International Journal of Surgery 54 (2018) 76–81

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International Journal of Surgery

journal homepage: www.elsevier.com/locate/ijsu

Original Research

Evaluation of the BISAP scoring system in prognostication of acute T

pancreatitis – A prospective observational study
Sumitra Hagjer, Nitesh Kumar∗
Department of General Surgery, Silchar Medical College & Hospital, Silchar, Assam, India

A R T I C LE I N FO A B S T R A C T

Keywords: Introduction: Severe acute pancreatitis has a high mortality and its early identification is important for man-
Acute pancreatitis agement and risk stratification. The bedside index for severity in acute pancreatitis (BISAP) is a simple scoring
Scoring system system done at admission which predicts the severity of pancreatitis. Procalcitonin is an inflammatory marker
Pancreatic necrosis which is raised very early and helps in early prediction of the severity of disease. This study aims to evaluate the
Organ failure
BISAP score and Procalcitonin in prognostication of acute pancreatitis.
Procalcitonin
Methods: A prospective observational study of 60 patients presenting with acute pancreatitis was done at XXX
Medical College and Hospital from July 2015 to June 2016. BISAP, APACHE-II, Ranson criteria, and CT severity
index (CTSI) of all patients were calculated. Procalcitonin card test was done for all patients. The patients were
stratified according by BISAP score and procalcitonin positivity into categories of severe pancreatitis, organ
failure and pancreatic necrosis, as well as the number of deaths. The comparison of BISAP with other scoring
systems, Procalcitonin (PCT), C-reactive protein (CRP), hematocrit, and body mass index (BMI) was done by the
area under the receiver-operating curve (AUC) to prediction of severe acute pancreatitis, organ failure, necrosis,
and death.
Results: Of the 60 patients, 14 (23.3%) developed severe acute pancreatitis, 11 (18.3%) Organ failure, 21 (35%)
pancreatic necrosis and 7 (11.6%) died. A BISAP score of ≥3 was a statistically significant cutoff value. AUCs for
predicting severe pancreatitis and death of BISAP were 0.875 and 0.740respectively, similar to those for Ranson
criteria (0.802, 0.763) and APACHE-II (0.891, 0.769) and greater than AUCs for CTSI (0.641, 0.554). The AUC
for prediction of organ failure were 0.906, 0.833, 0.874 and 0.623 for BISAP, Ranson criteria, APACHE-II, and
CTSI respectively. AUCs for PCT predicting severity, organ failure, and death were 0.940, 0.923 and 0.769
respectively were similar to BISAP but greater than those for CRP (0.755, 0.719, 0.693), hematocrit (0.540,
0.570, 0.550), and BMI (0.493, 0.523, 0.497).
Conclusion: The BISAP predicts severity, organ failure and death, in acute pancreatitis very well.It is as good as
APACHE-II but better than Ranson criteria, CTSI, CRP, hematocrit, and BMI. PCT is a promising inflammatory
marker with prediction rates similar to BISAP.

1. Introduction is often difficult to predict. Though the mortality of AP is 2–5% overall

but it reaches to about 20–30% in severe cases [6]. The high mortality
Acute pancreatitis (AP) is a common clinical condition which results of the severe acute pancreatitis (SAP) calls for methods to assess the
from inflammation of the pancreas with possible peripancreatic tissue severity of the disease early and accurately for initiating more ag-
and multiorgan involvement [1,2]. Majority of the cases of acute pan- gressive interventions which will decrease the adverse outcomes and
creatitis (80%) are mild and self limiting with no sequelae. But severe high mortality. So, careful ongoing clinical assessments along with
disease develops in about 10–20% of the cases where necrosis occurs in multi-factorial scoring system and imaging studies are required for the
parts of pancreas and the surrounding tissues. An acute inflammatory prediction of the SAP [7–9].
response sets in these patients which progresses to systemic in- Varieties of scoring systems are available such as Ranson criteria
flammatory response syndrome leading to multiorgan failure resulting [10], Acute Physiology and Chronic Health Evaluation (APACHE) II
in death [3–5]. [11] and computed tomography severity index (CTSI) [12], etc. But
The response to pancreatic injury varies from person to person and these systems are either complicated or require data that are not

