Scoring Systems for Assessing Gastrointestinal Bleeding Severity
The primary scoring systems used to assess gastrointestinal bleeding severity are the Rockall score for upper GI bleeding and the Oakland score for lower GI bleeding, with shock index serving as an initial rapid assessment tool for both types of bleeding. 1, 2
Initial Rapid Assessment
Shock Index
- Calculate shock index by dividing heart rate by systolic blood pressure
- Shock index >1 indicates hemodynamic instability requiring immediate intervention
- Used for both upper and lower GI bleeding as an initial triage tool 1, 2
Upper Gastrointestinal Bleeding Severity Assessment
Rockall Score
The Rockall scoring system is the most established tool for upper GI bleeding risk stratification:
| Variable | 0 | 1 | 2 | 3 |
|---|---|---|---|---|
| Age (years) | <60 | 60-79 | >80 | |
| Shock | No shock (SBP >100, HR <100) | Tachycardia (SBP >100, HR >100) | Hypotension (SBP <100) | |
| Comorbidity | None | Cardiac failure, IHD, major comorbidity | Renal/liver failure, metastatic cancer | |
| Diagnosis | Mallory-Weiss tear, no lesion | All other diagnoses | Upper GI malignancy | |
| Major SRH | None or dark spot | Blood, adherent clot, visible or spurting vessel |
Interpretation:
- Score <3: Excellent prognosis (low risk)
- Score >8: High risk of death (>40% mortality)
- Complete Rockall score requires endoscopic findings 1
Glasgow-Blatchford Score (GBS)
Used for early risk stratification before endoscopy:
- Includes clinical and laboratory parameters (blood urea, hemoglobin, systolic BP, pulse, melena, syncope, liver/cardiac disease)
- GBS = 0-1 identifies very low-risk patients who may be suitable for outpatient management 3, 4
Lower Gastrointestinal Bleeding Severity Assessment
Oakland Score
The most validated tool for lower GI bleeding severity assessment:
| Predictor | Score |
|---|---|
| Age | |
| <40 | 0 |
| 40-69 | 1 |
| ≥70 | 2 |
| Gender | |
| Female | 0 |
| Male | 1 |
| Previous LGIB admission | |
| No | 0 |
| Yes | 1 |
| DRE findings | |
| No blood | 0 |
| Blood | 1 |
| Heart rate | |
| <70 | 0 |
| 70-89 | 1 |
| 90-109 | 2 |
| ≥110 | 3 |
| Systolic blood pressure | |
| <90 | 5 |
| 90-119 | 4 |
| 120-129 | 3 |
| 130-159 | 2 |
| ≥160 | 0 |
| Hemoglobin (g/L) | |
| <70 | 22 |
| 70-89 | 17 |
| 90-109 | 13 |
| 110-129 | 8 |
| 130-159 | 4 |
| ≥160 | 0 |
Interpretation:
- Score ≤8: Minor bleed, suitable for outpatient management
- Score >8: Major bleed, requires hospital admission 1, 2
BLEED Classification System
Used for lower GI bleeding risk stratification:
- B: Ongoing Bleeding
- L: Low systolic blood pressure
- E: Elevated prothrombin time
- E: Erratic mental status
- D: Unstable comorbid disease
Helps identify patients at high risk of adverse in-hospital outcomes (recurrent hemorrhage, need for surgery, death) 1
Clinical Application Algorithm
Initial Assessment:
- Calculate shock index (HR/SBP) immediately
- If shock index >1: Activate urgent resuscitation protocol
- If shock index <1: Proceed with risk scoring
For Suspected Upper GI Bleeding:
- Calculate Glasgow-Blatchford Score initially
- After endoscopy, calculate complete Rockall score
- GBS = 0-1 or Rockall <3: Consider outpatient management
- Higher scores: Admit and manage according to risk level
For Suspected Lower GI Bleeding:
- Calculate Oakland score
- Score ≤8: Consider outpatient management if no other indications for admission
- Score >8: Admit for inpatient management
- Apply BLEED classification for additional risk stratification
Important Considerations
- No scoring system is perfect; clinical judgment remains essential
- Scoring systems should guide but not replace clinical decision-making
- Comorbidities significantly impact mortality risk in GI bleeding patients
- Endoscopic findings (particularly for upper GI bleeding) are crucial for complete risk assessment
- Recurrent bleeding risk is an important outcome to consider in addition to mortality
Pitfalls to Avoid
- Relying solely on a scoring system without clinical context
- Failing to reassess patients as their clinical status changes
- Not considering comorbidities, which often drive mortality more than the bleeding itself
- Using incomplete scoring (e.g., pre-endoscopy Rockall without later completing the full score)
- Applying upper GI bleeding scores to lower GI bleeding patients or vice versa
By systematically applying these scoring systems, clinicians can more accurately stratify patients with GI bleeding, appropriately allocate resources, and improve patient outcomes by ensuring the right level of care for each patient's risk profile.