Computed Tomography Severity Index vs. Other Indices in the Prediction of Severity and Mortality in Acute Pancreatitis: A Predictive Accuracy Meta-analysis

Abstract

Background: The management of the moderate and severe forms of acute pancreatitis (AP) with necrosis and multiorgan failure remains a challenge. To predict the severity and mortality of AP multiple clinical, laboratory-, and imaging-based scoring systems are available. Aim: To investigate, if the computed tomography severity index (CTSI) can predict the outcomes of AP better than other scoring systems. Methods: A systematic search was performed in three databases: Pubmed, Embase, and the Cochrane Library. Eligible records provided data from consecutive AP cases and used CTSI or modified CTSI (mCTSI) alone or in combination with other prognostic scores [Ranson, bedside index of severity in acute pancreatitis (BISAP), Acute Physiology, and Chronic Health Examination II (APACHE II), C-reactive protein (CRP)] for the evaluation of severity or mortality of AP. Area under the curves (AUCs) with 95% confidence intervals (CIs) were calculated and aggregated with STATA 14 software using the metandi module. Results: Altogether, 30 studies were included in our meta-analysis, which contained the data of 5,988 AP cases. The pooled AUC for the prediction of mortality was 0.79 (CI 0.73-0.86) for CTSI; 0.87 (CI 0.83-0.90) for BISAP; 0.80 (CI 0.72-0.89) for mCTSI; 0.73 (CI 0.66-0.81) for CRP level; 0.87 (CI 0.81-0.92) for the Ranson score; and 0.91 (CI 0.88-0.93) for the APACHE II score. The APACHE II scoring system had significantly higher predictive value for mortality than CTSI and CRP (p = 0.001 and p < 0.001, respectively), while the predictive value of CTSI was not statistically different from that of BISAP, mCTSI, CRP, or Ranson criteria. The AUC for the prediction of severity of AP were 0.80 (CI 0.76-0.85) for CTSI; 0.79, (CI 0.72-0.86) for BISAP; 0.83 (CI 0.75-0.91) for mCTSI; 0.73 (CI 0.64-0.83) for CRP level; 0.81 (CI 0.75-0.87) for Ranson score and 0.80 (CI 0.77-0.83) for APACHE II score. Regarding severity, all tools performed equally. Conclusion: Though APACHE II is the most accurate predictor of mortality, CTSI is a good predictor of both mortality and AP severity. When the CT scan has been performed, CTSI is an easily calculable and informative tool, which should be used more often in routine clinical practice.

Keywords: CT-severity index; accuracy; acute pancreatitis; mortality; severity.

Figure 1

Flowchart of study selection.

Figure 2

Area under the curve (AUC) summarizing the predictive performance of scoring systems regarding mortality in acute pancreatitis. Size of squares for effect size reflects weight of studies in pooled analysis. Horizontal bars represent 95% confidence intervals (CI). CTSI, computed tomography severity index; BISAP, bedside index of severity in acute pancreatitis; mCTSI, modified computed tomography severity index; CRP, C-reactive protein; APACHE II, Acute Physiology And Chronic Health Examination II. The vertical line represents the line of no effect.

Figure 3

Area under the curve (AUC) summarizing the predictive performance of scoring systems regarding severity in acute pancreatitis. Size of squares for effect size reflects weight of trial in pooled analysis. Horizontal bars represent 95% confidence intervals (CI). CTSI, computed tomography severity index; BISAP, bedside index of severity in acute pancreatitis; mCTSI, modified computed tomography severity index; CRP, C-reactive protein; APACHE II, Acute Physiology And Chronic Health Examination II. The vertical line represents the line of no effect.

Figure 4

(A) Hierarchial summary receiver operating characteristic curves (HSROC) for computed tomography severity index (CTSI) for predicting mortality of acute pancreatitis. (B) HSROC for CTSI for predicting severity of acute pancreatitis.

Figure 5

(A) Hierarchial summary receiver operating characteristic curves (HSROC) for bedside index of severity in acute pancreatitis (BISAP) for predicting mortality. (B) HSROC for BISAP for predicting severity of acute pancreatitis.

Figure 6

(A) Hierarchial summary receiver operating characteristic curves (HSROC) for modified computed tomography severity index (mCTSI) for predicting mortality of acute pancreatitis. (B) HSROC for mCTSI for predicting severity of acute pancreatitis.

Figure 7

Hierarchial summary receiver operating characteristic curves (HSROC) for C-reactive protein (CRP) for predicting severity of acute pancreatitis.

Figure 8

(A) Hierarchial summary receiver operating characteristic curves (HSROC) for Ranson score for predicting mortality of acute pancreatitis. (B) HSROC for Ranson score for predicting severity of acute pancreatitis.

Figure 9

(A) Hierarchial summary receiver operating characteristic curves (HSROC) for Acute Physiology And Chronic Health Examination II (APACHE II) score for predicting mortality of acute pancreatitis. (B) HSROC for APACHE II score for predicting severity of acute pancreatitis.