Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 1  |  Page : 72-78  

Role of scoring systems in acute pancreatitis


Department of Surgery, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Web Publication22-Dec-2015

Correspondence Address:
Somnath Gooptu
Department of General Surgery, Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.167994

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  Abstract 

Background: Identification of patients at risk for severe disease early in the course of acute pancreatitis is an important step to formulating the management strategies for improving outcomes. Scoring systems designed for such assessment need critical evaluation regarding which and when to apply. Aims: To assess the efficacy of specific scoring systems like Ranson's score, Bedside Index for Severity in Acute Pancreatitis (BISAP) scoring, Acute Physiology Score and the Chronic Health Evaluation II (APACHE II), and Modified Computed Tomography Severity Index (MCTSI) to predict severity, organ failure, and complications leading to mortality in acute pancreatitis. Materials and Methods: Ranson's, APACHE II and BISAP scores were calculated within 24 h of admission. Ranson's score was evaluated also after 48 h of admission. CT scan was performed after a period of 48 h only if the clinical course was unpredictable, morphological changes were detected on ultrasound abdomen or on clinical suspicion. MCTSI was evaluated in such cases. Results: There were 48 patients with acute pancreatitis (89.6% male) of which 11 patients underwent contrast-enhanced CT scan. Six patients developed organ failure and were classified as severe acute pancreatitis. Three patients had died. Six patients had a BISAP score >3, 5 patients with Ranson's score >3, 3 patients with APACHE II >8 and MCTSI >2 was seen in 9 patients. Area under curve for BISAP, Ranson's, APACHE II, and MCTSI in predicting severity are 0.79 (confidence interval [CI]: 0.605-0.967), 0.79 (CI: 0.524-1), 0.94 (CI: 0-1), and 0.61 (CI: 0.286-0.936), respectively. Conclusion: We recommend that although APACHE II score is a better predictor of organ failure, BISAPS should be used for the identification of high-risk patients because of its simplicity. Ranson's score still holds its place in identifying patients at risk of developing severe acute pancreatitis and organ failure. MCTSI though did not perform well, but still helps to identify local and systemic complications without pancreatic necrosis. It also defines scope and extent of the surgical intervention.

Keywords: Acute Physiology Score and the Chronic Health Evaluation II, Bedside Index for Severity in Acute Pancreatitis, Modified Computed Tomography Severity Index, Ranson′s


How to cite this article:
Gooptu S, Singh G, Pithwa AK, Ali I, Nongmaithem M, Gooptu S. Role of scoring systems in acute pancreatitis . Med J DY Patil Univ 2016;9:72-8

How to cite this URL:
Gooptu S, Singh G, Pithwa AK, Ali I, Nongmaithem M, Gooptu S. Role of scoring systems in acute pancreatitis . Med J DY Patil Univ [serial online] 2016 [cited 2020 Aug 9];9:72-8. Available from: http://www.mjdrdypu.org/text.asp?2016/9/1/72/167994


  Introduction Top


Acute pancreatitis is defined as a reversible inflammatory process of the pancreas which can involve peri-pancreatic tissue and more distant organ sites. [1] The underlying mechanism of injury in pancreatitis is thought to be premature activation of pancreatic enzymes within the pancreas, leading to a process of autodigestion. However, the individual patient response is highly variable and often unpredictable. Therefore, good clinical judgment along with laboratory investigations will help in the appropriate management and predicting susceptibility of patients to complications like organ failure leading to death.

Various scores have been devised to assess severity and predict complications in acute pancreatitis.

The Ranson's score represented a major advance in evaluating the severity of acute pancreatitis includes data that are routinely collected during hospitalization but has the disadvantage of requiring a full 48 h to be completed. [2]

The Acute Physiology Score and the Chronic Health Evaluation II (APACHE II) is useful in predicting the severity of acute pancreatitis. It can be administered on any day but requires the collection of a large number of parameters, some of which may not be relevant for prognosis whereas other features like pancreatic injury and regional complications are missed.

The Bedside Index for Severity in Acute Pancreatitis (BISAP) has been proposed as an accurate method for early identification of patients at risk for in-hospital mortality. [3] This score used 5 points and was retrospectively derived and validated based on large number of population.

