A comparison of scoring systems and biomarkers to predict the severity of acute pancreatitis in patients referring to the emergency clinic

Abstract

To investigate scoring systems and biomarkers for determining the severity and prognosis of acute pancreatitis (AP). Between January and July 2023, 100 patients with AP diagnosed and treated in the emergency department were included. AP was divided into 2 groups according to severity: mild AP and moderately severe AP (MSAP-SAP), according to the revised Atlanta Classification in 2012. Demographic characteristics, severity, intensive care unit (ICU) admission, white blood cell count (WBC), hematocrit, red cell distribution width from whole blood taken at admission and 48 hours later, C-reactive protein (CRP) and biochemistry values, Bedside Index for Severity in Acute Pancreatitis (BISAP), Pancreatitis Activity Scoring System (PASS), and harmless AP score scores were recorded retrospectively. Our variables, which were found to be significant in multiple logistic regression results, were found to increase MSAP-SAP expectation by 4.36-, 7.85-, 6.63 and 5.80 times in the presence of CRP > 47.10, WBC > 13.10, PASS > 0, and necrotizing computed tomography findings, respectively. It was detected that the risk factor which was found significant as a single variable affecting the ICU admission increased the risk of ICU requirement by 28.88 when PASS > 0, by 3.96 when BISAP > 1, and it increased the Atlanta score by 9.93-fold. We found that WBC and CRP values at the time of hospital admission and WBC, CRP, and red cell distribution width values after 48 had the highest accuracy in determining AP disease severity. BISAP, which was found to be significant in determining MSAP-SAP expectations, lost its significance in multiple logistic regression results, and PASS was found to be effective. The PASS is an important score in the clinical evaluation of patients with AP and in determining the need for ICU hospitalization.

1. Introduction

Acute pancreatitis (AP) is one of the most common causes of acute abdominal pain, leading to hospitalization all over the world.^[1] Alcohol intake, gallstones, and hypertriglyceridemia are the most common etiological factors.^[2] The presentation of the disease may vary between a mild, self-limiting course and a severe form requiring hospitalization in the intensive care unit (ICU).^[3] The overall mortality rate is 2.1%; however, this rate may increase to 17% in severe acute pancreatitis.^[4] AP is divided into 3 parts according to severity: mild, moderately severe, and severe AP to the Atlanta Classification revised in 2012.^[5] Mild AP (MAP) is defined as AP without both organ failure and complications; moderately severe AP (MSAP) is defined as AP with organ failure or local complications for <48 hours, and severe AP (SAP) is defined as AP with organ failure persisting for more than 48 hours.^[6] Most patients present with MAP or MSAP, and 15% to 20% of patients have SAP only.^[7] The mortality rates of MAP and MSAP were significantly lower than that of SAP. MAP usually resolves within a few days without requiring hospitalization.^[8] Admission to the ICU is recommended for patients with SAP or major comorbidities. Early hospital admission or ICU treatment may improve the outcomes in these patients.^[9]

Early prediction of AP severity and rapid treatment may decrease morbidity and mortality rates.^[10] There is no specific treatment for AP, and the treatment is supportive.^[11] The treatment approach is mainly based on fluid administration, enteral nutrition, and pain management.^[12] Scoring systems and biochemical markers that predict disease severity are widely used in AP management. Some of these include the Bedside Index for Severity in Acute Pancreatitis (BISAP), Pancreatitis Activity Scoring System (PASS), and harmless AP score (HAPS). Biochemical markers such as blood urea nitrogen (BUN), amylase, lipase, C-reactive protein (CRP), and hematocrit (Hct) were also used for this purpose.

The BISAP score was developed to identify early mortality and high-risk patients during the course of AP.^[13] Calculation of the BISAP score is simple and uses routine clinical data within 24 hours of hospital admission.^[14]

HAPS is a scoring system that is easy to implement for AP and determines which patients will have mild pancreatitis.^[15,16]

Unlike severity scores, which categorize AP according to outcomes, PASS is calculated using dynamic symptoms.^[17] PASS reflects the development of disease symptoms during hospitalization and provides a real-time, dynamic measurement of disease activity.^[18]

The aim of our study was to investigate a noncomplex, rapid scoring system and biomarkers that can be easily measured in the early period to assess the severity of AP and reliably predict adverse outcomes. The aim of the present study was to analyze the superiority of the BISAP, PASS, HAPS scores, and biochemical markers in determining the severity of AP.

