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

Management of Coffee Ground Emesis

Immediately establish two large-bore IV cannulae (18-gauge or larger) in the antecubital fossae and begin rapid fluid resuscitation with normal saline while simultaneously assessing hemodynamic status and preparing for urgent upper endoscopy within 24 hours. 1, 2

Immediate Resuscitation and Stabilization

Vascular Access and Fluid Management

• Insert two large-bore peripheral IV cannulae (18-gauge or larger) in the antecubital fossae for all patients presenting with coffee ground emesis 3, 1, 2
• Begin rapid infusion of normal saline, typically 1-2 liters initially, to achieve hemodynamic stability (falling pulse rate, rising blood pressure, adequate urine output) 3, 1
• If the patient remains in shock after initial 1-2 liters of crystalloid, administer plasma expanders as this indicates at least 20% blood volume loss 3, 1

Hemodynamic Monitoring

• Continuously monitor pulse and blood pressure using automated monitoring equipment 3, 2
• Insert a urinary catheter and measure hourly urine output in severe cases (target >30 ml/hour indicates adequate resuscitation) 3, 1
• Consider central venous pressure monitoring in patients with significant cardiac disease to guide fluid replacement (target CVP 5-10 cm H₂O) 3, 1

Airway Protection

• Strongly consider endotracheal intubation before endoscopy if the patient has active hematemesis, inability to maintain or protect their airway, or altered mental status 3
• This is critical to prevent pulmonary aspiration during endoscopy, particularly in severely bleeding patients 3

Risk Stratification

Classify severity based on the following parameters 3, 1:

Severe bleeding indicators:

• Age >60 years
• Pulse >100 beats/min
• Systolic blood pressure <100 mm Hg
• Hemoglobin <100 g/L (10 g/dL)
• Presence of significant comorbidities (cardiac disease, liver disease, renal failure)

Laboratory Tests to Order STAT

• Complete blood count with hemoglobin and hematocrit 2
• Coagulation profile (PT/INR, PTT) 2
• Type and cross-match for blood products 2
• Serum lactate and base deficit to assess severity of shock 2

Blood Transfusion Criteria

Transfuse packed red blood cells when: 3, 2

• Hemoglobin <70 g/L (7 g/dL) in hemodynamically stable patients
• Hemoglobin <100 g/L (10 g/dL) in patients with active bleeding and hemodynamic instability
• Target hemoglobin of 70-100 g/L for most patients, but maintain 100 g/L in actively bleeding patients, elderly, or those at risk for myocardial infarction

Important caveat: Use a restrictive transfusion strategy (target Hgb 7-9 g/dL) as this is associated with decreased mortality and reduced rebleeding rates 3

Pharmacological Management

Proton Pump Inhibitors

• Administer high-dose intravenous omeprazole: 80 mg IV bolus followed by continuous infusion of 8 mg/hour for 72 hours 3, 2
• This should be given immediately in the acute setting to decrease the probability of high-risk stigmata at endoscopy 4

Vasoactive Drugs (if variceal bleeding suspected)

• Start octreotide if there is any suspicion of portal hypertension or liver disease: 50 mcg IV bolus (can repeat in first hour if ongoing bleeding), followed by continuous infusion of 50 mcg/hour for 2-5 days 3
• Somatostatin analogs inhibit gastric acid secretion, so co-administration of PPI is not required 3

Antibiotic Prophylaxis

• Administer prophylactic antibiotics if liver disease is suspected: ceftriaxone 1 g IV every 24 hours (maximum 7 days) 3, 2
• This reduces infections, rebleeding, and mortality in patients with cirrhosis 3

Prokinetic Agents

• Consider erythromycin 250 mg IV given 30-120 minutes before endoscopy to improve visualization (check QT interval first) 3, 4

Endoscopy Timing and Preparation

• Perform upper endoscopy within 24 hours of presentation after initial hemodynamic stabilization 3, 1, 2, 4
• Keep the patient fasted until hemodynamically stable 3, 1
• Endoscopy should only be performed after adequate resuscitation is achieved—ideally when blood pressure and central venous pressure are stable 3
• Ensure endoscopy is performed by experienced endoscopists capable of therapeutic interventions (injection, thermal, or mechanical hemostasis) 3

Critical pitfall to avoid: Do not delay resuscitation to perform endoscopy, but also do not delay endoscopy once the patient is adequately resuscitated 3, 2

Special Considerations

Identify Liver Disease Early

• Patients with significant liver disease require specific management protocols including vasoactive drugs and antibiotics 3, 2
• Look for stigmata of chronic liver disease on physical examination 3

Upper vs Lower Source

• Coffee ground emesis indicates an upper GI source, but up to 10-15% of patients with severe hematochezia may have an upper GI source 3, 2
• The coffee ground appearance results from gastric acid converting hemoglobin to hematin 4

Post-Endoscopy Management

• Continue close monitoring with continuous observation of pulse, blood pressure, and urine output 3, 1, 2
• Patients who are hemodynamically stable 4-6 hours after endoscopy can begin drinking and eating a light diet 3, 1
• Consider repeat endoscopy if there is clinical evidence of rebleeding: fresh hematemesis, fall in blood pressure, rise in pulse, or fall in CVP 3

Common Pitfalls to Avoid

• Do not use single hematocrit measurements as the sole guide for bleeding severity—hemoglobin may not reflect acute blood loss initially 2
• Do not over-transfuse—restrictive transfusion strategies improve outcomes 3
• Do not perform endoscopy before adequate resuscitation—this increases risk of aspiration and poor visualization 3, 1
• Do not forget to assess for liver disease—these patients need different management including vasoactive drugs and antibiotics 3