A comparative study of severity scoring systems in acute pancreatitis

Abstract

Objective: To investigate the prognostic and clinical usefulness of existing scoring systems in predicting the severity of acute pancreatitis (AP). Methods: This prospective, observational clinical study included patients with diagnosed AP. Ranson's, bedside index for severity in acute pancreatitis (BISAP) and PANC 3 scoring systems were used to stratify the severity of disease. Scores from each model were compared to clinical severity. Sensitivity, specificity and accuracy were computed for each model. A p<0.05 was considered statistically significant. Results: Of 54 patients, 25 patients had non-biliary (group I) and 29 patients had biliary pancreatitis (group II). Based on Ranson's scoring, 32% and 27.6% in group I and II were classified as severe pancreatitis whereas the calculated BISAP score predicted severe condition in 24% and 20.7% in group I and II (p=0.77). BISAP was the most accurate (78%) in predicting organ failure, followed by Ranson's (72%) and PANC 3 (65%). Accuracy of BISAP, Ranson's and PANC 3 scoring systems were 91%, 69% and 79.62%, respectively for predicting disease severity. Conclusion: It was seen that BISAP was better than Ranson's in assessing organ failure, mortality and clinical severity in terms of sensitivity, specificity, PPV, NPV and accuracy.

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International Journal of Surgery Science 2020; 4(2): 237-241
E-ISSN: 2616-3470
P-ISSN: 2616-3462
© Surgery Science
www.surgeryscience.com
2020; 4(2): 237-241
Received: 19-02-2020
Accepted: 21-03-2020
Meghana Taggarsi
Sagar Hospitals, Jayanagar ‘T’
Block, Tilaknagar, Bangalore,
India
Anil Kumar
Sagar Hospitals, Jayanagar ‘T’
Block, Tilaknagar, Bangalore,
India
HR Ravishankar
MBBS, M.S, DNB, FRCS Eng,
FRCS (Gastro), CCST
Consultant Gastrointestinal and
Laparoscopic Surgeon, Head of
Department of General Surgery,
Sagar Hospitals, Jayanagar,
Tilaknagar, Bangalore, India
Corresponding Author:
HR Ravishankar
MBBS, M.S, DNB, FRCS Eng,
FRCS (Gastro), CCST
Consultant Gastrointestinal and
Laparoscopic Surgeon, Head of
Department of General Surgery,
Sagar Hospitals, Jayanagar,
Tilaknagar, Bangalore, India
A comparative study of severity scoring systems in acute
pancreatitis
Meghana Taggarsi, Anil Kumar and HR Ravishankar
DOI: https://doi.org/10.33545/surgery.2020.v4.i2d.424
Abstract
Objective: To investigate the prognostic and clinical usefulness of existing scoring systems in predicting
the severity of acute pancreatitis (AP).
Methods: This prospective, observational clinical study included patients with diagnosed AP. Ranson’s,
bedside index for severity in acute pancreatitis (BISAP) and PANC 3 scoring systems were used to stratify
the severity of disease. Scores from each model were compared to clinical severity. Sensitivity, specificity
and accuracy were computed for each model. A p<0.05 was considered statistically significant.
Results: Of 54 patients, 25 patients had non-biliary (group I) and 29 patients had biliary pancreatitis (group
II). Based on Ranson’s scoring, 32% and 27.6% in group I and II were classified as severe pancreatitis
whereas the calculated BISAP score predicted severe condition in 24% and 20.7% in group I and II
(p=0.77). BISAP was the most accurate (78%) in predicting organ failure, followed by Ranson’s (72%) and
PANC 3 (65%). Accuracy of BISAP, Ranson’s and PANC 3 scoring systems were 91%, 69% and 79.62%,
respectively for predicting disease severity.
Conclusion: It was seen that BISAP was better than Ranson’s in assessing organ failure, mortality and
clinical severity in terms of sensitivity, specificity, PPV, NPV and accuracy.
