What is the appropriate management for a patient presenting with black vomit, indicative of upper gastrointestinal bleeding?

Management of Black Vomit (Coffee Ground Emesis)

Black vomit indicates upper gastrointestinal bleeding requiring immediate hospital evaluation, aggressive resuscitation with two large-bore IV lines and normal saline, followed by endoscopy within 24 hours after hemodynamic stabilization. 1, 2

Immediate Assessment and Resuscitation

Check vital signs immediately to determine severity and guide management: 1, 2

• Pulse >100 bpm, systolic blood pressure <100 mmHg, or signs of shock indicate severe bleeding requiring emergency intervention
• Hemodynamic instability despite resuscitation is a high-risk feature requiring aggressive management

Establish two large-bore IV lines in the anticubital fossae and begin aggressive fluid resuscitation with normal saline while simultaneously assessing hemodynamic stability—this takes absolute priority before any diagnostic procedures. 2

Infuse 1-2 liters of normal saline initially in hemodynamically compromised patients. 2

• If shock persists after 2 liters, add plasma expanders as this indicates ≥20% blood volume loss
• Insert urinary catheter and measure hourly urine output (target >30 ml/h indicates adequate resuscitation)

Transfuse red blood cells to maintain hemoglobin >7 g/dL (or >9 g/dL if massive bleeding or cardiovascular disease present). 1, 2

Risk Stratification

Coffee ground vomit results from gastric acid converting hemoglobin to hematin, creating the characteristic dark, granular appearance that indicates less active bleeding compared to bright red blood, as the blood has had time to be partially digested. 1

Most common causes include: 3, 4

• Peptic ulcer disease (35-50% of cases)
• Mallory-Weiss tears (15%)
• Gastroduodenal erosions (8-15%)
• Esophagitis (5-15%)
• Varices (5-10%)

Specifically assess for cirrhosis, as variceal bleeding mortality approaches 30% versus 10% for nonvariceal sources and requires specialized management with prophylactic antibiotics and vasoactive medications. 2, 4

Endoscopic Management

Perform endoscopy within 24 hours after achieving hemodynamic stability—blood pressure and CVP should ideally be stable before endoscopy. 1, 2

Critical pitfall: Do not perform endoscopy before adequate resuscitation in unstable patients, as this increases mortality. 1, 2

For hemodynamically stable patients, schedule endoscopy within 24 hours rather than emergently, as urgent timing does not improve outcomes in stable patients. 1

Keep patient fasted until hemodynamically stable. 2

In severely bleeding patients, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration. 2

Pharmacologic Management

Initiate intravenous proton pump inhibitors upon presentation to decrease the probability of high-risk stigmata seen during endoscopy. 5, 6

Following successful endoscopic therapy for ulcer bleeding, administer high-dose proton pump inhibitor therapy continuously or intermittently for 3 days, followed by twice-daily oral therapy for the first 2 weeks. 2, 7

Administer erythromycin 30 minutes to an hour before endoscopy as a prokinetic agent to aid in diagnosis. 5, 8

Special Considerations

Evaluate for non-GI conditions in hemodynamically stable patients, including acute myocardial infarction, sepsis, pulmonary emboli, small bowel obstruction, and acute renal failure, as these are frequently the primary diagnosis in stable patients with coffee ground material. 1, 4

Elderly patients (>65 years) have significantly higher mortality rates and require more aggressive inpatient management. 1, 2

Very low-risk young patients without hemodynamic compromise, significant comorbidities, or high-risk features may be managed as outpatients after appropriate evaluation, but most patients require hospital evaluation given the 30-day mortality rates associated with upper GI bleeding. 1

Post-Endoscopy Management

Monitor for rebleeding, defined as fresh hematemesis and/or melena associated with shock (pulse >100 bpm, systolic pressure <100 mmHg), CVP fall >5 mmHg, or hemoglobin reduction >20 g/L over 24 hours—rebleeding should always be confirmed by endoscopy. 3, 4

Address underlying causes: Helicobacter pylori eradication, acid suppression, and counsel regarding NSAID use. 2

For recurrent ulcer bleeding, treat with repeat endoscopic therapy; if endoscopic therapy fails, proceed to transcatheter arterial embolization, then surgery if hemostasis is not obtained. 6, 7