2. Material and method

A total (100) patients with AP who were diagnosed and started to be treated in the emergency clinic between January 2023 and July 2023 were enrolled in the study after approval from the Committee of Ethics (No:13.09.2023/125). The requirement for informed consent was waived because the data were anonymous and used retrospectively. Patient files were retrospectively reviewed, and various clinical and biochemical parameters were evaluated at a single center at admission and 48 hours after admission. Patients who were diagnosed with AP for the first time at and above 18 years of age and who fulfilled the diagnostic criteria for AP according to the Revised Atlanta Classification (2012) guidelines were included in the study. Patients below 18 years of age, pregnant patients, those with acute exacerbation of chronic pancreatitis, patients with any malignancy associated with AP, hematological disorders, other concomitant infections and inflammations, patients with missing clinical data, and those with incomplete follow-up information were excluded from this study. Demographic characteristics, etiology, severity, and prognosis of the disease, ICU admission, length of hospital stay, white blood cell count (WBC), hematocrit, red cell distribution width (RDW), CRP, amylase, lipase, BUN values, and BISAP, PASS, and HAPS scores were recorded. The ICU requirement was determined based on the clinical condition of the patient. All patients underwent computed tomography (CT) to determine the development of fluid collection, extent of inflammation, and necrotic changes within 48 hours of hospital admission.

AP was diagnosed based on the presence of 2 of the following 3 characteristics: persistent abdominal pain, a threefold increase in serum amylase and/or lipase levels, and characteristic findings on abdominal imaging.

The severity of AP was determined according to the Revised Atlanta Classification. Patients were divided into 2 groups, MAP and moderately severe acute pancreatitis (MSAP-SAP), according to AP severity.

BISAP was calculated from the first 24 hours and 48 hours after the patient’s admission using the following 5 parameters: BUN > 25 mg/dL, impaired mental status, presence of systemic inflammatory response syndrome, age > 60 years, and detection of pleural effusion by imaging. One point was given for each parameter and the total maximum score was calculated to be 5. A score below 3 indicated mild pancreatitis, whereas a score of ≥3 indicated severe pancreatitis.

PASS was calculated from the first 24 and 48 hours after the patient’s admission using the following 5 parameters: organ failure (100 points for organ failure in each system), oral intolerance to solid foods (40 points), systemic inflammatory response syndrome (25 points for each item), abdominal pain (5 points for each degree increase), and opioid administration (5 points for each mg).

HAPS was calculated from the first 24 hours and 48 hours after the patient’s admission using the following 3 parameters: peritonitis symptoms, serum creatinine, and Hct levels. The patient was classified as HAPS negative (−) if there were no signs of peritonitis at presentation, the serum creatinine level was below 2 mg/dL, and the Hct level was below 43% in males and below 39.6% in females. The HAPS was considered positive (+) if any of the above parameters were positive.

2.1. Statistical analysis

To determine the statistical methods to be applied, the Shapiro–Wilk normality test was first applied, and if the normality assumption was not met even in any of the groups, nonparametric test methods were selected. In this context, Student t test and/or Mann–Whitney U test were used to compare the variables obtained by measurement between 2 independent groups. To summarize continuous variables, mean and standard deviation and median (minimum–maximum) values were given along with median (minimum–maximum) values, and Fisher exact test and chi-square test results for categorical variables were expressed as frequency distributions and percentages. The area under the receiver operating characteristic curve provides an estimate of the overall accuracy of alternative tests. An area of 0.50 implies that the variable adds no information. The areas under the receiver operating characteristic curves and 95% confidence intervals for an alternative test were calculated as described by Hanley and McNeil.^[19] For the variables whose diagnostic powers were found to be statistically significant, the cutoff points determined according to the Youden index were given together with the relevant sensitivity and selectivity points. All variables with statistical significance in the univariate analyses were considered eligible for inclusion in multiple analyses and were tested for collinearity. Multiple logistic regression analysis using a Backward LR approach was performed. Variables that remained significant (P < .05) in the multivariate model were considered independent predictors. Hosmer-Lemeshow goodness of fit statistics were used to assess the model fit. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for all predictors.

