Necrotizing pancreatitis & interstitial oedematous pancreatitis are two types of acute pancreatitis. Inflammation & edema are present in the peripancreatic tissues and pancreatic parenchyma in interstitial edematous pancreatitis. Necrotizing pancreatitis appears when this condition deteriorates to the point of peripancreatic or pancreatic tissue death.[1] AP is associated with an overall mortality rate of 3–5 %.[2,3] According to a study done in India, it mainly affects males i.e., in ratio of 2.75:1 and the leading etiological factor was alcohol, i.e., in 80% cases.[4] Multi-organ failure (MOF) involving <2 organ systems and persistent (<48 h) organ failure (POF) are associated with a higher risk of death and local complications, especially pancreatic necrosis.[5] Organ failure is determined by assessing Cardiovascular, Respiratory and Renal systems.. Moreover, in the past 10 years it has been established that the increased frequency of death in acute pancreatitis is directly correlated with the development and extent of pancreatic necrosis.[6,7]Therefore, early identification of patients at risk of developing severe acute pancreatitis (SAP) is essential for triaging patients to the appropriate site of care and initiating management.[8,9] To determine the severity of AP, many biochemical, radiological & clinical scores had been devised in the past. Ranson's score, the CT-severity index (CTSI), the bedside index of severity in acute pancreatitis (BISAP), the Modified Glasgow Score, & APACHE-II are some of them.[10] Acute pancreatitis severity can now be determined with the use of these forecasting methods. Though complex & difficult to use in clinical settings, it has been shown that these multi-factorial scoring systems work with a high negative predictive value but a meagre overall sensitivity.[11] Besides assessment of relevant clinical and biochemical parameters in AP, in many centers, it is standard practice to obtain a computed tomography (CT) scan on admission (i.e., within 24 hours of hospitalization), not only for diagnostic purposes but also for assessing the severity of disease. The severity of AP by CT imaging can be evaluated using unenhanced or contrast-enhanced CT studies. Unenhanced CT scoring systems evaluate the extent of pancreatic and peripancreatic inflammatory changes (Balthazar grade [12] and “pancreatic size index” (PSI) [13]) or evaluate both peripancreatic inflammatory changes and extrapancreatic complications (“mesenteric oedema and peritoneal fluid” (MOP score),[14] “extrapancreatic” or EP score,[15] and the more recently developed “extrapancreatic inflammation on CT” or EPIC score.[16] In addition, there are two CT scoring systems that require the use of intravenous contrast agents to determine the presence and extent of pancreatic parenchymal necrosis. The “CT severity index” or CTSI is a numerical scoring system combining the quantification of extrapancreatic inflammation with the extent of pancreatic necrosis.[17] Mortele et al.,[18] proposed a “modified CTSI”(MCTSI), which, in addition to the CTSI, assigns points for extrapancreatic complications (vascular, gastrointestinal and extrapancreatic parenchymal complications as well as the presence of pleural effusion and / or ascites). 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 patients, 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,[18] which has been shown to be the primary determinant of outcome in the early phase of AP.[19]. There is a need to evaluate the efficacy of clinical scoring system versus CT severity index to triage the patient into intensive care. The present study is designed to examine the effect of using BISAP score on patient outcome and its value in comparison with MCTSI. The objectives of the study are as below: Primary Objective To compare prediction of severity of acute pancreatitis using BISAP score and MCTSI. Secondary Objectives a. To compare prediction of mortality by BISAP and MCTSI. b. To assess correlation between scoring systems and pancreatic necrosis. c. To evaluate association between scoring systems and hospital stay.

