Acute pancreatitis is a condition characterized by the rapid onset of pancreatic inflammation, which can lead to varying degrees of tissue damage. It can range from mild, self-limiting episodes to severe, life-threatening complications. Recognizing the diverse presentations and potential outcomes of acute pancreatitis is crucial for effective management and treatment [1,2]. The understanding and recognition of acute pancreatitis have evolved significantly over centuries. From ancient observations of its symptoms to modern advancements in diagnostics and therapeutics, the historical progression underscores both the growth of medical knowledge and the ongoing challenges in managing this complex condition [3]. Acute pancreatitis also poses substantial health risks and economic burdens worldwide. With its increasing incidence, diverse causes, and potential for severe complications, there is a critical need for comprehensive awareness among healthcare providers, researchers, policymakers, and the public. By deepening our understanding of acute pancreatitis, we can improve prevention, diagnosis, and treatment strategies, ultimately enhancing patient outcomes [3-5]. Early and accurate assessment of both the disease severity and prognosis is vital for guiding effective treatment and improving patient outcomes. To aid in this process, several scoring systems have been developed to predict clinical outcomes in AP. Among the most widely recognized are the BISAP’s score and the Modified Computed Tomography (CT) Scoring System, both of which help clinicians assess the severity of the disease and inform management strategies. [6] Given the variable nature of acute pancreatitis, prompt intervention based on these assessments is essential to reduce morbidity and mortality. In 2008, Wu et al. [7] developed a new scoring system known as the Bedside Index for Severity in Acute Pancreatitis (BISAP), designed to estimate the risk of in-hospital mortality in patients with acute pancreatitis (AP). The BISAP score is based on five key variables: blood urea nitrogen (BUN) levels >25 mg/dL, impaired mental status, the development of systemic inflammatory response syndrome (SIRS), age >60 years, and the presence of pleural effusion. Since its introduction, numerous studies have been conducted to validate the BISAP score’s reliability, simplicity, and accuracy in stratifying patients with AP. These studies have generally supported BISAP as an effective tool for predicting mortality risk and guiding clinical decision-making, offering a straightforward approach to identifying high-risk patients early in their hospitalization. The Modified CT Scoring System offers a radiological approach to assess the severity of acute pancreatitis and predict clinical outcomes. Derived from CT imaging findings, this system evaluates various parameters related to pancreatic inflammation, necrosis, and complications. These parameters include the degree of pancreatic edema, parenchymal enhancement, peripancreatic fat stranding, the presence and extent of pancreatic necrosis, peripancreatic fluid collections, hemorrhage, and involvement of adjacent structures. By quantifying the severity of these findings and calculating a total score, the Modified CT Scoring System allows clinicians to stratify patients into different risk categories, helping to anticipate disease progression. [8,9] While the Modified CTSI provides detailed information about the anatomical severity of acute pancreatitis based on CT findings, the BISAP score is a simpler, faster, and clinically relevant tool that can be used earlier in the disease course for predicting patient outcomes and identifying high-risk individuals. The BISAP score’s reliance on easily obtainable clinical parameters makes it better suited for early risk stratification, mortality prediction, and resource-limited environments. Since BISAP score is based on clinical parameters, it can easily be influenced by other systemic diseases and associated conditions and hence lacks specificity. Whereas, the modified CTSI is time consuming and subject to radiologist’s interpretation and is influenced by inter-observer variability.

The study was conducted at the Department of Surgery, Dr. D.Y. Patil Medical College, Hospital and Research Institute, Kolhapur, for a period of 18 months after receiving Institutional Ethical Clearance from the Institutional Ethics Committee. All patients diagnosed with acute pancreatitis who met the inclusion and exclusion criteria were included in the study. Inclusion Criteria: Patients aged above 18 years, diagnosed with acute pancreatitis, regardless of gender. Mild, moderate and severe cases of acute pancreatitis. Patients falling in the above criteria giving consent for the study. Exclusion Criteria: Patients with a history of chronic pancreatitis or pancreatic carcinoma. Patients who refused to give consent for participating in the study. Patients with a clinical suspicion of acute pancreatitis presenting to the OPD or casuality were first examined clinically, their history was taken and well-documented. The sample size taken for the study was 82 patients. A primary BISAP score was determined on the basis of the initial clinical parameters (GCS, presence of SIRS, patient’s age), the basis of which formed the deciding criteria of whether the patient was admitted in the ward or in an ICU setting (mild score of 0 or 1 admitted to ward; moderate and severe cases having score 2 or more admitted to the ICU). The patients were investigated further by subjecting them to laboratory tests that involved a complete blood count, electrolytes, renal function tests, liver function tests, and coagulation factors along with a blood gas analysis. Specific tests including serum amylase and lipase levels were also done. Additionally, the patients were also subjected to a chest radiograph to check for presence of pleural effusion. The initially determined BISAP score was re-evaluated on the basis of these to assess the need for shifting the patient from the ward to the ICU setting in case of any increase in the score. Patients were given proper standard of care and were monitored for any worsening of vitals for a period of 48 hours, after which they were all sent for a contrast enhanced CT scan of the abdomen, in order to obtain the modified CT severity score which was then documented. In the final stage, both - the CT Severity Score and the BISAP score were correlated for every individual patient by comparing parameters of severity grades, ICU stay and mortality. The patients were not subjected to any unnecessary investigations during the course of the study. Data was collected using Microsoft Excel. Epi Info [Version 7.1] was used for routine analysis and SPSS version 20.00 for advanced analysis.

