What are the causes of massive hematemesis?

Causes of Massive Hematemesis

Esophageal varices are the most common cause of massive hematemesis, accounting for approximately 66-70% of cases, particularly in patients with underlying liver disease and portal hypertension. 1, 2, 3

Primary Causes by Frequency

Variceal Bleeding (Most Common in Massive Hematemesis)

• Esophageal varices represent the leading cause of massive upper GI bleeding, with variceal causes accounting for 70% of all upper GI bleeding cases in many populations 2, 3
• Combined esophageal and gastric varices are present in 39.5% of variceal bleeding cases, isolated esophageal varices in 17.8%, and isolated gastric varices in 12.8% 3
• Varices develop when portal pressure exceeds 10 mmHg, with yearly hemorrhage rates of 5-15% and mortality of at least 20% at 6 weeks 1
• Among patients presenting specifically with massive bleeding, esophageal varices account for 66.7% of cases 2

Non-Variceal Causes (Less Common but Important)

• Peptic ulcer disease (duodenal and gastric ulcers) represents the most common cause of nonvariceal upper GI bleeding, accounting for approximately 50% of nonvariceal cases and 17.5% of all upper GI bleeding 4, 2
• Gastric erosions and erosive gastritis account for 12.5% of upper GI bleeding cases 2
• Mallory-Weiss tears from forceful vomiting or retching represent 7.5% of cases and typically present with bloody hematemesis rather than coffee-ground emesis 4, 2

Rare but Life-Threatening Causes

• Hemobilia (bleeding into the biliary tree) is a rare but potentially life-threatening cause, typically resulting from blunt liver trauma, hepatobiliary interventions, or post-cholecystectomy hepatic artery pseudoaneurysm 5
• Gastric diverticula can present with hematemesis requiring surgical intervention, though this is uncommon 6
• Dieulafoy lesions account for only 1-2% of acute upper GI bleeding cases 4

Risk Stratification and Clinical Context

High-Risk Features for Massive Bleeding

• Variceal bleeding has significantly higher recurrence rates (19.4%) compared to non-variceal bleeding (6.1%) 3
• Mortality is substantially higher with variceal bleeding (4.3%) versus non-variceal bleeding (1.5%) 3
• Independent risk factors for recurrent variceal bleeding include hypertension, ascites, grade IV esophageal varices, presence of gastric varices, and associated respiratory disorders 3

Patient Demographics and Geographic Considerations

• Massive hematemesis occurs more commonly in men and older subjects 2
• In tropical countries like India, esophageal varices account for approximately half of all cases, whereas in the US, peptic ulcer disease predominates 2
• Elderly patients (>65 years) have significantly higher mortality rates and require more aggressive management 7

Critical Clinical Distinctions

Presentation Patterns

• Bloody (fresh red) hematemesis suggests active, potentially more severe bleeding requiring urgent intervention 4
• Coffee-ground emesis indicates blood exposed to gastric acid and may represent less active bleeding, though still requires full evaluation 1, 4
• Black hematemesis (coffee-ground emesis) specifically indicates upper gastrointestinal bleeding where blood has been exposed to gastric acid 1

Common Pitfalls to Avoid

• Do not overlook medication history, particularly NSAIDs, antiplatelet agents (especially P2Y12 antagonists like clopidogrel), or anticoagulants that significantly increase bleeding risk 8, 4
• Do not delay endoscopy beyond 24 hours, as diagnostic and therapeutic success rates are highest within the first 36 hours of bleeding onset 1, 4, 9
• Without documented liver disease or cirrhosis, variceal bleeding is unlikely, making peptic ulcer disease and gastric erosions more probable 4
• Patients with significant comorbidities (cardiovascular, renal, or liver disease) are at higher risk for complications and mortality 7