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Forrest Classification for Bleeding Peptic Ulcer: A New Look at the Old Endoscopic Classification
Hsu-Heng Yen1,2,3,4, Ping-Yu Wu3, Tung-Lung Wu1
1Department of Internal Medicine, Division of Gastroenterology, Changhua Christian Hospital, Changhua 500209, Taiwan.
Insights
This study quantitatively analyzed endoscopic images of peptic ulcer bleeding. It found good agreement in Forrest classification among endoscopists, identifying distinct patterns for high-risk and low-risk bleeding ulcers.
Area of Science:
- Gastroenterology
- Endoscopic imaging
- Medical diagnostics
Background:
- Peptic ulcer bleeding management is complex.
- The Forrest classification aids risk stratification but has variable interpretation.
- Quantitative analysis of endoscopic images for Forrest classification has not been performed.
Purpose of the Study:
- To quantitatively analyze endoscopic images of peptic ulcer bleeding.
- To assess the agreement of Forrest classification among endoscopists.
- To identify distinct visual patterns associated with different Forrest classification stages.
Main Methods:
- Retrieved and reviewed 276 endoscopic still images of peptic ulcer bleeding.
- Assessed intra-rater and inter-rater agreement for Forrest classification.
- Manually delineated ulcer and bleeding areas on images.
- Quantitatively compared image regions of interest across Forrest stages.
Main Results:
- High intra-rater (0.92-0.98) and inter-rater (0.639-0.859) agreement for Forrest classification.
- Higher correlation among tutor and junior endoscopists compared to experienced ones.
- Distinct visual patterns identified for low-risk (Forrest IIC, III) versus high-risk (Forrest I, IIA, IIB) lesions.
Conclusions:
- Good agreement exists in Forrest classification among endoscopists within an institution.
- This study provides the first quantitative analysis and explanation of distinct bleeding ulcer patterns from endoscopic images.
- Findings support the utility of Forrest classification with potential for improved standardization.
Abstract:
The management of peptic ulcer bleeding is clinically challenging. For decades, the Forrest classification has been used for risk stratification for nonvariceal ulcer bleeding. The perception and interpretation of the Forrest classification vary among different endoscopists. The relationship between the bleeder and ulcer images and the different stages of the Forrest classification has not been studied yet. Endoscopic still images of 276 patients with peptic ulcer bleeding for the past 3 years were retrieved and reviewed. The intra-rater agreement and inter-rater agreement were compared. The obtained endoscopic images were manually drawn to delineate the extent of the ulcer and bleeding area. The areas of the region of interest were compared between the different stages of the Forrest classification. A total of 276 images were first classified by two experienced tutor endoscopists. The images were reviewed by six other endoscopists. A good intra-rater correlation was observed (0.92-0.98). A good inter-rater correlation was observed among the different levels of experience (0.639-0.859). The correlation was higher among tutor and junior endoscopists than among experienced endoscopists. Low-risk Forrest IIC and III lesions show distinct patterns compared to high-risk Forrest I, IIA, or IIB lesions. We found good agreement of the Forrest classification among different endoscopists in a single institution. This is the first study to quantitively analyze the obtained and explain the distinct patterns of bleeding ulcers from endoscopy images.
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