Table 1. BISAP Severity wise distribution of Patients BISAP Severity No. of Patients Percentage MILD (0 to 1) 29 35.37% MODERATE (2) 40 48.78% SEVERE (3 or more) 13 15.85% Total 82 100.00% The study categorized the severity of acute pancreatitis in 82 patients using the BISAP (Bedside Index for Severity in Acute Pancreatitis) scoring system. Among these patients, 40 were classified as having moderate pancreatitis, i.e, having a BISAP score of 2, making up the largest group at 48.78% of the total. This was followed by 29 patients with mild pancreatitis (BISAP score 0 or 1), accounting for 35.37% of the study population. The smallest group included 13 patients with severe pancreatitis (BISAP score 3 or more), representing 15.85% of the total. This distribution indicates that the majority of patients fell into the moderate severity category based on the BISAP grading system. Table 2. CTSI Severity wise distribution of Patients CTSI Severity No. of Patients Percentage MILD (0 to 2) 27 32.93% MODERATE (4 to 6) 36 43.90% SEVERE (8 to 10) 19 23.17% Total 82 100.00% The study assessed the severity of acute pancreatitis in 82 patients using the CT Severity Index (CTSI). Based on this grading system, 27 patients, or 32.93%, were classified as having mild pancreatitis (MCTSI of 0 to 2). The largest group included 36 patients, representing 43.90% of the total, who were categorized as having moderate pancreatitis (MCTSI of 4 to 6). The remaining 19 patients, accounting for 23.17% of the study population, were classified as having severe pancreatitis (MCTSI of 8 to 10). This distribution shows that the majority of patients had mild to moderate pancreatitis, with a smaller proportion experiencing severe disease according to the CTSI. Table 3. BISAP Severity wise distribution of death of Patients BISAP Severity No. of Patients No. of Death Percentage MILD 29 0 0.00% MODERATE 40 1 2.50% SEVERE 13 4 30.77% Total 82 5 6.10% The study categorized patients with acute pancreatitis based on BISAP severity scores and examined the associated mortality rates. Among the 29 patients classified as having mild pancreatitis, there were no reported deaths, resulting in a mortality rate of 0.00%. In the moderate category, which included 40 patients, there was 1 death, corresponding to a mortality rate of 2.50%. In contrast, the severe category comprised 13 patients, among whom 4 deaths occurred, leading to a significantly higher mortality rate of 30.77%. These findings suggest a strong association between increasing BISAP severity and a higher risk of mortality in patients with acute pancreatitis. Table 4. CTSI Severity wise distribution of death of Patients CTSI Severity No. of Patients No. of Deaths Percentage MILD 27 0 0.00% MODERATE 36 0 0.00% SEVERE 19 5 26.32% Total 82 5 6.10% The study evaluated the severity of acute pancreatitis using the CT Severity Index (CTSI) and analyzed the corresponding mortality rates. Among the 27 patients classified as having mild pancreatitis, there were no reported deaths, resulting in a mortality rate of 0.00%. Similarly, in the moderate category, which included 36 patients, there were also no deaths, maintaining a mortality rate of 0.00%. However, among the 19 patients classified as having severe pancreatitis, 5 deaths were recorded, leading to a significantly higher mortality rate of 26.32%. These findings highlight a marked increase in mortality risk among patients with severe pancreatitis as per the CTSI, while no deaths were observed in the mild and moderate categories. Table 5. Comparison of mean ICU stay duration according to BISAP score severity No. of Patients Average ICU Stay (in days) MILD 29 0.03 MODERATE 40 1.73 SEVERE 13 6.46 A progressive increase in ICU stay was observed with increasing BISAP severity. Patients categorized as mild had a negligible mean ICU stay of 0.03 days, reflecting minimal need for intensive care. In contrast, those with moderate BISAP scores had an average ICU stay of 1.73 days. The severe group demonstrated a markedly prolonged mean ICU stay of 6.46 days, indicating a significantly greater burden on critical care resources. These findings support the utility of BISAP scoring not only for early risk stratification but also for predicting ICU resource utilization. Table 6. Comparison of mean ICU stay duration according to CTSI No. of Patients Average ICU Stay (in days) MILD 27 0 MODERATE 36 1.38 SEVERE 19 5.47 A clear stepwise increase in ICU stay was observed with rising CTSI scores: Patients with mild CTSI scores had no requirement for ICU care, with a mean ICU stay of 0 days. Those in the moderate category had a mean ICU stay of 1.38 days. In contrast, patients with severe CTSI scores had a substantially higher mean ICU stay of 5.47 days. This trend emphasizes the correlation between higher CTSI and increased critical care needs. The findings support the clinical utility of CTSI in predicting not only local pancreatic complications but also the overall burden on ICU resources. Table 7. Correlation of BISAP and CTSI Scores with ICU Stay Duration Correlation Between Correlation Coefficient t-statistic p-value BISAP Score Number of days in ICU 0.74 9.8317 <0.001 CTSI Score Number of days in ICU 0.69 8.4367 <0.001 There was a strong positive correlation between the BISAP score and the number of days in ICU (r = 0.74, t = 9.83, p < 0.001), indicating that higher BISAP scores were significantly associated with longer ICU stays. Similarly, the CTSI score also showed a strong and statistically significant correlation with ICU duration (r = 0.69, t = 8.44, p < 0.001). These results suggest that both BISAP and CTSI scores may serve as useful predictors for the length of ICU stay in patients. Table 8. Correlation between BISAP and CTSI Scoring Correlation Between Correlation Coefficient t-statistic p-value BISAP CTSI 0.9 18.5191 0.00 (indicates significance, if p value <0.05) The study also assessed the correlation between the BISAP and CTSI severity scoring systems for acute pancreatitis. The correlation coefficient was 0.90, indicating a very strong positive linear relationship between the two scoring systems. The t-statistic was 18.52, and the p-value was effectively zero, providing strong evidence that the correlation is statistically significant. This suggests that as BISAP scores increase, CTSI scores tend to increase as well, and vice versa, reflecting strong agreement between the two methods in evaluating disease severity.