3. Findings

The present study included 100 patients diagnosed with AP. The mean age of the patients was 54.55 ± 20 years; 50% of the patients were female and 50% were male. Fifty-eight (58%) AP patients were in the MAP group and 42 (42%) were in the MSAP-SAP group.

There was no statistically significant difference between the mean ages of the patients in the MAP and MSAP-SAP groups (P = .722). WBC and CRP values at the time of hospital admission and WBC, CRP, and RDW values after 48 hours were significantly higher in the MSAP-SAP group than in the MAP group (P < .001). There were no statistically significant differences between the groups for any of the other parameters (Table 1).

Table 1.

Comparison of mild and moderate-severe-severe groups of acute pancreatitis according to Atlanta scoring in terms of parameters.

	Mild		Moderately severe-severe		P
Height	164.6 ± 9.93	165 (150–192)	165.81 ± 9.47	169 (148–192)	.543*
Weight	76.33 ± 12.55	73.5 (49–106)	75.31 ± 14.24	73.5 (50–110)	.706*
BMI	28.39 ± 4.98	27.75 (19.1–40.6)	27.38 ± 4.72	27.1 (18–38.8)	.310*
Age	53.93 ± 20.92	51.5 (19–92)	55.4 ± 19.53	54 (19–91)	.722*
AP attack count	1.55 ± 1.29	1 (1–6)	1.81 ± 1.89	1 (1–9)	.411
Amylase (U/I)	1065.12 ± 1020.29	562 (61–4185)	1152.66 ± 968.85	857 (106–3507)	.582
Amylase (U/I) (48 hours)	185.39 ± 181.54	111 (20–823)	309.1 ± 472.55	142 (20–2735)	.224
BUN (mg/dL)	17.55 ± 11.98	13.5 (4–86)	21.35 ± 14.72	18.5 (5–79)	.138
BUN (mg/dL) (48 hours)	11.21 ± 7.12	9 (3–35)	16.6 ± 15.59	11 (5–85)	.070
CRP (mg/dL)	35.58 ± 57.27	9.69 (0.9–254)	121.16 ± 132.64	58.64 (1.8–403)	<.001
CRP (mg/dL) (48 hours)	50.27 ± 62	25.25 (1.4–277)	190.72 ± 118.61	212.2 (10.2–398.2)	<.001
Hematocrit (%)	39.93 ± 5.07	40.5 (27–50)	39.74 ± 6.22	40 (19–51)	.867*
Hematocrit (%) (48 hours)	35.95 ± 5.16	36 (25–48)	35.73 ± 6.26	36 (18–53)	.851*
Lipase (U/I)	1949.22 ± 1703.38	1364.5 (201–7902)	1789.55 ± 1714.83	1153.5 (100–8027)	.451
Lipase (U/I) (48 hours)	325.17 ± 498.51	185.5 (16–2707)	312.27 ± 423.34	176 (25–1796)	.890
RDW	13.88 ± 2.35	13 (12–29)	14.12 ± 1.53	14 (12–19)	.128
RDW (48 hours)	13.78 ± 2.32	13 (12–29)	14.12 ± 1.49	14 (11–19)	.030
WBC (×103/mm3)	11.29 ± 5.32	9.76 (5.34–35.87)	14.59 ± 5.92	13.6 (4.6–28.33)	.001
WBC (×103/mm3) (48 hours)	7.67 ± 3.05	6.735 (3.61–17.45)	11.57 ± 5.72	10.62 (4.17–30.09)	<.001

Mean ± St. dev. and median (Min.-Max.).

Laboratory tests on admission and at 48 hours.

BMI = body mass index; BUN = blood urea nitrogen; CRP = C-reactive protein; RDW = red cell distribution width; WBC = white blood cell count.

^*Represents Student t test P value and all others Mann–Whitney U test.

