The Bedside Index for Severity in Acute Pancreatitis: a systematic review of prospective studies to determine predictive performance

Comparison of Bedside Index for Severity in Acute Pancreatitis and Emergency Department SpO2, Age and Systemic Inflammatory Response Syndrome Scores in Predicting Severe Acute Pancreatitis in Patients with Acute Pancreatitis in the Emergency Department

BACKGROUND

As the mortality of severe acute pancreatitis (SAP) is significantly higher than those with mild or moderate severity, it is of clinical significance to identify patients most likely to develop SAP at the time of emergency department (ED) presentation.

OBJECTIVES

The aim of this study was to compare the performance of the Bedside Index for Severity in Acute Pancreatitis (BISAP) and the Emergency Department SpO2, Age and SIRS (ED-SAS) scoring systems as early risk assessment tools for identifying patients at high-risk of developing SAP.

METHODS

We retrospectively reviewed adult patients with AP presented to ED between January 2019-September 2022. We calculated the scores of each patient with the parameters of the initial data. The primary outcome was SAP. The secondary outcomes were 30-day mortality, intensive care admission, and identifying low-risk patients without complications.

RESULTS

Of 415 patients, 34 (8.2%) developed SAP and 15 (3.6%) died. With regard to predicting SAP, BISAP and ED-SAS scores had similar discriminative ability with area under the curves (AUCs) of 0.84 (95% confidence interval [CI]:0.80-0.88) and 0.83 (95% CI:0.79-0.86), respectively (p = 0.642). At a cut-off score of ≥2 for SAP, sensitivity/specificity values were 73.5%/82.4% for BISAP, 76.5%/83.2% for ED-SAS. BISAP and ED-SAS scores of ≥3, yielded sensitivity/specificity values of 50%/95.8% and 35.3%/95.5%, respectively. BISAP and ED-SAS were also similar in predicting mortality (AUCs of 0.92 vs. 0.90, respectively) and intensive care unit admission (AUCs 0.91 vs. 0.91).

CONCLUSION

The BISAP and ED-SAS scores performed similarly in predicting SAP, mortality, and intensive care unit admission. As an easily calculated tool early in the ED, ED-SAS may be helpful in disposition decisions for emergency physicians.

Predictive value of the Ranson and BISAP scoring systems for the severity and prognosis of acute pancreatitis: A systematic review and meta-analysis

BACKGROUND

To systematically assess and compare the predictive value of the Ranson and Bedside Index of Severity in Acute Pancreatitis (BISAP) scoring systems for the severity and prognosis of acute pancreatitis (AP).

METHODS

PubMed, Embase, Cochrane Library, and Web of Science were systematically searched until February 15, 2023. Outcomes in this analysis included severity and prognosis [mortality, organ failure, pancreatic necrosis, and intensive care unit (ICU) admission]. The revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to evaluate the quality of diagnostic accuracy studies. The threshold effect was evaluated for each outcome. The sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the area under the summary receiver operating characteristic (SROC) curve (AUC) as well as 95% confidence intervals (CI) were calculated. The DeLong test was used for AUC comparisons. For the outcome evaluated by over 9 studies, publication bias was assessed using the Deeks' funnel plot asymmetry test.

