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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 22
| Issue : 3 | Page : 340-346 |
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Modified computed tomography severity index in evaluation of acute pancreatitis and its correlation with clinical outcome: A prospective observational study from a tertiary care teaching hospital, India
Archana D Dalal1, Yagnya D Dalal2, Devang A Rana3
1 Department of General Surgery, NHL Municipal Medical College, Ahmedabad, Gujarat, India
2 GCS Medical College, Hospital and Research Centre, Ahmedabad, Gujarat, India
3 Department of Pharmacology, NHL Municipal Medical College, Ahmedabad, Gujarat, India
| Date of Submission | 06-May-2022 |
| Date of Decision | 10-May-2022 |
| Date of Acceptance | 01-Aug-2022 |
| Date of Web Publication | 24-Jan-2023 |
Correspondence Address:
Archana D Dalal
Smt. NHL MMC, Ahmedabad, Gujarat
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/aam.aam_79_22
 Abstract | | |
Introduction: Acute pancreatitis (AP) is one of the most common yet, the most complex and challenging abdominal emergencies encountered by clinicians globally. It runs an unpredictable course. One-fifth of all AP patients develop complications. Many prognostic predictive scoring systems are used for AP. The aim of our study was to evaluate the usefulness of modified computed tomography severity index (MCTSI) scores to predict the need for intensive care unit (ICU) stay, complications, and mortality in patients of AP. Methodology: An observational, prospective study was conducted for 1 year. Fifty cases diagnosed as AP were included in this study. Contrast-enhanced computed tomography of the abdomen and pelvis was carried out in all patients. MCTSI was calculated according to CT findings. Patients' demographic details, clinical findings, duration of hospital stay, complications, and interventions were recorded. SPSS version 26.0 was used for statistical analysis. Results: A total of 50 patients were enrolled in the study. The mean age was 43.34 years. Total hospital stay was 9.02 ± 6.47 days, mean ward stay was 6.08 ± 2.73, and mean ICU stay was 2.94 ± 4.7 days. Five deaths were reported. There was a significant correlation between the necessity of ICU admission and grade of pancreatitis. There is significant correlation with age and ICU stay (r = 0.344, P = 0.014), age and ward stay (r = −0.340, P = 0.016), total duration of hospital stay and MCTSI score (r = 0.742, P = 0.000), duration of ward stay and MCTSI score (r = −0.442, P = 0.001), and strong correlation with duration of ICU stay and MCTSI score (r = 0.869, P = 0.000). A higher MCTSI score was significantly associated with the presence of local as well as systemic complications and with death (P = 0.0001). Conclusion: Grading by modified CT severity index has a significant direct correlation with the necessity of ICU admission, duration of ICU stay, and total duration of hospital stay. A modified CT severity index can be used to predict the possibility of developing local and systemic complications as well as the need for interventions. Modified CTSI is a reliable predictor of clinical course and outcome in cases of acute pancreatitis.
Résumé
Introduction: La pancréatite aiguë (PA) est l'une des urgences abdominales les plus courantes, les plus complexes et les plus difficiles rencontrées par les cliniciens du monde entier. Il suit un cours imprévisible. Un cinquième de tous les patients AP développent des complications. De nombreux scores pronostiques prédictifs systèmes sont utilisés pour AP. Le but de notre étude était d'évaluer l'utilité de l'indice de gravité de la tomodensitométrie modifiée (MCTSI) scores pour prédire le besoin de séjour en unité de soins intensifs (USI), les complications et la mortalité chez les patients atteints de PA. Méthodologie: Une observation, Une étude prospective a été menée pendant 1 an. Cinquante cas diagnostiqués comme AP ont été inclus dans cette étude. Tomodensitométrie à contraste amélioré de l'abdomen et du bassin a été réalisée chez tous les patients. Le MCTSI a été calculé en fonction des résultats de la TDM. Données démographiques des patients, les résultats cliniques, la durée du séjour à l'hôpital, les complications et les interventions ont été enregistrés. La version SPSS 26.0 a été utilisée pour l'analyse statistique. Résultats: Au total, 50 patients ont participé à l'étude. L'âge moyen était de 43,34 ans. Le séjour total à l'hôpital était de 9,02 ± 6,47 jours, en moyenne le séjour était de 6,08 ± 2,73 et le séjour moyen en USI était de 2,94 ± 4,7 jours. Cinq décès ont été signalés. Il y avait une corrélation significative entre la nécessité d'admission en USI et grade de pancréatite. Il existe une corrélation significative avec l'âge et le séjour en USI (r = 0,344, P = 0,014), l'âge et séjour en salle (r = −0,340, P = 0,016), durée totale du séjour à l'hôpital et score MCTSI (r = 0,742, P = 0,000), durée du séjour en salle et MCTSI score (r = -0,442, P = 0,001) et forte corrélation avec la durée du séjour en USI et le score MCTSI (r = 0,869, P = 0,000). Un score MCTSI plus élevé était significativement associée à la présence de complications locales et systémiques et au décès (P = 0,0001). Conclusion: classement par l'indice de gravité CT modifié a une corrélation directe significative avec la nécessité d'une admission en USI, la durée du séjour en USI et la durée totale de séjour à l'hôpital. Un indice de gravité CT modifié peut être utilisé pour prédire la possibilité de développer des complications locales et systémiques ainsi que le besoin d'interventions. Le CTSI modifié est un prédicteur fiable de l'évolution clinique et des résultats dans les cas de pancréatite aiguë.
