Acute pancreatitis (AP) is one of the most common gastrointestinal conditions requiring emergency medical care and hospitalization, with a rising global incidence.[1] The reported  incidence increases around 63% from 1990 to 2019 [1]. Despite advances in care, acute pancreatitis remains a potentially life-threatening condition with significant morbidity and mortality. Early severity assessment is essential to identify high-risk patients who may benefit from intensive management [2]

Most patients with acute pancreatitis recover uneventfully. GBD estimation of 1.4 deaths per 100,000 is also similar to the meta-analytical result (1.6 deaths per 100,000) [1]. To improve outcomes, various clinical scoring systems have been developed to stratify disease severity and predict prognosis in the early phase. Traditional scoring systems, such as Ranson’s criteria [3] and the modified Glasgow score [4], require parameters that may not be readily available during the initial evaluation in emergency settings, limiting their utility.

The APACHE II (Acute Physiology and Chronic Health Evaluation II) score is one of the most widely used severity scoring systems in intensive care units. Although it has demonstrated good prognostic accuracy in acute pancreatitis, it requires numerous physiological and laboratory variables, some of which may be difficult to obtain early and are not specific to pancreatitis. [5] To address these limitations, the Bedside Index of Severity in Acute Pancreatitis (BISAP) score was developed as a simple, easy-to-use, and accurate clinical tool.[6] BISAP can be calculated within the first 24 hours of hospitalization and is useful in stratifying patients by risk of in-hospital mortality, even before the onset of organ failure. Early risk stratification using BISAP is crucial for optimizing patient outcomes and resource allocation. [6]

Another promising marker is the Neutrophil-to-Lymphocyte Ratio (NLR), a cost-effective, readily available inflammatory marker derived from a routine complete blood count. Elevated total leukocyte count (TLC) is a known marker of systemic inflammation and is incorporated in several AP scoring systems, including Ranson’s, APACHE II, and SAPS II. Both neutrophilia and lymphopenia are physiological responses to systemic stress, infection, and inflammation, and their ratio (NLR) reflects the imbalance characteristic of systemic inflammatory response syndrome (SIRS) and progression to multiple organ dysfunction syndrome (MODS)—hallmarks of severe acute pancreatitis.[7]

The Atlanta Classification is a standardized clinical framework introduced to define the severity and complications of acute pancreatitis (AP). Originally established in 1992 and revised in 2012, it helps clinicians categorize disease severity, assess prognosis, and guide treatment. [8]

The present study aims to assess and compare the prognostic utility of the BISAP score and the Neutrophil-to-Lymphocyte Ratio (NLR) in predicting the severity of acute pancreatitis among patients presenting to the Emergency Department.

AIMS AND OBJECTIVES

To Compare BISAP scoring system & NLR score in terms of outcomes as average length of stay (ALOS), complications and survival of the patients.

This prospective observational study was conducted over one year (January 1, 2024 –December 31, 2024) in the Emergency Medicine Department, after getting institutional ethical clearanceKounis syndrome, Bee sting, Myocardial infarction. Patients aged 18–65 years diagnosed with acute pancreatitis (AP), based on at least two of the following criteria were included:

1. Characteristic abdominal pain
2. Serum amylase/lipase >3× normal
3. Ultrasonographic findings consistent with AP (within 7 days) [9]

Exclusion Criteria

1. Pregnant women
2. Carcinoma pancreas
3. Age <18 or >65 years
4. Prior treatment at another facility
5. Recurrent or chronic pancreatitis
6. Incomplete investigations or missing records

Initial evaluation included standard resuscitation and history (SAMPLE), followed by assessment using the Revised Atlanta Classification, BISAP score, and Neutrophil-to-Lymphocyte Ratio (NLR). Patients were categorized into mild (MAP) and moderate-to-severe (SAP) groups. Prognostication was based on outcomes including survival, complications, and average length of hospital stay (ALOS).