RESULTS

Totally 17 studies of 5476 AP patients were included. For severity, the pooled sensitivity of the Ranson and BISAP was 0.95 (95%CI: 0.87, 0.98) and 0.67 (95%CI: 0.27, 0.92); the pooled specificity of the Ranson and BISAP was 0.74 (0.52, 0.88) and 0.95 (95%CI: 0.85, 0.98); the pooled AUC of the Ranson and BISAP was 0.95 (95%CI: 0.93, 0.97) and 0.94 (95%CI: 0.92, 0.96) (P = 0.480). For mortality, the pooled sensitivity of the Ranson and BISAP was 0.89 (95%CI: 0.73, 0.96) and 0.77 (95%CI: 0.58, 0.89); the pooled specificity of the Ranson and BISAP was 0.79 (95%CI: 0.68, 0.87) and 0.90 (95%CI: 0.86, 0.93); the pooled AUC of the Ranson and BISAP was 0.91 (95%CI: 0.88, 0.93) and 0.92 (95%CI: 0.90, 0.94) (P = 0.480). For organ failure, the pooled sensitivity of the Ranson and BISAP was 0.84 (95%CI: 0.76, 0.90) and 0.78 (95%CI: 0.60, 0.90); the pooled specificity of the Ranson and BISAP was 0.84 (95%CI: 0.63, 0.94) and 0.90 (95%CI: 0.72, 0.97); the pooled AUC of the Ranson and BISAP was 0.86 (95%CI: 0.82, 0.88) and 0.90 (95%CI: 0.87, 0.93) (P = 0.110). For pancreatic necrosis, the pooled sensitivity of the Ranson and BISAP was 0.63 (95%CI: 0.35, 0.84) and 0.63 (95%CI: 0.23, 0.90); the pooled specificity of the Ranson and BISAP was 0.90 (95%CI: 0.77, 0.96) and 0.93 (95%CI: 0.89, 0.96); the pooled AUC of the Ranson and BISAP was 0.87 (95%CI: 0.84, 0.90) and 0.93 (95%CI: 0.91, 0.95) (P = 0.001). For ICU admission, the pooled sensitivity of the Ranson and BISAP was 0.86 (95%CI: 0.77, 0.92) and 0.63 (95%CI: 0.52, 0.73); the pooled specificity of the Ranson and BISAP was 0.58 (95%CI: 0.55, 0.61) and 0.84 (95%CI: 0.81, 0.86); the pooled AUC of the Ranson and BISAP was 0.92 (95%CI: 0.81, 1.00) and 0.86 (95%CI: 0.67, 1.00) (P = 0.592).

CONCLUSION

The Ranson score was an applicable tool for predicting severity and prognosis of AP patients with reliable diagnostic accuracy in resource and time-limited settings. Future large-scale studies are needed to verify the findings.

Updated Review of Radiologic Imaging and Intervention for Acute Pancreatitis and Its Complications

This is a current update on radiologic imaging and intervention of acute pancreatitis and its complications. In this review, we define the various complications of acute pancreatitis, discuss the imaging findings, as well as the timing of when these complications occur. The various classification and scoring systems of acute pancreatitis are summarized. Advantages and disadvantages of the 3 primary radiologic imaging modalities are compared. We then discuss radiologic interventions for acute pancreatitis. These include diagnostic aspiration as well as percutaneous catheter drainage of fluid collections, abscesses, pseudocysts, and necrosis. Recommendations for when these interventions should be considered, as well as situations in which they are contraindicated are discussed. Fortunately, acute pancreatitis usually is mild; however, serious complications occur in 20%, and admission of patients to the intensive care unit (ICU) occurs in over 10%. In this paper, we will focus on the imaging and interventional radiologic aspects for the serious complications and patients admitted to the ICU.

Real-time artificial intelligence predicts adverse outcomes in acute pancreatitis in the emergency department: Comparison with clinical decision rule

OBJECTIVE

Artificial intelligence (AI) prediction is increasingly used for decision making in health care, but its application for adverse outcomes in emergency department (ED) patients with acute pancreatitis (AP) is not well understood. This study aimed to clarify this aspect.

METHODS

Data from 8274 ED patients with AP in three hospitals from 2009 to 2018 were analyzed. Demographic data, comorbidities, laboratory results, and adverse outcomes were included. Six algorithms were evaluated, and the one with the highest area under the curve (AUC) was implemented into the hospital information system (HIS) for real-time prediction. Predictive accuracy was compared between the AI model and Bedside Index for Severity in Acute Pancreatitis (BISAP).

