Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The BISAP score is a useful clinical tool for assessing mortality risk in patients suffering from pancreatitis. This score is derived from five specific clinical factors, each contributing one point to the overall score range from 0 to 5. The factors are as follows:

- Age greater than 60 years
- Impaired mental status
- Presence of systemic inflammatory response syndrome (SIRS)
- Blood Urea Nitrogen (BUN) level greater than 25 mg/dL, or 8.92 mmol/L
- Presence of pleural effusion

The calculation is straightforward: for each factor present (indicated by a "true" value), 1 point is added to the score. If the factor is absent ("false"), it contributes 0 points. The sum of these points generates the total BISAP score.

Once the score is calculated, it is interpreted to provide insight into mortality risk:

- A score of 0 to 2 suggests a low risk of mortality, with less than 1% likelihood.
- A score of 3 indicates a higher mortality risk of about 5.3%.
- A score of 4 corresponds to an even greater risk of 12.7%.
- Finally, a score of 5 implies a significant risk of 22.5%.

This scoring system allows healthcare professionals to stratify patients by risk and potentially tailor management strategies accordingly.

The BISAP Score, or Bedside Index for Severity in Acute Pancreatitis, is a clinical calculator used to predict mortality in patients with acute pancreatitis. This scoring system is applied to patients within the first 24 hours of hospital admission and is used to stratify patients based on their risk of mortality. The BISAP score includes five parameters: Blood Urea Nitrogen (BUN) >25 mg/dL, Impaired mental status, Systemic Inflammatory Response Syndrome (SIRS), Age >60 years, and Pleural effusion. Each parameter contributes one point to the total score, which ranges from 0 to 5. Higher scores indicate a higher risk of mortality. The BISAP score is not recommended for use in patients with chronic pancreatitis or in those with pancreatitis due to causes other than gallstones or alcohol.

BISAP score for mortality in pancreatitis

The CT severity index for acute pancreatitis is a tool used to assess the condition's severity by examining two key inputs: the findings on a CT scan and the extent of pancreatic necrosis. These factors are each assigned specific scores that contribute to an overall severity score.

For the CT findings, evaluations are categorized and scored as follows:
- Normal pancreas: 0 points
- Focal or diffuse pancreatic enlargement: 1 point
- Pancreatic inflammation and/or peripancreatic fat: 2 points
- Single peripancreatic fluid collection: 3 points
- Two or more fluid collections and/or presence of retroperitoneal air: 4 points

The extent of necrosis is assessed similarly:
- No necrosis: 0 points
- Necrosis of one-third of the pancreas: 2 points
- Necrosis of half of the pancreas: 4 points
- Necrosis of 50% or more of the pancreas: 6 points

Each selected input reflects specific clinical observations and is converted into a corresponding numerical score. These scores are then summed to determine an overall score, which can range from 0 to 10.

The interpretation of the total score provides crucial insights into the patient's prognosis:
- Scores between 0 and 3 suggest a low risk, with associated morbidity at 8% and mortality at 3%.
- Scores from 4 to 6 indicate a moderate risk, where morbidity increases to 35% and mortality to 6%.
- Scores of 7 or above signify a high risk, with substantial morbidity at 92% and mortality at 17%.

This scoring system offers a quantitative method to infer the severity of acute pancreatitis, guiding clinicians in their decision-making process for patient management.

The CT Severity Index (CTSI) for Acute Pancreatitis is a clinical calculator used to assess the severity of acute pancreatitis in patients. It is based on computed tomography (CT) findings and is used to predict the clinical outcome of the disease. The CTSI is particularly useful in stratifying patients into different risk categories, which can guide management and treatment decisions. It takes into account factors such as the presence and extent of pancreatic inflammation, pancreatic necrosis, and extrapancreatic complications. The score ranges from 0 to 10, with higher scores indicating more severe disease. There are no specific exclusion criteria for its use, but it should be noted that the CTSI is most useful in the setting of acute pancreatitis and may not be as relevant in chronic pancreatitis or other pancreatic diseases.

CT severity index for acute pancreatitis

The Glasgow-Imrie criteria is a clinical tool used to gauge the severity of acute pancreatitis by assessing various patient factors. To determine the total severity score, assess each of the following indicators, adding 1 point for each that is met:

- Age greater than 55 years
- White blood cell count exceeding 15×10^3/mcL or 10^9/L
- Blood glucose level over 180 mg/dL or 10 mmol/L
- Blood urea nitrogen greater than 44.8 mg/dL or serum urea surpassing 16 mmol/L
- Arterial partial pressure of oxygen below 60 mmHg or 7.9 kPa
- Calcium level less than 8 mg/dL or 2 mmol/L
- Lactate dehydrogenase level over 600 IU/L
- Albumin level below 3.2 g/dL or 32 g/L

Each criterion is a straightforward boolean input: if true, add 1 point; if false, add no points. Sum these points to achieve a total score ranging from 0 to 8.

The interpretation of the total score is as follows:

- If the score is between 0 and 2, the risk of severe pancreatitis is considered low.
- For a score of 3 or more, the risk of severe pancreatitis is deemed high.

