What are the causes of hematemesis in adults?

Causes of Hematemesis in Adults

Peptic ulcer disease is the leading cause of hematemesis, accounting for 35-50% of upper gastrointestinal bleeding cases, followed by esophageal varices (5-10% overall but responsible for 66-70% of massive hematemesis), gastroduodenal erosions (8-15%), Mallory-Weiss tears (15%), and esophagitis (5-15%). 1

Primary Etiologies by Frequency

Most Common Causes (Nonvariceal)

• Peptic ulcer disease represents the single most frequent cause at 35-50% of all cases, typically involving duodenal or gastric ulcers often related to NSAID use, aspirin, or Helicobacter pylori infection 1, 2
• Gastroduodenal erosions account for 8-15% of cases and are strongly associated with NSAID use, stress, or metabolic conditions like diabetes 1
• Mallory-Weiss tears cause approximately 15% of cases, characteristically occurring after forceful vomiting or retching episodes 1, 3
• Esophagitis accounts for 5-15% of cases and more commonly presents as coffee ground emesis rather than frank hematemesis 1

Variceal Causes

• Esophageal varices cause 5-10% of upper GI bleeding overall but are responsible for 66-70% of massive hematemesis cases, with mortality approaching 30% versus 10% for nonvariceal sources 1, 4
• Esophageal varices alone represent 17.8% of variceal bleeding, while combined esophageal and gastric varices account for 39.5%, and isolated gastric varices 12.8% 5
• Variceal bleeding carries significantly higher rebleeding rates (19.4%) compared to nonvariceal causes (6.1%) 5

Less Common but Important Causes

• Upper GI malignancy and vascular malformations (including angiodysplasia) each represent approximately 1% of cases 1, 3
• Dieulafoy lesion accounts for 1-2% of acute bleeding and consists of a tortuous submucosal artery that penetrates through the mucosa, commonly at the posterior gastric wall 3
• Cameron's erosions in large hiatal hernias are a commonly overlooked cause, particularly in patients with upper gastrointestinal symptoms 4
• Gastric antral vascular ectasia occurs particularly in patients with chronic kidney disease and cirrhosis 4

Rare but Life-Threatening Causes

• Aortoenteric fistula represents a rare but catastrophic cause of GI hemorrhage, particularly in patients with prior abdominal aortic aneurysm repair 3, 4
• Hemobilia and hemosuccus pancreaticus are rare entities, with hemosuccus pancreaticus estimated to cause 1 in every 500 cases of upper GI bleeding 3, 4
• Hepatocellular carcinoma eroding into the duodenum can cause hematemesis 3

Iatrogenic Causes

• Endoscopic ultrasound-guided biopsies, ERCP-related injury, delayed hemorrhage from biliary metallic stenting, and nitinol esophageal or upper GI stent placement can all cause hematemesis 3
• Extrahepatic arterial injury after pancreatic surgery is another iatrogenic cause 3

Key Clinical Distinctions

Presentation Patterns

• Massive hematemesis (fresh red blood) suggests variceal bleeding in 66-70% of cases 6
• Coffee ground emesis indicates less active bleeding and is more frequently associated with esophagitis than frank hematemesis 1
• Approximately 75% of upper GI bleeding ceases spontaneously, though 25% rebleed after initial cessation and 10% have persistent bleeding 7

Population-Specific Considerations

• Inner-city populations show relatively higher proportions of variceal hemorrhage and erosive gastritis 3
• Patients over 60-65 years have significantly higher mortality and increased risk of vascular lesions, with vascular causes accounting for up to 40% in patients over 40 years old 6, 4
• In patients under 50 years, small bowel tumors are the most common cause of obscure bleeding 4

Medication-Related Risk Factors

• NSAID and aspirin use are common iatrogenic causes, with aspirin at any dose carrying a 2.6-3.1 times increased risk of major bleeding 6
• Anticoagulation with warfarin or direct oral anticoagulants increases bleeding risk and requires assessment of INR and reversal strategies 3, 6

Critical Pitfall

The most important clinical distinction is identifying cirrhotic patients with suspected variceal bleeding, as these patients require specialized management protocols with vasoactive agents, antibiotics, and early consideration of TIPS placement, given their 30% mortality rate compared to 10% for nonvariceal sources 4, 2. Hemodynamic instability, ongoing hematemesis, and presence of liver disease stigmata (jaundice, ascites, confusion) mandate immediate aggressive resuscitation and urgent endoscopy by experienced endoscopists capable of variceal intervention 4.