Forrest classification - Risk stratification of UGIB
Forrest classification system of upper gastrointestinal
hemorrhage is used for purposes of comparison and in selecting patients for
Please select the Forrest classification that best describes the current bleeding
/ Active bleed:
Forrest I a (Spurting hemorrhage)
Forrest I b (Oozing hemorrhage)
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)
Lesions without active bleeding:
Forrest III (Lesions without signs of recent hemorrhage or fibrin-covered
clean ulcer base)
Utilizing the Forrest classification in clinical practice:
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.
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.
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.
- Block, Berthold; Schachschal, Guido; Schmidt, Hartmut H. (2004-01-01).
Endoscopy of the Upper GI Tract: A Training Manual. Thieme.
- Hadzibulic E, Govedarica S.
Significance of Forrest classification, Rockall’s and
Blatchford’s risk scoring system in prediction of rebleeding in peptic ulcer
Acta Medica Medianae 2007,Vol.46
- 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.
- Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J
Med. 1994 Sep 15;331(11):717-27.
- Forrest, JA.; Finlayson, ND.; Shearman, DJ. (Aug 1974). "Endoscopy in
gastrointestinal bleeding". Lancet. 2 (7877): 394–7. PMID 4136718.