From the Guidelines
Coffee ground emesis is a medical emergency that requires immediate evaluation and treatment, as it indicates upper gastrointestinal bleeding that has had time to partially digest, and the initial management should focus on stabilizing vital signs, establishing IV access, and possibly administering proton pump inhibitors, such as pantoprazole 80mg IV bolus followed by 8mg/hr infusion, as recommended by recent guidelines 1.
The presentation of coffee ground emesis is characterized by vomit that resembles coffee grounds, appearing dark brown or black and granular, which occurs when blood in the upper gastrointestinal tract is exposed to stomach acid, converting the bright red hemoglobin to dark brown hematin. This condition is a sign of upper GI bleeding, which can be caused by various factors, including peptic ulcers, gastritis, esophageal varices, Mallory-Weiss tears, or malignancies, as highlighted in the study by Nagpal et al 1.
Key considerations in the management of coffee ground emesis include:
- Initial stabilization of vital signs and establishment of IV access for fluid resuscitation and possible blood transfusions if significant blood loss has occurred
- Administration of proton pump inhibitors to reduce stomach acid production, as recommended by the American College of Gastroenterology practice guidelines and the American Gastroenterological Association expert statement 1
- Identification of the underlying cause, typically through endoscopy within 24 hours, as emphasized in the study by Nagpal et al 1
- Patient education on the importance of not eating or drinking until evaluated, transporting the patient lying on their left side if possible, and bringing all current medications to the hospital.
It is essential to distinguish coffee ground emesis from hematemesis (bright red blood vomiting), which suggests more acute, active bleeding, as defined in the study by Gut 1. The management of coffee ground emesis should prioritize the reduction of morbidity, mortality, and improvement of quality of life, as emphasized in the study by Nagpal et al 1.
From the Research
Definition and Symptoms
- Coffee ground emesis, also known as coffee ground vomiting, is a symptom of upper gastrointestinal bleeding, characterized by the vomiting of blood that has been digested and has a coffee ground-like appearance 2.
- The clinical usefulness of coffee ground vomiting as an indicator of upper gastrointestinal bleeding is limited due to its low positive predictive value 3.
Endoscopic Findings and Outcomes
- A study analyzing endoscopic yield and 30-day outcomes in patients presenting with coffee ground vomiting found that it was associated with a lower risk of gastric ulcer, duodenal ulcer, varices, gastric cancer, esophageal cancer, and Mallory-Weiss tears compared to other groups 2.
- Coffee ground vomiting was also associated with a lower rate of blood transfusion and rebleeding, but 30-day mortality rates were similar to other groups 2.
- Another study found that urgent endoscopy did not modify therapeutic management or have a real impact on survival in patients with coffee ground vomiting 3.
Treatment and Management
- Proton pump inhibitors (PPIs) are used to manage upper gastrointestinal bleeding, but the method and dose of PPI therapy remains controversial 4.
- A study found that pre-endoscopic PPI use may not reduce mortality, but may reduce rebleeding and the need for endoscopic haemostatic treatment at index endoscopy 5.
- A comparison of oral and intravenous proton pump inhibitor on patients with high risk bleeding peptic ulcers found that both had equal effects on prevention of rebleeding after endoscopic therapy 6.
Timing of Endoscopy
- A study found that performing urgent endoscopy in patients with coffee ground vomiting is not beneficial in terms of morbimortality, and a more conservative strategy would allow to differ endoscopy, decreasing risks and reducing costs, without affecting the prognosis 3.
- The timing of endoscopy in patients with coffee ground vomiting may not be relevant, and a more conservative approach may be appropriate 3.