RESULTS

The mean ± SD age was 56.1 ± 16.7 years, with 67.7% being male. The AI model was successfully implemented in the HIS, with Light Gradient Boosting Machine (LightGBM) showing the highest AUC for sepsis (AUC 0.961) and intensive care unit (ICU) admission (AUC 0.973), and eXtreme Gradient Boosting (XGBoost) showing the highest AUC for mortality (AUC 0.975). Compared to BISAP, the AI model had superior AUC for sepsis (BISAP 0.785), ICU admission (BISAP 0.778), and mortality (BISAP 0.817).

CONCLUSIONS

The first real-time AI prediction model implemented in the HIS for predicting adverse outcomes in ED patients with AP shows favorable initial results. However, further external validation is needed to ensure its reliability and accuracy.

Clinical usefulness of scoring systems to predict severe acute pancreatitis: A systematic review and meta-analysis with pre and post-test probability assessment

BACKGROUND

Scoring systems for severe acute pancreatitis (SAP) prediction should be used in conjunction with pre-test probability to establish post-test probability of SAP, but data of this kind are lacking.

OBJECTIVE

To investigate the predictive value of commonly employed scoring systems and their usefulness in modifying the pre-test probability of SAP.

METHODS

Following PRISMA statement and MOOSE checklists after PROSPERO registration, PubMed was searched from inception until September 2022. Retrospective, prospective, cross-sectional studies or clinical trials on patients with acute pancreatitis defined as Revised Atlanta Criteria, reporting rate of SAP and using at least one score among Bedside Index for Severity in Acute Pancreatitis (BISAP), Acute Physiology and Chronic Health Examination (APACHE)-II, RANSON, and Systemic Inflammatory Response Syndrome (SIRS) with their sensitivity and specificity were included. Random effects model meta-analyses were performed. Pre-test probability and likelihood ratio (LR) were combined to estimate post-test probability on Fagan nomograms. Pooled severity rate was used as pre-test probability of SAP and pooled sensitivity and specificity to calculate LR and generate post-test probability. A priori hypotheses for heterogeneity were developed and sensitivity analyses planned.

RESULTS

43 studies yielding 14,116 acute pancreatitis patients were included: 42 with BISAP, 30 with APACHE-II, 27 with Ranson, 8 with SIRS. Pooled pre-test probability of SAP ranged 16.6%-25.3%. The post-test probability of SAP with positive/negative score was 47%/6% for BISAP, 43%/5% for APACHE-II, 48%/5% for Ranson, 40%/12% for SIRS. In 18 studies comparing BISAP, APACHE-II, and Ranson in 6740 patients with pooled pre-test probability of SAP of 18.7%, post-test probability when scores were positive was 48% for BISAP, 46% for APACHE-II, 50% for Ranson. When scores were negative, post-test probability dropped to 7% for BISAP, 6% for Ranson, 5% for APACHE-II. Quality, design, and country of origin of the studies did not explain the observed high heterogeneity.

CONCLUSIONS

The most commonly used scoring systems to predict SAP perform poorly and do not aid in decision-making.

Acute pancreatitis: A review of diagnosis, severity prediction and prognosis assessment from imaging technology, scoring system and artificial intelligence

Acute pancreatitis (AP) is a potentially life-threatening inflammatory disease of the pancreas, with clinical management determined by the severity of the disease. Diagnosis, severity prediction, and prognosis assessment of AP typically involve the use of imaging technologies, such as computed tomography, magnetic resonance imaging, and ultrasound, and scoring systems, including Ranson, Acute Physiology and Chronic Health Evaluation II, and Bedside Index for Severity in AP scores. Computed tomography is considered the gold standard imaging modality for AP due to its high sensitivity and specificity, while magnetic resonance imaging and ultrasound can provide additional information on biliary obstruction and vascular complications. Scoring systems utilize clinical and laboratory parameters to classify AP patients into mild, moderate, or severe categories, guiding treatment decisions, such as intensive care unit admission, early enteral feeding, and antibiotic use. Despite the central role of imaging technologies and scoring systems in AP management, these methods have limitations in terms of accuracy, reproducibility, practicality and economics. Recent advancements of artificial intelligence (AI) provide new opportunities to enhance their performance by analyzing vast amounts of clinical and imaging data. AI algorithms can analyze large amounts of clinical and imaging data, identify scoring system patterns, and predict the clinical course of disease. AI-based models have shown promising results in predicting the severity and mortality of AP, but further validation and standardization are required before widespread clinical application. In addition, understanding the correlation between these three technologies will aid in developing new methods that can accurately, sensitively, and specifically be used in the diagnosis, severity prediction, and prognosis assessment of AP through complementary advantages.