BISAP Scoring System

Calculated within 24 hours of admission; 1 point each for: BUN >25 mg/dL, GCS <15, SIRS criteria ≥2, Age >60 years, Pleural effusion. A Score ≤2: Mild AP, Score ≥3: Severe AP

NLR Calculation

NLR was calculated using admission-day neutrophil and lymphocyte counts. A cut-off value of 4.7 was used to differentiate severity according to available data. [10]

Outcome variables were documented during admission and follow-up using a structured proforma. Data were analysed using IBM SPSS Statistics V.22.0 (IBM Corp, Armonk, New York, USA).The sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) were also calculated. A 2-tailed P value < .05 was considered statistically significant.

This prospective study was conducted at Guwahati Medical College & Hospital, 82 patients aged 18–65 years were included for further analysis (figure 1). Demographics are tabulated in table 1, median age of 34.5 years and mean age of 37.1 ± 11.73 years. Males comprised 68.3% (n=56) and females 31.7% (n=26). According to the Revised Atlanta Classification, 48 patients (58.5%) had mild acute pancreatitis (MAP), and 34 (41.5%) had severe acute pancreatitis (SAP). Age and sex were not significantly associated with severity (p=0.227 and p=0.231 respectively).

Table 1 - Demographics in patients with Acute pancreatitis among mild acute pancreatitis (MAP), severe acute pancreatitis (SAP)

Figure 1: The study population flowchart shows the number of patients hospitalised with acute abdomen, the number of patients excluded, and the final number included in the research.

BISAP and Neutrophil-Lymphocyte Ratio (NLR) scores were applied to predict severity and outcomes. BISAP identified 46 patients as MAP (score <3) and 36 as SAP (score ≥3), while NLR categorised 55 as MAP and 27 as SAP. Compared to the Atlanta classification, BISAP showed higher sensitivity (97.06%), specificity (93.75%), PPV (79.52%), NPV (99.22%), and AUC of 0.95. In contrast, NLR had sensitivity 76.4%, specificity 97.9%, PPV 90.17%, NPV 94.33%, and AUC 0.87 (Figure 2).

Regarding outcomes, the average hospital stay (ALOS) for MAP was 2.54 days (BISAP) and 3.15 days (NLR), while for SAP it was 7 days (BISAP) and 7.26 days (NLR). Local complications occurred in 91.6% (33/36) BISAP-defined SAP patients and 96.3% of NLR-defined SAP patients (n=26/27), while systemic complications occurred in 23 (BISAP) and 18 (NLR) cases, with no statistically significant difference (p=0.456 and p=0.819, respectively). Mortality was (4/36) in BISAP, (3/27) in NLR group, not significantly different (p=1.0).

Overall, BISAP outperformed NLR in sensitivity, NPV, and overall prognostic accuracy for predicting severe acute pancreatitis and related outcomes.

Acute pancreatitis (AP) is a disease with a variable course and severity, often involving multiple organ systems. It is commonly encountered in emergency departments worldwide and requires prompt recognition and assessment to identify patients who may benefit from early intensive care. Clinical assessment alone often falls short in determining severity, especially in the early stages of the disease. The overall mortality of AP ranges from 5% to 10%, and due to the risk of rapid clinical deterioration in severe cases, early severity stratification is crucial for clinicians. [11, 12]

Over the years, several multifactorial scoring systems have been developed using clinical and biochemical parameters, including Ranson’s score (1974) and APACHE II. However, these scoring systems have limitations such as delayed applicability, complexity, and relatively low sensitivity and specificity. [12]

In our study, we used the Revised Atlanta Classification as the standard to assess the severity of pancreatitis and compared two simplified prognostic tools: the Bedside Index for Severity in Acute Pancreatitis (BISAP) and the Neutrophil–Lymphocyte Ratio (NLR). A total of 82 patients were enrolled after applying the inclusion and exclusion criteria. Of these, 56 (68%) were males and 26 (32%) females, showing a male predominance. The mean age of the study population was 37.10 ± 11.73 years, with the majority in the 31–40-year age group.

