Scoring systems for predicting outcomes of acute upper and lower gastrointestinal bleeding. How useful are these in clinical practice?

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ACHAIKI IATRIKI | 2025; 44(3):121–124

Editorial

Konstantinos Papantoniou, Evangelia Bourdalou, Konstantinos Thomopoulos

Division of Gastroenterology, Department of Internal Medicine, Patras Medical School, Greece

Received: 25 May 2025; Accepted: 26 May 2025

Corresponding author: Konstantinos Thomopoulos, Professor of Gastroenterology and Internal Medicine, Division of Gastroenterology, Department of Internal Medicine, Patras Medical School, Greece, Tel.: +306977563564, e-mail: kxthomo@hotmail.com

Keywords: Gastrointestinal bleeding, scoring systems, outcomes, prognosis, clinical practice

 

Introduction

Acute gastrointestinal (GI) bleeding is a common medical emergency associated with significant morbidity and mortality. Early risk stratification is essential to guide management decisions and improve patient outcomes [1]. Over the years, several scoring systems have been developed to predict severity, the need for intervention, and mortality risk associated with acute upper and lower GI bleeding. Among these, the AIMS65, Glasgow-Blatchford Score (GBS), and Rockall score are widely used for upper GI bleeding, while the NOBLADS, Strate, and BLEED scores aim to predict severity and guide for intervention in cases of lower GI hemorrhage [2] (Table 1). Despite their widespread use, questions remain regarding their clinical applicability. This editorial examines the strengths and limitations of these scoring systems and evaluates their practical relevance in clinical settings.

Acute nonvariceal upper gastrointestinal bleeding

Acute nonvariceal upper GI bleeding (NVUGIB) is a serious and potentially life-threatening condition, accounting for several hospital admissions each year. While many patients do not require inpatient treatment and can even be safely managed in an outpatient setting, NVUGIB continues to be associated with significant morbidity and mortality despite advances in management [3]. Therefore, early identification of patients at risk for poor outcomes is essential to ensure appropriate triage and management from the initial point of care.

Rockall score

The Rockall score (RS) is a scoring system based on both clinical characteristics and endoscopic findings. Factors used for its calculation include age, the presence of shock, and patient comorbidities, as well as endoscopic identification of the bleeding source and the presence or absence of stigmata that indicate recent hemorrhage [4]. Its use in clinical practice has shown promising results in the prediction of patient outcomes, including risk of rebleeding and mortality [4,5]. However, its reliance on endoscopy makes the use of RS in everyday practice challenging. The use of a pre-endoscopic Rockall score (pRS), which only requires knowledge of patient history and hemodynamic status, is a useful tool for the identification of patients with severe NVUGIB who will require intervention for bleeding cessation [6].

Glasgow-Blatchford score

The Glasgow-Blatchford score (GBS) was developed to predict the need for clinical intervention in patients admitted with acute NVUGIB. The score takes into account systolic blood pressure, heart rate, the presence of melena and/or syncope and/or hepatic disease, as well as blood urea nitrogen and hemoglobin levels [7]. GBS has proven to be useful in identifying patients who are at increased risk for rebleeding, hemostatic interventions, and transfusion requirements. GBS calculation does not require endoscopic data. Its application is therefore possible at the time of hospital admission [8].

AIMS-65

AIMS-65 was first studied in a retrospective study of 29,222 patients with acute NVUGIB.  Five factors are required for its calculation: albumin, international normalized ratio (INR), mental status, systolic blood pressure, and age. Higher scores were associated with increased in-hospital mortality, length of hospitalization, and healthcare costs (p<0.001) [9]. Use of this score as a prognostic factor in patients with NVUGIB is therefore reasonable, while its easy calculation makes it useful in the emergency setting.