Severe Acute Pancreatitis Prediction: A Model Derived From a Prospective Registry Cohort

Background Severe acute pancreatitis (SAP) has a mortality rate as high as 40%. Early identification of SAP is required to appropriately triage and direct initial therapies. The purpose of this study was to develop a prognostic model that identifies patients at risk for developing SAP of patients managed according to a guideline-based standardized early medical management (EMM) protocol. Methods This single-center study included all patients diagnosed with acute pancreatitis (AP) and managed with the EMM protocol Methodist Acute Pancreatitis Protocol (MAPP) between April 2017 and September 2022. Classification and regression tree (CART®; Professional Extended Edition, version 8.0; Salford Systems, San Diego, CA), univariate, and logistic regression analyses were performed to develop a scoring system for AP severity prediction. The accuracy of the scoring system was measured by the area under the receiver operating characteristic curve. Results A total of 516 patients with mild (n=436) or moderately severe and severe (n=80) AP were analyzed. CART analysis identified the cutoff values: creatinine (CR) (1.15 mg/dL), white blood cells (WBC) (10.5 × 109/L), procalcitonin (PCT) (0.155 ng/mL), and systemic inflammatory response system (SIRS). The prediction model was built with a multivariable logistic regression analysis, which identified CR, WBC, PCT, and SIRS as the main predictors of severity. When CR and only one other predictor value (WBC, PCT, or SIRS) met thresholds, then the probability of predicting SAP was >30%. The probability of predicting SAP was 72% (95%CI: 0.59-0.82) if all four of the main predictors were greater than the cutoff values. Conclusions Baseline laboratory cutoff values were identified and a logistic regression-based prognostic model was developed to identify patients treated with a standardized EMM who were at risk for SAP.

Early predictive value of scoring systems and routine laboratory tests in severity and prognosis of acute pancreatitis in pregnancy

Background

Currently, no guidelines specifically recommend scoring systems and biomarkers for early evaluation of the severity and prognosis of acute pancreatitis in pregnancy (APIP).

Objectives

This study aimed to explore the early predictive value of scoring systems and routine laboratory tests on APIP severity and maternofetal prognosis.

Design

This study retrospectively analyzed 62 APIP cases in a 6-year period.

Methods

The predictive value of scoring systems and routine laboratory tests that were collected 24 h and 48 h after admission, for APIP severity and fetal loss, were analyzed.

Results

To detect severe acute pancreatitis (SAP), a 24-h Bedside Index for severity in acute pancreatitis (BISAP) achieved a higher area under the curve (AUC) value of 0.910 than the Acute Physiology and Chronic Health Evaluation II (AUC = 0.898) and Ranson score (AUC = 0.880). The combination of BISAP, glucose, neutrophil-to-lymphocyte ratio (NLR), hematocrit (Hct), and serum creatinine (Scr) provided an AUC value of 0.984, which had greater predictive power than BISAP (p = 0.015). 24-h BISAP and Hct were independent risk factors for predicting SAP of APIP. The cutoff values of Hct and blood urea nitrogen (BUN) to predict SAP were 35.60% and 3.75 mmol/l in the APIP. Furthermore, 24-h BISAP had the highest predictive power (AUC = 0.958) for fetal loss.

