Evaluation of the BISAP scoring system in prognostication of acute pancreatitis – A prospective observational study

Accepted Manuscript Evaluation of the BISAP scoring system in prognostication of acute pancreatitis – A prospective observational study Sumitra Hagjer, Nitesh Kumar PII:

S1743-9191(18)30712-X

DOI:

10.1016/j.ijsu.2018.04.026

Reference:

IJSU 4598

To appear in:

International Journal of Surgery

Received Date: 22 December 2017 Revised Date:

5 April 2018

Accepted Date: 14 April 2018

Please cite this article as: Hagjer S, Kumar N, Evaluation of the BISAP scoring system in prognostication of acute pancreatitis – A prospective observational study, International Journal of Surgery (2018), doi: 10.1016/j.ijsu.2018.04.026. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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EVALUATION OF THE BISAP SCORING SYSTEM IN PROGNOSTICATION OF ACUTE PANCREATITIS – A PROSPECTIVE OBSERVATIONAL STUDY Sumitra Hagjer, Nitesh Kumar

Silchar Medical College & Hospital, Silchar, Assam, India

Nitesh Kumar Post Graduate Trainee, Department of General Surgery

Corresponding author: Nitesh Kumar Old PG Hostel, Room no- 12, Silchar Medical College & Hospital, Silchar, Ghungoor- 788014, Cachar, Assam, India

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e-mail: [email protected]

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Tel.: +919612108473

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Silchar Medical College & Hospital, Silchar, Assam, India

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Professor, Department of General Surgery

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Sumitra Hagjer

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ABSTRACT: INTRODUCTION: Severe acute pancreatitis has a high mortality and its early identification is important for management and risk stratification. The bedside index for severity in acute pancreatitis (BISAP) is a simple scoring system done at admission which predicts the severity of pancreatitis. Procalcitonin is an inflammatory marker

BISAP score and Procalcitonin in prognostication of acute pancreatitis.

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which is raised very early and helps in early prediction of the severity of disease. This study aims to evaluate the

METHODS: A prospective observational study of 60 patients presenting with acute pancreatitis was done at XXX Medical College and Hospital from July 2015 to June 2016. BISAP, APACHE-II, Ranson criteria, and CT severity

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index (CTSI) of all patients were calculated. Procalcitonin card test was done for all patients. The patients were stratified according by BISAP score and procalcitonin positivity into categories of severe pancreatitis, organ failure and pancreatic necrosis, as well as the number of deaths. The comparison of BISAP with other scoring systems,

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Procalcitonin (PCT), C-reactive protein (CRP), hematocrit, and body mass index (BMI) was done by the area under the receiver-operating curve (AUC) to prediction of severe acute pancreatitis, organ failure, necrosis, and death. RESULTS: Of the 60 patients, 14 (23.3%) developed severe acute pancreatitis, 11 (18.3%) Organ failure, 21 (35%) pancreatic necrosis and 7 (11.6%) died. A BISAP score of ≥3 was a statistically significant cutoff value. AUCs for predicting severe pancreatitis and death of BISAP were 0.875 and 0.740respectively, similar to those for Ranson criteria (0.802, 0.763) and APACHE-II (0.891, 0.769) and greater than AUCs for CTSI (0.641, 0.554). The AUC for

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prediction of organ failure were 0.906, 0.833, 0.874 and 0.623 for BISAP, Ranson criteria, APACHE-II, and CTSI respectively. AUCs for PCT predicting severity, organ failure, and death were 0.940, 0.923 and 0.769 respectively were similar to BISAP but greater than those for CRP (0.755, 0.719, 0.693), hematocrit (0.540, 0.570, 0.550), and BMI (0.493, 0.523, 0.497).

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CONCLUSION: The BISAP predicts severity, organ failure and death, in acute pancreatitis very well.It is as good as APACHE-II but better than Ranson criteria, CTSI, CRP, hematocrit, and BMI. PCT is a promising inflammatory

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marker with prediction rates similar to BISAP.

KEY WORDS: acute pancreatitis; scoring system; pancreatic necrosis; organ failure; procalcitonin.

