Computed Tomography Evaluation of Acute Pancreatitis and Its Prognostic Correlation with the CT Severity Index

Prognostic indicators in acute pancreatitis: CT vs APACHE II

Introduction and aim. Computed tomography severity index (CTSI) and Balthazar score are among the most frequently used scorings in the determination of severe acute pancreatitis. The primary purpose of this study is evaluation of the effects of biochemical parameters, Balthazar score and CTSI on mortality in acute pancreatitis. At the same time, correlations with biochemical parameters, CTSI and Balthazar score were evaluated in patients with AP. Material and methods. In this study, the amylase, lipase, CRP, and procalcitonin values of ​​ patients diagnosed with acute pancreatitis were retrospectively recorded. Contrast-enhanced computed tomography (CECT) images obtained at the time of presentation to the emergency department or within seven days of admission were re-evaluated by two radiologists. The CTSI scores and Balthazar scores of the patients were calculated. Results. The study included 240 patients. The amylase level of the patients was positively correlated with the Balthazar score at a statistically significant level (R=0.189, p=0.003). In addition,, the relationship between pancreatic scoring systems and mortality, the AUC value for CTSI was 0.9 (95% CI: 0.826-0.973) and was higher than other scoring systems. Conclusion. CTSI had better performance in the prediction of mortality in patients with acute pancreatitis.

Early detection of necrosis in low-enhanced pancreatic parenchyma using contrast-enhanced computed tomography was a better predictor of clinical outcomes than pancreatic inflammation: A multicentric cohort study of severe acute pancreatitis

IntroductionAcute pancreatitis (AP) is a pancreatic inflammatory disease that can range in severity from mild, self-limiting forms to severe cases with high mortality rates. AP has various etiologies, including lifestyle factors like alcohol consumption and obesity, and its rapid progression makes early and accurate prediction of severity critical for effective management and improved patient outcomes.The traditional AP severity assessment tools, such as Ranson's criteria and APACHE II, require extensive data and time, making them less feasible in emergency settings. In response, simpler biomarkers that can quickly predict AP severity upon patient presentation are needed to enable early risk stratification and targeted interventions.The study aims to address this research gap by evaluating the neutrophil-to-lymphocyte ratio (NLR) as a potential biomarker for predicting AP severity, as well as assessing its correlation with the CT Severity Index, a widely used measure of AP severity.MethodsThe study used a retrospective analytical design, conducted at the R L Jalappa Hospital & Research Centre in Karnataka, India. The researchers included 118 patients diagnosed with acute pancreatitis (AP) according to the Revised Atlanta Classification.The dataset collected from the participants' medical records included variables such as age, gender, history of alcohol and tobacco use, duration of abdominal pain, ICU stay, CT Severity Index scores, and the neutrophil-to-lymphocyte ratio (NLR).Statistical analysis was performed using SPSS software version 21.0 (IBM Corp., Armonk, NY, USA). A p-value of less than 0.05 was considered statistically significant.This comprehensive methodological approach aimed to provide precise insights into the role of NLR in predicting AP severity while accounting for variability in patient data.ResultsThe study included 118 patients, with 85 classified as having mild to moderate pancreatitis and 33 with severe pancreatitis. There were no significant differences between the two groups in terms of demographic factors such as gender, BMI, alcohol use, smoking, and comorbidities.The study also examined the relationship between the neutrophil-to-lymphocyte ratio (NLR) and the CT Severity Index, a measure of pancreatitis severity. The results showed a strong positive correlation between NLR and the CT Severity Index (r = 0.860, p < 0.001). This indicates that higher NLR values are associated with more severe pancreatitis, as measured by the CT Severity Index.These relationships suggest that NLR reflects the inflammatory response in acute pancreatitis, with higher levels of inflammatory markers associated with elevated NLR values.ConclusionThis study aimed to evaluate the neutrophil-to-lymphocyte ratio (NLR) as a biomarker for predicting the severity of acute pancreatitis (AP). We conducted a retrospective analysis of 118 AP patients, categorizing them into mild-to-moderate and severe groups. NLR was significantly higher in the severe AP group compared to the mild-to-moderate group, suggesting its potential as an early predictor of AP severity. The study also examined the correlation between NLR and the CT Severity Index, a widely used measure of AP severity, further supporting the utility of NLR as a rapid and accessible tool for risk stratification in AP management.

