European Journal of Cardiovascular Medicine

Acute pancreatitis is the cause in 5% of patients presenting to the emergency with abdominal pain, depending on age and other underlying factors^[1]. Although most patients have a mild attack that resolves spontaneously, 20% to 30% present with severe disease, which is characterized by necrosis of the pancreas and organ failure, which accounts for increased morbidity and mortality.^[2]

The peak age of incidence of acute pancreatitis occurs in the third and fourth decades; however, mortality increases with age. Incidence has been thought to differ across geographic regions and socio-economic regions and is likely related to differences in the use of alcohol and the occurrence of biliary calculi, the two major causes of acute pancreatitis.^[3,4]

The increased morbidity and mortality associated with acute pancreatitis can be decreased if we diagnose and intervene early. To diagnose it as acute pancreatitis 2 components out of the 3 must be present:

1. Abdominal pain which starts in the epigastrium and radiates to the back
2. Serum amylase and or lipase >3 times the upper limit of normal, and
3. Characteristic findings on CT scan^[5]

 The exact pathogenesis of pancreatitis remains debatable, it may be probably closely related to the dysfunction of balance between pro-inflammatory and anti-inflammatory responses. After premature activation of pancreatic proteases and extravasation of these enzymes into the pancreas and peripancreatic tissues, cytokines and other inflammatory mediators are produced and released with excessive leukocyte activation. They stimulate the inflammatory cascade, leading to systemic inflammatory response syndrome^[6]

Proinflammatory cytokines, such as tumor necrosis factor (TNF)-α and interleukin (IL)-1β, IL-6, and IL-8, increase the capillary permeability with fluid loss, aggravating pancreatic injury.^[6] TNF-α damages the acinar cells and is probably responsible for pancreatic necrosis (PN) and damage to other organs, such as the lungs, liver, intestine, and spleen.^[7,8]

The reported mortality rate in SAP is 7%–15%.^[9,10] The risk is higher in patients with persistent organ failure and infected necrosis. PN in itself is a severe complication and a significant cause of death in AP; the mortality rate can reach up to 10%–23%^[8].

Many prognostic scores had developed for severity assessment in acute pancreatitis. Some of them are 11 criteria described by Ranson et al. in the 1970s^[11], the Glasgow score (eight criteria)^[12], the MOSS score (12 criteria), the BISAP score (5 criteria), and the acute physiology and chronic health evaluation (APACHE II) score (14 criteria)^[13]. The sensitivity and specificity of these scoring systems to predict the severity of acute pancreatitis ranges from 55% to 90% and also depends on the cut-off number and the time of scoring^[14].

The intent of the study:

 Bisap scoring system identifies patients with high morbidity as well as the risk of mortality, before organ failure sets in.(within 24 hours), but Balthazar grading using ct scan done after 48 hours, by the time the patient may have developed multi-organ failure and also data on comparison of balthazar score with BISAP is limited. It is also not clear if CT is needed for prognostication in acute pancreatitis when an assessment with BISAP has been made on admission.

Study Design and Methodology

Data Collection:

1. Clinical Examinations
2. Biochemical Investigations: Complete blood count, renal function tests
3. Radiological Investigations: Chest X-ray (posteroanterior view), computed tomography (CT) abdomen

Study Duration:

• One year from the date of approval by the Institutional Scientific and Ethical Committee. Done from April 2023 to April 2024.

Study Setting:

• Department of General Surgery, SVRRGGH, Tirupati

Sample Size:

• 115 patients meeting the inclusion criteria

Study Design:

• Prospective Comparative Study

Inclusion Criteria:

1. Patients aged ≥18 years diagnosed with acute pancreatitis
2. Diagnosis based on:
   • Clinical and biochemical parameters (serum amylase and serum lipase levels elevated threefold)
   • Radiological evidence (abdominal ultrasound suggestive of acute pancreatitis)
3. Patients willing to provide written informed consent

Exclusion Criteria:

1. Patients aged ≤18 years
2. Patients with chronic pancreatitis
3. Pancreatitis in pregnancy
4. Post-traumatic pancreatitis
5. Post-COVID pancreatitis

Statistical Analysis:

• Data Entry: Microsoft Excel 2013
• Analysis: SPSS Version 16
• Qualitative Data: Expressed as frequencies and percentages
• Quantitative Data: Expressed as mean and standard deviation
• Tests Used:
  • Chi-square test for qualitative data
  • ROC analysis to determine cutoff values for prognostic scores
• Graphical Representation: Bar diagrams and pie charts
• Significance Level: P-value <0.05 considered statistically significant

Table 1: Age and Gender Distribution of Study Participants

Table 2: Distribution of Elevated Amylase and Lipase Levels Among Patients

Table 3: patients with Normal or Abnormal findings on Ultra Sonography

Table 4: Distribution of Pancreatic Inflammation and Necrosis Scores

Fig; 1 Grading based on Balthazar score

Table 5: patients with Blood Urea Nitrogen (BUN)

Table 10 shows the distribution of participants with elevated blood urea nitrogen (BUN) levels. It indicates that 47.0% (54 individuals) have BUN levels greater than 25 mg/dl, while 53.0% (61 individuals) do not

