Esophageal Varix with Nipple Sign

Rami Musallam, MD, Gastroenterology Fellow,

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, Professor of Medicine

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA 

 A 50-year-old patient with a history of cirrhosis due to ethanol use presented to the emergency room with hematemesis and melena for one day. The patient had clinical features consistent of chronic liver disease (spider angiomas, ascites, palmar erythema and jaundice). The hemoglobin was 8 gr/dl. An EGD was performed (Photo).

Figure 1. Large esophageal varices. A. Three columns of esophageal varices extending from  the distal esophagus to the mid-esophagus. B. The stomach was full of coffee-ground like material, bile and blood clots. C. Classic nipple sign shown with yellow arrow. D. Nipple sign. E. The transparent banding cap allows for great visualization of the nipple sign (yellow arrow). F. No arrow on this photo to allow for “eye training” to detect nipple sign”. G. and H. Successful endoscopic band ligation of varix with high-risk stigmata (nipple sign).

There are various signs of impending or recent hemorrhage from esophageal varices. These include red stops, red whale sign, nipple-like sign and active bleeding (oozing or spurting) (1, 2). The “nipple-like projection” or “nipple sign” was described in 1996 (1). This lesion represents an opening varix covered by fibrin, indicating a recent bleed with spontaneous “hemostasis”. Any varix with nipple-like projection is at extremely high risk of (recurrent) bleeding, as this fibrin plug may fall off any time. Whenever this sign is encountered a quick decision to place endoscopic bands must be made. In this case we saw large esophageal varices (Panel A), then saw the lesion (Panels C and D). The stomach was full of old blood. As there was a clear culprit explaining the recent hemorrhage (fibrin nipple, panels C, D). Further cleaning of the stomach might have resulted in loss of the fibrin plug on the varix and catastrophic bleeding. Therefore, a quick decision was taken to place endoscopic band ligation on the high-risk lesion (panels E to H).

Recognizing a high-risk marker like the "nipple sign" can be the difference between routine banding and a catastrophic bleed. But what about the countless other challenging scenarios in GI bleeding?

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