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CLASSIFICATION
Classification
Forrest classification (peptic ulcer bleeding)
Endoscopic stigmata of peptic ulcer bleeding (Ia–III). Shared language for rebleeding risk and whether endoscopic therapy is needed.
Classification overview
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Active hemorrhage
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Ia · Spurting hemorrhage
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Ib · Oozing hemorrhage
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Signs of recent hemorrhage
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IIa · Non-bleeding visible vessel
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IIb · Adherent clot
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IIc · Flat pigmented spot
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No stigmata
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III · Clean ulcer base
Active hemorrhage
Ia
Spurting hemorrhage
Finding
Active spurting arterial hemorrhage
Risk
High risk of persistent bleeding or rebleeding if untreated
Note: Indication for endoscopic hemostasis.
Ib
Oozing hemorrhage
Finding
Active oozing hemorrhage
Risk
High risk of persistent bleeding or rebleeding if untreated
Note: Indication for endoscopic hemostasis.
Signs of recent hemorrhage
IIa
Non-bleeding visible vessel
Finding
Non-bleeding visible vessel
Risk
High risk of rebleeding if untreated
Note: Indication for endoscopic hemostasis.
IIb
Adherent clot
Finding
Adherent clot on the ulcer base
Risk
Intermediate risk; clot removal is used to expose the underlying stigma
IIc
Flat pigmented spot
Finding
Flat pigmented haematin (coffee-ground) spot on the ulcer base
Risk
Low risk of rebleeding
Note: IIc / III are usually observed without endoscopic therapy for the stigma itself.
No stigmata
III
Clean ulcer base
Finding
Clean, fibrin-covered ulcer base without stigmata of recent hemorrhage
Risk
Lowest risk of rebleeding; endoscopic therapy is not indicated for the stigma itself
Zhou 2025, Fig. 1, Not original, CC BY-NC-ND
Reference
Original article
Forrest JA, Finlayson ND, Shearman DJ. Lancet 1974;2:394-397
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Decision support only. Follow current guidelines and local protocols. Classification definitions and terminology follow the original publication language.