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


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.


CONCLUSIONS
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.
Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands.
Nicolette L
NL
de Groot
Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands.
Martijn G H
MG
van Oijen
Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands.
Koen
K
Kessels
Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands.
Maarten
M
Hemmink
Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands.
Bas L A M
BL
Weusten
Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands.
Robin
R
Timmer
Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands.
Wouter L
WL
Hazen
Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands.
Niels
N
van Lelyveld
Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands.
Reinoud R
RR
Vermeijden
Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
Wouter L
WL
Curvers
Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
Bert C
BC
Baak
Department of Gastroenterology and Hepatology, Medical Center Haaglanden, Den Haag, The Netherlands.
Robert
R
Verburg
Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands.
Joukje H
JH
Bosman
Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands.
Laetitia R H
LR
de Wijkerslooth
Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands.
Janne
J
de Rooij
Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede, The Netherlands.
Niels G
NG
Venneman
Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands.
Marieke
M
Pennings
Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands.
Koen
K
van Hee
Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, Den Bosch, The Netherlands.
Bob C H
BC
Scheffer
Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands.
Rachel L
RL
van Eijk
Department of Gastroenterology and Hepatology, The Gelderse Vallei Hospital, Ede, The Netherlands.
Ruby
R
Meiland
Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands.
Peter D
PD
Siersema
Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands.
Albert J
AJ
Bredenoord
D000368:Aged; D000369:Aged, 80 and over; D019540:Area Under Curve; D004381:Duodenal Ulcer / Q000145:classification* / Q000150:complications; D005260:Female; D016558:Hemostasis, Endoscopic; D006801:Humans; D008297:Male; D008875:Middle Aged; D010438:Peptic Ulcer Hemorrhage / Q000145:classification* / Q000401:mortality / Q000628:therapy; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D012008:Recurrence; D018570:Risk Assessment; D013276:Stomach Ulcer / Q000145:classification* / Q000150:complications