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Severity and Outcomes of Upper Gastrointestinal Bleeding With Bloody Vs. Coffee-Grounds Hematemesis

Laine, Loren MD1,2; Laursen, Stig B MD, PhD3; Zakko, Liam MD1; Dalton, Harry R DPhil, DipMedEd4; Ngu, Jing H MBChB, PhD5; Schultz, Michael MD, Dr Habil (Germany)6; Stanley, Adrian J MBChB, MD7

American Journal of Gastroenterology: March 2018 - Volume 113 - Issue 3 - p 358–366
doi: 10.1038/ajg.2018.5

OBJECTIVES: Numerous reviews indicate bloody hematemesis signifies more severe bleeding than coffee-grounds hematemesis. We assessed severity and outcomes related to bleeding symptoms in a prospective study.

METHODS: Consecutive patients presenting with hematemesis or melena were categorized as bloody emesis (N=1209), coffee-grounds emesis without bloody emesis (N=701), or melena without hematemesis (N=1069). We assessed bleeding severity (pulse, blood pressure) and predictors of outcome (hemoglobin, risk stratification scores) at presentation, and outcomes of bleeding episodes. The primary outcome was a composite of transfusion, intervention, or mortality.

RESULTS: Bloody and coffee-grounds emesis were similar in pulse ≥100 beats/min (35 vs. 37%), systolic blood pressure ≤100 mm Hg (12 vs. 12%), and hemoglobin ≤100 g/l (25 vs. 27%). Risk stratification scores were lower with bloody emesis. The composite end point was 34.7 vs. 38.2% for bloody vs. coffee-grounds emesis; mortality was 6.6 vs. 9.3%. Hemostatic intervention was more common (19.4 vs. 14.4%) with bloody emesis (due to a higher frequency of varices necessitating endoscopic therapy), as was rebleeding (7.8 vs. 4.5%). Outcomes were worse with hematemesis plus melena vs. isolated hematemesis for bloody (composite: 62.4 vs. 25.6%; hemostatic intervention: 36.5 vs. 13.8%) and coffee-grounds emesis (composite: 59.1 vs. 27.1%; hemostatic intervention: 26.4 vs. 8.1%).

CONCLUSIONS: Bloody emesis is not associated with more severe bleeding episodes at presentation or higher mortality than coffee-grounds emesis, but is associated with modestly higher rates of hemostatic intervention and rebleeding. Outcomes with hematemesis are worsened with concurrent melena. The presence of bloody emesis plus melena potentially could be considered in decisions regarding timing of endoscopy.

1Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA

2Section of Digestive Diseases, VA Connecticut Healthcare System, West Haven, Connecticut, USA

3Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark

4Gastrointestinal Unit, Royal Cornwall Hospital, Cornwall, UK

5Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore

6Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand

7Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK

Correspondence: Loren Laine, MD, Section of Digestive Diseases, Yale School of Medicine, P.O. Box 208019, New Haven, Connecticut 06520-8019, USA. E-mail:

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published online 30 January 2018

SUPPLEMENTARY MATERIAL accompanies this paper at

Received 26 September 2017; accepted 12 December 2017

© The American College of Gastroenterology 2018. All Rights Reserved.
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