What is the treatment for a patient presenting with hematemesis (vomiting blood) characterized by black vomit?

Management of Black Vomit (Hematemesis)

Black vomit indicates upper gastrointestinal bleeding requiring immediate hospital evaluation with aggressive resuscitation, early endoscopy within 24 hours, and high-dose proton pump inhibitor therapy following endoscopic intervention. 1, 2

Immediate Resuscitation (Priority #1)

Establish two large-bore IV lines in the anticubital fossae and begin aggressive fluid resuscitation with 1-2 liters of normal saline immediately while assessing hemodynamic stability. 1, 2

• Check pulse, blood pressure, and hemoglobin: patients with pulse >100 bpm, systolic BP <100 mmHg, and hemoglobin <100 g/L represent severe bleeding requiring intensive monitoring 1, 2
• Insert urinary catheter and measure hourly urine output (target >30 ml/h indicates adequate resuscitation) 1
• If shock persists after 2 liters of saline, add plasma expanders as this indicates ≥20% blood volume loss 1, 2
• Transfuse red blood cells to maintain hemoglobin >7 g/dL (or >9 g/dL with massive bleeding or cardiovascular comorbidities) 1, 2
• Consider central venous pressure monitoring in patients with significant cardiac disease (target CVP 5-10 cm H₂O) 1

Critical Pitfall to Avoid

Never perform endoscopy before achieving hemodynamic stability—this is a critical error that increases mortality. 1, 2 Keep the patient fasted until hemodynamically stable. 1

Understanding Black Vomit vs. Fresh Blood

• Black vomit (coffee ground emesis) results from gastric acid converting hemoglobin to hematin, creating the characteristic dark, granular appearance that indicates less active bleeding compared to bright red blood 2
• This appearance means blood has had time to be partially digested, suggesting slower or intermittent bleeding 2
• However, coffee ground emesis still requires full evaluation with endoscopy within 24 hours 3, 2

Risk Stratification and Differential Diagnosis

Specifically assess for cirrhosis, as variceal bleeding mortality approaches 30% versus 10% for nonvariceal sources and requires specialized management. 3, 2

Most Common Causes:

• Peptic ulcer disease: 35-50% of cases (leading nonvariceal cause) 3, 2
• Mallory-Weiss tears: 15% (typically from forceful vomiting) 3, 2
• Gastroduodenal erosions: 8-15% (commonly NSAID-associated) 3
• Esophagitis: 5-15% (more common in coffee ground emesis than frank hematemesis) 3
• Esophageal varices: 5-10% overall, but cause massive hematemesis when present 3

Special Consideration for Stable Patients:

In hemodynamically stable patients with coffee ground emesis, evaluate for non-GI conditions including acute myocardial infarction, sepsis, pulmonary emboli, small bowel obstruction, and acute renal failure, as these are frequently the primary diagnosis. 2

Endoscopic Evaluation

Perform esophagogastroduodenoscopy (EGD) within 24 hours after achieving hemodynamic stability, as it has both diagnostic and therapeutic capabilities. 1, 2

• Endoscopy should be performed by experienced endoscopists capable of therapeutic interventions for ulcers and varices 1
• In severely bleeding patients, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration 1
• Most endoscopy can be done semi-electively in the endoscopy unit, but facilities must be available for urgent procedures with full resuscitation equipment 1

Post-Endoscopy Management

Following successful endoscopic therapy in patients with ulcer bleeding, high-dose proton pump inhibitor therapy is recommended. 1

• Pantoprazole 40 mg IV can be used for acid suppression in upper GI bleeding 4
• Address underlying causes: Helicobacter pylori eradication, acid suppression, and counsel regarding NSAID use 1, 2
• Monitor for rebleeding, defined as fresh hematemesis/melena with shock (pulse >100 bpm, systolic pressure <100 mmHg), CVP fall >5 mmHg, or hemoglobin reduction >20 g/L over 24 hours 3, 2

Special Populations

Cirrhotic Patients:

• Early identification is critical as variceal bleeding has 30% mortality 2
• Prophylactic antibiotics and vasoactive medications are required 2
• Early TIPS placement should be considered in Child-Pugh class C (score 10-13) or class B with active bleeding despite vasoactive agents 1

Elderly Patients (>65 years):

• Significantly higher mortality rates requiring more aggressive inpatient management 1, 2
• More intensive monitoring and lower threshold for intervention 1

Very Low-Risk Young Patients:

• Without hemodynamic compromise, significant comorbidities, or high-risk features may be managed as outpatients after appropriate evaluation 1, 2