The pancreas functions as both an endocrine and exocrine organ. Its exocrine part releases digestive enzymes, while the endocrine portion secretes hormones into the bloodstream. Claude Bernard, in 1856, suggested that acute pancreatitis (AP) was caused by bile reflux into the pancreatic duct¹. Later in 1901, Eugene Opie identified gallstone migration as a primary cause of AP. The disease occurs when protective mechanisms fail, leading to premature trypsinogen activation. This triggers autodigestion of the pancreas and localized inflammation. AP can manifest as interstitial edematous or necrotizing pancreatitis, depending on severity.Most patients with acute pancreatitis (AP) experience localized inflammation, but about 20% progress to multiple organ dysfunction syndrome (MODS), which significantly increases mortality². The overall mortality rate of AP is estimated at 3–5%. A study from India reported a male predominance (2.75:1) with alcohol as the leading cause in 80% of cases. While many cases of AP are mild and self-limiting, around 20% develop moderate to severe disease with complications such as pancreatic necrosis, fluid collections, and organ failure. Severe acute pancreatitis (SAP) carries a mortality rate of 20–40%. Despite a rising incidence of AP, SAP-related deaths have not increased³, likely due to improved early recognition, enteral nutrition, and ICU care. Multi-organ failure (MOF) involving fewer than two systems and persistent organ failure (POF) for more than 48 hours are linked to poor outcomes. Cardiovascular, respiratory, and renal functions are key indicators of organ failure. The extent of pancreatic necrosis is a critical factor in mortality⁴. Early identification of high-risk patients is vital for timely intervention and appropriate care.A diagnosis of acute pancreatitis (AP) requires characteristic abdominal pain, elevated amylase and/or lipase levels (≥3 times normal), and imaging findings consistent with AP. The Atlanta Classification, first introduced in 1992, has been used to assess AP severity, though its original criteria were unclear^5,6; it was revised in 2012 to include persistent organ failure. Identifying patients at risk of complications prompted the development of various scoring systems based on clinical and imaging criteria. Tools such as Ranson’s score, CTSI, BISAP, Modified Glasgow Score, and APACHE-II are commonly used⁷, though they can be complex and offer limited sensitivity. CT imaging is often performed within 24 hours of admission to aid diagnosis and severity assessment. Unenhanced CT scores like Balthazar grade, PSI, MOP score, EP score, and EPIC score evaluate inflammatory changes and complications. Contrast-enhanced CT allows assessment of pancreatic necrosis using CTSI^8,9. The modified CTSI (MCTSI) adds scoring for extrapancreatic complications like vascular and gastrointestinal issues or pleural effusion. These tools help guide clinical management and predict outcomes in AP.In contrast to the CTSI, the MCTSI incorporates extrapancreatic complications in the assessment and simplifies the evaluation of the extent of pancreatic parenchymal necrosis (none, ≤ 30%, or > 30%) and peripancreatic inflammation (presence or absence of peripancreatic fluid). In the initial study of 66 patients¹⁰, the MCTSI, when compared with the CTSI, better correlated with patient outcome, in particular, with regard to the length of hospital stay and, more important, the development of organ failure,¹¹ which has been shown to be the primary determinant of outcome in the early phase of AP¹².

AIM

Comparative evaluation of clinical and radiological scoring system in early prediction of severity in acute pancreatitis using BISAP score and MCTSI

This hospital-based observational study was conducted in the Department of General Medicine at Mahatma Gandhi Medical College and Hospital, Jaipur. Following approval from the institutional research and ethical committee, the study was carried out over a period of 18 months—12 months dedicated to data collection and 6 months to data analysis. The study population included patients diagnosed with acute pancreatitis who visited the hospital during the study period. Inclusion criteria comprised patients aged 18 to 65 years of either gender with clinical and/or radiological evidence of acute pancreatitis and those willing to provide informed consent for participation. Exclusion criteria included patients below 18 years of age, cases of traumatic or autoimmune pancreatitis, individuals with known chronic kidney disease, chronic liver disease, or hepatocellular carcinoma, as well as pregnant women. Additionally, patients undergoing radiotherapy or chemotherapy, those with anemia or on vitamin B12/iron therapy, immunodeficient individuals, and patients unwilling to provide consent were excluded from the study.

