Black (Coffee-Ground) Vomitus: Causes and Clinical Significance
Black or coffee-ground vomitus typically indicates upper gastrointestinal bleeding from a source proximal to the ligament of Treitz, most commonly caused by peptic ulcer disease, gastric erosions, or esophagitis. 1
Primary Causes of Coffee-Ground Emesis
Most Common Etiologies
- Peptic ulcer disease (gastric and duodenal ulcers) accounts for approximately 50% of upper GI bleeding cases in the United States and is the leading cause of coffee-ground vomitus 1, 2
- Gastric erosions represent the second most common cause, frequently associated with NSAID use or stress 1
- Esophagitis is more commonly associated with coffee-ground vomitus compared to frank hematemesis 3
- Mallory-Weiss tears at the gastroesophageal junction from forceful vomiting can produce this appearance 1, 2
Less Common but Important Causes
- Gastric or esophageal malignancy should be considered, particularly in older patients with weight loss 1
- Vascular malformations including angiodysplasia and Dieulafoy lesions (accounting for 1-2% of acute bleeding) 1
- Hemorrhagic gastritis can occur in diabetic ketoacidosis, where up to 25% of patients develop coffee-ground emesis 1
- Variceal bleeding less commonly presents as coffee-ground vomitus compared to frank hematemesis 4
Critical Distinction: Coffee-Ground vs. Frank Hematemesis
Coffee-ground vomitus carries significantly lower clinical risk than frank hematemesis. The "coffee-ground" appearance results from partial digestion of blood by gastric acid, suggesting slower or less active bleeding 5, 2.
Key Clinical Differences
- Coffee-ground vomitus is associated with lower endoscopic yield for significant bleeding lesions compared to hematemesis or melena 3
- Patients with coffee-ground vomitus require blood transfusion less frequently than those with frank hematemesis 3
- Rebleeding rates are significantly lower in coffee-ground vomitus patients 3
- 30-day mortality rates are similar across all upper GI bleeding presentations, suggesting coffee-ground vomitus may represent non-bleeding causes in many cases 3
- Coffee-ground vomitus alone (without hemodynamic instability) does not require urgent endoscopy within 24 hours, as timing does not impact morbidity or mortality 6
Important Caveats and Pitfalls
When Coffee-Ground Vomitus Demands Urgent Action
- Hemodynamic instability (tachycardia, hypotension, shock) mandates immediate resuscitation and urgent endoscopy regardless of vomitus appearance 1, 2
- Age >60 years with comorbidities increases mortality risk and warrants closer monitoring 2
- Progression to frank hematemesis or melena indicates active bleeding requiring urgent intervention 1
- Hematochezia with coffee-ground vomitus suggests massive upper GI bleeding and requires emergency management 2
Common Misinterpretations
- Not all coffee-ground vomitus represents GI bleeding—the low positive predictive value means many patients have no significant endoscopic findings 3, 6
- Normal nasogastric aspirate does not exclude upper GI bleeding, as 3-16% of patients with confirmed bleeding have negative aspirates 1
- Coffee-ground vomitus in diabetic ketoacidosis may reflect hemorrhagic gastritis rather than peptic disease 1
Diagnostic Approach
Initial Assessment
- Assess hemodynamic status (heart rate, blood pressure, orthostatic changes) to determine urgency 1, 2
- Check for melena on rectal examination, which increases likelihood of significant bleeding 2
- Obtain hemoglobin/hematocrit and coagulation studies 1
- Review medication history for NSAIDs, anticoagulants, or antiplatelet agents 1
Endoscopic Evaluation Timing
- Urgent endoscopy (within 24 hours) is indicated for hemodynamic instability, ongoing bleeding, or high-risk features 1, 5
- Scheduled endoscopy (beyond 24 hours) is appropriate for isolated coffee-ground vomitus without red flags, as timing does not affect outcomes 6
- Upper endoscopy identifies the bleeding source in 95% of cases and allows therapeutic intervention 1