∗
Corresponding author. Old PG Hostel, Room no- 12, Silchar Medical College & Hospital, Silchar, Ghungoor, 788014, Cachar, Assam, India.
E-mail address: [email protected] (N. Kumar).

https://doi.org/10.1016/j.ijsu.2018.04.026
Received 22 December 2017; Received in revised form 5 April 2018; Accepted 14 April 2018
Available online 21 April 2018
1743-9191/ © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
S. Hagjer, N. Kumar International Journal of Surgery 54 (2018) 76–81

Table 1 calcium, serum electrolytes, Liver function tests, and serum amylase
Individual components of the BISAP scoring system. and lipase and Arterial Blood Gas (ABG) analysis. C-reactive protein
Blood Urea Nitrogen (BUN) > 25 mg/dl (CRP) and procalcitonin card test (PCT) was also done within 24 h of
Impaired mental status (Glasgow Coma Scale Score < 15) admission. Rectal temperature was taken and Body Mass Index (BMI)
Systemic Inflammatory Response Syndrome (SIRS): was calculated. PCT-Q test [17](B·R·A·H·M·S PCT-Q Thermo Fisher
SIRS is defined as presence of two or more of the following Scientific) was done by pipetting 200 μl of blood sample (plasma or
1) Temperature of < 36 or > 38 °C
2) Respiratory rate > 20 breaths/min or P a CO2 < 32 mm Hg
serum) on the test strip at room temperature and the result was read
3) Pulse > 90 beats/min after 30 min. An ultrasound scan of the abdomen and plain radiograph
4) WBC < 4000 or > 12,000 cells/mm 3 or > 10% immature bands of the abdomen and chest was done on the day of admission.
Age > 60years BISAP and APACHE II scores were calculated from the laboratory
Pleural effusion detected on imaging
values and radiological reports obtained within first 24 h after admis-
BISAP: bedside index of severity in acute pancreatitis, WBC: white blood count.
One point is assigned for each variable within 24 h of presentation and added for sion. Ranson score was calculated from the laboratory values obtained
a composite score of 0–5. within the first 48 h. CTSI was obtained from the report of the CT scan
which was done after 72 h and within 7 days. The reporting of the scans
was done by same set of radiologists.
collected as a routine in early stages of disease and making the process
of early risk stratification difficult [3,4]. 2.1. Definitions
A new prognostic scoring system for estimating the severity of AP in
the early phase, which was named the bedside index of severity in acute Acute pancreatitis was diagnosed in a patient when two of the fol-
pancreatitis (BISAP), was proposed by Wu et al. [13] in 2008. The 5- lowing three features were present: 1) pain abdomen consistent with
point BISAP score system incorporates the variables: blood urea ni- acute pancreatitis (persistent, severe, epigastric pain of acute onset
trogen level > 25 mg/dl, impaired mental status, systemic in- which often radiates to back); 2) serum amylase and/or lipase at least
flammatory response syndrome (SIRS), and age > 60 years, and pre- three times greater than the upper limit of normal value; and 3) CECT,
sence of pleural effusion [6] (Table 1). less commonly MRI or transabdominal ultrasound showing character-
A number of biological markers are also used in prediction of the istic manifestations of acute pancreatitis [19].
severity of pancreatitis. Procalcitonin (PCT) is propeptide of calcitonin The presence or absence of organ failure and/or local complications
consisting of 116-amino acids which has no known hormonal activity, such as peripancreatic fluid collections and infected necrosis was used
and can be detected in high concentrations in serum during severe to classify AP as mild or severe according to revised Atlanta classifi-
bacterial or fungal but not viral infections [14,15]. Hepatocytes and cation. Duration of organ failure defined it to be transient (< 48 h) or
inflammatory cells synthesize and secrete PCT in response to proin- persistent (> 48 h). The most extreme laboratory value or clinical
flammatory mediators. PCT was introduced as an early marker of the measurement of all patients in each 24 h was taken up to 72 h for cal-
systemic inflammatory response, sepsis, and MOF. It was found that culation of the organ failure scores. Organ failure included one or more
increased serum concentration levels of PCT (> 0.5 ng/ml) was a reli- of the following 1) shock (systolic blood pressure < 90 mmHg), 2)
able early predictor of a severe disease, mortality and infected pan- pulmonary insufficiency (arterial PO2 < 60 mmHg in room air or the
creatic necrosis [17,18]. need for mechanical ventilation) and 3) renal failure (serum creatinine
During the past years, very few studies have been conducted in level > 2 mg/dl after rehydration or hemodialysis) indicating a score of
India to validate the accuracy of BISAP in estimating the severity of AP, ≥2 according to modified Marshall scoring system (Table 2). CECT
but no studies have been done to validate BISAP and PCT in the north showing lack of enhancement of pancreatic parenchyma was defined as
eastern part of India. The aim of this study was to evaluate the use- pancreatic necrosis [20].
fulness of BISAP and procalcitonin for the early prediction of the se-
verity, organ failure, pancreatic necrosis and death in acute pancreatitis 2.2. Statistical analysis
in our hospital and compare it with the existing systems.
Median and interquartile ranges were used for representation of
2. Materials and methods continuous variables and proportions for categorical data. Cochran-
Armitage trend test was used for assessing the distributions of severity,
A prospective observational study was carried out in XXX medical necrosis, organ failure, and death by BISAP point score. Sensitivity,
college and hospital from 30th June 2015 to 29th June 2016 for a period specificity, positive predictive value (PPV), and negative predictive
of one year after ethical committee approval. The study was funded by value (NPV) were calculated for individual scoring systems. The op-
DBT, New delhi, the DBT nodal cell, XXX University.The work has been timal BISAP, Ranson, APACHE-II, and CTSI scores for predicting se-
reported in line with the STROCSS criteria[19].Patients presenting with verity, necrosis, organ failure, and death was determined by their
features of acute pancreatitis to emergency and outdoor were admitted, characteristic Receiver-operating (ROC) curves. The Area Under the
thoroughly examined and investigated further. Laboratory and bio- Curve (AUC) of the scoring systems were compared with each other at a
chemical tests were done either at the time of admission or within 24 h time by the nonparametric approach developed by DeLong et al. [21]. A
of admission and at 48 h. Tests included total leukocyte count, hema- pvalue of < 0.05 was chosen to be significant for all tests. Univariate
tocrit, blood glucose level, blood urea, serum creatinine, serum linear regression was used to analyze the association of BISAP and

