Dr. Elizabeth Squirell

Lower GI bleed

Shock index, CT angiography, Oakland score triage, transfusion and antithrombotics (BSG pathway)

Reviewed October 2026 · For healthcare professionals. Follow your local protocols.

Tools: Oakland score

First hour

  • Resuscitate. Bloods: CBC, group and screen, INR, urea, creatinine.
  • Digital rectal exam (it is part of the Oakland score).
  • Shock index = heart rate ÷ systolic BP. Shock index >1 = unstable (BSG 2019 Rec 1).
  • Ask about anticoagulants, antiplatelets, prior bleeding admissions, cardiovascular disease.

The pathway (BSG 2019)

Group Definition Action
Unstable Shock index >1 after initial resuscitation, or active bleeding suspected CT angiography first (Rec 4). If positive: catheter angiography and embolisation as soon as possible, within 60 min where 24/7 IR exists (Rec 6). If negative: gastroscopy immediately (Rec 5)
Stable, major bleed Oakland score >8 Admit for colonoscopy on the next available list (Rec 3)
Stable, minor bleed Oakland score ≤8, bleeding has stopped, no other reason to admit Discharge for urgent outpatient investigation (Rec 2)
  • An Oakland score ≤8 predicts a 95% chance of safe discharge (Oakland 2017).
  • ESGE 2021 limits discharge on Oakland ≤8 to a self-limited bleed with no adverse clinical features. A low score never overrides instability.
  • No emergency laparotomy until bleeding has been localised by CT or endoscopy, except in exceptional circumstances (Rec 7).
  • If the patient stabilises after resuscitation and an upper source is suspected, gastroscopy may come first (Rec 5).

Oakland score

Item Points
Age <40: 0 · 40–69: 1 · ≥70: 2
Sex Female: 0 · Male: 1
Previous admission for LGIB No: 0 · Yes: 1
Blood on rectal exam No: 0 · Yes: 1
Heart rate <70: 0 · 70–89: 1 · 90–109: 2 · ≥110: 3
Systolic BP ≥160: 0 · 130–159: 2 · 120–129: 3 · 90–119: 4 · <90: 5
Hemoglobin (g/L) ≥160: 0 · 130–159: 4 · 110–129: 8 · 90–109: 13 · 70–89: 17 · <70: 22

Source: BSG 2019 Table 1.

Transfusion

Patient Transfuse when Hb Target after transfusion
Stable, no cardiovascular disease 70 g/L 70–90 g/L
Cardiovascular disease 80 g/L 100 g/L

BSG 2019 Rec 8; ESGE 2021 is the same. ACG 2023 uses 70 g/L.

Colonoscopy: when

  • BSG 2019: major bleed → next available list.
  • ACG 2023: nonurgent inpatient colonoscopy; urgent colonoscopy within 24 h has not improved rebleeding or other key outcomes.
  • ESGE 2021: during the admission.

Anticoagulants and antiplatelets

Drug During the bleed Restart
Warfarin Hold at presentation. Unstable: reverse with PCC and vitamin K (BSG Rec 9; ESGE 2021: IV vitamin K + 4-factor PCC) Low thrombotic risk: day 7 (BSG). High risk (mechanical mitral valve, AF with valve or mitral stenosis, VTE <3 months): consider LMWH at 48 h (BSG Rec 10)
DOAC Hold at presentation. Life-threatening bleed: consider idarucizumab (dabigatran) or andexanet (BSG Rec 14). In Canada, andexanet (Ondexxya) was cancelled post-market in August 2026: check local stock and your hematology protocol Within 7 days at most (BSG Rec 14)
ASA, primary prevention Stop permanently (BSG Rec 11) Do not restart
ASA, secondary prevention Do not stop routinely (BSG Rec 12) If stopped, restart once hemostasis is achieved
Dual antiplatelet (coronary stents) Do not stop routinely; involve cardiology. If unstable and the P2Y12 inhibitor is held, continue ASA (BSG Rec 13) P2Y12 inhibitor within 5 days

Guidelines disagree on reversal. The Canadian co-authored ACG–CAG 2022 guideline suggests against routine FFP, vitamin K, PCC for DOACs, idarucizumab and andexanet. ACG 2023 reserves reversal for life-threatening bleeding not responding to resuscitation. Reverse only when the bleed is life-threatening, and involve thrombosis or hematology.

Red flags

  • Shock index >1 or ongoing hemodynamically significant bleeding.
  • Brisk rectal bleeding with hemodynamic compromise, a high urea:creatinine ratio, peptic ulcer history, portal hypertension or antiplatelet use: think upper source (BSG 2019).
  • Bleeding that starts in a patient already in hospital: in-hospital mortality 18%, vs 3.4% overall (BSG 2019).

Pitfalls

  • Using the Oakland score in an unstable patient.
  • Sending an unstable patient to colonoscopy instead of CT angiography.
  • Forgetting gastroscopy when CT angiography is negative.
  • Stopping cardiac ASA by reflex.

Follow your local protocols.

Sources

  1. Oakland K, et al. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019;68:776–789. PMID 30792244 Recommendations 1–14: shock index >1 = unstable; Oakland ≤8 discharge for urgent outpatient investigation; major bleed → next available colonoscopy; CTA then embolisation (within 60 min where 24/7 IR); immediate gastroscopy if CTA negative; transfusion triggers 70/80 g/L; warfarin, DOAC and antiplatelet management. Table 1: Oakland score.
  2. Oakland K, 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;2:635–643. PMID 28651935 Oakland score ≤8 predicts a 95% probability of safe discharge.
  3. Triantafyllou K, et al. Diagnosis and management of acute lower gastrointestinal bleeding: ESGE Guideline. Endoscopy 2021;53:850–868. PMID 34062566 Oakland ≤8 for discharge only with a self-limited bleed and no adverse features; same transfusion triggers; CTA if unstable; colonoscopy during the admission; IV vitamin K + 4-factor PCC for VKA with instability; restart P2Y12 within 5 days.
  4. Sengupta N, et al. Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. Am J Gastroenterol 2023;118:208–231. PMID 36735555 Risk tools such as Oakland ≤8 to identify low-risk patients; restrictive transfusion at 70 g/L; CTA for ongoing hemodynamically significant bleeding; nonurgent inpatient colonoscopy (urgent <24 h does not improve outcomes); reversal only for life-threatening bleeding not responding to resuscitation.
  5. Abraham NS, Barkun AN, et al. ACG–CAG Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Am J Gastroenterol 2022;117:542–558. PMID 35297395 Canadian co-authored. Applies to upper and lower GI bleeding: against routine FFP, vitamin K, PCC for DOACs, idarucizumab, andexanet, and platelet transfusion; keep secondary-prevention ASA.
  6. Health Canada. Drug Product Database: Ondexxya (andexanet alfa), drug code 102725; Praxbind (idarucizumab), drug code 94091 (checked 11 October 2026). Ondexxya cancelled post-market 21 August 2026 (marketed from May 2024); Praxbind marketed.
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