Can enteral feeding be continued via a nasogastric tube in a patient vomiting dark (coffee‑ground) fluid?

No, enteral feeding via nasogastric tube should be immediately stopped in a patient vomiting black (coffee-ground) fluid

Vomiting black or coffee-ground material indicates upper gastrointestinal bleeding, which is an absolute contraindication to continuing nasogastric tube feeding and requires urgent medical evaluation.

Immediate Management Steps

Stop All Enteral Feeding

• Discontinue NGT feeding immediately when a patient presents with hematemesis (vomiting blood) or coffee-ground emesis, as this indicates active or recent upper GI bleeding 1
• The presence of vomiting itself is documented as a sign of enteral nutrition intolerance, with vomiting/gastric retention occurring in 32% of patients receiving enteral nutrition 1
• Continuing to feed into a bleeding stomach increases aspiration risk, worsens hemodynamic instability, and prevents proper assessment of ongoing blood loss

Assess the Clinical Situation

• Evaluate for signs of hemodynamic instability (hypotension, tachycardia) that would indicate significant blood loss
• Check for escalating vasopressor requirements or uncontrolled shock, which are recognized contraindications to enteral nutrition 1
• Assess for severe GI symptoms, which constitute a contraindication to early enteral nutrition even in critically ill patients 1

Determine the Source and Severity

• Coffee-ground emesis suggests partially digested blood from an upper GI source (esophagus, stomach, or duodenum)
• Common causes include peptic ulcer disease, gastritis, esophageal varices, or Mallory-Weiss tears
• The NGT itself can cause mucosal irritation, though this typically presents with minor bleeding rather than coffee-ground vomitus

When to Consider Resuming Enteral Nutrition

After Stabilization

• Stabilize the patient first before considering any nutrition support, providing intravenous fluids as needed 1
• Once bleeding is controlled and the patient is hemodynamically stable, reassess the need for enteral nutrition
• Consider whether the patient requires endoscopic evaluation and treatment before resuming feeds

Alternative Routes if Needed

• If the patient has high nutritional risk and gastric feeding remains contraindicated, consider post-pyloric (nasojejunal) feeding as an alternative 2, 3
• Nasojejunal tubes are specifically indicated for patients with gastric reflux or delayed gastric emptying 1, 3
• Parenteral nutrition may be necessary if enteral feeding cannot be safely resumed and the patient is malnourished 1

Critical Pitfalls to Avoid

Do Not Rely on Gastric Residual Volume Alone

• While high gastric residual volumes (>300 mL) should prompt feeding adjustment 2, the presence of blood in vomitus is a more urgent concern than residual volume measurements
• Vomiting with blood indicates active pathology requiring investigation, not just feeding intolerance

Do Not Continue Feeding "Through" the Vomiting

• Some clinicians may be tempted to reduce feeding rates rather than stop completely, but this is inappropriate when blood is present 1
• The priority shifts from nutrition to hemostasis and preventing aspiration of blood

Verify Tube Position After Any Vomiting Episode

• Vomiting can dislodge the NGT from proper gastric position 4, 5
• Confirm tube placement via pH testing (should be <5.5) or radiography before any attempt to resume feeding 2, 6
• Never rely on auscultation alone, which has only 79% sensitivity and 61% specificity 2

Documentation and Communication

• Document the appearance, volume, and timing of the vomitus in the medical record 6
• Notify the treating physician immediately about the coffee-ground emesis
• Hold all enteral feeding orders until the source of bleeding is identified and controlled
• Consider whether the patient needs urgent endoscopy or other diagnostic interventions