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Draft of Coffee Ground Emesis

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Coffee ground vomiting (also known as coffee ground emesis) is a particular appearance of vomit due to the presence of oxidized blood. Iron located in the heme molecules of red blood cells can be oxidized by stomach acid, producing a red-brown vomitus that closely resembles coffee grounds, both in color and texture. Coffee ground vomiting can be the result of many pathologies, but is most commonly caused by bleeding in the upper gastrointestinal system.

Causes

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Coffee ground emesis is typically caused by bleeding of the upper gastrointestinal system, proximal to the ligament of Trietz[1]. It is usually indicative of a slow bleed[2], while faster bleeding is more associated with bright red hematemesis. Bleeding occurring distal to the ligament of Trietz will result in blood being excreted in stool, as will upper-GI bleeding that is not vomited. Oxidized blood excreted as stool appears dark and tar-like, and is known as melena.

The most common causes of coffee ground emesis are[1]:

Other medical causes include cancers, AV malformations, and infections such as malaria[3] and ebola. Non-gastrointestinal causes have also been documented. Iron supplements can give vomitus a similar appearance to coffee grounds[1].

Diagnosis

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Upper endoscopy can be used to locate bleeding in the upper gastrointestinal system. In this method a camera ins inserted through the mouth to visualize the esophagus, stomach, and duodenum.

Numerous studies have suggested that urgent endoscopy is not required for coffee ground emesis alone[4][5]. Other factors, such as hemodynamic stability, hemoglobin concentration, and various elements of the patient's history may guide clinicians to obtain or defer urgent endoscopy. Additionally, nasogastric aspirates can be used to predict the likelihood that endoscopy will reveal high-risk bleeding[6].

While endoscopic visualization may be sufficient for diagnosis, a biopsy may also be taken during endoscopy, aiding in the diagnosis of H. pylori infections, and differentiating tumors.

CT angiography may also be used to locate the source of upper-GI bleeding[7].

Treatment

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Treatment of coffee ground emesis depends on underlying etiology. Patient history and initial labs, especially hemoglobin, can help stratify patients by need for immediate intervention.

Bleeding ulcers believed to be caused by H. pylori infections are typically treated with a combination of medications. Medications used in the treatment of such ulcers fall into two categories. First, medications are used to decrease pain associated with ulcers by limiting acid exposure to sensitive ulcers. This can be accomplished by antacids such as proton pump inhibitors (PPI) or H2-blockers, or through conventional antacids. Sucralfate is also effective in this role, as it coats the ulcer, thus protecting it from caustic stomach acid. Second, antibiotic therapy is used to eliminate the underlying bacterial infection. Clarithromycin and amoxicillin are commonly used in tandem, but antibiotic regiments may vary based on organism susceptibility, side effects, and patient allergies. Gastric ulcers caused by NSAID use can be treated with NSAID cessation, or a proton pump inhibitor if cessation is not possible. Non-healing ulcers should be examined for other causes, such as cancer or Zollinger-Elison syndrome.[8]

Esophageal bleeding is predominantly caused by gastrointestinal reflux disease (GERD). PPI medications are preferred to H2-blocking medication due to increased rates of patient improvement, though both medications are commonly used. Severe cases of GERD may be refractory to these medications and require fundoplication, a surgery in which the gastroesophageal junction is surgically reinforced. While lifestyle modifications, diet modification, and antacid use may reduce GERD symptoms such as heartburn, these methods are not sufficient to heal esophageal ulcers.[9]

Variceal bleeding may be treated through a variety of medications and interventions, depending on underlying causes and severity. Severe cases are unlikely to present as coffee ground emesis, and are more likely to present as bright red emesis.[10]

Esophageal lacerations (Mallory-Weiss tears) are mostly self-limiting, though the majority require blood transfusions to compensate for blood loss. Endoscopic interventions, including epinephrine injections, clipping, and cauterization may be utilized if needed.[11]