Mots-clés: pancréatite aiguë, admission en unité de soins intensifs, complications locales et systémiques, gravité de la tomodensitométrie modifiée indice, pronostic
Keywords: Acute pancreatitis, intensive care unit admission, local and systemic complications, modified computed tomography severity index, prognosis
How to cite this article:
Dalal AD, Dalal YD, Rana DA. Modified computed tomography severity index in evaluation of acute pancreatitis and its correlation with clinical outcome: A prospective observational study from a tertiary care teaching hospital, India. Ann Afr Med 2023;22:340-6 |
How to cite this URL:
Dalal AD, Dalal YD, Rana DA. Modified computed tomography severity index in evaluation of acute pancreatitis and its correlation with clinical outcome: A prospective observational study from a tertiary care teaching hospital, India. Ann Afr Med [serial online] 2023 [cited 2023 Sep 26];22:340-6. Available from: https://www.annalsafrmed.org/text.asp?2023/22/3/340/368486 |
| Introduction | |  |
The incidence of acute pancreatitis (AP) per 100,000 population ranges from 5 to 80 cases per year, with the highest incidence rates reported in both Finland and the USA.[1] A South India-based tertiary care center reported 13.3% increase in cases of pancreatitis from 2000–2006 to 2007–2013.[2]
According to the Atlanta Classification, severe AP (SAP) is defined as an AP associated with local and/or systemic complications. Atlanta classification is a clinically based classification defining AP, its severity, and complications. As per the definition development of organ dysfunction within 72 h of symptom onset is called an early SAP.
AP is an important cause of morbidity and mortality. It may run an unpredictable course.[3]
Severe pancreatitis occurs in 20%–30% of all patients with AP and is characterized by a protracted clinical course, multiorgan failure, and pancreatic necrosis.[4]
Pancreatic necrosis is considered a potential risk for infection, which represents the primary cause of late mortality. The occurrence of acute respiratory failure (ARF), cardiovascular failure (CVF), and renal failure (RF) can predict the fatal outcome in SAP. Individual laboratory indices (markers of pancreatic injury, markers of inflammatory response), while promising, have not yet gained clinical acceptance. Ranson and Acute Physiology and Chronic Health Evaluation (APACHE) II are commonly used numeric grading scales used today as indicators of disease severity. RANSON score cannot be used for the first 48 h, and APACHE score is tedious to use. There are other scoring systems available such as the Glasgow score (eight criteria),[5] MOSS score (12 criteria), and BISAP score (5 criteria).[6]
Computed tomography (CT) severity index was used initially which was popularly called the Balthazar scoring system. Modified Computed Tomography Severity Index (MCTSI) differs from the computed tomography severity index (CTSI) by including the presence of extrapancreatic complications and grading the peripancreatic fluid collection in terms of the presence or absence instead of the number of fluid collections. The grading of pancreatic necrosis is also different in this system.[7]
Dynamic contrast-enhanced CT (CECT) has been shown to detect pancreatic parenchymal necrosis with a diagnostic sensitivity of 87% and an overall detection rate of 90%.
A comparison of the original CTSI showed a significant correlation between higher CTSI values and mortality and morbidity, and this holds true for the MCTSI. Furthermore, the MCTSI correlates well with the need for intensive care unit (ICU) stay, total length of hospital stay, and the development of organ failure.[8]
Objective
This study aimed to correlate the MCTSI grading system with patient outcomes in terms of organ failure, mortality, duration of ICU, and total hospital stay.
| Methodology | | |
This was a prospective observational study conducted for 1 year at a tertiary care teaching hospital. Fifty cases diagnosed as AP based on clinical findings, ultrasonography (USG) and/or CT findings, and serum amylase/lipase levels were included in the study. The institutional ethics committee approval and written informed consent were taken from the patient in writing both in English and vernacular language after assessing the following criteria.
Inclusion criteria
- Patients aged above 18 years
- Both male and female gender
- All patients with clinical/laboratory/radiological diagnosis of AP were willing to undergo CECT. The presence of at least two of the following:[9]
- Acute abdominal pain and tenderness suggestive of pancreatitis
- Serum amylase/lipase levels more than or equal to three times the normal value
- USG and/or CT imaging findings suggestive of AP.