The rates of ICU admission, mortality, and necrotizing pancreatitis on CT were significantly higher in the MSAP-SAP group than in the MAP group (P = .001; P = .036; P = .010, respectively) (Table 2). The ex rate was 3 times higher in the MSAP-SAP group.

Table 2.

Demographic data of mild and moderate-severe-severe groups of acute pancreatitis according to Atlanta scoring.

n(%)		Mild	Moderately severe-severe	P
Alcohol	Non-alcohol consumer	51 (87.93)	39 (92.86)	.843*
	Alcohol consumer	6 (10.34)	3 (7.14)
	Quitted alcohol intake	1 (1.72)	0 (0)
CT finding	Edematous	51 (94.44)	32 (76.19)	.010
	Necrotizing	3 (5.56)	10 (23.81)
Gender	Female	31 (53.45)	19 (45.24)	.418
	Male	27 (46.55)	23 (54.76)
Diabetes	No	40 (68.97)	28 (66.67)	.808
	Yes	18 (31.03)	14 (33.33)
Hypertension	No	37 (63.79)	25 (59.52)	.664
	Yes	21 (36.21)	17 (40.48)
Cardiovascular disease	No	49 (84.48)	36 (85.71)	1.000*
	Coronary artery disease	7 (12.07)	5 (11.9)
	Heart failure	2 (3.45)	1 (2.38)
CRF	No	56 (96.55)	40 (95.24)	1.000*
	Yes	2 (3.45)	2 (4.76)
COPD	No	55 (94.83)	42 (100)	.262*
	Yes	3 (5.17)	0 (0)
Cholecystectomy	No	51 (87.93)	39 (92.86)	.513*
	Yes	7 (12.07)	3 (7.14)
Mortality	Survive	53 (91.38)	32 (76.19)	.036
	Exitus	5 (8.62)	10 (23.81)
Smoking	Nonsmoker	36 (62.07)	23 (54.76)	.669*
	Smoker	17 (29.31)	16 (38.1)
	Quit smoking	5 (8.62)	3 (7.14)
ICU admission	No	56 (96.55)	31 (73.81)	.001
	Yes	2 (3.45)	11 (26.19)

COPD = chronic obstructive pulmonary disease, CRF = chronic renal failure, CT = computed tomography, ICU = intensive care unit.

^*Represents Fisher exact P value.

In the MSAP-SAP group, BISAP and PASS scores were significantly higher at presentation and 48 hours after presentation (Table 3) (Fig. 1). There was no statistically significant difference in the HAPS scores of the patients in the MAP and MSAP-SAP groups (P = .392).

Table 3.

Comparison of moderate-severe and mild groups in terms of BISAP, PASS score according to Atlanta scoring.

	Mild		Moderately severe-severe		P
BISAP (admission)	0.74 ± 0.93	0 (0–3)	1.52 ± 1.29	1 (0–4)	.002
BISAP (48 hours)	0.52 ± 0.71	0 (0–2)	1.22 ± 1.24	1 (0–4)	.003
PASS (admission)	0.07 ± 0.26	0 (0–1)	0.69 ± 1.42	0 (0–8)	<.001
PASS (48 hours)	0.03 ± 0.18	0 (0–1)	0.95 ± 2.19	0 (0–10)	<.001

Mean ± st. dev. and median (min.–max.).

BISAP = Bedside Index of Severity in Acute Pancreatitis, PASS = Pancreatitis Activity Scoring System.

Figure 1.

Comparison of moderate–severe and mild groups in terms of BISAP, PASS score according to Atlanta scoring.

Among the continuous variables, the values of WBC, CRP, WBC, CRP, and RDW at the time of hospital admission and 48 hours later were found to have the power to diagnose MSAP-SAP. The cutoff points for these variables were calculated according to the Youden index. The Youden index cutoff points where the sensitivity and selectivity points were the highest together were calculated as >13.1, >47.1, >9.1, >98, and >14, respectively, for the values of WBC, CRP, WBC, CRP, and RDW after 48 hours (Table 4). A graph of the area under the curve is presented in Figure 2.

Table 4.

ROC analysis results for WBC, CRP, RDW values at admission and 48 hours later.

