How to use it
Use it for adults with acute lower GI bleeding (bright or dark red blood, clots, or blood mixed with stool). Enter the first vital signs and hemoglobin. The tool works out the shock index (heart rate ÷ systolic BP) as you type.
The BSG pathway has two steps. First, is the patient unstable? BSG defines that as a shock index above 1. Then, for stable patients, the Oakland score sorts the bleed into minor (8 or less) or major (above 8).
Reading the result
| Situation | BSG 2019 pathway |
|---|---|
| Shock index >1 (or SBP <90) | Unstable: resuscitate, CT angiography, then embolisation or endoscopic therapy. Upper endoscopy if CTA is negative. |
| Stable, Oakland >8 | Major bleed: admit; colonoscopy on the next available list |
| Stable, Oakland ≤8, bleed stopped, no other reason to admit | Minor bleed: discharge for urgent outpatient investigation |
A score of 8 or less predicts about a 95% chance of safe discharge. In a US validation of 38,067 patients, ≤8 had a sensitivity of 98.4% for safe discharge. Extending the cut-off to 10 caught twice as many low-risk patients with a sensitivity of 96.0%, but no guideline has adopted 10, so this tool uses 8.
Why heart rate ≥110 is not an “unstable” rule here
An earlier version of this tool called any heart rate of 110 or more unstable. That rule is not in the Oakland score or in BSG or ESGE guidance. BSG uses the shock index. A heart rate of 110 or more already adds 3 points to the score, and a tachycardic patient with a low blood pressure will have a shock index above 1. You can still admit any patient you are worried about: the “other reason to admit” question is there for that.
Pitfalls
- Beta-blockers blunt the heart rate, so a normal shock index can hide shock (BSG).
- Hypotension with a normal shock index. A slow heart rate with an SBP below 90 gives a shock index under 1. This tool still treats SBP below 90 as unstable.
- Brisk hematochezia with instability can come from an upper GI source. Think of a gastroscopy.
- Validated in UK and US populations. The derivation cohort transfused liberally, so the score is cautious.
- Anticoagulants. BSG and ESGE give detailed advice on warfarin, DOACs and antiplatelets. ESGE suggests not interrupting anticoagulation for a minor self-limited bleed.
For upper GI bleeding, use the Glasgow-Blatchford score.