Evaluation of Severity in Acute Pancreatitis

Ji Kon Ryu

doi:10.4166/kjg.2009.54.4.205

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Ryu: Evaluation of Severity in Acute Pancreatitis

Review

Korean J Gastroenterol 2009;54(4):205-211.

Published online: 21 February 2009

DOI: https://doi.org/10.4166/kjg.2009.54.4.205

Evaluation of Severity in Acute Pancreatitis

Ji Kon Ryu, M.D.

Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea

Correspondence to: Ji Kon Ryu, M.D. Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, 101, Daehagro, Jongno-gu, Seoul 110-744, Korea Tel: +82-2-2072-1962, Fax: +82-2-762-9662 E-mail: jkryu@snu.ac.kr

Abstract

Acute pancreatitis has a variable etiology and natural history, and some patients have severe complications with a significant risk of death. The prediction of severe disease should be achieved by careful ongoing clinical assessment coupled with the use of a multiple factor scoring system and imaging studies. Over the past 30 years several scoring systems have been developed to predict the severity of acute pancreatitis. However, there are no complete scoring index with high sensitivity and specificity till now. The interest in new biological markers and predictive models for identifying severe acute pancreatitis testifies to the continued clinical importance of early severity prediction. Among them, IL-6, IL-10, procalcitonin, and trypsinogen activation peptide are most likely to be used in clinical practice as predictors of severity. Even if contrast-enhanced CT has been considered the gold standard for diagnosing pancreatic necrosis, early scanning for the prediction of severity is limited because the full extent of pancreatic necrosis may not develop within the first 48 hour of presentation.

Keywords: Acute pancreatitis, Severity, Scoring system

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Table 1.

Atlanta Criteria for Severity of Acute Pancreatitis

Severity criteria	Definition
Organ failure with 1 or more
Shock	Systolic blood pressure ＜90 mmHg
Pulmonary insufficiency	PaO2＜60 mmHg
Renal failure	Serum creatinine level ＞2 mg/dL after rehydration
Gastrointestinal tract bleeding	500 mL in 24 hours
Local complications
Pancreatic necrosis	More than 30% of the parenchyma or more than 3 cm
Pseudocyst	Collection of pancreatic juice enclosed by a wall
Abscess	Circumscribed collection of pus containing little or no pancreatic necrosis
Ranson score	＞3
APACHE II score	＞8

Table 2.

Ranson's Criteria for the Prediction of Severity of Acute Pancreatitis

On admission	During initial 48 h
Age＞55 years (＞70 years) White cell count＞16,000/mm³ (18,000/mm³)	Decrease in hematocrit by 10% (same) Blood urea nitrogen increases by ＞5 mg/dL (＞2 mg/dL)
Lactate dehydrogenase＞350 U/L (＞400 U/L)	Calcium＜8 mg/dL (same)
Aspartate aminotransferase＞250 U/L (same)	PaO2＜60 mmHg (omitted)
Glucose＞200 mg/dL (＞220 mg/dL)	Base deficit＞4 mEq/L (＞6 mEq/L)
	Fluid sequestration＞6 L (＞4 L)

The criteria for nongallstone (alcoholic) acute pancreatitis are listed first; the changes (if any) in the criteria for gallstone pancreatitis are in parentheses.

Table 3.

Glasgow Severity Scoring System for Acute Pancreatitis

Age＞55 years

White cell count＞15,000/mm³

PaO2＜60 mmHg

Serum lactate dehydrogenase＞600 U/L

Serum aspartate aminotransferase＞200 U/L

Serum albumin＜3.2 g/dL

Serum calcium＜8 mg/dL

Serum glucose＞180 mg/dL

Serum urea＞45 mg/dL

Table 4.

Japanese Severity Score for Acute Pancreatitis

Factor	Clinical findings	Laboratory measurements
Prognostic factor I	Shock	Base excess＜−3 mEq/L
2 points per positive item	Impaired level of consciousness	Hematocrit＜30% after hydration
	Respiratory failure	BUN＞40 mg/dL
	Severe sepsis	Serum creatinine＞2 mg/dL
	Disseminated intravascular coagulation
Prognostic factor II		Calcium level＜7.5 mg/dL
1 point per positive item		Serum glucose＞200 mg/dL
		Protein＜6.0 g/dL
		Lactate dehydrogenase＞700 IU/L
		PaO2＜60 mmHg (on room air)
		Prothrombin time＞15s Platelet count＜1×10⁵/mm³
		Balthazar score D or E
Prognostic factor III	SIRS score＞3 (2 points)
	Age＞70 years (1 point)

Table 5.

BISAP (Bedside Index for Severity in Acute Pancreatitis) Scoring System

BUN＞25 mg/dL

Impaired mental status (Glasgow Coma Scale Score＜15)

SIRS

SIRS is defined as two or more of the following:

(1) Temperature of ＜36 or ＞38^oC

(2) Respiratory rate ＞20 breaths/min or PaCO2＜32 mmHg

(3) Pulse＞90 beats/min

(4) WBC ＜4,000 or ＞12,000 cells/mm³ or ＞10% immature bands

Age＞60 years

Pleural effusion detected on imaging

One point is assigned for each variable within 24 h of presentation and added for a composite score of 0-5.

Table 6.

Balthazar CT Score

Grade	CT findings
A	Normal
B	Focal or diffuse enlargement of the pancreas, including irregularities of contour and inhomogeneous attenuation
C	Pancreatic gland abnormalities in grade B plus per pancreatic inflammation
D	Grade C plus a single fluid collection
E	Grade C plus 2 or more fluid collections and/or the presence of gas in or adjacent to the pancreas

Table 7.

CT Severity Index

CT grade	Assigned score	Percent necrosis	Assigned score
A	0	None	0
B	1	＜30	2
C	2	30-50	4
D	3	＞50	6
E	4

CT grade based on Balthazar score plus pancreatic necrosis with a maximum score of 10 points.

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