European Journal of Cardiovascular Medicine

Acute pancreatitis (AP) is one of the most common causes of acute abdomen requiring hospitalisation worldwide. Its incidence has been rising over the past two decades, with reported rates ranging from 13 to 49 cases per 100,000 population per year in different parts of the world [1–4]. The disease has a highly variable clinical course, from mild, self‑limiting interstitial oedematous pancreatitis to severe necrotizing pancreatitis with persistent organ failure, infected necrosis and high mortality [5–8]. Gallstones and alcohol together account for more than 80% of cases globally, though the relative contribution of each etiology varies between regions [3,5,9].

The Revised Atlanta Classification (RAC) categorises AP into mild, moderately severe and severe based on the presence and duration of organ failure and local or systemic complications [11,12]. Severe AP, characterised by persistent organ failure lasting more than 48 hours, is associated with mortality rates as high as 15–35% in some series [13–18]. Early identification of patients at risk of severe disease is therefore critical in guiding level of care, monitoring intensity, nutritional strategy and timely intervention when required.

Several clinical, laboratory and radiological scoring systems have been developed to predict the severity and outcome of AP. Ranson’s score is one of the earliest and most commonly used disease‑specific scores, but it requires 48 hours to complete and uses variables that may not be routinely available in all settings [19,20]. The APACHE II score, although widely applied in intensive care units, is complex and non‑specific to AP, requiring a large number of physiological variables [21–23]. Imaging‑based indices such as the CT Severity Index (CTSI) and Modified CTSI (MCTSI) provide detailed anatomical assessment of pancreatic and peripancreatic involvement and correlate well with local complications but rely on cross‑sectional imaging typically performed after 48–72 hours [24–28].

The Chinese Simple Scoring System (CSSS) is a relatively new, simplified system developed to allow early risk stratification using a limited number of clinical and biochemical parameters that are usually available at the time of admission [29–32]. Given the burden of AP and the constraints in many resource‑limited healthcare settings, there is a need to evaluate such simplified tools in diverse populations. This study was therefore designed to compare the performance of CSSS with APACHE II, Ranson’s score and MCTSI in predicting the severity and prognosis of AP in an Indian tertiary‑care centre.

Aims and Objectives

Aim:

To compare the prognostic accuracy of the Chinese Simple Scoring System (CSSS) with APACHE II, Ranson’s score and the Modified CT Severity Index (MCTSI) in predicting severity and outcomes of acute pancreatitis.

Objectives:

1. To describe the demographic and etiological profile of patients presenting with acute pancreatitis.
2. To classify disease severity according to the Revised Atlanta Classification.
3. To calculate CSSS, Ranson’s score, APACHE II and MCTSI for each patient within the study cohort.
4. To compare the ability of these scores to predict severe disease, complications, intensive care requirement and mortality using ROC curve analysis.
5. To evaluate the feasibility of CSSS as a routine early triage tool in a resource‑limited setting.

Study design and setting:

This was a prospective observational study conducted in the Department of General Surgery, Rajindra Hospital, Government Medical College, Patiala, over a period of one year from June 2023 to May 2024. The study was approved by the institutional ethics committee, and informed consent was obtained from all participants.

Study population:

A total of 61 consecutive patients older than 16 years, admitted with a diagnosis of acute pancreatitis, were included. Acute pancreatitis was diagnosed when at least two of the following three criteria were present: typical upper abdominal pain, serum amylase or lipase levels at least three times the upper limit of normal, and characteristic imaging findings on contrast‑enhanced CT (CECT) [11,32]. Patients with chronic pancreatitis, acute‑on‑chronic pancreatitis, recurrent pancreatitis, pancreatic malignancy, or those unwilling to participate were excluded.

Data collection:

Demographic data (age, sex), risk factors (alcohol use, gallstone disease, metabolic and other comorbidities), time from onset of pain to admission, and clinical presentation were recorded on a structured proforma. Vital signs and systemic examination findings were documented at admission and monitored closely during hospital stay. Baseline laboratory investigations included complete blood count, liver function tests, renal function tests, serum electrolytes, random blood sugar, serum calcium, and serum amylase and lipase. Relevant tests were repeated at 48 hours or as clinically indicated.

Imaging and severity classification:

All patients underwent ultrasound of the abdomen to assess gallbladder and biliary tree and to evaluate for peripancreatic collections. CECT of the abdomen was performed within 72 hours in patients without contraindications to intravenous contrast. Disease severity was classified according to the Revised Atlanta Classification into mild, moderately severe and severe AP [11,12]. Local complications (acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection, walled‑off necrosis) and systemic complications were recorded.

Scoring systems:

Each patient was scored using four prognostic indices:

• Ranson’s/modified Ranson’s score, calculated using admission and 48‑hour parameters [19,20].