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INTRODUCTION Acute pancreatitis (AP) is a common clinical condition which results from inflammation of the pancreas with possible peripancreatic tissue and multiorgan involvement

[1, 2]

. Majority of the cases of acute pancreatitis

(80%) are mild and self limiting with no sequelae. But severe disease develops in about 10-20% of the cases where

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necrosis occurs in parts of pancreas and the surrounding tissues. An acute inflammatory response sets in these patients which progresses to systemic inflammatory response syndrome leading to multiorgan failure resulting in death [3, 4, 5].

The response to pancreatic injury varies from person to person and is often difficult to predict. Though the [6]

. The high mortality of the severe

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mortality of AP is 2-5% overall but it reaches to about 20-30% in severe cases

acute pancreatitis (SAP) calls for methods to assess the severity of the disease early and accurately for initiating more aggressive interventions which will decrease the adverse outcomes and high mortality. So, careful ongoing the SAP [7, 8, 9].

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clinical assessments along with multi-factorial scoring system and imaging studies are required for the prediction of

Varieties of scoring systems are available such as Ranson criteria [10], Acute Physiology and Chronic Health Evaluation (APACHE) II

[11]

and computed tomography severity index (CTSI)

[12]

, etc. But these systems are either

complicated or require data that are not collected as a routine in early stages of disease and making the process of

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early risk stratification difficult [3, 4].

A new prognostic scoring system for estimating the severity of AP in the early phase, which was named the bedside index of severity in acute pancreatitis (BISAP), was proposed by Wu et al. [13] in 2008. The 5-point BISAP score system incorporates the variables: blood urea nitrogen level >25 mg/dl, impaired mental status, systemic

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inflammatory response syndrome (SIRS), and age >60 years, and presence of pleural effusion [6] (Table 1).

TABLE 1: Individual components of the BISAP scoring system Blood Urea Nitrogen (BUN) > 25 mg/dl

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Impaired mental status ( Glasgow Coma Scale Score < 15) Systemic Inflammatory Response Syndrome (SIRS): SIRS is defined as presence of two or more of the following 1) Temperature of < 36 or > 38 ° C 2) Respiratory rate > 20 breaths/min or P a CO2 < 32 mm Hg 3) Pulse > 90 beats/min 4) WBC < 4,000 or >12,000 cells/mm 3 or >10% immature bands Age > 60years

Pleural effusion detected on imaging

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BISAP: bedside index of severity in acute pancreatitis, WBC: white blood count. One point is assigned for each variable within 24 h of presentation and added for a composite score of 0 – 5.

A number of biological markers are also used in prediction of the severity of pancreatitis. Procalcitonin

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(PCT) is propeptide of calcitonin consisting of 116-amino acids which has no known hormonal activity, and can be detected in high concentrations in serum during severe bacterial or fungal but not viral infections [14, 15]. Hepatocytes and inflammatory cells synthesize and secrete PCT in response to proinflammatory mediators. PCT was introduced as an early marker of the systemic inflammatory response, sepsis, and MOF. It was found that increased serum concentration levels of PCT (> 0.5ng/ml) was a reliable early predictor of a severe disease, mortality and infected

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pancreatic necrosis [17, 18].

During the past years, very few studies have been conducted in India to validate the accuracy of BISAP in

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estimating the severity of AP, but no studies have been done to validate BISAP and PCT in the north eastern part of India. The aim of this study was to evaluate the usefulness of BISAP and procalcitonin for the early prediction of the severity, organ failure, pancreatic necrosis and death in acute pancreatitis in our hospital and compare it with the existing systems.

Materials and Methods:

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A prospective observational study was carried out in XXX medical college and hospital from 30th June 2015 to 29th June 2016 for a period of one year after ethical committee approval. The study was funded by DBT, New delhi, the DBT nodal cell, XXX University.The work has been reported in line with the STROCSS criteria[19].Patients presenting with features of acute pancreatitis to emergency and outdoor were admitted,

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thoroughly examined and investigated further. Laboratory and biochemical tests were done either at the time of admission or within 24 hrs of admission and at 48 hours. Tests included total leukocyte count, hematocrit, blood glucose level, blood urea, serum creatinine, serum calcium, serum electrolytes, Liver function tests, and serum

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amylase and lipase and Arterial Blood Gas (ABG) analysis. C-reactive protein (CRP) and procalcitonin card test (PCT) was also done within 24 hours of admission. Rectal temperature was taken and Body Mass Index (BMI) was calculated. PCT-Q test

[17]

(B·R·A·H·M·S PCT-Q Thermo Fisher Scientific)was done by pipetting 200µl of blood

sample(plasma or serum) on the test strip at room temperature and the result was read after 30 minutes. An ultrasound scan of the abdomen and plain radiograph of the abdomen and chest was done on the day of admission.

