Endoscopy 2014; 46(01): 46-52
DOI: 10.1055/s-0033-1344884
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Reassessment of the predictive value of the Forrest classification for peptic ulcer rebleeding and mortality: can classification be simplified?

Nicolette L. de Groot
1  Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
,
Martijn G. H. van Oijen
1  Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
3  Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
,
Koen Kessels
4  Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
,
Maarten Hemmink
4  Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
,
Bas L. A. M. Weusten
4  Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
5  Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands
,
Robin Timmer
4  Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
,
Wouter L. Hazen
6  Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
,
Niels van Lelyveld
6  Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
,
Reinoud R. Vermeijden
6  Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands
,
Wouter L. Curvers
7  Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
,
Bert C. Baak
7  Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
,
Robert Verburg
8  Department of Gastroenterology and Hepatology, Medical Center Haaglanden, Den Haag, The Netherlands
,
Joukje H. Bosman
1  Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
,
Laetitia R. H de Wijkerslooth
1  Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
,
Janne de Rooij
9  Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
,
Niels G. Venneman
9  Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands
,
Marieke Pennings
10  Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
,
Koen van Hee
10  Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
,
Bob C. H. Scheffer
10  Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
,
Rachel L. van Eijk
11  Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands
,
Ruby Meiland
11  Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands
,
Peter D. Siersema
1  Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
,
Albert J. Bredenoord
1  Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
4  Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
5  Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, The Netherlands
› Author Affiliations
Further Information

Publication History

submitted: 18 February 2013

accepted after revision: 31 July 2013

Publication Date:
11 November 2013 (eFirst)

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.