At what Oakland score (Lower Gastrointestinal Bleeding score) does a patient require hospitalization?

Oakland Score Threshold for Hospitalization in Lower GI Bleeding

Patients with an Oakland score >8 points should be hospitalized for management of lower gastrointestinal bleeding, while those with a score ≤8 points can be safely discharged for outpatient investigation. 1

Oakland Score Components and Risk Stratification

The Oakland score is a validated risk assessment tool that helps determine the need for hospitalization in patients with lower gastrointestinal bleeding (LGIB). It includes the following components:

• Age:

  • <40 years: 0 points
  • 40-69 years: 1 point
  • ≥70 years: 2 points 1

• Gender:

  • Female: 0 points
  • Male: 1 point 1

• Previous LGIB admission:

  • No: 0 points
  • Yes: 1 point 1

• Digital Rectal Examination findings:

  • No blood: 0 points
  • Blood: 1 point 1

• Heart rate:

  • <70 bpm: 0 points
  • 70-89 bpm: 1 point
  • 90-109 bpm: 2 points
  • ≥110 bpm: 3 points 1

• Systolic blood pressure:

  • <90 mmHg: 5 points
  • 90-119 mmHg: 4 points
  • 120-129 mmHg: 3 points
  • 130-159 mmHg: 2 points
  • ≥160 mmHg: 0 points 1

• Hemoglobin (g/L):

  • <70: 22 points
  • 70-89: 17 points
  • 90-109: 13 points
  • 110-129: 8 points
  • 130-159: 4 points
  • ≥160: 0 points 1

Management Algorithm Based on Oakland Score

1. Initial assessment:

   • Evaluate hemodynamic stability using shock index (heart rate/systolic BP)
   • Shock index >1 indicates instability requiring immediate resuscitation 1, 2

2. For hemodynamically stable patients:

   • Calculate the Oakland score 1

3. Decision based on Oakland score:

   • Score ≤8 points: Safe for discharge with outpatient investigation

     • Characterized by absence of rebleeding, need for transfusion, therapeutic intervention, in-hospital death, and readmission within 28 days 1
     • Should have urgent outpatient colonoscopy (within 2 weeks if high-risk features present) 1

   • Score >8 points: Requires hospital admission

     • Classified as a major bleed
     • Should undergo inpatient colonoscopy on the next available list 1

Evidence Supporting the Oakland Score Threshold

• The Oakland score has been both internally and externally validated with high predictive accuracy (AUROC 0.85-0.87) 3, 4

• At the threshold of ≤8 points:

  • Sensitivity for safe discharge: 97-98.4%
  • Specificity: 16% 3, 4
  • Negative predictive value: >97% (indicating very low risk of adverse outcomes) 4

• Recent external validation studies confirm the reliability of the Oakland score in identifying patients who can be safely discharged, with consistent performance across different healthcare settings 4, 5

Potential Pitfalls and Caveats

• The Oakland score was developed in the UK and may perform differently in other populations 1

• The score may underestimate the number of patients who can be safely discharged due to liberal use of blood transfusions in the derivation population 1

• Some studies suggest extending the threshold to ≤10 points could identify more low-risk patients (17.8% vs. 8.7% of patients) while maintaining reasonable sensitivity (96% vs. 98.4%) 4

• Always consider other indications for hospital admission beyond the LGIB itself, as the Oakland score only predicts LGIB-related adverse outcomes 1, 2

• Initial assessment should always include digital rectal examination to assess for anorectal causes, which account for approximately 16.7% of LGIB diagnoses 1