Severity classification remains pivotal in managing AP, influencing decisions ranging from hospitalization and ICU admission to surgical interventions. In the study, both BISAP and Modified CTSI stratified the majority of patients into mild and moderate categories, with fewer in the severe group. Interestingly, CTSI appeared slightly more sensitive in identifying severe cases (23.17%) than BISAP (15.85%). This trend was also seen in studies by Venkatesh et al., where severe AP by BISAP was 18.3% and 28.7% by CTSI, and reaffirms the reliability of radiological assessment when available [10]. This discrepancy likely arises from the fundamental nature of the two systems: BISAP is a clinical score emphasizing early systemic involvement, while CTSI relies on radiological findings that often evolve over several days. Anatomical complications such as pancreatic necrosis, peri pancreatic fluid collections, or pseudocysts are better delineated on CT, hence CTSI’s higher severe classification [7]. The Modified CTSI includes scoring for necrosis percentage and extra-pancreatic complications, offering detailed insights into disease morphology and anatomical damage. Despite this, BISAP’s strength lies in its speed and practicality. It uses five simple parameters (BUN >25 mg/dL, impaired mental status, SIRS, age >60, pleural effusion) available within the first 24 hours, providing valuable guidance in emergency settings. Cho et al. have validated BISAP’s effectiveness in early risk stratification and mortality prediction [11]. In Venkatesh et al.’s study, severe acute pancreatitis as per BISAP was 18.3%, while CTSI categorized 28.7% as severe—closely mirroring my findings. [10] Wu et al., in their foundational BISAP study, reported a progressive increase in mortality with higher BISAP scores, though they did not directly compare it with CTSI. The ability to predict poor outcomes with minimal investigation makes BISAP particularly useful in resource-constrained or time-sensitive clinical settings. [7] Thus, BISAP can serve as a frontline triage tool, while CTSI refines severity assessment once imaging becomes feasible. The ideal strategy, particularly in high-volume tertiary hospitals, may involve a stepwise approach: use BISAP at admission and reassess severity with CTSI post-48–72 hours when imaging data is available. This approach ensures early treatment decisions and allows fine-tuning as the clinical picture evolves. MORTALITY AND PREDICTIVE ACCURACY Mortality is a crucial endpoint in evaluating scoring systems. The observed mortality rate, as per the findings of the study, among BISAP severe cases was 30.77%, slightly higher than the 26.32% in CTSI severe cases. In contrast, the predicted mortality rate in BISAP severe cases was 12 to 27% while that in CTSI was 67% as per previous studies [7, 12]. Importantly, both systems accurately identified all fatal outcomes within their severe categories, with zero deaths in mild and moderate groups, affirming their discriminative validity. This alignment in mortality prediction underscores their clinical relevance in stratifying patients early and appropriately. This finding emphasizes that both scores are highly reliable in distinguishing high-risk individuals. While BISAP provides early prognostic clues, CTSI enhances specificity by identifying local complications that may progress to organ failure or infection if untreated. The combination of early systemic assessment and delayed morphological evaluation ensures comprehensive risk profiling. It is worth noting that statistical comparison (p=1.0) found no significant difference in mortality prediction between the two tools. This suggests that either score may be confidently used in clinical practice, though the timing of their application should be considered. These observations echo findings by Vege et al. and Bollen et al., who emphasized the need for both systemic and morphological assessments in AP [13,14]. Venkatesh et al. reported overall mortality of 7.3%, with significantly higher rates among those with BISAP ≥3 and CTSI ≥8.[10] Wu et al.’s original study showed a sharp rise in mortality with increasing BISAP scores, with mortality exceeding 20% when BISAP ≥3, comparable to my observations.[7] Further refinement of mortality prediction might require integration of emerging biomarkers (e.g., procalcitonin, IL-6) or dynamic scoring models that incorporate evolving clinical data over time. Biomarkers could help bridge the gap in diagnostic sensitivity and specificity, especially during the transitional phase of clinical deterioration [15] . ICU ADMISSIONS AND CLINICAL UTILITY In study cohort, ICU admissions sharply increased with severity, confirming the predictive strength of both the BISAP and CTSI scores. Notably, all patients categorized as severe by BISAP required ICU support, reinforcing its utility as an early red flag for clinicians. BISAP’s applicability within the first 24 hours of presentation makes it a valuable bedside tool in acute triage situations, allowing timely escalation of care. Similarly, CTSI showed strong predictive capability: 89.5% of severe cases required ICU admission, compared to 47.2% of moderate and none in mild cases, supporting its role in radiological severity stratification. In the above study, both BISAP and CTSI severity scores demonstrated a strong positive correlation with the length of ICU stay, reaffirming their utility as predictive tools in acute pancreatitis. A progressive increase in mean ICU stay was observed across severity categories in both scoring systems, indicating that higher scores reliably predicted greater critical care needs. With the BISAP score, patients categorized as mild had an almost negligible mean ICU stay of 0.03 days, while moderate and severe groups required 1.73 and 6.46 days respectively. Similarly, using the CTSI, mild cases had no ICU requirement, while moderate and severe cases had mean ICU stays of 1.38 and 5.47 days, respectively. These findings suggest that both scoring systems can stratify patients according to ICU resource utilization effectively. Notably, the BISAP score—being a simple bedside clinical tool that can be calculated within the first 24 hours—showed a slightly sharper gradation in ICU stay with increasing severity compared to CTSI. However, CTSI also showed good discriminatory ability, particularly in predicting ICU need in moderate to severe cases. This aligns with existing literature that supports the use of BISAP for early triage and CTSI for imaging-based confirmation and complication assessment. The above findings are aligned with those of Venkatesh et al., who reported that most patients with BISAP scores ≥3 and CTSI scores ≥8 required intensive care admission [10] . Similarly, Singh et al. demonstrated a direct association between higher CTSI scores and ICU stay, supporting my observation that radiological severity correlates well with the intensity of clinical management. [16] These correlations underline that both BISAP and CTSI are not merely prognostic markers, but are also operational tools that can directly inform care allocation and ICU triage decisions. From a clinical management standpoint, the integration of both BISAP and CTSI offers a comprehensive framework. BISAP, being simple, quick, and cost-effective, is particularly valuable in the emergency setting and in resource-limited healthcare systems. It allows early identification of patients at high risk, enabling timely fluid resuscitation, closer monitoring, and if necessary, prompt ICU referral. CTSI, on the other hand, refines the risk assessment through imaging, helping confirm the presence of local complications and informing the need for more aggressive or surgical interventions. Moreover, resource-limited settings stand to benefit significantly from this dual approach. Relying initially on BISAP for triage decisions and reserving imaging for ambiguous or deteriorating cases ensures efficient utilization of diagnostic tools without compromising care quality. This staged use of severity scoring systems supports rational resource allocation, especially in high-volume or under-equipped centers. Thus, the above study reinforces the value of both BISAP and Modified CTSI in predicting the need for ICU care. Their combined use enhances early recognition of severe cases, optimizes care escalation, and aligns with both national and global evidence. The strong statistical correlations and alignment with Indian and international studies underscore their reliability and real-world utility in the management of acute pancreatitis.

