scoring and risk stratification of acute pancreatitis

REVISED ATLANTA CLASSIFICATION &

SEVERITY SCORING SYSTEMS

DR. ADITI AICH (Internee Malda Medical College and Hospital)

Why speak of a classification

Revised atlanta classification

Need of severity stratification

Different stratification systems

What about Paediatric age group

Recommendation

OVERVIEW

WHY SPEAK OF A CLASSIFICATION

-Early assessment and accurate prediction - Wide spectrum of the disease- Care of patients is highly individualised- Difference of treatment protocol on basis of severity- Difference of treatment protocol in different set ups.

Atlanta classification, 1992.

Determinant based atlanta classification(2012)

Revised Atlanta classification, 2013

ATLANTA CLASSIFICATION FOR ACUTE PANCREATITIS

•ORGAN FAILURE•LOCAL COMPLICATIONS

*RANSON’S SCORE>/=3 *APACHE II SCORE >/=8

Local determinants: Fluid collectionsNecrosis of pancreas +/

Peripancreatic tissue (covered by the term peripancreatic necrosis)

Systemic determinants: Certain degree of OF due

to AP

DETERMINANT BASED CLASSIFICATION

Define Organ failure:ShockPulmonary insufficiencyRenal failure after rehydrationGI bleeding

According to the Revised Atlanta Classification - complications of AP can be

Organ failure Organ failure to be evaluated by the Modified Marshall

Scoring System. Organ failure = Marshall Score ≥ 2

Local complications Systemic complications

Organ failure: Transient: resolves

within 48 h of onset Persistent : persists ≥

48 h

REVISED ATLANTA CLASSIFICATION

Local complications: o Fluid collections

o Gastric outlet dysfunction, o Splenic and portal vein thrombosis, and o Colonic necrosis.

Four discrete types of collections:• Acute peripancreatic fluid collection (APFC), • Pancreatic pseudocyst (PP)• Acute necrotic collection (ANC) • Walled off necrosis (WON)

Atlanta classification(1992)

Revised Atlanta classification (2013)

Determinant based classification(2012)

Mild AP: Minimal organ

dysfunction and uneventful recovery

Absence of organ failure and/or local complications

Severe AP: Organ failure and/or

local complications

Mild AP: No organ failure No local or systemic

complicationsModerately severe AP: Transient organ failure

AND/OR local or systemic complication OR exacerbation of pre-existing co-morbidities

Severe AP: Persistent organ failure

(single/multiple)

Mild AP: No organ failure No (peri) pancreatic

necrosisModerate AP: Sterile (peri) pancreatic

necrosis AND/OR transient organ failure

Severe AP: Infected (peri) pancreatic

necrosis OR persistent organ failure

Critical AP: Infected (peri) pancreatic

necrosis AND persistent organ failure

Definition of severity of acute pancreatitis according to different classification system

WHY A SEVERITY STRATIFICATION IS NEEDED:-

SEVERITY STRATIFICATION OF ACUTE PANCREATITIS

WHY A SEVERITY STRATIFICATION IS NEEDED:-

Diagnosis

Severity stratificationPredicted

mild diseasePredicted

severe disease

Aetiologicalassessment

Management on ward

Treatment of other

aetiological factors

Referral to a specialist unit

Eradication of gallstones

Management on HDU/ITU

Dynamic CT?ERCP

Monitor for complications

Management of complications

SCORING SYSTEMSPathology-specific scoring systems Ranson Glasgow and Imrie

To evaluate patients in intensive care units APACHE scoring systems (APACHE II)

To distinguish and diagnosis local complications. CT severity index(CTSI)

Organ Failure (OF) Based Scoring Systems / should be treated in ICU Marshall

SOFATo predict the mortality risk during the first 24 hours of the diseases. BISAP

Variables of the Ranson criteria and Modified Glasgow system:For Acute Non Gall Stone Pancreatitis

