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A comparison of APACHE II, BISAP, Ranson’s score and modified CTSI in predicting the severity of acute pancreatitis based on the 2012 revised Atlanta Classification

A comparison of APACHE II, BISAP, Ranson’s score and modified CTSI in predicting the severity of... Objective: Our aim was to prospectively compare the Accuracy of Acute Physiology and Chronic Health Evaluation (APACHE) II, Bedside Index of Severity in Acute Pancreatitis (BISAP), Ranson’s score and modified Computed Tomography Severity Index (CTSI) in predicting the severity of acute pancreatitis based on Atlanta 2012 definitions in a tertiary care hospital in northern India. Methods: Fifty patients with acute pancreatitis admitted to our hospital during the period of March 2015 to September 2016 were included in the study. APACHE II, BISAP and Ranson’s score were calculated for all the cases. Modified CTSI was also determined based on a pancreatic protocol contrast enhanced computerized tomography (CT). Optimal cut-offs for these scoring systems and the area under the curve (AUC) were evaluated based on the receiver operating characteristics (ROC) curve and these scoring systems were compared prospectively. Results: Of the 50 cases, 14 were graded as severe acute pancreatitis. Pancreatic necrosis was present in 15 patients, while 14 developed persistent organ failure and 14 needed intensive care unit (ICU) admission. The AUC for modified CTSI was consistently the highest for predicting severe acute pancreatitis (0.919), pancreatic necrosis (0.993), organ failure (0.893) and ICU admission (0.993). APACHE II was the second most accurate in predicting severe acute pancreatitis (AUC 0.834) and organ failure (0.831). APACHE II had a high sensitivity for predicting pancreatic necrosis (93.33%), organ failure (92.86%) and ICU admission (92.31%), and also had a high negative predictive value for predicting pancreatic necrosis (96.15%), organ failure (96.15%) and ICU admission (95.83%). Conclusion: APACHE II is a useful prognostic scoring system for predicting the severity of acute pancreatitis and can be a crucial aid in determining the group of patients that have a high chance of need for tertiary care during the course of their illness and therefore need early resuscitation and prompt referral, especially in resource-limited developing countries. Key words: Acute pancreatitis; Accuracy of Acute Physiology and Chronic Health Evaluation II (APACHE II); Bedside Index of Severity in Acute Pancreatitis (BISAP); Ranson’s score; modified Computed Tomography Severity Index (modified CTSI) Submitted: 27 February 2017; Revised: 2 June 2017; Accepted: 6 June 2017 V C The Author(s) 2017. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-Sen University This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/gastro/article-abstract/6/2/127/4055926 by Ed 'DeepDyve' Gillespie user on 20 June 2018 128 | A. Harshit Kumar and M. Singh Griwan Introduction Materials and methods Data collection Acute pancreatitis is a common and frequent inflammatory dis- order of the pancreas with variable involvement of other re- Demographic, clinical, biochemical and radiographic data were gional tissues or remote organ systems [1]. The disease has a prospectively collected from 50 patients admitted over the dura- varying etiology with an overall mortality of 5–10%. Most cases tion of March 2015 to September 2016 in the Department of (80–90%) are mild and self-limited with a good outcome. The re- General Surgery in Pt. B. D. Sharma PGIMS, Rohtak. The study maining 10–20% of patients with severe disease characteristi- was limited to 50 patients, since the it had to be completed dur- cally have pancreatic necrosis or distant organ failure and can ing a fixed timeframe of 2 years and only patients admitted and anticipate the need for intensive care and possible operative in- treated under the direct supervision of the authors were tervention with a mortality rate of up to 40% [2]. considered. Early diagnosis and precise staging of disease severity are The diagnoses of acute pancreatitis was based on the pres- important goals in the initial evaluation and management of ence of two of the following three criteria: (i) abdominal pain acute pancreatitis. While patients with mild acute pancreatitis characteristic of acute pancreatitis; (ii) serum amylase and/or li- can be managed with fluid resuscitation and supportive care, pase levels at least three times the upper limit of normal; and those with severe acute pancreatitis require maximal non- (iii) characteristic findings of acute pancreatitis on abdominal operative care and nutritional support in an intensive care unit ultrasonography and/or computerized tomography (CT) scan. (ICU). Due to the risk of rapid deterioration in severe acute pan- Patients who presented to the emergency department and were creatitis, the assessment of severity becomes crucial to a clini- diagnosed as having acute pancreatitis based on the criteria cian [3]. mentioned above were informed about the study and written A clinically based classification system for acute pancreatitis consent was taken. Patients who were diagnosed to have was established in the International Symposium on Acute chronic pancreatitis based on their previous hospital records or Pancreatitis in Atlanta, Georgia, in 1992. However, criticism of found to have features of chronic pancreatitis upon radiological the Atlanta severity classification system was growing be- investigations during the course of their stay such as pancreatic cause it was retrospective, the duration of organ failure was calcifications, dilated pancreatic duct, areas of atrophy and unspecified and local complications did not seem to increase pseudocysts were excluded from the study. mortality. The Atlanta classification was revised via an interna- After detailed history and physical examination, laboratory tional, web-based consensus in 2012 that provided clear defini- investigations were sent at the time of admission—arterial tions to classify acute pancreatitis using easily identifiable blood gas analysis, hematocrit, kidney function test, liver func- clinical and radiologic criteria. Greater emphasis was laid on or- tion test, serum electrolytes, serum amylase, serum lipase and gan failure and severity was graded as mild, moderately severe complete hemogram. All patients underwent abdominal ultra- and severe acute pancreatitis [4]. sonography at admission and contrast enhanced pancreatic Several