Exclusion criteria
- Patients not willing to undergo any contrast study
- Patients with known history of allergy to contrast agents
- Patients with deranged renal function test (serum creatinine >1.5 mg/dl after rehydration)
- Pregnant females
- Patients with chronic pancreatitis
- Patients who were discharged against medical advice.
The clinical details included demographic data; detailed clinical history with presenting symptoms such as abdominal pain, nausea, vomiting, and fever with their duration. Any history suggestive of possible etiology or risk factors such as gallstone disease, alcohol intake, abdominal trauma, metabolic diseases, or any recent surgical procedure was also noted. Physical examination (local and systemic) including pulse rate, blood pressure, respiratory rate, temperature, icterus, and abdominal examination (tenderness, guarding, and rigidity)
These patients underwent CECT of the abdomen and pelvis. Postcontrast study was performed from the base of the thorax to the pubic symphysis. Contiguous axial sections were taken and reconstructed in different planes with varied thicknesses ranging from 1 mm to 10 mm. MCTSI was calculated according to CT findings.
Mortelé KJ MCTSI Scoring (2004)[10]
Patients were classified as mild, moderate, and SAP, based on the presence of organ failure for >48 h and local complications. Organ failure included shock (systolic blood pressure <90 mmHg), pulmonary insufficiency (arterial PO2 <60 mmHg at room air or the necessity for mechanical ventilation), or RF (serum creatinine level >2 mg/dl after rehydration or hemodialysis). Pancreatic necrosis was assessed by CECT. Evidence of pancreatic necrosis on CT scan was defined as a lack of enhancement of pancreatic parenchyma with contrast. The percentage of necrosis was calculated by inbuilt software.
The statistical significance of the correlation between MCTSI and need for ICU admission, duration of ICU stay, and total duration of hospital stay was calculated in terms of P value. P < 0.05 was considered statistically significant.
| Results | | |
The distribution of patients in our study according to the MCTSI is given in [Table 1]. The development of local and systemic complications is depicted in [Figure 1]. [Table 2] depicts mean of age, intensive care unit stay, ward stay, and total hospital stay in days with computed tomography grade. And [Table 3] depicts correlation of ICU stay, ward stay, and total hospital stay in days with computed tomography grade. | Table 1: Modified computed tomography severity index grade and number of patients (n=50)
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 | Figure 1: Correlation of CT grade with development of local and systemic complications. CT = Computed tomography
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 | Table 2: Mean of age, intensive care unit stay, ward stay, and total hospital stay in days with computed tomography grade
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 | Table 3: Correlation of intensive care unit stay, ward stay, and total hospital stay in days with computed tomography grade
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There was a significant correlation between the necessity of ICU admission and grade of pancreatitis. There is significant correlation with age and ICU stay (r = 0.344, P = 0.014), age and ward stay (r = −0.340, P = 0.016), total duration of hospital stay and CTSI score (r = 0.742, P = 0.000), duration of ward stay and CTSI score (r = −0.442, P = 0.001), and strong correlation with duration of ICU stay and CTSI score (r = 0.869, P = 0.000). Higher CT grade is significantly associated with the presence of local as well as systemic complications and death P = 0.0001.
| Discussion | | |
CECT is the gold standard modality for the diagnosis and staging of AP. We evaluated our cases with CECT and correlated the findings with patients' outcomes. The total age range of patients was from 22 years to 66 years. This observation was different from that of a study conducted by Lankisch et al.[11] which reported 2 years to 67 years.
Previous studies by Bollen et al. and Mortele et al. also have classified scores 0 and 2 as mild, scores 4 and 6 as moderate, and scores 8 and 10 as severe which is in accordance with our study.[12],[13]
Patients with a mild grade pancreatitis needed ICU admission in an average of 37.5%, moderate grade needed admission in 57.89%, and severe grade needed ICU admission in 100% of patients. There is statistically significant correlation between the duration of ICU stay and grade of pancreatitis too. Patients with a mild grade had a mean duration of stay in ICU of 0.42 days, moderate grade had a duration of stay of 2.26 days, and severe grade of pancreatitis had a duration of stay of 13.43 days. A strong correlation was seen between patients' CT grade and total duration of hospital stay. The mean duration of total hospital stay was 5.54 days for mild, 8.21 days for moderate, and 23.14 days for severe pancreatitis. The mean duration of ICU stay was 0.42 days for mild, 2.26 days for moderate, and 13.43 days for severe pancreatitis. A study by Mortele et al. (published in 2004) showed a significant proportionate correlation between the grade of pancreatitis and length of hospital stay.[13] The local complications identified in our study were pseudocysts, acute necrotic collections, infected necrosis, pancreatic abscess, and ascites. Pseudocyst was seen in 3 (6%) patients in our study. Pseudocyst formation occurred in half number of the patients in a study conducted by Gonzale et al.[14] Pancreatic abscess was detected in 2 (4%) patients in our study.
