Forest Classification Flashcards
Forrest classification
*Forrest I – for Active bleeding:
Ia: Arterial spurting
Ib: Oozing bleeding
*Forrest II – for signs of recent Hge :
IIa: Visible Blood vessel but not bleeding
IIb: adherent clot
IIc: flat pigmented spot in the ulcer
*Forrest III – no signs of bleeding
Clean base of the ulcer
Management
*Classes Ia–IIa: Require endoscopic hemostasis and PPI therapy.
*Class IIb: May attempt to remove clot and treat underlying lesion.
*Classes IIc & III: Managed medically with PPIs and observation.
. A 65 year‐old man went to the hospital, complaining of melena. He is a
heavy smoker with controlled DM (on insulin, for 4 years) and coronary artery
disease for which he is taking daily Clopidogril 75 mg, for 3 years. He has no
history of chronic liver disease, kidney disease or any other comorbidity. His
Hb was 8 gm/dl, WBCs = 9000/mm3 & platelets = 200 000/mm3. Upper
endoscopy was performed and revealed an ulcer in the antrum classified as
Forrest IIc.
A) Does this patient need red cell transfusion? (Explain your answer)
Yes,
*In stable patients without active bleeding, transfusion is generally considered if Hb <7 g/dL.
In symptomatic patients (signs of anemia like chest pain, dyspnea, hypotension, tachycardia) or patients with cardiovascular disease (especially coronary artery disease like this patient), transfusion may be indicated at a higher threshold, around 8–9 g/dL.
So, this patient would need to receive packed RBCS
Does this antral ulcer need endoscopic intervention? (Clarify)
No , according to forest classification
for a Forrest IIc ulcer, no endoscopic treatment is needed. The main treatment would be intensive proton pump inhibitor (PPI) therapy and medical management.
*Forrest IIc = flat pigmented spot (a healed or healing lesion).
These ulcers have a low risk of rebleeding (<5%).
When to discharge this patient from hospital?
He can be discharged when:
*Hemodynamic status is stable (no hypotension, tachycardia).
*Hemoglobin levels are stable without ongoing transfusion needs.
*No evidence of ongoing bleeding (no fresh melena, stable stools).
*He has received adequate PPI therapy and oral medications are well tolerated.
*Comorbid conditions (especially cardiac status) are well controlled.
*Typically, patients with low-risk ulcers (Forrest IIc) can be discharged early (within 72 hours) if stable.
