Coffee ground emesis describes vomit with a dark brown, granular appearance resembling used coffee grounds. This distinctive presentation is a direct result of partially digested blood within the stomach and always indicates a medical emergency. It signals bleeding in the upper gastrointestinal tract (esophagus, stomach, or small intestine) and requires immediate attention by calling 911 or proceeding to the nearest emergency room. Do not attempt to drive yourself or wait for symptoms to resolve, as this can be a sign of significant internal blood loss.
The Immediate Significance of Coffee Ground Emesis
The characteristic “coffee grounds” appearance results from a chemical reaction between blood and highly acidic stomach contents. When blood enters the stomach, hydrochloric acid acts on hemoglobin, the oxygen-carrying protein in red blood cells. This process, called acid hematin formation, oxidizes the iron within the hemoglobin molecules.
The resulting dark brown or black substance suggests the blood has been in the stomach for some time—typically at least 30 minutes to several hours—allowing the acid to act upon it. While bright red blood in vomit (hematemesis) suggests very fresh, active bleeding, coffee grounds indicate an upper gastrointestinal bleed (UGIB) has occurred. This symptom requires urgent medical evaluation because the underlying bleeding source must be identified and stopped to prevent life-threatening complications.
Common Conditions Leading to This Symptom
The majority of upper gastrointestinal bleeding episodes resulting in coffee ground emesis stem from a few specific conditions. Peptic Ulcer Disease (PUD) is the most frequent cause, accounting for roughly half of all UGIB cases. PUD involves open sores on the lining of the stomach (gastric ulcers) or the upper small intestine (duodenal ulcers), often due to Helicobacter pylori infection or nonsteroidal anti-inflammatory drugs (NSAIDs).
Other common causes involve inflammation or tears in the digestive lining. Severe gastritis (inflammation of the stomach lining) and esophagitis (inflammation of the esophagus) can lead to erosions that bleed. A Mallory-Weiss tear is a laceration in the mucous membrane of the lower esophagus or upper stomach. This tear often happens after forceful or prolonged vomiting.
Less common but severe causes include bleeding from esophageal varices, which are enlarged veins in the lower esophagus. These varices typically form in patients with severe liver disease, such as cirrhosis, and can rupture spontaneously, leading to rapid hemorrhage. Other sources include vascular lesions like Dieulafoy’s lesion or cancers of the stomach or esophagus.
What to Do Immediately and Initial Medical Steps
The first step upon seeing coffee ground emesis is to immediately call emergency services. Do not attempt to eat or drink anything, and remain still while awaiting medical personnel. Trying to self-transport is hazardous due to the risk of hemodynamic instability, such as a sudden drop in blood pressure.
Once in the emergency department, medical staff prioritize stabilization using the “ABCs” (airway, breathing, and circulation). Two large-bore intravenous (IV) lines are typically placed for rapid fluid resuscitation with crystalloid solutions, like saline, to restore lost volume. Blood samples are drawn immediately for a complete blood count (CBC), coagulation studies, and blood typing for potential transfusion.
If the patient shows signs of significant blood loss (e.g., rapid heart rate or low blood pressure), a high-dose intravenous proton pump inhibitor (PPI) is often started. This medication, such as an 80 mg bolus followed by a continuous infusion, works by reducing stomach acid production. Reducing acidity helps stabilize existing blood clots in the stomach, which lowers the immediate risk of re-bleeding before a definitive procedure can be performed.
Addressing the Underlying Cause
After initial stabilization, the definitive procedure for both diagnosis and treatment is an upper endoscopy, or esophagogastroduodenoscopy (EGD). This involves passing a flexible tube with a camera down the throat to visually inspect the esophagus, stomach, and duodenum, usually performed within 24 hours. The primary goal of the EGD is to pinpoint the exact source of the bleeding and treat it directly.
Endoscopic Hemostasis Techniques
Therapeutic endoscopy allows for several hemostatic (blood-stopping) techniques to be performed at the bleeding site. One common approach is injection therapy, where a diluted solution of epinephrine is injected into the tissue around the bleeding vessel. This creates a tamponade effect, compressing the vessel, while the epinephrine causes local constriction.
Injection therapy is often paired with a secondary method for robust hemostasis. Mechanical methods, such as applying endoscopic clips (hemoclips) or thermal coagulation using probes, are frequently used in combination with the epinephrine injection. These clips or thermal probes physically seal the vessel to prevent further blood loss.
Following a successful endoscopic procedure, high-dose intravenous PPI therapy is continued for 72 hours to ensure the fragile clot remains stable in the acidic environment. If endoscopic methods fail to stop the bleed or if the patient continues to lose blood rapidly, further interventions become necessary. These may include angiographic embolization, which involves blocking the bleeding artery from within, or, as a last resort, emergency surgery to repair the source of the hemorrhage.