Table 2
Criteria for organ failure based on Marshall scoring system.
Organ system Score

0 1 2 3 4

Respiratory (P a O 2/F i O 2) > 400 301–400 201–300 101–200 < 101

Renal (serum creatinine, mg/dl) ≤1.5 > 1.5 to ≤ 1.9 > 1.9 to ≤ 3.5 > 3.5 to ≤ 5.0 > 5.0
Cardiovascular (systolic blood pressure, mm Hg) > 90 < 90, fluid < 90, fluid < 90, pH < 7.3 < 90,
responsive unresponsive pH < 7.2

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S. Hagjer, N. Kumar International Journal of Surgery 54 (2018) 76–81

Table 3 Table 5
Demographic, clinical characteristics, and outcomes of patients Distribution of severity, organ failure, necrosis an mortality according to PCT-Q
(n = 60). values.
Variables Data PCT (ng/ml) SEVERITY ORGAN NECROSIS MORTALITY TOTAL
(n, %) FAILURE (n, %) (n, %) (n, %)
Male: Female 2.16:1 (41/19) (n, %)
Mean age (years) 37.167 ± 11.768
Etiology < 0.5 2 (4.2) 0 (0) 15 (31.9) 0 (0) 47 (78.8)
1. Alcoholic 27 (45%) ≥0.5 - < 2 2 (66.6) 2 (66.6) 1 (33.3) 0 (0) 3 (5)
2. Gall Stone 24 (40%) ≥2 – < 10 10 (100) 9 (90) 5 (50) 7 (70) 10 (16.6)
3. Idiopathic 09 (15%) ≥10 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Severity TOTAL 14 (23.3) 11 (18.3) 21 (35) 7 (11.6) 60 (100)
1. Mild AP 46 (76.6%)
2. Severe AP 14 (23.3%) PCT: Procalcitonin.
Organ Failure
1. Absent 49 (81.6%)
2. Present 11 (18.3%) Armitage trend test yielded significant p values for association of BISAP
Necrosis
with severity, organ failure and mortality (p < 0.05). PCT also showed
1. Absent 39 (65%)
2. Present 21 (35%) similar trends as of BISAP and the trend test was significant for asso-
BISAP ciation of PCT and severity, organ failure and mortality (p < 0.05)
1. < 3 48 (80%) (Table 5).
2. > 3 12 (20%)
PCT
1. < 0.5 ng/ml 47 (78.8%)
3.1. Comparison of BISAP with different scoring systems and biomarkers
2. ≥ 0.5–2.0 ng/ml 3 (5%)
3. ≥ 2.0–10 ng/ml 10 (16.6%) The AUC of the different scoring systems and the biomarkers for
Mortality 7 (11.6%) predicting severity, organ failure, necrosis and mortality were obtained
Hematocrit 39.045 ± 5.165
from their ROC curves and is listed in Table 6. BISAP had AUCs of 0.875
BMI 25.483 ± 4.168
CRP 92.667 ± 54.645 (95% CI, 0.77–0.97), 0.915 (95% CI, 0.86–0.97), 0.576 (95% CI,
Hospital stay 0.46–0.67) and 0.892 (95% CI, 0.81–0.97) for prediction of the se-
1. Mild AP 7.52 ± 3.053 verity, organ failure, necrosis and mortality respectively. The AUC of
2. Severe AP 10.429 ± 5.872 BISAP in predicting the Severity of disease was almost similar to that of
ICU admission 13 (21.6%)
APACHE II (0.872; 95% CI- 0.78-0.96, p = 0.612) but was slightly
AP: Acute Pancreatitis, BISAP: bedside index of severity in acute higher than that of RANSON (0.810; 95% CI- 0.71-0.90, p = 0.134) but
pancreatitis, PCT: Procalcitonin, BMI: Body Mass Index, CRP: C- the differences were statistically insignificant. In predicting the Organ
Reactive protein, ICU: Intensive Care Unit. failure in AP AUC of BISAP was almost similar to that of APACHE II
(0.923; 95% CI, 0.87–0.97, p value = 0.431) but was significantly
hospital stay. XL Stat 2016 was used for performing all the statistical higher than that of RANSON (0.839; 95% CI, 0.74–0.93, p value <