The Computed Tomography Severity Index (CTSI) which was proposed by Balthazar et al. used a 10-point severity scale which helped the clinicians to predict the severe outcomes of acute pancreatitis. However now, this has been changed to Modified CTSI (MCTSI) which is more closely related to patient outcome. [4]

The present study is undertaken to assess the efficacy of specific scoring systems like Ranson's score, BISAP scoring, APACHE II, and MCTSI, to predict severity, organ failure and complications leading to mortality in acute pancreatitis.


  Materials and Methods Top


The demographic, clinical, laboratory, and radiological data of consecutive patients admitted or transferred to our hospital from July 2012 to September 2014 with a diagnosis of acute pancreatitis were prospectively collected for this study. The diagnosis of acute pancreatitis was bases on the presence of two of the following three features:

  1. Characteristic abdominal pain,
  2. Increased levels of serum amylase and/lipase 3 times the normal value,
  3. Characteristic finding of acute pancreatitis on abdominal CT scan.
On certain occasions, all the vital parameters or laboratory values were not available for patients included in our study. No points were given for missed values. The Ranson's, APACHE II, and BISAP was calculated within 24 h of admission. Ranson's score was also evaluated after 48 h of admission. CT scan was performed after a period of 48 h only if the clinical course was unpredictable; morphological changes were detected on ultrasound abdomen or on clinical suspicion. MCTSI was evaluated.

Prediction of severity and outcome of pancreatitis was assessed as per the scoring system protocol and organ failure was identified based on any one of the following features:

  1. Acute respiratory insufficiency (PO 2 <60 mm Hg requiring ventilation or oxygen therapy by mask for >5 days),
  2. Renal failure (urine output <400 ml/24 h with a rising blood urea and serum creatinine and with no response to 24 h fluid therapy),
  3. Left ventricular failure and pulmonary edema which were diagnosed clinically and supported by characteristic changes on the chest X-ray.
All the CT scans were reviewed by radiologists dedicated to abdominal imaging, who were blinded to laboratory data and clinical course.

Statistical analysis

Values of continuous variables are presented as median and interquartile range for continuous variables. Categorical data are presented as proportions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for individual scoring systems. Receiver operating characteristics curves for organ failure was calculated for Ranson's, APACHE II, BISAP, and MCTSI scores and the predictive accuracy of each scoring system was measured by the area under the receiver-operating curve.


  Results Top


Receiver operating characteristic curve of each of the scoring systems [Figure 1] [Figure 2] [Figure 3] [Figure 4] yielded an area under the curve of each scoring systems which are given in [Table 1]. APACHE II score showed a slightly higher accuracy for predicting severity 0.94 (confidence interval: 0-1). MCTSI was not the most accurate method of predicting severity.
Figure 1: Area under receiver operating characteristic for Bedside Index for Severity in Acute Pancreatitis for predicting severity in acute pancreatitis

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Figure 2: Area under receiver operating characteristic for Ranson's for predicting severity in acute pancreatitis

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Figure 3: Area under receiver operating characteristic for Acute Physiology Score and the Chronic Health Evaluation II for predicting severity in acute pancreatitis

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Figure 4: Area under receiver operating characteristic for Modified Computed Tomography Severity Index for predicting severity in acute pancreatitis

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Table 1: AUC of different scoring system in predicting severity

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The observed incidence of severe disease stratified by the above BISAP, Ranson's, APACHE II, and MCTSI cut-offs with the corresponding odds ratio are shown in [Table 2].
Table 2: Incidence of organ failure stratifi ed by BISAP, Ranson's, APACHE II, MCTSI score with corresponding OR

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The sensitivity, specificity, PPV, and NPV of different scoring systems are depicted in [Table 3].
Table 3: Sensitivity, specificity, PPV, NPV of different scoring system in predicting organ failure

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In a patient whose MCTSI score was 6, there was evidence of heterogenous echotexture suggestive of pancreatic inflammation associated. A large multiloculated thin walled (2-3 mm thickness) cystic lesion (CT value 30-40 HU) with enhancing wall and septae was noted anterior to the pancreas in the lesser sac [Figure 5]. There was significant peri-pancreatic and mesenteric fat stranding. Gross ascites noted in the peri-hepatic, peri-splenic, interbowel loops, hepato-renal, spleno-renal pouches, and pelvis [Figure 6]. Patient recovered without developing any systemic complications.