BISAP and APACHE II scores were calculated from the laboratory values and radiological reports obtained within first 24 hours after admission. Ranson score was calculated from the laboratory values obtained

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within the first 48 hours. CTSI was obtained from the report of the CT scan which was done after 72 hours and within 7 days. The reporting of the scans was done by same set of radiologists.

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Definitions: Acute pancreatitis was diagnosed in a patient when two of the following three features were present: 1) pain abdomen consistent with acute pancreatitis (persistent, severe, epigastric pain of acute onset which often radiates to back); 2) serum amylase and/or lipase at least three times greater than the upper limit of normal value; and 3) CECT, less commonly MRI or transabdominal ultrasound showing characteristic manifestations of acute

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pancreatitis [19].

The presence or absence of organ failure and/or local complications such as peripancreatic fluid collections and infected necrosis was used to classify AP as mild or severe according to revised Atlanta classification. Duration

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of organ failure defined it to be transient (<48 hrs) or persistent (>48 hours). The most extreme laboratory value or clinical measurement of all patients in each 24 hour was taken up to 72 hours for calculation of the organ failure scores. Organ failure included one or more of the following 1) shock (systolic blood pressure <90 mmHg), 2) pulmonary insufficiency (arterial PO <60 mmHg in room air or the need for mechanical ventilation) and 3) renal 2

failure (serum creatinine level >2 mg/dL after rehydration or hemodialysis) indicating a score of ≥2 according to modified Marshall scoring system (table 2). CECT showing lack of enhancement of pancreatic parenchyma was

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defined as pancreatic necrosis [20].

TABLE 2: Criteria for organ failure based on Marshall scoring system Organ system

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Respiratory (P a O 2 / F i O 2 ) Renal (serum creatinine, mg/dl)

0 > 400 ≤1.5 > 90

Score 2 201 – 300 >1.9 to ≤ 3.5

< 90, fluid responsive

< 90, fluid unresponsive

3 101 – 200 > 3.5 to ≤ 5.0

4 < 101 > 5.0

< 90, pH < 7.3

< 90, pH < 7.2

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Cardiovascular (systolic blood pressure, mm Hg)

1 301 – 400 >1.5 to ≤ 1.9

Statistical analysis

Median and interquartile ranges were used for representation of continuous variables and proportions for

categorical data. Cochran-Armitage trend test was used for assessing the distributions of severity, necrosis, organ failure, and death by BISAP point score. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for individual scoring systems. The optimal BISAP, Ranson, APACHE-II, and CTSI scores for predicting severity, necrosis, organ failure, and death was determined by their characteristic Receiver-operating (ROC) curves. The Area Under the Curve (AUC) of the scoring systems were compared with each other at a time by the nonparametric approach developed by DeLong et al [21]. A pvalue of <0.05 was chosen to

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be significant for all tests. Univariate linear regression was used to analyze the association of BISAP and hospital stay. XL Stat 2016 was used for performing all the statistical calculations. Results: 60 patients of AP were admitted and included in our study of one year. The demographics, clinical

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characteristics and the outcomes are summarized in table 3. Males were predominant in our study, mean age was in late thirties and etiology was almost equally distributed between alcohol and gallstones. Severe disease developed in 23.3 % of patients and 11.6 % died.

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TABLE 3: Demographic, clinical characteristics, and outcomes of patients (n=60) Variables Data Male: Female 2.16:1 (41/19) Mean age (years) 37.167±11.768 Etiology: 1. Alcoholic 27 (45 %) 2. Gall Stone 24 (40 %) 3. Idiopathic 09 (15 %) Severity: 1. Mild AP 2. Severe AP

46 (76.6 %) 14 (23.3 %)

Organ Failure: 1. Absent 2. Present

49 (81.6 %) 11 (18.3 %) 39 (65%) 21 (35 %)

BISAP: 1. < 3 2. > 3

48 (80 %) 12 (20 %)

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Necrosis: 1. Absent 2. Present

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PCT: 1. 2.

