Comparison of different risk stratification systems for prediction of acute pancreatitis severity in patients referred to the emergency department of a tertiary care hospital.
Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma & emergency surgery : TJTES
BACKGROUND:Prognostic prediction and estimation of severity at early stages of acute pancreatitis (AP) are crucial to reduce the complication rates and mortality. The objective of the present study is to evaluate the predicting ability of different clinical and radiological scores in AP. METHODS:We retrospectively collected demographic and clinical data from 159 patients diagnosed with AP admitted to Canakkale Onsekiz Mart University Hospital between January 2017 and December 2019. Bedside index for severity AP (BISAP), and acute phys-iology and chronic health evaluation II (APACHE II) score at admission, Ranson and modified Glasgow Prognostic Score (mGPS) score at 48 h after admission were calculated. Modified computed tomography severity index (CTSI) was also calculated for each patient. Area under the curve (AUC) was calculated for each scoring system for predicting severe AP, pancreatic necrosis, length of hospital stay, and mortality by determining optimal cutoff points from the (ROC) curves. RESULTS:mGPS and APACHE II had the highest AUC (0.929 and 0.823, respectively) to predict severe AP on admission with the best specificity and sensitivity. In predicting mortality BISAP (with a sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of 75.0%, 70.9%, 98.2%, and 12.0%, respectively, [AUC: 0.793]) and APACHE II (with a sensitivity, specificity, NPV and PPV of 87.5%, 86.1%, 99.2%, and 25.0%, respectively, [AUC: 0.840]). CONCLUSION:mGPS can be a valuable tool in predicting the patients more likely to develop severe AP and maybe somewhat better than BISAP score, APACHE II Ranson score, and mCTSI.
The visceral adiposity index predicts the severity of hyperlipidaemic acute pancreatitis.
Xia Weizhi,Yu Huajun,Huang Yingbao,Yang Yunjun,Shi Liuzhi
Internal and emergency medicine
It is important to clarify the severity of acute pancreatitis (AP) in the early stages of the disease. The visceral adiposity index (VAI), calculated using the waist circumference (WC), body mass index (BMI), triglyceride (TG) levels, and high-density lipoprotein cholesterol (HDL-c), indirectly reflects visceral adiposity function and can be used to explore its value in evaluating and predicting the severity of hyperlipidaemic acute pancreatitis (HLAP). The VAIs of 227 patients with HLAP were calculated by retrospective analysis of body parameters and laboratory indicators. The correlation between the VAI and HLAP severity, local complications, and systemic inflammatory response syndrome (SIRS) response was analysed. The VAI was significantly higher in patients with severe and moderately severe AP than in patients with mild AP (both p < 0.05). Length of hospital stay (LOS), AP severity, systemic complications, Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, and SIRS score were significantly correlated with the VAI in HLAP patients. The VAI had the highest area under the curve of receiver operating characteristics (ROC) (0.755, 95% confidence interval [CI], 0.691-0.819) for predicting AP severity. The multivariate-adjusted odds ratio (HR) for the VAI in the relationship of body parameters and the severity of HLAP was 3.818 (95% CI, 1.395-10.452). Our study shows that the VAI is a valuable indicator for predicting and assessing the severity of hyperlipidaemic acute pancreatitis. Its increase is closely related to poor prognosis in patients with HLAP.
Computed Tomography Severity Index vs. Other Indices in the Prediction of Severity and Mortality in Acute Pancreatitis: A Predictive Accuracy Meta-analysis.
Mikó Alexandra,Vigh Éva,Mátrai Péter,Soós Alexandra,Garami András,Balaskó Márta,Czakó László,Mosdósi Bernadett,Sarlós Patrícia,Erőss Bálint,Tenk Judit,Rostás Ildikó,Hegyi Péter
Frontiers in physiology
The management of the moderate and severe forms of acute pancreatitis (AP) with necrosis and multiorgan failure remains a challenge. To predict the severity and mortality of AP multiple clinical, laboratory-, and imaging-based scoring systems are available. To investigate, if the computed tomography severity index (CTSI) can predict the outcomes of AP better than other scoring systems. A systematic search was performed in three databases: Pubmed, Embase, and the Cochrane Library. Eligible records provided data from consecutive AP cases and used CTSI or modified CTSI (mCTSI) alone or in combination with other prognostic scores [Ranson, bedside index of severity in acute pancreatitis (BISAP), Acute Physiology, and Chronic Health Examination II (APACHE II), C-reactive protein (CRP)] for the evaluation of severity or mortality of AP. Area under the curves (AUCs) with 95% confidence intervals (CIs) were calculated and aggregated with STATA 14 software using the metandi module. Altogether, 30 studies were included in our meta-analysis, which contained the data of 5,988 AP cases. The pooled AUC for the prediction of mortality was 0.79 (CI 0.73-0.86) for CTSI; 0.87 (CI 0.83-0.90) for BISAP; 0.80 (CI 0.72-0.89) for mCTSI; 0.73 (CI 0.66-0.81) for CRP level; 0.87 (CI 0.81-0.92) for the Ranson score; and 0.91 (CI 0.88-0.93) for the APACHE II score. The APACHE II scoring system had significantly higher predictive value for mortality than CTSI and CRP ( = 0.001 and < 0.001, respectively), while the predictive value of CTSI was not statistically different from that of BISAP, mCTSI, CRP, or Ranson criteria. The AUC for the prediction of severity of AP were 0.80 (CI 0.76-0.85) for CTSI; 0.79, (CI 0.72-0.86) for BISAP; 0.83 (CI 0.75-0.91) for mCTSI; 0.73 (CI 0.64-0.83) for CRP level; 0.81 (CI 0.75-0.87) for Ranson score and 0.80 (CI 0.77-0.83) for APACHE II score. Regarding severity, all tools performed equally. Though APACHE II is the most accurate predictor of mortality, CTSI is a good predictor of both mortality and AP severity. When the CT scan has been performed, CTSI is an easily calculable and informative tool, which should be used more often in routine clinical practice.
