European Journal of Internal Medicine 20 (2009) e43 – e48

www.elsevier.com/locate/ejim

Original article
A simple prognostic score for risk assessment in patients
with acute pancreatitis
A. Gonzálvez-Gascha,⁎, G. García de Casasolab , R. Barba Martínb , B. Herrerosc , C. Guijarroc
a
Unidad de Medicina Interna, USP Hospital San Jaime, Partida de la Loma s/n, 03184 Torrevieja, Alicante, Spain
b
Hospital Infanta Cristina, Carretera de Madrid-Toledo (N-401), Km 23.6, 28980, Madrid, Spain
c
Hospital Universitario Fundación Alcorcón, C/ Budapest-1, 28922 Alcorcón, Madrid, Spain
Received 30 July 2008; received in revised form 6 September 2008; accepted 24 September 2008
Available online 22 November 2008

Abstract

Background: Acute pancreatitis (AP) is a common disease that poses potential serious problems. Its clinical course is often unpredictable.
Identification of high risk patients enables early appropriate treatment.
Methods: We conducted a prospective study to develop a new prognostic method that can objectively and easily grade the severity of AP within
the first 72 h of admission. The prediction rule was based on clinical and analytical parameters in 308 patients admitted in a community-based
hospital. We validated the score in 193 additional patients in the same hospital.
Results: Independent prognostic factors related to poor prognosis were age N 65 years, leucocytes N 13,000/mm3, albumin b 2.5 mg/dL, calcium
b 8.5 mg/dL and reactive C protein N150 mg/dL. We assigned points to each of the independent factors for complicated AP in proportion to the
regression coefficients. We defined three different risk groups according to the points obtained in the prediction rule. Low risk, 0 points (18%
patients, 0% risk), moderate, 1–3 points (56% patients, 19% risk) and high, 4–6 points (26% patients, 73% risk). The sensitivity of this formula
was 90% with specificity of 63%. The positive and negative predictive values were 50% and 94% respectively.
Conclusions: Our simple prediction rule is an additional tool that may help physicians stratifying the severity of AP. Patients with high risk for
complicated AP should be kept under close surveillance whereas low risk patients would not need special monitoring.
© 2008 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

Keywords: Acute pancreatitis; Prognosis; Prognostic factors; Severity stratification

1. Introduction outcome. Identifying which patients are likely to develop a

Most patients with AP run a benign course while up to 20%
develop severe complications [1]. Variability in disease pre-
sentation has contributed to the lack of consensus in the
management of patients with AP. The need of antibiotics [2],
nutritional treatment [3], endoscopic retrograde cholangiopan-
creatography [4] or surgery [5] is not well established. Quan-
tifying the severity of AP can monitor treatment and predict
⁎ Corresponding author. Avenida Oscar Espla-11, planta 1, puerta 1, Santa
Pola (Alicante) 03130, Spain. Tel.: +34 966921382, 966921313, +34
660404575 (Mobile phone); fax: +34 966922529.
E-mail address: asunggasch@yahoo.es (A. Gonzálvez-Gasch).
0953-6205/$ - see front matter © 2008 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.ejim.2008.09.014
complicated course might help the physician selecting the ones
who would benefit most from close surveillance or aggressive
intervention that would not help all patients with pancreatitis.
The optimal score to predict unfavourable prognosis in AP is
still lacking. Several classification models including a variety of
clinical and laboratory factors are available. Ranson system [6]
is the most commonly used in clinical practice though in our
opinion has several disadvantages. The original Ranson's study
was retrospective and focused on alcoholic AP which is pre-
dominant in middle aged men while in Spain, the main cause
of AP is microlithiasis and women are most frequently af-
fected. Thus, Ranson criteria might be poorly predictive when
applied to different groups of patients. In this study we aim
to prospectively develop an alternative prognostic system for
patients with AP in our clinical setting using physiologic and
e44 A. Gonzálvez-Gasch et al. / European Journal of Internal Medicine 20 (2009) e43–e48
laboratory features readily available during the first 72 h after
admission.