In another patient, with MCTSI score of 8 had 30-50% evidence of necrosis of parenchyma which was associated with pancreatic and gross peri-pancreatic fluid collection. It was also associated with peri-pancreatic complications where there was evidence of superior mesenteric vein and splenic vein thrombosis [Figure 7] and [Figure 8]. This patient had in-hospital mortality.
Figure 5: Large multiloculated thin walled (2-3 mm thickness) cystic lesion (computed tomography value 30-40 HU) with enhancing wall and septate is seen anterior to the pancreas in the lesser sac with significant peri-pancreatic and mesentric fat stranding

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Figure 6: Gross ascites seen in the perihepatic, perisplenic, interbowel loops, heptorenal, splenorenal pouches and pelvis

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Figure 7: Necrosis of pancreatic parenchyma associated with pancreatic and gross peri-pancreatic fluid collection

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Figure 8: Portal vein is replaced by multiple collateral venous channels suggestive of cavernoma formation with distal most portion of superior mesenteric vein shows partial fl oating thrombus within

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  Discussion Top


Acute pancreatitis is an inflammatory process of the pancreas with possible peri-pancreatic tissue and multi-organ involvement inducing multi-organ dysfunction syndrome leading to mortality. [1] The course of the disease is unpredictable. It may resolve with appropriate management or may lead to complications which may end in fatality. The clinician is at pain to predict such complications at the preventable stage with a view to reducing morbidity and mortality in such patients. Development of various scoring systems is steps taken to achieve this goal. This study was undertaken to evaluate Ranson's, APACHE II, BISAP, and MCTSI in predicting severity, organ failure, and mortality in acute pancreatitis.

This study group consisted of 48 patients diagnosed as acute pancreatitis over a period of 2 years.

In our study, the prevalence of acute pancreatitis was higher in males (89.6%) than in females (10.4%) which is in accordance with other studies in which the males were more affected than females. [2],[5]

Acute pancreatitis was seen below 30 years of age. However, in certain other studies it has been observed that the middle aged people were more affected than the younger age group. [6],[7] High incidence of alcohol consumption in the younger patients could be the reason for this difference.

In a study by Kaya et al. it was observed that the most common cause of acute pancreatitis was Biliary pathology, followed by the idiopathic group. [8] However, in another study it was observed that consumption of alcohol was the most common cause. [9] In our study also, alcohol consumption was the most common etiological factor which was followed by biliary disease.

Ranson's score helps in the prediction of patients who may develop severe acute pancreatitis and organ failure. A composite score of 3 or more has been used to classify a patient as having a severe disease.

Ranson's score performed well (sensitivity 50%, specificity 95.24%, PPV 60%, and NPV 93.02%) in this study, as we used a definition of severe acute pancreatitis based on the organ dysfunction for at least 48 h. A meta-analysis comprising of 1300 patients reported that Ranson's score has an overall sensitivity of 75%, specificity 77%, PPV 49%, and NPV of 91%. [10] However, the low PPV of Ranson's score in these studies may only reflect that about half of the patients with score >3 did not meet the definition of severe disease that was chosen.

Analysis of the components of Ranson's score reveals that it is weighted toward detecting multi-organ failure linked to systemic inflammatory response syndrome (SIRS) and vascular leak syndromes.

APACHE II score is the most widely used scoring system in acute pancreatitis. [11] It has a large number of variables which are difficult to remember by the clinicians. However, the laboratory tests which are required are simple, routine and readily available. APACHE II may prove to be a useful addition to the management and study of these patients, providing an objective indication of the severity and the possible outcome of an attack soon after admission to the hospital. [12]

In this study, APACHE II score performed well (sensitivity 50%, specificity 100%, PPV 100%, and NPV 93.33%). In one study, APACHE II had sensitivity 63%, specificity 81%, PPV 46%, and NPV 89%. [13] In another study APACHE, II had sensitivity 75%, specificity 60%, PPV 55%, and NPV 78%. [8] APACHE II score at the time of admission was slightly less reliable but proved to be a useful screening score with very good NPVs.

Therefore, APACHE II scoring system is much more accurate that Ranson's score in the prediction of severity as it had a high specificity in our study.

It was also observed that 3 patients who were not predicted also developed organ failure which could be explained by the fact that these patients presented to the hospital after 48 h of onset of symptoms, by which time the severity of symptoms had subsided, and the recorded scores were spuriously low.

