|Year : 2019 | Volume
| Issue : 2 | Page : 63-68
Comparison of Modified Atlanta Classification With Modified CT Severity Index in Acute Gallstone Pancreatitis
Gumi Padu, Pawanindra Lal, Anubhav Vindal
Department of Surgery, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi, India
|Date of Web Publication||20-Aug-2019|
MS, Senior Resident Gumi Padu
Department of Surgery, NEIGRIHMS Shillong
Source of Support: None, Conflict of Interest: None
Acute Pancreatitis is one of the commonest gastro-intestinal diseases, in which patients need emergency hospitalization. It carries 10-30% mortality in severe cases. Early identification of severe cases helps in prognostication of the disease and institution of aggressive treatment. Aim To evaluate the severity of acute gall stone pancreatitis using Modified Atlanta Classification at admission and 48 hours. To compare severity of acute pancreatitis as assessed by Modified Atlanta Classification with Modified CT Severity Index (CTSI) in the second week. Materials and Methods We use Modified Marshal Score, as recommended by Revised Atlanta Classification, in our study group of 26 patients. Patients were classified into Mild, Moderate, and Severe categories at 48hrs. Contrast Enhance Computer Tomography of chest and abdomen (Gold standard) was performed at 2 weeks of presentation. Using Modified CTSI Score, patients were again categorised into Mild, Moderate, Severe cases. Results Modified Atlanta Classification correctly picked up the severe pancreatitis cases, as early as at 48hrs, with 100% sensitivity and specificity, which corresponded with CTSI at 2wks.
Keywords: acute pancreatitis, gallstone, modified atlanta classification, modified marshal score, modified CT severity index
|How to cite this article:|
Padu G, Lal P, Vindal A. Comparison of Modified Atlanta Classification With Modified CT Severity Index in Acute Gallstone Pancreatitis. MAMC J Med Sci 2019;5:63-8
|How to cite this URL:|
Padu G, Lal P, Vindal A. Comparison of Modified Atlanta Classification With Modified CT Severity Index in Acute Gallstone Pancreatitis. MAMC J Med Sci [serial online] 2019 [cited 2019 Dec 8];5:63-8. Available from: http://www.mamcjms.in/text.asp?2019/5/2/63/264775
| Introduction|| |
Acute pancreatitis (AP) is one of the most common gastrointestinal disorders requiring acute hospitalization worldwide, with a reported annual incidence of 13 to 45 cases per 100,000 persons. Gallstone is the most common cause of AP followed by alcohol consumption contributing to 38% and 36% of cases, respectively.,
Overall mortality associated with pancreatitis is 2% to 10%, whereas it is 10% to 30% in severe cases. So, to prognosticate the disease and aggressive treatment in severe cases, various classification systems, such as Ranson, Glassgow, Acute Physiology And Health Care Evaluation (APACHE), Bedside index of severity in acute pancreatitis (BISAP), and Harmless Acute Pancreatitis Score (HAPS), are in practice but these methods are time taking, complicated, cumbersome, and insufficiently sensitive in predicting the development of severe AP.,,,,, Recently, Atlanta classification was revised in 2012 to classify the patients with pancreatitis into mild, moderate, and severe types by using Modified Marshal scoring.,, Conventionally, contrast-enhanced computer tomography (CECT) has been used as the gold standard in classifying the severity of AP into mild, moderate, and severe using modified CT severity index (CTSI). However, CT scan is usually performed at 2 weeks, so as to establish the necrosis following the episodes of pancreatitis.,,,, Modified Marshal score, used in revised Atlanta classification, is an easy bedside calculation system based on clinical and hematological investigations. Comparison of severity status using revised Atlanta classification at 48 h will help in early identification of sick patients more accurately and thus implementation of intensive treatment.
| Aims and Objectives|| |
The aim of this study is to evaluate the severity of acute gallstone pancreatitis using modified Atlanta classification at admission and at 48 h and to compare severity of AP as assessed by modified Atlanta classification with modified CTSI in the second week.
| Materials and Methods|| |
The study was conducted in the Department of Surgery, Maulana Azad Medical College and associated Lok Nayak Hospital, New Delhi, in collaboration with the Department of Radiodiagnosis over a period of 26 months. Patients presenting in surgical emergency/outpatient department with acute pain abdomen, secondary to gallstone-induced pancreatitis, were selected on the basis of clinical history, physical examination, biochemical investigations, as well as ultrasound abdomen.
- Age above 18 years.
- Acute gallstone pancreatitis.
- AP presenting beyond 48 h of onset of pain abdomen.
- Recurrent pancreatitis.
- Allergy to contrast (Iohexol).
- Treatment for pancreatitis already started.