In conclusion, both BISAP and Modified CTSI are robust tools for assessing severity, predicting ICU need, and estimating mortality in patients with acute pancreatitis. Their complementary use can improve diagnostic confidence and inform more precise and timely clinical interventions. By embracing a structured, evidence-based approach and enhancing one’s predictive capabilities, we can significantly improve the quality of care and outcomes for patients suffering from this potentially life-threatening condition. The path forward includes not only clinical innovation but also systemic reform in how acute pancreatitis is diagnosed, monitored, and treated across varied healthcare settings, ensuring equitable and effective care for all.

1. Boxhoorn L, Voermans RP, Bouwense SA, Bruno MJ, Verdonk RC, Boermeester MA, et al. Acute pancreatitis. Lancet. 2020 Sep 12;396(10252):726–34. doi:10.1016/S0140-6736(20)31511-0 2. Pandol SJ, Saluja AK, Imrie CW, Banks PA. Acute pancreatitis: bench to the bedside. Gastroenterology. 2007 Mar;132(3):1127–51. doi:10.1053/j.gastro.2006.11.064 3. Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology. 2013 Jun;144(6):1252–61. doi:10.1053/j.gastro.2013.02.068 4. Beger HG, Rau B, Mayer J, Pralle U. Natural course of acute pancreatitis. World J Surg. 1997 Feb;21(2):130–5. doi:10.1007/s002689900032 5. Petrov MS, Yadav D. Global epidemiology and holistic prevention of pancreatitis. Nat Rev Gastroenterol Hepatol. 2019 Mar;16(3):175–84. doi:10.1038/s41575-018-0117-1 6. Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002 Jun;223(3):603–13. doi:10.1148/radiol.2233010680 7. Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698–1703. doi:10.1136/gut.2008.152702 8. Van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al. A step‑up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010 Apr 22;362(16):1491–502. doi:10.1056/NEJMoa0908821 9. Baillie J, DeWitt J, Vege SS, Tenner S. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013 Sep;108(9):1400–15. doi:10.1038/ajg.2013.218 10. Venkatesh N, Seshadri RS, Amin AM, et al. Evaluation and comparison of prognostic scoring systems in acute pancreatitis. Int Surg J. 2020 Jul;7(7):2204–10. doi:10.18203/2349-2902.isj20202956 11. Cho JH, Kim TN, Chung HH. Comparison of scoring systems in predicting the severity of acute pancreatitis. World J Gastroenterol. 2015 Mar 21;21(8):2387–97. doi:10.3748/wjg.v21.i8.2387 12. Samavedam S, Prasad Kumar P, Dasari K, Nagesh VS, Rao PV, Alapati A, Bansal A. Comparative analysis of computed tomography severity index (CTSI) and modified CTSI (mCTSI) in acute pancreatitis. F1000Research. 2022;11:1272. doi:10.12688/f1000research.26512.2. 13. Bollen TL, van Santvoort HC, Besselink MG, van Leeuwen MS, Horvath KD, Freeny PC, et al. The Atlanta Classification of acute pancreatitis revisited. Br J Surg. 2008 Jan;95(1):6–21. doi:10.1002/bjs.6010 14. Vege SS, Gardner TB, Chari ST, Munukuti P, Pearson RK, Clain JE, Petersen BT, Baron TH, Farnell MB, Sarr MG. Low mortality and high morbidity in severe acute pancreatitis without organ failure: a case for revising the Atlanta classification to include “moderately severe acute pancreatitis”. Am J Gastroenterol. 2009 Mar;104(3):710–5. doi:10.1038/ajg.2008.77 15. Mofidi R, Suttie SA, Patil PV, Ogston S, Parks RW. The value of procalcitonin at predicting the severity of acute pancreatitis and development of infected pancreatic necrosis: systematic review. Surgery. 2009 Jul;146(1):72–81. doi:10.1016/j.surg.2009.02.005 16. Singh VK, Wu BU, Bollen TL, Repas K, Maurer R, Mortele KJ, et al. A prospective evaluation of the Revised Atlanta Classification of acute pancreatitis. Clin Gastroenterol Hepatol. 2013 May;11(5):675–82.e2. doi:10.1016/j.cgh.2012.12.031

Acute pancreatitis is a condition characterized by the rapid onset of pancreatic inflammation, which can lead to varying degrees of tissue damage. It can range from mild, self-limiting episodes to severe, life-threatening complications. Recognizing the diverse presentations and potential outcomes of acute pancreatitis is crucial for effective management and treatment [1,2]. The understanding and recognition of acute pancreatitis have evolved significantly over centuries. From ancient observations of its symptoms to modern advancements in diagnostics and therapeutics, the historical progression underscores both the growth of medical knowledge and the ongoing challenges in managing this complex condition [3]. Acute pancreatitis also poses substantial health risks and economic burdens worldwide. With its increasing incidence, diverse causes, and potential for severe complications, there is a critical need for comprehensive awareness among healthcare providers, researchers, policymakers, and the public. By deepening our understanding of acute pancreatitis, we can improve prevention, diagnosis, and treatment strategies, ultimately enhancing patient outcomes [3-5]. Early and accurate assessment of both the disease severity and prognosis is vital for guiding effective treatment and improving patient outcomes. To aid in this process, several scoring systems have been developed to predict clinical outcomes in AP. Among the most widely recognized are the BISAP’s score and the Modified Computed Tomography (CT) Scoring