A 58-year-old man with a history of chronic NSAID use for osteoarthritis presents with hematemesis and melena. Upper GI endoscopy reveals a gastric ulcer with a non-bleeding visible vessel in the ulcer base. The endoscopic appearance is classified as shown in the diagram, marked as **D** — Forrest IIa. Which of the following management approaches is most appropriate for this finding?

## Why Combination endoscopic therapy with epinephrine injection plus thermal coagulation or hemoclips is right Forrest IIa (non-bleeding visible vessel) carries a 50% re-bleeding risk without therapy and is a Class I indication for endoscopic intervention. The Forrest classification directly predicts re-bleeding risk and guides therapy. Combination therapy (epinephrine injection in 4 quadrants for vasoconstriction and tamponade, PLUS thermal modality such as bipolar/heat probe/argon plasma OR mechanical hemoclips) is superior to monotherapy alone. Epinephrine monotherapy is never used alone; it must be combined with thermal or mechanical therapy. This approach aligns with Harrison 21e Ch 324 and Bailey & Love 28e Ch 65 guidelines for peptic ulcer hemorrhage management. ## Why each distractor is wrong - **Observation alone with high-dose PPI and H. pylori testing; endoscopic therapy deferred unless re-bleeding occurs**: Forrest IIa is a HIGH-RISK lesion (50% re-bleed rate) and is a definite indication for endoscopic therapy. Deferring therapy in this setting is unsafe and contradicts evidence-based practice. Observation is only appropriate for Forrest IIc (flat pigmented spot, <10% re-bleed) or Forrest III (clean base, <5% re-bleed). - **Endoscopic therapy with epinephrine injection alone, followed by PPI and H. pylori eradication**: Epinephrine monotherapy is explicitly contraindicated in the Forrest classification management. Epinephrine must ALWAYS be combined with either thermal coagulation or mechanical hemoclips. Monotherapy leaves unacceptable re-bleeding risk and is not standard of care. - **Immediate surgical intervention with ulcer oversewing, as Forrest IIa lesions have >80% re-bleeding risk without intervention**: This overstates the re-bleeding risk (Forrest IIa is 50%, not >80%) and prematurely escalates to surgery. Surgery is reserved for endoscopic therapy failure or hemodynamic instability. First-line management is always endoscopic combination therapy, with surgery as a last resort. **High-Yield:** Forrest IIa = 50% re-bleed risk = ALWAYS treat with combination therapy (epinephrine + thermal/mechanical); epinephrine monotherapy is never acceptable. [cite: Harrison 21e Ch 324; Bailey & Love 28e Ch 65]