Study protocol was approved by local ethical committee. All patients were informed about the management protocol and written consent was taken. Disease severity assessment using clinical examination and hematological investigation was performed at presentation as well as at 48 h. Treatment was accordingly instituted. Severity reassessment using imaging (CECT) was performed at 2 weeks.
At admission, diagnosis of pancreatitis was made when two of the following three features were present:
- Abdominal pain consistent with AP (acute onset of a persistent, severe, epigastric pain radiating to the back).
- Serum amylase/lipase value, at least three times greater than the upper limit of normal.
- Characteristic findings of gallstone pancreatitis on ultrasound.
All patients were admitted. Detailed history, clinical examination, and relevant investigations were performed. Modified Marshal scoring was performed at admission. Patients with score 0 and 1 were classified into mild, category whereas those with ≥2 were classified into severe category. The patients were conservatively managed. Scoring was again performed at 48 h of admission. The patients whose initial scoring was ≤1, if had a repeat score ≤1, were classified into mild category of revised Atlanta classification. The patients whose initial score was ≥2, but decreased to ≤1, were classified into moderate pancreatitis category. The patients whose modified Marshal score [[Table 1]] was ≥2, and it remained ≥2 at 48 h, were kept into severe pancreatitis category. The patients were managed conservatively. CECT of the chest and abdomen was performed at 2 weeks of presentation., Modified CTSI Score [[Table 2]] was calculated. Considering it as a gold standard, the patients were classified into mild, moderate, and severe pancreatitis category according to their modified CTSI score [Table 2].
The sensitivity and specificity for assessing the predictive value of modified Atlanta classification as compared to modified CTSI is not available in the world literature. Therefore, the formula is applied as
N = (Z1−α/2)2Sn(1−sn)/d2 × p
where Z1−α/2 is constant whose value is 1.96 at 95% confidence limits. Sn is sensitivity, d is precision whose value is 0.05, and p is prevalence.
As per our literature search, there are no data available to calculate sensitivity and specificity of modified Atlanta classification with reference to modified CTSI; therefore, total number of sample size was taken as 26 for convenience.
The data was fed into Microsoft Excel format in a computer and was analyzed using SPSS software, version 21. Categorical variables were presented as number and continuous data were presented as mean ± standard deviation. The comparison between qualitative data was determined by applying chi-square or Fishers’s exact test. The continuous data was compared by Student’s t test/Mann-Whitney U test, wherever required. A P value less than 0.05 was considered significant. Sensitivity, specificity, and predictive value of modified Atlanta classification was calculated using modified CTSI as gold standard.
| Results|| |
Between January 2016 and February 2018, 30 patients with AP presented, of which four patients were excluded. Finally, the study was carried out in 26 patients. The average age of presentation was 34.6 (range 31–37) years. There was female preponderance (80.7%, n = 21) in our study.
At admission, 73.1% (n = 19) patient had mild pancreatitis whereas 26.9% (n = 7) had severe pancreatitis according to the modified Atlanta classification [[Figure 1]]. After conservative management, reassessment was performed at 48 h of admission; now 73.1% (n = 19) of patients had mild pancreatitis, 15.4% (n = 4) had moderate pancreatitis, and 11.5% (n = 3) had severe pancreatitis based on modified Atlanta classification [[Figure 2]]. CECT was performed at second week and modified CTSI scoring was calculated. Out of the 26 patients, 18 (69.23%) showed mild AP, five (19.23%) had moderate AP, and three (11.54%) patients had severe AP [[Figure 3]].
Modified Atlanta classification at 48 h vs. modified CTSI at the end of second week
Modified CTSI was considered as the gold standard objective parameter for categorizing the severity of AP. Correlation was performed between modified Atlanta classification at 48 h with modified CTSI at second week [[Table 3]]. Modified Atlanta classification had sensitivity and specificity of 89.47% and 9.44% with positive predictive value (PPV) and negative predictive value (NPV) of 94.44% and 75.00%, respectively, for the mild AP, and sensitivity and specificity of 75.00% and 90.91% with PPV and NPV of 60.00% and 95.24%, respectively, for moderate AP. Sensitivity and specificity of 100% with PPV and NPV of 100% was found for severe AP (P value <0.05).
|Table 3 Correlation between Modified Atlanta Classification at 48 hrs and Modified CTSI at end of 2nd week.|
Click here to view
| Discussion|| |
AP is a common ailment encountered by the physicians and surgeons in any part of the world, and forms a good proportion of emergency admissions in emergency unit. The most common cause of AP in many western and Asian countries is cholelithiasis, accounting for 35% to 60% of cases. It is of utmost importance to make an early diagnosis and assess the severity of AP in the beginning. This study was conducted for comparison of modified Atlanta classification (clinical assessment) at 48 h with modified CTSI (radiological assessment) at the end of second week in acute gallstone pancreatitis.