Conclusion

BISAP is a convenient and reliable indicator for the early prediction of SAP and fetal loss in APIP. The combination of BISAP, glucose, NLR, Hct and Scr proved to be the optimal early markers for the prediction of SAP in APIP within 24 h after admission. In addition, Hct > 35.60% and BUN > 3.75 mmol/l may be suitable thresholds for predicting SAP in APIP.

65 yaş üstü hastalarda puanlama sistemlerinin şiddetli akut pankreatiti ve mortaliteyi erken öngörme açısından değerlendirilmesi

Purpose: The aim of this study is to investigate the power of disease severity scores to predict the development of Severe Acute Pancreatitis (SAP) and mortality in the early period over 65 years old diagnosed with acute pancreatitis in the emergency department. Materials and Methods: We calculated RANSON (on admission) and Computed Tomography Severity Index (CTSI) in addition to Bedside Index for Severity in Acute Pancreatitis (BISAP) score on admission to the emergency department. Results: One hundred and sixty patients (46.9% over 80 years of age) were included in the study. We observed statistically higher length of hospitalization, longer duration of stay in the intensive care unit, SAP and higher mortality in patients over 80 years of age. When we examined the ROC curve, we determined that the AUC values of the BISAP score were highest in both SAP and mortality estimation (AUC: 0.911, 95% CI 0.861-0.962; AUC: 0.918, 95% CI 0.864-0.9722, respectively). Binary logistic analysis indicated a 4.7-fold increased risk for SAP and a 12.3-fold increased mortality for each unit increase in BISAP score value. Conclusion: BISAP may be a good predictor for SAP and mortality estimation on admission to the emergency department in patients over 65 years of age with acute pancreatitis.

Effect of abdominal fat distribution on severity of acute pancreatitis

Aim of the study

Obesity is a well-determined risk factor for acute pancreatitis. Increased visceral fat has been shown to increase the proinflammatory environment experienced by patients. In this study, we aimed to research the correlation between abdominal fat distribution parameters measured with computed tomography (CT) and severity of acute pancreatitis (AP).

Material and methods

The study included patients monitored due to AP in the internal medicine clinic of GOP Education and Research Hospital from January 2015 to December 2018. The Acute Physiology and Chronic Health Evaluation (APACHE) score, the Imrie score and the Bedside Index of Severity in Acute Pancreatitis (BISAP) scores were calculated. Advanced image processing analysis software (INFINIT Xelis, v 1.0.6.3) was used to calculate individual abdominal fat distribution parameters from CT screening with division of abdominal tissues. Measurements were performed from –50 to –250 Hounsfield units (HU) between vertebrae L2-L3.

Results

When mild and moderate AP groups were compared, there were statistically significant differences in duration of hospital stay and scoring (APACHE, Imrie and BISAP) (p < 0.001), while there were no significant differences in abdominal fat distribution parameters (p > 0.05). There was no significant correlation of visceral and subcutaneous fat volumes with development of systemic complications, while a significant correlation was identified for visceral to total fat tissue area ratio (VTR) with local complications (p < 0.001). Pearson correlation analysis found no correlations of mortality and pancreatitis severity with visceral (VFA) and subcutaneous fat area (SFA) (p > 0.05). Positive correlations were identified for VFA with Imrie, BISAP and APACHE scores (p < 0.01), and positive correlations were identified for visceral adipose tissue (VAT) with visceral to subcutaneous fat ratio (VSR) and APACHE scores (r = 0.256 and 0.252, respectively, p < 0.001). Positive correlations were identified for VTR and VSR ratios with BISAP scores (r = 0.266 and r = 0.277, respectively, p < 0.001).

Conclusions

In patients with AP diagnosis and abdominal CT scans, increased VFA and VTR ratio were found to be associated with increased AP clinical scores with no significant correlation identified in terms of local/systemic complication development. Our study shows that VFA is linked to AP clinical scoring systems and should be included in AP predictive scoring systems.