Ranson criteriaUpon admission:1) Age > 55 years2) WBC > 16000/mm3

3) Glucose > 200 mg /dl4) LDH > 350 IU/L5) AST > 250 IU/LWithin 48 hours6) Drop in HCT > 10%7) Serum Calcium < 8 mg/dl8) Base deficit > 4mE/L9) Increase BUN > 5 mg/dl10) Fluid deficit > 6L11) Arterial PO2 < 60 mm Hg

Modified Glasgow System1) Arterial PO2 <60 mm

Hg2) Ser albumin<3.2

mg/dl3) Ser Calcium<8 mg/dl4) WBC > 15000/mm3

5) AST > 200 IU / L6) LDH > 600 IU/L7) Glucose > 180 mg /dl8) BUN > 45 mg/dl

Variables of the Ranson criteria: For Acute Gall Stone PancreatitisUpon admission:1) Age > 70 years2) WBC > 18000/mm3

3) Glucose > 220 mg /dl4) LDH > 400 IU/L5) AST > 440 IU/L

Within 48 hours1) Drop in HCT > 10%2) Serum Calcium < 8 mg/dl3) Base deficit > 4mE/L4) Increase BUN > 2 mg/dl5) Fluid deficit > 6L6) Arterial PO2 < 60 mm Hg

0-2(mortality 0%)

3-4(mortality 3-4%)

5-6(mortality 50%)

>6(mortality70-90%)

APACHE The acute physiology score and the chronic health evaluation: First major attempts to quantify the severity of the illness in ICU patients

It contains 12 continuous variables

The major advantage of the APACHE II scoring system:

It can be used in monitoring the patient’s response to therapy(Ranson and the Glasgow scales are mainly meant for the assessment at presentation)

The APACHE II scoring system: 12 variables (1) Body temperature, (2) mean arterial pressure

(mm Hg), (3) Heart rate(HR), (4) respiratory rate (R.R/mt), (5) Oxygenation (mm Hg), (6) PH,

(7) Na (mmol/l), (8) k (mmol/l), (9) Creatinine

(mg/100ml), (10) Haematocrit, (11) total leucocyte count

and the (12) Glasgow coma score.

APACHE II - Score ≥ 8: organ failure / Substantial pancreatic necrosis Score ≥ 3: severe pancreatitis likely. Score Mortality 0-2 2%3-4 15%5-6 40%7-8 100%

APACHE II score > 8 points predicts 11% to 18% mortality.

APACHE О is proposed by Johnson et al

In patients with a BMI > 30,

It showed similar results between APACHE O and APACHE II

CTSI: Computed Tomography Severity Index

Grading system used to determine the severity of acute pancreatitis.

The numerical CTSI has a maximum of ten points It is the sum of the Balthazar grade points and

pancreatic necrosis grade points

CT SEVERITY INDEX (BALTHAZAR, 1990)

MODIFIED CT SEVERITY INDEX (MORTELE, 2004)

PROGNOSTIC INDICATOR

POINTS

PROGNOSTIC INDICATOR

POINTS

PANCREATIC

INFLAMMATION

PANCREATIC INFLAMMATION

NORMAL PANCREAS

0 NORMAL PANCREAS

0ENLARGED PANCREAS

1 PANCREATIC ABN +/-

PERIPANCREATIC INFLAMMATION

2

PANCREATIC ABNORMALITIES

WITH PERIPANCREATI

C INFLAMMATION

2 PANCREATIC OR PERIPANCREATIC

FLUID COLLECTION/ FAT

NECROSIS

4

SINGLE FLUID COLLECTION

32/MORE

COLLECTION OR GAS

4

CT SEVERITY INDEX (BALTHAZAR,1990)

MODIFIED CT SEVERITY INDEX (MORTELE,2004)

PROGNOSTIC INDICATOR

POINTS

PROGNOSTIC INDICATOR

POINT

SPANCREATIC NECROSIS

PANCREATIC NECROSIS

NONE 0 NONE 0

<30% 2 <30% 2 30-50% 4 >30% 4 >50% 6 EXTRAPANCREATIC

COMPLICATIONS 2

CT SEVERITY INDEX AND MODIFIED CTSI

Defining severity of Pancreatitis in terms of Ranson’s criteria, APACHE II, CT Severity Index