	AUC ± st. error	95% C.I. (L-U)	P	Sensitivity	Specificity	Youden
WBC (×103/mm3)	0.684 ± 0.056	0.574–0.795	.002	64.29	77.59	>13.1
WBC (×103/mm3) (48 hours)	0.733 ± 0.052	0.631–0.835	.000	58.54	79.31	>9.1
CRP (mg/dL)	0.767 ± 0.049	0.672–0.863	<.001	59.52	82.76	>47.1
CRP (mg/dL) (48 hours)	0.847 ± 0.040	0.768–0.927	<.001	72.50	89.66	>98
RDW (48 hours)	0.629 ± 0.057	0.517–0.742	.030	29.27	87.93	>14.0
RDW	0.597 ± 0.058	0.483–0.712	.101

AUC = area under the curve, CI = confidence interval, CRP = C-reactive protein, RDW = red cell distribution width, ROC = receiver operating characteristic, WBC = white blood cell count.

Figure 2.

ROC analysis results for WBC, CRP, RDW values at admission and 48 hours later. ROC = receiver operating characteristic.

The values of the continuous variables BISAP and PASS at the time of hospital admission and 48 hours later were found capable of distinguishing the patients in the MSAP-SAP group from those in the MAP group (Table 5) (Fig. 3).

Table 5.

ROC analysis results for BISAP, CRP, PASS values at admission and 48 hours later.

	AUC ± St. error	95% C.I. (L-U)	P	Sensitivity	Specificity	Youden
BISAP (admission)	0.661 ± 0.056	0.551–0.771	.007	76.19	55.17	>0.0
BISAP (48 hours)	0.663 ± 0.057	0.551–0.774	.006	65.85	60.34	>0.0
PASS (admission)	0.631 ± 0.059	0.515–0.748	.027	35.71	93.10	>0.0
PASS (48 hours)	0.624 ± 0.060	0.507–0.741	.038	27.50	96.55	>0.0

AUC = area under the curve, BISAP = Bedside Index of Severity in Acute Pancreatitis, CI = confidence interval, PASS = Pancreatitis activity scoring system, ROC = receiver operating characteristic.

Figure 3.

ROC analysis results for WBC PASS RDW at admission and 48 hours later. ROC = receiver operating characteristic.

Logistic regression analysis was used to determine the MSAP-SAP risk factors. A multiple logistic regression model was established with CRP, WBC, PASS, CT, and BISAP, which were determined as univariate risk factors. It was found that BISAP, which was significant as a univariate, lost its significance in multiple logistic regression results, and its effect was found to be within the other significant variables. Multiple logistic regression results demonstrated that CRP level above 47.10 increased the MSAP-SAP expectation by 4.36-fold, WBC above 13.10 by 7.85-fold, PASS above 0 by 6.63-fold, and necrotizing CT finding by 5.80-fold (Table 6).

Table 6.

Factors affecting MSAP-SAP risk.

Univariate log regression				Multiple log. regression
Variables	B ± S.E.	OR (95C.I.)	P	B ± S.E.	OR (95C.I.)	P
CRP > 47.10	1.83 ± 0.45	6.28 (2.55–15.46)	<.001	1.47 ± 0.55	4.36 (1.46–13.00)	.008
WBC > 13.10	1.73 ± 0.44	5.65 (2.33–13.52)	<.001	2.06 ± 0.55	7.85 (2.64–23.37)	<.001
PASS > 0.0	2.01 ± 0.61	7.50 (2.26–24.79)	.001	1.89 ± 0.70	6.63 (1.65–26.59)	.008
CT (Necrotizing)	1.67 ± 0.69	5.31 (1.35–20.77)	.016	1.75 ± 0.85	5.80 (1.09–30.68)	.039
BISAP > 0.0	1.37 ± 0.44	3.93 (1.63–9.48)	.002

BISAP = Bedside Index of Severity in Acute Pancreatitis, CRP = C-reactive protein, CT = computed tomography, PASS = Pancreatitis activity scoring system, WBC = white blood cell count

BISAP and PASS scores at the time of admission and 48 hours later were found to be higher in patients admitted to the ICU; however, there was no statistically significant difference in terms of the HAPS score. This shows that the BISAP and PASS scores predict ICU admission of patients with AP.

