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images in clinical medicineT h e ne w e ngl a nd jou r na l o f m e dic i ne n engl j med 362;5 nejm.org february 4, 2010 e13A 52-year-old man with cirrhosis associated with alcohol abuse presented to the emergency department with hematemesis and lightheadedness, which had developed 3 hours earlier, after binge drinking. He had no history of decompensated liver disease and took no medications. During the physical examination, he was alert and oriented, with a pulse rate of 140 beats per minute and a blood pressure of 90/60 mm Hg. Spider angiomata and ascites were present. Results of laboratory tests showed a hematocrit of 21%. The alanine aminotransferase level was 47 U per liter, the aspartate aminotransferase level was 102 U per liter, the albumin level was 2.6 g per deciliter, the total bilirubin level was 2.3 mg per deciliter (39 μmol per liter), the direct bilirubin level was 1.4 mg per deciliter (24 μmol per liter), and the prothrombin time was 15.4 seconds. The patient was hospitalized, and he underwent volume resuscitation and was given omeprazole and octreotide. Emergency upper endoscopy showed active bleeding from esophageal varices (video), which was controlled with band ligation. Hemorrhage from esophageal varices is a severe complication of cirrhosis with portal hypertension. After band ligation, the patient's condition stabilized, with no further bleeding.