What are the signs of recent hemorrhage in varices?

Signs of Recent Hemorrhage in Varices

The diagnosis of recent variceal hemorrhage is confirmed when endoscopy demonstrates active bleeding from a varix, a "white nipple" overlying a varix, clots overlying a varix, or varices with blood in the stomach and no other identifiable bleeding source. 1

Endoscopic Findings Indicating Recent Variceal Bleeding

Definitive Signs

• Active bleeding from a varix - Direct visualization of blood spurting or oozing from the variceal site confirms acute hemorrhage 1
• "White nipple" sign - A fibrin plug or platelet plug overlying a varix represents the site of recent bleeding and is pathognomonic for recent variceal hemorrhage 1
• Adherent clot on a varix - Fresh clot overlying a variceal column indicates recent bleeding from that specific site 1

Presumptive Signs

• Varices as the only lesion with blood in the stomach - When varices are present without other potential bleeding sources and blood is found in the gastric lumen, variceal hemorrhage should be inferred 1
• Large esophageal varices with intragastric blood - The presence of large varices combined with blood in the stomach without another recognizable cause establishes the diagnosis 1

Clinical Presentation Features

Hemodynamic Indicators of Significant Bleeding

• **Systolic blood pressure <100 mm Hg** or postural drop >20 mm Hg at presentation 1
• Heart rate >100 beats/min at time of admission 1
• Transfusion requirement ≥2 units of blood within 24 hours of presentation 1

Bleeding Manifestations

• Fresh hematemesis (vomiting bright red blood) indicates active or very recent bleeding 1, 2
• Coffee-ground emesis suggests altered blood from slower or resolved bleeding 1
• Melena (black tarry stools) indicates upper GI bleeding, though patients with hematemesis and melena typically have more severe bleeding than those with melena alone 1

Timing Considerations for Endoscopy

Endoscopy should be performed as soon as possible and not more than 12 hours after presentation to identify signs of recent hemorrhage while they remain visible. 1 If endoscopy is performed after 24 hours of hemorrhage, the diagnosis of variceal bleeding should be inferred when varices are the only lesion found. 1

Common Pitfalls to Avoid

• Do not delay endoscopy beyond 12 hours - Stigmata of recent bleeding such as white nipples and adherent clots may resolve, making diagnosis more difficult 1
• Do not assume all upper GI bleeding in cirrhosis is variceal - Approximately 20-30% of bleeding episodes in cirrhotic patients are from non-variceal sources such as peptic ulcers or erosions 1
• Do not overlook gastric varices - While esophageal varices are more common, gastric varices can also bleed and require identification 1