Among continuous variables, BISAP and PASS were found to be capable of identifying ICU patients (Table 7) (Fig. 4).

Table 7.

ROC analysis results for BISAP and PASS values on admission and 48 hours later in patients admitted to ICU.

	AUC ± st. error	95% C.I. (L-U)	P	Sensitivity	Specificity	Youden
BISAP (admission)	0.719 ± 0.083	0.557–0.882	.014	61.54	71.26	>1.0
BISAP (48 hours)	0.804 ± 0.080	0.551–0.774	.001	66.67	86.21	>1.0
PASS (admission)	0.844 ± 0.077	0.693–0.995	<.001	76.92	89.66	>0.0
PASS (48 hours)	0.819 ± 0.085	0.507–0.741	<.001	66.67	94.19	>0.0

AUC = area under the curve, BISAP = Bedside Index of Severity in Acute Pancreatitis, CI = confidence interval, PASS = Pancreatitis activity scoring system, ROC = receiver operating characteristic.

Figure 4.

The area under the curve graph for BISAP and PASS on admission and 48 hours later in patients admitted to ICU.

It was detected that the risk factor which was found significant as a single variable affecting the ICU admission increased the risk of ICU requirement by 28.88 PASS was above 0, by 3.96 when BISAP was above 1; and it increased the Atlanta score by 9.93-fold. It was found that BISAP and Atlanta were no longer determinants in the presence of PASS according to the multiple models (Table 8).

Table 8.

Factors affecting the intensive care risk.

Univariate log regression				Multiple log. regression
Variables	B ± S.E.	OR (95C.I.)	P	B ± S.E.	OR (95C.I.)	P
PASS > 0.0	3.36 ± 0.74	28.88 (6.68–124.78)	<.001	2.91 ± 0.77	18.46 (4.02–84.73)	<.001
BISAP > 1.0	1.37 ± 0.61	3.96 (1.18–13.30)	.026
Atlanta	2.29 ± 0.80	9.93 (2.06–47.71)	.004

BISAP = Bedside Index of Severity in Acute Pancreatitis, PASS = Pancreatitis Activity Scoring System.

Therefore, we believe that the PASS may be the most effective score for the early prediction of AP patients who require ICU hospitalization.

4. Discussion

The effectiveness of the BISAP, PASS, HAPS scores, and biochemical markers in determining the severity of AP was evaluated in the present study. We found that WBC and CRP values at the time of hospital admission and WBC, CRP, and RDW values after 48 hours had the highest accuracy in the determination of AP disease severity. PASS and BISAP had the highest accuracy in predicting MSAP-SAP. BISAP, which was found to be significant univariately to determine the MSAP-SAP expectation, lost its significance in the multiple logistic regression results, and PASS was found to be effective. We believe that the PASS could be used as an important score in the clinical evaluation of patients with AP and to determine the need for ICU hospitalization.

AP is an inflammatory process, and CRP, which is an acute phase reactant, is a common marker for determining its severity.^[20] It was reported in the World Gastroenterology Congress Guideline published in 2022 that CRP level above 15 mg/dL measured 48 hours later was a prognostic factor.^[21] In our study, WBC and CRP values at hospital admission and WBC and CRP values 48 hours later were found to be significantly higher in the MSAP-SAP group. This confirms the conclusion that these values have predictive value in determining AP severity. Similar to our results, Ünal et al found that WBC and CRP increases were useful parameters to indicate the severity of AP.^[22] Bhatia et al found that patients with lower CRP levels at baseline had a milder course of AP and fewer associated complications.^[23] Many studies have concluded that the clinical utility of CRP in the early stages of AP is limited and that the use of CRP alone potentially fails to detect severe cases of AP earlier.^[24,25]

RDW, which is a calculable measure of variability in erythrocyte volume, is an easy, cheap, and routinely used parameter as part of the complete blood count test. Hu et al found that RDW was positively correlated with AP severity and was an important prognostic marker of AP severity and mortality.^[26] In our study, RDW values 48 hours later were found to be significantly higher in the MSAP-SAP group, and we believe that these parameters are useful to show the severity of AP.

