S2185 “Red Nipple Sign”: A Precursor to “White Nipple Sign”

Abstract

INTRODUCTION: Cirrhosis affects approximately 3.6 out of every 1000 adults in North America and leads to about 32,000 deaths annually. Variceal hemorrhage occurs in 25–40% of patients with cirrhosis and is a major cause of cirrhosis related morbidity and mortality, associated with up to 20 percent mortality. Additionally, those patients who survive a variceal hemorrhage have a 70 percent chance of recurrent variceal hemorrhage within one year. CASE DESCRIPTION/METHODS: We present a case of a 70-year-old male with past medical history of alcoholic cirrhosis, hypertension and rheumatoid arthritis (taking nonsteroidal anti-inflammatory drugs [NSAIDs]) admitted with hematochezia and hematemesis. The patient was started on a proton pump inhibitor (PPI), octreotide and ceftriaxone, and underwent an emergent esophagogastroduodenoscopy (EGD). Two columns of large esophageal varices were identified extending from Z-line to mid-esophagus (Figure 1). One of the varices was noted to contain two adjacent red spots which appeared similar to stigmata labeled as “white nipple sign” but red in color (Figure 2). A decision was made to perform band ligation and one band was deployed to each variceal column base resulting in excellent decompressive effect. One additional band was then deployed over both “red spots,” which during suctioning into the bander cap began to actively spurt heme, however, bleeding resolved after band deployment. The sites of previous “red spots” were then noted to have classic “white nipple sign” appearance (Figure 3). The patient tolerated the procedure well, was monitored as inpatient and subsequently discharged home with follow-up in a hepatology clinic. DISCUSSION: Variceal hemorrhage is a gastrointestinal emergency with prognosis reliant on achieving hemostasis and preventing future hemorrhage. Therefore, it is extremely important to recognize endoscopic features of high-risk stigmata for future hemorrhage. The most commonly reported features are often described as “red signs,” and include red wales marks, cherry red spots and hematocystic spots. One stigma of recent hemorrhage is known as “white nipple sign,” which owes its appearance to the platelet-fibrin plug overlying a varix. On literature review, we found this to be the first case of showing endoscopic transition of a red spot (“red nipple sign”) into a “white nipple sign,” demonstrating likely pathogenesis from a finding significant for high risk of hemorrhage to the finding consistent with post hemorrhage state.Figure 1.: Two columns of large varices extending from z-line to mid-esophagus.Figure 2.: Close up endoscopic image of red spot overlying varix.Figure 3.: Site of previous red spot, subsequently noted to have "white nipple sign" after band ligation of varix.