Comparison of scoring systems in predicting the severity

of acute pancreatitis.
Cho JH1, Kim TN1, Chung HH1, Kim KH1.
Author information
Abstract
AIM:
To investigate the prognostic usefulness of several existing scoring systems in predicting the
severity of acute pancreatitis (AP).

METHODS:
We retrospectively analyzed the prospectively collected clinical database from consecutive patients
with AP in our institution between January 2011 and December 2012. Ranson, Acute Physiology
and Chronic Health Evaluation (APACHE)-II, and bedside index for severity
in acute pancreatitis (BISAP) scores, and computed tomography severity index (CTSI) of all patients
were calculated. Serum C-reactive protein (CRP) levels were measured at admission (CRPi) and
after 24 h (CRP24). Severe AP was defined as persistent organ failure for more than 48 h. The
predictive accuracy of each scoring system was measured by the area under the receiver-operating
curve (AUC).

RESULTS:
Of 161 patients, 21 (13%) were classified as severe AP, and 3 (1.9%) died. Statistically significant
cutoff values for prediction of severe AP were Ranson≥3, BISAP≥2, APACHE-II≥8, CTSI≥3, and
CRP24≥21.4. AUCs for Ranson, BISAP, APACHE-II, CTSI, and CRP24 in predicting severe AP
were 0.69 (95%CI: 0.62-0.76), 0.74 (95%CI: 0.66-0.80), 0.78 (95%CI: 0.70-0.84), 0.69 (95%CI: 0.61-
0.76), and 0.68 (95%CI: 0.57-0.78), respectively. APACHE-II demonstrated the highest accuracy for
prediction of severe AP, however, no statistically significant pairwise differences were observed
between APACHE-II and the other scoring systems, including CRP24.

CONCLUSION:
Various scoring systems showed similar predictive accuracy for severity of AP. Unique models are
needed in order to achieve further improvement of prognostic accuracy.
A comparison of the BISAP score and serum
procalcitonin for predicting the severity of acute
pancreatitis.
Kim BG1, Noh MH, Ryu CH, Nam HS, Woo SM, Ryu SH, Jang JS, Lee JH, Choi SR, Park BH.
Author information
Abstract
BACKGROUND/AIMS:
The bedside index of severity in acute pancreatitis (BISAP) is a new, convenient, prognostic
multifactorial scoring system. As more data are needed before clinical application, we compared
BISAP, the serum procalcitonin (PCT), and other multifactorial scoring systems simultaneously.

METHODS:
Fifty consecutive acute pancreatitis patients were enrolled prospectively. Blood samples were
obtained at admission and after 48 hours and imaging studies were performed within 48 hours of
admission. The BISAP score was compared with the serum PCT, Ranson's score, and the acute
physiology and chronic health examination (APACHE)-II, Glasgow, and Balthazar computed
tomography severity index (BCTSI) scores. Acute pancreatitis was graded using the Atlanta criteria.
The predictive accuracy of the scoring systems was measured using the area under the receiver-
operating curve (AUC).

RESULTS:
The accuracy of BISAP (≥ 2) at predicting severe acute pancreatitis was 84% and was superior to
the serum PCT (≥ 3.29 ng/mL, 76%) which was similar to the APACHE-II score. The best cutoff
value of BISAP was 2 (AUC, 0.873; 95% confidence interval, 0.770 to 0.976; p < 0.001). In logistic
regression analysis, BISAP had greater statistical significance than serum PCT.

CONCLUSIONS:
BISAP is more accurate for predicting the severity of acute pancreatitis than the serum PCT,
APACHE-II, Glasgow, and BCTSI scores.
A comparative evaluation of radiologic and clinical
scoring systems in the early prediction of severity in
acute pancreatitis.
Bollen TL1, Singh VK, Maurer R, Repas K, van Es HW, Banks PA, Mortele KJ.
Author information
Abstract
OBJECTIVES:
The early identification of clinically severe acute pancreatitis (AP) is critical for the triage and
treatment of patients. The aim of this study was to compare the accuracy of computed tomography
(CT) and clinical scoring systems for predicting the severity of AP on admission.
METHODS:
Demographic, clinical, and laboratory data of all consecutive patients with a primary diagnosis of AP
during a two-and-half-year period was prospectively collected for this study. A retrospective analysis
of the abdominal CT data was performed. CT scoring systems (CT severity index (CTSI) AND
Balthazar grade as well as two clinical scoring systems: Acute Physiology, Age, and Chronic Health
Evaluation (APACHE)-II and Bedside Index for Severity in AP (BISAP) were comparatively
evaluated with regard to their ability to predict the severity of AP on admission (first 24 h of
hospitalization). Clinically severe AP was defined as one or more of the following: mortality,
persistent organ failure and/or the presence of local pancreatic complications that require
intervention. All CT scans were reviewed in consensus by two radiologists, each blinded to patient
outcome. The accuracy of each imaging and clinical scoring system for predicting the severity of AP
was assessed using receiver operating curve analysis.
RESULTS:
Of 346 consecutive episodes of AP, there were 159 (46%) episodes in 150 patients (84 men, 66
women; mean age, 54 years; age range, 21-91 years) who were evaluated with a contrast-
enhanced CT scan (n = 131 episodes) or an unenhanced CT scan (n = 28 episodes) on the first day
of admission. Clinically severe AP was diagnosed in 29/159 (18%) episodes; 9 (6%) patients died.
Overall, the Balthazar grading system (any CT technique) and CTSI (contrast-enhanced CT only)
demonstrated the highest accuracy among the CT scoring systems for predicting severity, but this
was not statistically significant. There were no statistically significant differences between the
predictive accuracies of CT and clinical scoring systems.
CONCLUSIONS:
The predictive accuracy of CT scoring systems for severity of AP is similar to clinical scoring
systems. Hence, a CT on admission solely for severity assessment in AP is not recommended.