calculations. 0.014).For prediction of Mortality the AUC of BISAP was similar to that
of APACHE II (0.893; 95% CI, 0.81–0.97, p value = 0.534) and slightly
higher than that of RANSON (0.803; 95% CI, 0.69–0.90, p
3. Results value = 0.143) but was insignificant. The AUC of CTSI (0.879; 95% CI,
0.77–0.96) in predicting the Necrosis was higher than other scoring
60 patients of AP were admitted and included in our study of one systems and was statistically significant (p value < 0.001).
year. The demographics, clinical characteristics and the outcomes are Among the biomarkers the AUC of PCT was comparable to that of
summarized in Table 3. Males were predominant in our study, mean BISAP in prediction of Severity (0.925; 95% CI, 0.87–0.97, p
age was in late thirties and etiology was almost equally distributed value = 0.238), Organ failure (0.942; 95% CI, 0.89–0.99, p
between alcohol and gallstones. Severe disease developed in 23.3% of value = 0.146) and mortality (0.898; 95% CI, 0.81–0.97, p
patients and 11.6% died. value = 0.452) but was greater than CRP, HCT and BMI (p value <
The severity of disease, organ failure, pancreatic necrosis and 0.05 for all). The AUC of hematocrit was higher than other biomarkers
mortality distributions according to the BISAP point score are shown in and BISAP in prediction of necrosis (0.710) and the data was statisti-
Table 4. There was increasing trend in the percentage of severity, organ cally significant (p value < 0.05) but was significantly lower than CTSI
failure, necrosis and mortality with increasing BISAP scores. Cochran- (p value > 0.05). The ROC curves of different scoring systems and PCT
for prediction of severity of disease is shown in Fig. 1.
Table 4 The following cutoffs were generated on the basis of highest sensi-
Distribution of severity, organ failure, necrosis an mortality according to BISAP tivity and specificity obtained from ROC curves; BISAP ≥3, Ranson
point scores. ≥3, APACHE ≥8, CTSI ≥4, PCT ≥0.05 ng/ml, CRP ≥150 mg/L, Hct
BISAP SEVERITY ORGAN NECROSIS MORTALITY TOTAL ≥44, BMI ≥30. The sensitivity, specificity, PPV, NPV was calculated
SCORE (n, %) FAILURE (n, %) (n, %) (n, %) for the different scoring systems and PCT using these cutoffs obtained
(n, %) from the ROC curves (Table 7). Increasing BISAP scores were associated
with increase duration of hospital stay by univariate linear regression
0 0 0 5 (31.2) 0 16 (26.6)
1 1 (5.8) 0 5 (29.4) 0 17 (28.3) (R2 = 0.201) was also found to be significant (p value < 0.05). Similar
2 3 (20) 1 (6.6) 4 (26.6) 1 (6.6) 15 (25.0) findings were obtained for PCT (R2 = 0.198) (see Table 8).
3 5 (71) 5 (71) 4 (57.1) 2 (28.5) 7 (11.6)
4 4 (100) 4 (100) 3 (75) 3 (75) 4 (6.6)
4. Discussion
5 1 (100) 1 (100) 0 1 (100) 1 (1.6)
Total 14 (23.3%) 11 (18.3%) 21 (35%) 7 (11.6%) 60 (100)
In this study the usefulness of BISAP and procalcitonin was eval-
BISAP: bedside index of severity in acute pancreatitis. uated for the early prediction of the severity, organ failure, pancreatic
necrosis and death in acute pancreatitis in our hospital and compared it

