Are traditional scoring systems for severity stratification of acute pancreatitis sufficient?

Abstract

Backgrounds/aims: Ranson's score (RS) and Glasgow score (GS) have been utilized to stratify the severity of acute pancreatitis (AP). The aim of this study was to validate RS and GS for stratifying the severity of acute pancreatitis and audit our experience of managing AP.

Methods: We conducted a retrospective review of patients treated for AP from July 2009 to September 2016. Final severity was determined using the revised Atlanta classification. Mortality and complications were analyzed.

Results: From July 2009 to September 2016, a total of 675 patients with a diagnosis of AP were admitted at the hospital. Of them, 669 patients who had sufficient data were analyzed. Their average age±SD was 58.7±17.4 years (range, 21-98 years). There was a male preponderance (n=393, 53.8%). A total of 82 (12.3%) patients had eventual severe pancreatitis. RS demonstrated a sensitivity of 92.7% and a specificity of 52.8% with a positive predictive value (PPV) of 21.5% and a negative predictive value (NPV) of 98.1%. GS demonstrated a sensitivity of 76.8% and a specificity of 69.2% with a PPV of 25.8% and a NPV of 95.5%. For severity prediction, areas under the curve (AUCs) for RS and GS were 0.848 (95% CI: 0.819-0.875) and 0.784 (95% CI: 0.750-0.814), respectively (p=0.003). Twelve (1.6%) patients died in the hospital.

Conclusions: RS has higher sensitivity, NPV and AUC for predicting severity of AP than GS.

Keywords: Glasgow score; Ranson score; Scoring; Severe acute pancreatitis.

Fig. 1. Tan tock seng hospital algorithm for management of acute pancreatitis. CXR, chest X-ray; ECG, electrocardiogram; FBC, full blood count; RP, renal panel; UPT, urine pregnancy test; LFT, liver function test; IVF, intravenous fluids; CT, Computed Tomography; CBD, common bile duct; ERCP, endoscopic retrograde cholangiopancreatography; MRCP, magnetic retrograde cholangiopancreatography; SOFA, sequential organ failure assessment; ASP, antibiotic stewardship programme. ^@Any form of elevation in bilirubin, alkaline phosphatase, or gamma glutamyl transferase is considered derangement. ^#Liberal practice of MRCP scan in preference to intraoperative cholangiography. ^*At least two imaging modalities are done prior to concluding non-biliary aetiology. All patients were offered endoscopic ultrasonography before diagnosis of idiopathic pancreatitis. ^{^}Laparoscopic cholecystectomy is discussed with and offered to all patients with idiopathic pancreatitis.

Fig. 2. Distribution of patients by Ranson score.

Fig. 3. Distribution of patients by Glasgow score.

Fig. 4. Area under receiver-operator curves of Ranson's score and Glasgow score.