Q: 52 year old male admitted to ICU with upper gastrointestinal (UGI) bleed. Patient stabilized with resuscitation, pRBC transfusions, and IV proton pump inhibitor drip. UGI scope performed and revealed adherent clot. What are the chances of rebleed during hospitalization?

A) 80%
B) 50%
C) 25%
D) none as clot is already formed
E) there is no way to predict it


Answer: C

Forrest classification is developed to predict  risk of recurrent bleeding depending on endoscopic findings, and also known as stigmata of recent hemorrhage,

• Class Ia – Spurting hemorrhage  - 90% chances of rebleed
• Class Ib – Oozing hemorrhage  - 10-20% chances of rebleed 
• Class IIa – Visible vessel - 50% chances of rebleed
• Class IIb – Adherent clot  - 25-30% chances of rebleed
• Class IIc – Flat pigmented spot - 7-10% chances of rebleed
• Class III – Clean ulcer base - 3-5% chances of rebleed

References:

1. Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet 1974; 2:394.

2. Heldwein W; Schreiner J; Pedrazzoli J; Lehnert P (Nov 21, 1989). "Is the Forrest classification a useful tool for planning endoscopic therapy of bleeding peptic ulcers?". Endoscopy 21 (6): 258–62.