The role of the BISAP score in predicting acute pancreatitis severity according to the revised Atlanta classification: a single tertiary care unit experience from Turkey

BACKGROUND/AIMS

In this study, we examine the utility of Bedside Index of Severity in Acute Pancreatitis (BISAP), which is an increasingly more commonly used simple and practical novel scoring system for predicting the prognosis and severity of the disease at presentation.

MATERIALS AND METHODS

Consecutive patients diagnosed with AP between January 2013 and December 2020 were evaluated retrospectively. The AP severity was assessed using the revised Atlanta classification (RAC). BISAP score, demographic characteristics, pancreatitis etiology, pancreatitis history, duration of hospital stay, and mortality rates of the patients were recorded.

RESULTS

A total of 1000 adult patients were included, of whom 589 (58.9%) were female and 411 (41.1%) were male. The mean age in female and male patients was 62.15 ± 17.79 and 58.1 ± 16.33 years, respectively (p >0.05). The most common etiological factor was biliary AP (55.8%), followed by idiopathic AP (23%). Based on RAC, 389 (38.9%), 418 (41.8%), and 193 (19.3%) patients had mild, moderate, and severe AP. Of the 1000 patients, 42 (4.2%) died. Significant predictors of mortality included advanced age (>65 y) (p=0.003), hypertension (p=0.007), and ischemic heart disease (p=0.001). A BISAP score of ≥3 had a sensitivity, specificity, positive predictive value, and negative predictive value (NPV) of 79.79%, 91.57%, 69.37%, and 94.99%, respectively, for determining SAP patients according to RAC.

CONCLUSION

BISAP is an effective scoring system with a high NPV in predicting the severity of AP in the early course of the disease in a Turkish population.

Evaluation of 880 patients diagnosed with acute pancreatitis according to the Revised Atlanta Classification: A single-center experience

OBJECTIVE The Revised Atlanta Classification (RAC) is increasingly used in the evaluation of patients diagnosed with acute pancreatitis (AP). In our study, we aimed to evaluate the etiology, disease severity, and mortality rates of patients diagnosed with AP in our center in the previous 6 years. METHODS Patients diagnosed with AP between 2013 and 2018 were evaluated. AP etiology, demographic data, disease severity, and mortality rates according to the RAC were evaluated. RESULTS A total of 880 patients were included in the study. Five hundred and eighteen (59%) patients were female and 362 (41%) were male. Regarding the etiology, 474 (53.9%) patients had biliary AP (BAP), 71 (8.1%) had hyperlipidemic AP (HAP), and 44 (5%) had alcoholic AP (AAP). According to the RAC, 561 (63.7%) patients were considered to be in the mild AP group (MAP), 268 (30.5%) in the moderately severe AP (MSAP), and 51 (5.8%) in the severe AP (SAP). The mortality rate was 4.8% in the MSAP group and 49% in the SAP group. Mortality was 2.3 times in patients over 65 years old and 3.7 times higher in patients with ischemic heart disease. CONCLUSIONS In our country, BAP is still the main etiology of acute pancreatitis. Over the years, we have seen a decrease in BAP and idiopathic AP cases, while there was an increase in HAP cases due to factors such as lifestyle changes and fatty nutrition. We found that mortality was associated with disease severity, advanced age (> 65 y), hypertension, and ischemic heart disease regardless of the etiology.

Multifactorial Scores and Biomarkers of Prognosis of Acute Pancreatitis: Applications to Research and Practice

Acute pancreatitis (AP) is a severe inflammation of the pancreas presented with sudden onset and severe abdominal pain with a high morbidity and mortality rate, if accompanied by severe local and systemic complications. Numerous studies have been published about the pathogenesis of AP; however, the precise mechanism behind this pathology remains unclear. Extensive research conducted over the last decades has demonstrated that the first 24 h after symptom onset are critical for the identification of patients who are at risk of developing complications or death. The identification of these subgroups of patients is crucial in order to start an aggressive approach to prevent mortality. In this sense and to avoid unnecessary overtreatment, thereby reducing the financial implications, the proper identification of mild disease is also important and necessary. A large number of multifactorial scoring systems and biochemical markers are described to predict the severity. Despite recent progress in understanding the pathophysiology of AP, more research is needed to enable a faster and more accurate prediction of severe AP. This review provides an overview of the available multifactorial scoring systems and biochemical markers for predicting severe AP with a special focus on their advantages and limitations.

