Comparison between Ransons score and modified CTSI in predicting the severity of acute pancreatitis based on modified Atlanta classification 2012

Abstract

Background: Acute pancreatitis is an inflammatory process of the pancreas with possible peripancreatic tissue and multiorgan involvement inducing multiorgan dysfunction syndrome (MODS) with a high mortality rateand hence early identification of patients at risk for severe disease is of vital importance.Methods: Data were collected from 50 patients who presented to the emergency department of hospitals attached to BMCRI, Bangalore, having acute pancreatitis.Results: The study included 50 patients- 40 males and 10 females and median patient age was 54.5years.Out of the 50 patients, 40% had gall stones, 56% were alcoholic and 4% had idiopathic pancreatitis.56% were found to have a Ransons score of >3 and 44% had score < 3; 52%had a modified CTSI score of 0-2, 52%had a score of 4-6 and 22% had a score of 8-10. The incidence of severe acute pancreatitis in patients with Ransons score >3 has a p value <0.002. Also, the incidence of severe acute pancreatitis in patients with modified CTSI score >4 has a p value of <0.001.With respect to mortality, all 4 patients who died had a modified CTSI score of >4 (p=0.002) and 3 patients had Ransons score >3 (p=0.03) which is statistically significant.Conclusions: In our country where facility for CECT is not available to a major proportion of population, early assessment of severe pancreatitis can be performed by Ransons scoring, which is found to be comparable to modified CTSI scoring.

Full text

International Surgery Journal | May 2019 | Vol 6 | Issue 5 Page 1596
International Surgery Journal
Manjunath BD et al. Int Surg J. 2019 May;6(5):1596-1600
http://www.ijsurgery.com
pISSN 2349-3305 | eISSN 2349-2902
Original Research Article
Comparison between Ransons score and modified CTSI in predicting
the severity of acute pancreatitis based on modified Atlanta
classification 2012
Manjunath B. D., Mohammed Arafath Ali*, Abdul Razack, Harindranath H. R.,
Avinash K., Kavya T., Lakshmi Vijayakumar
INTRODUCTION
Acute pancreatitis is an inflammatory process of the
pancreas with possible peripancreatic tissue and
multiorgan involvement inducing multiorgan dysfunction
syndrome (MODS) with a high mortality rate.1
The incidence of acute pancreatitis per 100,000
population ranges from 5 to 80 cases per year with an
overall mortality of 5–10%.2
To improve the prognosis and survival, early assessment
of the severity and identification of patients at risk for
severe disease is of vital importance.3
About 15% of patients present with severe acute
pancreatitis and the mortality rate is alarmingly high-
20%.Hence, prediction of severity is important for
improving survival. Several scoring systems have been
devised for predicting prognosis and severity of acute
pancreatitis, which help in further management of the
ABSTRACT
Background: Acute pancreatitis is an inflammatory process of the pancreas with possible peripancreatic tissue and
multiorgan involvement inducing multiorgan dysfunction syndrome (MODS) with a high mortality rateand hence
early identification of patients at risk for severe disease is of vital importance.
Methods: Data were collected from 50 patients who presented to the emergency department of hospitals attached to
BMCRI, Bangalore, having acute pancreatitis.
Results: The study included 50 patients- 40 males and 10 females and median patient age was 54.5years.Out of the
50 patients, 40% had gall stones, 56% were alcoholic and 4% had idiopathic pancreatitis.56% were found to have a
Ransons score of >3 and 44% had score < 3; 52%had a modified CTSI score of 0-2, 52%had a score of 4-6 and 22%
had a score of 8-10. The incidence of severe acute pancreatitis in patients with Ransons score >3 has a p value <0.002.
Also, the incidence of severe acute pancreatitis in patients with modified CTSI score >4 has a p value of <0.001.With
respect to mortality, all 4 patients who died had a modified CTSI score of >4 (p=0.002) and 3 patients had Ransons
score >3 (p=0.03) which is statistically significant.
Conclusions: In our country where facility for CECT is not available to a major proportion of population, early
assessment of severe pancreatitis can be performed by Ransons scoring, which is found to be comparable to modified
CTSI scoring.