This scoring system allows healthcare providers to quickly assess and respond to the severity of pancreatitis, facilitating more informed clinical decisions.

The Glasgow-Imrie Criteria, also known as the Imrie Scoring System or Glasgow Score, is a clinical calculator used to assess the severity of acute pancreatitis. This scoring system is applicable to patients diagnosed with acute pancreatitis and is used to predict the prognosis and potential complications of the disease. 

The Glasgow-Imrie Criteria evaluates eight parameters within 48 hours of admission: age, white blood cell count, blood glucose, serum lactate dehydrogenase, serum aspartate transaminase, blood urea nitrogen, arterial partial pressure of oxygen, and albumin. Each parameter is scored as 0 or 1, and a total score of 3 or more indicates severe pancreatitis with a higher risk of complications and mortality.

There are no specific exclusion criteria for the use of the Glasgow-Imrie Criteria. However, it should be noted that this scoring system is not intended to replace clinical judgment or to guide treatment decisions in isolation. It should be used in conjunction with other clinical findings and diagnostic tests.

Glasgow-Imrie criteria for severity of acute pancreatitis

The Harmless Acute Pancreatitis Score (HAPS) is a tool used to evaluate the severity of acute pancreatitis based on three clinical criteria. Each criterion can contribute one point to a total score ranging from 0 to 3.

The inputs evaluated are binary, with each input being true (affirmative) or false:

- Peritonitis rebound tenderness or guarding
- Elevated creatinine levels (greater than or equal to 2 mg/dL or 177 mcmol/L)
- Elevated hematocrit levels (43% or more for males, and 39.6% or more for females)

For each criterion that returns true, a score of 1 is assigned. The total score is the sum of all affirmative inputs.

Here's how the score is interpreted:

- A total score of 0 suggests a low likelihood of needing aggressive medical interventions such as artificial ventilation, dialysis, and the patient is unlikely to experience necrosis or mortality. This indicates a less severe episode of pancreatitis.
  
- A score of 1 or higher suggests an increased risk of severe outcomes, including the potential necessity for artificial ventilation, dialysis, and a higher risk of necrosis or mortality. This indicates a more severe condition that might require immediate medical attention. 

This scoring system helps healthcare professionals quickly assess the severity of acute pancreatitis, enabling informed decisions for patient management.

The Harmless Acute Pancreatitis Score (HAPS) is a clinical calculator used in the management of patients with acute pancreatitis. This scoring system is specifically designed to predict the likelihood of a benign course of acute pancreatitis within the first 24 hours of admission. The HAPS is calculated based on five parameters: hematocrit, age, pleural effusion, sex, and serum calcium levels. 

The clinical utility of the HAPS is to assist clinicians in identifying patients who are likely to have a mild course of acute pancreatitis, thereby aiding in decision-making regarding hospital admission, level of care, and resource allocation. 

The HAPS should not be used in patients with chronic pancreatitis or those with a known history of severe acute pancreatitis, as it is not designed to predict severity in these populations. Additionally, it may not be accurate in patients with conditions that can affect the parameters used in the score, such as chronic kidney disease (which can affect serum calcium levels) or lung disease (which can cause pleural effusion).

Harmless Acute Pancreatitis Score (HAPS)

This tool helps determine if the diagnostic criteria for acute pancreatitis are met. It guides users through selecting relevant clinical features and automatically evaluates these selections.

Here’s how the process unfolds:

Diagnosis hinges on three critical indicators:

- Abdominal pain is described as acute, persistent, severe, and primarily in the epigastric region, typically extending to the back.
- Levels of the enzymes lipase or amylase are three times higher than the normal maximum.
- Imaging via CT or MRI shows findings characteristic of pancreatitis.

Using these criteria, the calculator assesses whether the combination of any two of these factors is present:

- If the abdominal pain and elevated enzyme levels are reported, or
- If elevated enzyme levels and characteristic imaging findings are observed, or
- If abdominal pain and characteristic imaging findings are noted.

The diagnostic conclusion is simple:

- If any two out of the three key indicators coincide, the tool concludes that the diagnostic criteria for acute pancreatitis are met.
- If fewer than two criteria are present, the criteria are not satisfied. 

This straightforward evaluation ensures users can easily understand if the combination of clinical symptoms aligns with a diagnosis of acute pancreatitis.

The calculator in question is the Diagnostic Criteria for Acute Pancreatitis. This is a clinical scoring system used to diagnose acute pancreatitis, a sudden inflammation of the pancreas. It is applicable to patients presenting with abdominal pain and other symptoms suggestive of pancreatitis.

The clinical utility of this calculator is to aid in the diagnosis of acute pancreatitis, which can be a life-threatening condition if not promptly identified and treated. The criteria include the presence of two of the following three features: 1) abdominal pain consistent with acute pancreatitis, 2) serum lipase activity (or amylase activity) at least three times greater than the upper limit of normal, and 3) characteristic findings of acute pancreatitis on contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI), or transabdominal ultrasonography.