Elevated Serum Triglyceride Levels in Acute Pancreatitis: A Parameter to be Measured and Considered Early.
World journal of surgery
BACKGROUND:The value of serum triglycerides (TGs) related to complications and the severity of acute pancreatitis (AP) has not been clearly defined. Our study aimed to analyze the association of elevated levels of TG with complications and the severity of AP. METHODS:The demographic and clinical data of patients with AP were prospectively analyzed. TG levels were measured in the first 24 h of admission. Patients were divided into two groups: one with TG values of<200 mg/dL and another with TG≥200 mg/dL. Data on the outcomes of AP were collected. RESULTS:From January 2016 to December 2019, 247 cases were included: 200 with TG<200 mg/dL and 47 with TG≥200 mg/dL. Triglyceride levels≥200 mg/dL were associated with respiratory failure (21.3 vs. 10%, p=0.033), renal failure (23.4 vs. 12%, p=0.044), cardiovascular failure (19.1 vs. 7.5%, p=0.025), organ failure (34 vs. 18.5%, p=0.02), persistent organ failure (27.7 vs. 9.5%, p=0.001), multiple organ failure (19.1 vs. 8%, p=0.031), moderately severe and severe AP (68.1 vs. 40.5%, p=0.001), pancreatic necrosis (63.8 vs. 34%, p<0.001), and admission to the intensive care unit (27.7 vs. 9.5%, p=0.003). In the multivariable analysis, a TG level of≥200 mg/dL was independently associated with respiratory, renal, and cardiovascular failure, organ failure, persistent organ failure, multiple organ failure, pancreatic necrosis, severe pancreatitis, and admission to the intensive care unit (p<0.05). CONCLUSIONS:In our cohort, TG≥200 mg/dL was related to local and systemic complications. Early determinations of TG levels in AP could help identify patients at risk of complications.
Volume, but Not the Location of Necrosis, Is Associated with Worse Outcomes in Acute Pancreatitis: A Prospective Study.
Medicina (Kaunas, Lithuania)
: The course and clinical outcomes of acute pancreatitis (AP) are highly variable. Up to 20% of patients develop pancreatic necrosis. Extent and location of it might affect the clinical course and management. The aim was to determine the clinical relevance of the extent and location of pancreatic necrosis in patients with AP. : A cohort of patients with necrotizing AP was collected from 2012 to 2018 at the Hospital of Lithuanian University of Health Sciences. Patients were allocated to subgroups according to the location (entire pancreas, left and right sides of pancreas) and extent (<30%, 30-50%, >50%) of pancreatic necrosis. Patients were reviewed for demographic features, number of performed surgical interventions, local and systemic complications, hospital stay and mortality rate. All contrast enhanced computed tomography (CECT) scans were evaluated by at least two experienced abdominal radiologists. All patients were treated according to the standard treatment protocol based on current international guidelines. : The study included 83 patients (75.9% males ( = 63)) with a mean age of 53 ± 1.7. The volume of pancreatic necrosis exceeded 50% in half of the patients ( = 42, 51%). Positive blood culture ( = 14 (87.5%)), multiple organ dysfunction syndrome ( = 17 (73.9%)) and incidences of respiratory failure ( = 19 (73.1%)) were significantly more often diagnosed in patients with pancreatic necrosis exceeding 50% ( < 0.05). Patients with >50% of necrosis were significantly ( < 0.05) more often diagnosed with moderately severe ( = 24 (41.4%)) and severe ( = 18 (72%)) AP. The number of surgical interventions ( = 18 (72%)) and ultrasound-guided interventions ( = 26 (65%)) was also significantly higher. In patients with whole-pancreas necrosis, incidence of renal insufficiency ( = 11 (64.7%)) and infected pancreatic necrosis ( = 19 (57.6%)) was significantly higher ( < 0.05). : The clinical course and outcome were worse in the case of pancreatic necrosis exceeding 50%, rendering the need for longer and more complex treatment.
Pancreatic necrosis volume - A new imaging biomarker of acute pancreatitis severity.
Pamies-Guilabert Jose,Del Val Antoñana Adolfo,Collado Javier Jesús,Rudenko Polina,Meseguer Angels
European journal of radiology
OBJECTIVE:Determine if the pancreatic necrosis volume (PNV) in computed tomography scan (CT) is a useful marker to predict the severity of acute pancreatitis (AP) comparing its predictive value with current clinical scoring systems. METHODS:This retrospective study was conducted in a tertiary hospital, including patients hospitalized with AP during the period of 24 months. Demographic, clinical data, length of hospital stay and analytical parameters were collected from the hospital clinical information digital systems. Other information on the severity of the disease was also reviewed, including BISAP score, organ failure (OF) or admission to the ICU, as well as, complications during hospitalization as infected necrotic collections, surgical procedure or death. The quantification of the necrosis volume, CT severity index and Balthazar score were assessed in the CT studies. ROC curves were carried to compare the correlation between different scoring systems and the acute complications. RESULTS:This study included 163 patients with AP. The calculated average value of PNV in the CT studies was 242 cc (0-1575 cc). PNV showed lineal correlation with hospital stay (Pearson 0.696) and statistically significant association with acute complications as OF, multiple organ failure, infection, need of treatment or hospitalization at ICU (P < 0.05). The optimal cut-off value for predicting complications of necrosis as infections or need of surgery treatments was 75 cc. Sensibility and specificity were 100 % and 78 %, respectively. ROC curves showed that PNV was the best radiological finding correlated with AP complications. CONCLUSION:Necrosis volume is a radiological biomarker highly correlated with AP complications.