2. Materials and methods
Between January, 2004 and December, 2005, a total of 308
consecutive unselected patients with AP and aged more than
18 years old were included in the study.
The following clinical and laboratory data available on
admission and during the first 72 h of hospitalization were
recorded: age, gender, comorbidity, American Society of
Anesthesiologists score [7] calculated in each individual case,
AP etiology, number of previous AP, fever, hemoglobin,
hematocrit, platelets, leucocytes, glucose, urea, creatinine,
aspartate aminotransferase, alanine aminotransferase, alkaline
phosphatase, lactate dehydrogenase (LDH), bilirubin, albumin,
calcium, reactive C protein (RCP), arterial oxygen saturation
and bicarbonate.
The 308 patients group was evaluated to produce a clinical
prediction rule for complicated AP. Once the score was deve-
loped in the original group it was prospectively validated in an
independent set of 209 patients with AP admitted in our hospital
from January, 2006 to July, 2007.
AP was considered to be complicated or to have an un-
favourable outcome if any of the following variables was
present: hospital stay ≥ 11 days, need of pancreatic surgery or
draining procedures, need of admission in an intensive care unit,
computed tomography severity index (CTSI) [8] ≥ 6 or death.
2.1. Statistical methods
Statistical analysis was done with the Statistical Package for
the Social Sciences (SPSS, version 12.0).
Patients were divided in two different groups according to
their clinical outcome: favourable or unfavourable. Clinical and
laboratory data were compared between both sets.
The univariate significance of baseline continuous and cate-
gorical variables was estimated by the two-tailed Student's
t-test and the chi-square test respectively.
The accepted level of statistical significance for entry of
each covariate into logistic regression analysis was 0.05 or
b 0.10 if the variable was considered clinically relevant. Uni-
variate analysis was performed on the original set to evaluate
single prognostic factors for complicated AP during the first
72 h of admission. Multivariate logistic regression analysis
was used to assess the independent prognostic significance of
covariates which were significantly associated with poor prog-
nosis in univariate analysis.
2.2. Development of the prediction rule
The independent prognostic factors in the test group were
used to create a prediction rule. The predictive model to grade
the severity of AP was constructed using a computer program.
A forward entry-backward elimination method of selection
was used. p values for entry in and removal from the logistic
regression model were 0.10 and 0.05 respectively. All cova-
Table 1
Observed rates of each outcome indicating “complicated AP” according to
different etiologies and final composite outcome.
Biliary Idiopathic Alcoholic Others Total
Hospital stay ≥11 days 45 (24%) 17 (28%) 5 (11%) 1 (5%) 68 (22%)
CTSI ≥6 9 (4%) 3 (5%) 2 (4%) 0 14 (4%)
ICU 7 (3%) 2 (3%) 2 (4%) 0 11 (3%)
Surgery/drainage 10 (5%) 3 (5%) 3 (7%) 0 16 (5%)
Death 10 (5%) 1 (1%) 0 0 11 (3%)
CTSI: computed tomography severity index. ICU: admission to an intensive
care unit.
riates were considered categorical using cut off levels pre-
viously assigned to each parameter.
The probability of suffering a complicated AP is calculated
according to the formula: prob(CAP) = 1/(1 + e− Z ), where
Z = b0 + b1x1 + b2x2 + … + bnxn. In this formula, x1 to xn are the
values of covariates included in the predictive model, b1 to bn
are their corresponding regression coefficients and b0 is a
constant. The values of b0 to bn are calculated by the logistic
regression procedure.
Each value of prob(CAP) corresponds to a single Z value.
The discrimination of patients predicted to have a complicated
AP is based on the value of Z, which is a linear function of x1 to
xn. To reduce calculations of the formula we simplified
coefficients b1 to bn with decimal places, that is, a calculated
coefficient of 1.2 was simplified to 1.