Aim The objective of this study is to evaluate Neutrophil-Lymphocyte ratio in foreseeing the severe pancreatitis in the severe acute and early diagnostic phase, keeping the CTSI as standard. Method Validation (cross sectional) study from 20th July 2023 to 19th July 2024 at General surgery ward (1 and 2). A total of 107 patients diagnosed with acute pancreatitis, aged 18-70 years of either gender were included. Patients with diseases such as chronic pancreatitis, diabetes, cardiovascular diseases, trauma, ERCP (iatrogenic), hypertriglyceridemia, alcohol, and end-stage renal and hepatic diseases were excluded. Laboratory investigations included CBC, LFT, serum amylase, serum lipase and ultrasound abdomen. Amylase lipase levels greater than three times normal, and ultrasonographic evidence of cholelithiasis, was reviewed by a surgical specialist; to confirm the diagnosis of acute biliary pancreatitis. All patients underwent CT severity index (CTSI) at 72 hours. Results 41 (38.31%) and 7 (6.54%) came out to be true and false positives respectively in the positive NLR group. Out of 59 (55.14%) who were NLR below cut-off, 55 (55.40%) and 4 (3.73%) were true and false negative respectively. The positive predictive value was 85.42% whereas, the negative predictive value was 93.22%. Sensitivity and specificity were 91.11% and 88.71% respectively. Conclusions It is concluded that NLR remains a highly effective minimally invasive and reproducible method in predicting the outcome of acute pancreatitis, especially in the first few hours of presentation.

Introduction: Fatty liver (FL) is often recognized in patients with acute pancreatitis (AP) and is frequently found in clinical practice because of substantial variables that put one at risk of complications. Aim: To evaluate the severity of acute pancreatitis in patients with and without fatty liver using CT severity index. Methodology: In this prospective study was carried out from June 2020 till December 2022. Liver and spleen mean attenuation values were examined using plain CT scans abdomen of patients with AP. Fatty liver was defined as a mean Hounsfield Unit (HU) liver/spleen) ratio &lt; 1. Contrast-enhanced computed tomography (CECT) scan and CT Severity Index (CTSI) to grade the severity of AP. Analyzed information in SPSS. Degree of significance was determined using the chi-square test. Results: This study comprised of 100 Patients with AP (88 (88.0%) males and 32 (32.0%) female, mean age 34.68 12.762 years), 46 (46.0%) had FL and 54 (54.0%), without FL. Patients with FL experienced much worse pancreatitis than patients without FL. Acute edematous pancreatitis (39.4% vs. 60.6%) and acute necrotic collections (58.8% vs. 41.2%) were observed in patients with FL and without FL respectively. Conclusion: The severity of acute pancreatitis is significantly influe

Objective To study the change of serum diamine oxidase (DAO) level in patients with severely acute pancreatitis (SAP) in order to explore the role of DAO in assessing the severity of SAP and the magnitude of gastrointestinal dysfunction.Methods From January 2012 through December 2013,56 SAP patients with 33 male and 23 female and average age (45-± 14) years admitted within 3 days after onset were enrolled for this study.At admission,serum diamine oxidase (DAO) was detected,and APACHE Ⅱ score,computed tomography severity index (CTSI) score and Balthazar grading and gastrointestinal dysfunction score were calculated.And at the corresponding time,serum procalcitonin (PCT) was detected.The correlations between serum DAO level and 4 other markers were analyzed.Results The high level of serum DAO was found at admission in SAP patients correlating positively with serum PCT concentrations (r =0.516,P＜ 0.01),APACHE Ⅱ score (r =0.631,P＜ 0.01),CTIS score (r=0.640,P ＜ 0.01),and the degree of gastrointestinal dysfunction (r =0.730,P ＜ 0.01).Conclusions The role of serum DAO in assessing the severity of SAP and magnitude of gastrointestinal dysfunction in SAP patients is really valid. Key words: Serum diamine oxidase; Computed tomography (CT) severity index scores; Gastrointestinal dysfunction score; Acute physiology and chronic health evaluation Ⅱ ; Serum calcitonin original