Table 1: Age distribution among the study subjects

As depicted in table 1, study subjects were distributed according to age. Peak incidence was reported in 3rd decade of life i.e., between 31-40 years of age (n=48, 48%), followed by 26% between 21-30 years of age, 18% in 41-50 years of age group and 8% in 51-65 years of age group.

Table 2: Distribution of etiology among the study subjects

As depicted in table 2, 100 study subjects were distributed according to etiology of acute pancreatitis. Etiologies of acute pancreatitis included gallstones in 47 (47%) episodes, alcohol in 22 (22%) episodes, idiopathic in 13 (13%) episodes, hyperlipidemia in 12 (12%) episodes, trauma in 4 (4%) episodes and drug-induced in 2 (2%) episodes.

Table 3: Distribution of clinical features among the study subjects

As depicted in table 3, study subjects were distributed according to clinical features. The most common presentation was predominantly abdominal pain (65%), vomiting (61%), tenderness (43%), pain radiating to the back (33%), guarding (26%) and fever (22%).

Table 4: Severity of AP according to the recently revised Atlanta Classification

As depicted in table 4, subjects were distributed according to severity of AP according to the recently revised Atlanta Classification. 61 episodes (61%) were labelled as moderate AP, 22 (22%) episodes as mild AP and 17 episodes (17%) as clinically severe AP.

Table 5: Classification of cases according to Modified CT Severity index

As depicted in table 5, subjects were distributed according to severity of AP according to the Modified CT Severity index. 49 episodes (49%) were labelled as moderate AP, 27 (27%) episodes as mild AP and 24 episodes (24%) as clinically severe AP.

Table 6: Classification of cases according to BISAP

Of the 100 patients, 61 patients (61%) had BISAP score <3 (mild disease) and 39 patients (39%) had BISAP score ≥3 (severe disease).

Table 7: Hospital stay among the study subjects

The length of hospital stays ranges from 1 day to 27 days. The Mean length of hospital stay was 8.28±3.11 days in this study. (Table 7)

Table 8: Association between severity of acute pancreatitis and Modified CT Severity index

A statistically significant correlation was found when severity of acute pancreatitis was recorded according to the recently revised Atlanta Classification and Modified CT Severity index with a p value of 0.008. (Table 8)

Table 9: Association between severity of acute pancreatitis and BISAP

A statistically significant correlation was found when severity of acute pancreatitis was recorded according to the recently revised Atlanta Classification and BISAP with a p value of 0.005. (Table 9)

Table 10: Diagnostic efficacy of Modified CT Severity index and BISAP in predicting mortality

Diagnostic efficacy of Modified CT Severity index had sensitivity of 100% and specificity of 58.5% in predicting mortality. Diagnostic efficacy of BISAP had sensitivity of 100% and specificity of 73.5% in predicting mortality.

Acute pancreatitis (AP) is an inflammatory condition with varying severity, and early assessment is crucial for effective management and improved outcomes. This single-center, hospital-based observational study at Mahatma Gandhi Medical College, Jaipur, included 100 patients and assessed AP severity using BISAP and Modified CTSI scores.

Peak incidence was reported in 3rd decade of life i.e., 48%, followed by 26% between 21-30 years of age, 18% in 41-50 years of age group and 8% in 51-65 years of age group. Patients less than 20 years of age were excluded in this study, because the normal values of heart rate and respiratory rate are higher at younger age group. So, if these patients had been included in this study, they could have got higher scores incorrectly and could have predicted incorrectly as at risk for developing severe pancreatitis, even with mild disease.These findings were also similar with results of Murugadasan P et al., (2017)¹³ who found that 41% of subject were between 31-40 years of age, followed by 24% in <30 years of age group, like in our study. These outcomes above probably were responsible for strong work and life pressure, smoking, absent exercise, high-calorie food, and irregular sleeping schedule in young male patients.