Evaluating the Laboratory Risk Indicator to Differentiate 
Cellulitis from Necrotizing Fasciitis in
the Emergency Department.
Neeki MM1,2, Dong F3, Au C3, Toy J3, Khoshab N1, Lee C1,2, Kwong E1,2, Yuen HW1,2, Lee
J1, Ayvazian A1, Lux P1,2, Borger R1,2.
Author information
Abstract
INTRODUCTION: Necrotizing fasciitis (NF) is an uncommon but rapidly progressive infection that results in gross

morbidity and mortality if not treated in its early stages.

The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is used to distinguish NF from other soft

tissue infections such as cellulitis or abscess. This study analyzed the ability of the LRINEC score to accurately rule

out NF in patients who were confirmed to have cellulitis, as well as the capability to differentiate cellulitis from NF.

METHODS:

This was a 10-year retrospective chart-review study that included emergency department (ED) patients ≥18 years old

with a diagnosis of cellulitis or NF. We calculated a LRINEC score ranging from 0-13 for each patient with all

pertinent laboratory values. Three categories were developed per the original LRINEC score guidelines denoting

NF risk stratification: high risk (LRINEC score ≥8), moderate risk (LRINEC score 6-7), and low risk (LRINEC score
≤5). All cases missing laboratory values were due to the absence of a C-reactive protein (CRP) value. Since the

score for a negative or positive CRP value for the LRINEC score was 0 or 4 respectively, a LRINEC score of 0 or 1

without a CRP value would have placed the patient in the "low risk" group and a LRINEC score of 8 or greater without

CRP value would have placed the patient in the "high risk" group. These patients missing CRP values were added to

these respective groups.

RESULTS:

Among the 948 ED patients with cellulitis, more than one-tenth (10.7%, n=102 of 948) were moderate or high risk for

NF based on LRINEC score. Of the 135 ED patients with a diagnosis of NF, 22 patients had valid

CRP laboratory values and LRINEC scores were calculated. Among the other 113 patients without CRP values, six

patients had a LRINEC score ≥ 8, and 19 patients had a LRINEC score ≤ 1. Thus, a total of 47 patients were further

classified based on LRINEC score without a CRP value. More than half of the NF group (63.8%, n=30 of 47) had a

low risk based on LRINEC ≤5. Moreover, LRINEC appeared to perform better in the diabetes population than in the

non-diabetes population.

CONCLUSION:

The LRINEC score may not be an accurate tool for NF risk stratification and differentiation between cellulitis and NF

in the ED setting. This decision instrument demonstrated a high false positive rate when determining

NF risk stratification in confirmed cases of cellulitis and a high false negative rate in cases of confirmed NF.
A comparison between modified Alvarado score and
RIPASA score in the diagnosis of acute appendicitis.
Singla A1,2, Singla S3, Singh M3, Singla D4.
Author information
Abstract
Acute appendicitis is a common but elusive surgical condition and remains a diagnostic dilemma. It
has many clinical mimickers and diagnosis is primarily made on clinical grounds, leading to the
evolution of clinical scoring systems for pin pointing the right diagnosis. The modified Alvarado and
RIPASA scoring systems are two important scoring systems, for diagnosis of acute appendicitis. We
prospectively compared the two scoring systems for diagnosing acute appendicitis in 50 patients
presenting with right iliac fossa pain. The RIPASA score correctly classified 88 % of patients with
histologically confirmed acute appendicitis compared with 48.0 % with modified Alvarado score,
indicating that RIPASA score is more superior to Modified Alvarado score in our clinical settings.
Comparative analysis of diagnostic scales of acute
appendicitis: Alvarado, RIPASA and AIR.
[Article in Spanish; Abstract available in Spanish from the publisher]
Bolívar-Rodríguez MA1, Osuna-Wong BA1, Calderón-Alvarado AB1, Matus-Rojas J1, Dehesa-
López E2, Peraza-Garay FJ2.
Author information
Abstract
in English, Spanish

INTRODUCTION:
Acute appendicitis is the most common surgical disease in emergency surgery, however, it remains
a diagnostic problem and represents a challenge despite the experience and the different clinical
and paraclinical diagnostic methods.

