<prompt> A male executive, 50 year of age is seen in casualty with hypotension and hematemesis. There is previous history suggestive of alcohol intake of 100 ml. daily. The blood loss is around 2 litres. Most probable diagnosis is ?GastritisDuodenal ulcerMallory-Weiss tearEsophageal varices  <response>: Ans. is b ie. Duodenal Ulcer 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 varices Gastritis Mallory weiss tear Neoplams of esophagus, stomach and duodenum Duodenal ulcer : Peptic ulcer is the most common cause of upper GI bleeding, present in one-half to two-third 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 gday of ethanol -- produces fatty liver 80 - 160 gday of ethanol for 10 - 20 yrs -- causes hepatitis or cirrhosis Women exhibit increased susceptibility to alcoholic liver disease at quantities 20 gday He drinks 100 ml daily. Different types of drinks contain varied amounts of alcohol. What this pt. drinks is not known but even strong drinks such as 86-proof beverage contains 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 varices can be ruled out. Moreever even in patients with alcoholic cirrhosis, varices are cause of massive GI bleed in only 12 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 vomitting is without blood, but after retching and vomitting with epigastric pain, bleeding and haematemesis begin. Gastritis Acute gastritis can presents 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 much more common cause. 