Etiologies of acute pancreatitis included gallstones in 47 (47%) episodes, alcohol in 22 (22%) episodes, idiopathic in 13 (13%) episodes, hyperlipidemia in 12 (12%) episodes, trauma in 4 (4%) episodes and drug-induced in 2 (2%) episodes. These findings were similar to results of Agrawal S et al., (2023)¹⁴ the main cause for acute pancreatitis was gall stones (70.3%) followed by alcohol (27%) only 2.7% cases were due to idiopathic cause, as in present study. Other Indian studies also showed similar distribution in etiological agents. In our study the most common cause of pancreatitis was gallstone followed by alcoholism as in other Indian studies.

The most common presentation was predominantly abdominal pain (65%), vomiting (61%), tenderness (43%), pain radiating to the back (33%), guarding (26%) and fever (22%). This is because in AP the patient commonly describes moderate to severe abdominal pain in the epigastrium associated with nausea. Similar were the results of Manoharan GV et al., (2016)¹⁵ who found that most common presentation was predominantly abdominal pain (100%), vomiting (74%) and fever (64%), almost as in our study.

In present study, 61 episodes (61%) were labelled as moderate AP, 22 (22%) episodes as mild AP and 17 episodes (17%) as clinically severe AP, according to recently revised Atlanta Classification (RAC). In present study, majority of patients according to MCTSI scoring had a moderate disease (49%) while 27% had mild disease and 24% of patients had severe disease. In present study, 61 patients (61%) had BISAP score <3 (mild disease) and 39 patients (39%) had BISAP score ≥3 (severe disease). The presence of higher number of patients moderate to severe pancreatitis in our study is attributed to the fact that our hospital being a tertiary care centre, very sick patients having acute pancreatitis were referred to us. These findings were in accordance to results ofJingoniya NK et al., (2022)¹⁶ who found that of the 96 patients, 57 patients (59.37%) patients had BISAP score ≥3 (severe disease) and 39 patients (40.62%) had BISAP score <3 (mild disease).

The length of hospital stays ranges from 1 day to 27 days. The Mean length of hospital stay was 8.28±3.11 days in this study. These findings were in accordance of results of Manoharan GV et al., (2016)¹⁵ who found that the mean length of hospital was 8.32 +/- 7.742.

A statistically significant correlation was found when severity of acute pancreatitis was recorded according to the recently RAC and MCTSI with a p value of 0.008. A statistically significant correlation was found when severity of acute pancreatitis was recorded according to the RAC and BISAP with a p value of 0.005. These findings were similar to study done by Biradar NN, MU DJ., (2021)¹⁷ who found a strong significant correlation between Modified CT severity score and BISAP score when compared with RAC.

Diagnostic efficacy of Modified CT Severity index had sensitivity of 100% and specificity of 58.5% in predicting mortality. Diagnostic efficacy of BISAP had sensitivity of 100% and specificity of 73.5% in predicting mortality. This shows that BISAP is more accurate in predicting mortality in comparison to MCTSI.  Almost same were the results of Murugadasan P et al., (2017)¹³ who found that on comparing BISAP and MCTSI, BISAP having high odds ratio predicts mortality more accurately, as in present study.

To classify patients with acute pancreatitis into mild and severe groups, BISAP is a reliable prognostic tool. The components of BISAP are clinically relevant and easy to obtain. The sensitivity of BISAP score in predicting mortality was found to be 100% and specificity of 73.5%. Diagnostic efficacy of Modified CT Severity index had sensitivity of 100% and specificity of 58.5% in predicting mortality. This leads to conclusion that BISAP score is more reliable in predicting mortality compared to MCTSI. From this study, we conclude that BISAP score could be simple and accurate clinical scoring system for the evaluation of disease severity in acute pancreatitis, so CT needed not be taken in first 24 hours of admission.