In our study, APACHE II is a good indicator of organ failure, is impaired only by the high false positive ratio which goes in accordance with the study by Simoes et al. [14]

The difference in the mean APACHE II scores in the patients who had fatal outcome could be explained by the fact that 2 out of 3 patients who died had a higher APACHE II score.

MCTSI is the best scoring system available for predicting severity, local complications and organ failure. Pancreatic necrosis can be diagnosed only by contrasted enhanced CT scan or by laparotomy or necropsy. It is important to evaluate the degree of pancreatic necrosis as these patients will have to be monitored closely in the ICU and may need surgical intervention.

However, in our study CT scan was only done when the clinical course was unpredictable, morphological changes were detected on the ultrasound of the abdomen or on clinical suspicion. Simoes et al. performed CT scan on similar grounds. [14] CT scan is also done in order to confirm the clinical diagnosis of acute pancreatitis or to differentiate from other acute abdominal conditions which mimic pancreatitis.

CT scan which are performed within the first 12 h may show equivocal findings whereas those obtained after 3 days have a higher chances of depicting features of necrotizing pancreatitis. [15] In our study, CT scan was conducted after 48 h, that too only in suspected patients. However, in a study by O'Connor et al. CT scan was performed on admission and after 48 h for detecting necrotizing pancreatitis. [15]

MCTSI did not perform well (sensitivity 100%, specificity 22.2%, PPV 22.22%, and NPV 100%) as their results were biased on the pretest probability and small sample size. However, in another study it was observed that MCTSI performed well (sensitivity 26.7%, specificity 100%).

BISAP is a newly developed prognostic scoring system, which was reported to perform well in the preliminary studies for identifying the "at risk" patients of in-hospital mortality due to acute pancreatitis. [3] It has been proposed that the primary advantage over the traditional scoring systems is its simplicity.

In our experience, BISAP score, although a 5 points index, takes SIRS variables into consideration which makes it an eight variable system for calculating 5 points although simple to perform.

BISAP has the advantage as it can be calculated within 24 h of admission over Ranson's score. However, it appears to be more heavily weighted toward the immune response to injury and older age. [16] This is because Ranson's score takes age more than 55 years under consideration while BISAP takes age more than 60 years. As the age increases for an individual, the body's immune response also decreases.

BISAP score (sensitivity 50%, specificity 92.86%, PPV 50%, and NPV 92.86%) was a better predictor of developing organ failure than mortality in our study. In another study performed on Chinese patients, BISAP performed better (sensitivity 61.4%, specificity 83.1%, PPV 48.1%, and NPV 89.4%) than APACHE II (sensitivity 65%, specificity 76%, PPV 48.1%, and, NPV 89.4%). [17] This difference from our study may be due to several factors. First, there are differences in the characteristics of study participants such as race, lifestyle, and genetic basis. Second, this study had a higher number of alcoholic pancreatitis while the previous study had a higher number of biliary pancreatitis.

In our study, APACHE II score performed better than BISAP with a higher sensitivity and specificity. This was because out of the 6 patients predicted to develop organ failure by both the scores, only 3 actually developed. However, in patients who had mortality, the APACHE II score predicted correctly in 2 patients, whereas BISAP score predicted in 1 patient only.

Ranson's and BISAP predicted persistent organ dysfunction correctly at 24 and 48 h in our study. However, in a study it has been observed that Ranson's perform with higher accuracy in predicting organ dysfunction at 48 h whereas, BISAPS predict transient organ dysfunction at 24 h. [16]

In our study, it has been observed that BISAP score >3 have a higher risk of developing organ failure and persistent organ failure. Also, it has been observed that APACHE II has a higher predictive value than BISAP, MCTSI, and Ranson's score for organ failure. However, in another study, it was observed that BISAP had a higher predictive value than the other scores. [18]

All the above multifactorial clinical scoring systems are useful in evaluating the severity but the overall disadvantage lies in the fact that they are not able to predict potentially preventable complications and are least useful when intervention can reduce the risk of complications. [16]


  Conclusion Top


We recommend that although APACHE II score is a better predictor of organ failure, BISAPS should be used for the identification of high-risk patients due to its simplicity. Ranson's Score still holds its place in identifying patients at risk of developing severe acute pancreatitis and organ failure. MCTSI, although did not perform well, but still helps to identify local and systemic complications without pancreatic necrosis and those needing surgical intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A, et al. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol 2010;105:435-41.  Back to cited text no. 16
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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