Although clinical presentation and elevated pancreatic enzymes are important in the diagnosis of AP, CT scans are commonly used to confirm the diagnosis and estimate disease severity.^[27] The presence of necrosis on CT scans in AP was associated with mortality.^[28] Our study confirmed this result, and necrotizing CT findings were higher in the MSAP-SAP group.

The annual incidence of AP is increasing. Patients with MSAP and SAP have higher mortality rates.^[29] Therefore, early prediction and intervention for the progression of AP to severe disease is important for clinicians. In the present study, a higher difference in mortality was found in the MSAP-SAP group. Identification of high-risk patients is a useful predictor for effective treatment in the ICU. In our study, a significant difference was observed in the MSAP-SAP group in terms of ICU hospitalization.

Prognosis assessment using only 1 biochemical marker or score is unreliable. Multiple scores are often required to assess patients with MSAP or SAP. BISAP has been proposed as a simple method for predicting severe AP.^[30] Gao et al found that the BISAP is a useful score for predicting SAP in their study.^[13]

The PASS, which is another scoring system, is important for predicting the severity of the disease, as well as for measuring responses to treatment. Buxbaum et al found in their study that PASS values at hospital admission and afterwards were correlated with the clinical outcomes of AP.^[31] Higher PASS values at hospitalization have also been associated with additional parameters such as increased length of hospital stay and the need for ICU admission. PASS may provide useful information about the expected length of hospital stay, even within the first 24 hours.^[17] The inclusion of elements reflecting patient symptoms (qualitative measures such as pain and ability to tolerate oral feeding) in addition to biochemical parameters is hypothesized to underpin the score’s ability to predict the length of hospital stay and early readmission.^[32] The PASS is a promising score for measuring responses to treatment and evaluating the resolution of the disease. In our study, BISAP and PASS values were significantly higher in the MSAP-SAP group. In the multiple model, PASS above 0 increased the expectation of MSAP-SAP by 6.63-fold. The ability of the PASS to predict important clinical events at different points in the disease course suggests that it is a valid measure of activity in patients with AP.

The HAPS, which may be administered approximately 30 minutes after hospitalization, is a simple and convenient score for identifying patients with MPA.^[33] It accurately identifies patients with non-severe AP and facilitates the selection of patients who may be discharged after a short stay in the clinic or even be cared for at home.^[34] This may enable the utilization of hospital beds for other purposes and reduce health care costs. In our study, the HAPS was found to be ineffective in determining the severity of AP. The HAPS was designed to exclude patients with AP requiring ICU admission.^[35] In this study, it was not found to be effective in excluding patients with AP who required ICU hospitalization.

5. Conclusion

It was observed that the first 24 hours after symptom onset in AP is critical in identifying patients at risk of developing complications requiring ICU admission or death. Therefore, early hospitalization or ICU treatment by identifying high-risk patients with biomarkers and scores may be applied quickly, simply, and cheaply to prevent serious complications and reduce morbidity and mortality is very important. We found that WBC and CRP values at the time of hospital admission and WBC, CRP, and RDW values after 48 hours had the highest accuracy in the determination of AP disease severity. BISAP, which was detected significantly univariately for the determination of the MSAP-SAP expectation, lost its significance in multiple logistic regression results, and PASS was found to be effective. Furthermore, the PASS was found to be superior to other prognostic scoring methods in identifying patients with AP admitted to the ICU.

6. Limitation

Our study had some limitations, as it was a retrospective study. Furthermore, the sample size of the present study was small, and the study was conducted at a single tertiary care center. Further prospective and multicenter studies are required.

Acknowledgments

The authors thank Dr Deniz Öğütmen Koç for her advice and assistance.

Author contributions

Conceptualization: Ayşe Vahapoğlu.

Data curation: Mustafa Çalik.

Formal analysis: Ayşe Vahapoğlu.

Methodology: Ayşe Vahapoğlu.

Resources: Mustafa Çalik, Ayşe Vahapoğlu.

Software: Mustafa Çalik, Ayşe Vahapoğlu.

Writing – original draft: Ayşe Vahapoğlu.

Writing – review & editing: Ayşe Vahapoğlu