What is the management approach for a patient presenting with coffee ground emesis?

Management of Coffee Ground Emesis

For patients presenting with coffee ground emesis, a CT scan of the chest, abdomen, and pelvis is recommended to evaluate for both gastrointestinal bleeding sources and potential non-GI causes, as coffee ground emesis often indicates underlying conditions beyond upper GI bleeding. 1

Initial Assessment and Stabilization

• Evaluate hemodynamic stability including vital signs, as coffee ground emesis may represent upper GI bleeding which can lead to hypovolemic shock in approximately 15% of cases 2
• Assess for volume depletion and provide aggressive fluid resuscitation with isotonic fluids (10-20 mL/kg boluses of normal saline) as needed 2
• Check hemoglobin/hematocrit levels to determine if blood transfusion is required 1
• Consider nasogastric tube lavage in ventilated patients only, as this procedure can increase risk of gagging, vomiting, and aerosolization in unsedated patients 2

Diagnostic Approach

• CT chest/abdomen/pelvis is valuable as patients with coffee ground emesis often have non-GI bleeding etiologies that may be overlooked if focus is solely on GI bleeding 1
• Consider alternative diagnostic modalities such as CT angiography if patient is hemodynamically stable but upper GI bleeding remains in the differential 2
• Patients with coffee ground vomiting have significantly lower endoscopic yield compared to those with frank hematemesis or melena 3
• Document and photograph emesis when possible to guide management decisions 2

Medical Management

• Initiate proton pump inhibitor therapy:
  • Consider high-dose continuous infusion (80 mg bolus followed by 8 mg/hour for 72 hours) for patients with suspected active bleeding 2, 4
  • Standard dosing (40 mg IV twice daily) may be sufficient for stable patients with coffee ground emesis 4
• Administer antiemetics to control ongoing vomiting:
  • Ondansetron (5-HT3 antagonist) is considered first-line due to superior efficacy and fewer side effects 5
  • Consider dexamethasone as an adjunctive agent for persistent nausea/vomiting 5
  • Lorazepam may be beneficial to reduce anxiety associated with nausea 5

Endoscopic Considerations

• Early upper endoscopy should be considered, though patients with coffee ground emesis have significantly fewer high-risk bleeding lesions compared to those with frank hematemesis 1, 3
• For patients with endoscopically confirmed bleeding ulcers, combination of endoscopic therapy (epinephrine injection and/or hemoclips) plus PPI therapy is standard management 6
• Consider deferring endoscopic evaluation in hemodynamically stable patients with coffee ground emesis and no drop in hemoglobin/hematocrit 1, 3

Important Clinical Caveat

• Hemodynamically stable patients with coffee ground emesis should be evaluated for non-GI bleeding conditions even while managing the potential GI bleed 1
• Associated diagnoses to consider include: acute myocardial infarction, urosepsis, small bowel obstruction, pulmonary emboli, and acute renal failure 1
• Coffee ground emesis has similar 30-day mortality rates to other presentations of GI bleeding despite lower rates of active bleeding, suggesting non-bleeding causes may contribute to outcomes 3

Follow-up and Monitoring

• Monitor for rebleeding, which occurs less frequently with coffee ground emesis compared to frank hematemesis or melena 3
• Correct any electrolyte abnormalities, particularly in patients with prolonged vomiting 7
• Consider scheduled rather than as-needed antiemetics for persistent nausea/vomiting 5