The resulting prognostic model based on simple objective
data was computed from the multivariate logistic regression
model assigning points in proportion to the regression
coefficients. The final clinical score stratifies the probability
of complicated AP into high, moderate and low.
The area under the receiver–operating characteristic curve
was used as a method of accuracy of the predictor model in
separating complicated from uncomplicated AP.
3. Results
Within the period of study, 308 episodes of AP were
included in the analysis, 215 with a first attack and the rest with
more than one episode of AP (30% had recurrent AP). The
estimated incidence was 61.6/100,000 population/year. The
mortality rate was 3.6%.
The average age was 63.7 ± 2.1 years (range 19–101 years).
Overall, 153 were men (49.7%) and 155 women (50.3%). Women
were significantly older than men (67.7 vs 59.7 years respectively,
p b 0.001).
The most common cause of AP was biliary (60.7%). The
etiology was unknown in 19.2%. Alcohol accounted for 14.3%
of all the AP. Other etiologies were responsible for the re-
maining 5.8%. Cholelithiasis was most frequent in female
patients (59 vs 41%, p b 0.001) whereas alcohol was most
common in male patients (95.5 vs 4.5%, p b 0.001). No dif-
ferences in sex were seen in the remaining etiologies. Table 1
summarizes the rates of complicated AP (composite outcome)
and the observed rates of each event indicating unfavourable
prognosis according to the etiology of AP.
 A. Gonzálvez-Gasch et al. / European Journal of Internal Medicine 20 (2009) e43–e48 e45

Table 2 Table 4
Factors significantly related to complicated AP. Prognostic model for AP during the first 72 h of admission.
Covariate Odds ratio; CI 95% p Covariate Points
Age N65 years 3.0 (1.7–5.0) 0.000 Age N65 years 1
Comoribidity 1.7 (1.03–2.9) 0.03 Leucocytes N13,000/mm3 1
Biliar etiology 1.8 (1.03–3.05) 0.02 Albumin b2.5 mg/dL 1
Fever 11.2 (5.4–23.2) 0.000 Calcium b8.5 mg/dL 1
Leucocytes N13,000/mm3 5.7 (3.3–9.8) 0.000 RCP N150 mg/dL 2
Glucose N150 mg/dL 3.5 (2.1–6.1) 0.000
Urea N45 mg/dL 3.0 (1.8–5.1) 0.000 Final points Risk for complicated AP
LDH N600 U/L 3.3 (1.9–5.7) 0.000 0 Low (0%)
Albumin b2.5 mg/dL 8.5 (4.8–15.1) 0.000 1–3 Moderate (19%)
Calcium b8.5 mg/dL 2.9 (1.6–5.3) 0.000 4–6 High (73%)
RCP N150 mg/dL 10.2 (5.6–18.5) 0.000
RCP: reactive C protein. AP: acute pancreatitis.
Univariate analysis.
LDH: lactate dehydrogenase. RCP: reactive C protein.
rule, we defined three different risk groups according to the
points obtained in the Z score: low risk group, 0 points (18%
In the original set of 308 episodes the following covariates patients, 0% risk), moderate, 1–3 points (56% patients, 19%
were significantly associated with complicated AP in the risk) and high, 4–6 points (26% patients, 73% risk). Table 4
univariate analysis: age, comorbidity, biliary etiology, fever,
leucocytes, glucose, urea, creatinine, LDH, albumin, calcium
and RCP (Table 2). Table 5
Multivariate logistic regression analysis was performed to Original and validation sets of patients.
