What is the appropriate diagnosis and management for an adult patient, possibly with a history of gastrointestinal issues or NSAID (Non-Steroidal Anti-Inflammatory Drug) use, presenting with low-grade fever and coffee ground emesis?

Diagnosis and Immediate Management of Low-Grade Fever with Coffee Ground Emesis

This patient requires urgent evaluation for upper gastrointestinal bleeding with immediate hospital admission, intravenous proton pump inhibitor therapy, and endoscopy within 24 hours. 1, 2

Initial Diagnostic Assessment

Coffee ground emesis indicates digested blood from upper GI bleeding and mandates urgent evaluation, regardless of hemodynamic stability. 1, 3 The presence of low-grade fever alongside coffee ground emesis raises concern for:

• Peptic ulcer disease (accounts for 50-70% of nonvariceal upper GI bleeding) with potential perforation or penetration 2
• Gastric or duodenal ulcer complicated by infection or inflammation 4, 1
• NSAID-induced ulceration if the patient has recent NSAID use 4

Critical First Steps

Immediately assess hemodynamic status before any other intervention: 1, 2

• Check pulse (tachycardia >100 bpm indicates significant blood loss) 1, 2
• Measure blood pressure (systolic <100 mmHg indicates shock) 1, 2
• Calculate shock index (heart rate/systolic BP; >1 indicates severe bleeding requiring intensive monitoring) 2
• Obtain orthostatic vital signs if patient is stable 5

Obtain immediate laboratory studies: 1, 2

• Complete blood count (hemoglobin <80 g/L triggers transfusion threshold) 2
• Blood urea nitrogen and creatinine (elevated BUN:creatinine ratio suggests upper GI source) 2
• Coagulation studies (INR, PTT) 2
• Type and crossmatch blood 1, 2

Immediate Resuscitation Protocol

Establish two large-bore IV lines (18-gauge or larger in antecubital fossae) and begin aggressive crystalloid resuscitation with normal saline. 1, 2 Most patients require 1-2 liters initially; if shock persists after 2 liters, add plasma expanders as this indicates ≥20% blood volume loss. 1, 2

Transfuse red blood cells when: 2

• Hemoglobin <80 g/L in patients without cardiovascular disease 2
• Hemoglobin <90 g/L in patients with cardiovascular comorbidities 2
• Active hematemesis with shock is present 1

Start high-dose intravenous proton pump inhibitor therapy immediately upon presentation: 2, 6

• Pantoprazole 80 mg IV bolus, followed by 8 mg/hour continuous infusion 2
• This should be initiated before endoscopy and does not delay the procedure 2

Risk Stratification

High-risk features requiring intensive monitoring and urgent intervention include: 1, 2

• Age >60 years (mortality increases significantly, reaching 30% in patients >90 years) 2
• Hemodynamic instability (heart rate >100 bpm, systolic BP <100 mmHg) 1, 2
• Hemoglobin <100 g/L 2
• Significant comorbidities (renal insufficiency, liver disease, cardiovascular disease) 2
• History of NSAID use, anticoagulation, or alcohol use 1, 5

The presence of fever alongside coffee ground emesis is particularly concerning because: 7

• It may indicate perforation or penetration of an ulcer 7
• It suggests potential sepsis from a non-GI source that may be overlooked due to focus on bleeding 7
• Hemodynamically stable patients with coffee ground emesis may have other serious conditions (myocardial infarction, pulmonary embolism, urosepsis) that require evaluation 7

Endoscopic Management

Perform esophagogastroduodenoscopy (EGD) within 24 hours of presentation after initial hemodynamic stabilization. 4, 1, 2 For high-risk patients with hemodynamic instability despite resuscitation, consider earlier endoscopy within 12 hours. 2

Before endoscopy: 1, 2

• Ensure hemodynamic stability (blood pressure and central venous pressure stable) 1
• Consider endotracheal intubation if high-volume bleeding is present to prevent pulmonary aspiration 1, 2
• Insert urinary catheter to monitor urine output (target >30 mL/hour indicates adequate resuscitation) 1

Endoscopic therapy is indicated for high-risk stigmata: 2, 8

• Active bleeding (spurting or oozing) 2, 8
• Non-bleeding visible vessel 2, 8
• Adherent clot (consider targeted irrigation to dislodge with treatment of underlying lesion) 2

Use combination endoscopic therapy (epinephrine injection PLUS thermal coagulation or mechanical clips)—never use epinephrine injection alone. 2, 8

Post-Endoscopy Management

After successful endoscopic therapy for high-risk lesions, continue high-dose PPI therapy: 2, 8

• Pantoprazole 80 mg IV bolus followed by 8 mg/hour continuous infusion for exactly 72 hours 2
• Then switch to oral PPI twice daily for 14 days 2
• Continue once daily thereafter for duration dependent on bleeding lesion etiology 2

Test all patients for Helicobacter pylori and provide eradication therapy if positive: 4, 2, 6

• Eradication reduces risk of ulcer recurrence and future gastric malignancy 4, 2
• Triple therapy: omeprazole + clarithromycin + amoxicillin 6
• Testing during acute bleeding may have false-negative rates; confirmatory testing outside acute context may be necessary 2

Addressing the Fever Component

The low-grade fever requires specific attention because: 7

• Coffee ground emesis patients are often hemodynamically stable and may have other serious non-GI conditions 7
• Evaluate for concurrent myocardial infarction, pulmonary embolism, urosepsis, small bowel obstruction, or acute renal failure 7
• Obtain chest X-ray, urinalysis, and ECG as clinically indicated 7
• Consider blood cultures if sepsis is suspected 7

Critical Pitfalls to Avoid

Never assume coffee ground emesis is benign—it represents upper GI bleeding until proven otherwise. 1, 5 However, recognize that hemodynamically stable patients with coffee ground emesis have lower endoscopic yield (fewer high-risk lesions) compared to those with frank hematemesis. 7, 9

Do not delay endoscopy for complete hemodynamic normalization in actively bleeding patients—balance resuscitation with timely diagnosis. 1, 2 Performing endoscopy before adequate resuscitation increases mortality. 1

Never use epinephrine injection alone for endoscopic hemostasis—it must always be combined with thermal or mechanical therapy. 2, 8

Do not overlook NSAID use history: 4 If NSAIDs are the cause, discontinue them; if they must be resumed, use low-dose COX-2 selective NSAID plus PPI. 2, 8

Recognize that routine second-look endoscopy is not recommended, though it may be useful in selected high-risk patients. 2, 8

Hospital Admission Criteria

All patients with coffee ground emesis and any of the following require hospital admission: 1, 2

• Hemodynamic instability or shock 1, 2
• Age >55 years 4
• Significant comorbidities 2
• Hemoglobin <100 g/L 2
• Active bleeding or high-risk endoscopic findings 2

High-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis in a monitored setting. 2