Keywords: Acute pancreatitis, Modified CTSI, Mortality, Ranson’s score
Department of General Surgery, Bangalore Medial College and Research Institute, Bangalore, Karnataka, India
Received: 24 November 2018
Revised: 02 April 2019
Accepted: 03 April 2019
*Correspondence:
Dr. Mohammed Arafath Ali,
E-mail: arafathali0708@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2349-2902.isj20191876

Manjunath BD et al. Int Surg J. 2019 May;6(5):1596-1600
International Surgery Journal | May 2019 | Vol 6 | Issue 5 Page 1597
patient. Ideal predicting criteria should be simple, easily
available and accurate.
Many scoring systems have been developed for the early
detection of severe AP which includes of Ranson,
Glasgow, MOSS, SIRS, BISAP, APACHE-II, CTSI
Scores etc.4
The above scoring systems have their limitations
including the low sensitivity and specificity, difficulty of
the scoring system as well as inability to obtain a final
score until 48 hours after admission.
Contrast enhanced scans have brought about a major
improvement in the grading system. Detection of
pancreatic necrosis, parenchymal injury etc. can serve as
predictors of severity. Contrast enhanced CT has shown
an overall accuracy of 87% with a sensitivity of 100% for
the detection of extended pancreatic necrosis. The
sensitivity and specificity for diagnosing pancreatic
necrosis increase with greater degrees of pancreatic non-
enhancement, and complications have also been shown to
correlate with the degree of non-enhancement. In 2004,
modified CTSI was introduced to improve the staging of
acute pancreatitis.3,5
This study is aimed at comparing one of the oldest
scoring systems, i.e., Ranson’s scoring system and one of
the newer systems, i.e., modified CTSI for predicting the
severity of acute pancreatitis, based on the revised
Atlanta 2012 classification.6
METHODS
Demographic, radiographic, and laboratory data were
collected from 50 patients (sample size calculated based
on convenience sampling) who presented to the
emergency department of hospitals attached to BMCRI,
Bangalore, found to have acute pancreatitis, over a period
of one year (June 2017 to June 2018) the diagnosis of
which was based on the presence of atleast two out of the
three criteria, i.e., : (1) abdominal pain characteristic of
AP, (2) serum amylase and/or lipase ≥3 times the upper
limit of normal, and (3) characteristic finding of AP on
abdominal CT Scan or ultrasonography.1
Revised Atlanta Classification 2012 was used to classify
acute pancreatitis as mild with no local or systemic
complications or organ failure, moderately severe, i.e.,
organ failure that resolves within 48 hours or local or
systemic complications without persistent organ failure or
severe, i.e., persistent organ failure more than 48 hours.
The following prognostic markers were used to know the
severity of the disease i.e., pancreatic necrosis,
requirement of ICU admission and mortality.7,8
Ranson’s score was calculated based on age, TC, LDH,
AST, RBS at admission and haematocrit, BUN, Calcium,
PO2, Base deficit and fluid sequestration at 48 hours.
Modified CTSI score was calculated. CECT was
performed in required cases on day 4 to look for
pancreatic necrosis, local complications, and possible
aetiology of AP. CTSI score was noted after CT scan.9
Patients were classified as mild, moderately severe and
severe acute pancreatitis, based on the presence of organ
failure for more than 48 hrs and local complications.
Organ failure included shock (systolic blood pressure
<90 mmHg), pulmonary insufficiency (arterial PO2
<60 mmHg at room air or the need for mechanical
ventilation), or renal failure (serum creatinine level
>2 mg/dl after rehydration or hemodialysis ).7,8
Pancreatic necrosis was assessed by CECT; evidence of
pancreatic necrosis on CT was defined as lack of
enhancement of pancreatic parenchyma with contrast.
Table 1: Ranson’s scoring.10
Parameter
Alcohol
induced
Gallstone
induced
On admission
Age (years)
>55
>70
WBC (/ml)
>16,000
>18,000
Glucose (mg/dl)
>200
>220
LDH (IU/L)
>350
>400
AST (IU/L)
>250
>250
Within 48 hours
HCT decreases (points)
>10
BUN increases (mg/dl)
>5
>2
Calcium (mg/dl)
<8
<8
PaO2 (mmHg)
<60
Base deficit (mEq/L)
>4
>5
Fluid (input-output)
>6
>4
Table 2: Modified ct severity index (2004).