Comparison In clinical practice

GBS has demonstrated superior performance and reliability compared to the RS in predicting the need for intervention and transfusion requirements. This underlines its clinical importance in the early identification of patients requiring endoscopic or surgical treatment. Current European Society of Gastrointestinal Endoscopy (ESGE) Guidelines recommend the use of the GBS for pre-endoscopy risk stratification of patients presenting with NVUGIB. Patients with GBS score of 0-1 are considered to be at a low risk for complications and can be managed as outpatients with close follow up [1]. However, less than 19% of patients have Glasgow-Blatchford score ≤1, so the majority of patients should be closely monitored in the first days following bleeding [3]. For prediction of mortality, the pre-endoscopic AIMS-65 score is preferred when compared with post-endoscopic scores. However, further studies comparing its value to GBS are required [10]. The scores mentioned above are not useful for predicting outcomes in patients with variceal UGIB. Other prognostic tools, such as Child-Pugh Turcotte and Meld scores, are useful in patients with cirrhosis and portal hypertension [6].

Acute lower gastrointestinal bleeding

As with UGIB, many prognostic scores have been developed for the prediction of possible adverse events and safe discharge of patients presenting with acute lower gastrointestinal bleeding (LGIB). However, their use in clinical practice remains controversial, with ongoing debate among clinicians.

BLEED score

The BLEED score was developed to predict in-hospital adverse events, including mortality. On-going bleeding, systolic blood pressure, prothrombin time, altered mental status and unstable comorbidities are used for its calculation [11]. Studies examining its prognostic value in patients with LGIB show it is useful for predicting mortality, but not other outcomes, such as transfusion requirements and hemostatic therapy [2].

Strate score

The Strate score was developed from a study of 252 patients with LGIB. It is estimated based on patient medical history (aspirin use and co-morbidity) and clinical findings (heart rate, blood pressure, presence of syncope, non-tender abdominal examination, bleeding per rectum in the first 4 hours after presentation) [12]. Although its use initially appeared promising, external validation studies have failed to prove its reliability in predicting LGIB severity and adverse events [2,13].

NOBLADS score

The NOBLADS score takes into account several clinical parameters: nonsteroidal anti-inflammatory drug use, antiplatelet use, presence of diarrhea and/or abdominal tenderness and/or syncope, blood pressure, serum albumin levels and disease scores of 2 or higher [14]. Brito et al. examined the prognostic value of the score in an external validation study which included 173 patients with LGIB. They found that high NOBLADS values were significantly associated with LGIB severity (p<0.001) and aided recognition of patients with LGIB who will require transfusions, therapeutic intervention and longer duration of hospitalization [15].

Oakland score

The Oakland score was developed as a tool to predict which patients can be safely discharged after presenting with acute LGIB. It is calculated based on age, gender, previous LGIB admission, digital rectal examination findings, heart rate, systolic blood pressure and hemoglobin levels. A score lower than eight has been associated with safe outpatient management [16]. Whiteway et al. recently examined the value of the Oakland score in predicting safe discharge of 144 LGIB patients in a single-center study. They concluded that the score was useful for identifying patients who did not require intervention or hospitalization and suggested further evaluation, as scores higher than eight were also associated with favorable outcomes [17].

Comparison in clinical practice

Concurrent use of these scores in different studies has failed to identify a single clinical risk tool with superior predictive ability across all outcomes [16,18]. The prognostic value of tools used for patients with UGIB has also been examined in LGIB, with comparable results [2]. Almaghrabi et al. conducted a meta-analysis of nine studies comparing the Oakland, Strate, NOBLADS and BLEED scores in patients with LGIB. They concluded that the Oakland score had the best predictive value for safe discharge, severe bleeding, and transfusion requirements, while the Strate score was the most accurate in predicting the need for hemostatic intervention [19]. Current ESGE guidelines recommend the use of an Oakland score of ≤ 8 points to guide medical decisions regarding patients with acute LGIB without evidence of severe bleeding [20].

Conclusions

The use of scoring systems aimed at predicting outcomes in patients with acute GI bleeding aids clinicians in providing improved patient care. The GBS score is currently recommended for risk stratification of patients presenting with NVUGIB, while the Oakland score can aid the identification of patients presenting with LGIB that do not require hospitalization. Despite their usefulness, these tools cannot replace clinician judgment. Further studies are required to determine which patients will mostly benefit from the use of these scores in clinical practice.

Conflict of Interest disclosure

The authors declare that there are no conflicts of interest associated with the publication of this editorial.

Declaration of Funding Sources

None to declare.

Author Contributions

KP, Literature review, Writing – Original Draft, Review & Editing; EB, Literature review, Writing – Original Draft; KT, Conceptualization, Supervision, Writing– Review & Editing

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