You have a patient vomiting large amounts of bright red blood, with no abdominal pain, pale, cool, clammy and jaundiced skin; pulse 128. Which condition is most likely?

• A. Ruptured hernia
• B. Esophageal tear
• C. Esophageal varices
• D. Ulcer ruptured

Answer: (C)

The key idea is that a large, rapid upper GI bleed in a patient who is jaundiced points to esophageal variceal bleeding from portal hypertension due to liver disease. Varices are dilated veins in the lower esophagus that can rupture and pour out bright red blood, leading to shock-like signs such as pale, cool, clammy skin and a fast pulse. The jaundice suggests underlying liver dysfunction, which drives portal hypertension and the formation and rupture of these varices.

Other causes don’t fit as well here. A Mallory-Weiss tear follows forceful vomiting and often presents with painful bleeding or chest/abdominal pain, which isn’t described. A peptic ulcer can bleed, but abdominal pain is common and you wouldn’t expect jaundice to be present. A ruptured hernia would typically cause abdominal pain and signs of obstruction rather than massive hematemesis with underlying liver disease.