Extrapancreatic necrosis volume: A new tool in acute pancreatitis severity assessment?
Cucuteanu Bogdan,Negru Dragoş,Gavrilescu Otilia,Popa Iolanda Valentina,Floria Mariana,Mihai Cătălina,Cijevschi Prelipcean Cristina,Dranga Mihaela
World journal of clinical cases
BACKGROUND:Many scores have been suggested to assess the severity of acute pancreatitis upon onset. The extrapancreatic necrosis volume is a novel, promising score that appears to be superior to other scores investigated so far. AIM:To evaluate the discriminatory power of extrapancreatic necrosis volume to identify severe cases of acute pancreatitis. METHODS:A total of 123 patients diagnosed with acute pancreatitis at Institute of Gastroenterology and Hepatology, St Spiridon Hospital between January 1, 2017 and December 31, 2019 were analyzed retrospectively. Pancreatitis was classified according to the revised Atlanta classification (rAC) as mild, moderate, or severe. Severity was also evaluated by computed tomography and classified according to the computed tomography severity index (CTSI) and the modified CTSI (mCTSI). The results were compared with the extrapancreatic volume necrosis to establish the sensitivity and specificity of each method. RESULTS:The CTSI and mCTSI imaging scores and the extrapancreatic necrosis volume were highly correlated with the severity of pancreatitis estimated by the rAC ( = 0.926, < 0.001 and = 0.950, < 0.001; = 0.784, < 0.001, respectively). The correlation of C-reactive protein with severity was positive but not as strong, and was not significant ( = 0.133, = 0.154). The best predictor for the assessment of severe pancreatitis was the extrapancreatic necrosis volume [area under the curve (AUC) = 0.993; 95% confidence interval (CI): 0.981-1.005], with a 99.5% sensitivity and 99.0% specificity at a cutoff value of 167 mL, followed by the mCTSI 2007 score (AUC = 0.972; 95%CI: 0.946-0.999), with a 98.0% sensitivity and 96.5% specificity, and the CTSI 1990 score (AUC = 0.969; 95%CI: 0.941-0.998), with a 97.0% sensitivity and 95.0% specificity. CONCLUSION:Radiological severity scores correlate strongly and positively with disease activity. Extrapancreatic necrosis volume shows the best diagnostic accuracy for severe cases.
Role of Extrapancreatic Necrosis Volume in Assessing the Severity and Predicting the Outcomes of Severe Acute Pancreatitis.
International journal of general medicine
OBJECTIVE:To observe the relationship between the extrapancreatic necrosis volume and outcomes in patients with severe acute pancreatitis (SAP). METHODS:We retrospectively analyzed 125 patients with SAP admitted to Severe Acute Pancreatitis Treatment Center of Guizhou Province from August 2013 to August 2018. All patients had extrapancreatic necrosis. The general clinical data of patients, C-reactive protein (CRP) value within 72 hours of onset, Ranson score, organ failure within 3 days after onset, complications, outcomes, CT severity index (CTSI), extrapancreatic necrosis volume and other information were collected. The correlation between extrapancreatic necrosis volume and hospitalization time, ICU stay, hospitalization cost, and CRP value was analyzed. The incidence of complications was obtained from the electronic medical record system. RESULTS:The mean extrapancreatic necrosis volume was 680 ± 473 mL. The median length of hospital stay was 18.2 (3-76) days, and the ICU stay was 13.5 (3-66) days. The extrapancreatic necrosis volume was positively correlated with hospitalization time, ICU stay time, cost of hospitalization and CRP ( < 0.05). The extrapancreatic necrosis volume in organ failure group was significantly higher than that in non-organ failure group ( < 0.05). The extrapancreatic necrosis volume in patients with death was also higher than that in survival ( < 0.05). With the increase of extrapancreatic necrosis volume, the incidence of complications increased significantly. On the basis of extrapancreatic necrosis volume, the ROC curves yielded an AUC of 0.92 (95% CI: 0.83, 0.99) in predicting the mortality, which was higher than Ranson score (0.90, 95% CI 0.82-0.96) and CTSI (0.85, 0 95% CI 0.77-0.91). CONCLUSION:With the increase of extrapancreatic necrosis volume, the incidence of complications increased significantly. The extrapancreatic necrosis volume has the potential to be used as a valuable tool to predict the poor outcome of acute pancreatitis.
Evaluation of the modified computed tomography severity index (MCTSI) and computed tomography severity index (CTSI) in predicting severity and clinical outcomes in acute pancreatitis.