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S. Hagjer, N. Kumar International Journal of Surgery 54 (2018) 76–81

Table 6
AUC of the different scoring systems and the biomarkers in predicting severity, organ failure, necrosis and mortality.
AUC (95% CI) SEVERITY ORGAN FAILURE NECROSIS MORTALITY

BISAP 0.875 (0.77–0.97) 0.915 (0.86–0.97) 0.576 (0.46–0.67) 0.892 (0.81–0.97)

Ranson 0.810 (0.71–0.90) 0.839 (0.74–0.93) 0.556 (0.44–0.67) 0.803 (0.69–0.90)
APACHE II 0.872 (0.78–0.96) 0.923 (0.87–0.97) 0.521 (0.41–0.62) 0.893 (0.81–0.97)
CTSI 0.653 (0.46–0.66) 0.627 (0.53–0.73) 0.879 (0.77–0.96) 0.509 (0.40–0.60)
PCT 0.925 (0.87–0.97) 0.942 (0.89–0.99) 0.556 (0.44–0.67) 0.898 (0.81–0.97)
CRP 0.755 (0.65–0.85) 0.719 (0.61–0.82) 0.556 (0.44–0.67) 0.693 (0.59–0.79)
HCT 0.540 (0.44–0.65) 0.570 (0.46–0.67) 0.710 (0.61–0.81) 0.550 (0.44–0.67)
BMI 0.493 (0.39–0.59) 0.523 (0.41–0.62) 0.490 (0.39–0.59) 0.497 (0.39–0.60)

AUC: Area Under Curve, BISAP: bedside index of severity in acute pancreatitis, APACHE II: Acute Physiology and Chronic Health Evaluation, CTSI: computed
tomography severity index, PCT: procalcitonin, CRP: C-Reactive protein, HCT: Hematocrit, BMI: Body mass index.