Pancreatic
inflammation
0- Normal pancreas
2-Intrinsic pancreatic abnormalities
with or without inflammatory
changes in peri pancreatic fat
4-Pancreatic or peripancreatic fluid
collection or peripancreatic fat
necrosis
Pancreatic
necrosis
0-None
2- <30%
4->30%
Extrapancreatic
complications
One or more of the following-
pleural effusion, ascites, vascular
complications, parenchymal
complications or gastrointestinal
tract involvement.
Mild pancreatitis- Modified CTSI score 0-2
Moderate pancreatitis- Modified CTSI score- 4-6
Severe pancreatitis- Modified CTSI score- 8-10

Manjunath BD et al. Int Surg J. 2019 May;6(5):1596-1600
International Surgery Journal | May 2019 | Vol 6 | Issue 5 Page 1598
Table 3: Revised Atlanta classification 2012.11,12
Management
Patients who presented to emergency, diagnosed as acute
pancreatitis were managed by aggressive fluid
resuscitation, analgesia, oxygen supplementation,
monitoring of vitals and biochemical parameters,
nasogastric drainage, antibiotics, and supportive therapy
in case of organ failure.13,14
Statistics
All the data was subjected to statistical analysis to
measure the objectives. SPSS version 24 was used for
analysis and various descriptive statistics were used to
calculate ratios, frequencies, percentages, median, means
and standard deviation. Tables were used for data
presentation, while the categorical data such as gender
and comparison of modified CTSI with Ranson’s score
and patient outcome etc. was expressed as frequency and
percentages using chi-square test. P<0.05 was taken as
significant.
RESULTS
The study included 50 patients- 40 males and 10 females
(Table 4).
Table 4: Patient characteristics.
Characteristics
Category
Number of patients
Sex
Male
40 (80%)
Female
10 (20%)
The median patient age was 54.5 years (Figure 1).
Patients were classified as per Atlanta 2012 classification
as mild acute pancreatitis (40%), moderately severe acute
pancreatitis (36%) and severe acute pancreatitis (24%).
Figure 1: Age groups.
Etiology
Out of the 50 patients, 20 (40%) had gall stones, 28(56%)
were alcoholic and 2(4%) had idiopathic pancreatitis
(Table 5).
Table 5: Etiology.
N (%)
Gall stone disease
20 (40)
Alcoholic
28 (56)
Idiopathic
2 (4)
Presentation
All the patients (50-100%) presented with pain abdomen,
15(30%) had peritonitis. 36(72%) presented with
vomiting, 24(48%) had abdominal distension and
20(40%) presented with non passage of stools/flatus.
(Table 6).
Table 6: Presentations.
Symptom
Number of
patients
Percentage
(%)
Pain abdomen
50
100
Peritonitis
15
30
Vomiting
36
72
Abdominal distension
24
48
Non passage of
stools/flatus
20
40
Scoring systems
Out of the 50 patients, 28(56%) were found to have a
ransons score of >3 and 22(44% had Ransons score < 3;
26(52%) had a modified CTSI score of 0-2, 26(52%) had
a score of 4-6 and 11(22%) had a score of 8-10. Also, 16
12
18
12
5
3
0
>60 50-59 40-49 30-39 20-29 <20

Manjunath BD et al. Int Surg J. 2019 May;6(5):1596-1600
International Surgery Journal | May 2019 | Vol 6 | Issue 5 Page 1599
% patients had mild acute pancreatitis according to
Atlanta 2012 grading, 20(40%) were found to have
moderately severe acute pancreatitis and 14(28%) had
severe pancreatitis (Table 7).
Table 7: Scoring systems.
N (%)
Ranson’s score
>3
28 (56)
<3
22 (44)
Modified CTSI
0-2
26 (52)
4-6
26 (52)
8-10
11 (22)
Atlanta 2012
grading
Mild
16 (32)
Moderately severe
20 (40)
Severe
14 (28)
Outcome
Out of the 50 patients, 40(80%) were discharged, 4(8%)
died, 5 (10%) were discharged against medical advice
and 12(24%) had to undergo ICU care (Figure 2).
