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Reassessment of the predictive value of the Forrest classification for peptic ulcer rebleeding and mortality: can classification be simplified?
submitted: 18 February 2013
accepted after revision: 31 July 2013
11 November 2013 (online)
Background and study aims: This study aimed to reassess whether the Forrest classification is still useful for the prediction of rebleeding and mortality in peptic ulcer bleedings and, based on this, whether the classification could be simplified.
Patients and methods: Prospective registry data on peptic ulcer bleedings were collected and categorized according to the Forrest classification. The primary outcomes were 30-day rebleeding and all-cause mortality rates. Receiver operating characteristic curves were used to test whether simplification of the Forrest classification into high risk (Forrest Ia), increased risk (Forrest Ib – IIc), and low risk (Forrest III) classes could be an alternative to the original classification.
Results: In total, 397 patients were included, with 18 bleedings (4.5 %) being classified as Forrest Ia, 73 (18.4 %) as Forrest Ib, 86 (21.7 %) as Forrest IIa, 32 (8.1 %) as Forrest IIb, 59 (14.9 %) as Forrest IIc, and 129 (32.5 %) as Forrest III. Rebleeding occurred in 74 patients (18.6 %). Rebleeding rates were highest in Forrest Ia peptic ulcers (59 %). The odds ratios for rebleeding among Forrest Ib – IIc ulcers were similar. In subgroup analysis, predicting rebleeding using the Forrest classification was more reliable for gastric ulcers than for duodenal ulcers. The simplified Forrest classification had similar test characteristics to the original Forrest classification.
Conclusion: The Forrest classification still has predictive value for rebleeding of peptic ulcers, especially for gastric ulcers; however, it does not predict mortality. Based on these results, a simplified Forrest classification is proposed. However, further studies are needed to validate these findings.
- 1 Laine L, Yang H, Chang SC et al. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009. Am J Gastroenterol 2012; 107: 1190-1195
- 2 Button LA, Roberts SE, Evans PA et al. Hospitalized incidence and case fatality for upper gastrointestinal bleeding from 1999 to 2007: a record linkage study. Aliment Pharmacol Ther 2011; 33: 64-76
- 3 Enestvedt BK, Gralnek IM, Mattek N et al. An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium. Gastrointest Endosc 2008; 67: 422-429
- 4 Lanas A, Wu P, Medin J et al. Low doses of acetylsalicylic acid increase risk of gastrointestinal bleeding in a meta-analysis. Clin Gastroenterol Hepatol 2011; 9: 762-768
- 5 Lau JY, Sung J, Hill C et al. Systematic review of the epidemiology of complicated peptic ulcer disease: incidence, recurrence, risk factors and mortality. Digestion 2011; 84: 102-113
- 6 Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012; 107: 345-360
- 7 Chiu PW, Ng EK, Cheung FK et al. Predicting mortality in patients with bleeding peptic ulcers after therapeutic endoscopy. Clin Gastroenterol Hepatol 2009; 7: 311-316
- 8 Guglielmi A, Ruzzenente A, Sandri M et al. Risk assessment and prediction of rebleeding in bleeding gastroduodenal ulcer. Endoscopy 2002; 34: 778-786
- 9 Forrest JA, Finlayson ND, Shearman DJ. Endoscopy in gastrointestinal bleeding. Lancet 1974; 2: 394-397
- 10 Rockall TA, Logan RF, Devlin HB et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996; 38: 316-321
- 11 Hadzibulic E, Govedarica S. Significance of Forrest classification, Rockall’s and Blatchford’s risk scoring system in prediction of rebleeding in peptic ulcer disease. Acta Medica Medianae 2007; 46: 38-43
- 12 Laine L, Peterson WL. Bleeding peptic ulcer. N Engl J Med 1994; 331: 717-727
- 13 Sung JJ, Barkun A, Kuipers EJ et al. Intravenous esomeprazole for prevention of recurrent peptic ulcer bleeding: a randomized trial. Ann Intern Med 2009; 150: 455-464
- 14 Sung JJ, Mossner J, Barkun A et al. Intravenous esomeprazole for prevention of peptic ulcer re-bleeding: rationale/design of Peptic Ulcer Bleed study. Aliment Pharmacol Ther 2008; 27: 666-677
- 15 Bour B, Person B, Cales P et al. Interobserver agreement on endoscopic diagnosis of bleeding peptic ulcers. Gastrointest Endosc 1997; 46: 27-32
- 16 Mondardini A, Barletti C, Rocca G et al. Non-variceal upper gastrointestinal bleeding and Forrest’s classification: diagnostic agreement between endoscopists from the same area. Endoscopy 1998; 30: 508-512
- 17 Chang-Chien CS, Wu CS, Chen PC et al. Different implications of stigmata of recent hemorrhage in gastric and duodenal ulcers. Dig Dis Sci 1988; 33: 400-404
- 18 Barkun AN, Bardou M, Kuipers EJ et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010; 152: 101-113
- 19 Khuroo MS, Yattoo GN, Javid G et al. A comparison of omeprazole and placebo for bleeding peptic ulcer. N Engl J Med 1997; 10; 336: 1054-1058
- 20 Katschinski B, Logan R, Davies J et al. Prognostic factors in upper gastrointestinal bleeding. Dig Dis Sci 1994; 39: 706-712
- 21 Cappell MS. Therapeutic endoscopy for acute upper gastrointestinal bleeding. Nat Rev Gastroenterol Hepatol 2010; 7: 214-229
- 22 Bratanic A, Puljiz Z, Ljubicic N et al. Predictive factors of rebleeding and mortality following endoscopic hemostasis in bleeding peptic ulcers. Hepatogastroenterology 2013; 60: 112-117