Prognostic significance of the white nipple sign in variceal bleeding

The prognostic significance of the white nipple sign in variceal bleeding was evaluated prospectively in 203 separate admissions for bleeding esophageal varices in 145 cirrhotic patients. During all admissions a standardized protocol of management defined the failure of transfusion and vasoactive drugs (conservative measures) to stop bleeding and the occurrence of early rebleeding, at which time either emergency sclerotherapy or a staple transection of the esophagus was used. The finding of a white nipple in 18 admissions (9%) did not have predictive value as regards the failure of conservative measures to stop bleeding within 24 hours or rebleeding within 5 days, and there was no association with increased mortality. In one case, a white nipple was seen to occur after spontaneous cessation of a variceal venous spurt, suggesting it is a platelet-fibrin plug. The white nipple sign is diagnostic of a varix that has bled but has no adverse prognostic significance.