Purpose: Obesity is implicated in the severity and outcome of acute pancreatitis. The impact of abdominal fat and the influence of hepatic steatosis on the severity and outcome of the acute pancreatitis (AP) have not been studied. Hepatic dysfunction associated with obesity might enhance the systemic inflammatory response by altering the detoxification of inflammatory mediators. We aim to study the relationship of abdominal adiposity and hepatic steatosis with the severity and outcome of acute pancreatitis. Methods: A retrospective chart review on 108 (mean age 53 yrs, male 52%) of 257 patients with AP seen between January 2002 and December 2009 meeting the inclusion criteria were included. Ranson's and CT severity index score calculations were performed. Hepatic attenuation index (HSA) was obtained by calculating the ratio of hepatic to splenic attenuation (Hounsfield units); HSA < 1.0 was used to diagnose moderate to severe macrovesicular steatosis. Total abdominal fat was calculated using sagital and coronal reformation images on CT of the abdomen and pelvis using data from the superior end plate of T10 to the inferior symphysis pubis. Hounsfield units < - 200 HU and > -20 HU were excluded yielding total abdominal fat content; a histogram profile of this remaining volume using a post processing Workstation, GE AW 4.2 (GE Milwaukee, WI) was used to calculate the fat volume. Results: Etiology of AP was alcohol in 19 (17.6%), ERCP-induced 8 (7.4%), gallstone 42 (38.9%) and other etiologies 39 (36.1%). Based on Ranson's score at 48 hrs, 22 (20.4%) had severe AP (score ≥3), and of the 87(80.6%) subjects whose CT severity index was available 20 (23%) had severe AP (score ≥3). HSA < 1.0 was noted in 44 (40.7%) patients. The severity of pancreatitis on Ranson's criteria at 48 hrs (1.57±1.43 vs. 1.20±1.3, p=0.14) and by CT severity index (3.13±2.51 vs. 2.15±1.75, p=0.08) trended to be higher in patients with low-HSA (with fatty liver) compared to high-HSA (without fatty liver). When patients with ERCP induced pancreatitis were excluded, subjects with low-HSA had significantly more severe AP on CT severity index (3.21±2.5 vs. 2.12±1.8, p=0.04). Mean total abdominal fat content was not significantly different in patients with severe (score > 3) vs. milder (score < 3) pancreatitis by Ranson's criteria (15.6±6.7 vs. 13±4.7 liters, p=0.14). No significant difference was noted in the need for ICU admission (31.8% vs. 28.1%), fraction of patients with necrosis (13.6% vs. 12.5%) or pseudocyst formation (9.1 vs. 7.8%), or length of hospital stay (11.6±9.4 vs. 12.2±19.2, p=0.07) in patients with low-HSA and high-HSA. Conclusion: Patients with hepatic steatosis may be predisposed to more severe acute pancreatitis.

Bedside index for severity in acute pancreatitis: comparison with other scoring systems in predicting severity and organ failure

Objective: To determine the diagnostic accuracy of numerical CT severity index (CTSI) and Ranson score in pre­dicting severe Acute Pancreatitis (AP) keeping organ failure as the gold standard. Methodology: This descriptive cross-sectional study was carried out in the Department of Surgery, Medical Teaching Institute, Lady Reading Hospital Peshawar, from November 2020 to May 2021 on 238 patients with acute pancreatitis. All patients were subjected to the prediction of Severe Acute Pancreatitis (SAP)/organ failure on CTSI and Ranson criteria. Results: The mean age of the participants was 30.7+7.6 years. There were 54.2% male and 45.8% female as per gender distribution. The mean duration of AP at presentation was 3.8 +1.8 days. Prediction of SAP in terms of organ failure was predicted in 55.9% of patients on Ranson criteria and 59.2% of patients on CTSI. The sensi­tivity of Ranson criteria was 37.5% and specificity of 25.4% with a Positive Predictive Value (PPV) of 33.8% and a Negative Predictive Value (NPV) of 28.5%. The sensitivity of CTSI was 88.9% and specificity 71.1% with PPV of 75.9% &amp; NPV of 86.6%. Conclusion: CTSI is a highly sensitive and specific tool for predicting the severity of acute pancreatitis when compared to the Ranson criteria in patients presenting with acute pancreatitis.