Alberti Piero,Pando Elizabeth,Mata Rodrigo,Vidal Laura,Roson Nuria,Mast Richard,Armario David,Merino Xavier,Dopazo Cristina,Blanco Laia,Caralt Mireia,Gomez Concepción,Balsells Joaquim,Charco Ramon
Journal of digestive diseases
OBJECTIVE:Our main purpose was to compare the modified computed tomography severity index (MCTSI), computed tomography severity index (CTSI), and acute physiological and chronic health evaluation (APACHE)-II predictions regarding severity according to the revised Atlanta classification 2012 and local complications in acute pancreatitis in a consecutive prospective cohort. METHODS:One hundred and forty-nine patients diagnosed with acute pancreatitis were prospectively enrolled. APACHE-II, MCTSI, and CTSI were calculated for all cases. Severity parameters included persistent organ or multiorgan failure, length of hospitalization, the need for intensive care, death, and local complications (intervention against necrosis and infected necrosis). Area under the receiver operating characteristic curve (AUROC) was calculated and the value of scoring systems was compared. RESULTS:Both CTSI and MCTSI were associated significantly with all the evaluated severity parameters and showed a correlation between imaging severity and the worst clinical outcomes. Persistent organ failure, persistent multiorgan failure, and death were found in 30 (20.1%), 20 (13.4%), and 13 (8.7%) patients, respectively. The most common extrapancreatic finding was pleural effusion in 76 (51.0%) patients. The AUROC for CTSI was higher for predicting persistent organ failure (0.749, 95% confidence interval [CI] 0.640-0.857), death (AUROC 0.793, 95% CI 0.650-0.936), intervention against necrosis (AUROC 0.862, 95% CI 0.779-0.945), and infected necrosis (AUROC 0.883, 95% CI 0.882-0.930). CONCLUSIONS:CT indexes outperformed the classic APACHE-II score for evaluating severity parameters in acute pancreatitis, with a slight advantage of CTSI over MCTSI. CTSI accurately predicted pancreatic infections and the need for intervention.
Chest computed tomography semi-quantitative pleural effusion and pulmonary consolidation are early predictors of acute pancreatitis severity.
Quantitative imaging in medicine and surgery
BACKGROUND:To study the predictive value of semi-quantitative pleural effusion and pulmonary consolidation for acute pancreatitis (AP) severity. METHODS:Thorax-abdominal computed tomography (CT) examinations were performed on 309 consecutive AP patients in a single center. Among them, 196 were male, and 113 were female, and the average age was 50±16 years. The etiology of AP was biliary in 43.7% (n=135), hyperlipidemia in 22.0% (n=68), alcoholic in 7.4% (n=23), trauma in 0.6% (n=2), and postoperative status in 1.6% (n=5) cases; 24.6% (n=76) of patients did not have specified etiologies. The prevalence of pleural effusion and pulmonary consolidation was noted. The pleural effusion volume was quantitatively derived from a CT volume evaluation software tool. The pulmonary consolidation score was based on the number of lobes involved in AP. Each patient's CT severity index (CTSI), acute physiology and chronic health evaluation II (APACHE II) scoring system, and bedside index for severity in acute pancreatitis (BISAP) scores were obtained. The semi-quantitative pleural effusion and pulmonary consolidation were compared to these scores and clinical outcomes by receiver operator characteristic (ROC) curve and area under the curve (AUC) analysis. RESULTS:In the 309 patients, 39.8% had pleural effusion, and 47.9% had pulmonary consolidation. The mean pleural effusion volume was 41.7±38.0 mL. The mean pulmonary consolidation score was 1.0±1.2 points. The mean CTSI was 3.7±1.8 points, the mean APACHE II score was 5.8±5.1 points, and the mean BISAP score was 1.3±1.0 points; 5.5% of patients developed severe AP, and 13.9% of patients developed organ failure. Pleural effusion volume and pulmonary consolidation scores correlated to the scores for the severity of AP. In predicting severe AP, the accuracy (AUC 0.839) of pleural effusion volume was similar to that of the CTSI score (P=0.961), APACHE II score (P=0.757), and BISAP score (P=0.906). The accuracy (AUC 0.805) of the pulmonary consolidation score was also similar to that of the CTSI score (P=0.503), APACHE II score (P=0.343), and BISAP score (P=0.669). In predicting organ failure, the accuracy (AUC 0.783) of pleural effusion volume was similar to that of the CTSI score (P=0.473), APACHE II score (P=0.119), and BISAP score (P=0.980), and the accuracy (AUC 0.808) of the pulmonary consolidation score was also similar to that of the CTSI score (P=0.236), APACHE II score (P=0.293), and BISAP score (P=0.612). CONCLUSIONS:Pleural effusion and pulmonary consolidation are common in AP and correlated to the severity of AP. Furthermore, the pleural effusion volume and pulmonary consolidation lobes can provide early prediction of severe AP and organ failure.
Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis.