multi-factorial scoring systems based on clinical and protocol CT scan 72 hours after symptom onset. biochemical data have been used over the past few decades. Patients were subsequently examined daily and laboratory These include Ranson’s score described in 1974, BISAP and investigations relevant to APACHE II, Ranson’s criteria and APACHE II to name a few. Each of these scoring systems has its BISAP score were sent. APACHE II score was evaluated for each own limitations including the low sensitivity and specificity, patient within first 24, 48 and 72 hours of admission. BISAP was complexity of the scoring system as well as inability to obtain a calculated within first 24 hours of admission. Ranson’s score final score until 48 hours after admission [5]. was evaluated within first 48 hours of admission. With the advent of contrast enhanced scans, there has been major improvement in the grading system. Attenuation values of pancreatic parenchyma during an intra-venous bolus study can Definitions be used as an indicator of pancreatic necrosis and as a predictor At the time of discharge/death, patients were graded as having of disease severity [6,7]. Contrast enhanced CT has shown an mild, moderately severe and severe acute pancreatitis based on overall accuracy of 87% with a sensitivity of 100% for the detec- the Atlanta 2012 classification. Patients with mild acute pancre- tion of extended pancreatic necrosis. The sensitivity and specific- atitis had neither local complications nor organ failure. Patients ity for diagnosing pancreatic necrosis increase with greater with moderately severe acute pancreatitis had transient organ degrees of pancreatic non-enhancement, and complications failure or local complications or both, whereas patients with se- have also been shown to correlate with the degree of non- vere acute pancreatitis had persistent organ failure. enhancement [8]. However, early CT scans often fail to identify Organ failure was defined based on the Modified Marshall developing necrosis until such areas are better demarcated, scoring system. A score of 2 for more than 48 hours was con- which may become evident only 2–3 days after the initial clinical sidered as persistent organ failure, whereas a score of 2 for onset of symptoms. In 2004, modified CTSI was introduced to im- less than 48 hours was considered as transient organ failure. prove the staging of acute pancreatitis. A study of comparison be- Local complications included pancreatic necrosis, acute fluid tween CTSI and modified CTSI and comparison of both with collections, pseudocyst, acute necrotic collections and walled- APACHE II concluded that modified CTSI was better than CTSI for off necrosis. assessing the severity of acute pancreatitis and the CTSI is better than APACHE II in assessing severe acute pancreatitis [9]. There have been few studies comparing these prognostic Management protocols scoring systems based on the revised Atlanta classification. This study aimed to assess and compare the prediction of sever- Patients presenting to the emergency department, suspected of ity of acute pancreatitis based on multi-factorial scoring sys- having acute pancreatitis, were adequately resuscitated using tems viz. Ranson, BISAP, APACHE II and modified CTSI in a crystalloids, primarily ringer’s lactate. Inotropes and colloids tertiary care center. were added if the patients failed to respond to crystalloids. Downloaded from https://academic.oup.com/gastro/article-abstract/6/2/127/4055926 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Scoring systems for predicting severity of acute pancreatitis | 129 Table 1. Patient characteristics All patients were catheterized to monitor the urine output and ascertain the adequacy of resuscitation. Central venous ac- Characteristics Category No. of patients (%) cess was obtained for patients who failed to respond to initial resuscitation measures to monitor the central venous pressure Sex Male 17 (34%) and guide further fluid management. A nasogastric tube was Female 33 (66%) placed for all patients. All patients were kept nil per oral for the Age group (years) 60 16 (32%) first 24 hours. Subsequently, patients were examined daily and 50–59 11 (22%) enteral feeding by means of a nasogastric tube or orally was ini- 40–49 10 (20%) tiated as soon as features of ileus resolved. 30–39 7 (14%) Patients with pancreatic necrosis who failed to improve 20–29 5 (10%) <20 1 (2%) were planned for necrosectomy and open drainage. A total of Etiology Gall stone disease 37 (74%) two patients underwent surgical intervention for pancreatic ne- Alcoholic 9 (18%) crosis. Patients with cholelithiasis underwent pre-anesthetic Traumatic 1 (2%) checkup and pre-operative work-up prior to discharge and Idiopathic 3 (6%) planned to undergo cholecystectomy after 6 weeks as per insti- Presentation Pain in abdomen 50 (100%) tutional protocol. Facilities for endoscopic retrograde cholangio- Radiating 32 (64%) pancreatography (ERCP) are not available at our institute. Non-radiating 18 (36%) Peritonitis 44 (88%) Localized 26 (59%) Statistics Diffuse 18 (41%) Severity of the disease was evaluated in terms of ICU admission, Vomiting 39 (78%) length of hospital stay, final grade as per Atlanta 2012 classifica- Distension of abdomen 28 (56%) tion and presence of pancreatic necrosis. Data were collected Non-passage of stool 22 (44%) prospectively in a Microsoft Excel Database. After completion of and flatus data collection, the database was imported into SPSS for Mac APACHE II (within 8 30 (60%) (v24.0, SPSS, Chicago, IL, USA). Continuous based line descrip- first 72 hours) <8 20 (40%) tive variables were expressed as mean with standard deviation BISAP score 3 23 (46%) and were compared using the Mann-Whitney Test and univari- <3 18 (36%) Ranson’s score 3 22 (44%) ate ANNOVA test. Categorical variables were expressed as abso- <3 18 (36%) lute numbers and proportions. Bivariate relationships for Modified CTSI 0–2 14 (28%) categorical variables were assessed using Fischer’s exact test 4–6 22 (44%) and Pearson’s chi square test. Sensitivity, specificity, positive 8–10 14 (28%) predictive value and negative predictive value were calculated Atlanta 2012 grade Mild 19 (38%) for each scoring system. Receiver operating characteristics Moderately severe 17 (34%) (ROC) curves for severe acute pancreatitis, ICU admission, pan- Severe 14 (28%) creatic necrosis and organ failure were plotted for Ranson’s Outcome Discharged 43 (86%) score, BISAP, APACHE II and modified CTSI, and predictive