Figure 2: Outcome of the study.
CT findings
On CECT, 14(28%) patients were found to have
pancreatic necrosis, 19(38%) were found to have peri
pancreatic fluid collection, 26(52%) had ascites and
30(60%) had pleural effusion (Table 8).
Comparison between ranson’s and modified CTSI
Ransons score and modified CTSI scores were compared
based on mortality and incidence of severe acute
pancreatitis. Out of the 4 deaths, 3(75%) had a Ransons
score of >3, and 4(100%) had a modified CTSI score of
>4. 12(85%) patients with acute severe pancreatitis had a
Ransons score of >3, and 13(92%) had a modified CTSI
score of >4. The incidence of severe acute pancreatitis in
patients with Ransons score >3 has a p value <0.002
which is statistically significant. Also, the incidence of
severe acute pancreatitis in patients with modified CTSI
score >4 has a p value of <0.001 which is again
statistically significant. With respect to mortality, all 4
patients who died had a modified CTSI score of >4 (p
=0.002) and 3 patients had Ransons score >3 (p- 0.03)
which is statistically significant (Table 9).
Table 8: CT findings.
Findings
Number of
patients
Percentage
Pancreatic necrosis
14
28
Peripancreatic
fluid collection
19
38
Ascites
26
52
Pleural effusion
30
60
Table 9: Comparison between Ransons Score
and modified CTSI.
Ransons
score >3
Modified
CTSI >4
N (%)
N (%)
Mortality (n- 4)
3 (75)
4 (100)
Severe acute pancreatitis
(n- 14)
12 (85)
13 (92)
DISCUSSION
Acute pancreatitis is a common disease presenting as an
emergency, and early identification of severe acute
pancreatitis is necessary for appropriate resuscitation and
management of the patient.
The study included 50 patients- 40 males and 10 females
as opposed to female preponderance in most of the
studies conducted worldwide. The median patient age
was 54.5 years which seconds the study conducted by
Kaya et al. in Turkey.14
Patients were classified as per Atlanta 2012 classification
as mild acute pancreatitis (40%), moderately severe acute
pancreatitis (36%) and severe acute pancreatitis (24%).
Out of the 50 patients, 40(80%) were discharged, 4(8%)
died, 5 (10%) were discharged against medical advice
and 12(24%) had to undergo ICU care which was similar
to the statistics of the study conducted by Kumar AH et al
in Rohtak.2
In this study, the relationship between Ransons score and
modified CTSI score in patients with severe acute
pancreatitis has been compared. Also, the relationship
between the mortality in patients having Ransons score
>3 and modified CTSI score >4 has been evaluated. Out
of the 50 patients, 28(56%) were found to have a Ransons
0
5
10
15
20
25
30
35
40
45
DISCHARGED DEATH DISCHARGED
AGAINST
MEDICAL
ADVICE
ICU
ADMISSION
OUTCOME

Manjunath BD et al. Int Surg J. 2019 May;6(5):1596-1600
International Surgery Journal | May 2019 | Vol 6 | Issue 5 Page 1600
score of >3 and 22(44%) had Ransons score <3; 26(52%)
had a modified CTSI score of 0-2, 26(52%) had a score
of 4-6 and 11(22%) had a score of 8-10. Also, 16 %
patients had mild acute pancreatitis according to Atlanta
2012 grading, 20(40%) were found to have moderately
severe acute pancreatitis and 14(28%) had severe
pancreatitis which was similar to a study conducted by
Khanna AK et al in Uttar Pradesh, India.4
Out of the 4 deaths, 3(75%) had a Ransons score of >3,
and 4(100%) had a modified CTSI score of >4 which is
in concordance with the study conducted by Shabbir S et
al in Pakistan.15
12(85%) patients with acute severe pancreatitis had a
Ransons score of >3, and 13(92%) had a modified CTSI
score of >4.
In our country where facility for CECT is not available to
a major proportion of population, either due to financial
constraints or inaccessibility, early assessment of severe
pancreatitis can be performed by Ransons scoring, which
is found to be comparable to modified CTSI scoring.
