Positive white nipple sign on esophageal varices: Not a just bystander; our experience

Background and study aims  The goal of this study was to assess whether a white nipple sign on esophageal varices is of no prognostic significance or mandates more attention. Patients and methods  We retrospectively analyzed data from 2601 patients undergoing upper gastrointestinal endoscopy for variceal bleed from January 2008 to January 2020. Intraprocedural events like onset of active spurt while performing endoscopy, active spurt while attempting to band the varix with a nipple, need for rescue glue therapy required to control bleed in cases of failed endoscopic variceal ligation (EVL), slipping of band and rebleed despite successful band application, need for emergency intubation, and pulmonary aspiration-related complications were noted. Results  A total of 2601 patients underwent endoscopy for variceal bleeding. Of them, 631 had a positive white nipple sign. Of that subgroup, 137 (21.7 %) patients developed active spurt during endoscopy. In patients with the white nipple sign, 12.3 % required endotracheal intubation and 6.7 % developed aspiration pneumonia, which were significantly higher than in those without the sign. Rescue glue injection in esophageal varices was needed in 5.6 % as compared to 0.6 % in those without white nipple. Conclusions  The white nipple sign is not only a predictor of recent bleed, but it carries statistically significant increased risk of intraoperative bleeding, need for endotracheal intubation, esophageal glue injections, and aspiration-related complications. Therefore, it is not just a bystander, but rather, a sign of increased danger and a need to be more vigilant with patient management.