with the existing systems. It was found that BISAP was similar to 2) it predicts the in hospital death in early stages of the disease
Ranson and APACHE II in prediction of severity of disease and the [2,3,6,13]. Age, GCS and SIRS is used in both BISAP and APACHE II but
mortality and was better than Ranson in prediction of organ failure. only with addition of BUN and pleural effusion BISAP attains a high
PCT was also very useful biomarker for prediction of severity, organ predictive ability to detect severe disease and predict the mortality
failure and death and was comparable to BISAP but was better than which is equivalent to the complex APACHE II. A BISAP score of ≥3
other biomarkers (CRP, HCT and BMI). Necrosis was best predicted by was associated with more severe disease, more organ failure and higher
CTSI and HCT. Both BISAP and PCT had linear relation with the hos- mortality in the ROC curve. BISAP score of ≥3 was used as cutoff by
pital stay. most of the authors [6,22,24] and ≥2 by few [2,23]. Revised Atlanta
The existing prognostic scoring systems have drawbacks and diffi- classification defines severe disease by presence of local pancreatic
culties which are overcome by the BISAP scoring system. Ranson and complications and extrapancreatic organ failure and more recently
Glasgow scores require 48 h for calculation and also require data that is organ failure is considered as a much stronger predictor of severe dis-
not routinely collected at the time of admission and not readily avail- ease and duration of hospitalization [6,8,20]. BISAP predicts organ
able in small centers [2,5,9,10]. APACHE II was initially devised for failure more accurately in the early stage of the disease, thus adding to
prognostication of ICU patients is most commonly used scoring system the advantage of this scoring system.
but it requires many parameters of which some are not relevant for AP. Park et al. [2]in his retrospective study of the 303 patientscompared
Also the chronic health profile portion of the score requires a detailed BISAP score with other scoring systems. AUCs for BISAP predicting
history and medical records which are difficult to obtain in all patients. severe pancreatitis, organ failure and death were 0.80, 0.93 and 0.86,
It is cumbersome and difficult to remember for the clinicians [3–5,11]. respectively, which were similar to those for APACHE-II (0.80, 0.95,
CT is not useful for prognosis in early stages of the disease as the 0.87) and Ranson criteria (0.74, 0.84, 0.74) and greater than AUCs for
morphological changes develop late [1,5,12]. CTSI (0.67, 0.57, 0.42). In his study BISAP predicted severity, death,
BISAP score has several advantages from the other scoring systems; and especially organ failure in acute pancreatitis as good as APACHE-II
1) it requires data that are very easy to obtain at the time of admission did and was better than Ranson criteria, CTSI, CRP, hematocrit, and
(physical examination, vital signs, few laboratory data and imaging for BMI. Table 6 lists the results of various studies comparing with our
detection of pleural effusion) which makes it much easier to calculate, study.

Fig. 1. Comparison of AUC of different scores and Pct for severity prediction.

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S. Hagjer, N. Kumar International Journal of Surgery 54 (2018) 76–81

