Predicting Mortality in Acute Pancreatitis

Acute pancreatitis is defined as sudden inflammation of the pancreas with no or little fibrosis. It can be further categorized based on its severity- edematous pancreatitis, or necrotizing pancreatitis. 

The identification of the severity of pancreatitis is vital as any delayed management could result in serious complication and death. Various score systems such as the Modified Glasgow criteria, Ranson’s criteria and (APACHE) II have been used to predict the prognosis for acute pancreatitis. 

The news below shows a new and simple scoring system for acute pancreatitis. Have fun reading it!

Simple Tool May Help Predict Mortality in Acute Pancreatitis

Laurie Barclay, MD  

January 13, 2009 — A new mortality-based prognostic scoring system for use in acute pancreatitis may help identify patients at increased risk for in-hospital mortality, according to the results of a large, population-based study reported in the January issue of Gut.

"Identification of patients at risk for mortality early in the course of acute pancreatitis (AP) is an important step in improving outcome," write Dr. B.U. Wu, from Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, and colleagues. "Current methods of risk stratification in AP have important limitations."

The goal of the study was to develop a simple and accurate clinical scoring system that would classify patients with acute pancreatitis based on their risk for in-hospital mortality, with use of Classification and Regression Tree analysis. Data from 17,992 cases of acute pancreatitis from 212 hospitals from 2000 to 2001 were used to derive the scoring system, and data from 18,256 cases of acute pancreatitis from 177 hospitals in 2004 to 2005 were used to validate the new scoring system.

The area under the receiver operating characteristic curve allowed determination of the accuracy of the scoring system to predict mortality. By comparing predictive accuracy of the new scoring system vs Acute Physiology and Chronic Health Examination (APACHE) II, performance of the new tool was further validated.

Based on Classification and Regression Tree analysis, there were 5 variables identified that predicted in-hospital mortality, each of which was assigned 1 point if present during the first 24 hours: blood urea nitrogen more than 25 mg/dL, impaired mental status, systemic inflammatory response syndrome, age older than 60 years, or pleural effusion (BISAP). Mortality rates ranged from less than 1% in the lowest-risk group to more than 20% in the highest-risk group. BISAP receiver operating characteristic curve was 0.82 (95% confidence interval, 0.79 - 0.84) in the validation cohort vs an APACHE II receiver operating characteristic curve of 0.83 (95% confidence interval, 0.80 - 0.85).

"A new mortality-based prognostic scoring system for use in AP has been derived and validated," the study authors write. "The BISAP is a simple and accurate method for the early identification of patients at increased risk for in-hospital mortality."

Limitations of the study include subjective assessment of mental status; differences between the validation cohort and the derivation cohort; and reliance on International Classification of Diseases, Ninth Revision, data for diagnosis.

"The BISAP score stratifies patients within the first 24 h of admission according to their risk of in-hospital mortality and was able to identify patients at increased risk of mortality prior to the onset of organ failure," the study authors conclude. "The ability to risk-stratify patients early in their course is a major step to improving future management strategies in acute pancreatitis."

In an accompanying commentary, Peter Layer, MD, PhD, from Israelitic Hospital in Hamburg, Germany, notes that although none of the predictive variables were truly surprising, this study should be considered a "significant contribution."

"This new index offers an attractive extension of our diagnostic armamentarium in acute pancreatitis," Dr. Layer writes. "On first glance its main appeal appears to be its easy practicability. However, provided the reported respectable accuracy rates can be confirmed elsewhere, it may be expected that such an uncomplicated, quick and reasonably reliable assessment of disease severity on admission could gain broad acceptance in routine use, not by replacing clinical assessment (which will maintain its indisputable prominence), but rather by complementing and objectifying it."

The study authors and Dr. Layer have disclosed no relevant financial relationships.

Source: Gut. 2009;57:1645-1646, 1698-1703