The patients in the present study were in the age range of 23 to 70 years. Mean age was 44.73 ± 11.61 years. Antonio Carnovale included patients with age range of 18 to 93 years with a median age of 61.5 years. Uhl et al. reported the mean age in the study as 50 years. The mean age was 42.9 ± 15.9 years (range: 18–80 years) in a study by Raghu et al. that correlates best with our study.
In our study, female patients outnumbered males with a ratio of 5.2:1. Female-to-male ratio was found as 2:1, 1:0.6, and 3:2 by Malik et al., Sandblom et al., and Ugane et al., respectively.
In the present study, the patients with severe AP had longer duration of hospital stay (mean 20 days) when compared with mild AP (mean stay of 6.56 days). Similar result was found in the study conducted by Gürleyik et al. who noted a mean hospital stay of 10.3 days in mild cases and a mean hospital stay of 21.4 days in severe cases, respectively.
Modified Atlanta classification was performed at admission and 48 h using mainly the modified Marshall scoring for organ failure. This scoring may change the categorization of the patient performed at presentation to a better or worse category as per scoring performed at 48 h. Mild AP is identified by the absence of organ failure at admission; thus, when organ failure is present within the first 24 h, it may be difficult to determine the final grade of severity, because it is not known whether the patient will improve to have transient or persistent organ failure. All such patients were scored as severe AP at admission. If the organ failure resolves within 48 h (indicating only transient organ failure), the patient would get classified as having moderate AP. If the patient develops persistent organ failure, they would be classified as having severe AP., In the present study, 19 (73.08%) patients diagnosed as mild by modified Atlanta classification at admission continued to remain mid at the scoring repeated at 48 h. However, among 7 (26.92%) patients those were initially classified as severe AP on admission got rescored to 4 (15.38%) as moderate AP, whereas 3 (11.54%) continued to be in severe AP at 48 h [Figure 2]. These findings are similar to the study by Pongprasobchai et al. who also found the distribution of AP as 72%, 16%, and 12% as mild, moderate, and severe AP, respectively, as per revised Atlanta classification. However, this study included all patients with AP, with gallstone AP contributing to 45% cases.
Modified CTSI was considered as the gold standard scoring system to objectively categorize the patients with AP into mild, moderate, and severe AP. Out of 26 patients, 18 (69.23%) patients were having mild, 5 (19.23%) moderate, and 3 (11.54%) severe pancreatitis according to modified CTSI at end of second week [Figure 3]. This corresponds with the study conducted by Bollen et al. in which out of 196 patients, 136 (66. 9%) patients showed mild pancreatitis, 41 (21%) patients had moderate, and 19 patients (10%) had moderate AP. Modified Atlanta classification was performed at admission that showed 19 patients were having mild and seven patients were with severe AP [Figure 1]. The scoring was repeated at 48 h, which showed that out of 26 patients, 17 (73.08%) had mild AP, 6 (19.23%) had moderate AP, and three (11.54%) had severe AP [Figure 2]. Modified Atlanta classification performed at 48 h showed 100% sensitivity and 100% specificity for prediction of severe AP as compared with modified CTSI. However, sensitivity and specificity for moderate AP was 75.00% and 90.91%, respectively. Yang et al. showed that modified Atlanta classification has sensitivity and specificity of 80.9% and 90.0%, respectively, for severe AP at 48 h. Further prospecting studies with large number of patients would be required for assessing the validity of modified Atlanta classification in severe acute gallstone AP and comparing with objective index study modified CTSI.
| Conclusions|| |
Modified Atlanta classification is as effective as CECT in correctly picking up the severe pancreatitis patients at a much earlier time. It represents a cheaper and easy substitute to CECT, with almost same benefits, in prognosticating the disease and thus in the decision of further treatment planning for surgeons and physicians.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fagenholz PJ, Castillo CF, Harris NS, Pelletier AJ, Camargo Jr CA. Increasing United States hospital admissions for acute pancreatitis, 1988-2003. Ann Epidemiol 2007;17:491-7.
Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006;101:2379-400.
Bailey H, Ellis BW, Brown SP. Hamilton Bailey’s Emergency Surgery, Vol. 13. United Kingdom: CRC Press; 2000. pp. 384-92.
Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med 2006; 354: 2142–50.
Bradely EL III. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992. Arch Surg 1993;128:586-90.
Bollen TL, van Santvoort HC, Besselink MG, van Leeuwen MS, Horvath KD, Freeny PC et al.
