What are the recommended discharge criteria for a patient with lower gastrointestinal (GI) bleeding?

Recommended Discharge Criteria for Lower GI Bleeding

Patients with lower GI bleeding can be safely discharged from the emergency department if they have an Oakland score ≤8 points, with no other indications requiring hospital admission, and should be scheduled for urgent outpatient colonoscopy within 2 weeks. 1

Risk Stratification Using the Oakland Score

The Oakland score is the validated tool for determining discharge eligibility and incorporates seven clinical variables 1:

• 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 present (1 point) 1
• Heart rate: <70 (0 points), 70-89 (1 point), 90-109 (2 points), ≥110 (3 points) 1
• Systolic blood pressure: <90 (5 points), 90-119 (4 points), 120-129 (3 points), 130-159 (2 points), ≥160 (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

Patients scoring ≤8 points are suitable for immediate discharge from the emergency department with outpatient investigation. 1, 2

Definition of Safe Discharge

Safe discharge is characterized by the absence of all of the following adverse outcomes 1:

• No rebleeding episodes 1
• No red blood cell transfusion requirement 1
• No therapeutic intervention to control bleeding (endoscopic, radiological, or surgical hemostasis) 1
• No in-hospital death (all-cause mortality) 1
• No readmission with further LGIB within 28 days 1

Absolute Contraindications to Discharge

Do not discharge patients with any of the following, regardless of Oakland score 1, 3:

• Hemodynamic instability (shock index >1, calculated as heart rate divided by systolic blood pressure) 1, 3
• Oakland score >8 points (classified as major bleed requiring hospital admission) 1
• Other medical indications for hospital admission (significant comorbidities, inability to tolerate oral intake, lack of social support) 1, 2
• Ongoing bleeding despite initial resuscitation 2

Outpatient Follow-Up Requirements

Discharged patients must have colonoscopy arranged, with timing based on cancer risk 1:

• Within 2 weeks for patients aged >50 years with unexplained rectal bleeding (6% have underlying bowel cancer) 1
• Timing otherwise depends on clinical urgency and patient preference 1

Research data shows that discharged patients have only a 46% outpatient follow-up rate, highlighting the critical importance of ensuring scheduled appointments before discharge 4.

Important Caveats and Pitfalls

The Oakland score may underestimate the number of patients who can be safely discharged because it was derived from a population with liberal red blood cell transfusion practices 1. This means some patients scoring 9-10 points might still be safe for discharge in centers using restrictive transfusion strategies, though the guideline does not formally support this 1.

Always perform digital rectal examination as part of the initial assessment, as findings directly impact the Oakland score and help exclude anorectal pathology 1, 2.

Consider upper GI bleeding in patients with hemodynamic instability, even when presenting with hematochezia, as this may indicate a briskly bleeding upper GI source 3, 5.

Mortality Context

Mortality in lower GI bleeding is generally related to underlying comorbidity rather than exsanguination, with overall in-hospital mortality of 3.4%, rising to 18% for inpatient-onset LGIB and 20% for patients requiring ≥4 units of red blood cells 3. This underscores that the Oakland score's primary value is identifying low-risk patients who can avoid unnecessary hospitalization rather than preventing death from bleeding itself 1.