accu- Death 3 (6%) racy of each scoring system was measured by the area under Left against medical 4 (8%) ROC curve (AUC) with 95% confidence interval. AUC values were advice compared for statistical significance using De Long test. A ICU admission 14 (28%) p-value of <0.05 was considered statistically significant. CT findings Pancreatic necrosis 15 (30%) Pancreatic fluid 20 (40%) collection Results Pleural effusion 27 (54%) Ascites 24 (48%) Patient characteristics The mean age of patients included in the study was 48.42 (19–80 years). Most of the patients were above the age of 50 years and was 5.63 days, for moderately severe acute pancreatitis 6.58 females (66%). The most common etiology of acute pancreatitis days and for severe acute pancreatitis 9.28 days. This difference was biliary (74%) followed by alcoholic (18%). Patients were clas- in length of stay was statistically significant (p< 0.05). sified as per Atlanta 2012 classification as mild acute pancreati- tis (38%), moderately severe acute pancreatitis (34%) and severe Comparison of scoring systems in predicting severe acute pancreatitis (28%) (Table 1). Out of the 50 patients, 86% acute pancreatitis, organ failure, pancreatic necrosis were discharged in satisfactory condition after recovery from and ICU admission acute phase. A mortality rate of 6% was recorded during the study. Four (8%) patients left against medical advice during the In predicting severe acute pancreatitis according to AUC, modi- course of the study. fied CTSI had the highest accuracy (0.919) followed by APACHE Based on contrast enhanced CT findings, pancreatic necrosis II (0.834), Ranson (0.754) and BISAP (0.684). In predicting pancre- was noted in 30% of patients, pancreatic fluid collections were atic necrosis according to AUC, modified CTSI was the most ac- noted in 40%, pleural effusions were noted in 54% and ascites curate (0.993) followed by Ranson’s score (0.910), APACHE II was noted in 48% (Table 1). ICU care was deemed necessary for (0.855) and BISAP (0.822). In predicting ICU admission according 28% of patients. to AUC, modified CTSI was the most accurate (0.993) followed The mean length of stay in the study was 6.98 days. The by Ranson’s score (0.910), APACHE II (0.885) and BISAP (0.877). In length of stay for those graded as having mild acute pancreatitis predicting organ failure according to AUC, modified CTSI was Downloaded from https://academic.oup.com/gastro/article-abstract/6/2/127/4055926 by Ed 'DeepDyve' Gillespie user on 20 June 2018 130 | A. Harshit Kumar and M. Singh Griwan Table 2. Area under the curve (with 95% confidence interval) of different scoring systems predicting severe acute pancreatitis, pancreatic ne- crosis, organ failure and ICU admission a b Scoring system Severe acute pancreatitis (n¼ 31) Pancreatic necrosis (n¼ 15) Organ failure (n¼ 27) ICU admission (n¼ 14) Ranson’s score 0.754 (0.606–0.901) 0.910 (0.767–1.000) 0.757 (0.602–0.912) 0.910 (0.767–1.000) BISAP 0.684 (0.518–0.849) 0.822 (0.672–0.972) 0.762 (0.605–0.919) 0.877 (0.739–1.000) APACHE II 0.834 (0.711–0.957) 0.855 (0.731–0.979) 0.831 (0.704–0.959) 0.885 (0.783–0.987) Modified CTSI 0.919 (0.844–0.994) 0.993 (0.975–1.000) 0.893 (0.798–0.987) 0.993 (0.975–1.000) Including patients with moderately severe (n¼ 17) and severe acute pancreatitis (n¼ 14). Including transient (n¼ 13) and permanent organ failure (n¼ 14). Table 3. Predictive value of different scoring systems for pancreatic necrosis, organ failure and ICU admission Sensitivity (%) Specificity (%) Positive predictive value (%) Negative predictive value (%) Pancreatic necrosis Ranson’s score (3) 80.00 (44.39–97.48) 96.55 (82.24–99.91) 88.89 (53.21–98.25) 93.33 (80.18–97.98) BISAP (3) 81.82 (48.22–97.72) 83.33 (65.28–94.36) 64.29 (43.55–80.77) 92.59 (77.94–97.79) APACHE II (8) 93.33 (68.05–99.83) 71.43 (53.70–85.36) 58.33 (44.90–70.63) 96.15 (78.81–99.41) Modified CTSI (>4) 93.33 (68.05–99.83) 77.14 (59.86–89.58) 63.64 (48.40–76.55) 96.43 (80.12–99.45) Organ failure Ranson’s score (3) 88.89 (51.75–99.72) 96.67 (82.78–99.92) 88.89 (53.46–98.24) 96.67 (82.03–99.46) BISAP (3) 90.00 (55.50–99.75) 83.87 (66.27–94.55) 64.29 (44.00–80.48) 96.30 (80.10–99.41) APACHE II (8) 92.86 (66.13–99.82) 69.44 (51.89–83.65) 54.17 (41.43–66.39) 96.15 (78.91–99.40) Modified CTSI (>4) 92.86 (66.13–99.82) 75.00 (57.80–87.88) 59.09 (44.61–72.15) 96.43 (80.18–99.45) ICU admission Ranson’s score (3) 80.00 (44.39–97.48) 96.55 (82.24–99.91) 88.89 (53.21–98.25) 93.33 (80.18–97.98) BISAP (3) 90.91 (58.72–99.77) 86.67 (69.28–96.24) 71.43 (49.63–86.38) 96.30 (79.96–99.41) APACHE II (8) 92.31 (63.97–99.81) 65.71 (47.79–80.87) 50.00 (38.11–61.89) 95.83 (77.51–99.35) Modified CTSI (>4) 92.86 (66.13–99.82) 75.00 (57.80–87.88) 59.09 (44.16–72.15) 96.43 (80.18–99.45) Table 4. Pairwise comparison of AUC amongst APACHE II, BISAP and Ranson’s score using the De Long test Comparison Severe acute pancreatitis Pancreatic necrosis Organ failure ICU admission Z statistic P-value Z statistic P-value Z statistic P-value Z statistic P-value APACHE II vs BISAP 2.321 0.02 0.198 0.84 0.890 0.33 0.017 0.98 APACHE II vs Ranson 0.607 0.54 0.152 0.87 0.835 0.40 0.365 0.71 Ranson vs BISAP 1.302 0.19 1.114 0.26 0.261 0.79 0.366 0.71 APACHE II vs modified CTSI 1.488 0.13 2.254 0.02 0.983 0.32 2.244 0.02 BISAP vs modified CTSI 3.039 0.002 2.298 0.02 1.54 0.12 1.618 0.10 Ranson vs modified CTSI 2.449 0.01 1.220 0.22 1.620 0.10 1.220 0.22 the most accurate (0.893) followed by APACHE II (0.831), BISAP benefit from early intensive care therapy. In most cases, it is dif- (0.762) and Ranson’s score (0.762) (Table 2). ficult to assess the severity clinically alone. Based on the highest sensitivity and specificity values gener- The mean age of the study population was 48.42 years and ated from the ROC curves, the following cut-offs were selected for the male-to-female ratio was 0.51 (34% males). Gall stone dis- further analysis: Ranson’s score (3), BISAP (3), APACHE II (8) ease (74%) followed by alcohol (18%) were the most common eti- andmodifiedCTSI(>4), and the results are shown in Table 3. ological factors in our study. The higher incidence of gall stone The AUC derived were further compared using the De Long disease and female preponderance in our study as compared to test. Accuracy of APACHE II was found to be significantly higher similar studies in other parts of India could be attributed to the as compared to BISAP in terms of predicting the severity of higher prevalence of gall stone disease in northern India, where acute