further assess which of these 11 variables was independently Original set (n = 308) Validation set (n = 193)
associated with a poor outcome. In the final model 5 variables Age 63 (18–101) 64 (18–98)
remained as independent predictors of complicated AP, namely Sex Female 155 (50.3%) Female 96 (49.7%)
advanced age (N 65 years), leucocytes N 13,000/mm3, albumin Male 153 (49.7%) Male 97 (50.3%)
Department
b 2.5 mg/dL, calcium b 8.5 mg/dL and high serum RCP
Internal medicine 166 (54%) 134 (69.4%)
(N150 mg/dL). Gastroenterology 138 (45%) 50 (29.0%)
The results of multivariate analysis and the construction of Surgery 4 (1.3%) 1 (0.5%)
the prognostic rule are summarized in Table 3. The formula Etiology
prob(CAP) = 1/(1 + e− Z) gives a certain Z value for each patient Biliary 187 (60.7%) 105 (54.4%)
Idiopathic 59 (19.2%) 50 (25.9%)
which represents the risk for complicated AP. The equation is:
Alcoholic 44 (14.3%) 19 (9.8%)
Z = b0 + b1x1 + b2x2 + b3x3 + b4x4 + b5x5, where b0 is a constant Others 18 (5.8%) 19 (9.8%)
calculated by the logistic regression procedure. We have Recurrent AP 93 (30.1%) 57 (29.5%)
simplified the beta coefficient of covariates albumin and RCP Comorbidity
from 1.2 and 1.9 to 1 and 2 respectively. Thus, the Z score Total 189 (61.5%) 117 (60.6%)
Cardiological illness 72 (23.4%) 41 (21.2%)
ranged from 0 to 6 and the grading of each factor was as
Pneumological illness 34 (11%) 20 (10.4%)
follows: age 1, leucocytes 1, albumin 1, calcium 1 and reactive Diabetes 62 (20.1%) 44 (22.8%)
C protein 2. Renal insuficiency 11 (3.6%) 11 (5.7%)
The Z score points and the risk of unfavourable outcome in Hepatic illness 38 (12.3%) 6 (3.1%)+
the original set of patients with AP were as follows: 0 points, 56 ASA
Grade 1 117 (37.9%) 71 (36.8%)
patients, 0% risk; 1 point, 83 patients, 12% risk; 2 points, 51
Grade 2 142 (46.0%) 83 (43.0%)
patients, 19% risk; 3 points, 40 patients, 35% risk; 4 points, 35 Grade 3 45 (14.9%) 39 (20.2%)
patients, 57% risk; 5 points, 33 patients, 89% risk and finally, 6 Grade 4 4 (1.3%) 0
points, 10 patients, 100% risk. In order to simplify the prediction Pseudocyst 35 (11.3%) 19 (9.8%)
Abscess 16 (5.1%) 9 (4.7%)
Necrosis ≥30 17 (5.5%) 10 (5.1%)
CTSI ≥6 14 (4.5%) 11 (5.7%)
Table 3 Infected necrosis 10 (3.2%) 4 (2.1%)
Independent prognostic factors for complicated AP. MOD 21 (6.8%) 8 (4.1%)
ICU 11 (3.6%) 6 (3.1%)
Covariate Odds ratio; CI 95% Beta coefficient p
Surgery/drainage 16 (5.1%) 4 (2.1%)
x1: Age N65 years 2.8 (1.3–5.7) b1: 1 0.004 Hospital stay ≥11 days 68 (22.0%) 51 (26.4%)
x2: Leucocytes N13,000/mm3 2.5 (1.2–5.0) b2: 1 0.008 Death 11 (3.6%) 6 (3.1%)
x3: Albumin b2.5 mg/dL 3.3 (1.6–6.7) b3: 1.2 = 1 0.001 Complicated AP 91 (29.5%) 49 (25.4%)
x4: Calcium b8.5 mg/dL 2.5 (1.1–5.6) b4: 1 0.02
General characteristics.
x5: RCP N150 mg/dL 6.8 (3.3–14.0) b5: 1.9 = 2 0.000
ASA: “American Society of Anesthesiologists” surgical severity score. CTSI:
Development of the prognostic model. computed tomography severity index. MOD: multiorganic dysfunction. ICU:
RCP: reactive C protein. admission to an intensive care unit. +p b 0.01.
e46 A. Gonzálvez-Gasch et al. / European Journal of Internal Medicine 20 (2009) e43–e48
Fig. 1. Validation set. Expected (grey line) and observed (black line) rates of
complicated AP (CAP) according to the risk group in the Z score. Expected CAP
with its corresponding 95% Confidence Interval described in vertical lines in
each group of patients.
summarizes the final prognostic model with the three risk
groups.
