What are the causes of coffee ground emesis?

Causes of Coffee Ground Emesis

Coffee ground emesis is most commonly caused by peptic ulcer disease (35-50% of cases), followed by gastroduodenal erosions (8-15%), Mallory-Weiss tears (15%), esophagitis (5-15%), and less frequently by esophageal varices (5-10%), with malignancy and vascular malformations each representing approximately 1% of cases. 1

Primary Etiologies

Most Common Causes

• Peptic ulcer disease is the leading nonvariceal cause, accounting for 35-50% of upper GI bleeding cases presenting with coffee ground emesis 1

  • Typically associated with chronic NSAID use, Helicobacter pylori infection, or other risk factors 2
  • One study from Iran found 75% of upper GI bleeding patients had history of regular low-dose aspirin or NSAID consumption 3

• Gastroduodenal erosions cause 8-15% of cases 1

  • Commonly associated with NSAID use, stress, or metabolic conditions like diabetes 1

• Mallory-Weiss tears account for approximately 15% of cases 1

  • Result from forceful vomiting or retching 1
  • Typically present immediately after an episode of prolonged vomiting, distinguishing them from peptic ulcer disease 2

• Esophagitis accounts for 5-15% of cases 1

  • More frequently found in coffee ground emesis compared to frank hematemesis 1

Less Common but Important Causes

• Esophageal varices cause 5-10% of upper GI bleeding overall 1

  • When present, varices more commonly cause massive hematemesis (66-70% of massive cases) rather than coffee grounds 1
  • Require underlying portal hypertension from cirrhosis or chronic liver disease, making them unlikely in patients with no prior medical history 2
  • Typically present with more massive hemorrhage and hemodynamic instability 2

• Upper GI malignancy (gastric or esophageal cancer) represents approximately 1% of cases 1

• Vascular malformations represent approximately 1% of cases 1

Critical Clinical Caveat: Non-GI Causes

A crucial pitfall is assuming coffee ground emesis always represents significant GI bleeding—hemodynamically stable patients with coffee ground emesis should be evaluated for non-GI conditions that may be the primary problem. 1, 4

• Non-GI causes to consider include:

  • Acute myocardial infarction 1, 4
  • Sepsis/urosepsis 1, 4
  • Pulmonary emboli 1, 4
  • Acute renal failure 1, 4
  • Small bowel obstruction 4

• A case series found that in hemodynamically stable patients with coffee ground emesis, endoscopy failed to find any significant upper GI lesions in 50% of cases, while more significant non-GI diagnoses were present 4

• A large database study (6,054 patients) found coffee ground vomiting was associated with significantly lower endoscopic yield compared to hematemesis or melena, with increased likelihood of finding esophagitis or no source at all 5

Diagnostic Significance

• Coffee ground emesis indicates less active bleeding compared to fresh red hematemesis, as the blood has been exposed to gastric acid long enough to oxidize 1

• Despite lower acuity, full evaluation with endoscopy within 24 hours is still recommended after hemodynamic stabilization 1

• However, recent evidence questions the urgency of endoscopy in isolated coffee ground vomiting without hemodynamic instability, as urgent endoscopy (within 24 hours) showed no benefit in morbidity, mortality, ICU admission, or rebleeding compared to scheduled endoscopy 6

Risk Stratification Factors

• Age >65 years significantly increases mortality risk and requires more aggressive management 1, 7

• Hemodynamic instability (tachycardia >100 bpm, systolic BP <100 mmHg) indicates higher risk 1

• Concomitant steroid use with NSAIDs increases mortality risk 3

• Significant comorbidities (cardiovascular, renal, or liver disease) increase complication risk 7