pancreatitis (p¼ 0.02) and could be comparable to modi- our institute is located [10,11]. fied CTSI (p¼ 0.13). APACHE II was also comparable to BISAP In this study, 17 (34%) patients are graded as moderately se- and Ranson’s score in predicting pancreatic necrosis, organ fail- vere and 14 (28%) were graded as having severe acute pancrea- ure and ICU admission (Table 4). titis. Pancreatic necrosis was present in 15 (30%) patients, while 14 (28%) developed persistent organ failure and 14 (28%) needed ICU admission. During the course of the study, mortal- Discussion ity was recorded in three (6%) patients. All three patients were graded as having severe acute pancreatitis based on Atlanta Acute pancreatitis is a common ailment encountered by physi- 2012 criteria. The cause of death in all three patients was mul- cians in emergency departments all over the world. It is critical tiple organ failure. Similar mortality rates have been reported to identify patients with severe acute pancreatitis who will Downloaded from https://academic.oup.com/gastro/article-abstract/6/2/127/4055926 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Scoring systems for predicting severity of acute pancreatitis | 131 in large series by Carnovale et al. (4.8%) and Singh et al.(3.5%) References [12,13]. 1. Brivet FG, Emilie D, Galanaud P. Pro- and anti-inflammatory Considering the poor availability of CT scanning and ICU fa- cytokines during acute severe pancreatitis: an early and sus- cilities in our country, we aimed to compare various prognostic tained response, although unpredictable of death. Parisian scoring systems, which may aid in decision making regarding Study Group on Acute Pancreatitis. Crit Care Med 1999;27: which patients need to be referred to a tertiary care center at 749–55. the earliest. 2. Bradley EL 3rd. A clinically based classification system for The AUC for modified CTSI was the highest for all the four acute pancreatitis. In: Summary of the International Symposium parameters considered as markers for severity of acute pancrea- on Acute Pancreatitis, Atlanta, GA, 11–13 September 1992. Arch titis, namely pancreatic necrosis (0.993), need for ICU admission Surg 1993;128:586–90. (0.993), severe acute pancreatitis (0.919) and organ failure 3. Forsmark CE, Baillie J. AGA Institute technical review on (0.893). Most other studies with similar study designs include acute pancreatitis. Gastroenterology 2007;132:2022–44. CTSI rather than modified CTSI. It is important to note that CTSI 4. Banks PA, Bollen TL, Dervenis C et al. Classification of acute has no weight for extra-pancreatic complications such as pleu- pancreatitis—2012: revision of the Atlanta classification and ral effusions and vascular complications, while giving addi- definition by international consensus. Gut 2013;62:102–11. tional weight to pancreatic necrosis involving >50% of the 5. Balthazar EJ, Freeny PC, van Sonnenberg E. Imaging and inter- pancreas. Banday et al. and Mortele et al. observed that modified vention in acute pancreatitis. Radiology 1994;193:297–306. CTSI is a simpler and more accurate scoring tool as compared to 6. Kivisaari L, Somer K, Standertskjold-Nordenstam CG et al. CTSI and has a stronger statistical correlation with length of Early detection of acute fulminant pancreatitis by contrast- stay, development of infection, organ failure and mortality enhanced computed tomography. Scand J Gastroenterol 1983; [14,15]. In one of the few similar studies using modified CTSI, 18:39–41. Yang et al. observed modified CTSI to have outstanding perfor- 7. Beger HG, Maier W, Block S et al. How do imaging methods in- mance (AUC 0.791) in predicting local complications as com- fluence the surgical strategy in acute pancreatitis? In: pared to APACHE II and BISAP [16]. However, it performed Malfertheiner P, Ditschuneit H (eds). Diagnostic Procedures in poorly compared to these scoring systems in predicting severity Pancreatic Disease. Berlin, Germany: Springer-Verlag, 1986, and mortality, and contrast enhanced CT was performed within 54–60. 3 days of onset, which may reduce its sensitivity. Moreover, the 8. Balthazar EJ, Robinson DL, Megibow AJ et al. Acute pancreati- study population was exclusively limited to patients with tis: value of CT in establishing prognosis. Radiology 1990;171: hyperlipidemic acute pancreatitis. 331–6. In the present study, based on AUC comparisons, only 9. Bollen TL, Singh VK, Maurer R et al. Comparative evaluation APACHE II was found to be comparable to modified CTSI in of the modified CT severity index in assessing severity of terms of severity of acute pancreatitis (p¼ 0.13). On the other acute pancreatitis. Am J Roentegenol 2011;197:386–92. hand, the AUC of modified CTSI was significantly higher than 10. Khanna AK, Meher S, Prakash S et al. Comparison of Ranson, Ranson’s score (p¼ 0.02) as well as BISAP (p¼ 0.002) in predicting Glasgow, MOSS, SIRS, BISAP, APACHE II, CTSI Scores, IL-6, the severity of acute pancreatitis. The AUC of APACHE II was CRP and Procalcitonin in predicting severity, organ failure, also found to be significantly higher than BISAP score in predict- pancreatic necrosis, and mortality in acute pancreatitis. HPB ing the severity of acute pancreatitis (p¼ 0.02). Even though the Surg 2013;2013:367581. AUC of Ranson’s score was higher than APACHE II in predicting 11. Yadav J, Yadav SK, Kumar S et al. Predicting morbidity and pancreatic necrosis and ICU admission, the difference was not mortality in acute pancreatitis in an Indian population: a significant (both p> 0.05). Mounzer et al., in a similar study, comparative study of BISAP score, Ranson’s Score and CT se- compared several prognostic scores and also found APACHE II verity index. Gastroenterol Rep (Oxf) 2016;4:216–20. to be more accurate as compared to Ranson’s and BISAP [17]. 