The best discrimination between patients with or without
complicated AP was achieved at a cut-off = 0.50 in the area
under the receiver–operating characteristic curve. The sensitiv-
ity, specificity, positive and negative predictive values of the
score was 90%, 63%, 50% and 94%.
3.1. Validation of the prognostic rule
The independent validation set consisted of prospectively
collected data of 209 consecutive patients with AP. Sixteen
patients had insufficient information on one or more variables
and were excluded, leaving 193 eligible patients. Patient's
characteristics in the test and validation groups were similar
(Table 5). Percentage of patients suffering a complicated AP on
these groups was 29.5% and 25.4% respectively. No significant
difference was found between both sets except for the rate of
hepatic comorbidity which was significantly higher in the
original set of patients (p b 0.001).
The probability of suffering a complicated AP in the
validation group was prospectively calculated according to the
formula prob(CAP) = 1/(1 + e− Z) in each group of risk (low,
moderate and high).
Of the 193 patients, 36 subjects (19%) had 0 points in the
prediction rule. The expected rate of complicated AP in this low
risk group according to our Z score was 3% (CI95% 0.6–5.5).
Complicated AP actually occurred in no patient. Having ≥ 4
points, 56 patients (29%) were included in the high risk group.
The actually observed frequency of complicated AP was 62%
and the corresponding predicted probability was 83% (CI95%
76.1–87.0). The remaining 101 patients (52%) had 1 to 3 points
with a predicted rate of complicated AP of 21% (CI95% 14.5–
26.7). The observed rate of unfavourable AP in the moderate
risk group was 14%. The expected rate of complicated AP in the
validation set according to our prognostic model was slightly
higher than that actually observed, especially at higher Z score
points. The sensitivity, specificity, positive and negative pre-
dictive values of the score was 90%, 63%, 50% and 94% in the
original sample. The described rule was applied to the 193 new
patients and the corresponding results in the validating sample
were 93.8%, 63.3%, 47% and 97%. Thus, the applicability of
the clinical prediction rule in the validation group was similar to
the derivation set (Fig. 1).
4. Discussion
The international symposium held in Atlanta in 1992 [9]
established a severity classification system for AP in order to
use standard definitions and make possible valid comparisons of
illness. However, in our experience, not all the Atlanta criteria
correlate with poor outcome. In the present analysis we have
used different criteria to define complicated AP. Many other
authors agree that the Atlanta criteria include heterogeneous
patients with different prognoses, thus, although still accepted
in most publications, new severity parameters have also been
suggested in recent studies [5,10,11].
A simple, objective, inexpensive and widely applicable
prognostic score for complicated AP is difficult to attain. A
recent review has interestingly classified the prognostic markers
into predictors of severity, pancreatic necrosis, infected
pancreatic necrosis and mortality [12]. However, there is no
agreement in current guidelines regarding which is the best
method for severity stratification [13–15]. Most authors
recommend APACHE II score [16]. It is in fact the most
accurate method available nowadays, but it is also extremely
time-consuming to be used outside an intensive care unit.
