Hematemesis is suggestive of massive upper GI bleed, the impoant causes of which in descending order are Peptic ulcer Duodenal ulcer (MC cause) Gastric ulcer Esophageal varies Gastritis Mallory Weiss tear Neoplasm of esophagus, stomach and duodenum Duodenal ulcer: Peptic ulcer is the most common cause of upper GI bleeding, present in one-half to two-thirds of pts. with upper GI bleed. Bleeding may be the initial presenting symptoms in up to 10 percent of pts with peptic ulcer. Duodenal ulcer bleeding is four times more common than gastric ulcer bleeding. Esophageal varices : Bleeding esophageal varices or gastric varices in the presence of liver disease account for about 10-20% of massive upper GI bleeding. In this pt. esophageal varices appears to be the cause as the pt. is a chronic alcoholic But here the amount he drinks daily should be taken into consideration. In men 40 - 80 g/day of ethanol - produces fatty liver 80 - 160 g/day of ethanol for 10 - 20 yrs - causes hepatitis or cirrhosis (Women exhibit increased susceptibility* to alcoholic liver disease at quantities > 20 g/day) He drinks 100 ml daily. Different types of drinks contain varying amounts of alcohol. What this pt. drinks is not known but even strong drinks such as 86-proof beverage contain 80 gm of ethanol in 250 ml of drinks (Wine contain 80 gm of ethanol in 1000 ml of drinks) Thus this patient is unlikely to have an alcoholic liver disease and so esophageal varies can be ruled out. Moreover even in patients with alcoholic cirrhosis, avarices are cause of massive GI bleed in only 1/2 the cases. Peptic ulcer or gastritis form rest of the half. Mallory-Weiss tear It accounts for a small percentage (5 to 10%) It presents in a classic pattern - initially vomiting is without blood, but after retching and vomiting with epigastric pain, bleeding and haematemesis begin. Gastritis Acute gastritis can present as massive bleeding (though rarely) It is most commonly associated with intake of NSAIDS, alcohol, coicosteroids and oral potassium supplements. I do not have any valid reason to rule out gastritis. But duodenal ulcer is a much more common cause. Ref : CSDT 13/e p494