References

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  1. ^ a b c Dhere, Tanvi (2012-02-17), Sitaraman, Shanthi V.; Friedman, Lawrence S. (eds.), "Acute Gastrointestinal Bleeding", Essentials of Gastroenterology (1 ed.), Wiley, pp. 315–334, doi:10.1002/9781119959762.ch22, ISBN 978-0-470-65625-9, retrieved 2023-02-10
  2. ^ Kovacs, Thomas O.G.; Jensen, Dennis M. (2016-08-01), Wallace, Michael B.; Aqel, Bashar A.; Lindor, Keith D.; Talley, Nicholas J. (eds.), "Hematemesis", Practical Gastroenterology and Hepatology Board Review Toolkit, Oxford, UK: John Wiley & Sons, Ltd, pp. 79–81, doi:10.1002/9781119127437.ch13, ISBN 978-1-119-12743-7, retrieved 2023-02-10
  3. ^ Zodda, David; Procopio, Gabrielle; Hewitt, Kevin; Parrish, Andrew; Balani, Bindu; Feldman, Joseph (2018-06-01). "Severe malaria presenting to the ED: A collaborative approach utilizing exchange transfusion and artesunate". The American Journal of Emergency Medicine. 36 (6): 1126.e1–1126.e4. doi:10.1016/j.ajem.2018.03.023. ISSN 0735-6757.
  4. ^ Schneider, James R.; Thomson, John M.; Fraser, Andrew; Vijayan, Balasubramaniam; Bassett, Paul; Leeds, John S. (2020-07). "Is coffee ground vomiting important? Findings from a large bleeding unit database and outcomes at 30 days". European Journal of Gastroenterology & Hepatology. 32 (7): 797–803. doi:10.1097/MEG.0000000000001701. ISSN 0954-691X. {{cite journal}}: Check date values in: |date= (help)
  5. ^ Khani, Aria; Maksunova, Yulia; Patel, Mehul; Besherdas, Kalpesh (2018-06-01). "PTH-035 Coffee ground vomit:does it justify an urgent endoscopy?". Gut. 67 (Suppl 1): A29–A30. doi:10.1136/gutjnl-2018-BSGAbstracts.56. ISSN 0017-5749.
  6. ^ Aljebreen, Abdulrahman M; Fallone, Carlo A; Barkun, Alan N; for the RUGBE investigators (2004-02). "Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding". Gastrointestinal Endoscopy. 59 (2): 172–178. doi:10.1016/S0016-5107(03)02543-4. {{cite journal}}: Check date values in: |date= (help)
  7. ^ "UpToDate". www.uptodate.com. Retrieved 2023-02-10.
  8. ^ Cashin, Paul A.; Chung, S.C. Sydney (2019-12-18), Smith, Julian A.; Kaye, Andrew H.; Christophi, Christopher; Brown, Wendy A. (eds.), "Peptic ulcer disease", Textbook of Surgery (1 ed.), Wiley, pp. 133–141, doi:10.1002/9781119468189.ch16, ISBN 978-1-119-46808-0, retrieved 2023-02-17
  9. ^ Zerbib, Frank (2018), Bardan, Eytan; Shaker, Reza (eds.), "Erosive Esophagitis", Gastrointestinal Motility Disorders, Cham: Springer International Publishing, pp. 91–99, doi:10.1007/978-3-319-59352-4_8, ISBN 978-3-319-59350-0, retrieved 2023-02-17
  10. ^ Zanetto, Alberto; Garcia-Tsao, Guadalupe (2020), Rahimi, Robert S. (ed.), "Gastroesophageal Variceal Bleeding Management", The Critically Ill Cirrhotic Patient, Cham: Springer International Publishing, pp. 39–66, doi:10.1007/978-3-030-24490-3_4, ISBN 978-3-030-24489-7, retrieved 2023-02-17
  11. ^ Schroder, Jacob N.; Branch, Malcolm S. (2010), Pryor, Aurora D.; Pappas, Theodore N.; Branch, Malcolm Stanley (eds.), "Mallory–Weiss Syndrome", Gastrointestinal Bleeding, New York, NY: Springer New York, pp. 79–84, doi:10.1007/978-1-4419-1693-8_7, ISBN 978-1-4419-1692-1, retrieved 2023-02-17
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