Keywords: acute pancreatitis, BISAP, PANC3, accuracy
1. Introduction
Acute pancreatitis (AP) is an inflammatory process with a variable clinical course and most
patients with AP present a mild disease that can be resolved spontaneously. However, despite
critical care, 10%-20% of patients experience a severe attack with high mortality up to 30% [1, 2].
In case of mild to moderate pancreatitis, mortality is less than 5%, although, 30% of them
develop secondary infection [3-4 weeks later than onset], which increases the mortality rate [3].
Ever since its establishment, the Atlanta Classification has been considered the global standard
tool for the assessment of AP severity [4]. Nonetheless, with time and varying clinical
representation, the Atlanta classification was revised with an emphasis on persistent organ
failure in 2012 [5].
Therefore, it is of foremost importance to assess the severity and identify patients at risk for an
early intensive therapy and timely intervention, and also, it has been shown to improve
prognosis and survival.
In this context, various multi-factorial scoring systems including Ranson’s [6] and Acute
Physiology and Chronic Health Evaluation (APACHE)-II scores [7] have been validated and used
for assessment of the severity of AP. However, due to their complex [8-10], a new prognostic
scoring system, the Bedside Index for Severity in Acute Pancreatitis (BISAP), was recently
proposed as an accurate and simple method for early identification of patients at risk of in-
hospital mortality [11, 12]. Although various scoring models exist to clinically evaluate the severity
of AP and organ failure, hitherto no single system has been considered ideal, thereby influencing
surgeon’s preference of choosing a method for prognostic assessment of AP. With this
background, we performed a study to compare the accuracy of Ranson’s criteria, BISAPs and
PANC 3 scoring systems in predicting the severity of an attack of AP.
2. Methods
This prospective comparative observational clinical study was conducted from May 2015 to
April 2017 in Sagar hospitals, a tertiary referral healthcare in Bangalore, India.

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The study protocol was approved by the institutional ethical
committee. The diagnosis of Acute pancreatitis was made based
on history, clinical examination, laboratory values of serum
amylase and lipase, and imaging study – ultrasound of abdomen,
to study the pancreas as well as to rule out or confirm biliary
cause for pancreatitis. The presence of any 2 of the 3 criteria was
diagnostic of pancreatitis.
Patients aged 18 years and above, diagnosed of AP (either first
attack or recurrent attacks), presenting with acute onset of
persistent severe epigastric pain, with or without radiation, and
increased serum amylase and lipase levels were included. On the
other hand, patients with pre-existing chronic pancreatitis or
with co-existing local complications of pancreatitis, cardiac
failure, liver failure, renal failure or any lung pathology were
excluded.
2.1 Assessment of severity and associated complications
Ranson’s, BISAPs and PANC 3 scoring systems were used to
stratify the severity of disease, within 48 hours of admission
(Table 1). The scores obtained from each of the scoring system
were compared to the clinical severity, as defined by Revised
Atlanta Classification 2012.
A score of ≥ 3 in first 48 hours for Ranson’s and first 24 hours
for BISAP indicated a likely severe pancreatitis condition.
Table 1: Description of parameters for BISAP and PANC 3 models
BISAPS
PANC 3
BUN
HCT
Mental status
BMI
SIRS
Chest X-Ray
Age
Pleural effusion
BMI: body mass index; BUN: blood urea nitrogen; HCT: haematocrit;
SIRS:
Data pertaining to duration of nil per oral, absence, presence or
persistence of organ failure, local complications, need for
interventions, ICU care, in-hospital mortality and length of
hospital stay was collected prospectively for each patient and
clinical severity was assessed.
Organ failure was defined according to the Marshall scoring
system. Respiratory (PaO2/FIO2), renal (serum creatinine) and
cardiovascular organ (systolic blood pressure) functions were
scored from 0-4. A score of 2 or more, involving one or more
than 1 organ, which may be persistent, lasting for more than 48
hours or transient, lasting for not more than 48 hours was
considered as organ failure. The clinical severity was assessed
during the course in the hospital, according to Revised Atlanta
classification 2012.