Papachristou Georgios I,Muddana Venkata,Yadav Dhiraj,O'Connell Michael,Sanders Michael K,Slivka Adam,Whitcomb David C
The American journal of gastroenterology
OBJECTIVES:Identification of patients at risk for severe disease early in the course of acute pancreatitis (AP) is an important step to guiding management and improving outcomes. A new prognostic scoring system, the bedside index for severity in AP (BISAP), has been proposed as an accurate method for early identification of patients at risk for in-hospital mortality. The aim of this study was to compare BISAP (blood urea nitrogen >25 mg/dl, impaired mental status, systemic inflammatory response syndrome (SIRS), age>60 years, and pleural effusions) with the "traditional" multifactorial scoring systems: Ranson's, Acute Physiology and Chronic Health Examination (APACHE)-II, and computed tomography severity index (CTSI) in predicting severity, pancreatic necrosis (PNec), and mortality in a prospective cohort of patients with AP. METHODS:Extensive demographic, radiographic, and laboratory data from consecutive patients with AP admitted or transferred to our institution was collected between June 2003 and September 2007. The BISAP and APACHE-II scores were calculated using data from the first 24 h from admission. Predictive accuracy of the scoring systems was measured by the area under the receiver-operating curve (AUC). RESULTS:There were 185 patients with AP (mean age 51.7, 51% males), of which 73% underwent contrast-enhanced CT scan. Forty patients developed organ failure and were classified as severe AP (SAP; 22%). Thirty-six developed PNec (19%), and 7 died (mortality 3.8%). The number of patients with a BISAP score of > or =3 was 26; Ranson's > or =3 was 47, APACHE-II > or =8 was 66, and CTSI > or =3 was 59. Of the seven patients that died, one had a BISAP score of 1, two had a score of 2, and four had a score of 3. AUCs for BISAP, Ranson's, APACHE-II, and CTSI in predicting SAP are 0.81 (confidence interval (CI) 0.74-0.87), 0.94 (CI 0.89-0.97), 0.78 (CI 0.71-0.84), and 0.84 (CI 0.76-0.89), respectively. CONCLUSIONS:We confirmed that the BISAP score is an accurate means for risk stratification in patients with AP. Its components are clinically relevant and easy to obtain. The prognostic accuracy of BISAP is similar to those of the other scoring systems. We conclude that simple scoring systems may have reached their maximal utility and novel models are needed to further improve predictive accuracy.
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.
Harshit Kumar Anubhav,Singh Griwan Mahavir
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.
Early Prediction of Acute Biliary Pancreatitis Using Clinical and Abdominal CT Features.
Zver Thibaut,Calame Paul,Koch Stéphane,Aubry Sébastien,Vuitton Lucine,Delabrousse Eric
Background Assessment of the biliary origin of acute pancreatitis (AP) is crucial because it affects patient treatment to avoid recurrence. Although CT is systematically performed to determine severity in AP, its usefulness in assessing AP biliary origin has not been evaluated. Purpose To assess abdominal CT features associated with acute biliary pancreatitis (ABP) and to evaluate the predictive value of a combination of CT and clinical data for determining a biliary origin in a first episode of AP. Materials and Methods From December 2014 to May 2019, all consecutive patients who presented with a first episode of AP and with at least 6 months of follow-up were retrospectively reviewed. Evidence of gallstones was mandatory for a clinical diagnosis of ABP. Abdominal CT images were reviewed by two abdominal radiologists. Univariable and multivariable statistical analyses were performed, and a nomogram was constructed on the basis of the combination of clinical and CT features. This nomogram was validated in a further independent internal cohort of patients. Results A total of 271 patients (mean age ± standard deviation, 56 years ± 20; 160 men) were evaluated. Of these, 170 (63%) had ABP. At multivariable analysis, age (odds ratio [OR], 1.06; 95% CI: 1.03, 1.09; < .001), alanine aminotransferase level (OR, 1.00; 95% CI: 1.00, 1.01; = .009), gallbladder gallstone (OR, 15.59; 95% CI: 4.61, 68.62; < .001), choledochal ring sign (OR, 5.73; 95% CI: 2.11, 17.05; < .001), liver spontaneous attenuation (OR, 1.07; 95% CI: 1.04, 1.11; < .001), and duodenal thickening (OR, 0.17; 95% CI: 0.03, 0.61; = .01) were independently associated with ABP. The matching nomogram combining both clinical and CT features displayed an area under the curve of 0.94 (95% CI: 0.91, 0.97) in the study sample ( = 271) and 0.91 (95% CI: 0.84, 0.99) in the validation cohort ( = 51). Conclusion Abdominal CT provided useful features for diagnosis of acute biliary pancreatitis (ABP). Combining CT and clinical features in a nomogram showed good diagnostic performance for early diagnosis of ABP. © RSNA, 2021 See also the editorial by Chang in this issue.
A nomogram for clinical estimation of acute biliary pancreatitis risk among patients with symptomatic gallstones: A retrospective case-control study.
Frontiers in cellular and infection microbiology
Background/Purpose:Currently, there are no effective tools to accurately assess acute biliary pancreatitis (ABP) risk in patients with gallstones. This study aimed to develop an ABP risk nomogram in patients with symptomatic gallstones. Methods:We conducted a retrospective nested case-control study and data on 816 conservatively treated patients with symptomatic gallstones admitted to The First Affiliated Hospital of Harbin Medical University between January 6, 2007 and January 22, 2016 were retrospectively collected. We conducted a propensity-score matched (PSM) analysis based on follow-up time in a ratio of 1:4 between ABP group (n=65) and non-ABP group (n=260). These matched patients were randomly divided into study cohort (n=229) and validation cohort (n=96) according to a ratio of 7:3. In the study cohort, independent risk factors for ABP occurrence identified using Cox regression were included in nomogram. Nomogram performance and discrimination were assessed using the concordance index (C-index), area under the curve (AUC), calibration curve, decision curve analysis (DCA) and clinical impact curve (CIC). The model was also validated in the validation cohort. Results:Nomogram was based on 7 independent risk factors: age, diabetes history, gallbladder wall thickness, gallstone diameter, coexisting common bile duct (CBD) stones, direct bilirubin (DBIL), and white blood cell count (WBC). The C-index of nomogram was 0.888, and the 10-year AUCs of nomogram was 0.955. In the validation cohort, nomogram still had good discrimination (C-index, 0.857; 10-year AUC, 0.814). The calibration curve showed good homogeneity between the prediction by nomogram and the actual observation. DCA and CIC demonstrated that nomogram was clinically useful. Conclusions:The ABP risk nomogram incorporating 7 features is useful to predict ABP risk in symptomatic gallstone patients.
