Red Color Signs in Esophageal Varices
Red color signs are endoscopic features on esophageal varices that include red wale markings, cherry red spots, and hematocystic spots—all representing microtelangiectasias and changes in variceal wall structure that indicate high bleeding risk and warrant prophylactic treatment even in small varices. 1
Definition and Types of Red Color Signs
Red color signs are specific endoscopic findings that predict variceal hemorrhage by reflecting structural changes in the variceal wall and increased tension associated with microtelangiectasia development. 1 The specific types include:
- Red wale markings (RWM): Longitudinal dilated venules resembling whip marks on the variceal surface 1
- Cherry red spots: Discrete red spots on the variceal surface 1
- Hematocystic spots (HCS): Blood-filled blebs that carry particularly high and early bleeding risk 2
Clinical Significance and Bleeding Risk
The presence of red color signs dramatically increases bleeding risk regardless of variceal size. Studies demonstrate that 80% of patients with cherry red spots or blue varices with red color signs bled from varices, establishing these as critical predictors of variceal hemorrhage. 1
Risk Stratification by Red Color Sign Type
Hematocystic spots represent the highest risk subtype, associated with both overall bleeding and early bleeding events. 2 In contrast, red wale markings alone may not predict early bleeding as strongly, though they still indicate increased overall bleeding risk. 2
The bleeding rate in untreated red color sign-positive varices reaches 78% during follow-up, compared to only 10% in those receiving prophylactic treatment. 2
Pathophysiology
Red color signs represent:
- Changes in variceal wall structure with decreased wall thickness 1
- Increased tension on the variceal wall 1
- Development of microtelangiectasias in areas of structural weakness 1
These features indicate that the varix is under high tension and at imminent risk of rupture. 1
Treatment Implications
Red color signs mandate prophylactic treatment regardless of variceal size. 1 Current guidelines specify that even small esophageal varices with red color signs in patients with decompensated cirrhosis require non-selective beta-blockers (propranolol or nadolol) to prevent first variceal bleeding. 1
Treatment Urgency by Red Color Sign Type
- Hematocystic spots require immediate intervention due to high early bleeding risk 2
- Red wale markings alone may allow slightly more time for treatment planning, though prophylaxis should not be delayed 2
- Prophylactic treatment reduces bleeding risk from 78% to 10% and significantly extends the bleeding-free period (1156 days vs 105 days) 2
Predictive Factors for Red Color Sign Development
The appearance of red color signs correlates with:
- Number of variceal columns (most significant predictor) 3
- Size of varices 3
- Platelet count (lower counts predict appearance) 3
- Alpha-fetoprotein levels 3
The cumulative incidence of red color sign appearance increases with baseline variceal size: 11.4% in patients without varices, 45.4% with small varices, and 65.0% with mid-size varices at 10 years. 3
Common Pitfalls
Do not delay treatment in red color sign-positive varices based on small variceal size alone—the red color sign itself indicates high bleeding risk independent of size. 1, 2 Additionally, do not assume all red color signs carry identical risk—hematocystic spots require more urgent intervention than red wale markings alone. 2