The present hospital based observational study was conducted in the Department of General Medicine, ESIC Medical College and Hospital, MIA, Desula, Alwar, Rajasthan. The ethical clearance for study was taken from the Institutional Review Board of the Hospital. All subjects /attendants were explained about the procedure involved and purpose of the study. All consenting patients /attendants were asked to sign a written informed consent form (in the language best understood by them). Complete confidentiality regarding patient’s information was maintained at all stages of study and was not revealed at any point of time. No changes in standard treatment plan were made for the purpose of this study. There was no additional financial burden on the patient due to the study. Cases of acute pancreatitis who visited the College and Hospital were recruited. The study was conducted over a period of six months from the date of Institutional Ethics Committee approval or until the required sample size was achieved, whichever was later. Sample Size: The sample size was calculated based on findings reported by Jingoniya et al. (2022) and Murugadasan et al. (2017), where the sensitivity of BISAP score for predicting severe acute pancreatitis was reported to be approximately 78% and that of MCTSI approximately 92%. Considering: Sensitivity of BISAP (P1) = 78% Sensitivity of MCTSI (P2) = 92% Confidence level = 95% Power = 80% Alpha error = 5% Using the formula for comparison of two proportions: n=98.1, Therefore, the minimum required sample size was 99 patients. After rounding off: Final sample size = 100 patients. 100 patients diagnosed with acute pancreatitis or six months of duration which is earlier to complete. Sample size was calculated based on BISAP and MCTSI with 95% confidence interval and 80% power. Inclusion criteria: ● All patient with acute pancreatitis between 18 to 65 years of age of either gender. ● All patients with clinical and/or radiological evidence of acute pancreatitis. ● Patients who were willing to give consent for the participation in study. Exclusion criteria • Age less than 18 years. • Traumatic / autoimmune pancreatitis. • Known case of chronic kidney disease. • Known case of chronic liver disease. • Hepatocellular carcinoma. • Expecting (pregnant) women. • The patients receiving radiotherapy – chemotherapy. • Those with anemia (including those receiving vitamin B12, iron therapy). • Immunodeficiency patients. • Patient unwilling to give consent. Study procedure: All patients with Acute Pancreatitis presenting to the Department of General Medicine who fit the inclusion criteria were included in the study after obtaining informed consent. Extensive demographic, radiographic and laboratory data which includes complete haemogram, serum electrolytes, renal function test, liver function test, serum amylase, lipid profile, chest X-ray, USG abdomen etc were collected. BISAP score was calculated using data from the first 24 hours from admission. Criteria For BISAP Score: BUN more than 25mg/dl, Abnormal mental status with GCS <15, Evidence of SIRS, Age> 60 years, Presence of Pleural Effusion on X Rays. One point is given for each score. SIRS is defined by the presence of >2 of the following criteria: Pulse rate > 90/min, Respiratory rate > 20/min or PaCO2 < 32mm Hg, Temperature>100.40F or <96.80F, WBC count > 12,000 or < 4,000 cells/ mm 3 or >10% immature neutrophils. MCTSI was calculated from CECT within 48 hours. Modified CT Severity Score is calculated as follows: Normal Pancreas-Point 0, Intrinsic Pancreatic Abnormality with Peripancreatic fat stranding-Point 2, Peripancreatic fluid collection-Point 4, Pancreatic Necrosis – Absent-Point 0, <30 percent-Point 2, ≥30 percent-Point2, Extra Pancreatic Complications- Point 2. Total point is calculated. Patients were closely monitored during the entire stay in hospital and evidence of organ failure documented. Patients were classified as mild acute pancreatitis and severe acute pancreatitis based on the presence of organ failure that persist for more than 48hours. Oxygen failure is defined by-Shock (Systolic BP <90 mm Hg), Pulmonary Insufficiency (PO2<60mmHg at room air or need of mechanical ventilator), Renal Failure (serum creatinine> 2mg/dl after rehydration or hemodialysis). Pancreatic necrosis was assessed from CECT. Pancreatic necrosis is defined as lack of enhancement of pancreatic parenchyma with contrast. Comparison of prediction of severity of acute pancreatitis by BISAP and MCTSI score is the primary outcome of interest and comparison of prediction of mortality and pancreatic necrosis by both scores is the secondary outcome of interest. Statistical analysis: Data so collected was tabulated in an excel sheet, under the guidance of statistician. The means and standard deviations of the measurements per group were used for statistical analysis (SPSS 22.00 for windows; SPSS inc, Chicago, USA). The level of significance was set at p < 0.05.