Liver spontaneous hypoattenuation on CT is an imaging biomarker of the severity of acute pancreatitis.
Diagnostic and interventional imaging
PURPOSE:The purpose of this study was to evaluate the relationship between liver spontaneous attenuation (LSA) on computed tomography (CT) reflecting the degree of steatosis, and the severity of acute pancreatitis (AP). MATERIALS AND METHODS:All consecutive patients admitted from December 2014 to September 2020 for an episode of AP were retrospectively reviewed. LSA was evaluated on early CT examination and all abdominal CT examinations were reviewed by two abdominal radiologists. Severity of AP was categorized using Atlanta classification and CT severity index. Univariable and multivariable statistical analyses were performed. RESULTS:A total of 467 patients were included. There were 297 men and 170 women, with a mean age of 57 ± 19 (SD) years (range: 18-98 years). Among them, 236 patients (51%) had acute biliary pancreatitis, 134 (29%) had acute alcoholic pancreatitis and 97 (20%) had AP due to other etiologies. A total of 44 (9%) patients had severe AP and 423 (91%) had non severe AP. Median LSA was significantly lower in patients with severe AP (36 Hounsfield units [HU]; interquartile range [IQR]:18; 54) than in patients with non-severe AP (45 HU; IQR: 35; 51) (P < 0.001). In patients with alcoholic AP, median LSA was significantly lower in patients with severe AP (29 HU; IQR: 3; 43) than in those with non-severe AP (42 HU; IQR: 27; 50) (P = 0.022). At multivariable analysis, the third and fourth quartiles of liver spontaneous attenuation values (i.e., < 45 HU/>30 HU and < 30 HU) were independently associated with severe AP (OR, 3.23; 95% CI: 1.33-51.2; P = 0.038 and OR, 8.82; 95% CI: 1.91-69.7; P = 0.014; respectively). CONCLUSION:LSA on CT is associated with clinical severity of AP and may be used as an additional marker of disease severity.
The diffuse reduction in spleen density: an indicator of severe acute pancreatitis?
Shao Guangdong,Zhou Yanmei,Song Zengfu,Jiang Maitao,Wang Xiaoqian,Jin Xiangren,Sun Bei,Bai Xuewei
We observed that acute pancreatitis (AP) was associated with diffuse reduction in spleen density (DROSD) in some patients. Furthermore, the condition of these patients was more serious, and the potential relationship between DROSD and structural and functional injury of the spleen remained unclear. Therefore, we performed a preliminary exploration of these factors. We analysed pertinent clinical data for AP patients with normal spleen density (control group) and for those with DROSD (reduction group) at the First Affiliated Hospital of Harbin Medical University (June 2013-June 2015). We measured the immunoglobulin M (IgM) B-cells of the AP patients and examined pancreatic and splenic tissues from AP rats with optical microscopy and TEM. The reduction group had a higher acute physiology and chronic health evaluation II (APACHE II) score, a longer length of stay (LOS) and lower serum calcium than the control group. The levels of triglycerides (TG) and total cholesterol (TC) did not differ significantly between the two groups. The percentage of IgM memory B-cells was significantly lower in the DROSD group than in the control group. TEM revealed that the spleen T-lymphocytes were normal in AP rats, but pyroptotic and necrotic spleen B-cells were observed in the severe AP rats. In AP, DROSD was an independent indicator of more severe conditions. Furthermore, spleen B-lymphocytes showed obvious damage at the cellular level, and the immunological function of the spleen was down-regulated when AP was associated with DROSD.
Can Disturbed Liver Perfusion Revealed in p-CT on the First Day of Acute Pancreatitis Provide Information about the Expected Severity of the Disease?
Gastroenterology research and practice
BACKGROUND:The aim of the study was to evaluate the prognostic properties of perfusion parameters of liver parenchyma based on computed tomography (CT) of patients with acute pancreatitis (AP) made on the first day of onset of symptoms, to assess their usefulness in identifying patients with increased risk of the development of severe AP. METHODS:79 patients with clinical symptoms and biochemical criteria indicative of AP underwent perfusion computed tomography (p-CT) within 24 hours after onset of the symptoms. Perfusion parameters in 41 people who developed a severe form of AP were compared with parameters in 38 patients in whom the course of AP was mild. RESULTS:Statistical differences in the liver perfusion parameters between the group of patients with mild and severe AP were shown. The permeability-surface area product was significantly lower, and the hepatic arterial fraction was significantly higher in the group of patients with progression of AP. CONCLUSIONS:Based on the results, it seems that p-CT performed on the first day from the onset of AP is a method that, by revealing disturbances in hepatic perfusion, can help in identifying patients with increased risk of the development of severe AP.
Liver injury associated with acute pancreatitis: The current status of clinical evaluation and involved mechanisms.