The Atlanta Classification of acute pancreatitis revisited. Br J Surg 2008;95:6-21.
Afghani E, Pandol SJ, Shimosegawa T. Acute pancreatitis − progress and challenges: a Report on an International Symposium. Pancreas 2015;44:1195-210.
Forsmark CE, Baillie J. AGA Institute technical review on acute pancreatitis. Gastroenterology 2007;132:2022-44.
Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974;139:68-81.
Imrie CW, Benjamin IS, Ferguson JC, McKay AJ, Mackenzie I, O’Neill J. A single-centre double-blind trial of Trasylol therapy in primary acute pancreatitis. Br J Surg 1978;65:337-41.
Larvin M, McMahon MJ. APACHE II scores for assessment and monitoring of acute pancreatitis. Lancet 1989;2:201-5.
Pednekar JL, Patil S, Pednekar S. Bedside index of severity in acute pancreatitis score for predicting prognosis in acute pancreatitis. IAIM 2015;2:62-7.
Lankisch PG, Weber DB, Hebel K, Maisonneuve P, Lowenfels AB. The harmless acute pancreatitis score: a clinical algorithm for rapid initial stratification of nonsevere disease. Clino Gastroentrol Hepatol 2009;7:702-5.
Bollen TL. Imaging of acute pancreatitis: update of the revised Atlanta classification. Radiol Clin North Am 2012;50:429-45.
Foitzik T, Bassi DG, Schmidt J, Lewandrowski KB, Fernandez-del Castillo C, Rattner DW et al.
Intravenous contrast medium accentuates the severity of acute necrotizing pancreatitis in the rat. Gastroenterology 1994;106:207-14.
Schmidt J, Hotz HG, Foitzik T, Ryschich E, Buhr HJ, Warshaw AL et al.
Intravenous contrast medium aggravates the impairment of pancreatic microcirculation in necrotizing pancreatitis in the rat. Ann Surg 1995;221:257-64.
Nordestgaard AG, Wilson SE, Williams RA. Early computerized tomography as a predictor of outcome in acute pancreatitis. Am J Surg 1986;152:127-32.
Casas JD, Díaz R, Valderas G, Mariscal A, Cuadras P. Prognostic value of CT in the early assessment of patients with acute pancreatitis. AJR Am J Roentgenol 2004;182:569-74.
Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG et al.
Classification of acute pancreatitis − 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-11.
Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med 1995;23:1638-52.
Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990;174:331-6.
Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology 2002;223:603-13.
Mortele KJ, Zou KH, Banks PA, Silverman SG. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. Pancreas 2004;29:36-43.
Tse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012;(5):C D009779.
Carnovale A. Mortality in acute pancreatitis. Is it an early or late event? JOP 2005;6:438-44.
Uhl W, Buchler M, Malfertheiner P, Beger H, Adler G, Gaus W et al.
A randomized double blind, multi-centric trial of octreotide in moderate to severe acute pancreatitis. Gut 1999;45:97-104.
Raghu MG. Lung complications in acute pancreatitis. J Pancreas 2007;8:177-85.
Malik AM. Acute pancreatitis. A more common and severe complication of gallstones in males. Int J Health Sci (Qassim) 2015;9:141-145.
Sandblom G, Bergman T, Rasmussen I. Acute pancreatitis in patients 70 years of age or older. Clin Med Insights Geriat 2008;1:27.
Ugane SP, Dhanke P, Qazi H. A study of gallstones associated acute pancreatitis and its management in rural india. IJCRR 2012;4:146.
Gürleyik G, Emir S, Kilicoglu G. CT, APACHE II and serum CRP for predicting the severity of acute pancreatitis. J Pancreas 2005;6:562-7.
Johnson CD, Abu-Hilal M. Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis. Gut 2004;53:1340-4.
Johnson CD, Kingsnorth AN, Imrie CW. Double blind, randomised, placebo controlled study of a platelet activating factor antagonist, lexipafant, in the treatment and prevention of organ failure in predicted severe acute pancreatitis. Gut 2001;48:62-9.
Pongprasobchai S, Vibhatavata P, Apisarnthanarak P. Severity, treatment, and outcome of acute pancreatitis in Thailand: the first comprehensive review using revised Atlanta classification. Gastroenterol Res Prac 2017;7:201-17.
Bollen TL, Singh VK, Maurer R. Comparative evaluation of the modified CT severity index and CT severity index in assessing severity of acute pancreatitis. Am J Roentgenol 2011;197:386-92.
Yang Z, Dong L, Zhang Y, Yang C, Gou S, Wang C. Prediction of severe acute pancreatitis using a decision tree model based on the revised Atlanta classification of acute pancreatitis. PLOS One 2015;99:320-5.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]