Others support the accuracy of reactive C protein alone [17]. In
our opinion, a combination of serum markers and clinical
parameters would be more reliable than a single factor to predict
severity. Interestingly, some guidelines just do not state which is
the best way to accurate predict a severe AP. Furthermore,
though not recommended in current guidelines, Ranson system
[6] is still the most frequently used prognostic score in daily
practice since it was originally designed in 1974. To our
knowledge, there are some limitations in Ranson score. First,
the method has proved to be useful in alcoholic AP occurring
mainly in men. In Spain, the leading cause of AP is gallstones
and women are affected much more than men [18]. Second,
some authors have pointed out that Ranson signs are not
as useful in elderly as they are in young patients [19]. The
incidence of AP has increased in aged patients as population
grows old. In fact, the mean age in our cohort was 63 years
which is significantly higher than that reported in previous
studies [20,21]. Third, not all the Ranson criteria have the same
predictive value [22]. When examined individually, certain
parameters are more accurate in predicting outcome than others.
Another drawback of Ranson score is that it was designed more
than three decades ago. Improvements in resuscitation,
antibiotic therapy and critical care have been made. The pre-
sence of N3 criteria was associated with 60% mortality in the
original study while nowadays patients survive routinely with
more than 5 positive variables. Finally, the original study was
retrospective and the 11 factors that were significantly asso-
ciated with complicated AP in the univariate analysis were not
further examined in a multivariate logistic regression analysis.
Because Ranson criteria might be poorly predictive when ap-
plied to other groups of patients with AP we sought to determine
 A. Gonzálvez-Gasch et al. / European Journal of Internal Medicine 20 (2009) e43–e48
the variables associated with poor prognosis in a prospective
analysis with non-selected patients in our own hospital.
In this analysis, advanced age (N65 years) was a risk factor
for complicated AP. In many but not all reports [23], older age
has correlated with a more severe prognosis [6,24–26]. Some
authors state that older individuals have a poor outcome because
of comorbid disease rather than old age itself [19,27]. We have
separately analyzed the influence of age and comorbidity in
the evolution of AP. By univariate analysis, the incidence
of unfavourable AP was linked to comorbidity, in particular,
diabetes and cardiopathy, whereas logistic regression failed to
show significant association. Similarly, higher ASA scores did
not correspond with more frequent occurrence of complicated
AP. Thus, we conclude that in this cohort advanced age worsens
prognosis irrespective the comorbid diseases. Unfavourable
outcome in older individuals could be put down to the dimi-
nished physiological response typical of elderly patients.
Infectious complications are common in AP and are known
to increase mortality [5]. Leucocytosis is an indirect sign of
ongoing infection although it can also be related to the presence
of a systemic inflammatory response syndrome in an otherwise
healthy patient with pancreatitis. In our cohort, a white blood
cell count over 13,000/mm3 independently influenced the num-
ber of patients with complicated AP. This finding has already
been reported in previous analysis [23,28], still the cut off
values differ depending on the various studies reviewed.
Low serum calcium correlates with severe AP and the
development of necrotic AP according to previous reports
[6,26,29,30]. We observed that serum calcium was significantly
lower in patients with complicated AP. Some authors defend
that hypocalcemia can be attributed to binding of calcium in
areas of fat necrosis and may as well be related to altered levels
of circulating parathormone in AP [31]. There is also evidence
that hypoalbuminemia can contribute with low serum calcium.
Actually, we reported that patients with low serum albumin had
a higher risk of unfavourable outcome. The incidence of poor
prognosis in patients with AP is known to be associated with
hypoalbuminemia [32]. It is a biochemical feature frequently
related to systemic inflammatory response and fluid sequestra-
tion, yet, nutritional status prior to the pancreatitis episode
might also influence the level of low serum albumin.
The rate of complicated AP was higher in patients with
reactive C protein (RCP) ≥ 150 mg/dL. In accordance to pre-
vious studies [23,33], high serum RCP level has proved to be
predictive of a subsequent adverse outcome. It is not clear
which is the best cut-off value but most authors agree that RCP
above 150 mg/dL accurately distinguishes episodes of AP likely
to complicate from those without adverse events.