Liu Wei,Du Juan-Juan,Li Zeng-Hui,Zhang Xin-Yu,Zuo Hou-Dong
World journal of clinical cases
Acute pancreatitis (AP) is a very common acute disease, and the mortality rate of severe AP (SAP) is between 15% and 35%. The main causes of death are multiple organ dysfunction syndrome and infections. The mortality rate of patients with SAP related to liver failure is as high as 83%, and approximately 5% of the SAP patients have fulminant liver failure. Liver function is closely related to the progression and prognosis of AP. In this review, we aim to elaborate on the clinical manifestations and mechanism of liver injury in patients with AP.
Association between computerized tomography (CT) study of body composition and severity of acute pancreatitis: Use of a novel Z-score supports obesity paradox.
Clinical nutrition (Edinburgh, Scotland)
BACKGROUND & AIMS:The association between body composition parameters measured on computed tomography (CT) and severity of acute pancreatitis (AP) is conflicting because these composition parameters vary considerably by sex and age. We previously developed normative body composition data, in healthy subjects. Z-score calculated from the normative data gives age and sex adjusted body composition parameters. We studied the above association using this novel Z-score in a large cohort of patients with AP. METHODS:Between January 2014 and March 2018, patients admitted with AP and had CT scans within a week of admission, were enrolled. Body composition data including skeletal muscle (SM), subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) were calculated from the CT scan using deep learning automated algorithm. Then we converted the value to Z-score, and then compared the same score between mild AP, moderately severe AP and severe AP defined by revised Atlanta criteria. RESULTS:Out of 514 patients, 336 (65.4%) are mild AP, 130 (25.3%) moderately severe AP, and 48 (9.3%) severe AP. Patients with moderately severe AP had significantly lower SM-z-score than those with mild AP (1.21 vs1.73, p = 0.048) and patients with severe AP had significantly lower SAT-z-score than those with mild AP (0.70 vs.1.29, p = 0.016). VAT-z-score was not significantly different between three groups. (p = 0.76). CONCLUSION:Lower SM-z-score and SAT-z-score were associated with moderately severe and severe types of AP, respectively. Future prospective studies in patients with AP using Z-scores, may define the association between body composition and severity of AP, and explain the inconsistencies reported in previous studies.
CT Characteristics of Acute Pancreatitis with Preexisting Fatty Liver and Its Impact on Pancreatitis Severity and Persistent Systemic Inflammatory Response Syndrome.
International journal of general medicine
Purpose:To study the CT characteristics of acute pancreatitis (AP) associated with preexisting fatty liver (FL) and the impact of preexisting FL on the severity of AP and persistent systemic inflammatory response syndrome (SIRS). Patients and Methods:A total of 189 patients with AP were divided into AP with and without preexisting FL. The CT features, clinical characteristics, severity of AP, and presence of persistent SIRS between the two groups were compared. Univariate and multivariate analyses were performed to determine the risk factors for predicting SIRS. The diagnostic performances of the risk factors were evaluated by receiver operating characteristic (ROC) curve analysis. Results:Among the 189 patients, 49.7% (94/189) had preexisting FL. On CT, AP patients with preexisting FL were more likely to develop necrosis (23.4% vs 10.5%, p=0.021), local complications (45.7% vs 29.5%, p=0.025) and persistent SIRS (59.6% vs 27.4%, p<0.001). Multivariate analysis showed that preexisting FL (OR=2.863, 95% CI: 1.264-6.486, p=0.012), APACHE II≥6 (OR=1.334, 95% CI: 1.117-1.594, p=0.002), and MCTSI ≥4 (OR=1.489, 95% CI: 1.046-2.119, p=0.027) could be independent risk factors for persistent SIRS. The areas under the ROC curve of preexisting FL, APACHE II, and MCISI in diagnosing AP patients with persistent SIRS were 0.664, 0.703, and 0.783, respectively. Conclusion:Patients with preexisting FL were more likely to develop necrosis and local complications on CT and present more severe AP and persistent SIRS. Preexisting FL can be an independent risk factor in predicting the presence of persistent SIRS in patients with AP.
A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome.
Mortele Koenraad J,Wiesner Walter,Intriere Lisa,Shankar Shridhar,Zou Kelly H,Kalantari Babek N,Perez Alex,vanSonnenberg Eric,Ros Pablo R,Banks Peter A,Silverman Stuart G
AJR. American journal of roentgenology
OBJECTIVE:This study was conducted to assess the correlation with patient outcome and interobserver variability of a modified CT severity index in the evaluation of patients with acute pancreatitis compared with the currently accepted CT severity index. MATERIALS AND METHODS:Of 266 consecutive patients diagnosed with acute pancreatitis during a 1-year period, 66 underwent contrast-enhanced MDCT within 1 week of the onset of symptoms. Three radiologists who were blinded to patient outcome independently scored the severity of the pancreatitis using both the currently accepted and modified CT severity indexes. The modified index included a simplified assessment of pancreatic inflammation and necrosis as well as an assessment of extrapancreatic complications. Outcome parameters included the length of hospital stay; the need for surgery or percutaneous intervention; and the occurrences of infection, organ failure, and death. For both the current and modified indexes, correlation between the severity of the pancreatitis and patient outcome was estimated using the Wilcoxon's rank sum test and Fisher's exact test. Interobserver agreement for both indexes was calculated using the kappa statistic. RESULTS:When applying the modified index, the severity of pancreatitis and the following parameters correlated more closely than when the currently accepted index was applied: the length of the hospital stay (0-34 days) (modified index [p = 0.0054-0.0714] vs current index [p = 0.0052-0.3008]); the need for surgical or percutaneous procedures (10/66 patients) (modified index [p = 0.0112] vs current index [p = 0.0324]); and the occurrence of infection (21/66 patients) (modified index [p < 1e(-10)] vs current index [p < 1e(-04)]). Significant correlation between the severity of pancreatitis and the development of organ failure (9/66 patients) was seen only using the modified index (p = 0.0024), not the current index (p = 0.0513). The interobserver agreement was similar with the modified (kappa range, 0.71-0.85) and the current (kappa range, 0.63-0.86) indexes. CONCLUSION:The modified CT severity index correlates more closely with patient outcome measures than the currently accepted CT severity index, with similar interobserver variability.
