The white nipple sign: please do not disturb

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.