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    Forrest Classification of Upper GI Bleeding

    Stratifies severity of upper GI bleeding according to endoscopic findings.
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    When to Use
    Pearls/Pitfalls
    Why Use

    Patients with peptic ulcers seen on endoscopy that are or have been bleeding.

    • Standardized classification system for endoscopists to describe peptic ulcers.
    • Reliably risk-stratifies patients with peptic ulcers and predicts risk of rebleeding and/or mortality.
    • Endoscopic appearance of ulceration guides endoscopic therapeutic decision and post-EGD medical treatment/disposition (i.e., admit vs. discharge, level of care, and length of stay).
    • There may be some inter-observer variation in classifying ulcers depending on timing of endoscopy, adequate visualization, vigorous irrigation, and level of training.
    • Since Forrest et al’s seminal study, the advent of proton pump inhibitors and development of endoscopic therapies for peptic ulcer bleeding has dramatically improved outcomes. Etiologies of peptic ulcer disease have also changed (e.g. ubiquity of NSAID use).
    • Helps prognosticate and risk stratify patients based on stigmata of recent hemorrhage and decide on discharge versus close inpatient monitoring.
    • Provides gastroenterologists a system to uniformly and simply classify and describe peptic ulcers.
    Active spurting
    Active oozing
    Non-bleeding visible vessel
    Adherent clot
    Flat pigmented spot
    Clean ulcer base

    Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    The Forrest Classification should be used to characterize all peptic ulcers, as it provides prognostic information on the need for endoscopic therapeutic intervention, the risk of rebleeding and death.

    Formula

    Select the appropriate class:

    Class 1A

    Active spurting

    Class 1B

    Active oozing

    Class 2A

    Non-bleeding visible vessel

    Class 2B

    Adherent clot

    Class 2C

    Flat pigmented spot

    Class 3

    Clean ulcer base

    Examples:

    Forrest class 1A Forrest class 1A

    Active spurting (1A)


    Forrest class 1B Forrest class 1B

    Active oozing (1B)


    Forrest class 2A Forrest class 2B

    Non-bleeding visible vessel (2A)

    Adherent clot (2B)


    Forrest class 2C Forrest class 3

    Flat pigmented spot (2C)

    Clean ulcer base (3)

     Images courtesy of Shawn L. Shah, MD, Weill Cornell Medicine, Division of Gastroenterology and Hepatology.

    Facts & Figures

    Interpretation:

    Class

    Description

    Rebleeding rate

    Mortality

    Class 1A

    Active spurting

    55%

    11%

    Class 1B

    Active oozing

    55%

    11%

    Class 2A

    Non-bleeding visible vessel

    43%

    11%

    Class 2B

    Adherent clot

    22%

    7%

    Class 2C

    Flat pigmented spot

    10%

    3%

    Class 3

    Clean ulcer base

    5%

    2%

    From Laine 1994.

    Evidence Appraisal

    The Forrest Classification was derived from 111 endoscopies performed on 106 patients at the Royal Infirmary in Edinburgh, Scotland, in a Lancet study published by John Forrest in 1974.

    A prospective registry data study in 2013 looked at 397 patients with peptic ulcer bleeds and categorized them by Forrest Classification, looking at the incidence of rebleeding and mortality; the authors found that the Forrest Classification still has predictive value for rebleeding, but did not accurately predict the risk of mortality.

    Dr. John A. H. Forrest

    About the Creator

    John Arthur Hunter Forrest, MD, FRCP, (d. 2010) specialized in gastrointestinal and liver diseases at the Royal Infirmary and the Western General Hospital in Edinburgh, Scotland. He was also secretary of the Caledonian Gastroenterology Society, now called the Scottish Society of Gastroenterology. Dr. Forrest's research interests included gastrointestinal and liver disease, in particular around drug use, abuse, and metabolism.

    To view Dr. John A. H. Forrest's publications, visit PubMed

    Content Contributors
    • Shawn L. Shah, MD
    Reviewed By
    • Carl V. Crawford, MD
    About the Creator
    Dr. John A. H. Forrest
    Content Contributors
    • Shawn L. Shah, MD
    Reviewed By
    • Carl V. Crawford, MD