The presence of local complications was positively associated with CT grading. No local complications were seen in patients with mild pancreatitis. About 26.31% of patients with moderate pancreatitis and 100% of patients with severe pancreatitis had developed complications. In our study, 12 (24%) patients needed surgical debridement or radiological intervention. Thus, patients who needed intervention had severe CT grades and reported more complications. This is similar to the study by Bollen et al. which concluded that the development of local complications and the necessity for intervention were significantly associated with the grade of pancreatitis.[12] Systemic complications developed in 3 (6%) patients. The complications seen were shock and multiorgan failure. Systemic complications were seen only in patients with a CT grade of 8 and 10, which showed a statistically significant association. A significant association was also reported between the development of systemic complications and grading of AP by Bollen et al. Maximum patients who reported systemic complications were in severe grade.[12] In our study, infected pancreatic necrosis was identified in 4 (8%) patients. A study by Bollen et al. and Mortele et al. identified pancreatic necrosis in 18% and 15% of patients with AP, respectively.[12],[13] Necrosis occurs early, within the first 24–48 h, and with few exceptions remains stable during a given episode of AP.[4]
Mortality was seen in 5 (10%) patients in our study. Bollen et al. and Mortele et al. reported 6% and 1.5% mortality, respectively. All patients with grade 8 and grade 10 needed ICU admission.[12],[13] Diagnosis on basis of clinical evaluation is missed in 30%–40% of patients with fatal necrotizing pancreatitis until the time of autopsy. Thus, clinical signs have only limited value for the assessment of the severity of AP.[15]
In predicting the prognosis, there are several scoring indices that have been used as predictors of outcomes. Two commonly used scoring systems are the Ranson criteria and APACHE II indices. Most studies report that the APACHE score may be more accurate.[16],[17]
The APACHE II can be fully calculated on admission. However, the APACHE II is more cumbersome to calculate. Ranson's criteria had been used for many years to assess the severity of AP but have the disadvantage of requiring 48 h for a complete evaluation. The advantage of the APACHE-II score is the availability of this information within the first 24 h and daily. Increasing APACHE-II score in the first 48 h is strongly suggestive of the development of severe pancreatitis, whereas decreasing APACHE-II scores in the first 48 h strongly suggest mild pancreatitis. A previous study reported sensitivity and specificity of the APACHE II system as 75% and 79%, respectively.[18]
Many studies concluded the superiority of CTSI for grading pancreatitis over other clinico-biochemical indices such as APACHE II, Ranson, and C-reactive protein level.[19]
It was developed by Balthazar et al. to assess pancreatic edema, necrosis, and the presence of peripancreatic fluid collections. In the CTSI pilot study, a score of 7–10 was able to predict 92% morbidity and 17% mortality rate in patients with AP, compared to the low morbidity (2%) and mortality (0%) associated with a CTSI score of 0–1.[20]
The MCTSI correlates more closely with patient's outcome than the CT severity index, with similar interobserver variability. According to Bollen et al., when comparing the MCTSI and APACHE II, no statistically significant difference was found in mortality, ICU stay, and organ failure.[12] The MCSTI accurately correlated with pancreatic infection and the need for intervention compared with APACHE II. CECT is the investigation of choice for detecting local complications. Thus, the MCTSI is as useful as APACHE II in predicting the severity of AP in terms of ICU stay and organ failure and is better than APACHE II in detecting the local complications and confirming necrosis in AP. However, MCTSI has a disadvantage that the study cannot be carried out within 48 h as this is the time taken to demonstrate necrosis. However, the APACHE II score can be calculated even at the time of admission. However, the APACHE-II scoring system is not organ specific. It may vary in the presence of other concomitant pathologies. MCTSI is more organ specific. Hence, it can more accurately predict the outcome. The limitations of our study were – it was a nonrandomized study with small sample size; patients with mild clinical, laboratory, or USG features of AP could not be included in the present study as CT scan is not indicated in all cases of pancreatitis. Furthermore, we excluded pancreatitis patients with RF in the study. MCTSI score as expected had the highest accuracy for the prediction of pancreatic necrosis among the scoring systems.[1]
| Conclusion | | |
Grading by MCTSI has a significant proportionate correlation with the necessity of ICU admission, duration of ICU stay, and total duration of hospital stay. MCTSI can be used to predict the possibility of occurrence of local and systemic complications as well as the necessity for the interventions. It helps in escalating the management plans in patients with AP at the earlier stages and may help decrease morbidity and mortality. MCTSI is a reliable prognostic indicator for clinical outcomes in patients of AP. The rising incidence of AP in India and the reliability of MCTSI in predicting the behavior of AP mandate easy availability of CT scan facilities across the nation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3]
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