CONCLUSION
In this study, the relationship between Ransons score and
modified CTSI score in patients with severe acute
pancreatitis has been compared. Also, the relationship
between the mortality in patients having Ransons score
>3 and modified CTSI score >4 has been evaluated.
In our country where facility for CECT is not available to
a major proportion of population, either due to financial
constraints or inaccessibility, early assessment of severe
pancreatitis can be performed by Ransons scoring, which
is found to be comparable to modified CTSI scoring.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: Not required
REFERENCES
1. Al Mofleh IA. Severe acute pancreatitis:
pathogenetic aspects and prognostic factors. World J
Gastroenterol. 2008;14(5):675-84.
2. Kumar AH, Griwan MS. 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.
Gastroenterol Rep (Oxf). 2018;6(2):127-31.
3. Bollen TL, Singh VK, Maurer R. Comparative
evaluation of the modified CT severity index in
assessing severity of acute pancreatitis. Am J
Roentegenol. 2011;197:386-92.
4. Khanna AK, Meher S, Prakash S, Tiwary SK, Singh
U, Srivastava A, et al. Comparison of Ranson,
Glasgow, MOSS, SIRS, BISAP, APACHE-II, CTSI
Scores, IL-6, CRP, and procalcitonin in predicting
severity, organ failure, pancreatic necrosis, and
mortality in acute pancreatitis. Hpb Surgery.
2013;2013.
5. Yadav J, Yadav SK, Kumar S. Predicting morbidity
and mortality in acute pancreatitis in an Indian
population: a comparative study of BISAP score,
Ranson’s Score and CT severity
index. Gastroenterol Rep (Oxf). 2016;4:216-20.
6. Banday IA, Gattoo I, Khan AM. Modified computed
tomography severity index for evaluation of acute
pancreatitis and its correlation with clinical
outcome: a tertiary care hospital based observational
study. J Clin Diagn Res. 2015;9:TC01–5.
7. Banks PA. Epidemiology, natural history, and
predictors of disease outcome in acute and chronic
pancreatitis. Gastrointestinal
Endoscopy. 2002;56(6):S226-S30.
8. Kong L, Santiago N, Han T-Q, Zhang S-D. Clinical
characteristics and prognostic factors of severe acute
pancreatitis. WJ Gastroenterol. 2004;10(22):3336-
8.
9. Yang L, Liu J, Xing Y. Comparison of BISAP,
Ranson, MCTSI and APACHE II in predicting
severity and prognoses of hyperlipidemic acute
pancreatitis in Chinese patients. Gastroenterol Res
Pract. 2016;2016.
10. Aphinives P, Karunasumetta C, Bhudhisawasdi
V, Saesaew OT. Acute pancreatitis: assessment
severity with Ranson score and CT evaluation. J
Med Assoc Thai. 2011;94(4):437-40.
11. Bradley EL. A clinically based classification system
for acute pancreatitis. In: Summary of the
International Symposium on Acute Pancreatitis,
Atlanta, GA, 11–13 September 1992. Arch Surg.
1993;128:586-90.
12. Banks PA, Bollen TL, Dervenis C. Classification of
acute pancreatitis-2012: revision of the Atlanta
classification and definition by international
consensus. Gut 2013;62:102-11.
13. Kivisaari L, Somer K, Standertskjold-Nordenstam
CG. Early detection of acute fulminant pancreatitis
by contrast-enhanced computed tomography. Scand
J Gastroenterol. 1983;18:39-41.
14. Kaya E, Derviolu A, Polat C. Evaluation of
diagnostic findings and scoring systems in outcome
prediction in acute pancreatitis. World J
Gastroenterol. 2007; 13:3090-4.
15. Shabbir S, Jamal S, Khaliq T, Khan ZM.
Comparison of BISAP Score with Ranson'sScore in
Determining the Severity of Acute Pancreatitis. J
Coll Physicians Surg Pak. 2015;25(5):328-31.
Cite this article as: Manjunath BD, Ali MA, Razack
A, Harindranath HR, Avinash K, Kavya T, et al.
Comparison between Ransons score and Modified
CTSI in predicting the severity of acute pancreatitis
based on modified atlanta classification 2012. Int
Surg J 2019;6:1596-600.