• APACHE II score, computed from the worst physiological variables within the first 24 hours of admission [21–23].

• Modified CT Severity Index (MCTSI), derived from CECT findings, incorporating pancreatic inflammation, necrosis and extrapancreatic complications [24–27].

• Chinese Simple Scoring System (CSSS), based on predefined clinical and biochemical variables obtained within the early phase of the disease [29–32].

Outcomes and statistical analysis:

Primary outcomes included development of moderately severe or severe AP, local and systemic complications, organ failure (respiratory, renal or cardiovascular), need for intensive care unit (ICU) admission, and in‑hospital mortality. Receiver operating characteristic (ROC) curves were constructed for each scoring system to predict severity and poor outcome. Area under the curve (AUC), sensitivity, specificity and optimal cut‑off points were derived from ROC analysis. Comparative AUCs were used to assess relative performance of the four scoring systems.

Demographic and etiological profile:
The study included 61 patients with acute pancreatitis, with a mean age of 45.2 years. There was a male predominance with a male:female ratio of approximately 1.7:1. Gallstone disease was the most common etiology, accounting for 55.74% of cases, followed by alcohol‑related AP in 44.26%. Gallstone‑related AP was more frequent among females, whereas alcohol‑related AP was confined to males.

Severity and complications:
According to the Revised Atlanta Classification, 42.62% of patients had mild AP, 34.42% had moderately severe AP, and 22.95% had severe AP. Peripancreatic fluid collections were observed in 72% of patients, pancreatic or peripancreatic necrosis in 18%, and infected necrosis in 8%. Organ failure (transient or persistent) occurred in approximately 23% of patients. The overall in‑hospital mortality was 4.92% (3 of 61 patients), predominantly among older patients with severe disease and multiple organ dysfunction.

Table 1. Demographics and Etiology

Table 2. Severity (Revised Atlanta Classification)

Table 3. Complications and Outcomes

ROC analysis of scoring systems:
The ROC analysis is summarised in Table 4 and Figure 1. For prediction of severity, CSSS had an AUC of 0.897, Ranson’s/modified Ranson’s 0.765–0.852 (depending on endpoint), APACHE II 0.909, and MCTSI 0.914 for severity‑related endpoints fileciteturn2file0. For prediction of adverse outcomes (including ICU requirement, organ failure and mortality), the AUCs were 0.948 for Ranson’s/modified Ranson’s, 0.845 for MCTSI, 0.810 for APACHE II, and 0.897–0.941 for CSSS fileciteturn2file0. CSSS thus demonstrated excellent discriminatory ability for both severity and overall outcome, with performance comparable to Ranson’s score and MCTSI and better early applicability than the latter.

Table 4. AUC Values for Severity and Outcome Prediction

Acute pancreatitis (AP) continues to pose substantial morbidity and mortality worldwide, and early identification of patients at risk of severe disease is crucial to improving outcomes. The present prospective study, conducted in a tertiary‑care centre in North India, reinforces previously described epidemiological patterns while providing new comparative data on the performance of CSSS, APACHE II, Ranson’s score and MCTSI.

Epidemiology and etiology:

The demographic profile in our study—with a mean age in the mid‑forties and male predominance—is consistent with population‑based data from Europe, North America and Asia, where AP commonly affects individuals between the ages of 30 and 60 years [1–4]. Gallstones and alcohol were the leading etiologies, together accounting for more than 90% of cases, similar to global patterns [3,5,9]. Several studies have reported that gallstone‑related AP tends to present more frequently in females, whereas alcohol‑related AP is more common in males, a pattern also observed in our cohort [5–8]. Severe disease and complications were more frequent in gallstone‑related AP, which may be related to delayed presentation, recurrent impaction or coexisting biliary sepsis [9,10].

Severity, complications and mortality:

Using the Revised Atlanta Classification, approximately one‑fifth of our patients had severe AP and one‑third had moderately severe disease, in line with international estimates suggesting that 15–25% of patients develop moderately severe or severe AP [11–13]. Local complications such as peripancreatic fluid collections and necrosis were frequent, and infected necrosis occurred in a subset of patients, mirroring the observations of Petrov et al. and other large cohorts where local complications strongly correlate with severity and adverse outcomes [14,15]. Our overall in‑hospital mortality of 4.92% compares favourably with reported mortality rates of 3–10% in unselected AP cohorts and 15–35% in severe AP [16–18]. This may reflect early resuscitation, close monitoring and timely referral to higher levels of care.

