This composite educational clinical image demonstrates the Forrest classification for peptic ulcer bleeding (PUB) via six gastroscopic panels. Top row (Active Bleeding): Forrest Ia shows 'spurting hemorrhage' with an arterial jet; Forrest Ib shows 'oozing hemorrhage' without a visible vessel. Middle and bottom rows (Recent Hemorrhage Signs): Forrest IIa depicts a 'non-bleeding visible vessel' as a protuberant lesion; Forrest IIb shows an 'adherent clot' covering the ulcer base; Forrest IIc presents 'flat pigmented spots' (hematin) indicating recent stasis; and Forrest III displays a 'clean-based ulcer' with a white fibrin base and no stigmata of hemorrhage. This classification system is essential for gastroenterologists to assess rebleeding risk and determine the necessity of endoscopic hemostasis therapy during emergency esophagogastroduodenoscopy (EGD).

A composite of six endoscopic images illustrating the Forrest classification for upper gastrointestinal bleeding risk assessment in peptic ulcer disease. (a) Forrest Ia: demonstrates active, high-pressure spurting bleeding from an arterial source. (b) Forrest Ib: shows active oozing bleeding without pulsatility. (c) Forrest IIa: displays a non-bleeding visible vessel appearing as a raised, red protuberance within the ulcer bed. (d) Forrest IIb: shows an adherent clot, a dark, thick mass of coagulated blood firmly attached to the ulcer. (e) Forrest IIc: depicts a flat, pigmented spot (haematin) indicating recent hemorrhage. (f) Forrest III: shows a clean-based ulcer with a white or yellow fibrin base and no signs of recent bleeding. This series is a critical educational tool for gastroenterology to differentiate between high-risk (Ia-IIb) and low-risk (IIc-III) lesions, guiding endoscopic intervention and pharmacological management.

Comparison of two upper gastrointestinal endoscopy (UGIE) frames of the gastric antrum, labeled Figure 1a and Figure 1b, documenting the progression of a gastric ulcer. Figure 1a shows the initial presentation of a gastric ulcer located along the lesser curvature, characterized by the presence of an adherent clot, consistent with a Forrest class IIb bleeding classification. The surrounding mucosa displays patchy erythema. Figure 1b, captured two days post-intervention, shows the same ulcer at the incisura now featuring a clean base without an adherent clot, corresponding to Forrest class III. The surrounding gastric tissue exhibits signs of induration and persistent erythema. These images illustrate the diagnostic and monitoring utility of endoscopy in assessing upper gastrointestinal bleeding and the evolution of peptic ulcer disease in the context of H. pylori-positive gastritis.

Summary : This flowchart outlines the recommended clinical management pathway for patients presenting with upper gastrointestinal bleeding, based on initial risk stratification using the Glasgow-Blatchford Score, pre-endoscopic management, and endoscopic findings. flowchart: # Nodes : • Initial risk stratification and triage (rectangle) – Very-Low Clinical Risk (rectangle) • Risk score indicates 0–1% false negatives for transfusion, hemostatic intervention, or death • Glasgow-Blatchford Score 0–1 – Not Very-Low Clinical Risk (rectangle) • Risk score indicates >1% false negatives for transfusion, hemostatic intervention, or death • Glasgow-Blatchford Score ≥2 – Discharge from emergency department with outpatient management if no other reason for hospitalization (rectangle) – Admit to hospital or observation unit (rectangle) • Pre-endoscopic management (rectangle) – Resuscitation, attention to active comorbidities – RBC transfusion if hemoglobin <7 g/dL – Suggest erythromycin 250mg infusion 30–90 minutes before upper endoscopy – No recommendation for or against proton pump inhibitors • Upper endoscopy within 24 hours of presentation (rectangle) • Endoscopy (rectangle) – Low-risk endoscopic findings (rectangle) • e.g., clean-based ulcer, nonbleeding Mallory-Weiss tear, erosions • Discharge patient if stable vital signs and hemoglobin, and no other reason for hospitalization – Non-low-risk endoscopic findings (rectangle) • e.g., ulcer with stigmata of hemorrhage, varices, neoplasm, Dieulafoy lesion • Patient remains in hospital # Connectors : • From "Initial risk stratification and triage" split into two branches: – Very-Low Clinical Risk → Discharge from emergency department – Not Very-Low Clinical Risk → Admit to hospital or observation unit • Both branches converge to "Pre-endoscopic management" • "Pre-endoscopic management" leads to "Upper endoscopy within 24 hours of presentation" • "Endoscopy" splits into: – Low-risk endoscopic findings → Discharge patient if stable – Non-low-risk endoscopic findings → Patient remains in hospital # Layout : • Vertical flow from top (Initial risk stratification) to bottom (Endoscopy outcomes) • Two main branches at the top (Very-Low vs Not Very-Low Clinical Risk) merge before pre-endoscopic management • Endoscopy results split into two outcome branches (discharge vs remain in hospital) # Analysis : • The flowchart provides a clear, stepwise approach for triaging and managing upper GI bleeding based on risk assessment and endoscopic findings. • Patients with very-low clinical risk (Glasgow-Blatchford Score 0–1) are discharged early, while higher-risk patients are admitted. • Pre-endoscopic management is standardized for all admitted patients, focusing on resuscitation and transfusion thresholds. • Endoscopic findings further stratify patients into those suitable for discharge versus those requiring continued hospitalization. • The process emphasizes early risk stratification and timely endoscopy (within 24 hours) to optimize patient outcomes.