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< 0.5 ng/ml 47 (78.8 %) ≥ 0.5- 2.0 3 (5 %) ng/ml 10 (16.6 %) 3. ≥ 2.0 – 10 ng/ml Mortality 7 (11.6 %) Hematocrit 39.045 ± 5.165 BMI 25.483 ± 4.168 CRP 92.667 ± 54.645 Hospital stay 1. Mild AP 7.52 ± 3.053 2. Severe AP 10.429 ± 5.872 ICU admission 13 (21.6%) AP: Acute Pancreatitis, BISAP: bedside index of severity in acute pancreatitis, PCT: Procalcitonin, BMI: Body Mass Index, CRP: C-Reactive protein, ICU: Intensive Care Unit

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The severity of disease, organ failure, pancreatic necrosis and mortality distributions according to the BISAP point score are shown in table 4. There was increasing trend in the percentage of severity, organ failure, necrosis and mortality with increasing BISAP scores. Cochran-Armitage trend test yielded significant p values for

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association of BISAP with severity, organ failure and mortality (p < 0.05). PCT also showed similar trends as of BISAP and the trend test was significant for association of PCT and severity, organ failure and mortality (p < 0.05) (Table 5).

1 (5.8)

0

2

3 (20)

1(6.6)

3

5 (71)

4 5

0

17 (28.3)

4 (26.6)

1 (6.6)

15 (25.0)

5 (71)

4 (57.1)

2 (28.5)

7 (11.6)

4 (100)

4 (100)

3 (75)

3 (75)

4 (6.6)

1 (100)

1 (100)

0

1 (100)

1 (1.6)

14 (23.3%)

11 (18.3%)

21 (35%)

7 (11.6%)

60 (100)

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Total

5 (29.4)

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TABLE 4: Distribution of severity, organ failure, necrosis an mortality according to BISAP point scores SEVERITY ORGAN NECROSIS MORTALITY TOTAL BISAP (n, %) FAILURE (n, %) (n, %) (n, %) SCORE (n, %) 0 0 5 (31.2) 0 16 (26.6) 0

BISAP: bedside index of severity in acute pancreatitis

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TABLE 5: Distribution of severity, organ failure, necrosis an mortality according to PCT-Q values SEVERITY ORGAN NECROSIS MORTALITY TOTAL (n, PCT (ng/ml) (n, %) FAILURE (n, %) (n, %) %) (n, %) 2 (4.2) 0 (0) 15 (31.9) 0 (0) <0.5 47 (78.8) ≥0.5 - <2

2 (66.6)

2 (66.6)

1 (33.3)

0 (0)

3 (5)

≥2 – <10

10 (100)

9 (90)

5 (50)

7 (70)

10 (16.6)

0 (0)

0 (0)

0 (0)

0 (0)

0 (0)

14 (23.3)

11 (18.3)

21 (35)

7 (11.6)

60 (100)

≥ 10

TOTAL

PCT: Procalcitonin

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Comparison of BISAP with different scoring systems and Biomarkers: The AUC of the different scoring systems and the biomarkers for predicting severity, organ failure, necrosis and mortality were obtained from their ROC curves and is listed in table 6. BISAP had AUCs of 0.875 (95% CI, 0.77-0.97), 0.915 (95% CI, 0.86-0.97), 0.576 (95% CI, 0.46-0.67) and 0.892 (95% CI, 0.81-0.97) for

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prediction of the severity, organ failure, necrosis and mortality respectively. The AUC of BISAP in predicting the Severity of disease was almost similar to that of APACHE II (0.872; 95% CI- 0.78-0.96, p = 0.612) but was slightly higher than that of RANSON (0.810; 95% CI- 0.71-0.90, p = 0.134) but the differences were statistically insignificant. In predicting the Organ failure in AP AUC of BISAP was almost similar to that of APACHE II (0.923; 95% CI, 0.87-0.97, p value = 0.431) but was significantly higher than that of RANSON (0.839; 95% CI, 0.74-0.93,

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p value < 0.014).For prediction of Mortality the AUC of BISAP was similar to that of APACHE II (0.893; 95% CI, 0.81-0.97, p value = 0.534) and slightly higher than that of RANSON (0.803; 95% CI, 0.69-0.90, p value = 0.143) but was insignificant. The AUC of CTSI (0.879; 95% CI, 0.77-0.96) in predicting the Necrosis was higher than other

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scoring systems and was statistically significant (p value < 0.001).