2.2 Statistical methods
Descriptive statistics was used to present continuous
measurements as mean ± standard deviation (SD) and
categorical measurements were presented as number and
percentages (%). Student t test was used to compare parameters
between two groups for continuous variables and Chi-square/
Fisher Exact test was used for categorical parameters.
Sensitivity, specificity, positive predictive value (PPV), negative
predictive value (NPV) and accuracy were computed to find the
diagnostic properties of Ranson’s, BISAP and PANC 3 scoring
to predict the severity of disease. SPSS 18.0, and R environment
ver.3.2.2 were used for the analysis. A p<0.05 was considered as
significant.
3. Results
A total of 54 patients (age range: 18 - 82 years) were included in
the study, of which 25 patients had non-biliary (group I, mean
age: 41.3±14.7 years) pancreatitis, and 29 patients had biliary
pancreatitis (group II, mean age: 55.6±14.7 years). However, all
the 54 patients were considered as a single group to draw
inference regarding outcomes of the scoring systems.
It was seen that the disease was more common in men (n=35)
than in women (n=19), although non-biliary pancreatitis was
more common in men (76% vs. 55.2%), while biliary
pancreatitis was more common in women (44.8% vs. 24%).
Biochemical parameters for two groups are presented in Table 2.
Table 2: Demographic and biochemical characters in two groups of
patients
Variables
Group I
Group II
PCV day1
39.93±6.31
39.67±5.80
PCV day2
36.57±6.91
36.79±5.84
TLC
14090.40±4959.24
12980.69±4972.59
BUN day 1
13.96±10.57
13.76±7.10
BUN day 2
15.84±12.3
15.24±7.06
RBS (mg/dl)
161.16±73.98
159.55±66.98
AST
106.68±167.02
207.31±200.02*
Calcium
8.46±0.88
8.71±0.67
Fluid sequestration
1201.80±669.53
1210.34±783.78
BMI (kg/m2)
26.14±5.50
26.29±4.45
PCV: packed cell volume; TLC: total leukocyte count; BUN: blood
urea nitrogen; RBS: random blood sugar; AST: aspartate
aminotransferase; BMI: body mass index
Based on Ranson’s scoring, 32% in group I and 27.6% in group
II were classified as severe pancreatitis whereas the calculated
BISAP score predicted severe condition in 24% of patients in
group I and 20.7% in group II (P=0.77). It was seen that all 54
patients had a PANC 3 score of less than 3, suggesting that each
of them would have mild or moderately severe pancreatitis.
PANC 3 score did not predict any cases to be severe in our study
(Table 3).
Table 3: Score code distribution among patients
Ranson's score code
Group I
Group II
Mild/ moderately severe (<3)
17 (68%)
21 (72.4%)
Severe pancreatitis (>/=3)
8 (32%)
8 (27.6%)
BISAP score
Mild/moderately severe (<3)
19 (76%)
23 (79.3%)
Severe (>/=3)
6(24%)
6 (20.7%)
PANC 3 score
Mild/moderately severe (<3)
25(100%)
29 (100%)
Severe (=3)
0 (0)
0(0)
As per revised Atlanta Classification 2012, 35 patients (64.8%)
of 54 had mild pancreatitis, 8 (14.8%) had moderately severe
and 11 (20.4%) had a severe disease (Table 4).
Table 4: Clinical (actual) severity analysis
Actual Severity
Group I
Group II
Not severe (mild + moderately severe)
19 (76%)
24 (82.7%)
Severe
6(24%)
5(17.2%)
Among the three scoring systems, BISAP was the most accurate
(78%) in predicting organ failure, with Ranson’s having an
accuracy of 72%, and PANC 3 depicted least accuracy (65%),
Graph 1

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Graph 1: Performance of Ranson’s, BISAP and PANC 3 for organ failure
As shown in graph 2, in terms of local complications, all three
models were accurate; however, PANC 3 had the highest
specificity (100%). PANC 3 was seen to be accurately scoring
patients for mortality with highest specificity when compared to
other two models (Graph 3).
