Endoscopic appearance of a bleeding peptic ulcer — rebleed risk and need for haemostasis
Endoscopic finding at the ulcer
Ia — active spurting haemorrhage
Ib — active oozing haemorrhage
IIa — non-bleeding visible vessel
IIc — flat pigmented spot
Evidence
Original publication
Forrest JAH, Finlayson NDC, Shearman DJC. Endoscopy in gastrointestinal bleeding. Described the endoscopic stigmata of recent haemorrhage in peptic ulcers (active bleeding, visible vessel, adherent clot, pigmented spot, clean base) and their relation to the risk of continued or recurrent bleeding.
Lancet, 1974
Guideline
International consensus and ACG/ESGE guidance: Forrest Ia–IIa lesions warrant endoscopic haemostasis (injection plus a second modality, or clips / thermal therapy) and high-dose proton-pump inhibitor therapy; IIb clots should be irrigated and, if they persist, considered for removal and treatment of the underlying lesion; IIc and III lesions are low risk and do not require endoscopic therapy. Combine with a validated risk score (Glasgow-Blatchford, Rockall, AIMS65).
Last reviewed: 2026-09
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