Among the biomarkers the AUC of PCT was comparable to that of BISAP in prediction of Severity (0.925; 95% CI, 0.87-0.97, p value = 0.238), Organ failure (0.942; 95% CI, 0.89-0.99, p value = 0.146) and mortality (0.898; 95% CI, 0.81-0.97, p value = 0.452) but was greater than CRP, HCT and BMI (p value < 0.05 for all). The AUC of hematocrit was higher than other biomarkers and BISAP in prediction of necrosis (0.710) and the data was statistically significant (p value <0.05) but was significantly lower than CTSI (p value > 0.05). The ROC curves of

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different scoring systems and PCT for prediction of severity of disease is shown in figure 1. The following cutoffs were generated on the basis of highest sensitivity and specificity obtained from ROC curves; BISAP ≥ 3, Ranson ≥ 3, APACHE ≥8, CTSI ≥ 4, PCT ≥ 0.05 ng/ml, CRP ≥150 mg/L, Hct ≥ 44, BMI ≥ 30. The sensitivity, specificity, PPV, NPV was calculated for the different scoring systems and PCT using these cutoffs obtained from the ROC curves (Table 7). Increasing BISAP scores were associated with increase duration of

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hospital stay by univariate linear regression (R2 = 0.201) was also found to be significant (p value < 0.05). Similar findings were obtained for PCT (R2 = 0.198).

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TABLE 6: AUC of the different Scoring Systems and the Biomarkers in predicting severity, organ failure, necrosis and mortality SEVERITY

ORGAN FAILURE

NECROSIS

MORTALITY

0.875 (0.77-0.97)

0.915 (0.86-0.97)

0.576 (0.46-0.67)

0.892 (0.81-0.97)

Ranson

0.810 (0.71-0.90)

0.839 (0.74-0.93)

0.556 (0.44-0.67)

0.803 (0.69-0.90)

APACHE II

0.872 (0.78-0.96)

0.923 (0.87-0.97)

0.521(0.41-0.62)

0.893 (0.81-0.97)

CTSI

0.653 (0.46-0.66)

0.627 (0.53-0.73)

0.879 (0.77-0.96)

0.509 (0.40-0.60)

PCT

0.925 (0.87-0.97)

0.942 (0.89-0.99)

0.556 (0.44-0.67)

0.898 (0.81-0.97)

AUC (95% CI) BISAP

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CRP

0.755 (0.65-0.85)

0.719 (0.61-0.82)

0.556 (0.44-0.67)

0.693 (0.59-0.79)

HCT

0.540 (0.44-0.65)

0.570 (0.46-0.67)

0.710 (0.61-0.81)

0.550 (0.44-0.67)

BMI

0.493 (0.39-0.59)

0.523 (0.41-0.62)

0.490 (0.39-0.59)

0.497 (0.39-0.60)

AUC: Area Under Curve, BISAP: bedside index of severity in acute pancreatitis, APACHE II: Acute Physiology

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and Chronic Health Evaluation, CTSI: computed tomography severity index, PCT: procalcitonin, CRP: C-

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Reactive protein, HCT: Hematocrit, BMI: Body mass index.

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Fig 1: Comparison of AUC of different scores and Pct for severity prediction Table 7: sensitivity, specificity, PPV, NPV of different scoring systems and PCT

Specificity

PPV

NPV

BISAP

0.714

0.957

0.833

0.917

Ranson

0.571

0.935

0.727

0.878

APACHE II

0.786

0.957

0.846

0.936

CTSI

0.379

0.903

0.786

0.609

PCT

0.857

0.978

0.923

0.957

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Sensitivity

Severity:

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Organ failure: 0.909

0.959

0.833

0.979

Ranson

0.727

0.939

0.727

0.939

APACHE II

0.909

0.939

0.769

0.979

CTSI

0.310

0.935

0.818

0.592

PCT

0.989

0.959

0.846

0.979

BISAP

0.333

0.872

0.583

Ranson

0.238

0.846

0.455

APACHE II

0.286

0.821

0.462

CTSI

0.999

0.795

0.724

0.999

PCT

0.286

0.821

0.462

0.681

BISAP

0.857

Ranson

0.857

APACHE II

0.999

CTSI

0.172

PCT

0.999

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Mortality:

0.708 0.673 0.681

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Necrois:

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BISAP

0.887

0.500

0.979

0.906

0.545

0.980

0.887

0.538

0.999

0.935

0.714

0.547

0.887

0.538

0.999

BISAP: bedside index of severity in acute pancreatitis, APACHE II:

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Acute Physiology and Chronic Health Evaluation, CTSI: computed tomography severity index, PCT: procalcitonin,

Discussion:

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In this study the usefulness of BISAP and procalcitonin was evaluated for the early prediction of the severity, organ failure, pancreatic necrosis and death in acute pancreatitis in our hospital and compared it with the existing systems. It was found that BISAP was similar to Ranson and APACHE II in prediction of severity of

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disease and the mortality and was better than Ranson in prediction of organ failure. PCT was also very useful biomarker for prediction of severity, organ failure and death and was comparable to BISAP but was better than other biomarkers (CRP, HCT and BMI). Necrosis was best predicted by CTSI and HCT. Both BISAP and PCT had linear relation with the hospital stay.

The existing prognostic scoring systems have drawbacks and difficulties which are overcome by the BISAP

scoring system. Ranson and Glasgow scores require 48 hours for calculation and also require data that is not routinely collected at the time of admission and not readily available in small centers

[2, 5, 9, 10]

. APACHE II was

initially devised for prognostication of ICU patients is most commonly used scoring system but it requires many parameters of which some are not relevant for AP. Also the chronic health profile portion of the score requires a detailed history and medical records which are difficult to obtain in all patients. It is cumbersome and difficult to

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remember for the clinicians

[3, 4, 5, 11]

. CT is not useful for prognosis in early stages of the disease as the

morphological changes develop late

[1, 5, 12]

.

BISAP score has several advantages from the other scoring systems; 1) it requires data that are very easy to obtain at the time of admission (physical examination, vital signs, few laboratory data and imaging for detection of pleural effusion) which makes it much easier to calculate, 2) it predicts the in hospital death in early stages of the [2, 3, 6, 13]

. Age, GCS and SIRS is used in both BISAP and APACHE II but only with addition of BUN and

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disease

pleural effusion BISAP attains a high predictive ability to detect severe disease and predict the mortality which is equivalent to the complex APACHE II. A BISAP score of ≥3 was associated with more severe disease, more organ failure and higher mortality in the ROC curve. BISAP score of ≥3 was used as cutoff by most of the authors [6, 22, 24] and ≥ 2 by few

[2, 23]

. Revised Atlanta classification defines severe disease by presence of local pancreatic

predictor of severe disease and duration of hospitalization

[6, 8, 20]

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complications and extrapancreatic organ failure and more recently organ failure is considered as a much stronger . BISAP predicts organ failure more accurately in

the early stage of the disease, thus adding to the advantage of this scoring system.

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Park et al [2]in his retrospective study of the 303 patientscompared BISAP score with other scoring systems. AUCs for BISAP predicting severe pancreatitis, organ failure and death were 0.80, 0.93 and 0.86, respectively, which were similar to those for APACHE-II (0.80, 0.95, 0.87) and Ranson criteria (0.74, 0.84, 0.74) and greater than AUCs for CTSI (0.67, 0.57, 0.42). In his study BISAP predicted severity, death, and especially organ failure in acute pancreatitis as good as APACHE-II did and was better than Ranson criteria, CTSI, CRP, hematocrit, and BMI.

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Table 6 lists the results of various studies comparing with our study.

TABLE 8: Comparison of AUC of different scoring systems in different studies for severity prediction Our Study

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SCORING SYSTEMS

Park el al2

Zhang et al21

Khanna et al22

Papachristou et al23

0.875

0.80

0.793

0.80

0.81

RANSON

0.810

0.74

0.903

0.85

0.94

0.872

0.80

0.836

0.88

0.78

0.653

0.67

--

0.66

0.84

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BISAP

APACHE II CTSI

Many biomarkers have been studied in pancreatitis including Interleukin (IL-6), PCT, trupsinogen-2 and

trypsinogen activated protein. However CRP is the only biomarker which has been used widely [25]. CRP is limited by its delay in attaining the peak value after onset of symptoms which is up to 72 hours [17]

[17, 25]

.

