European Journal of Cardiovascular Medicine

Acute pancreatitis is an inflammatory process of the pancreas and its incidence is increasing nowadays. It is the third most common gastrointestinal disorder requiring acute hospitalization in the United States.¹ It has a highly variable clinical course. It may vary from a mild disease without or with only transitional systemic manifestation in approximately 80% to 90% of patients, while the remaining 10 to 20% develop local and systemic complications and may be life-threatening.² The overall mortality rate of acute pancreatitis is 2-5% but may range up to 20-30% in severe cases.³ Gallstone disease and alcohol are the major etiological factors among the Indian population, however hypercalcemia, drug-induced pancreatitis and iatrogenic comprise other causes.⁴ Severe acute pancreatitis can cause organ failure, local problems, or necrosis, leading to interruption of the pancreatic blood supply.⁵

Prognostic indicators have been discovered to stratify the severity of acute pancreatitis. For decades, multifactorial scoring methods using clinical and biochemical criteria have been used to determine severity levels.⁶    Predicting the severity and disease course of pancreatitis in the early hours is crucial and guides to maximize fluid therapy and helps in the prevention of organ dysfunction and complications. Unfortunately, the management of the disease is hampered by the inability to distinguish mild from severe disease in the early stages. However, there is no ideal clinical scoring system that can predict disease course based on routine laboratory and diagnostic testing in the early hours.⁷

Ranson’s and modified Glasgow score contain investigations that are not routinely done in emergency settings and also require 48 hours for completion, leading to loss of potential early therapeutic window.⁸ APACHE II score is non-specific for AP as it requires a lot of variables and can be cumbersome to do in emergency settings.⁹ The Ranson score was developed in 1974 to evaluate the severity status in patients with acute pancreatitis and has been used for over three decades. Ranson's score is evaluated using five factors at the time of admission and six factors after 48 hours of hospitalization.¹⁰   However, the BISAP score is a newly proposed score for prognostication of the severity of the disease. It combines findings of physical examination, vital signs, routine laboratory tests, and imaging studies. The BISAP score stratifies patients according to the severity within 24 hours of admission and can identify patients at increased risk of dying during treatment.¹¹

Each of the scores has its strengths and limitations, there is always a dilemma regarding the use of a particular score. So, this study aimed to compare the diagnostic accuracy of the BISAP score with the already established Ranson’s score in predicting the severity of acute pancreatitis and risk stratification of patients.

This prospective descriptive study was conducted in the Department of General Surgery, Pt. B. D. Sharma Postgraduate Institute of Medical Sciences, Rohtak, and approved by the ethical committee of PGIMS, Rohtak. This study recruited 60 patients, In this study, patients of age >15 years of either sex admitted with the diagnosis of acute pancreatitis within 24 hrs of admission were included. The patients with chronic pancreatitis and suspected pancreatic malignancy were excluded from the study. All the patients who presented with acute pancreatitis were assessed by routine investigations. The BISAP score was calculated at the time of admission while the Ranson’s score was calculated at the time of admission and 48 hours. For both the scores, ≥3 was considered as severe acute pancreatitis.

STATISTICAL ANALYSIS

The data was analyzed using SPSS Version 25.0 software. Descriptive statistical analysis was done for continuous and categorical variables. Spearman’s rank correlation test was used to find correlations between various variables. A logistic regression analysis was utilized to find the prognosis of the disease using BISAP and Ranson’s score. Receiver Operating Characteristics (ROC) analysis was done to compare the area under curve (AUC) and the sensitivity of the tests. Also, both the scoring systems were compared with the McNemar test.