System, both of which help clinicians assess the severity of the disease and inform management strategies. [6] Given the variable nature of acute pancreatitis, prompt intervention based on these assessments is essential to reduce morbidity and mortality. In 2008, Wu et al. [7] developed a new scoring system known as the Bedside Index for Severity in Acute Pancreatitis (BISAP), designed to estimate the risk of in-hospital mortality in patients with acute pancreatitis (AP). The BISAP score is based on five key variables: blood urea nitrogen (BUN) levels >25 mg/dL, impaired mental status, the development of systemic inflammatory response syndrome (SIRS), age >60 years, and the presence of pleural effusion. Since its introduction, numerous studies have been conducted to validate the BISAP score’s reliability, simplicity, and accuracy in stratifying patients with AP. These studies have generally supported BISAP as an effective tool for predicting mortality risk and guiding clinical decision-making, offering a straightforward approach to identifying high-risk patients early in their hospitalization. The Modified CT Scoring System offers a radiological approach to assess the severity of acute pancreatitis and predict clinical outcomes. Derived from CT imaging findings, this system evaluates various parameters related to pancreatic inflammation, necrosis, and complications. These parameters include the degree of pancreatic edema, parenchymal enhancement, peripancreatic fat stranding, the presence and extent of pancreatic necrosis, peripancreatic fluid collections, hemorrhage, and involvement of adjacent structures. By quantifying the severity of these findings and calculating a total score, the Modified CT Scoring System allows clinicians to stratify patients into different risk categories, helping to anticipate disease progression. [8,9] While the Modified CTSI provides detailed information about the anatomical severity of acute pancreatitis based on CT findings, the BISAP score is a simpler, faster, and clinically relevant tool that can be used earlier in the disease course for predicting patient outcomes and identifying high-risk individuals. The BISAP score’s reliance on easily obtainable clinical parameters makes it better suited for early risk stratification, mortality prediction, and resource-limited environments. Since BISAP score is based on clinical parameters, it can easily be influenced by other systemic diseases and associated conditions and hence lacks specificity. Whereas, the modified CTSI is time consuming and subject to radiologist’s interpretation and is influenced by inter-observer variability.

The study was conducted at the Department of Surgery, Dr. D.Y. Patil Medical College, Hospital and Research Institute, Kolhapur, for a period of 18 months after receiving Institutional Ethical Clearance from the Institutional Ethics Committee. All patients diagnosed with acute pancreatitis who met the inclusion and exclusion criteria were included in the study. Inclusion Criteria: Patients aged above 18 years, diagnosed with acute pancreatitis, regardless of gender. Mild, moderate and severe cases of acute pancreatitis. Patients falling in the above criteria giving consent for the study. Exclusion Criteria: Patients with a history of chronic pancreatitis or pancreatic carcinoma. Patients who refused to give consent for participating in the study. Patients with a clinical suspicion of acute pancreatitis presenting to the OPD or casuality were first examined clinically, their history was taken and well-documented. The sample size taken for the study was 82 patients. A primary BISAP score was determined on the basis of the initial clinical parameters (GCS, presence of SIRS, patient’s age), the basis of which formed the deciding criteria of whether the patient was admitted in the ward or in an ICU setting (mild score of 0 or 1 admitted to ward; moderate and severe cases having score 2 or more admitted to the ICU). The patients were investigated further by subjecting them to laboratory tests that involved a complete blood count, electrolytes, renal function tests, liver function tests, and coagulation factors along with a blood gas analysis. Specific tests including serum amylase and lipase levels were also done. Additionally, the patients were also subjected to a chest radiograph to check for presence of pleural effusion. The initially determined BISAP score was re-evaluated on the basis of these to assess the need for shifting the patient from the ward to the ICU setting in case of any increase in the score. Patients were given proper standard of care and were monitored for any worsening of vitals for a period of 48 hours, after which they were all sent for a contrast enhanced CT scan of the abdomen, in order to obtain the modified CT severity score which was then documented. In the final stage, both - the CT Severity Score and the BISAP score were correlated for every individual patient by comparing parameters of severity grades, ICU stay and mortality. The patients were not subjected to any unnecessary investigations during the course of the study. Data was collected using Microsoft Excel. Epi Info [Version 7.1] was used for routine analysis and SPSS version 20.00 for advanced analysis.

