What is the emergency management for a patient presenting with coffee‑ground (dark brown) emesis and bright red hematemesis indicating upper gastrointestinal hemorrhage?

Emergency Management of Coffee-Ground and Bright Red Hematemesis

Immediately establish two large-bore IV lines, begin aggressive fluid resuscitation with normal saline, and perform early endoscopy within 24 hours after hemodynamic stabilization—this approach reduces mortality and allows both diagnosis and therapeutic intervention for upper gastrointestinal hemorrhage. 1, 2

Immediate Resuscitation (First Priority)

Hemodynamic stabilization takes absolute priority before any diagnostic procedures. 2

• Insert two large-bore IV lines in the anticubital fossae and start rapid infusion of 1-2 liters of normal saline 2
• Assess pulse, blood pressure, and calculate shock index (heart rate/systolic BP); a shock index >1 indicates severe bleeding requiring intensive monitoring 3, 2
• Define hemodynamic instability as pulse >100 bpm and systolic BP <100 mmHg—these patients require aggressive intervention 3, 2
• If shock persists after 2 liters of crystalloid, add plasma expanders as this indicates ≥20% blood volume loss 2
• Insert a urinary catheter and target urine output >30 mL/hour to confirm adequate resuscitation 2
• Consider central venous pressure monitoring in patients with cardiac disease (target CVP 5-10 cm H₂O) 2

Blood Transfusion Strategy

• Transfuse packed red blood cells when hemoglobin falls below 7 g/dL 1, 2, 4
• Use a higher threshold of 9 g/dL for patients with massive bleeding, cardiovascular comorbidities, or active hematemesis with shock 3, 1, 2
• This restrictive transfusion strategy improves outcomes compared to liberal transfusion 1

Risk Stratification

Use the Glasgow-Blatchford Score (GBS) for pre-endoscopy risk assessment; patients with GBS ≤1 can be managed as outpatients, while higher scores mandate admission. 4

• The presence of bright red blood (fresh hematemesis) indicates more severe bleeding than coffee-ground emesis alone 3, 2
• Patients presenting with both hematemesis and melena have more severe bleeding than those with melena alone 3
• Hemodynamic instability despite resuscitation is a high-risk feature requiring urgent intervention 2
• Elderly patients (>65 years) have significantly higher mortality rates (up to 30% in those >90 years) and require aggressive management 2, 5

Airway Protection

• In patients with massive hematemesis or altered mental status, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration 2
• This is particularly critical in actively bleeding patients who cannot protect their airway 2

Endoscopic Timing and Approach

Perform early endoscopy within 24 hours of presentation after achieving hemodynamic stability. 1, 4

• Urgent endoscopy (<12 hours) does not improve outcomes compared to early endoscopy (within 24 hours) in most patients 4, 6
• Hemodynamically unstable patients or those with ongoing active bleeding require endoscopy sooner, ideally within 12 hours 1
• Keep the patient fasted until hemodynamically stable 2
• Endoscopy must be performed by experienced endoscopists capable of therapeutic interventions 2

Important Caveat About Coffee-Ground Emesis

Hemodynamically stable patients with coffee-ground emesis alone (without bright red blood) should be evaluated for non-GI conditions including acute myocardial infarction, sepsis, pulmonary emboli, and acute renal failure, as these are frequently the primary diagnosis. 5, 7

• Coffee-ground emesis has low positive predictive value for significant upper GI bleeding 6, 7
• In stable patients with coffee-ground emesis that clears easily on nasogastric lavage and no hemoglobin drop, urgent endoscopy may be safely deferred 6, 7

Pre-Endoscopy Medical Management

• Do NOT delay resuscitation to perform nasogastric tube placement—it does not reliably aid diagnosis, does not affect outcomes, and causes complications in one-third of patients 3
• Start high-dose proton pump inhibitor (PPI) therapy: 80 mg IV bolus followed by 8 mg/hour continuous infusion 4
• If variceal bleeding is suspected (cirrhosis, portal hypertension), immediately start vasoactive drugs (octreotide or terlipressin) before endoscopy 1
• Administer prophylactic antibiotics if variceal bleeding is suspected to reduce mortality 1

Endoscopic Therapy

For actively bleeding ulcers or visible vessels, use combination therapy: 4

• Epinephrine injection plus a second modality (contact thermal, mechanical therapy, or sclerosing agent) 4
• For esophageal varices, endoscopic variceal ligation (EVL) is the treatment of choice with >90% success rates 1

Post-Endoscopy Management

• Continue high-dose PPI therapy (80 mg bolus then 8 mg/hour infusion) for 72 hours post-endoscopy in patients who received endoscopic hemostasis 4
• If variceal bleeding was treated, continue vasoactive drugs for 2-5 days 1
• Monitor for rebleeding: defined as fresh hematemesis/melena with shock (pulse >100, systolic BP <100), CVP fall >5 mmHg, or hemoglobin drop >20 g/L over 24 hours 3
• Admit high-risk patients to a monitored setting (ICU or high-dependency unit) for at least 24 hours 3

Management of Rebleeding

If rebleeding occurs despite initial endoscopic therapy, attempt a second endoscopy with cap-mounted clip; if this fails, proceed to transcatheter angiographic embolization (TAE), with surgery reserved for TAE failure or unavailability. 4

Common Pitfalls to Avoid

• Never perform endoscopy before adequate resuscitation—this critical error increases mortality 2
• Do not assume coffee-ground emesis always represents significant GI bleeding; evaluate for other acute conditions in stable patients 5, 7
• Do not interrupt aspirin in patients on low-dose aspirin for secondary cardiovascular prophylaxis; if interrupted, restart within 3-5 days 4
• Avoid excessive fluid resuscitation in suspected variceal bleeding as this increases portal pressure and worsens bleeding 1