MDCT of acute pancreatitis: Intraindividual comparison of single-phase versus dual-phase MDCT for initial assessment of acute pancreatitis using different CT scoring systems.
Avanesov Maxim,Weinrich Julius M,Kraus Thomas,Derlin Thorsten,Adam Gerhard,Yamamura Jin,Karul Murat
European journal of radiology
OBJECTIVES:The purpose of the retrospective study was to evaluate the additional value of dual-phase multidetector computed tomography (MDCT) protocols over a single-phase protocol on initial MDCT in patients with acute pancreatitis using three CT-based pancreatitis severity scores with regard to radiation dose. METHODS:In this retrospective, IRB approved study MDCT was performed in 102 consecutive patients (73 males; 55years, IQR48-64) with acute pancreatitis. Inclusion criteria were CT findings of interstitial edematous pancreatitis (IP) or necrotizing pancreatitis (NP) and a contrast-enhanced dual-phase (arterial phase and portal-venous phase) abdominal CT performed at ≥72h after onset of symptoms. The severity of pancreatic and extrapancreatic changes was independently assessed by 2 observers using 3 validated CT-based scoring systems (CTSI, mCTSI, EPIC). All scores were applied to arterial phase and portal venous phase scans and compared to score results of portal venous phase scans, assessed ≥14days after initial evaluation. For effective dose estimation, volume CT dose index (CTDIvol) and dose length product (DLP) were recorded in all examinations. RESULTS:In neither of the CT severity scores a significant difference was observed after application of a dual-phase protocol compared with a single-phase protocol (IP: CTSI: 2.7 vs. 2.5, p=0.25; mCTSI: 4.0 vs. 4.0, p=0.10; EPIC: 2.0 vs. 2.0, p=0.41; NP: CTSI: 8.0 vs. 7.0, p=0.64; mCTSI: 8.0 vs. 8.0, p=0.10; EPIC: 3.0 vs. 3.0, p=0.06). The application of a single-phase CT protocol was associated with a median effective dose reduction of 36% (mean dose reduction 31%) compared to a dual-phase CT scan. CONCLUSIONS:An initial dual-phase abdominal CT after ≥72h after onset of symptoms of acute pancreatitis was not superior to a single-phase protocol for evaluation of the severity of pancreatic and extrapancreatic changes. However, the effective radiation dose may be reduced by 36% using a single-phase protocol.
Comparison of the Accuracy of Modified CT Severity Index Score and Neutrophil-to-Lymphocyte Ratio in Assessing the Severity of Acute Pancreatitis.
Tahir Hasan,Rahman Sheeraz,Habib Zahid,Khan Yusra,Shehzad Saleha
Background Acute pancreatitis is an acute gastrointestinal emergency with significant morbidity and mortality if not treated. It can lead to local as well as systemic complications and has a prevalence of 51.07%. Laboratory investigations such as amylase and lipase and ultrasound scan are typically used for the diagnosis. A contrast-enhanced CT scan is considered the gold standard. Both laboratory and radiological investigation-based scoring systems have been reported in the literature and are in practice. However, these modalities demand several laboratory investigations and are expensive. Our study aims to determine the congruency of the neutrophil-to-lymphocyte ratio (NLR) and the modified CT severity index score (MCTSI) with the revised Atlanta classification in assessing the severity of acute pancreatitis. In addition, the accuracy of NLR and MCTSI is determined. The secondary objective is to determine whether NLR can predict the severity of acute pancreatitis to the same extent as MCTSI through expensive radiological imaging and other clinical scoring systems through a list of investigations. Methodology The data for this study were collected retrospectively and patients with a diagnosis of acute pancreatitis were included through the nonprobability convenience sampling method. All patients underwent relevant laboratory workup (including complete blood count) and radiological workup (including CT scan) during their hospital stay. The main outcome measures were sensitivity, specificity, and accuracy of NLR and MCTSI, and the congruency of these with the revised Atlanta classification in assessing the severity of acute pancreatitis. Results A total of 166 patients with acute pancreatitis were included, of which 107 (64.45%) were males and 59 (35.55%) were females, with a mean age of 43.7. The sensitivity, specificity, and accuracy of NLR were 67%, 90.9%, and 76%, respectively, whereas the sensitivity, specificity, and accuracy of MCTSI were 95%, 13.6%, and 62%, respectively. The area under the curve for NLR was 0.855 whereas that for MCTSI was determined to be 0.645. Conclusions NLR has a good concordance with the revised Atlanta classification and assesses the disease severity, especially in moderate-to-severe cases of acute pancreatitis compared to MCTSI. In addition, NLR can be used in acute and/or resource-poor settings to predict the severity of acute pancreatitis.