Forrest Classification of Upper GI Bleeding

Why 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.

When to Use

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

Formula

Pearls / Pitfalls

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).

Management

From the American College of Gastroenterology Guidelines on Management of Patients with Ulcer Bleeding .

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.

More Information

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 .