12. Carnovale A, Rabitti PG, Manes G et al. Mortality in acute pan- APACHE II was also found to have a high sensitivity and neg- creatitis: is it an early or late event? J Pancreas 2007;8:177–85. ative predictive value for predicting pancreatic necrosis (93.33% 13. Singh VK, Wu B, Bollen TL et al. A prospective evaluation of and 96.15%), organ failure (92.86% and 96.15%) and ICU admis- the Bedside Index for Severity in Acute Pancreatitis score in sion (92.31% and 95.8%), which makes it an ideal scoring system assessing mortality and Intermediate marker of severity in for decision making regarding referral to higher centers. acute pancreatitis. Am J Gastroenterol 2009;104:966–71. The current study has a few limitations. The sample size is 14. Banday IA, Gattoo I, Khan AM et al. Modified computed tomog- too small to make definitive comparisons amongst the scoring raphy severity index for evaluation of acute pancreatitis and systems. The study population consists mostly of pancreatitis its correlation with clinical outcome: a tertiary care hospital secondary to gall stone disease and therefore no meaningful based observational study. J Clin Diagn Res 2015;9:TC01–5. comparisons can be made amongst the various scoring systems 15. Mortele KJ, Wiesner W, Intriere L et al. A modified CT severity for different etiologies. Study differs from other similar studies index for evaluating acute pancreatitis: improved correlation in the use of modified CTSI instead of CTSI, which may make with patient outcome. Am J Roentgenol 2004;183:1261–5. comparisons with other similar studies difficult. 16. Yang L, Liu J, Xing Y et al. Comparison of BISAP, Ranson, In conclusion, although the study is limited by its small sam- MCTSI and APACHE II in predicting severity and prognoses of ple size, which makes it difficult to make any broad recommen- hyperlipidemic acute pancreatitis in Chinese patients. dations, it can be safely said that APACHE II can be a useful tool Gastroenterol Res Pract 2016;2016:1834256. in predicting which patients are likely to develop severe disease 17. Mounzer R, Langmead CJ, Wu BU et al. Comparison of existing early in the course of their illness and it may be somewhat bet- clinical scoring systems to predict persistent organ failure in ter than Ranson’s score and BISAP in this regard. patients with acute pancreatitis. Gastroenterology 2012;142: Conflict of interest statement: none declared. 1476–82. 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A comparison of APACHE II, BISAP, Ranson’s score and modified CTSI in predicting the severity of acute pancreatitis based on the 2012 revised Atlanta Classification

Kumar, Anubhav Harshit; Griwan, Mahavir Singh
Gastroenterology Report , Volume Advance Article (2) – Jul 28, 2017
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Abstract

Objective: Our aim was to prospectively compare the Accuracy of Acute Physiology and Chronic Health Evaluation (APACHE) II, Bedside Index of Severity in Acute Pancreatitis (BISAP), Ranson’s score and modified Computed Tomography Severity Index (CTSI) in predicting the severity of acute pancreatitis based on Atlanta 2012 definitions in a tertiary care hospital in northern India. Methods: Fifty patients with acute pancreatitis admitted to our hospital during the period of March 2015 to September 2016 were included in the study. APACHE II, BISAP and Ranson’s score were calculated for all the cases. Modified CTSI was also determined based on a pancreatic protocol contrast enhanced computerized tomography (CT). Optimal cut-offs for these scoring systems and the area under the curve (AUC) were evaluated based on the receiver operating characteristics (ROC) curve and these scoring systems were compared prospectively. Results: Of the 50 cases, 14 were graded as severe acute pancreatitis. Pancreatic necrosis was present in 15 patients, while 14 developed persistent organ failure and 14 needed intensive care unit (ICU) admission. The AUC for modified CTSI was consistently the highest for predicting severe acute pancreatitis (0.919), pancreatic necrosis (0.993), organ failure (0.893) and ICU admission (0.993). APACHE II was the second most accurate in predicting severe acute pancreatitis (AUC 0.834) and organ failure (0.831). APACHE II had a high sensitivity for predicting pancreatic necrosis (93.33%), organ failure (92.86%) and ICU admission (92.31%), and also had a high negative predictive value for predicting pancreatic necrosis (96.15%), organ failure (96.15%) and ICU admission (95.83%). Conclusion: APACHE II is a useful prognostic scoring system for predicting the severity of acute pancreatitis and can be a crucial aid in determining the group of patients that have a high chance of need for tertiary care during the course of their illness and therefore need early resuscitation and prompt referral, especially in resource-limited developing countries. Key words: Acute pancreatitis; Accuracy of Acute Physiology and Chronic Health Evaluation II (APACHE II); Bedside Index of Severity in Acute Pancreatitis (BISAP); Ranson’s score; modified Computed Tomography Severity Index (modified CTSI) Submitted: 27 February 2017; Revised: 2 June 2017; Accepted: 6 June 2017 V C The Author(s) 2017. Published by Oxford University Press and Sixth Affiliated Hospital of Sun Yat-Sen University This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/gastro/article-abstract/6/2/127/4055926 by Ed 'DeepDyve' Gillespie user on 20 June 2018 128 | A. Harshit Kumar and M. Singh Griwan Introduction Materials and methods Data collection Acute pancreatitis is a common and frequent inflammatory dis- order of the pancreas with variable involvement of other re- Demographic, clinical, biochemical and radiographic data were gional tissues or remote organ systems [1]. The disease has a prospectively collected from 50 patients admitted over the dura- varying etiology with an overall mortality of 5–10%. Most cases tion of March 2015 to September 2016 in the Department of (80–90%) are mild and self-limited with a good outcome. The re- General Surgery in Pt. B. D. Sharma PGIMS, Rohtak. The study maining 10–20% of patients with severe disease characteristi- was limited to 50 patients, since the it had to be completed dur- cally have pancreatic necrosis or distant organ failure and can ing a fixed timeframe of 2 years and only patients admitted and anticipate the need for intensive care and possible operative in- treated under the direct supervision of the authors were tervention with a mortality rate of up to 40% [2]. considered. Early diagnosis and precise staging of disease severity are The diagnoses of acute pancreatitis was based on the pres- important goals in the initial evaluation and management of ence of two of the following three criteria: (i) abdominal pain acute pancreatitis. While patients with mild acute pancreatitis characteristic of acute pancreatitis; (ii) serum amylase and/or li- can be managed with fluid resuscitation and supportive care, pase levels at least three times the upper limit of normal; and those with severe acute pancreatitis require maximal non- (iii) characteristic findings of acute pancreatitis on abdominal operative care and nutritional support in an intensive care unit