Comparison of scoring systems:

The central aim of this study was to compare the four prognostic scoring systems. Ranson’s score, although one of the earliest and most widely cited AP‑specific severity scores, requires the collection of variables over a 48‑hour period and uses several laboratory parameters that may not be routinely available in resource‑limited settings [19,20]. In our study, Ranson’s score showed high predictive accuracy for poor outcome (AUC 0.948), which is in keeping with earlier literature; however, its delayed applicability limits its usefulness for early triage.

APACHE II is a general ICU scoring system that has been evaluated extensively in AP [21–23]. While it offers the advantage of being calculated within the first 24 hours, it requires a substantial number of physiological inputs and chronic health data, making it cumbersome to apply consistently outside of well‑resourced intensive care units. In our cohort, APACHE II showed reasonable performance (AUC ~0.78–0.81), similar to previous reports, but did not outperform CSSS or MCTSI in predicting key outcomes.

Imaging‑based indices such as CTSI and MCTSI incorporate the extent of pancreatic inflammation, necrosis and extrapancreatic complications and have been shown to correlate strongly with local complications and overall prognosis [24–27]. Our findings support this, with MCTSI demonstrating high AUC values, particularly for severity‑related endpoints (AUC >0.90 for certain severity measures) fileciteturn2file0. However, MCTSI is inherently limited by its reliance on CECT, which is ideally performed after 48–72 hours to allow necrosis to evolve [24,28]. In addition, CT may not be feasible in patients with renal dysfunction or hemodynamic instability.

Performance and advantages of CSSS:

The Chinese Simple Scoring System (CSSS) was developed to permit early and simple risk stratification in AP using a small set of clinical and biochemical parameters [29–32]. In our study, CSSS demonstrated excellent predictive performance, with an AUC of 0.897 for severity and 0.941 for adverse outcomes, comparable to or better than the other scoring systems evaluated fileciteturn2file0. These findings are consistent with the work of Wu et al., Wang et al. and others, who reported that CSSS has strong discriminatory power for severe AP, organ failure and mortality [29–32].

The key strength of CSSS lies in its simplicity: it uses variables that are routinely available at the time of admission in most hospitals, without the need for complex calculations or specialised software. This makes it particularly attractive for use in emergency departments and in resource‑limited settings, where APACHE II may be difficult to implement and CT may not be readily available. Several Indian and international studies have also highlighted the prognostic value of simple biochemical markers such as CRP, blood urea nitrogen, haematocrit and serum calcium in predicting severe AP [33–35], many of which are incorporated in CSSS.

Clinical implications:

Our data suggest that CSSS can be integrated into the initial assessment of AP patients to rapidly identify those at higher risk of severe disease and poor outcomes. Such patients can be prioritised for intensive monitoring, aggressive fluid resuscitation, early nutritional support and timely transfer to high‑dependency or intensive care units. Meanwhile, low‑risk patients can be managed safely in standard wards with appropriate monitoring, leading to more efficient resource utilisation. The complementary use of CSSS and imaging‑based indices such as MCTSI may offer a balanced approach, combining early clinical risk stratification with later anatomical assessment of local complications.

Limitations:

The present study has several limitations. It was conducted at a single centre with a relatively small sample size, which may limit the generalisability of the findings. Advanced biomarkers such as procalcitonin or interleukin‑6 were not routinely measured, and dynamic changes in scores over time were not analysed. Larger, multicentre studies are needed to validate CSSS further and to compare it rigorously with other emerging prognostic models, including machine‑learning‑based tools.

Despite these limitations, this study adds to the growing body of evidence supporting the utility of CSSS as an early, simple and effective scoring system in acute pancreatitis. When combined with sound clinical judgement and appropriate use of imaging, CSSS has the potential to improve triage and optimise outcomes, particularly in resource‑constrained settings where the burden of AP is substantial.

The present prospective study demonstrates that the Chinese Simple Scoring System (CSSS) is a reliable, simple and effective tool for early prediction of severity and prognosis in acute pancreatitis. CSSS showed predictive accuracy comparable to Ranson’s score and MCTSI and superior early applicability compared to APACHE II. Given its ease of calculation and reliance on routinely available clinical and laboratory parameters, CSSS is particularly well suited for use in emergency and resource‑limited settings. Incorporation of CSSS into routine clinical practice, alongside established clinical and imaging criteria, may facilitate better triage, more judicious resource utilisation and improved patient outcomes in acute pancreatitis.

1.       Yadav D, Lowenfels AB. The epidemiology of pancreatitis and pancreatic cancer. Gastroenterology. 2013.

2.       Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013.

3.       Iannuzzi JP, King JA, Leong JH, et al. Global incidence of acute pancreatitis is increasing over time: a systematic review and meta‑analysis. Gastroenterology. 2022.

4.       Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015.

5.       Vege SS, et al. Management of acute pancreatitis in the twenty‑first century. Gastroenterology. 2018.

6.       Sternby H, Bolado F, Canaval‑Zuleta HJ, et al. Determinants of severity in acute pancreatitis: a nation‑wide prospective cohort study. Ann Surg. 2019.