We applied the BISAP score using data readily available at emergency presentation—vital signs, basic labs, and imaging. Among 82 patients, BISAP identified 46 (56.1%) with mild AP and 36 (43.9%) with severe AP using a cutoff score of <3 and ≥3, respectively. The sensitivity and specificity were 97.06% and 93.75%, with PPV of 79.52% and NPV of 99.22%. The area under the ROC curve (AUC) was 0.95 (95% CI: 0.90–1.00).

Patients identified with severe AP using BISAP had an average length of stay (ALOS) of 7 days, with local complications (e.g., necrosis, pseudocyst, peritonitis) in 91.67% and systemic complications (e.g., respiratory failure, renal failure) in 63.89%.

We also evaluated the NLR score at ED presentation and repeated it after 48 hours. We used a cutoff of NLR ≥ 4.7, based on existing literature. Among 82 patients, NLR categorized 55 (67.1%) as mild and 27 (32.9%) as severe. The sensitivity and specificity were 76.47% and 97.92%, respectively, with PPV of 90.17% and NPV of 94.33%. The AUC was 0.87 (95% CI: 0.78–0.96).

Azab et al. (n=283) in New York (2004–2007) reported that NLR was superior to total WBC, neutrophil count, or lymphocyte count in predicting ICU admission and LOS. Their patients were grouped into tertiles; those with NLR > 7.6 had significantly higher ICU admissions and LOS >7 days. They proposed NLR ≥ 4.7 as a reliable cutoff for predicting severity with high sensitivity (85.2%) but lower specificity (~48%). The high NPV made NLR a useful triage tool. [10]

Patients classified with severe AP based on NLR had an ALOS of 7.26 days. Local complications were seen in 96.3%, and systemic complications in 66.67%. Mortality in both groups was 11.1% though this was not statistically significant.

Several systematic reviews have evaluated the prognostic accuracy of the BISAP score in acute pancreatitis (AP). Chandra et al.[13] reported that BISAP demonstrated strong predictive value for severe AP under the Revised Atlanta Classification, with an AUC of 0.92 (95% CI: 0.90–0.95). However, a prior meta-analysis found that while BISAP had low sensitivity (0.65) for identifying severe cases, it maintained high specificity (0.84)[14]. Similarly, Gao et al.[15] concluded that BISAP is a reliable tool for predicting both severity and mortality in AP, noting it had lower sensitivity but higher specificity compared to the Ranson score. Zhu J et al.,[16] was the first to comprehensively compare Ranson and BISAP scores for predicting acute pancreatitis severity and prognosis. It found that while Ranson had higher sensitivity, BISAP demonstrated greater specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR), indicating comparable overall predictive performance.

BISAP had higher sensitivity and NPV, making it better for early severity stratification. In contrast, NLR showed higher specificity, aiding in ruling in severe cases, though it was slightly less sensitive. The average length of hospital stay was marginally longer in the NLR severe AP group (7.26 days) compared to the BISAP group (7 days). Complication rates and mortality did not differ significantly between BISAP and NLR groups (p > 0.05).

Limitations

Our study was limited by its single-center design and relatively small sample size. Moreover, external factors like variations in clinical management, laboratory timings, and imaging could influence scoring performance. Additionally, no long-term follow-up was done to evaluate late complications or readmissions.

Both BISAP and NLR are valuable bedside tools for early risk stratification in acute pancreatitis. BISAP, with its higher sensitivity and negative predictive value, is better suited for early identification of mild cases and ruling out severe disease. NLR, due to its higher specificity, can support the confirmation of severe cases, especially when BISAP scores are inconclusive. However, both scoring systems showed comparable performance in predicting complications, hospital stay, and mortality.