ultrasonography and/or computerized tomography (CT) scan. (ICU). Due to the risk of rapid deterioration in severe acute pan- Patients who presented to the emergency department and were creatitis, the assessment of severity becomes crucial to a clini- diagnosed as having acute pancreatitis based on the criteria cian [3]. mentioned above were informed about the study and written A clinically based classification system for acute pancreatitis consent was taken. Patients who were diagnosed to have was established in the International Symposium on Acute chronic pancreatitis based on their previous hospital records or Pancreatitis in Atlanta, Georgia, in 1992. However, criticism of found to have features of chronic pancreatitis upon radiological the Atlanta severity classification system was growing be- investigations during the course of their stay such as pancreatic cause it was retrospective, the duration of organ failure was calcifications, dilated pancreatic duct, areas of atrophy and unspecified and local complications did not seem to increase pseudocysts were excluded from the study. mortality. The Atlanta classification was revised via an interna- After detailed history and physical examination, laboratory tional, web-based consensus in 2012 that provided clear defini- investigations were sent at the time of admission—arterial tions to classify acute pancreatitis using easily identifiable blood gas analysis, hematocrit, kidney function test, liver func- clinical and radiologic criteria. Greater emphasis was laid on or- tion test, serum electrolytes, serum amylase, serum lipase and gan failure and severity was graded as mild, moderately severe complete hemogram. All patients underwent abdominal ultra- and severe acute pancreatitis [4]. sonography at admission and contrast enhanced pancreatic Several multi-factorial scoring systems based on clinical and protocol CT scan 72 hours after symptom onset. biochemical data have been used over the past few decades. Patients were subsequently examined daily and laboratory These include Ranson’s score described in 1974, BISAP and investigations relevant to APACHE II, Ranson’s criteria and APACHE II to name a few. Each of these scoring systems has its BISAP score were sent. APACHE II score was evaluated for each own limitations including the low sensitivity and specificity, patient within first 24, 48 and 72 hours of admission. BISAP was complexity of the scoring system as well as inability to obtain a calculated within first 24 hours of admission. Ranson’s score final score until 48 hours after admission [5]. was evaluated within first 48 hours of admission. With the advent of contrast enhanced scans, there has been major improvement in the grading system. Attenuation values of pancreatic parenchyma during an intra-venous bolus study can Definitions be used as an indicator of pancreatic necrosis and as a predictor At the time of discharge/death, patients were graded as having of disease severity [6,7]. Contrast enhanced CT has shown an mild, moderately severe and severe acute pancreatitis based on overall accuracy of 87% with a sensitivity of 100% for the detec- the Atlanta 2012 classification. Patients with mild acute pancre- tion of extended pancreatic necrosis. The sensitivity and specific- atitis had neither local complications nor organ failure. Patients ity for diagnosing pancreatic necrosis increase with greater with moderately severe acute pancreatitis had transient organ degrees of pancreatic non-enhancement, and complications failure or local complications or both, whereas patients with se- have also been shown to correlate with the degree of non- vere acute pancreatitis had persistent organ failure. enhancement [8]. However, early CT scans often fail to identify Organ failure was defined based on the Modified Marshall developing necrosis until such areas are better demarcated, scoring system. A score of 2 for more than 48 hours was con- which may become evident only 2–3 days after the initial clinical sidered as persistent organ failure, whereas a score of 2 for onset of symptoms. In 2004, modified CTSI was introduced to im- less than 48 hours was considered as transient organ failure. prove the staging of acute pancreatitis. A study of comparison be- Local complications included pancreatic necrosis, acute fluid tween CTSI and modified CTSI and comparison of both with collections, pseudocyst, acute necrotic collections and walled- APACHE II concluded that modified CTSI was better than CTSI for off necrosis. assessing the severity of acute pancreatitis and the CTSI is better than APACHE II in assessing severe acute pancreatitis [9]. There have been few studies comparing these prognostic Management protocols scoring systems based on the revised Atlanta classification. This study aimed to assess and compare the prediction of sever- Patients presenting to the emergency department, suspected of ity of acute pancreatitis based on multi-factorial scoring sys- having acute pancreatitis, were adequately resuscitated using tems viz. Ranson, BISAP, APACHE II and modified CTSI in a crystalloids, primarily ringer’s lactate. Inotropes and colloids tertiary care center. were added if the patients failed to respond to crystalloids. Downloaded from https://academic.oup.com/gastro/article-abstract/6/2/127/4055926 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Scoring systems for predicting severity of acute pancreatitis | 129 Table 1. Patient characteristics All patients were catheterized to monitor the urine output and ascertain the adequacy of resuscitation. Central venous ac- Characteristics Category No. of patients (%) cess was obtained for patients who failed to respond to initial resuscitation measures to monitor the central venous pressure Sex Male 17 (34%) and guide further fluid management. A nasogastric tube was Female 33 (66%) placed for all patients. All patients were kept nil per oral for the Age group (years) 60 16 (32%) first 24 hours. Subsequently, patients were examined daily and 50–59 11 (22%) enteral feeding by means of a nasogastric tube or orally was ini- 40–49 10 (20%) tiated as soon as features of ileus resolved. 