GI Bleed Severity

Margaret Schifano, PA-C

Management of upper and lower gastrointestinal (GI) bleeds poses significant challenges from an emergency medicine perspective, requiring swift and accurate decision-making to optimize patient outcomes and ensure appropriate disposition. Clinical decision tools have emerged as indispensable aids in guiding healthcare professionals through the complex process of assessing and stratifying patients with GI bleeds. These tools facilitate a systematic evaluation of patients and assist in determining the appropriate level of intervention, thereby enhancing the efficiency and precision of clinical decisions in the critical context of upper and lower GI bleeding episodes.

Oakland Score: used to assess safe discharge after lower GI bleed

By incorporating key clinical parameters, such as patient demographics, clinical history, exam findings, and lab results, the Oakland Score provides a structured approach to evaluating lower GI bleeding cases, enabling healthcare professionals to make informed decisions regarding patient disposition and intervention strategies The Oakland Score has undergone notable scrutiny and refinement over the years, particularly in its threshold for risk stratification. Originally established with a cutoff of 8 or lower, this scoring system was designed to identify low-risk patients who could safely be discharged from the hospital in the setting of a lower GI bleed.

However, a pivotal study published in JAMA in 2020 introduced a potential shift in this paradigm by suggesting an increased cutoff to 10. This investigation, aiming to reassess the score’s efficacy, revealed that at the traditional threshold of 8, the sensitivity and specificity were 98.4% and 16%, respectively. Intriguingly, with the threshold extended to 10, the sensitivity and specificity stood at 96.0% and 31.9%, offering fresh insights into the balance between sensitivity and specificity in identifying patients suitable for safe discharge by assessing need for further interventions including blood transfusions, 28-day readmissions, absence of bleeding, therapeutic interventions, and/or death.

AIMS65: used to assess mortality risk for upper GI bleed

0 = 0.3% mortality rate
1 = 1.2% mortality rate
2 = 5.3% mortality rate
3 = 10.3% mortality rate
4 = 16.5% mortality rate
5 = 24.5% mortality rate

The AIMS65 score, is a clinical decision tool used to assess mortality risk for upper gastrointestinal (GI) bleeding, and stands out for its simplicity and accessibility in emergency settings. This scoring system utilizes a mnemonic approach, with each letter, including the age component “65,” representing an equally weighted risk factor. The cumulative effect of these factors provides a comprehensive evaluation of the severity of upper GI bleeding, aiding healthcare professionals in making timely and informed decisions. The pros of this tool are that it doesn’t not rely on endoscopy to determine mortality risk and can be calculated in the emergency department

Glasgow-Blatchford Bleeding Score:

This score assesses upper GI bleeding patients who are “low-risk” and candidates for outpatient management.

The Glasgow-Blatchford Bleeding Score, is a clinical decision tool used in the context of upper gastrointestinal (GI) bleeding, and serves as a guide for determining “low risk” patients who may be appropriate for outpatient management. It is composed of nine variables, each carrying a specific weight, the score provides a systematic approach to evaluating the severity of upper GI bleeds. Notably, any presence of these variables increases the priority for admission and the need for acute intervention. A score of 0 suggests a low risk of complications (0.5%), indicating that these patients may not necessarily require admission for further workup

As with all scoring systems for decision-making, a thorough review of the patient’s history and comorbidities should be taken. I hope this brief summary is helpful the next time you must decide to admit or discharge a patient with a GI Bleed!

References

Oakland K, Kothiwale S, Forehand T, et al. External Validation of the Oakland Score to Assess Safe Hospital Discharge Among Adult Patients With Acute Lower Gastrointestinal Bleeding in the US. JAMA Netw Open. 2020;3(7):e209630. doi:10.1001/jamanetworkopen.2020.9630

Saltzman JR, Tabak YP, Hyett BH, Sun X, Travis AC, Johannes RS. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc.2011;74:1215–1224.

Oakland K, Jairath V, Uberoi R, et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. Lancet Gastroenterol Hepatol. 2017;2(9):635-643.

Blatchford O, et. al. A risk score to predict need for treatment for upper gastrointestinal haemorrhage. Lancet 2000.

Margaret Schifano

A native of Minnesota, Margaret completed her undergraduate degree in Biology and Hispanic Studies at Pepperdine University in California. She later went on to Harding University in Arkansas for her degree in Physician Assistant Studies. She completed the General Emergency Medicine Physician Assistant Fellowship at Columbia in 2021 and stayed on full-time after that for a year until recently moving to DC with her husband and daughter. She now works full time at George Washington University Hospital in the Emergency Department where she serves as the APP New Graduate Program Onboarding & Education Coordinator as well as Assistant Clinical Professor of Emergency Medicine. She continues to work per-diem for the department. Her interests in Emergency Medicine include education and ultrasound. She is currently pursuing a Doctorate degree in Leadership in Clinical Practice and Education.