Table 6: Distribution of Clinical Parameters Among Patients

Fig;2 Distribution According to BISAP Score

Table 7: Organ Failure Parameters

Table 8: Comparison of BISAP Score with Balthazar score

Table 8 compares BISAP scores with Balthazar scores. Among participants with severe BISAP scores, 11.5% had mild Balthazar scores, 23.5% had moderate Balthazar scores, and 74.5% had severe Balthazar scores. For those with non- severe BISAP scores, 88.5% had mild Balthazar scores, 76.5% had moderate Balthazar scores, and 25.5% had severe Balthazar scores. The comparison is statistically significant with a chi-square value of 37.46 and a P-value less than 0.001.

Table 9: Clinical Outcomes Based on Balthazar and BISAP Scores in Acute Pancreatitis

Table 10: Comparison of BISAP Score with Balthazar score

Table 10; compares BISAP scores with Balthazar scores, indicating a strong correlation between higher scores on both scales. The data shows that among participants with severe BISAP scores, a significant majority also had severe Balthazar scores

Fig; 3 ROC analysis on Accuracy of Balthazar score in predicting prognosis of Acute pancreatitis

Acute pancreatitis (AP) remains a significant cause of morbidity and mortality worldwide, necessitating early risk stratification to guide management and predict complications [5]. Our study compared the effectiveness of two widely used scoring systems—Bedside Index for Severity in Acute Pancreatitis (BISAP) and Balthazar Computed Tomography Severity Index (CTSI)—in predicting disease severity and patient outcomes.

Our findings indicate that BISAP is a simple and effective bedside scoring system that correlates well with disease severity and ICU admission rates. Patients with a BISAP score ≥3 had a significantly higher risk of developing severe acute pancreatitis (SAP) and organ failure, in line with previous studies by Wu et al. (2008), who demonstrated that BISAP scores ≥3 had an 80% sensitivity in predicting mortality in AP patients [15]. Similarly, Mounzer et al. (2012) confirmed that BISAP is comparable to APACHE-II in predicting severe AP but is simpler to apply in clinical settings [16]. Our results align with these findings, further validating BISAP as a valuable early predictor of AP severity.

The Balthazar CTSI, based on contrast-enhanced computed tomography (CECT), provides a radiological assessment of pancreatic necrosis and local complications. Our study observed that higher Balthazar scores correlated significantly with increased risk of pancreatic necrosis, multi-organ dysfunction, and prolonged hospitalization, similar to findings by Balthazar et al. (1990), who originally established the prognostic value of this scoring system [14]. Additionally, Mortelé et al. (2004) demonstrated that a modified CTSI incorporating extrapancreatic complications improved predictive accuracy, which supports our study's finding that CTSI alone may underestimate systemic complications but remains essential for assessing local pancreatic damage [17].

Correlation Between BISAP and Balthazar CTSI

A key finding of our study is that while both BISAP and Balthazar scores correlate with disease severity, they predict different aspects of AP progression. BISAP, based on clinical and laboratory parameters, allows for early stratification within the first 24 hours, while Balthazar CTSI provides structural imaging insights into pancreatic necrosis and peripancreatic inflammation. Our results are consistent with a study by Papachristou et al. (2010), which found that combining BISAP and CTSI improved predictive accuracy for pancreatic necrosis and organ failure [18]. Similarly, Singh et al. (2009) demonstrated that BISAP is superior for early mortality prediction, while CTSI is more useful for evaluating local complications [19].

Comparison with Other Scoring Systems

While our study focused on BISAP and Balthazar CTSI, other authors have examined the role of APACHE-II and Ranson's criteria in AP prognosis. Studies by Mounzer et al. (2012) and Papachristou et al. (2010) reported that APACHE-II is more complex but has similar predictive power to BISAP, while Ranson’s criteria require 48 hours to assess and are less practical for early intervention [16,18]. Our study supports the growing consensus that BISAP is preferable due to its simplicity and early applicability.

Clinical Implications

The findings of our study suggest that BISAP should be the primary tool for early clinical assessment, while Balthazar CTSI should be used to confirm and evaluate local complications. This dual-approach strategy aligns with previous recommendations by Banks et al. (2013), who emphasized that early clinical scoring combined with imaging-based risk stratification improves patient outcomes [5].

Limitations and Future Directions

Despite its strengths, our study has some limitations. First, sample size constraints may have affected statistical power, and larger multicenter studies are needed for validation. Second, interobserver variability in CT interpretation could influence Balthazar scoring reliability. Lastly, our study was conducted in a single tertiary care center, limiting generalizability to broader populations. Future studies should investigate the integration of biomarkers and machine learning models with these scoring systems to enhance predictive accuracy.

Our study confirms that both BISAP and Balthazar CTSI are valuable tools in predicting AP severity, with BISAP excelling in early risk stratification and CTSI in assessing local complications. The combination of these scoring systems enhances clinical decision-making and aligns with previous research supporting a multimodal assessment strategy for acute pancreatitis.

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