Forrest classification

Medical classification system for peptic ulcer bleeding

The Forrest classification is a system used to categorize the severity of bleeding in patients with peptic ulcer disease. It is primarily used in endoscopy to assess the risk of rebleeding and to guide treatment decisions. The classification was first introduced by J.A. Forrest and colleagues in 1974 and has since become a standard tool in the management of upper gastrointestinal bleeding.

Classification

The Forrest classification divides peptic ulcers into three major categories based on the appearance of the ulcer during endoscopy:

Forrest I: Active Bleeding

• Forrest Ia: Spurting hemorrhage - This indicates active arterial bleeding, which is a high-risk situation requiring immediate intervention.
• Forrest Ib: Oozing hemorrhage - This involves slower, venous bleeding and also requires prompt treatment.

Forrest II: Recent Hemorrhage

• Forrest IIa: Visible vessel - A non-bleeding visible vessel is present, indicating a high risk of rebleeding.
• Forrest IIb: Adherent clot - A clot is attached to the ulcer base, suggesting recent bleeding.
• Forrest IIc: Flat pigmented spot - This indicates a lower risk of rebleeding compared to IIa and IIb.

Forrest III: Lesions without Active Bleeding

• Forrest III: Clean base - The ulcer base is clean, indicating no active bleeding and a low risk of rebleeding.

Endoscopic image of a duodenal ulcer

Clinical Significance

The Forrest classification is crucial in determining the management strategy for patients with bleeding peptic ulcers. It helps in assessing the risk of rebleeding and the need for therapeutic interventions such as endoscopic hemostasis, angiographic embolization, or surgery.

• High-risk lesions (Forrest Ia, Ib, IIa) often require endoscopic treatment, such as thermal coagulation, injection therapy, or hemoclipping.
• Intermediate-risk lesions (Forrest IIb) may benefit from endoscopic therapy, especially if the clot can be removed to reveal a high-risk lesion underneath.
• Low-risk lesions (Forrest IIc, III) generally do not require endoscopic treatment and can be managed conservatively with proton pump inhibitors and monitoring.

Prognosis

The risk of rebleeding and mortality is closely linked to the Forrest classification. Patients with Forrest I and IIa lesions have a higher risk of rebleeding and may require more aggressive treatment and monitoring. Forrest III lesions have the best prognosis with the lowest risk of rebleeding.

Related pages

• Peptic ulcer disease
• Gastrointestinal bleeding
• Endoscopy
• Proton pump inhibitor