A COMPARATIVE STUDY BETWEEN APACHE II AND RANSON’S SCORING SYSTEMS IN PREDICTING THE SEVERITY OF ACUTE PANCREATITIS

Abstract

Aims and Objectives: The aims and objectives of the study are to compare the Ranson’s scoring system with APACHE II score in predicting the severity of acute pancreatitis. Methods: 50 cases having acute pancreatitis were included in this study on the basis of a predefined inclusion and exclusion criteria. Institutional ethical committee was approved the study. The duration of study was 2 years. Informed consent was obtained from the patients. Assessment of severity of pancreatitis was done on the basis of Ranson’s scoring as well as APACHE II score. Final severity score of the patients on the basis of both the scoring systems was assessed to determine the efficacy of each scoring system in predicting the severity. Results: Out of these 50 cases, there were 37 (74%) males and 13 (26%) females. The mean age of affected cases was found to be 36.86±7.91 years. The most common etiological factor was chronic alcoholism which was seen in 22 (44%) patients followed by biliary tract disease or stones (24%), hypertriglyceridemia (14%), post ERCP (2%), idiopathic (14%), and autoimmune pancreatitis (2%). Mild and severe pancreatitis was seen in 35 (70%) and 15 (30%), respectively. APACHE II score was found to be having more sensitivity and positive predictive value for the diagnosis of severe pancreatitis as compared to Ranson’s score. There was no significant difference in specificity, negative predictive value, and accuracy as determined by Ranson’s and APACHE II Score. Conclusion: APACHE II score is better in predicting severity of acute pancreatitis as it is found to have a better sensitivity and positive predictive value for the diagnosis of severe pancreatitis as compared to Ranson’s score.

Full text

Vol 16, Issue 6, 2023
Online - 2455-3891
Print - 0974-2441
A COMPARATIVE STUDY BETWEEN APACHE II AND RANSON’S SCORING SYSTEMS IN
PREDICTING THE SEVERITY OF ACUTE PANCREATITIS
MANOHAR KADAM1*, DHARMENDRASINH GOHIL2
Received: 02 April 2023, Revised and Accepted: 15 May 2023
ABSTRACT
Methods: 50 cases having acute pancreatitis were included in this study on the basis of a predefined inclusion and exclusion criteria. Institutional
ethical committee was approved the study. The duration of study was 2 years. Informed consent was obtained from the patients. Assessment of
severity of pancreatitis was done on the basis of Ranson’s scoring as well as APACHE II score. Final severity score of the patients on the basis of both
the scoring systems was assessed to determine the efficacy of each scoring system in predicting the severity.
Results: Out of these 50 cases, there were 37 (74%) males and 13 (26%) females. The mean age of affected cases was found to be 36.86±7.91 years.
The most common etiological factor was chronic alcoholism which was seen in 22 (44%) patients followed by biliary tract disease or stones (24%),
hypertriglyceridemia (14%), post ERCP (2%), idiopathic (14%), and autoimmune pancreatitis (2%). Mild and severe pancreatitis was seen in
35 (70%) and 15 (30%), respectively. APACHE II score was found to be having more sensitivity and positive predictive value for the diagnosis of severe
pancreatitis as compared to Ranson’s score. There was no significant difference in specificity, negative predictive value, and accuracy as determined
by Ranson’s and APACHE II Score.
Conclusion: APACHE II score is better in predicting severity of acute pancreatitis as it is found to have a better sensitivity and positive predictive value
for the diagnosis of severe pancreatitis as compared to Ranson’s score.
Keywords: Acute pancreatitis, Ranson’s, APACHE II score, Complications, Sensitivity.
INTRODUCTION
Acute pancreatitis can be defined as inflammation of pancreatic
parenchyma as well as surrounding peri-pancreatic tissue. It
is one of the leading causes of gastrointestinal system-related
morbidity as well as mortality in surgical practice. The pre-disposing