7.       Sarr MG, et al. The management of acute pancreatitis: current and emerging therapies. Pancreas. 2010.

8.       Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013.

9.       Roberts SE, Akbari A, Thorne K, et al. The incidence of acute pancreatitis: impact of social deprivation, alcohol consumption, seasonal and demographic factors. Aliment Pharmacol Ther. 2013.

10.    Forsmark CE, Vege SS, Wilcox CM. Acute pancreatitis. N Engl J Med. 2016.

11.    Working Group IAP/APA. IAP/APA evidence‑based guidelines for the management of acute pancreatitis. Pancreatology. 2013.

12.    Dellinger EP, Forsmark CE, Layer P, et al. Determinant‑based classification of acute pancreatitis severity: an international multidisciplinary consultation. Ann Surg. 2012.

13.    Petrov MS, Shanbhag S, Chakraborty M, et al. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Ann Surg. 2009.

14.    Buter A, Imrie CW, Carter CR, et al. Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis. Ann Surg. 2002.

15.    Beger HG, Rau BM. Severe acute pancreatitis: clinical course and management. Gut. 2007.

16.    Freeman ML. Interventions for necrotizing pancreatitis. N Engl J Med. 2010.

17.    Mofidi R, Duff MD, Wigmore SJ, et al. Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis. Br J Surg. 2006.

18.    Whitcomb DC. Clinical practice. Acute pancreatitis.

       Gastroenterology. 2006.

19.    Ranson JH, Rifkind KM, Roses DF, et al. Objective early identification of severe acute pancreatitis. Am J Gastroenterol. 1974.

20.    Leppäniemi A, Tolonen M, Tarasconi A, et al. WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg. 2019.

21.    Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985.

22.    Larvin M, McMahon MJ. APACHE‑II score for assessment and monitoring of acute pancreatitis. Br J Surg. 1994.

23.    Papachristou GI, Muddana V, Yadav D, et al. Comparison of BISAP, Ranson’s, APACHE‑II, and CT Severity Index scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010.

24.    Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990.

25.    Mortele KJ, Wiesner W, Intriere L, et al. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. AJR Am J Roentgenol. 2004.

26.    Thoeni RF. The revised Atlanta classification of acute pancreatitis: its importance for the radiologist and its effect on treatment. Radiology. 2012.

27.    Zhou J, Li Y, Tang Y, et al. Prognostic value of CT severity index in acute pancreatitis: a systematic review. Insights Imaging. 2020.

28.    Manrai M, Kochhar R, Thandassery RB, et al. Outcome of acute pancreatitis in patients with normal serum amylase and lipase. Gastroenterology. 2015.

29.    Wu Q, Wang J, Qin M, et al. Accuracy of conventional and novel scoring systems in predicting severity and outcomes of acute pancreatitis: a retrospective study. Lipids Health Dis. 2021.

30.    Wang L, Zeng YB, Chen JY, et al. A simple new scoring system for predicting the mortality of severe acute pancreatitis: a retrospective clinical study. Medicine (Baltimore). 2020.

31.    Li S, Zhang Y, Li W, et al. Validation of a simple scoring system for predicting severe acute pancreatitis. Pancreatology. 2019.

32.    Geng Y, Li W, Sun L, et al. Scoring systems for predicting mortality of severe acute pancreatitis. J Gastrointest Surg. 2018.

33.    Sharma V, Rana SS, Sharma RK, et al. A study of radiological scoring system evaluating extrapancreatic inflammation with conventional radiological and clinical scores in predicting outcomes in acute pancreatitis. Ann Gastroenterol. 2015.

34.    Kumar H, Anubhav, Griwan MS, et al. A comparison of APACHE II, BISAP, Ranson’s score and modified CTSI in predicting the severity of acute pancreatitis. Gastroenterol Rep. 2018.

35.    Bhattacharya S. The importance of early prognostic markers in acute pancreatitis. Int J Surg. 2020.

36.    Zhao K, Hu W, Wang H, et al. External validation of a simple scoring system for predicting the mortality of severe acute pancreatitis. BMC Gastroenterol. 2020.

37.    Zhou Y, Li W, Zhou J, et al. Evaluation of various scoring systems in predicting the severity of acute pancreatitis. World J Gastroenterol. 2021.

38.    Mounzer R, Langmead CJ, Wu BU, et al. Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2012.

39.    Singh VK, Wu BU, Bollen TL, et al. A prospective evaluation of the bedside index for severity in acute pancreatitis score in an independent cohort of patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2009.

40.  Petrov MS. Acute pancreatitis: current therapy and future perspectives. Crit Care. 2012.