Predicting Severity of Pancreatitis: Multiple Validated Scoring Systems
All of the scoring systems mentioned (BISAP, Ranson's criteria, and APACHE II) are validated tools for predicting the severity of pancreatitis, with each having specific advantages in different clinical scenarios. 1, 2
Major Scoring Systems and Their Accuracy
BISAP (Bedside Index for Severity in Acute Pancreatitis): A simple 5-point scoring system that evaluates BUN >25 mg/dl, Impaired mental status, SIRS, Age >60 years, and Pleural effusion within 24 hours of admission. A BISAP score ≥2 is a statistically significant cutoff for predicting severe acute pancreatitis, organ failure, and mortality. 1, 3
Ranson's criteria: Evaluates 11 parameters (5 on admission and 6 at 48 hours). A score ≥3 indicates severe pancreatitis with sensitivity of 75-87% and specificity of 68-77.5%. 1
APACHE II: Evaluates chronic health score and 12 physiologic measurements. A score ≥8 indicates severe acute pancreatitis with sensitivity of 83.3% and specificity of 91%. It has the highest accuracy for prediction of severe acute pancreatitis in some studies. 1, 2
CT Severity Index (CTSI): Combines assessment of pancreatic inflammation and necrosis with scores ranging from 0-10. Higher scores correlate with increased morbidity and mortality. 1
Comparative Performance
A study of 161 patients found that APACHE-II demonstrated the highest accuracy for predicting severe acute pancreatitis compared to other scoring systems. 1
The BISAP score has similar accuracy to the APACHE-II score for predicting death but is much simpler to calculate at the bedside. 2, 4
A meta-analysis showed that BISAP has excellent specificity (91%) but moderate sensitivity (56%) for predicting mortality, while Ranson and APACHE-II showed higher sensitivity but lower specificity. 5
A retrospective analysis of 303 patients revealed that BISAP predicts severity, death, and especially organ failure in acute pancreatitis as well as APACHE-II does and better than Ranson criteria, CTSI, CRP, hematocrit, and BMI. 3
Practical Application
Early assessment (within 24 hours): BISAP and APACHE-II can be calculated and provide valuable prognostic information. 2, 3
48-hour assessment: Ranson's criteria can be fully calculated at this point. 1
3-10 days after admission: Dynamic contrast-enhanced CT scan should be performed in severe cases to calculate CTSI. 2
Additional markers: C-reactive protein (CRP ≥150 mg/l on day 3) and procalcitonin are valuable adjuncts for predicting severity and pancreatic necrosis. 2, 6
Clinical Pitfalls to Avoid
Do not rely solely on a single scoring system; using multiple complementary systems improves predictive accuracy. 7
APACHE-II, while accurate, is cumbersome and not all parameters are routinely collected in clinical practice. 1
All scoring systems have limitations in their predictive accuracy, with most having reached their maximal utility. 4
Remember that clinical judgment remains essential alongside scoring systems, particularly for ongoing assessment of disease progression. 2