factors for development of pancreatitis include cholelithiasis,
hypertriglyceridemia, chronic alcoholism, trauma, and viral infections
such as cytomegalovirus, mums, and Epstein–Bar virus. Drug-induced
pancreatitis can be secondary to the drugs such as azathioprine,
sulfonamides, tetracycline, and didanosine. The less common causes
include autoimmune pancreatitis, neoplastic diseases, and procedures
such as endoscopic retrograde cholangiopancreatography [1].
Acute pancreatitis usually presents as dull abdominal pain which
gradually increases in severity and is usually associated with nausea
vomiting as well as anorexia. The abdominal pain in pancreatitis
characteristically reduces upon sitting but this improvement is usually
temporary and there is gradual worsening of abdominal pain [2]. Unless
it is diagnosed early and appropriately managed acute pancreatitis has
the potential to culminate into catastrophic complications such as shock
multi-organ dysfunction that may eventually cause death. According to
the severity, acute pancreatitis is divided into mild acute pancreatitis
(absence of organ failure and local or systemic complications,
moderately acute pancreatitis (no organ failure or transient organ
failure <48 h with or without local complications) and severe acute
pancreatitis (persistent organ failure more than 48 h that may involve
one or multiple organs) [3].
Since in many cases, abdominal pain initially is dull and bearable and
many times associated with nausea, vomiting as well as diarrhea, it
may be attributed to other gastrointestinal diseases and a high index
of suspicion, particularly in individuals known to have risk factors for
development of acute pancreatitis, is essential for early diagnosis of
acute pancreatitis [4]. Serum amylase and lipase levels are increased
in cases with acute pancreatitis, however, these enzymes are non-
specific and cannot be relied upon for the diagnosis. The diagnosis of
pancreatitis is usually confirmed on the basis of imaging techniques
such as ultrasound imaging, computed tomography, and in selected
cases, magnetic resonance imaging can be done [5]. In cases of acute
pancreatitis, on ultrasound, pancreas usually appears to be having
heterogeneous echotexture with decreased echogenicity and presence
of peripancreatic fluid collection. Ultrasound examination, however,
is having less sensitivity particularly in obese and non-cooperative
patients. On computerized tomography, acute pancreatitis may present
as diffusely enlarged pancreas with indistinct margins and surrounding
fat stranding. On MRI diffusion-weighted images, it may present as
hyperintense signal of the involved parenchyma [6].
Identification of severity is one of the essential parts of management
of patients with acute pancreatitis and is essential in further guiding
management strategies in cases of pancreatitis [7]. Several scoring
system, such as APACHE II, Ranson’s score bedside index for severity
in acute pancreatitis (BISAP), and modified Glasgow score, is in use for
the assessment of severity. Out of these scores, APACHE II and Ranson’s
score are more commonly used for the assessment of severity in cases
of acute pancreatitis [8].
We conducted this study to compare the efficacy of APACHE II and
Ranson’s score in the assessment of severity of cases having acute
pancreatitis.
© 2023 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (http://creativecommons.org/
licenses/by/4.0/) DOI: http://dx.doi.org/10.22159/ajpcr.2023v16i6.48438. Journal homepage: https://innovareacademics.in/journals/index.php/ajpcr
Research Article
1Department of General Surgery, Vedanta Institute of Medical Sciences, Dhundalwadi, Maharashtra, India. 2Department of General
Surgery, PDU Medical College and Hospital, Rajkot, Gujarat, India. Email: drmanoharka93@gmail.com
Objectives: The aims and objectives of the study are to compare the Ranson’s scoring system with APACHE II score in predicting the
severity of acute pancreatitis.