1. Janjua, S. S., et al. "Comparison of Ranson’s Score, BISAP and CTSI in Predicting the Severity of Acute Pancreatitis." JIMDC, vol. 7, no. 4, 2018, pp. 255–259.
2. Yadav, J., et al. "Predicting Morbidity and Mortality in Acute Pancreatitis in an Indian Population: A Comparative Study of the BISAP Score, Ranson's Score and CT Severity Index." Gastroenterology Report (Oxford), vol. 4, no. 3, 2016, pp. 216–220.
3. Kim, B. G., et al. "A Comparison of the BISAP Score and Serum Procalcitonin for Predicting the Severity of Acute Pancreatitis." Korean Journal of Internal Medicine, vol. 28, no. 3, 2013, pp. 322–329.
4. Papachristou, G. I., et al. "Comparison of BISAP, Ranson’s, APACHE-II, and CTSI Scores in Predicting Organ Failure, Complications, and Mortality in Acute Pancreatitis." American Journal of Gastroenterology, vol. 105, no. 2, 2010, pp. 435–441.
5. Hagjer, S., and N. Kumar. "Evaluation of the BISAP Scoring System in Prognostication of Acute Pancreatitis – A Prospective Observational Study." International Journal of Surgery, 2018.
6. Whitcomb, D. C. "Clinical Practice. Acute Pancreatitis." New England Journal of Medicine, vol. 354, no. 20, 2006, pp. 2142–2150.
7. Fagenholz, P. J., et al. "Increasing United States Hospital Admissions for Acute Pancreatitis, 1988–2003." Annals of Epidemiology, vol. 17, no. 7, 2007, pp. 491–497.
8. Banks, P. A., and M. L. Freeman. "Practice Guidelines in Acute Pancreatitis." American Journal of Gastroenterology, vol. 101, no. 10, 2006, pp. 2379–2400.
9. Wu, B. U., et al. "The Early Prediction of Mortality in Acute Pancreatitis: A Large Population-Based Study." Gut, vol. 57, no. 12, 2008, pp. 1698–1703.
10. Yeung, Y. P., B. Y. Lam, and A. W. Yip. "APACHE System Is Better Than Ranson System in the Prediction of Severity of Acute Pancreatitis." Hepatobiliary & Pancreatic Diseases International, vol. 5, 2006, pp. 294–299.
11. Larvin, M., and M. J. McMahon. "APACHE-II Score for Assessment and Monitoring of Acute Pancreatitis." The Lancet, vol. 2, no. 8656, 1989, pp. 201–205.
12. Balthazar, E. J., et al. "Acute Pancreatitis: Value of CT in Establishing Prognosis." Radiology, vol. 174, no. 2, 1990, pp. 331–336.
13. Ranson, J. H., and B. S. Pasternack. "Statistical Methods for Quantifying the Severity of Clinical Acute Pancreatitis." Journal of Surgical Research, vol. 22, no. 2, 1977, pp. 79–91.
14. Murugadasan, P., and R. Ravi. "A Comparative Evaluation of Clinical and Radiological Scoring Systems in the Early Prediction of Severity in Acute Pancreatitis." IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), vol. 16, no. 12, 2017, pp. 11–15.
15. Agarwal, Samagra, et al. "Acute Pancreatitis Is Characterized by Generalized Intestinal Barrier Dysfunction in Early Stage." Pancreatology, vol. 23, no. 1, 2023, pp. 9–17. https://doi.org/10.1016/j.pan.2022.11.011.
16. Manoharan, G. V., C. Balamurugan, and S. Shanmugam. "A Comparative Evaluation of Radiologic and Clinical Scoring System in the Early Prediction of Severity in Acute Pancreatitis." IAIM, vol. 3, no. 7, 2016, pp. 159–165.
17. Jingoniya, N. K., et al. "Comparative Evaluation of BISAP Score and Computed Tomography Severity Index as a Predictor for Severity of Acute Pancreatitis." International Surgery Journal, vol. 9, 2022, pp. 421–425.
18. Biradar, Nivedita N., and Jeevika M. U. "Comparative Study of Scoring Systems in Acute Pancreatitis." Indian Journal of Basic and Applied Medical Research, vol. 10, no. 4, 2021, pp. 116–120. DOI: 10.36848/IJBAMR/2020/29215.55650.