1. Li CL, Jiang M, Pan CQ, Li J, Xu LG. The global, regional, and national burden of acute pancreatitis in 204 countries and territories, 1990-2019. BMC Gastroenterol. 2021 Aug 25;21(1):332. doi: 10.1186/s12876-021-01906-2. PMID: 34433418; PMCID: PMC8390209.
2. Li, T., Qin, C., Zhao, B. et al. Global and regional burden of pancreatitis: epidemiological trends, risk factors, and projections to 2050 from the global burden of disease study 2021. BMC Gastroenterol 24, 398 (2024). https://doi.org/10.1186/s12876-024-03481-8
3. Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974;139:69–81.
4. Fan ST, Choi TK, Lai EC, Wong J. Prediction of severity of acute pancreatitis: an alternative approach. Gut. 1989 Nov;30(11):1591-5. doi: 10.1136/gut.30.11.1591. PMID: 2489025; PMCID: PMC1434335.
5. Papachristou, Georgios I MD1,2; Muddana, Venkata MD1; Yadav, Dhiraj MD1; O'Connell, Michael PhD1; Sanders, Michael K MD1; Slivka, Adam MD, PhD1; Whitcomb, David C MD, PhD1,3,4. Comparison of BISAP, Ranson's, APACHE-II, and CTSI Scores in Predicting Organ Failure, Complications, and Mortality in Acute Pancreatitis. American Journal of Gastroenterology 105(2):p 435-441, February 2010. | DOI: 10.1038/ajg.2009.622
6. Gao W, Yang HX, Ma CE. The value of BISAP score for predicting mortality and severity in acute pancreatitis: a systematic review and meta-analysis. PloS one. 2015 Jun 19;10(6):e0130412.
7. BhanouNMS,BalachandramG,JainNB.Neutrophil to lymphocyte ratio(NLR) in acute pancreatitis as an early predictor of severiyy and outcome.IntSurg J 2018;5:3545-8
8. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS; Acute Pancreatitis Classification Working Group.
9. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013 Jan;62(1):102–111. doi: 10.1136/gutjnl-2012-302779
10. Fitzgerald PJ. Medical anecdotes concerning some diseases of the pancreas.The pancreas. 1980:17-9.
11. Azab B, Jaglall N, Atallah JP, Lamet A, Raja-Surya V, Farah B, Lesser M, Widmann WD. Neutrophil-lymphocyte ratio as a predictor of adverse outcomes of acute pancreatitis. Pancreatology. 2011;11(4):445-52.
12. Cho Y-S, Kim H-K, Jang E-C, Yeom J-O, Kim S-Y, Yu J-Y, et al. Usefulness of the Bedside Index for severity in acute pancreatitis in the early prediction of severity and mortality in acute pancreatitis. Pancreas. 2013 Apr;42(3):483–7.
13. Harshit Kumar A, Singh Griwan M. A comparison of APACHE II, BISAP, Ranson’s score and modified CTSI in predicting the severity of acute pancreatitis based on the 2012 revised Atlanta Classification. Gastroenterol Rep. 2018 May;6(2):127–31
14. Chandra S, Murali A, Bansal R, Agarwal D, Holm A. The Bedside Index for Severity in Acute Pancreatitis: a systematic review of prospective studies to determine predictive performance. J Community Hosp Intern Med Perspect. 2017;7(4):208–13. Epub 2017/10/20. doi: 10.1080/20009666.2017.1361292
15. Yang YX, Li L. Evaluating the Ability of the Bedside Index for Severity of Acute Pancreatitis Score to Predict Severe Acute Pancreatitis: A Meta-Analysis. Med Princ Pract. 2016;25(2):137–42. Epub 2015/11/28. doi: 10.1159/000441003 .
16. Gao W, Yang HX, Ma CE. The Value of BISAP Score for Predicting Mortality and Severity in Acute Pancreatitis: A Systematic Review and Meta-Analysis. PLoS One. 2015;10(6):e0130412. Epub 2015/06/20. doi: 10.1371/journal.pone.0130412 .
17. Zhu J, Wu L, Wang Y, Fang M, Liu Q, Zhang X. Predictive value of the Ranson and BISAP scoring systems for the severity and prognosis of acute pancreatitis: A systematic review and meta-analysis. PLoS One. 2024 Apr 30;19(4):e0302046. doi: 10.1371/journal.pone.0302046. PMID: 38687745; PMCID: PMC11060534.