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Kadam and Gohil
METHODS
This was a comparative study conducted in the department of general
surgery of PDU Medical College and Hospital of Saurashtra University
to compare the RANSON scoring system with APACHE II score in
predicting the severity of acute pancreatitis. 50 patients diagnosed to
be having acute pancreatitis were included in this study on the basis
of a predefined inclusion and exclusion criteria. Institutional ethical
committee approved the study. The duration of study was 2 years.
Informed and written consent was obtained from the patients before
enrolling them in the study.
Sample size calculation was calculated on the basis of pilot studies done
for analyzing cases of acute pancreatitis. Keeping power (1-Beta error) at
80% and confidence interval (1-alpha error) at 95%, the minimum sample
size required was 40 patients; therefore, we included 50 cases in this study.
A detailed history was taken in all the cases particularly with respect to
predisposing factors such as alcohol intake, cholelithiasis, and drug intake
for the development of pancreatitis. A thorough clinical examination
was done in all the cases. Routine investigations such as complete blood
count, renal function tests, hepatic function test, and coagulation profile
was done in all cases. Diagnosis of acute pancreatitis was made on the
basis Atlanta criteria that consisted of acute abdominal pain suggestive
of pancreatitis along with either serum amylase or lipase level >3 times
the upper normal value or characteristic imaging findings. Imaging
studies consisted of ultrasound as well as computerized tomography. In
addition to the diagnosis of pancreatitis, imaging also was used for the
detection of biliary causes of pancreatitis such as cholelithiasis and/or
choledocholithiasis. Acute pancreatitis was classified as alcohol related
when the patient reported a regular higher intake of alcohol or an alcoholic
binge directly before the onset of the disease and no signs of possible
other causes will be found like gall stones pancreatitis. The cases were
classified as severe pancreatitis if there was presence of multiorgan failure
or complications such as hypotension and shock (systolic BP <90 mmHg),
pulmonary insufficiency (PaO2 60 mmHg or less), renal failure (serum
creatinine >2 mg), or gastrointestinal bleeding (>500 mL/24 h).
Assessment of severity of pancreatitis was done on the basis of Ranson’s
scoring [9] as well as APACHE II score [10]. Final severity score of
the patients on the basis of both the scoring systems was assessed to
determine the efficacy of each scoring system in predicting the severity.
For statistical purposes, SSPS 21.0 software was used. Sensitivity,
specificity, positive predictive value, and negative predictive value were
calculated. p<0.05 was taken as statistically significant.
Inclusion criteria
1. Patients admitted and diagnosed to be having acute pancreatitis on
the basis of imaging
2. Age above 20 years
3. Patients who gave informed written consent to be part of study.
Exclusion criteria
1. Patient who refused consent to be part of study
2. Known cases of chronic pancreatitis
3. Recurrence of acute pancreatitis
4. Patients with severe comorbid conditions such as uncontrolled
diabetes, uncontrolled hypertension, and severe systemic
autoimmune conditions.
RESULTS
Total 50 patients were studied. Out of these 50 cases, there were
37 (74%) males and 13 (26%) females. There was a male preponderance
with an M: F ratio being 1:0.35 (Fig. 1).
The analysis of patients on the basis of age group showed that the
most common affected age group was between 31 and 40 (42%)
years followed by 41–50 (36%) years and 20–30 years (16%). 3 (6%)
patients were above 50 years of age. The mean age of affected cases was
found to be 36.86±7.91 years (Table 1).
The analysis of predisposing factors for the development of pancreatitis
showed that the most common etiological factor was chronic alcoholism
which was seen in 22 (44%) patients followed by biliary tract disease or
stones (24%), hypertriglyceridemia (14%), post-ERCP (2%), idiopathic
(14%), and autoimmune pancreatitis (2%) (Fig. 2).
The analysis of patients on the basis of severity showed that out of
50 studied cases, mild and severe pancreatitis was seen in 35 (70%)
and 15 (30%), respectively. Most common age group to be affected by
severe pancreatitis was between 31 and 40 years (12%) followed by
31–40 years (10%). Only 1 patient (2%) above 50 years was found to
be above 50 years of age (Table 2).
The analysis of patients on the basis of clinical classification showed
that 15 (30%) were having severe pancreatitis. 9 (18%) and 13 (26%)
patients were found to be having severe pancreatitis as assessed by
Ranson’s and APACHE II score, respectively (Table 3).
The analysis of severity of pancreatitis as assessed by Ranson’s score
as well as APACHE II score showed that the sensitivity of Ranson’s
and APACHE II score for the diagnosis of severe pancreatitis was 60%
Fig. 1: Gender distribution of the studied cases
Table 1: Gender‑wise distribution of age in studied cases
Age Male Female
No of
cases
Percentage No of
cases
Percentage
20–30 years 5 10 3 6
31–40 years 16 32 5 10
41–50 years 14 28 4 8
Above 50 years 2 4 1 2
Total 37 74% 13 26
Mean age=36.86±7.91 years
Fig. 2: Predisposing factors for the acute pancreatitis