30–39 7 (14%) Patients with pancreatic necrosis who failed to improve 20–29 5 (10%) <20 1 (2%) were planned for necrosectomy and open drainage. A total of Etiology Gall stone disease 37 (74%) two patients underwent surgical intervention for pancreatic ne- Alcoholic 9 (18%) crosis. Patients with cholelithiasis underwent pre-anesthetic Traumatic 1 (2%) checkup and pre-operative work-up prior to discharge and Idiopathic 3 (6%) planned to undergo cholecystectomy after 6 weeks as per insti- Presentation Pain in abdomen 50 (100%) tutional protocol. Facilities for endoscopic retrograde cholangio- Radiating 32 (64%) pancreatography (ERCP) are not available at our institute. Non-radiating 18 (36%) Peritonitis 44 (88%) Localized 26 (59%) Statistics Diffuse 18 (41%) Severity of the disease was evaluated in terms of ICU admission, Vomiting 39 (78%) length of hospital stay, final grade as per Atlanta 2012 classifica- Distension of abdomen 28 (56%) tion and presence of pancreatic necrosis. Data were collected Non-passage of stool 22 (44%) prospectively in a Microsoft Excel Database. After completion of and flatus data collection, the database was imported into SPSS for Mac APACHE II (within 8 30 (60%) (v24.0, SPSS, Chicago, IL, USA). Continuous based line descrip- first 72 hours) <8 20 (40%) tive variables were expressed as mean with standard deviation BISAP score 3 23 (46%) and were compared using the Mann-Whitney Test and univari- <3 18 (36%) Ranson’s score 3 22 (44%) ate ANNOVA test. Categorical variables were expressed as abso- <3 18 (36%) lute numbers and proportions. Bivariate relationships for Modified CTSI 0–2 14 (28%) categorical variables were assessed using Fischer’s exact test 4–6 22 (44%) and Pearson’s chi square test. Sensitivity, specificity, positive 8–10 14 (28%) predictive value and negative predictive value were calculated Atlanta 2012 grade Mild 19 (38%) for each scoring system. Receiver operating characteristics Moderately severe 17 (34%) (ROC) curves for severe acute pancreatitis, ICU admission, pan- Severe 14 (28%) creatic necrosis and organ failure were plotted for Ranson’s Outcome Discharged 43 (86%) score, BISAP, APACHE II and modified CTSI, and predictive accu- Death 3 (6%) racy of each scoring system was measured by the area under Left against medical 4 (8%) ROC curve (AUC) with 95% confidence interval. AUC values were advice compared for statistical significance using De Long test. A ICU admission 14 (28%) p-value of <0.05 was considered statistically significant. CT findings Pancreatic necrosis 15 (30%) Pancreatic fluid 20 (40%) collection Results Pleural effusion 27 (54%) Ascites 24 (48%) Patient characteristics The mean age of patients included in the study was 48.42 (19–80 years). Most of the patients were above the age of 50 years and was 5.63 days, for moderately severe acute pancreatitis 6.58 females (66%). The most common etiology of acute pancreatitis days and for severe acute pancreatitis 9.28 days. This difference was biliary (74%) followed by alcoholic (18%). Patients were clas- in length of stay was statistically significant (p< 0.05). sified as per Atlanta 2012 classification as mild acute pancreati- tis (38%), moderately severe acute pancreatitis (34%) and severe Comparison of scoring systems in predicting severe acute pancreatitis (28%) (Table 1). Out of the 50 patients, 86% acute pancreatitis, organ failure, pancreatic necrosis were discharged in satisfactory condition after recovery from and ICU admission acute phase. A mortality rate of 6% was recorded during the study. Four (8%) patients left against medical advice during the In predicting severe acute pancreatitis according to AUC, modi- course of the study. fied CTSI had the highest accuracy (0.919) followed by APACHE Based on contrast enhanced CT findings, pancreatic necrosis II (0.834), Ranson (0.754) and BISAP (0.684). In predicting pancre- was noted in 30% of patients, pancreatic fluid collections were atic necrosis according to AUC, modified CTSI was the most ac- noted in 40%, pleural effusions were noted in 54% and ascites curate (0.993) followed by Ranson’s score (0.910), APACHE II was noted in 48% (Table 1). ICU care was deemed necessary for (0.855) and BISAP (0.822). In predicting ICU admission according 28% of patients. to AUC, modified CTSI was the most accurate (0.993) followed The mean length of stay in the study was 6.98 days. The by Ranson’s score (0.910), APACHE II (0.885) and BISAP (0.877). In length of stay for those graded as having mild acute pancreatitis predicting organ failure according to AUC, modified CTSI was Downloaded from https://academic.oup.com/gastro/article-abstract/6/2/127/4055926 by Ed 'DeepDyve' Gillespie user on 20 June 2018 130 | A. Harshit Kumar and M. Singh Griwan Table 2. Area under the curve (with 95% confidence interval) of different scoring systems predicting severe acute pancreatitis, pancreatic ne- crosis, organ failure and ICU admission a b Scoring system Severe acute pancreatitis (n¼ 31) Pancreatic necrosis (n¼ 15) Organ failure (n¼ 27) ICU admission (n¼ 14) Ranson’s score 0.754 (0.606–0.901) 0.910 (0.767–1.000) 0.757 (0.602–0.912) 0.910 (0.767–1.000) BISAP 0.684 (0.518–0.849) 0.822 (0.672–0.972) 0.762 (0.605–0.919) 0.877 (0.739–1.000) APACHE II 0.834 (0.711–0.957) 0.855 (0.731–0.979) 0.831 (0.704–0.959) 0.885 (0.783–0.987) Modified CTSI 0.919 (0.844–0.994) 0.993 (0.975–1.000) 0.893 (0.798–0.987) 0.993 (0.975–1.000) Including patients with moderately severe (n¼ 17) and severe acute pancreatitis (n¼ 14). Including transient (n¼ 13) and permanent organ failure (n¼ 14). Table 3. Predictive value of different scoring systems for pancreatic necrosis, organ failure and ICU admission Sensitivity (%) Specificity (%) Positive predictive value (%) Negative predictive value (%) Pancreatic necrosis Ranson’s score (3) 80.00 (44.39–97.48) 96.55 (82.24–99.91) 88.89 (53.21–98.25) 93.33 (80.18–97.98) BISAP (3) 81.82 (48.22–97.72) 83.33 (65.28–94.36) 64.29 (43.55–80.77) 92.59 (77.94–97.79) APACHE II (8) 93.33 (68.05–99.83) 71.43 (53.70–85.36) 58.33 (44.90–70.63) 96.15 (78.81–99.41) Modified CTSI (>4) 93.33 (68.05–99.83) 77.14 (59.86–89.58) 63.64 (48.40–76.55) 96.43 (80.12–99.45) Organ failure Ranson’s score (3) 88.89 (51.75–99.72) 96.67 (82.78–99.92) 88.89 (53.46–98.24) 96.67 (82.03–99.46) BISAP (3) 90.00 (55.50–99.75) 83.87 (66.27–94.55) 64.29 (44.00–80.48) 96.30 (80.10–99.41) APACHE II (8) 92.86 (66.13–99.82) 69.44 (51.89–83.65) 54.17 (41.43–66.39) 96.15 (78.91–99.40) Modified CTSI (>4) 92.86 (66.13–99.82) 75.00 (57.80–87.88) 59.09 (44.61–72.15) 96.43 (80.18–99.45) ICU admission Ranson’s score (3) 80.00 (44.39–97.48) 96.55 (82.24–99.91) 88.89 (53.21–98.25) 93.33 (80.18–97.98) BISAP (3) 90.91 (58.72–99.77) 86.67 (69.28–96.24) 71.43 (49.63–86.38) 96.30 (79.96–99.41) APACHE II (8) 92.31 (63.97–99.81) 65.71 (47.79–80.87) 50.00 (38.11–61.89) 95.83 (77.51–99.35) Modified CTSI (>4) 92.86 (66.13–99.82) 