Table 7 test for the semi-quantitative detection of PCT. No well equipped la-
Sensitivity, specificity, PPV, NPV of different scoring systems and PCT. boratory or any laboratory personnel is required at the time of per-
Sensitivity Specificity PPV NPV forming the test. B·R·A·H·M·S PCT-Q test system requires serum to be
incubated only for 30 min and can be done at bedside making it very
Severity: useful and can be performed at lower level hospitals also. In this study a
BISAP 0.714 0.957 0.833 0.917
single PCT value was equivalent or slightly more sensitive and accurate
Ranson 0.571 0.935 0.727 0.878
APACHE II 0.786 0.957 0.846 0.936
than other scoring systems for the diagnosis and prognosis of severe AP.
CTSI 0.379 0.903 0.786 0.609 Hemoconcentration is shown to be early predictor of pancreatic
PCT 0.857 0.978 0.923 0.957 necrosis and organ failure in many studies [2,5,7] but one study has
Organ failure: shown it to be a poor predictor of the organ failure and severity [27]. In
BISAP 0.909 0.959 0.833 0.979
our study HCT at admission had low predictive values for severe pan-
Ranson 0.727 0.939 0.727 0.939
APACHE II 0.909 0.939 0.769 0.979 creatitis, organ failure, and death, but for necrosis the predictive value
CTSI 0.310 0.935 0.818 0.592 was greater than PCT, CRP, BMI and even BISAP. When compared with
PCT 0.989 0.959 0.846 0.979 CTSI the predictive value of HCT for necrosis was low but HCT had the
Necrois:
advantage of early prediction for necrosis.
BISAP 0.333 0.872 0.583 0.708
Ranson 0.238 0.846 0.455 0.673
Obesity (BMI ≥ 30) is also related with poor prognosis in patients of
APACHE II 0.286 0.821 0.462 0.681 AP and thought to be and independent prognostic factor [2,28]. Few
CTSI 0.999 0.795 0.724 0.999 studies have included BMI (and in particular the effect of obesity) in
PCT 0.286 0.821 0.462 0.681 BISAP but these do not report any additional prediction for adverse
Mortality:
outcome [29,30]. Obesity was a poor predictor of AP in our study
BISAP 0.857 0.887 0.500 0.979
Ranson 0.857 0.906 0.545 0.980 (mean BMI was 24.5), the low prevalence of obesity in this part of the
APACHE II 0.999 0.887 0.538 0.999 country may be the cause.
CTSI 0.172 0.935 0.714 0.547 So, we finally conclude from the study is that BISAP is as useful as
PCT 0.999 0.887 0.538 0.999 APACHE-II and more useful than Ranson criteria, CTSI, CRP, Hct and
BMI in predicting severity, organ failure, and death in patients with
BISAP: bedside index of severity in acute pancreatitis, APACHE II: Acute
Physiology and Chronic Health Evaluation, CTSI: computed tomography se- acute pancreatitis. PCT is a good independent prognostic marker for
verity index, PCT: procalcitonin. prediction of severity, organ failure and death and is comparable with
BISAP and APACHE II in accuracy. BISAP score are easy to obtain, data
Table 8 is clinically relevant and very easy to calculate within 24 h. Both BISAP
Comparison of AUC of different scoring systems in different studies for severity and PCT had accuracy for predicting organ failure which was greater
prediction. than their ability to predict severity of the disease. A larger prospective
study is needed comparing all the scores and individual parameters to
SCORING Our Study Park el Zhang Khanna Papachristou
SYSTEMS al2 et al. et al. [22] et al. [23] give a standard approach. Still the approach differs in institutions ac-
[21] cording to their preferences.
BISAP scores can be used with ease to identify the patients of acute
BISAP 0.875 0.80 0.793 0.80 0.81
pancreatitis within 24 h of admission who are at risk of developing
RANSON 0.810 0.74 0.903 0.85 0.94
APACHE II 0.872 0.80 0.836 0.88 0.78
severe disease, organ failure and likely to die in the hospital. PCT es-
CTSI 0.653 0.67 – 0.66 0.84 timation by B.R.A.H.M.S PCT-Q is easy and results can be obtained at
bed side, so it will also help to identify the patients at risk and will act
as an early guide for the accurate and required treatment resulting in
Many biomarkers have been studied in pancreatitis including improved patient outcomes.
Interleukin (IL-6), PCT, trupsinogen-2 and trypsinogen activated pro-
tein. However CRP is the only biomarker which has been used widely
[25]. CRP is limited by its delay in attaining the peak value after onset Ethical approval
of symptoms which is up to 72 h [17,25]. Kylanpaa et al. [17]showed a
sensitivity of only 37% for CRP at admission. In our study CRP at Yes. It was approved by ethical committee of Silchar medical college
presentation was analyzed which yielded low AUC and sensitivity for and Hospital. Serial number 36 of 2014 dated 18/06/15.
prediction of the severe disease and mortality.
Serum PCT was evaluated as a prognostic marker in AP in many
Sources of funding
studies [14–17,19,24,26]. PCT is a biologically inactive propeptide of
calcitonin, is a more rapid acute-phase reactant and is detectable early
DBT, New Delhi, the DBT Nodal Cell, Tezpur University. Grant
in course of the disease making it a useful prognostic marker. In several
number: BT/Med/15/Vision-NER/2011.
studied it has been reported to correlate with severity of infection and
as an early indicator of severe noninfectious SIRS also as a valuable
marker for the clinical course of the disease. It also differentiated be- Author contribution
tween sterile and infected necrosis [16]. Kylanpaa et al. [17] used
semiquantitative serum strips PCT-Q in 162 patients with AP and found Dr. Sumitra Hagjer: Study design, data collections, data analysis,
a sensitivity of 92% and specificity of 84% with a 97% NPV for de- writing.
tection of organ failure (cutoff- 0.5 ng/ml). Our study had sensitivity of Dr. Nitesh Kumar: Study design, data collections, data analysis,
98% and specificity of 95% with a 97% NPV for detection of organ writing.
failure (cutoff- 0.5 ng/ml). AUC of PCT for prediction of severity, organ
failure and death was comparable to BISAP and APACHE II but was
better than Ranson and the other biomarkers; similar findings were Conflicts of interest
reported by Kylanpaa et al. [17]. Several other studies also showed high
accuracy of the PCT comparable with the other biomarkers [19,23,26]. Dr. Sumitra Hagjer has no conflict of interest.
The B·R·A·H·M·S PCT-Q is an immunochromatografic rapid dipstick Dr. Nitesh Kumar has no conflict of interest.

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S. Hagjer, N. Kumar International Journal of Surgery 54 (2018) 76–81

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