for signs of active bleeding:
  • Ongoing emesis
  • Hemodynamic instability
  • Significant drop in hemoglobin
• Check for concurrent melena (significantly worsens prognosis) 2
• Consider COVID-19 status, as it can mimic or exacerbate hemodynamic effects of GI bleeding 1

3. Diagnostic Approach

• Nasogastric tube lavage: Consider in intubated patients to confirm upper GI source (avoid in non-sedated patients due to risk of aerosolization) 1
• Photographic documentation: Request photos of emesis if possible to guide management decisions 1
• Endoscopy: The definitive diagnostic and potentially therapeutic procedure
  • Timing: Urgent (within 24 hours) for active bleeding
  • Can be delayed in stable patients with self-limited bleeding 1
• Alternative diagnostics when endoscopy is not immediately available:
  • CT angiography
  • Bedside capsule endoscopy 1

4. Treatment

• Medical management:

  • Proton pump inhibitor therapy (IV infusion preferred over intermittent dosing)
  • Consider octreotide infusion if varices or liver disease suspected
  • Correct coagulopathies with appropriate blood products
  • Consider reversal agents for anticoagulants if appropriate 1

• Endoscopic intervention based on findings:

  • Injection therapy
  • Thermal coagulation
  • Mechanical hemostasis (clips)
  • Band ligation for varices

• Antiemetic therapy if needed:

  • 5-HT3 antagonists (ondansetron)
  • Dopamine antagonists (metoclopramide)
  • Consider adding dexamethasone 1

Special Considerations

COVID-19 Pandemic Considerations

• COVID-19 patients may develop prothrombotic disseminated intravascular coagulation
• Increased risk of thrombosis may lead to anticoagulant use, which can complicate GI bleeding management
• Consider COVID-19 testing in patients with unexplained GI bleeding 1

Common Pitfalls to Avoid

1. Underestimating coffee-ground emesis: Research shows it can be as severe as bloody emesis 2
2. Delaying endoscopy: Prompt endoscopy improves outcomes in active bleeding
3. Failing to recognize concurrent melena: Significantly worsens prognosis 2
4. Neglecting non-GI causes: Consider other sources of brown emesis such as:
   • Swallowed blood from epistaxis or oral sources
   • Medication effects
   • Food coloring

Follow-up

• For patients with self-limited bleeding and stable vital signs:
  • Consider outpatient endoscopy if appropriate
  • Prioritize patients requiring anticoagulation or antiplatelet therapy 1
• For patients with significant bleeding:
  • Monitor for rebleeding (defined as fresh hematemesis/melaena with shock, CVP drop >5 mmHg, or hemoglobin drop >20 g/L over 24 hours) 1
  • Confirm resolution with repeat endoscopy if clinically indicated

Brown emesis requires thorough evaluation as it represents altered blood from the upper GI tract and carries significant risk for morbidity and mortality, especially when accompanied by other signs of bleeding such as melena.