A Conceptual Bi-Dimensional Risk Assessment Framework in Bleeding Peptic Ulcers

Peptic ulcer disease remains one of the leading causes of non-variceal upper gastrointestinal bleeding. Despite advances in endoscopic therapy and pharmacological management, recurrent bleeding continues to represent a major cause of morbidity and mortality. Risk stratification is traditionally based on endoscopic stigmata according to the Forrest classification; however, ulcers with similar endoscopic findings may exhibit markedly different clinical outcomes. Increasing evidence suggests that ulcer-related anatomical factors, including size, location, and depth of penetration, may influence the risk of severe or recurrent hemorrhage, particularly in cases involving adjacent arterial structures. In this conceptual, hypothesis-generating review, we propose a conceptual bi-dimensional framework integrating endoscopic and anatomical determinants of bleeding risk. This approach aims to improve patient stratification by identifying a subgroup at "very-high-risk" of recurrent bleeding, in whom standard endoscopic therapy alone may be insufficient. Although this framework is hypothesis-generating and not yet validated, it may provide a conceptual basis for future studies aimed at improving individualized management strategies, including early imaging assessment and consideration of transarterial embolization in selected high-risk patients.