None of the remaining examined features were independent
prognostic factors of complicated AP in this cohort. Renal
impairment was more frequent in patients predicted to have a
complicated outcome, however, in the multivariate logistic
regression, neither creatinine nor urea were independent pre-
dictive factors for complicated a course. Similarly, low arterial
oxygen saturation, hemoglobin or hematocrit did not influence
the rate of complicated AP. The low mortality in this study
(3.6%) may explain the fact that variables which indicate single
e47
or multiple organ failure and tissue perfusion impairment such
as anemia and respiratory or renal insufficiency [23,34] were
not associated with poor outcome. We only reported two epi-
sodes of pancreatitis with shock, one digestive hemorrhage and
the rate of necrotizing AP was 5.5%, in consequence, it is not
surprising that features usually linked to fatal AP [27,35] were
not independent prognostic factors probably due to the reduced
number of patients.
We have constructed a simple rule including the 5 parameters
with independent significance of poor outcome in our cohort.
The resulting prognostic model, ranging from 0 to 6 points, has
been proved helpful to differentiate groups of patients at a high,
moderate or low risk for complicated AP in a validation set.
Despite the fact that the Z score slightly overestimates the risk
of suffering a complicated AP in the validation set, it has shown
to have a reasonable good predictive performance. Its high
negative predictive value (94%) makes it a useful tool to iden-
tify patients with minimal risk for unfavourable outcome (0
points) who will not need special surveillance. Conversely, all
patients with ≥ 1 point are at risk for unfavourable outcome.
Moreover, the prediction rule differentiates between high or
moderate risk in a particular patient with 1 point or more: those
with ≥ 4 points might benefit from close monitoring and
aggressive treatment while patients having 1 to 3 points would
only need intermediate surveillance.
We admit the score might have had better positive predictive
value: nearly 50% of patients expected to have a poor prognosis
actually do not develop complications. However, the major
problem is keeping under close surveillance and with supportive
treatment patients who finally will not need specific care.
Failure to misclassify an attack of AP as severe will not result in
serious consequences whereas the reverse may lead to poten-
tially avoidable problems. Our prognostic model helps care-
givers identifying high risk patients at an early stage in order to
take prophylactic measures, achieve early diagnosis of com-
plications and initiate appropriate and specific aggressive mea-
sures thereafter.
The study design has some limitations. The definition of
complicated AP in this analysis has been arbitrary. Though
useful on clinical daily practice, need of ICU admission or
surgery is dependent on local circumstances and somehow
unreliable. The applicability of the results in this cohort to
patients in other centers remains unknown. The treatment plans
for each patient were not standardized. Differences in therapy
can be considered a limitation and can have contributed in
heterogeneity in patients. However, our analysis was not in-
tended to determine the best treatment for AP but to design a
prognostic rule for unfavourable outcome in the most natural
scenario rather than in clinical trial conditions. Finally, our
prediction rule needs 72 h from admission to stratify severity.
Although most authors claim that the ideal predictor system
should not be measured after the first 24 h of hospitalization,
until there is a specific treatment for patients with AP effective
only over the first 24–48 h we consider that prognostic
assessment does not have to be necessarily settled before the
first 24 h of admission. The hallmarks of a prognostic method
are predict outcome, monitor progress and guide the best
e48 A. Gonzálvez-Gasch et al. / European Journal of Internal Medicine 20 (2009) e43–e48
treatment in a particular patient and these features can be also
assessed during hospitalization as daily evaluation of patient's
biochemical parameters are done routinely.
Our method has not been compared with any of the existing
prognostic systems for predictive accuracy. Ranson and
Glasgow scores demand 48 h to stratify severity while we
must await 72 h to use our prediction rule. Comparisons may
not be appropriate as the difference in time could introduce a
bias. Nonetheless, we are aware that future prospective com-
parisons with other models are needed to assess the effective-
ness of the prognostic score.
5. Conclusion and learning points
• Our simple prediction rule is an additional tool in the
severity stratification of AP.
• Patients with high risk for unfavourable outcome (≥ 4
points) should be kept under close surveillance whereas low risk
patients (0 points) would not need special monitoring.
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