Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis

Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
The American Journal of Gastroenterology (Impact Factor: 10.76). 10/2009; 105(2):435-41; quiz 442. DOI: 10.1038/ajg.2009.622
Source: PubMed


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.
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).
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.
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.

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    • "some and inaccurate [3]. Some of them are: a) the Acute Physiology, Age and Chronic Health Evaluation (Apache II) [4] [7] [9] [14]; b) Structured Interview of Reported Symptoms (SIRS) [4] [9]; c) the Ranson score [4] [7] [9]; d) Bedside index for severity in AP (BISAP) (blood urea nitrogen >25mg/dl, impaired mental status, Systemic inflammatory response syndrome, age >60 years and pleural effusions) [2] [3] [15]; e) The Harmless Acute Pancreatitis Score (HAPS) (no rebound tenderness and/ or guarding, normal hematocrit and normal serum creatinine level) allows rapid identification of patients who present mild AP in 98% of cases; f) CT severity index (CTSI) based on local complications and percentage of pancreatic necrosis seen on a CT scan [2] [4] [5] [17] [18]. Various laboratory tests and biomarkers for predicting AP outcome have been described: a) elevated C-reactive protein (CRP) [1] [4] [13] [14] [19] [20]; b) elevated hematocrit (Ht) [5] [7] [14] [21] [22]; and c) high serum creatinine, as a doubtful predictor of pancreatic necrosis [23] [24]. "
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    ABSTRACT: Abstract None of the definitions of severity used in acute pancreatitis (AP) is ideal. Many of the scoring systems used to predict and measure its severity are complex, cumbersome and inaccurate. Aim to evaluate the usefulness of the most commonly used early markers for predicting severity, necrosis and mortality in patients with AP, and the need for surgery or Intensive Care Unit (ICU) admission. Material&methods Prospective study was performed from March 2009 to August 2010 based on patients diagnosed with AP seen consecutively at a secondary hospital. The early prognostic markers used were Apache II score ≥8 and Ranson’s score ≥3, RCP>120mg/l and Ht>44% in the first 24 hours. Results 131 patients were prospectively enrolled. Median age was 63 years, 60% were men. The most frequent etiology of AP was biliary (68%). Fifteen patients were admitted to the ICU (11.6%) and five (3.9%) required surgery. Twelve patients (9.2%) had necrosis on CT. Four patients (3%) died, all of them in the Severe AP group. Only hematocrit>44 was predictor of mortality in univariate analysis. Conclusion hematocrit ≥ 44% was a significant predictor of mortality. The other indicators present limitations for predicting severity, necrosis and mortality, especially in the first 24 hours.
    Full-text · Article · Aug 2014 · Central European Journal of Medicine
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    • "what they aim to predict) [4]. Definitions include local and/or systemic complications (as defined by the 1992 Atlanta symposium) [5], infectious pancreatic complications alone, admission to an ICU, length of ICU or hospital stay, complications requiring intervention, grading by radiological imaging [6], and multifactorial prognostic clinico-biochemical scores [7]. It has been argued that improvements in predicting severity of acute pancreatitis can hardly be achieved without agreement on which endpoints should be used [2]. "
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    ABSTRACT: Background Persistent organ failure and infected pancreatic necrosis are major determinants of mortality in acute pancreatitis, but there is a gap in the literature assessing the best available predictors of these two determinants. The purpose of this review was to investigate the utility of predictors of persistent organ failure and infected pancreatic necrosis in patients with acute pancreatitis, both alone and in combination. Methods We performed a systematic search of the literature in 3 databases for prospective studies evaluating predictors of persistent organ failure, infected pancreatic necrosis, or both, with strict eligibility criteria. Results The best predictors of persistent organ failure were the Japanese Severity Score and Bedside Index of Severity in Acute Pancreatitis when the evaluation was performed within 48 h of admission, and blood urea nitrogen and Japanese Severity Score after 48 h of admission. Systemic Inflammation Response Syndrome was a poor predictor of persistent organ failure. The best predictor of infected pancreatic necrosis was procalcitonin. Conclusions Based on the best available data, it is justifiable to use blood urea nitrogen for prediction of persistent organ failure after 48 h of admission and procalcitonin for prediction of infected pancreatic necrosis in patients with confirmed pancreatic necrosis. There is no predictor of persistent organ failure that can be justifiably used in clinical practice within 48 h of admission.
    Full-text · Article · May 2014 · Digestive and Liver Disease
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    • "The APACHE-II score has the advantage of reflecting systemic complications. An increasing APACHE-II score reflects the general condition of the patient becoming more serious [14], [30]. MRI is a reliable method of grading the severity of acute pancreatitis and has prognostic value [31]. "
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    ABSTRACT: To study the MRI findings of the normal transverse mesocolon and the involvement of the mesocolon in acute pancreatitis (AP) as well as the relationship between the involvement of the mesocolon and the severity of AP. Forty patients without pancreatic disorders were retrospectively analyzed to observe the normal transverse mesocolon using MRI; 210 patients with AP confirmed by clinical and laboratory tests were retrospectively analyzed using MRI to observe transverse-mesocolon involvement (TMI). The severity of TMI was recorded as zero points (no abnormalities and transverse-mesocolon vessel involvement), one point (linear and patchy signal in the transverse mesocolon) or two points (transverse-mesocolon effusion). The AP severity was graded by the MRI severity index (MRSI) and the Acute Physiology And Chronic Healthy Evaluation II (APACHE II) scoring system. The correlations of TMI with MRSI and APACHE-II were analyzed. In a normal transverse mesocolon, the display rates of the middle colic artery, the middle colic vein and the gastrocolic trunk on MRI were 95.0%, 82.5% and 100.0%, respectively. Of the 210 patients with AP, 130 patients (61.9%) had TMI. According to the TMI grading, 40%, 39% and 20% of the patients were graded at zero, one and two points, respectively. TMI was strongly correlated with the MRSI score (r = 0.759, P = 0.000) and the APACHE-II score (r = 0.384, P = 0.000). MRI could be used to visualize transverse-mesocolon involvement. The severity of TMI could reflect that of AP in the clinical setting and imaging. TMI might be a supplementary indicator of the severity of AP.
    Full-text · Article · Apr 2014 · PLoS ONE
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