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Forrest classification - Risk stratification of UGIB

The Forrest classification system of upper gastrointestinal hemorrhage is used for purposes of comparison and in selecting patients for endoscopic treatment.

Please select the Forrest classification that best describes the current bleeding peptic
ulcer activity

Type 1: Acute hemorrhage / Active bleed:
Forrest I a (Spurting hemorrhage)
Forrest I b (Oozing hemorrhage)

Type 2: Signs of recent hemorrhage:
Forrest II a (Non bleeding Visible vessel)
Forrest II b (Adherent clot)
Forrest II c  (Flat pigmented haematin on ulcer base)

Type 3: Lesions without active bleeding:
Forrest III (Lesions without signs of recent hemorrhage or fibrin-covered clean ulcer base)

Background Info

Utilizing the Forrest classification in clinical practice:  

The Forrest classification is vital when stratifying patients with upper gastrointestinal hemorrhage into risk categories that are then used to guide continued therapy and help predict the rebleeding risk and the incidence of death based on the endoscopic findings. 

Please review:

Heldwein W, Schreiner J, Pedrazzoli J, Lehnert P.  Is the Forrest classification a useful tool for planning endoscopic therapy of bleeding peptic ulcers?  Endoscopy. 1989 Nov;21(6):258-62.

A prospective controlled study was carried out to determine the validity of the Forrest classification in terms of improved laser therapy. Out of 153 consecutive patients with bleeding peptic ulcers, 137 patients--74 with arterial ulcer bleeding and 63 with non-arterial ulcer bleeding--were included in the trial. In arterial ulcer bleeding a significantly lower rate of permanent hemostasis was achieved, and the frequency of urgent surgery and mortality was higher than in non-arterial ulcer bleeding. Patients with spurting arterial bleeding (Forrest Ia) and those with large non-bleeding visible vessels (Forrest IIa) include almost all patients at risk of further bleeding and death. Combined laser therapy clearly minimizes the risk of rebleeding and death in small non-bleeding visible vessels (Forrest IIa). In contrast, decreased hemoglobin and a requirement for blood transfusion are of limited prospective value for the individual emergency patient. Overall, our results demonstrate that Forrest criteria are essential for proper planning of endoscopic therapy and urgent surgery in bleeding peptic ulcers. Emergency endoscopy must therefore be performed as early as possible.


  1. Block, Berthold; Schachschal, Guido; Schmidt, Hartmut H. (2004-01-01). Endoscopy of the Upper GI Tract: A Training Manual. Thieme. ISBN 9783131367310.

  2. Hadzibulic E, Govedarica S.  Significance of Forrest classification, Rockall’s and Blatchford’s risk scoring system in prediction of rebleeding in peptic ulcer disease.   Acta Medica Medianae 2007,Vol.46

  3. Heldwein W; Schreiner J; Pedrazzoli J; Lehnert P (Nov 21, 1989). "Is the Forrest classification a useful tool for planning endoscopic therapy of bleeding peptic ulcers?". Endoscopy. 21 (6): 258–62.  PMID 2693077

  4. Laine L, Peterson WL.  Bleeding peptic ulcer.  N Engl J Med. 1994 Sep 15;331(11):717-27.

  5. Forrest, JA.; Finlayson, ND.; Shearman, DJ. (Aug 1974). "Endoscopy in gastrointestinal bleeding". Lancet. 2 (7877): 394–7.  PMID  4136718.

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