Type of Pancreatitis

Ranson’s criteria

APACHE II CT Severity Index

Mild Pancreatitis

≤ 3 < 8 < 7

Severe Pancreatitis

> 3 ≥ 8 ≥ 7

Marshall Scoring System

Most sensitive for evaluation of AP patients. 50% of the patients with necrotising acute pancreatitis develop organ

failure with severe acute pancreatitis. 15% of edematous acute pancreatitis develop organ failure.

Score > 3 is associated with Severe course, Systemic complications and Significant correlation with fatal outcome (Р = 0.007) .

Criteria for organ failure based on Marshall scoring system:Organ system

Score0 1 2 3 4

Respiratory (PaO2/FiO2)

>400 301-400 201-300 101-200 <100

Renal (Serum Creatinine md/dl)

≤1.5 >1.5 - ≤ 1.9

>1.9 - ≤ 3.5 >3.5 - ≤ 5.0

> 5.0

Cardiovascular (systolic blood pressure, mm Hg)

>90 <90, fluid responsiv

e

<90, fluid unresponsi

ve

<90, pH<7.3

<90, pH<7.2

SOFA: SEQUENTIAL ORGAN FAILURE ASSESSMENT

It is a mortality prediction score that is based on the degree of dysfunction of 6 organ systems.

The score is calculated on admission and every 24 hours until discharge using the worst parameters measured during the prior 24 hours.

SOFA SCORESOFA Score

Variables 0 1 2 3 4

Respiratory(PaO2/FiO2)

> 400 ≤ 400 ≤ 300 ≤ 200 ( with respiratory support)

≤ 100(with respiratory support)

Coagulation ( Platelets x 103/µL)

> 150 ≤ 150 ≤ 100 ≤ 50 ≤ 20

Liver( Bilirubin: mg/dl)

< 1.2 1.2 – 1.9 2.0 – 5.9 6.0 – 11.9 > 12.0

Cardiovascular (Hypotension)

No hypotension

Mean Arterial Pressure < 70 mm of Hg

Dopamine ≤ 5 (microgram/kg/min) or Dobutamine (any dose)Adrenergic agents administered for atleast one hour

Dopamine > 5 (microgram/kg/min), Epinephrine ≤ 0.1 (microgram/kg/min), or Norepinephrine ≤ 0.0Adrenergic agents administered for atleast one hour

Dopamine > 15 (microgram/kg/min), Epinephrine > 0.1 (microgram/kg/min), or Norepinephrine > 0.0Adrenergic agents administered for atleast one hour

Central nervous system(Glasgow coma scale)

15 13-14 10-12 6-9 <6

Renal(Creatinine – mg/dl or Urine output ml/day

<1.2 1.2-1.9 2.0-3.4 3.5-4.9 or < 500 > 5.0 or < 200

BISAP: Bedside index for severity in Acute Pancreatitis

1. BUN > 25mg/dl.

2. Impaired mental status ( Glasgow Coma Score < 13)3.

SIRS

4. Age > 60 years

5. Pleural effusion detected on imaging.

One point is assigned for each variable within 24 hours of presentation and added for a composite score of 0-5.

• Incremental increases in the BISAP score (3 or more) have been shown to correlate with an increased risk of organ failure pancreatic necrosis and mortality

WHAT WE ARE USING IN MLDMCH

• RANSON’S *BALTHAZAR *APACHEII

WHAT WE AIM AT USING

• APACHEII *MARSHALL’S *SOFA

A STEP TOWARDS BETTERMENT

RECOMMENDATION

Severity stratification should be made in all patients within 48 hrs. It is recommended that all patients should be assessed by glasgow score and CRP.

The APACHE II score is equally accurate and may be used for initial assessment and ongoing monitoring in severe cases.

THANK YOU