Kylanpaa et al

showed a sensitivity of only 37% for CRP at admission. In our study CRP at presentation was analyzed which

yielded low AUC and sensitivity for prediction of the severe disease and mortality.

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Serum PCT was evaluated as a prognostic marker in AP in many studies [14-17,19, 24, 26]. PCT is a biologically inactive propeptide of calcitonin, is a more rapid acute-phase reactant and is detectable early in course of the disease making it a useful prognostic marker. In several studied it has been reported to correlate with severity of infection and as an early indicator of severe noninfectious SIRS also as a valuable marker for the clinical course of the disease. It also differentiated between sterile and infected necrosis

[16]

. Kylanpaa et al

[17]

used semiquantitative

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serum strips PCT-Q in 162 patients with AP and found a sensitivity of 92% and specificity of 84% with a 97% NPV for detection of organ failure (cutoff- 0.5 ng/ml). Our study had sensitivity of 98% and specificity of 95% with a 97% NPV for detection of organ failure (cutoff- 0.5 ng/ml). AUC of PCT for prediction of severity, organ failure and death was comparable to BISAP and APACHE II but was better than Ranson and the other biomarkers; similar [17]

findings were reported by Kylanpaa et al

.

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comparable with the other biomarkers

. Several other studies also showed high accuracy of the PCT

[19, 23, 26]

The B·R·A·H·M·S PCT-Q is an immunochromatografic rapid dipstick test for the semi-quantitative detection of PCT. No well equipped laboratory or any laboratory personnel is required at the time of performing the

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test. B·R·A·H·M·S PCT-Q test system requires serum to be incubated only for 30 minutes and can be done at bedside making it very useful and can be performed at lower level hospitals also. In this study a single PCT value was equivalent or slightly more sensitive and accurate than other scoring systems for the diagnosis and prognosis of severe AP.

Hemoconcentration is shown to be early predictor of pancreatic necrosis and organ failure in many studies [2, 5, 7]

but one study has shown it to be a poor predictor of the organ failure and severity

[27]

. In our study HCT at

admission had low predictive values for severe pancreatitis, organ failure, and death, but for necrosis the predictive

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value was greater than PCT, CRP, BMI and even BISAP. When compared with CTSI the predictive value of HCT for necrosis was low but HCT had the advantage of early prediction for necrosis. Obesity (BMI ≥ 30) is also related with poor prognosis in patients of AP and thought to be and independent prognostic factor [2, 28]. Few studies have included BMI (and in particular the effect of obesity) in BISAP but these

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do not report any additional prediction for adverse outcome [29, 30]. Obesity was a poor predictor of AP in our study (mean BMI was 24.5), the low prevalence of obesity in this part of the country may be the cause. So, we finally conclude from the study is that BISAP is as useful as APACHE-II and more useful than

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Ranson criteria, CTSI, CRP, Hct and BMI in predicting severity, organ failure, and death in patients with acute pancreatitis. PCT is a good independent prognostic marker for prediction of severity, organ failure and death and is comparable with BISAP and APACHE II in accuracy. BISAP score are easy to obtain, data is clinically relevant and very easy to calculate within 24 hours. Both BISAP and PCT had accuracy for predicting organ failure which was greater than their ability to predict severity of the disease. A larger prospective study is needed comparing all the scores and individual parameters to give a standard approach. Still the approach differs in institutions according to their preferences. BISAP scores can be used with ease to identify the patients of acute pancreatitis within 24 hours of admission who are at risk of developing severe disease, organ failure and likely to die in the hospital. PCT estimation by B.R.A.H.M.S PCT-Q is easy and results can be obtained at bed side, so it will also help to identify the

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patients at risk and will act as an early guide for the accurate and required treatment resulting in improved patient

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outcomes.

Conflict of intrest:

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Authors have no conflict of intrest. Funding:

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Declared by the authors.

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Highlights: •

BISAP scores can be used with ease to identify the patients of acute pancreatitis within 24 hours of admission who are at risk of developing severe disease, organ failure and likely to die in the hospital. PCT estimation by B.R.A.H.M.S PCT-Q is easy and results can be obtained at bed side.

•

Both will help to identify the patients at risk and will act as an early guide for the accurate and required

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treatment resulting in improved patient outcomes.

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•