Majority of the study subjects were males i.e., 76 (76%), followed by 24 subjects who were females. 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 1). Table 1: Demographic distribution among the study subjects Variable Category N % Gender Male 76 76 Female 24 24 Age Group (Years) 21–30 26 26 31–40 48 48 41–50 18 18 51–65 8 8 Total 100 100 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. The most common presentation was predominantly abdominal pain (65%), vomiting (61%), tenderness (43%), pain radiating to the back (33%), guarding (26%) and fever (22%) as shown in table 2. Table 2: Distribution of etiology and clinical features among the study subjects Variable Category N=100 % Etiology Alcoholism 22 22 Gall stones 47 47 Trauma 4 4 Hyperlipidemia 12 12 Drug induced 2 2 Idiopathic 13 13 Clinical Features Pain in abdomen 65 65 Pain radiating to the back 33 33 Guarding 26 26 Tenderness 43 43 Fever 22 22 Vomiting 61 61 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. 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. Of the 100 patients, 61 patients (61%) had BISAP score <3 (mild disease) and 39 patients (39%) had BISAP score ≥3 (severe disease) as shown in table 3. Table 3: Severity classification of acute pancreatitis among the study subjects Variable Category N=100 % Recently Revised Atlanta Classification Mild AP 22 22 Moderate AP 61 61 Severe AP 17 17 Modified CT Severity Index (MCTSI) Mild 27 27 Moderate 49 49 Severe 24 24 BISAP Score <3 (Mild Disease) 61 61 ≥3 (Severe Disease) 39 39 A total of 7 out of100 patients (7%) died during hospitalization (Table 4). Table 4: Hospital stay and mortality among the study subjects Variable Category/Value Result Hospital Stay (days) Mean ± SD 8.28 ± 3.11 Mortality Yes 7 (7%) No 93 (93%) Total 100 (100%) 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 5). Table 5: Association between severity of acute pancreatitis and Modified CT Severity Index. Severity Mild Moderate Severe Total Mild AP 20 2 0 22 Moderate AP 6 46 9 61 Severe AP 1 1 15 17 Total 27 49 24 100 p value 0.008* *: statistically significant 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 6). Table 6: Association between severity of acute pancreatitis and BISAP Severity <3 ≥3 Total Mild AP 21 1 22 Moderate AP 39 22 61 Severe AP 1 16 17 Total 61 39 100 p value 0.005* *: statistically significant 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 (graph 1).

In present study, majority of the study subjects were males i.e., 76%, followed by 24% subjects who were females. 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.[106] In study done by Nie L et al., (2020) [20] there were more man patients than woman patients with AP (67.7% vs 32.3%), like in our study.These findings were also similar with results of Murugadasan P et al., (2017) [21] 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 Jingoniya NK et al., (2022) [22] Indian study, as majority of patients (91.6%) had biliary pancreatitis followed by 6 patients (6.3%) of alcoholic pancreatitis and 2 patients (2.1%) of hyperlipidaemia, almost as in present study. In another Indian study, done by Agrawal S et al., (2023) [23] 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. In our study the most common cause of pancreatitis was gallstone followed by alcoholism as in other Indian studies. In study done by Cho JH et al., (2015) [24] alcohol showed significant association with patients with severe AP. This may be attributed to the difference in dietary, social, genetic and cultural factors between Indian population and Western population. 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.[25] Similar were the results of Manoharan GV et al., (2016) [26] 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 of Chaudhary M et al., (2020) [27] who found majority of patients (62%) had moderate AP according to Modified CT severity index score. These findings were similar to results of Jingoniya NK et al., (2022) [22] 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 stay 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) [26] who found that the mean length of hospital was 8.32 +/- 7.742. A total of 7 out of100 patients (7%) died during hospitalization, in present study. Almost same were the results of Murugadasan P et al., (2017) [21] who found the in- hospital mortality rate was 8%. In study done by Bollen TL et al., (2012) [28] mortality rate was 6%, as in our study. 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) [29] 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) [21] who found that on comparing BISAP and MCTSI, BISAP having high odds ratio predicts mortality more accurately, as in present study. These findings were in accordance of results of Manoharan GV et al., (2016) [26] who found that the BISAP score predicted the Mortality significantly over the MCTSI score in patients with severe acute pancreatitis.

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

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