<table> <tr> <td colspan="2"><b>Table 1. </b>List of guideline statements with strength of recommendation and quality of evidence</td> </tr> <tr> <td colspan="2"><b>Risk stratification</b></td> </tr> <tr> <td>1.</td> <td>We suggest that patients presenting to the emergency department with upper gastrointestinal bleeding (UGIB) who are classified as very low risk, defined as a risk assessment score with ≤1% false negative rate for the outcome of hospital-based intervention or death (e.g., Glasgow-Blatchford score = 0–1), be discharged with outpatient follow-up rather than admitted to hospital (conditional recommendation, very-low-quality evidence).</td> </tr> <tr> <td colspan="2"><b>Red blood cell transfusion</b></td> </tr> <tr> <td>2.</td> <td>We suggest a restrictive policy of red blood cell transfusion with a threshold for transfusion at a hemoglobin of 7 g/dL for patients with UGIB (conditional recommendation, low-quality evidence).</td> </tr> <tr> <td colspan="2"><b>Pre-endoscopic medical therapy</b></td> </tr> <tr> <td colspan="2"><i>Prokinetic therapy with erythromycin</i></td> </tr> <tr> <td>3.</td> <td>We suggest an infusion of erythromycin before endoscopy in patients with UGIB (conditional recommendation, very-low-quality evidence).</td> </tr> <tr> <td colspan="2"><i>Proton pump inhibitor (PPI) therapy</i></td> </tr> <tr> <td>4.</td> <td>We could not reach a recommendation for or against pre-endoscopic PPI therapy for patients with UGIB.</td> </tr> <tr> <td colspan="2"><b>Endoscopy for UGIB</b></td> </tr> <tr> <td colspan="2"><i>Timing of endoscopy</i></td> </tr> <tr> <td>5.</td> <td>We suggest that patients admitted to or under observation in hospital for UGIB undergo endoscopy within 24 hr of presentation (conditional recommendation, very-low-quality evidence).</td> </tr> <tr> <td colspan="2"><i>Need for endoscopic hemostatic therapy for ulcers with active bleeding or nonbleeding visible vessels</i></td> </tr> <tr> <td>6.</td> <td>We recommend endoscopic therapy in patients with UGIB due to ulcers with active spurting, active oozing, and nonbleeding visible vessels (strong recommendation, moderate-quality evidence).</td> </tr> <tr> <td colspan="2"><i>Need for endoscopic hemostatic therapy for ulcers with adherent clot</i></td> </tr> <tr> <td>7.</td> <td>We could not reach a recommendation for or against endoscopic therapy in patients with UGIB due to ulcers with adherent clot resistant to vigorous irrigation.</td> </tr> <tr> <td colspan="2"><i>Choice of endoscopic hemostatic therapy for bleeding ulcers</i></td> </tr> <tr> <td>8.</td> <td>We recommend endoscopic hemostatic therapy with bipolar electrocoagulation, heater probe, or injection of absolute ethanol for patients with UGIB due to ulcers (strong recommendation, moderate-quality evidence).</td> </tr> <tr> <td>9.</td> <td>We suggest endoscopic hemostatic therapy with clips, argon plasma coagulation, or soft monopolar electrocoagulation for patients with UGIB due to ulcers (conditional recommendation, very-low- to low-quality evidence).</td> </tr> <tr> <td>10.</td> <td>We recommend that epinephrine injection not be used alone for patients with UGIB due to ulcers but rather in combination with another hemostatic modality (strong recommendation, very-low- to moderate-quality evidence).</td> </tr> <tr> <td>11.</td> <td>We suggest endoscopic hemostatic therapy with hemostatic powder spray TC-325 for patients with actively bleeding ulcers (conditional recommendation, very-low-quality evidence).</td> </tr> <tr> <td>12.</td> <td>We suggest over-the-scope clips as a hemostatic therapy for patients who develop recurrent bleeding due to ulcers after previous successful endoscopic hemostasis (conditional recommendation, low-quality evidence).</td> </tr> <tr> <td colspan="2"><i>Antisecretory therapy after endoscopic hemostatic therapy for bleeding ulcers</i></td> </tr> <tr> <td>13.</td> <td>We recommend high-dose PPI therapy given continuously or intermittently for 3 d after successful endoscopic hemostatic therapy of a bleeding ulcer (strong recommendation, moderate- to high-quality evidence).</td> </tr> <tr> <td>14.</td> <td>We suggest that high-risk patients with UGIB due to ulcers who received endoscopic hemostatic therapy followed by short-term high-dose PPI therapy in hospital continue on twice-daily PPI therapy until 2 wk after index endoscopy (conditional recommendation, low-quality evidence).</td> </tr> <tr> <td colspan="2"><i>Recurrent ulcer bleeding after successful endoscopic hemostatic therapy</i></td> </tr> <tr> <td>15.</td> <td>We suggest that patients with recurrent bleeding after endoscopic therapy for a bleeding ulcer undergo repeat endoscopy and endoscopic therapy rather than undergo surgery or transcatheter arterial embolization (conditional recommendation, low-quality evidence for comparison with surgery, very-low-quality evidence for comparison with transcatheter arterial embolization)</td> </tr> <tr> <td colspan="2"><i>Failure of endoscopic hemostatic therapy for bleeding ulcers</i></td> </tr> <tr> <td>16.</td> <td>We suggest patients with bleeding ulcers who have failed endoscopic therapy next be treated with transcatheter arterial embolization (conditional recommendation, very-low-quality evidence).</td> </tr> </table>