Table 1. BISAP Severity wise distribution of Patients BISAP Severity No. of Patients Percentage MILD (0 to 1) 29 35.37% MODERATE (2) 40 48.78% SEVERE (3 or more) 13 15.85% Total 82 100.00% The study categorized the severity of acute pancreatitis in 82 patients using the BISAP (Bedside Index for Severity in Acute Pancreatitis) scoring system. Among these patients, 40 were classified as having moderate pancreatitis, i.e, having a BISAP score of 2, making up the largest group at 48.78% of the total. This was followed by 29 patients with mild pancreatitis (BISAP score 0 or 1), accounting for 35.37% of the study population. The smallest group included 13 patients with severe pancreatitis (BISAP score 3 or more), representing 15.85% of the total. This distribution indicates that the majority of patients fell into the moderate severity category based on the BISAP grading system. Table 2. CTSI Severity wise distribution of Patients CTSI Severity No. of Patients Percentage MILD (0 to 2) 27 32.93% MODERATE (4 to 6) 36 43.90% SEVERE (8 to 10) 19 23.17% Total 82 100.00% The study assessed the severity of acute pancreatitis in 82 patients using the CT Severity Index (CTSI). Based on this grading system, 27 patients, or 32.93%, were classified as having mild pancreatitis (MCTSI of 0 to 2). The largest group included 36 patients, representing 43.90% of the total, who were categorized as having moderate pancreatitis (MCTSI of 4 to 6). The remaining 19 patients, accounting for 23.17% of the study population, were classified as having severe pancreatitis (MCTSI of 8 to 10). This distribution shows that the majority of patients had mild to moderate pancreatitis, with a smaller proportion experiencing severe disease according to the CTSI. Table 3. BISAP Severity wise distribution of death of Patients BISAP Severity No. of Patients No. of Death Percentage MILD 29 0 0.00% MODERATE 40 1 2.50% SEVERE 13 4 30.77% Total 82 5 6.10% The study categorized patients with acute pancreatitis based on BISAP severity scores and examined the associated mortality rates. Among the 29 patients classified as having mild pancreatitis, there were no reported deaths, resulting in a mortality rate of 0.00%. In the moderate category, which included 40 patients, there was 1 death, corresponding to a mortality rate of 2.50%. In contrast, the severe category comprised 13 patients, among whom 4 deaths occurred, leading to a significantly higher mortality rate of 30.77%. These findings suggest a strong association between increasing BISAP severity and a higher risk of mortality in patients with acute pancreatitis. Table 4. CTSI Severity wise distribution of death of Patients CTSI Severity No. of Patients No. of Deaths Percentage MILD 27 0 0.00% MODERATE 36 0 0.00% SEVERE 19 5 26.32% Total 82 5 6.10% The study evaluated the severity of acute pancreatitis using the CT Severity Index (CTSI) and analyzed the corresponding mortality rates. Among the 27 patients classified as having mild pancreatitis, there were no reported deaths, resulting in a mortality rate of 0.00%. Similarly, in the moderate category, which included 36 patients, there were also no deaths, maintaining a mortality rate of 0.00%. However, among the 19 patients classified as having severe pancreatitis, 5 deaths were recorded, leading to a significantly higher mortality rate of 26.32%. These findings highlight a marked increase in mortality risk among patients with severe pancreatitis as per the CTSI, while no deaths were observed in the mild and moderate categories. Table 5. Comparison of mean ICU stay duration according to BISAP score severity No. of Patients Average ICU Stay (in days) MILD 29 0.03 MODERATE 40 1.73 SEVERE 13 6.46 A progressive increase in ICU stay was observed with increasing BISAP severity. Patients categorized as mild had a negligible mean ICU stay of 0.03 days, reflecting minimal need for intensive care. In contrast, those with moderate BISAP scores had an average ICU stay of 1.73 days. The severe group demonstrated a markedly prolonged mean ICU stay of 6.46 days, indicating a significantly greater burden on critical care resources. These findings support the utility of BISAP scoring not only for early risk stratification but also for predicting ICU resource utilization. Table 6. Comparison of mean ICU stay duration according to CTSI No. of Patients Average ICU Stay (in days) MILD 27 0 MODERATE 36 1.38 SEVERE 19 5.47 A clear stepwise increase in ICU stay was observed with rising CTSI scores: Patients with mild CTSI scores had no requirement for ICU care, with a mean ICU stay of 0 days. Those in the moderate category had a mean ICU stay of 1.38 days. In contrast, patients with severe CTSI scores had a substantially higher mean ICU stay of 5.47 days. This trend emphasizes the correlation between higher CTSI and increased critical care needs. The findings support the clinical utility of CTSI in predicting not only local pancreatic complications but also the overall burden on ICU resources. Table 7. Correlation of BISAP and CTSI Scores with ICU Stay Duration Correlation Between Correlation Coefficient t-statistic p-value BISAP Score Number of days in ICU 0.74 9.8317 <0.001 CTSI Score Number of days in ICU 0.69 8.4367 <0.001 There was a strong positive correlation between the BISAP score and the number of days in ICU (r = 0.74, t = 9.83, p < 0.001), indicating that higher BISAP scores were significantly associated with longer ICU stays. Similarly, the CTSI score also showed a strong and statistically significant correlation with ICU duration (r = 0.69, t = 8.44, p < 0.001). These results suggest that both BISAP and CTSI scores may serve as useful predictors for the length of ICU stay in patients. Table 8. Correlation between BISAP and CTSI Scoring Correlation Between Correlation Coefficient t-statistic p-value BISAP CTSI 0.9 18.5191 0.00 (indicates significance, if p value <0.05) The study also assessed the correlation between the BISAP and CTSI severity scoring systems for acute pancreatitis. The correlation coefficient was 0.90, indicating a very strong positive linear relationship between the two scoring systems. The t-statistic was 18.52, and the p-value was effectively zero, providing strong evidence that the correlation is statistically significant. This suggests that as BISAP scores increase, CTSI scores tend to increase as well, and vice versa, reflecting strong agreement between the two methods in evaluating disease severity.

