portal hypertension is the most common complication of chronic liver disease , leading to the development of ascites , portal - systemic encephalopathy , and gastroesophageal varices .
hemorrhage from gastroesophageal varices is among the most lethal complications of cirrhosis and portal hypertension .
esophageal varices develop at a rate of 5% per year in patients with cirrhosis and portal hypertension [ 1 , 2 ] . in patients with esophageal varices
, hemorrhage occurs at a yearly rate of 5 - 15% [ 1 , 2 ] .
esophageal variceal bleeding is associated with a 15 - 20% early mortality [ 1 , 2 ] . in patients who survive the initial hemorrhage ,
the risk of rebleeding is as high as 60% within 2 years , with a 33% mortality . because of the high mortality associated with variceal hemorrhage , as well as the high likelihood of rebleeding after a first episode , the treatment of portal hypertension includes attempts at preventing the first bleed ( primary prophylaxis ) , management of acute variceal hemorrhage , and the prevention of rebleeding ( secondary prophylaxis ) [ 1 , 2 ] .
primary prophylaxis constitutes treatment with a non - selective beta - blocker to reduce portal pressure . for those who can not tolerate beta - blockade , endoscopic therapy in the form of endoscopic
variceal band ligation can be performed and repeated until the varices are obliterated . in those patients who have recovered from acute esophageal variceal hemorrhage , secondary prophylaxis or prevention of further variceal bleeding
should be performed in the form of endoscopic variceal ligation , in addition to portal pressure - reducing medication .
the treatment of choice for bleeding esophageal varices is a combination of pharmacologic therapy with somatostatin and its analogues ( such as octreotide ) or terlipressin , and endoscopic therapy , preferably variceal ligation [ 1 , 2 ] .
blood spurting or oozing from a varix confirms the diagnosis of variceal hemorrhage , however in most cases the bleeding has ceased by the time endoscopy is performed .
it is therefore important for the endoscopist to identify and recognize signs of recent variceal hemorrhage .
the most commonly seen stigmata are red color signs , including red wale marks ( longitudinal red streaks on varices that resemble red corduroy wales ) , cherry red spots , and hematocystic spots ( raised discrete red spots on the surface of varices that appear as blood blisters ) [ 1 , 3 , 4 ] .
a less commonly recognized stigma of recent variceal hemorrhage is a white nipple - like projection from a varix into the esophageal lumen [ 1 , 2 , 4 , 5 , 6 ] .
this platelet - fibrin plug , also referred to as the ' white nipple sign ' , is indicative of a site of recent bleeding [ 1 , 4 , 5 , 6 ] .
recognition of this stigma of recent hemorrhage is necessary so that endoscopic therapy may be performed in order to prevent further variceal bleeding [ 4 , 5 , 6 ] .
a 53-year - old male with a past medical history of alcoholic cirrhosis , hypertension , and depression presented to the emergency department with a history of hematemesis of frank red blood and clots .
admission vital signs were : heart rate 83 , respiratory rate 18 with spo2 94% and blood pressure 188/99 mm hg . physical examination revealed no jugular venous distention .
admission laboratory data included inr 1.3 , wbc 4,400/l , hemoglobin 12.2 g / dl , and platelets 51  106/l .
his basic metabolic panel revealed serum sodium 143 mmol / l , potassium 3.6 mmol / l , chloride 103 mmol / l , bicarbonate 28 mmol / l , bun 6 mg / dl and creatinine 0.6 mg / dl .
ast and alt were 60 and 154 u / l respectively , alkaline phosphatase 201 u / l , total bilirubin 1.6 mg / dl , total protein 7.8 g / dl and albumin 3.3 g / dl . in the emergency department , he was started on octreotide infusion and given intravenous pantoprazole . emergent endoscopy revealed grade ii - iii esophageal varices without any active bleeding .
there were no red wale markings or other red color signs . however , one of the larger varices had a protuberant white spot ( fig .
it was then inadvertently dislodged with gentle suctioning , resulting in brisk hemorrhage ( fig .
2 ) . variceal band ligation was promptly performed with successful control of bleeding ( fig .
3 ) . the patient was monitored in the intensive care unit post - procedure and was maintained on octreotide infusion for 96 h. antibiotic prophylaxis with intravenous piperacillin - tazobactam was initiated .
he continued to demonstrate hemodynamic stability without evidence of recurrent bleeding and was transferred out of the intensive care unit 2 days later .
the remainder of the hospitalization was uneventful and the patient was successfully discharged home 6 days after admission on beta - blocker therapy .
though not widely mentioned as a stigma of recent variceal hemorrhage , this finding was first reported by chung and lewis in 1984 .
they described it as a white nipple on top of a varix protruding into the lumen and noted its presence in up to 5% of cases of variceal bleeding .
it was thought to represent a platelet - fibrin plug at the site of recent variceal rupture .
they noted that dislodgement would be accompanied by jet - like bleeding and called it ' mount st .
two prospective studies have evaluated the finding of the ' white nipple sign ' as a diagnostic sign of recent hemorrhage .
siringo et al .   evaluated the white nipple sign prospectively in 203 separate admissions for esophageal variceal bleeding in 145 cirrhotic patients .
endoscopic therapy was not initially delivered to these patients in order to evaluate the risk of rebleeding .
they felt that the white nipple sign was diagnostic of a varix that had recently bled but found that it had no adverse prognostic significance . in another study done in taiwan ,
166 patients with recent variceal hemorrhage were prospectively studied with respect to presence or absence of the white nipple sign and to risk of rebleeding following endoscopic therapy .
the authors noted a white nipple sign in 21% of their cases of variceal hemorrhage .
they concluded that the white nipple sign suggested recent variceal hemorrhage and was more likely to be seen if endoscopy was performed soon after the bleeding episode .
our case reaffirms the finding of a white nipple sign as a definite stigma of recent variceal hemorrhage .
it is likely that endoscopists are not as familiar with this sign as they are with red color signs .
as chung and lewis   initially suggested , it should ' alert the endoscopist to take urgent measures to avert a disaster ' . recognizing it as such , attempts to dislodge the lesion must be avoided and endoscopic therapy should be undertaken .
 blood spurting or oozing from a varix confirms the diagnosis of variceal hemorrhage . in most cases of variceal hemorrhage , however , the bleeding has ceased by the time endoscopy is performed . 
 endoscopists rely on identification of stigmata of recent hemorrhage to determine whether varices are the cause of bleeding and to predict the likelihood of rebleeding . 
 most of the attention has focused on red color signs , such as red wale markings , described by beppu et al . 
 [ gastrointest endosc 1981;27:213 - 218 ] and well known to endoscopists . here 
 we describe our experience with a less recognized stigma of variceal hemorrhage known as the  white nipple sign , which resulted in active hemorrhage when manipulated . 
Introduction
Case Report
Discussion