What is the most likely cause of gastrointestinal bleeding in a 40-year-old man with acute hematemesis, no history of liver disease, normal liver function tests, and no previous similar episodes?

Most Likely Cause of Gastrointestinal Bleeding

The most likely cause of this patient's hematemesis is peptic ulcer disease (PUD), which accounts for 35-50% of acute upper GI bleeding cases and is the leading cause in patients without signs of chronic liver disease. 1

Clinical Reasoning

This 40-year-old man presents with acute hematemesis, hemodynamic compromise (tachycardia 110/min, borderline hypotension 105/65 mmHg), and anemia (Hb 95 g/L), but critically lacks any evidence of chronic liver disease:

• No jaundice or stigmata of chronic liver disease on examination 1
• Normal liver function tests (ALT 30 IU/L, normal PT 11 seconds) 1
• No prior bleeding episodes 2

Why Peptic Ulcer Disease is Most Likely

Peptic ulcer disease represents 35-50% of all acute upper GI bleeding presentations and is the dominant cause in patients without liver disease. 1, 3 The American College of Radiology specifically notes that gastric ulcers (32%) and duodenal ulcers (28%) together account for the majority of nonvariceal upper GI bleeding. 3

Key supporting features in this case:

• Age and demographics: PUD affects middle-aged adults, with male preponderance matching this patient 4
• Severity of presentation: The moderate bleeding with hemodynamic instability (tachycardia, borderline hypotension, Hb 95 g/L) is characteristic of peptic ulcer bleeding 1, 2
• No protective factors: No mention of PPI use, and the clinical picture suggests first presentation 2

Why Other Diagnoses Are Less Likely

Esophageal varices (Option C) are effectively ruled out because:

• Varices occur predominantly in cirrhotic patients with portal hypertension 3, 5
• This patient has normal liver function tests, normal PT, and no clinical signs of liver disease 1
• While varices represent 9% of upper GI bleeding overall, they are concentrated in the cirrhotic population 3
• In tropical countries, varices may account for up to 50% of cases, but only in patients with known liver disease 4

Erosive gastritis (Option A) is less likely because:

• Gastroduodenal erosions account for only 8-15% of acute upper GI bleeding 1
• Erosive gastritis typically causes less severe bleeding than this presentation 4
• The degree of hemodynamic compromise and anemia suggests a more substantial lesion 2

Mallory-Weiss tear (Option D) is unlikely because:

• Mallory-Weiss tears represent only 7.5-15% of upper GI bleeding cases 1, 4
• These tears classically occur after repeated forceful vomiting or retching, which is not mentioned in this history 2
• The patient has "no previous similar episodes," making the typical Mallory-Weiss presentation (vomiting followed by hematemesis) less consistent 1
• Mallory-Weiss tears generally cause less severe bleeding than peptic ulcers 6

Clinical Pitfalls to Avoid

Do not assume varices without evidence of liver disease. The absence of jaundice, normal liver enzymes, and normal coagulation studies make varices extremely unlikely despite the severity of bleeding. 1, 5

Do not overlook the need for urgent endoscopy. This patient has hemodynamic instability (HR >100, borderline BP) and should receive urgent endoscopy within 24 hours after resuscitation. 2, 5

Initiate high-dose PPI therapy immediately upon presentation, before endoscopy, as this is recommended for all patients with suspected peptic ulcer bleeding. 2, 5