In this study, out of 60 patients, there were 36 females and 24 males with mean age of 51.03±20.24 years. The mean duration of symptoms at presentation was 4.68 days. 43 patients had ≤1 week of hospital stay. However, there were only 8 patients who had ICU stays. 52 patients were discharged after treatment whereas 8 patients expired during treatment. On the BISAP score, there were 52 patients with <3 score and 8 patients with ≥3 scores. On Ranson’s score, there were 33 patients with <3 score and 27 patients with ≥3 score.  The correlation of BISAP and Ranson's score is given in Table 1. There was a statistically significant correlation of the BISAP and Ranson’s score with the patient’s outcome & ICU stay. BISAP score also had a statistically significant correlation with the duration of symptoms. However, there was no statistically significant correlation of BISAP and Ranson’s score with gender & hospital stay of patients. BISAP and Ranson’s scores were good tools for predicting patient outcomes and ICU stay for the prognosis of SAP as measured by logistic regression analysis (p<0.05). However, these were not a good predictor of the patient’s hospital stay. The findings of prediction/prognostic analysis are shown in Table 2. Sensitivity and specificity 2×2 table bedside index for severity in acute pancreatitis (BISAP) and Ranson scores are shown in Table 3. Table 4 shows the comparison of BISAP and Ranson’s scores in which a statistically significant difference was observed (p<0.05). On assessing the accuracy and AUC of both scores, it was found that the BISAP score (accuracy-90% & AUC-0.78) is more accurate in predicting SAP as compared to Ranson’s score (accuracy-65% & AUC-0.61). However, Ranson’s score sensitivity was 87.5% which was higher in comparison with BISAP score sensitivity (62.5%). ROC-AUC analysis of BISAP and Ranson’s score is shown in Figures 1 and 2 respectively.

Table 1: Correlation of BISAP and Ranson’s score with various variables using Spearman’s correlation test

                    (*. Correlation is significant at the < 0.05 level)          

Table 2: Logistic regression analysis to predict patient outcome, ICU stay, and hospital stay by BISAP and Ranson’s score

       *The p-value significant at <0.05

Table 3: Sensitivity and specificity 2×2 table bedside index for severity in acute pancreatitis (BISAP) and Ranson scores

        TP: True Positive; TN: True Negative; FN: False Negative; FP: False Positive

Table 4: Comparison of BISAP and Ranson’s score in predicting SAP by using the McNemar test based on mortality

*The p-value significant at <0.05

Figure 1: Graph showing ROC-AUC analysis for BISAP score

Figure 2: Graph showing ROC-AUC analysis for Ranson’s score

BISAP and RAnson’s score are two most commonly used scales for determining the severity of acute pancreatitis. So, this study was designed to compare two of the most widely used scoring systems i.e., the BISAP and Ranson’s scores in determining severity and predicting prognosis in patients of acute pancreatitis.^13,14

The current study had 60 patients with acute pancreatitis with female predominance (60%).  The results of the present study were in accordance with the study conducted by Arif et al. which reported a higher prevalence of AP in females.¹⁴ Similar results of female predominance in AP were observed in other studies. ^3,6,15 In contrast, Kapadia et al. and Kaushik et al. found a male preponderance (64.7% and 63.35% respectively).^7,16 The mean age of patients with AP in our study was 51.03 years with 35.0% of the population in the age range between 56-75 years. The age difference observed in this study might be due to differences in the age selection of patients with AP. The mean duration of symptoms in the study was 4.68 days. In this study, 71.7% of patients had a hospital stay of ≤1 week and 28.3% had a longer stay of >1 week. While 13.3% of patient required ICU care. Most of the patients (86.7%) were discharged after the treatment, and 13.3% of patients expired during hospital stay.

On the BISAP score, there were only eight patients with a ≥ 3 score which was categorized as SAP, and out of these eight patients, five died (mortality of 62.5% in patients with SAP). Singh et al. reported that patients with a BISAP score ≥ 3 developed organ failure more frequently than those with a BISAP score of less than three.¹⁷ On Ranson’s score, there were 27 patients with ≥ 3 scores which were categorized as SAP, out of which seven expired (mortality rate of 25.93%). These results were comparable with the study done by Cho et al. in which the incidence of SAP was reported to be 10% to 20%, and the death rate from SAP was 20% to 30%.¹⁸ Hameed et al. also reported a high prevalence of AP mortality (7.1%); mostly in SAP.¹⁹ A high mortality rate (>10%) has also been reported by Kaushik et al.⁷