Pediatric acute pancreatitis (AP) is a rare but important clinical entity associated with significant morbidity. Predicting the severity and outcome of AP in pediatric patients can be challenging because there are few validated severity scoring systems. Moreover, the etiology of pediatric AP in the Japanese population is different from that of Western populations. The performance of severity scores in pediatric AP with a high prevalence of severe cases is still unknown. The aim of this study was to assess the performance of existing severity scoring systems when used for Japanese children at a tertiary care center. We reviewed the electronic medical records of all children (≤18 years) treated for AP at between 2002 and 2012 at National Center for Child Health and Development, Tokyo. The modified Glasgow acute pancreatitis severity score (modified Glasgow), Ranson criteria (Ranson), Balthazar computed tomography severity index (CTSI), and pediatric acute pancreatitis severity (PAPS) score were assessed for their ability to distinguish severe pancreatitis from the milder forms. Thirty-three Japanese children with AP were identified. Among them, 37 episodes were analyzed for the performance of the scoring systems and 33 for the etiology. The most common etiology of AP was structural abnormality (n = 8). Sensitivity for the modified Glasgow, Ranson, PAPS, and CTSI was 42.9%, 52.4%, 81.0%, and 50.0%, respectively, while specificity was 81.3%, 81.3%, 37.5%, and 76.9%, respectively. We found PAPS to be the most reliable when used for discriminating the severe form of AP from the milder forms at a Japanese tertiary pediatric care center.

We aimed to compare the prognostic value of various predictors and complex scoring systems for prediction of severe acute pancreatitis (SAP) according to the revised Atlanta classification. C-reactive protein (CRP) and procalcitonin were obtained on admission, and CRP level 24 hours after admission (CRP2) was measured. Various scoring systems including Ranson, Acute Physiology and Chronic Health Examination (APACHE II), the Bedside Index for Severity in Acute Pancreatitis, and Computed Tomography Severity Index (CTSI) were calculated. There were 146 patients with acute pancreatitis (mean age, 50.6 ± 18.3 years; 63% male), of which 43 patients (29.5%) received a diagnosis of moderately severe AP, and 17 patients (11.6%) received a diagnosis of SAP. In patients with moderately severe acute pancreatitis to SAP, CTSI (odds ratio [OR], 10.46; 95% confidence interval [CI], 4.3-25.43; P < 0.001), APACHE II (OR, 3.87; 95% CI, 1.18-12.64; P = 0.025), and CRP2 (OR, 4.5; 95% CI, 1.53-13.1; P = 0.006) were strongly related to moderately severe acute pancreatitis and SAP. In patients with SAP compared with mild to moderately severe AP, procalcitonin (OR, 4.36; 95% CI, 1.01-18.96; P = 0.049) was the only factor strongly associated with SAP. Procalcitonin was the best predictor for patients with SAP; CTSI, APACHE II, and CRP2 were valuable predictors for patients with moderately severe acute pancreatitis and SAP.

To evaluate the accuracy of magnetic resonance elastography (MRE) in comparison to contrast-enhanced computed tomography (CE-CT) for early diagnosis and prediction of severity in acute pancreatitis (AP). This cross-sectional prospective study included 76 patients with suspected AP who underwent both CE-CT and 3.0T MRE within 24 hours of hospital admission. Pancreatic stiffness, CT severity index (CTSI), Acute Physiology and Chronic Health Evaluation (APACHE)-II, and Bedside Index for Severity in AP (BISAP) scores were comparatively evaluated using data from the first 24 hours of admission, and diagnosis and severity of AP were confirmed according to the revised Atlanta Classification (2012). The accuracy of MRE for predicting disease severity was compared with that of CE-CT and the clinical scoring systems using area under the receiver-operating curve (AUC) analysis. AP was confirmed in 56/76 patients (73.7%). Pancreatic stiffness values of >1.47 kPa showed significantly better diagnostic performance than CE-CT (AUC: 0.993 vs. 0.818, P < 0.001) along with greater sensitivity (96.4% vs. 78.6%, P = 0.006) and accuracy (96.1% vs. 81.6%, P = 0.007). Ten patients (10/76; 13.2%) had clinically severe AP. The accuracy of pancreatic stiffness >2.47 kPa was comparable to that of the CTSI, APACHE-II and BISAP scores for predicting severe AP (accuracy = 85.5%, 75.0%, 88.2%, and 78.9%, respectively). The pairwise comparisons were not significant after Bonferroni correction (P < 0.008 [0.05/6]), with P values of 0.008 (MRE vs. CTSI), 0.823 (MRE vs. APACHE-II) and 0.414 (MRE vs. BISAP). Early MRE is a useful, noninvasive method for both diagnosis and early severity assessment of AP. We recommend MRE at hospital admission for initial evaluation of AP. 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1311-1319.

