What is the best approach for scoring and managing acute pancreatitis?

Acute Pancreatitis Scoring and Management

The best approach for scoring acute pancreatitis is to use the Glasgow score and C-reactive protein (CRP) for initial severity stratification within 48 hours, with APACHE II for ongoing monitoring in severe cases, followed by contrast-enhanced CT scanning between 3-10 days after admission in severe cases. 1

Initial Severity Assessment

• Severity stratification should be completed within 48 hours of admission to identify patients at high risk for mortality and complications 1
• Clinical assessment alone is unreliable and will misclassify approximately 50% of patients 1
• The presence of organ failure (pulmonary, circulatory, or renal insufficiency) detected clinically indicates a severe attack according to the Atlanta definitions 1

Recommended Scoring Systems

• Glasgow Criteria: Validated in UK populations with 70-80% accuracy; three or more positive criteria based on initial admission score and subsequent tests over 48 hours constitutes severe disease 1
• C-reactive protein (CRP): Peak level >210 mg/l in first four days (or >120 mg/l at end of first week) has predictive performance similar to objective systems with 80% accuracy 1
• APACHE II Score: Equally accurate to Glasgow score; can be used for initial assessment and should be used for ongoing monitoring in severe cases 1
  • Score ≥9 indicates severe attack but excludes many with lower scores that will develop complications 1
  • Score ≥6 includes nearly all complications (95% sensitivity) but only 50% positive predictive value 1
  • Daily scoring can track recovery, disease progression, or onset of sepsis 1

Alternative Scoring Systems

• BISAP Score (Bedside Index of Severity in Acute Pancreatitis): Simpler to calculate with comparable accuracy to Ranson criteria 2, 3

  • Evaluates five parameters within 24 hours: BUN >25 mg/dl, Impaired mental status, SIRS, Age >60 years, and Pleural effusion 3
  • Shows good specificity (91%) but suboptimal sensitivity (51-56%) for predicting mortality and severe acute pancreatitis 4, 5
  • AUC for predicting severe pancreatitis (0.80) and death (0.86) similar to APACHE-II and better than CTSI 6

• Ranson Criteria: 70-80% accuracy in predicting severity with score ≥3 indicating severe disease with increased mortality risk 2, 7

  • Requires 48 hours for complete assessment, limiting early decision-making 8, 7

Radiological Assessment

• Dynamic CT Scan: Should be performed in all severe cases between 3-10 days after admission 1
  • Timing depends on clinical and logistic factors; best performed after initial resuscitation 1
  • Assesses degree of pancreatic necrosis and surrounding fluid collections 1
  • CT Severity Index (CTSI) combines assessment of inflammation and necrosis, with scores 0-10 3
  • CTSI correlates with morbidity and mortality but has lower predictive accuracy than clinical scoring systems 7, 5

Laboratory Markers

• C-reactive protein (CRP): Most valuable single laboratory marker 1

  • Combine with Glasgow criteria for improved prognostication 1
  • CRP ≥150 mg/l on day 3 indicates severe acute pancreatitis 3

• Other markers: Interleukin-6, PMN elastase, trypsinogen activation peptide, and methaemalbuminaemia correlate with severity but require further evaluation and are not routinely available 1

  • Procalcitonin shows promise for detecting pancreatic infection and has prediction rates similar to BISAP 5

Algorithmic Approach to Scoring and Management

1. Initial Assessment (0-24 hours):

   • Calculate APACHE II score at admission 1
   • Begin Glasgow score assessment 1
   • Assess for clinical signs of organ failure 1

2. Early Stratification (24-48 hours):

   • Complete Glasgow score assessment (≥3 indicates severe disease) 1
   • Continue daily APACHE II scoring in severe cases 1
   • Measure CRP levels 1

3. Management Based on Severity:

   • Mild cases: Standard supportive care 1
   • Severe cases: Intensive monitoring, aggressive fluid resuscitation, and consideration of ICU admission 1, 3
   • Perform contrast-enhanced CT scan between days 3-10 in severe cases 1

4. Ongoing Assessment:

   • Continue daily APACHE II scoring to monitor disease progression 1
   • Monitor for development of local complications and organ failure 1, 3
   • Reassess CRP levels 1

Pitfalls and Caveats

• No single scoring system perfectly predicts all patients who will develop complications 1
• Many patients initially classified as severe will have uncomplicated recovery 1
• Scoring criteria alone do not necessarily indicate need for surgery, as they don't accurately predict degree of pancreatic necrosis 1
• CT scanning should not be performed too early (before 3 days) as it may underestimate the extent of pancreatic necrosis 1
• Contrast-enhanced CT should be used cautiously in patients with renal insufficiency 1