Organ Failure Due to Systemic Injury in Acute Pancreatitis

Acute pancreatitis may be associated with both local and systemic complications. Systemic injury manifests in the form of organ failure, which is seen in approximately 20% of all cases of acute pancreatitis and defines "severe acute pancreatitis." Organ failure typically develops early in the course of acute pancreatitis, but also may develop later due to infected pancreatic necrosis-induced sepsis. Organ failure is the most important determinant of outcome in acute pancreatitis. We review here the current understanding of the risk factors, pathophysiology, timing, impact on outcome, and therapy of organ failure in acute pancreatitis. As we discuss the pathophysiology of severe systemic injury, the distinctions between markers and mediators of severity are highlighted based on evidence supporting their causality in organ failure. Emphasis is placed on clinically relevant end points of organ failure and the mechanisms underlying the pathophysiological perturbations, which offer insight into potential therapeutic targets to treat.

Severity stratification and prognostic prediction of patients with acute pancreatitis at early phase: A retrospective study

Severity stratification and prognostic prediction at early stage is crucial for reducing the rates of mortality of patients with acute pancreatitis (AP). We aim to investigate the predicting performance of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and red-cell distribution width (RDW) combined with severity scores (sequential organ failure assessment [SOFA], bed-side index for severity of AP [BISAP], Ranson criteria, and acute physiology and chronic health evaluation II [APACHE II]) for severe AP (SAP) and mortality.A total of 406 patients diagnosed with AP admitted in a tertiary teaching hospital were enrolled. Demographic information and clinical parameters were retrospectively collected and analyzed. NLR, PLR, RDW, blood urea nitrogen (BUN), and AP severity scores (SOFA, BISAP, Ranson, and APACHE II) were compared between different severity groups and the survival and death group. Receiver-operating characteristic (ROC) curves for SAP and 28-day mortality were calculated for each predictor using cut-off values. Area under the curve (AUC) analysis and logistic regression models were performed to compare the performance of laboratory biomarkers and severity scores.Our results showed that NLR, PLR, RDW, glucose, and BUN level of the SAP group were significantly increased compared to the mild acute pancreatitis (MAP) group on admission (P < .001). The severity of AP increased as the NLR, SOFA, BISAP, and Ranson increased (P < .01). The AUC values of NLR, PLR, RDW, BUN, SOFA, BISAP, Ranson, and APACHE II to predict SAP were 0.722, 0.621, 0.787, 0.677, 0.806, 0.841, 0.806, and 0.752, respectively, while their AUC values to predict 28-day mortality were 0.851, 0.693, 0.885, 0.765, 0.968, 0.929, 0.812, and 0.867, respectively. BISAP achieved the highest AUC, sensitivity and NPV in predicting SAP, while SOFA is the most superior in predicting mortality. The combination of BISAP + RDW achieved the highest AUC (0.872) in predicting SAP and the combination of SOFA + RDW achieved the highest AUC (0.976) in predicting mortality. RDW (OR = 1.739), SOFA (OR = 1.554), BISAP (OR = 2.145), and Ranson (OR = 1.434) were all independent risk factors for predicting SAP, while RDW (OR = 7.361) and hematocrit (OR = 0.329) were independent risk factors for predicting mortality by logistic regression model.NLR, PLR, RDW, and BUN indicated good predictive value for SAP and mortality, while RDW had the highest discriminatory capacity. RDW is a convenient and reliable indicator for prediction not only SAP, but also mortality.