In the current study, there was a significant association between Ranson’s score with patient’s outcome and ICU stay (p<0.05). However, no association was found between Ranson’s score and the patient’s gender, hospital stay, and duration of symptoms (p>0.05). Also, there was a significant correlation between BISAP and Ranson’s scores with each other. This signifies that BISAP scores correlate strongly with Ranson's scores, and it may be used to make early decisions while waiting for all the data needed for Ranson's criteria. This can speed up initial treatment approaches and enhance early management of AP. This is in concordance with a study done by Chatterjee et al.²⁰ Similar findings were observed in a study done by Senapati et al. in which they found that out of 13 expired patients, 12 had a ≥3 score on BISAP, showing that it was a good tool for predicting patient outcomes in the early stages of disease in AP.²¹ A few similar studies also showed that BISAP predicts in-hospital death in the early stages of the disease.^11,17,22 Shabbir et al. also found that BISAP and Ranson’s score significantly predict patient outcome i.e., mortality.¹⁵ Valverde-López et al. found that BISAP is a good predictor of patient outcome as well as ICU admission.²³ Eachempati et al. concluded that the Ranson score remains a good predictor of outcomes in patients with SAP.²⁴ However, it was a less operative method to predict SAP, mortality, and ICU admission despite its high sensitivity, since it needs at least 48 hours to be completed.²³

This study demonstrated a significant difference between BISAP and Ranson's score using the McNemar test (p<0.05). ROC curve analysis found that the BISAP score was more accurate than Ranson's score BISAP outperformed Ranson's score in terms of specificity, PPV, and AUC. In contrast, Ranson's score had a higher sensitivity and NPV than the BISAP score. Similar results were found in a study which observed that BISAP was more accurate as compared to Ranson’s score for AP within 24 hrs of admission.¹⁵ Slightly different results were observed in the study conducted by Kim et al. in which the accuracy of BISAP and Ranson’s scores for predicting severe acute pancreatitis was 84% and 94 % respectively.²⁵ Contrary to present study, Khanna et al. found a very low accuracy of the BISAP score.⁶ The results of our study were similar to Arif et al., who found that the Ranson score had a sensitivity of 97.4%.¹⁴ Similar results by Cho et al. in which the sensitivity of Ranson and BISAP scores was 85.7 % and 61.9% respectively.²⁶ Likewise, the BISAP score has a sensitivity of 58.33% reported by Kim et al.²⁵ Comparable results were shown in another study by Papachristou et al. with higher sensitivity and NPV of Ranson’s score in comparison with BISAP.²⁷ In terms of specificity of BISAP and Ranson’s scores, the results of this study were comparable with a study in which BISAP score had high specificity (98.9%) as compared to Ranson’s score (59.1%).¹⁸ Contradicting results were Khanna et al. that BISAP score had a low specificity (55.6%).⁶ Similar results were found by Cho et al., in which AUC was 0.94 for the BISAP score and 0.86 for Ranson’s score.¹⁸ Study conducted by Cho et al. and Park et al. also confirmed the findings of the present study, in which the AUC of the BISAP score was 0.74 whereas the AUC of Ranson’s score was 0.69.^26,28 Another study by Papachristou et al. and Lee et al., showed AUC for Ranson’s score is greater than the BISAP score.^25,29  Such variation can be attributed to the different cut-off values chosen in different studies, selection bias, and the demographic variables in the study population. The BISAP score is much less cumbersome to calculate and more economical. This makes it an ideal score to be used in the primary and secondary care setup for triage and risk stratification and decisions regarding referral to higher setups.

In the present study, both BISAP and Ranson’s scores were found to be reliable in predicting patient outcomes and ICU stay for the identification of severity of acute pancreatitis (AP). The BISAP score can be considered as a better predictor of outcomes in patients with AP when compared to Ranson’s score, due to its higher accuracy and specificity. However, Ranson’s score has more sensitivity to predict SAP.  In clinical practice, both BISAP and Ranson's scores can be used accurately in predicting patient outcomes and ICU stay. Given the findings that the BISAP score is a stronger predictor due to its greater accuracy and specificity, it should be preferred when an exact prognosis is required. Ranson's score, on the other hand, may be more beneficial in the early detection and wide screening of acute pancreatitis patients due to its higher sensitivity. So, in clinical practice, use these scores simultaneously to improve decision-making, patient management techniques, and overall SAP treatment results.

LIMITATIONS OF THE STUDY

It was a single-center study with a small sample size. A multicenter validation study is required to confirm our results and observations in severe acute pancreatitis. Also, this study was conducted in the surgery ward, mostly the patients had gallstone-induced pancreatitis. So, further studies are required to establish the validity of our results regarding other etiologies of acute pancreatitis, like alcohol, drug-induced, and idiopathic cases.

Conflicts of Interest—Nil

Source of support—Nil

Acknowledgement—All authors contributed well in preparing this article for publication in form of writing, editing and conceptualization.

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