A 55-year-old man with a 10-year history of alcohol use disorder presents with hematemesis and melena. Upper endoscopy reveals multiple dilated veins in the distal esophagus with cherry-red spots. What is the most common cause of upper gastrointestinal bleeding in this patient?

Explanation

## Most Common Cause of Upper GI Bleeding in Cirrhosis **Key Point:** Esophageal varices are the most common cause of life-threatening upper GI bleeding in patients with portal hypertension and cirrhosis. In this case, the patient's chronic alcohol use disorder strongly suggests underlying cirrhosis, and the endoscopic finding of dilated esophageal veins with cherry-red spots is pathognomonic for varices. **High-Yield:** Among all causes of upper GI bleeding, peptic ulcer disease is the most common overall (~40–50% of cases); however, in patients with known or suspected cirrhosis/portal hypertension, esophageal varices become the leading cause of acute, severe bleeding. **Clinical Pearl:** The presence of cherry-red spots (red wale sign) on varices indicates high risk of imminent rupture and is an indication for urgent variceal ligation or sclerotherapy. ## Comparative Epidemiology of Upper GI Bleeding Causes | Cause | Prevalence (Overall) | Prevalence (Cirrhotic) | Mortality if Bleeds | |-------|----------------------|------------------------|---------------------| | Peptic ulcer disease | 40–50% | 5–10% | 5–10% | | Esophageal varices | 15–20% | 50–60% | 30–50% | | Mallory-Weiss tear | 10–15% | 5–10% | <5% | | Gastric cancer | <5% | <5% | >50% | **Mnemonic:** **STAMP** for common causes of upper GI bleeding — **S**tress ulcer, **T**ear (Mallory-Weiss), **A**lcoholic varices, **M**allory-Weiss, **P**eptic ulcer. In cirrhosis, varices dominate. [cite:Harrison 21e Ch 297]