Background Acute pancreatitis (AP) isan acute inflammatory condition of the pancreas, peri-pancreatic tissues, and several organs, leading to multiple organ dysfunction syndrome and a higher risk of mortality. For many years, scoring systems that include biochemical, radiological, and clinical criteria for determining severity have been used. Though numerous studies have used various scoring methods to evaluate the severity of AP, this study has been conducted to compare four scoring systems: bedside index of severity in AP (BISAP), acute physiology and chronic health evaluation (APACHE II), Ranson's, and modified CT severity index (CTSI)based on clinical, biochemical, and radiological parameters. Materials and methods It was a prospective-comparative study. The study was conducted from December 2016 to August 2018 in the Department of General Surgery at Byramjee Jeejeebhoy Government Medical College (B.J.G.M.C.)and Sassoon Hospital, Pune, Maharashtra, India. A total of 75 participants were enrolled in the study. Results The study population ranged from 18 to 68 years, with a mean age of 40.8±11.5 years. AP was most prevalent in the age group of 31-40 years (33.3% cases). Out of 75 patients in this study, 14 patients (18.7%) had severe AP (SAP), 18 patients (24%) had moderate SAP, and 43 patients (57.3%) had mild AP. Ten patients expired, with a mortality rate of 13.3%. It has been observed that the BISAP score had the best specificity (100%) and the CTSI score had the highest sensitivity (96.9%) among our study's four scores for predicting pancreatic necrosis. When predicting persistent organ failure, BISAP had the highest specificity, and Ranson and CTSI scored the highest sensitivity. The modified CTSI poorly predicted AP, patients' mortality, and SAP. Conclusion The BISAP score provides a straightforward and accurate way to analyze the seriousness of AP. Ranson's score is also a reliable indicator of ongoing organ failure among AP cases. The most reliable technique for predicting pancreatitis mortality is the APACHE II score.

To analyze the clinical value of immature granulocytes in peripheral blood for prediction of persistent systemic inflammatory response syndrome (SIRS) in patients with acute pancreatitis (AP). 1 973 patients with AP in Hunan People's Hospital from 2012 to 2017 were retrospectively enrolled and divided by SIRS duration into the persistent SIRS group, temporary SIRS group and non-SIRS group. The independent risk factor for persistent SIRS in AP patients was evaluated by Logistic regression analysis, and predictive value of immature granulocytes for persistent SIRS in AP patients was analyzed by the receiver operating characteristic (ROC) curve. These 1 973 AP patients (1 165 males, 59.0%) with an average age of 49 (40, 60) years old, including 288 persistent SIRS, 189 temporary SIRS and 1 496 non-SIRS cases. There was no significant difference in gender, age and etiology among three groups. Compared with non-SIRS group, more severe symptoms were observed in the temporary and persistent SIRS groups. Moreover, The acute physiology and chronic health evaluation II (APACHE II), CT severity index (CTSI), multiple organ failure (MOF) and acute respiratory distress syndrome (ARDS) incidence, mortality and C-reactive protein (CRP), white blood cell count (WBC), procalcitonin (PCT) and immature granulocytes in persistent SIRS group were further higher than those in the temporary SIRS group [APACHE II: 9 (6, 12) vs. 5 (3, 7), CTSI: 6 (4, 6) vs. 4 (3, 6), MOF incidence: 92.0% vs. 32.8%, ARDS incidence: 39.9% vs. 10.1%, morbidity: 11.1% vs. 4.2%, CRP (mg/L): 25.00 (0.80, 212.25) vs. 0.80 (0.80, 123.50), WBC (×109/L): 15.17±6.78 vs. 14.84±5.86, PCT (g/L): 0.23 (0.10, 1.76) vs. 0.10 (0.10, 0.31), immature granulocytes: 1.95 (0.90, 4.95) % vs. 0.80 (0.40, 2.10) %, all P < 0.05]. Logistic regression analysis showed that besides pancreatic necrosis, WBC and CRP, immature granulocyte was an independent risk factor for persistent SIRS associated with AP [odds ratio (OR) = 1.844, 95% confidence interval (95%CI) = 1.372-2.220]. ROC curve showed that immature granulocytes had better predictive value for persistent SIRS, the area under the curve (AUC) was 0.806, which was significantly higher than the APACHE II (AUC = 0.783), CTSI (AUC = 0.752), PCT (AUC = 0.676), CRP (AUC = 0.677), WBC (AUC = 0.644). The cut-off value of immature granulocyte was 0.65%, the sensitivity was 84.0%, the specificity was 66.3%, the positive predictive value was 62.4%, and the negative predictive value was 76.3%. Immature granulocyte in peripheral blood is a potential indicator for persistent SIRS in AP patients.