OBJECTIVE:
To evaluate in a comparative way the scale of Alvarado, AIR and RIPASA to determine which one is
best as a diagnostic test of acute appendicitis in our population in order to arrive to an accurate
diagnosis in the shortest possible time and cost.

METHOD:
Observational, prospective, transversal and comparative study of 137 patients to whom the scale of
Alvarado, AIR and RIPASA was applied, who entered the emergency service of the Civil Hospital of
Culiacán (México) with abdominal pain syndrome suggestive of acute appendicitis.

RESULTS:
The Alvarado scale presented sensitivity 97.2% and specificity of 27.6%. AIR presented sensitivity of
81.9% and specificity of 89.5%. RIPASA showed the same results as Alvarado. All tests showed
diagnostic accuracy above 80.

CONCLUSIONS:
Alvarado and RIPASA presented good sensitivity, however, AIR is more specific, and has better
accuracy for the diagnosis of acute appendicitis, making a better screening and thus reducing
unnecessary surgeries. Therefore, it is recommended to use more AIR than Alvarado and RIPASA.
Comparison of ultrasound and the Alvarado score for the
diagnosis of acute appendicitis.
Stephens PL1, Mazzucco JJ.
Author information
Abstract
BACKGROUND:The Alvarado score assigns a numerical value to eight signs and symptoms
associated with acute appendicitis. Practically speaking, the Alvarado score is equivalent to one's
degree of clinical suspicion. Ultrasound is used in many institutions to aid in the diagnosis of acute
appendicitis. The following study compares the accuracy of the two modalities and examines the
value of using both modalities together.
STUDY DESIGN:This study is a retrospective review of all patients who underwent appendectomy
for presumed acute appendicitis at our institution in 1995. Seventy-five patients had a preoperative
ultrasound and all 94 patients received an Alvarado score from a retrospective chart review.
RESULTS: Ten (10.6%) patients had a normal appendix removed. Ultrasound alone resulted in a
correct diagnosis 87% of the time. Using the Alvarado score alone, a correct diagnosis was made
88% of the time. If the ultrasound alone were used for diagnosis, seven acute appendices would
have been missed (10% false negatives) and three unnecessary operations would have been
performed (4.6% false positives). If the Alvarado score alone were used for diagnosis, four acute
appendices would have been missed (5.9% false negatives) and five unnecessary operations would
have been performed (7.2% false positives). There were 45 true positives and no false positive
results when both modalities were positive for appendicitis. When the Alvarado score was negative
or equivocal, the addition of ultrasound decreased the false negative rate by 75%.
CONCLUSION:When comparing ultrasound to the Alvarado score for the diagnosis of acute
appendicitis, neither one is significantly advantageous. However, the false positive rate is reduced to
zero when both studies are positive and ultrasound improved diagnostic accuracy when the
Alvarado score was negative or equivocal. There is no advantage of ultrasound over the Alvarado
score for the diagnosis of acute appendicitis. Ultrasound is unnecessary when one's degree of
clinical suspicion is high. However, the additional information provided by ultrasound does improve
diagnostic accuracy in the case of a negative or equivocal Alvarado score. Acute appendicitis is the
most common surgical abdominal emergency with a lifetime prevalence of approximately one in
seven
Comparison of Tzanakis score vs Alvarado score in the
effective diagnosis of acute appendicitis.
Malla BR1, Batajoo H1.
Author information
Abstract
BACKGROUND:
Acute appendicitis is the most frequent surgical emergency encountered worldwide. This study was
conducted to compare the efficacy of Tzanakis score and Alvarado score in diagnosing acute
appendicitis.

OBJECTIVES:
The aim of this study is to compare the efficacy of Tzanakis scoring system with Alvarado scoring
system in diagnosing AA.

METHODS:
This was a retrospective and nonrandomized observational study conducted in Dhulikhel hospital. It
included 200 clinically diagnosed cases of acute appendicitis who underwent emergency open or
laparoscopic appendectomy during the year 2012. Final diagnosis of acute appendicitis was based
on histological findings given by pathologist.

RESULTS:
The sensitivity, specificity, positive predictive value and negative predictive value of Tzanakis score
was 86.9%, 75.0, 97.5% and 33.3% respectively. The sensitivity, specificity, positive predictive value
and negative predictive value of Alvarado score was 76.0%, 75.0%, 97.2% and 21.4% respectively.
Negative appendectomy was 8.0%.

CONCLUSION:
Tzanakis scoring system is an effective scoring system in diagnosing acute appendicitis.