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Endoscopic color Doppler ultrasonography (ECDUS) is a useful modality for obtaining color flow images of esophageal varices. The direction of blood flow in passageways is fundamentally hepatofugal flow according to ECDUS. The present study is designed to evaluate the alternate direction of color flow image of passageways via ECDUS in esophageal variceal patients.The study involved 125 patients with esophageal varices using ECDUS. The grades of red color (RC) were as follows: RC(+) in 79 cases, RC(+ +) in 35 cases, and RC(+ + +) in 11 cases. We investigated the alternate direction on color flow images of the left gastric vein, the palisade vein, and the perforating veins via ECDUS.Color flow images of the esophageal varices and the left gastric vein were obtained in all 125 (100%) patients by ECDUS. Color flow images of the perforating veins were obtained in 90 (72.0%) of the 125 patients. Vessel images of the palisade veins were detected in 33 (26.4%) of the 125 patients. The alternate direction on color flow images was detected in seven (5.6%) of the 125 patients with ECDUS: in three patients, left gastric vein; in three patients, perforating veins; and in one patients, left gastric vein and palisade veins. This phenomenon was observed periodically at regular intervals. The endoscopic findings were RC(+) in all seven patients.The alternate direction of blood flow in the passageways was observed in a few cases of RC(+) esophageal varices. We can observe the hemodynamics of esophageal varices non-invasively and in real time with ECDUS, and clarify the frequencies of the alternate direction of blood flow in RC-positive esophageal variceal patients.