Computed tomography scan imaging in diagnosing acute uncomplicated pancreatitis: Usefulness vs cost

BACKGROUND

Literature has suggested that imaging is over-utilized in the diagnosis of pancreatitis. If the diagnosis of acute pancreatitis (AP) is established with abdominal pain and increased serum amylase or lipase activity without systemic signs of severe disease, computed tomography (CT) imaging may not be necessary. We hypothesize that among patients with uncomplicated acute pancreatitis (AUP), there is a significant number of unwarranted CT imaging studies. This imposes increased expenditure and cost in our healthcare system and does not improve hospital stay or management of AUP.

AIM

To assess the overutilization and associated cost of CT imaging among patients meeting diagnostic criteria for AUP.

METHODS

In this Institutional Review Board-approved retrospective, single-center study, we identified all adult patients admitted with AP from January 1, 2012 through October 1, 2017. Patients were identified via International Classification of Diseases (ICD-9) code for AP (577.0) and ICD-10 codes for different etiological AP (K85.9 unspecified, K85.0 idiopathic, K85.1 biliary, K85.2 alcohol-induced, K85.3 drug-induced, and K85.8 other). Diagnosis was confirmed by chart review using established non-imaging diagnostic criteria (presence of typical abdominal pain and elevated lipase or amylase greater than 3 times upper limit of normal). Ranson criteria and BISAP scores on presentation were calculated and patients that met scores less than or equal to 2 for both were included to suggest AUP. The utilization and cost of imaging in these patients were recorded.

RESULTS

Between January 2012 and October 2017, 1305 patients presented to the emergency department with AP, and 405 patients (31%) met our inclusion criteria for AUP (201 males, 204 females; mean age 49 years, range 18-98). Of those, 210 patients (51.85%) underwent CT imaging. One patient (0.47%) had evidence of pancreatic necrosis, one patient had cyst formation (0.47%), and the remaining 208 patients (99.05%) had either normal CT scan imaging or findings consistent with mild AP without necrosis. The average cost of CT scan imaging was $4510 with a total cost of $947056. Median length of hospitalization stay was 3 d among both groups. Combining Ranson’s Criteria and BISAP score identified AUP in our patient population with an accuracy of 99.5%.

CONCLUSION

CT imaging is unnecessary when AUP is diagnosed clinically and biochemically. Reducing overuse of diagnostic CT scans will decrease healthcare expenditure and radiation exposure to patients.

Value of neutrophil to lymphocyte ratio combined with red blood cell distribution width for predicting severity of acute pancreatitis

AIM

To explore the value of neutrophil to lymphocyte ratio (NLR) combined with red blood cell distribution width (RDW) for predicting the severity of acute pancreatitis (AP).

METHODS

The clinical data of 120 patients with AP were retrospectively analyzed in this study. The patients were assigned to three groups: mild AP (MAP) group, moderately severe AP (MSAP) group, and severe AP (SAP) group. The clinical indexes (NLR and RDW) of the three groups of patients were measured at 24 h after hospitalization. All of these data were compared among the groups, and between dead patients and surviving cases. The receiver operator characteristic curves (ROCs) of NLR, RDW, and NLR plus RDW were plotted to assess their value in predicting the prognosis of AP.

RESULTS

With the increase of the severity of AP, the value of NLR increased significantly (P < 0.05). There was no significant difference in RDW between the MAP and MSAP groups (P > 0.05). The RDW value of the SAP group was significantly different from those of the MAP and MSAP groups (P < 0.05). The values of NLR and RDW in the death group were significantly higher than those in the survival group (P < 0.05). The area under the curve of NLR in predicting AP severity was 0.794, which was significantly higher than that of RDW (0.745; P < 0.05). The area under the NLR + RDW curve was 0.876 (sensitivity, 0.795; specificity, 0.852), which was significantly higher than that of NLR and RDW alone (P < 0.05).

CONCLUSION

NLR and RDW are both related to the severity of AP, and the combination of the two indexes can improve the sensitivity and specificity of predicting the severity of AP.