The Forrest classifification describes four types of peptic ulcers, based on the endoscopic

characteristics of the associated upper gastrointestinal hemorrhage as follows:

(i) Forrest Ia: spurting arterial bleeding;

(ii) Forrest Ib: oozing arterial hemorrhage;
(iii) Forrest IIa: large nonbleeding visible vessels;
(iv) Forrest IIb: adherent clot;
(v) Forrest IIc: hematin on ulcer base;
(vi) Forrest III: lesions without signs of recent hemorrhage.

Forrest Classification
The Forrest Classification was first described in 1974 by J.A. Forrest et
al. in TheLancet1. This classification is a widely used classification of ulcer-related upper
gastrointestinal bleeding. It was initially developed to unify the description of ulcer
bleeding for better communication amongst endoscopists. However, the Forrest
Classification is now used as a tool to identify patients who are at an increased risk for
bleeding, rebleeding and mortality 2–4.

Figure 1. Forrest Ia gastric ulcer with an active spurter

Figure 2a. Forrest Ib ulcer with active oozing

Figure 2b. Forrest Ib ulcer with active oozing

Figure 3a. Forrest IIa ulcer with a visible vessel

Figure 2c (i). Forrest Ib ulcer at the gastrojejunal anastomosis, with visible vessel and active
oozing.
Figure 2c (ii). The same ulcer as above, but after an injection of adrenaline. This shows a visible
vessel at the anastomotic ulcer.

Figure 3a. Forrest IIa ulcer with a visible vessel

Figure 3b(i). Forrest IIb ulcer at incisura. With ulcers with an adherent clot, it is important that
the clot must be removed by vigorous and meticulous flushing in order to reveal underlying
visible vessels.

Figure 3b(ii). The same ulcer as above, but after the clot was removed. It revealed an
underlying visible vessel.
Figure 4a. Forrest IIb ulcer with an adherent clot

Figure 4b. Forrest IIb ulcer with an adherent clot

Figure 5. Forrest IIc ulcer with a pigmented spot

Figure 6a. Forrest III ulcer at antrum with clean base

Figure 6b. Forrest III ulcer at anterior wall of D1/2 with clean base

References:

1. Graziella Guariso and Marco Gasparetto. Update on Peptic Ulcers in the Pediatric
Age. Hindawi Journal.2012
2. Forrest, JA.; Finlayson, ND.; Shearman, DJ. (Aug 1974). ‘Endoscopy in gastrointestinal
bleeding’. Lancet. 2 (7877): 394–7.
3. Rockall, TA, Logan, RF, Devlin, HB et al. ‘Risk assessment after acute upper
gastrointestinal haemorrhage’. Gut 1996; 38: 316–21.
4. Guglielmi A, Ruzzenente, A, Sandri, M et al. ‘Risk assessment and prediction of
rebleeding in bleeding gastroduodenal ulcer’. Endoscopy 2002; 34: 778–86.
5. Shannon Melissa Chan. Prince of Wales Hospital, The Chinese University of Hong Kong,
https://www.endoscopy-campus.com/