Severity classification remains pivotal in managing AP, influencing decisions ranging from hospitalization and ICU admission to surgical interventions. In the study, both BISAP and Modified CTSI stratified the majority of patients into mild and moderate categories, with fewer in the severe group. Interestingly, CTSI appeared slightly more sensitive in identifying severe cases (23.17%) than BISAP (15.85%). This trend was also seen in studies by Venkatesh et al., where severe AP by BISAP was 18.3% and 28.7% by CTSI, and reaffirms the reliability of radiological assessment when available [10]. This discrepancy likely arises from the fundamental nature of the two systems: BISAP is a clinical score emphasizing early systemic involvement, while CTSI relies on radiological findings that often evolve over several days. Anatomical complications such as pancreatic necrosis, peri pancreatic fluid collections, or pseudocysts are better delineated on CT, hence CTSI’s higher severe classification [7]. The Modified CTSI includes scoring for necrosis percentage and extra-pancreatic complications, offering detailed insights into disease morphology and anatomical damage. Despite this, BISAP’s strength lies in its speed and practicality. It uses five simple parameters (BUN >25 mg/dL, impaired mental status, SIRS, age >60, pleural effusion) available within the first 24 hours, providing valuable guidance in emergency settings. Cho et al. have validated BISAP’s effectiveness in early risk stratification and mortality prediction [11]. In Venkatesh et al.’s study, severe acute pancreatitis as per BISAP was 18.3%, while CTSI categorized 28.7% as severe—closely mirroring my findings. [10] Wu et al., in their foundational BISAP study, reported a progressive increase in mortality with higher BISAP scores, though they did not directly compare it with CTSI. The ability to predict poor outcomes with minimal investigation makes BISAP particularly useful in resource-constrained or time-sensitive clinical settings. [7] Thus, BISAP can serve as a frontline triage tool, while CTSI refines severity assessment once imaging becomes feasible. The ideal strategy, particularly in high-volume tertiary hospitals, may involve a stepwise approach: use BISAP at admission and reassess severity with CTSI post-48–72 hours when imaging data is available. This approach ensures early treatment decisions and allows fine-tuning as the clinical picture evolves. MORTALITY AND PREDICTIVE ACCURACY Mortality is a crucial endpoint in evaluating scoring systems. The observed mortality rate, as per the findings of the study, among BISAP severe cases was 30.77%, slightly higher than the 26.32% in CTSI severe cases. In contrast, the predicted mortality rate in BISAP severe cases was 12 to 27% while that in CTSI was 67% as per previous studies [7, 12]. Importantly, both systems accurately identified all fatal outcomes within their severe categories, with zero deaths in mild and moderate groups, affirming their discriminative validity. This alignment in mortality prediction underscores their clinical relevance in stratifying patients early and appropriately. This finding emphasizes that both scores are highly reliable in distinguishing high-risk individuals. While BISAP provides early prognostic clues, CTSI enhances specificity by identifying local complications that may progress to organ failure or infection if untreated. The combination of early systemic assessment and delayed morphological evaluation ensures comprehensive risk profiling. It is worth noting that statistical comparison (p=1.0) found no significant difference in mortality prediction between the two tools. This suggests that either score may be confidently used in clinical practice, though the timing of their application should be considered. These observations echo findings by Vege et al. and Bollen et al., who emphasized the need for both systemic and morphological assessments in AP [13,14]. Venkatesh et al. reported overall mortality of 7.3%, with significantly higher rates among those with BISAP ≥3 and CTSI ≥8.[10] Wu et al.’s original study showed a sharp rise in mortality with increasing BISAP scores, with mortality exceeding 20% when BISAP ≥3, comparable to my observations.[7] Further refinement of mortality prediction might require integration of emerging biomarkers (e.g., procalcitonin, IL-6) or dynamic scoring models that incorporate evolving clinical data over time. Biomarkers could help bridge the gap in diagnostic sensitivity and specificity, especially during the transitional phase of clinical deterioration [15] . ICU ADMISSIONS AND CLINICAL UTILITY In study cohort, ICU admissions sharply increased with severity, confirming the predictive strength of both the BISAP and CTSI scores. Notably, all patients categorized as severe by BISAP required ICU support, reinforcing its utility as an early red flag for clinicians. BISAP’s applicability within the first 24 hours of presentation makes it a valuable bedside tool in acute triage situations, allowing timely escalation of care. Similarly, CTSI showed strong predictive capability: 89.5% of severe cases required ICU admission, compared to 47.2% of moderate and none in mild cases, supporting its role in radiological severity stratification. In the above study, both BISAP and CTSI severity scores demonstrated a strong positive correlation with the length of ICU stay, reaffirming their utility as predictive tools in acute pancreatitis. A progressive increase in mean ICU stay was observed across severity categories in both scoring systems, indicating that higher scores reliably predicted greater critical care needs. With the BISAP score, patients categorized as mild had an almost negligible mean ICU stay of 0.03 days, while moderate and severe groups required 1.73 and 6.46 days respectively. Similarly, using the CTSI, mild cases had no ICU requirement, while moderate and severe cases had mean ICU stays of 1.38 and 5.47 days, respectively. These findings suggest that both scoring systems can stratify patients according to ICU resource utilization effectively. Notably, the BISAP score—being a simple bedside clinical tool that can be calculated within the first 24 hours—showed a slightly sharper gradation in ICU stay with increasing severity compared to CTSI. However, CTSI also showed good discriminatory ability, particularly in predicting ICU need in moderate to severe cases. This aligns with existing literature that supports the use of BISAP for early triage and CTSI for imaging-based confirmation and complication assessment. The above findings are aligned with those of Venkatesh et al., who reported that most patients with BISAP scores ≥3 and CTSI scores ≥8 required intensive care admission [10] . Similarly, Singh et al. demonstrated a direct association between higher CTSI scores and ICU stay, supporting my observation that radiological severity correlates well with the intensity of clinical management. [16] These correlations underline that both BISAP and CTSI are not merely prognostic markers, but are also operational tools that can directly inform care allocation and ICU triage decisions. From a clinical management standpoint, the integration of both BISAP and CTSI offers a comprehensive framework. BISAP, being simple, quick, and cost-effective, is particularly valuable in the emergency setting and in resource-limited healthcare systems. It allows early identification of patients at high risk, enabling timely fluid resuscitation, closer monitoring, and if necessary, prompt ICU referral. CTSI, on the other hand, refines the risk assessment through imaging, helping confirm the presence of local complications and informing the need for more aggressive or surgical interventions. Moreover, resource-limited settings stand to benefit significantly from this dual approach. Relying initially on BISAP for triage decisions and reserving imaging for ambiguous or deteriorating cases ensures efficient utilization of diagnostic tools without compromising care quality. This staged use of severity scoring systems supports rational resource allocation, especially in high-volume or under-equipped centers. Thus, the above study reinforces the value of both BISAP and Modified CTSI in predicting the need for ICU care. Their combined use enhances early recognition of severe cases, optimizes care escalation, and aligns with both national and global evidence. The strong statistical correlations and alignment with Indian and international studies underscore their reliability and real-world utility in the management of acute pancreatitis.

