A 52-year-old man with Child-Pugh B cirrhosis presents with hematemesis and melena. Urgent upper endoscopy reveals tortuous submucosal varices in the distal esophagus. The structure marked **B** in the diagram—red wale marks—is noted on the variceal surface. Which of the following best describes the clinical significance of this finding?

Explanation

## Why Red wale marks are endoscopic high-risk markers... is right Red wale marks (cherry red spots) are well-established endoscopic high-risk markers for variceal bleeding in esophageal varices. According to Harrison 21e and AASLD Guidelines, red wale marks—along with large variceal size (>5 mm, Grade 3), Child-Pugh C status, and ascites—are independent predictors of bleeding risk. The presence of red wale marks on the variceal surface indicates structural instability and impending hemorrhage, mandating urgent endoscopic hemostasis (band ligation preferred) combined with vasoactive drugs (terlipressin or octreotide) and prophylactic antibiotics (ceftriaxone). This is a critical prognostic marker that elevates the patient from observation-only management to active intervention. ## Why each distractor is wrong - **Red wale marks indicate chronic portal hypertension but do not influence urgency...**: This is dangerously incorrect. Red wale marks are NOT merely markers of chronic disease; they are HIGH-RISK FEATURES that directly influence management urgency and intensity. Ignoring them would delay life-saving intervention. - **Red wale marks are a sign of variceal sclerosis...**: Sclerosis indicates fibrosis and healing after prior intervention or thrombosis—the opposite of red wale marks, which represent active, friable, bleeding-prone mucosa. This confuses the endoscopic appearance of treated vs. untreated high-risk varices. - **Red wale marks represent gastric fundal varices...**: Red wale marks occur on esophageal varices (as shown in the diagram at the distal esophagus). Gastric fundal varices are a separate entity requiring different therapy (cyanoacrylate glue or BRTO). This is a common anatomical confusion. **High-Yield:** Red wale marks = cherry red spots = endoscopic HIGH-RISK MARKER → mandate urgent EVL + vasoactive drugs + antibiotics, NOT observation. [cite: Harrison 21e Ch 414; AASLD Guidelines on variceal hemorrhage]