Forrest Classification of Upper GI Bleeding
Endoscopic classification system for upper GI bleeding lesions based on stigmata of recent haemorrhage. Guides re-bleeding risk and need for endoscopic therapy.
Score interpretation
Forrest Ia: active spurting haemorrhage. Rebleeding ~55% without endoscopic therapy (active bleeding, Laine 1994).
→ Immediate endoscopic haemostasis (clips, thermal, injection). High-dose IV PPI (adults: 80mg bolus + 8mg/h). ICU post-procedure. Second-look endoscopy in 24h. Surgical/IR standby. Children: use a children's formulary.
Forrest Ib: active oozing haemorrhage. Rebleeding ~55% without endoscopic therapy (active bleeding, Laine 1994).
→ Endoscopic therapy. IV PPI infusion. Close monitoring. Second-look scope at 24h if haemostasis achieved.
Forrest IIa: non-bleeding visible vessel. Rebleeding ~43% without endoscopic therapy.
→ Endoscopic therapy required. IV PPI (adults: 80mg bolus + 8mg/h infusion × 72h). Admit. Monitor closely. Children: use a children's formulary.
Forrest IIb: adherent clot. Rebleeding ~22% without endoscopic therapy.
→ Attempt clot removal and treat underlying lesion. IV PPI. Admit for observation.
Forrest IIc: flat pigmented (haematin) spot. Rebleeding ~10%.
→ No endoscopic therapy required. Oral PPI. Discharge in 24–48h if stable. Oral diet resumed.
Forrest III: clean ulcer base. Rebleeding ~5%.
→ No endoscopic therapy needed. Oral PPI. Early discharge if low risk on GBS/Rockall. Test for H. pylori. Review NSAIDs/anticoagulants.
Interpretation bands for the Forrest Classification. Apply clinical judgement and local guidance.
References
- Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet. 1974;2(7877):394–397.
- Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med. 1994;331(11):717–727.
- NICE CG141. Acute upper gastrointestinal bleeding in over 16s: management. 2012 (updated 2016).
Related
Curated clinical cross-links plus same-class fallbacks.
- Vasopressin / Terlipressin · Vasopressin Analogue — Vasodilatory Shock / Variceal Bleeding
- Tranexamic Acid (Heavy Menstrual Bleeding) · Antifibrinolytic (Gynaecological Use)
- Omeprazole (Paediatric — GORD/Peptic) · Proton Pump Inhibitor (PPI)
- Esomeprazole (Burns — Curling's Ulcer Prophylaxis) · Proton Pump Inhibitor — Stress Ulcer Prophylaxis
- Tranexamic Acid (Surgical / Trauma Haemorrhage) · Antifibrinolytic (Haemostatic)
- Upper GI Bleeding · BSG Guidelines 2019; NICE NG141
- Lower Gastrointestinal Bleed · NICE; BSG; ACPGBI — Commissioning Guide
- Acute Pancreatitis · NICE; IAP/APA; ACPGBI — CG104
- Difficult Airway Algorithm (DAS) · DAS 2015; Royal College of Anaesthetists
- Major Haemorrhage Protocol · NICE NG24; UK MHP guidelines
- New-Onset Atrial Fibrillation · ESC 2020 AF Guidelines; NICE NG196
Decision support only — verify against a current formulary, NICE, or your local guideline before clinical use.