In conclusion, both BISAP and Modified CTSI are robust tools for assessing severity, predicting ICU need, and estimating mortality in patients with acute pancreatitis. Their complementary use can improve diagnostic confidence and inform more precise and timely clinical interventions. By embracing a structured, evidence-based approach and enhancing one’s predictive capabilities, we can significantly improve the quality of care and outcomes for patients suffering from this potentially life-threatening condition. The path forward includes not only clinical innovation but also systemic reform in how acute pancreatitis is diagnosed, monitored, and treated across varied healthcare settings, ensuring equitable and effective care for all.

1. Boxhoorn L, Voermans RP, Bouwense SA, Bruno MJ, Verdonk RC, Boermeester MA, et al. Acute pancreatitis. Lancet. 2020 Sep 12;396(10252):726–34. doi:10.1016/S0140-6736(20)31511-0 2. Pandol SJ, Saluja AK, Imrie CW, Banks PA. Acute pancreatitis: bench to the bedside. Gastroenterology. 2007 Mar;132(3):1127–51. doi:10.1053/j.gastro.2006.11.064 3. Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology. 2013 Jun;144(6):1252–61. doi:10.1053/j.gastro.2013.02.068 4. Beger HG, Rau B, Mayer J, Pralle U. Natural course of acute pancreatitis. World J Surg. 1997 Feb;21(2):130–5. doi:10.1007/s002689900032 5. Petrov MS, Yadav D. Global epidemiology and holistic prevention of pancreatitis. Nat Rev Gastroenterol Hepatol. 2019 Mar;16(3):175–84. doi:10.1038/s41575-018-0117-1 6. Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002 Jun;223(3):603–13. doi:10.1148/radiol.2233010680 7. Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698–1703. doi:10.1136/gut.2008.152702 8. Van Santvoort HC, Besselink MG, Bakker OJ, Hofker HS, Boermeester MA, Dejong CH, et al. A step‑up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010 Apr 22;362(16):1491–502. doi:10.1056/NEJMoa0908821 9. Baillie J, DeWitt J, Vege SS, Tenner S. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013 Sep;108(9):1400–15. doi:10.1038/ajg.2013.218 10. Venkatesh N, Seshadri RS, Amin AM, et al. Evaluation and comparison of prognostic scoring systems in acute pancreatitis. Int Surg J. 2020 Jul;7(7):2204–10. doi:10.18203/2349-2902.isj20202956 11. Cho JH, Kim TN, Chung HH. Comparison of scoring systems in predicting the severity of acute pancreatitis. World J Gastroenterol. 2015 Mar 21;21(8):2387–97. doi:10.3748/wjg.v21.i8.2387 12. Samavedam S, Prasad Kumar P, Dasari K, Nagesh VS, Rao PV, Alapati A, Bansal A. Comparative analysis of computed tomography severity index (CTSI) and modified CTSI (mCTSI) in acute pancreatitis. F1000Research. 2022;11:1272. doi:10.12688/f1000research.26512.2. 13. Bollen TL, van Santvoort HC, Besselink MG, van Leeuwen MS, Horvath KD, Freeny PC, et al. The Atlanta Classification of acute pancreatitis revisited. Br J Surg. 2008 Jan;95(1):6–21. doi:10.1002/bjs.6010 14. Vege SS, Gardner TB, Chari ST, Munukuti P, Pearson RK, Clain JE, Petersen BT, Baron TH, Farnell MB, Sarr MG. Low mortality and high morbidity in severe acute pancreatitis without organ failure: a case for revising the Atlanta classification to include “moderately severe acute pancreatitis”. Am J Gastroenterol. 2009 Mar;104(3):710–5. doi:10.1038/ajg.2008.77 15. Mofidi R, Suttie SA, Patil PV, Ogston S, Parks RW. The value of procalcitonin at predicting the severity of acute pancreatitis and development of infected pancreatic necrosis: systematic review. Surgery. 2009 Jul;146(1):72–81. doi:10.1016/j.surg.2009.02.005 16. Singh VK, Wu BU, Bollen TL, Repas K, Maurer R, Mortele KJ, et al. A prospective evaluation of the Revised Atlanta Classification of acute pancreatitis. Clin Gastroenterol Hepatol. 2013 May;11(5):675–82.e2. doi:10.1016/j.cgh.2012.12.031