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Kadam and Gohil
Table 2: Severity of pancreatitis in studied cases
Age Mild pancreatitis Severe pancreatitis
No of
cases
Percentage No of
cases
Percentage
20–30 years 5 10.00 3 6.00
31–40 years 15 30.00 6 12.00
41–50 years 13 26.00 5 10.00
Above 50 years 2 4.00 1 2.00
Total 35 70 15 30.00
Table 3: Assessment of severity of acute pancreatitis by
Ranson’s and APACHE II score
Severity of pancreatitis No of cases Percentage
Clinical
Mild pancreatitis 35 70
Severe pancreatitis (multiorgan
dysfunction, respiratory failure, renal
failure, or significant GI bleeding)
15 30
Ranson’s score
<3 41 76
≥3 9 24
APACHE II scoring system
<8 37 74
≥8 13 26
Fig. 3: Complication in studied cases
and 80%, respectively. APACHE II score was found to be having more
sensitivity and positive predictive value for the diagnosis of severe
pancreatitis as compared to Ranson’s score. There was no significant
difference in specificity, negative predictive value, and accuracy as
determined by Ranson’s and APACHE II score (Table 4).
The analysis of complications in the studied cases showed that out of 50
studied cases, complications were seen in 11 (22%) patients. The most
common complication was found to be local peripancreatic collection
which was seen in 3 (6%) patients. The other complications included
biliary obstruction (4%), respiratory failure (4%), and multiorgan
dysfunction (6%). Renal failure was seen in 1 (2%) patient (Fig. 3).
DISCUSSION
We conducted this study to compare Ranson’s and APACHE II scores
in the assessment of severity of acute pancreatitis. Total 50 patients
admitted with acute pancreatitis were included in this study on the basis
of a predefined inclusion and exclusion criteria. In our study, there were
37 (74%) males and 13 (26 %) females. There was a male preponderance
with an M: F ratio being 1:0.35. The most common affected age group
was found to be 31–40 years and the mean age was found to be
36.86±7.91 years. Ramu et al. conducted a study of patients with acute
pancreatitis [11]. In this study, out of 436 cases, 318 (72.9%) were males
and 118 (27.1%) were females. The mean age of studied cases was found
to be s 43.45 years (median 41 years). Similar male preponderance was
also reported by the authors such as Panda et al. [12] and Satoh et al. [13].
In our study, chronic alcoholism (44%) followed by biliary tract
disease or stones (24%), hypertriglyceridemia (14%), post-ERCP (2%),
idiopathic (14%), and autoimmune pancreatitis (2%) were common
predisposing factors for the development of acute pancreatitis.
Prasad and Nagarjuna conducted a study of 40 patients with acute
pancreatitis [14]. The common predisposing factors for pancreatitis in
this study were found to be biliary causes (55%) followed by alcoholism
(32.5%), idiopathic pancreatitis (7.5%), hyperlipidemia (2.5%), and
traumatic (2.5%) pancreatitis. Similar to our study, alcoholism and
biliary tract diseases were most common causes of acute pancreatitis
in this study. Similar predisposing factors were also reported to be the
authors such as Spicák [15] and Weiss et al. [16].
The most common complication was found to be local peripancreatic
collection which was seen in 3 (6%) patients. The other complications
included biliary obstruction (4%), respiratory failure (4%), and
multiorgan dysfunction (6%). Renal failure was seen in 1 (2%) patient.
In our study, complications were seen in 11 (22%) patients. Sonawane
et al. conducted a study of 53 patients with pancreatitis [17]. In this
study, 12 (22.6%) patients developed complications, 3(5.66%) had
acute fluid collections, 2(3.77%) had pseudocyst, 8(15.1%) had ascites,
9(16.98%) had pleural effusion, 2 (3.77%) had pancreatic necrosis,
1 (1.89%) had superior mesenteric vein thrombosis, 1 (1.89%) had GI
bleed, and 5 (9.43%) had organ failure. The complication rate in this
study was found to be comparable to our study.
The analysis of severity of pancreatitis as assessed by Ranson’s score
as well as APACHE II score showed that the sensitivity of Ranson’s
and APACHE II score for the diagnosis of severe pancreatitis was 60%
and 80%, respectively. APACHE II score was found to be having more
sensitivity and positive predictive value for the diagnosis of severe
pancreatitis as compared to Ranson’s score. There was no significant
difference in specificity, negative predictive value, and accuracy
as determined by Ranson’s and APACHE II score. In a prospective
study, Malathy and Sundarapandian enrolled 50 patients with acute
pancreatitis [18]. Severity of pancreatitis in these cases was assessed
by APACHE II and Ranson’s scores. The study found that an APACHE II
score of ≥10 on admission predicted a complicated outcome in patients
with acute pancreatitis with a sensitivity of 100%, specificity of 80%,
positive predictive value of 62%, and negative predictive value of 100%.
Scores below 10 predicted an uncomplicated outcome. On the basis of
these findings, the authors concluded that APACHE II score was a better
predictor of systemic complications (sensitivity 100%) than RANSON
score (sensitivity 66.7%). These findings were similar to our study.
Similar superiority of APACHE II score in assessment of severity of
acute pancreatitis was also reported by the authors such as Kumar and
Griwan [19] and Khanna et al. [20].
Table 4: Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in studied cases
Ranson’s score 60.00 94.24 81.82 84.62 84
APACHE II score 80.00 97.14 92.31 91.89 92
p-value 0.003 (significant) 0.49 (not significant) 0.049 (significant) 0.14 (not significant) 0.12 (not significant)
Sensitivity (%) Specificity (%) Positive predictive value (%) Negative predictive value (%) Accuracy (%)

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Limitation of the study
Relatively small number of cases is one of the important limitations of
this study. A large randomized control trial will further substantiate
the findings of this study. Moreover, the cases were not followed up for
prolonged period of time to assess long-term complications such as
pseudocyst formation.
CONCLUSION
APACHE II is found to be better in assessment of cases with acute
pancreatitis as it is found to have a better sensitivity and positive
predictive value for the diagnosis of severe pancreatitis as compared
to Ranson’s score.
WORK ATTRIBUTED TO
Department of General Surgery, PDU Medical College and Hospital,
Rajkot.
AUTHORS CONTRIBUTION
MK – Concept and design of the study, prepared first draft of manuscript;
DG – Interpreted the results, reviewed the literature, and manuscript
preparation and revision of the manuscript.
CONFLICT OF INTEREST
None.
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