Graph 2: Performance of Ranson’s, BISAP and PANC 3 for local
complications
Graph 3: Performance of Ranson’s, BISAP and PANC 3 for mortality
Local complications was present in 13 (24.1%) patients, which
included pseudocyst, necrosis, ascites, walled off necrosis and
recurrence, while 41 patients had no local complications
(p=0.20).
Out of 11 patients, who had clinically severe pancreatitis,
Ranson’s score in 5 of them and BISAP score in 9 of them was
more >/= 3. PANC 3 system did not predict severe pancreatitis
in any cases (score < 3 in all 11 patients). BISAP score of >/= 3
predicted severity of acute pancreatitis significantly (p <0.0000)
when compared to Ranson’s score (p = 0.19) and PANC 3 (p
value could not be calculated), Table 5.
Table 5: Correlation of Predicted scores with observed scores
Score
Actual severity
Total
p value
Ranson’s
Severe
Not severe
>/= 3
5
11
16
0.19
<3
6
32
38
Total
11
43
54
BISAPs
>/= 3
9
3
12
<0.000*
<3
2
40
42
Total
11
43
54
PANC 3
= 3
0
0
0
-
<3
11
43
54
Total
11
43
54
The performance of each scoring model as compared to actual
severity of disease is presented in Table 6. The accuracy of
BISAP, Ranson’s and PANC 3 scoring systems were 91%, 69%
and 79.62%, respectively for predicting the disease severity.
Table 6: Ranson’s, BISAP and PANC 3 scores for predicting disease
severity
Severity
Observation
Sensitivity
Specificity
PPV
NPV
Accuracy
RANSON score
45.45%
74.42%
31.25%
84.21%
69%
BISAP score
81.82%
93.02%
75%
95.24%
91%
PANC 3 score
0
100%
0
79.62%
79.62%
PPV: positive predictive value; NPV: negative predictive value
4. Discussion
Several markers have been validated for predicting the severity
for management of acute pancreatitis [13]. It has been
demonstrated that early recognition of a case can reduce the
mortality rate associated with acute pancreatitis significantly and
also improve outcome [14].
Multifactorial scoring systems such as Ranson’s, Glasgow,
APACHE II, CTSI, BISAP and PANC 3 are most commonly
used wherein various clinical data such as age, etiology and
obesity, blood urea nitrogen, lactate dehydrogenase, chronic
health status and inflammatory markers are also used to predict
the severity. However, owing to various risk factors considered
in each model to define the severity, it is difficult to fully
evaluate the actual sensitivity of the markers applied in
prognosticating the course of the disease [15]. The ideal predictor
of severity is described as being simple, highly sensitive, highly
specific, safe, reproducible, cheap and can be rapidly performed
[16]. The nature and purpose of this research work was to assess

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the predictive accuracy of Ranson’s criteria, BISAPs and PANC
3 scoring systems in predicting severity of an attack of acute
pancreatitis.
A total of 54 patients with acute pancreatitis were prospectively
studied and it was seen that majority of patients were men
(64.8%). This is in conjunction with findings of other studies
(62%) and it has been shown that alcohol is more common for
pancreatitis in men [17]. In our study, it was also seen that, 43
(79.6%) patients had mild to moderately severe acute
pancreatitis, while 11 (20.4%) patients had severe pancreatitis. 5
out of 11 and 9 out of 11 severe pancreatitis were correctly
predicted by Ranson’s score and BISAP, respectively. While,
PANC 3 did not predict any severe cases.
It was seen that BISAP was the most accurate (78%) in
predicting organ failure. Our results corroborate findings of
studies reported elsewhere. A prospective study of 100 patients,
done by, Lalithkumar et al. [18] showed that BISAP score had
better specificity (95.35%), and diagnostic accuracy (92%) when
compared to Ranson’s model (74.42%, 88% respectively) [18].