75.00 (57.80–87.88) 59.09 (44.16–72.15) 96.43 (80.18–99.45) Table 4. Pairwise comparison of AUC amongst APACHE II, BISAP and Ranson’s score using the De Long test Comparison Severe acute pancreatitis Pancreatic necrosis Organ failure ICU admission Z statistic P-value Z statistic P-value Z statistic P-value Z statistic P-value APACHE II vs BISAP 2.321 0.02 0.198 0.84 0.890 0.33 0.017 0.98 APACHE II vs Ranson 0.607 0.54 0.152 0.87 0.835 0.40 0.365 0.71 Ranson vs BISAP 1.302 0.19 1.114 0.26 0.261 0.79 0.366 0.71 APACHE II vs modified CTSI 1.488 0.13 2.254 0.02 0.983 0.32 2.244 0.02 BISAP vs modified CTSI 3.039 0.002 2.298 0.02 1.54 0.12 1.618 0.10 Ranson vs modified CTSI 2.449 0.01 1.220 0.22 1.620 0.10 1.220 0.22 the most accurate (0.893) followed by APACHE II (0.831), BISAP benefit from early intensive care therapy. In most cases, it is dif- (0.762) and Ranson’s score (0.762) (Table 2). ficult to assess the severity clinically alone. Based on the highest sensitivity and specificity values gener- The mean age of the study population was 48.42 years and ated from the ROC curves, the following cut-offs were selected for the male-to-female ratio was 0.51 (34% males). Gall stone dis- further analysis: Ranson’s score (3), BISAP (3), APACHE II (8) ease (74%) followed by alcohol (18%) were the most common eti- andmodifiedCTSI(>4), and the results are shown in Table 3. ological factors in our study. The higher incidence of gall stone The AUC derived were further compared using the De Long disease and female preponderance in our study as compared to test. Accuracy of APACHE II was found to be significantly higher similar studies in other parts of India could be attributed to the as compared to BISAP in terms of predicting the severity of higher prevalence of gall stone disease in northern India, where acute pancreatitis (p¼ 0.02) and could be comparable to modi- our institute is located [10,11]. fied CTSI (p¼ 0.13). APACHE II was also comparable to BISAP In this study, 17 (34%) patients are graded as moderately se- and Ranson’s score in predicting pancreatic necrosis, organ fail- vere and 14 (28%) were graded as having severe acute pancrea- ure and ICU admission (Table 4). titis. Pancreatic necrosis was present in 15 (30%) patients, while 14 (28%) developed persistent organ failure and 14 (28%) needed ICU admission. During the course of the study, mortal- Discussion ity was recorded in three (6%) patients. All three patients were graded as having severe acute pancreatitis based on Atlanta Acute pancreatitis is a common ailment encountered by physi- 2012 criteria. The cause of death in all three patients was mul- cians in emergency departments all over the world. It is critical tiple organ failure. 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Khanna AK, Meher S, Prakash S et al. Comparison of Ranson, Ranson’s score (p¼ 0.02) as well as BISAP (p¼ 0.002) in predicting Glasgow, MOSS, SIRS, BISAP, APACHE II, CTSI Scores, IL-6, the severity of acute pancreatitis. The AUC of APACHE II was CRP and Procalcitonin in predicting severity, organ failure, also found to be significantly higher than BISAP score in predict- pancreatic necrosis, and mortality in acute pancreatitis. HPB ing the severity of acute pancreatitis (p¼ 0.02). Even though the Surg 2013;2013:367581. AUC of Ranson’s score was higher than APACHE II in predicting 11. Yadav J, Yadav SK, Kumar S et al. Predicting morbidity and pancreatic necrosis and ICU admission, the difference was not mortality in acute pancreatitis in an Indian population: a significant (both p> 0.05). Mounzer et al., in a similar study, comparative study of BISAP score, Ranson’s Score and CT se- compared several prognostic scores and also found APACHE II verity index. Gastroenterol Rep (Oxf) 2016;4:216–20. to be more accurate as compared to Ranson’s and BISAP [17]. 12. Carnovale A, Rabitti PG, Manes G et al. Mortality in acute pan- APACHE II was also found to have a high sensitivity and neg- creatitis: is it an early or late event? J Pancreas 2007;8:177–85. ative predictive value for predicting pancreatic necrosis (93.33% 13. Singh VK, Wu B, Bollen TL et al. A prospective evaluation of and 96.15%), organ failure (92.86% and 96.15%) and ICU admis- the Bedside Index for Severity in Acute Pancreatitis score in sion (92.31% and 95.8%), which makes it an ideal scoring system assessing mortality and Intermediate marker of severity in for decision making regarding referral to higher centers. acute pancreatitis. Am J Gastroenterol 2009;104:966–71. The current study has a few limitations. The sample size is 14. Banday IA, Gattoo I, Khan AM et al. Modified computed tomog- too small to make definitive comparisons amongst the scoring raphy severity index for evaluation of acute pancreatitis and systems. The study population consists mostly of pancreatitis its correlation with clinical outcome: a tertiary care hospital secondary to gall stone disease and therefore no meaningful based observational study. J Clin Diagn Res 2015;9:TC01–5. comparisons can be made amongst the various scoring systems 15. Mortele KJ, Wiesner W, Intriere L et al. A modified CT severity for different etiologies. Study differs from other similar studies index for evaluating acute pancreatitis: improved correlation in the use of modified CTSI instead of CTSI, which may make with patient outcome. Am J Roentgenol 2004;183:1261–5. comparisons with other similar studies difficult. 16. Yang L, Liu J, Xing Y et al. Comparison of BISAP, Ranson, In conclusion, although the study is limited by its small sam- MCTSI and APACHE II in predicting severity and prognoses of ple size, which makes it difficult to make any broad recommen- hyperlipidemic acute pancreatitis in Chinese patients. dations, it can be safely said that APACHE II can be a useful tool Gastroenterol Res Pract 2016;2016:1834256. in predicting which patients are likely to develop severe disease 17. Mounzer R, Langmead CJ, Wu BU et al. Comparison of existing early in the course of their illness and it may be somewhat bet- clinical scoring systems to predict persistent organ failure in ter than Ranson’s score and BISAP in this regard. patients with acute pancreatitis. Gastroenterology 2012;142: Conflict of interest statement: none declared. 1476–82. Downloaded from https://academic.oup.com/gastro/article-abstract/6/2/127/4055926 by Ed 'DeepDyve' Gillespie user on 20 June 2018

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Published: Jul 28, 2017

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