Another retrospective study in 303 patients, by Park et al. [19].
showed that BISAP and Ranson’s sensitivity for organ failure
was 91.3% each, specificity was 85% and 71.4 %. PPV was 33.3
and 20.8, NPV was 99.2 and 99.0, respectively. It also showed
that BISAP system predicts severity, death, and organ failure in
acute pancreatitis better than Ranson’s criteria. Results from
current study supports the aforementioned findings.
Additionally, 13 patients in our study reported local
complications like necrosis, ascites, pseudocyst, walled off
necrosis and recurrence of the disease. Among the three models,
Ranson’s score had a higher sensitivity (53.85%) compared to
BISAP (46.15%) whereas PANC3 had highest specificity for
local complications (100%). BISAP and PANC 3 scoring
models were accurate (76%) in predicting local complications.
Park et al. [19] also showed that, for local complications
(particularly necrosis), BISAP and Ranson’s had a sensitivity of
22.5% and 32.5%, specificity of 79.5% and 66.5%, PPV of
14.3% and 12.9% and NPV of 87.1% and 86.6%, respectively.
Another report from Yadav et al. [15] also compared BISAP,
Ranson’s and CTSI in 119 patients prospectively, in predicting
necrosis, mortality and severity. It was seen that BISAP and
Ranson’s were equally sensitive (89.4%) for determining
necrosis, while specificity was higher in BISAP (95.8% versus
94.4%). The PPV was 93.3% and 91.3% for BISAP and
Ranson’s respectively, and NPV was 93.2% for both. The
accuracy of BISAP was 93.4% whereas that of Ranson’s was
92.7%.
In our study, for predicting mortality, Ranson’s and BISAP
scores had a sensitivity of 66.67% and highest specificity was
seen for PANC 3 (100%). We observed that PANC 3 was most
accurate in predicting mortality (94%). Comparable results were
also reported by Park et al. [19] and Yadav et al. [15]. On the
contrary, findings from another study, done by Koziel et al.
reported that BISAP was more accurate in predicting mortality
when compared to PANC 3 and Ranson’s [20]. Furthermore,
Singh V et al. [12], by a prospective study showed better accuracy
with APACHE II compared to BISAP for predicting mortality.
In the current study, it was also seen that the BISAP score was
most accurate amongst all three in predicting clinical severity
with highest sensitivity of 81.82%, PPV and NPV of 75% and
95.24%, respectively. In agreement with our data, BISAP was
seen to be better than Ranson’s for predicting severity in terms
of specificity, PPV, NPV and accuracy, in the study done by
Park et al. [19]. On the other hand, when PANC 3 was compared
with Ranson’s in a study done by Fukuda et al. [21], for
predicting the severity of the disease, it was concluded that
PANC 3 could be used to define the severity and predict acute
pancreatitis, as a method to be used in combination with the
Ranson’s criteria owing to its high accuracy, positive predictive
value and specificity. This hypothesis was further confirmed by
Shah AS et al. [22], wherein PANC 3 was concluded to be a cost-
effective, promising model for predicting severity allowing
prompt treatment and early referral to higher centre.
Although, the various parameters in our study with regard to
Ranson’s, BISAP and PANC 3, for predicting organ failure,
local complications, mortality and clinical severity, had
resemblance to various studies comparing the various scoring
systems, the sample size of our study was small to definitely
predict which scoring system of the three is the best to
accurately predict the clinical severity of acute pancreatitis.
In conclusion, we found that BISAP was better than Ranson’s in
assessing organ failure, local complications, mortality and
clinical severity in terms of sensitivity, specificity, PPV, NPV
and accuracy. BISAP was also better than PANC 3 in all
parameters except specificity, which was highest for PANC 3,
for predicting organ failure, local complications and mortality.
However, the current data does not provide clear guidance on
which models should be used in specific patient population and
further studies with larger sample size are needed to clearly
draw definite conclusions.
Conflict of interest: None
Funding source: None
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