There are no specific exclusion criteria for the use of this diagnostic criteria. However, it may not be applicable in patients with chronic pancreatitis or other conditions that can mimic the symptoms of acute pancreatitis. It is also important to note that while this criteria can aid in the diagnosis, clinical judgment and further investigations may be necessary in some cases.

Diagnostic criteria for acute pancreatitis

The Revised Atlanta Classification for acute pancreatitis assesses the severity of the condition based on user input regarding local or systemic complications and organ failure. The process involves evaluating two main inputs and determining the severity of acute pancreatitis (AP) by categorizing it as mild, moderate, or severe.

Inputs required are:

1. Local or systemic complications (such as pancreatic necrosis) with options:
   - Absent
   - Present

2. Organ failure with options:
   - Absent
   - Transient (resolving in <= 48 hours)
   - Persistent (> 48 hours; single or multiple)

The inputs are evaluated using a logic-based computation to result in one of the three categories of acute pancreatitis:

- Mild AP: Characterized by the absence of both local or systemic complications and organ failure. This is determined if local or systemic complications are absent and organ failure is absent (A and C).

- Moderate AP: Defined by the presence of local or systemic complications with no organ failure or transient organ failure, or when complications are absent but organ failure is transient. This is assessed when local or systemic complications are present, and organ failure is absent or transient (B and (C or D)); or when complications are absent and organ failure is transient (A and D).

- Severe AP: Identified by the presence of persistent organ failure, irrespective of local or systemic complications. This is recognized when organ failure is persistent (E).

In computation:

- If localOrSystemicComplications is absent and organFailure is absent, the result is Mild AP.
- If localOrSystemicComplications is present and organFailure is absent or transient, or if localOrSystemicComplications is absent and organFailure is transient, the result is Moderate AP.
- If organFailure is persistent, the result is Severe AP.

If all decision conditions are unmet, the output prompts the user to make a selection for all inputs as a result, signaling a missing or incorrect input configuration.

The system systematically evaluates the combination of inputs to place the condition in the appropriate category, thus informing about the severity level of acute pancreatitis. Here is the summary in a table format for clarity:

| Local or Systemic Complications | Organ Failure                        | Result     |
|--------------------------------|-------------------------------------|------------|
| Absent                          | Absent                              | Mild AP    |
| Present                         | Absent or Transient                 | Moderate AP|
| Absent                          | Transient                           | Moderate AP|
| Any                             | Persistent                          | Severe AP  |

The Revised Atlanta Classification for Acute Pancreatitis is a clinical scoring system used to classify the severity of acute pancreatitis. This classification system is applicable to patients who present with symptoms suggestive of acute pancreatitis, such as abdominal pain, nausea, vomiting, and elevated levels of pancreatic enzymes in the blood.

The Revised Atlanta Classification provides a standardized approach to stratify patients into different severity levels based on clinical and imaging findings. It categorizes acute pancreatitis into two phases: early (first week) and late (after the first week), and further classifies the disease into mild, moderately severe, and severe. This classification helps in predicting the clinical course, management, and prognosis of the disease.

The clinical utility of this calculator lies in its ability to guide clinicians in making decisions about the appropriate level of care, potential need for interventions, and to predict patient outcomes. It also aids in communication between healthcare providers and in research settings.

There are no specific exclusion criteria for the use of the Revised Atlanta Classification. However, it should be noted that it is not designed to diagnose acute pancreatitis, but rather to classify the severity of the disease in patients in whom a diagnosis of acute pancreatitis has already been established based on clinical, laboratory, and imaging findings.

Revised Atlanta classification for acute pancreatitis

The determinant-based classification system assesses the severity of acute pancreatitis by evaluating two critical factors: the status of pancreatic or peripancreatic necrosis and the degree of organ failure. This method assists in categorizing the condition into various severity levels to aid in treatment planning.

Inputs required for this classification are as follows:
- Pancreatic / Peripancreatic Necrosis:
  - Absent
  - Sterile
  - Infected
- Organ Failure:
  - Absent
  - Transient (<= 48 hours)
  - Persistent (> 48 hours)

The classification process uses these inputs to assign the patient's condition into one of four possible categories:

1. **Mild Acute Pancreatitis (AP)** is determined if:
   - Pancreatic / peripancreatic necrosis is 'Absent'
   - And organ failure is 'Absent'

2. **Moderate Acute Pancreatitis (AP)** is assessed if:
   - Pancreatic / peripancreatic necrosis is 'Sterile'
   - Or organ failure is 'Transient (<= 48 hours)'

3. **Severe Acute Pancreatitis (AP)** classification applies when:
   - Pancreatic / peripancreatic necrosis is 'Infected'
   - Or organ failure is 'Persistent (> 48 hours)'

4. **Critical Acute Pancreatitis (AP)** is the classification if both:
   - Pancreatic / peripancreatic necrosis is 'Infected'
   - And organ failure is 'Persistent (> 48 hours)'

Through this evaluation, health professionals can systematically determine the severity category, which provides a scientific basis for determining the urgency and type of intervention required. The method ensures a structured and reliable assessment of acute pancreatitis, supporting optimal patient management.

The calculator in question is the Determinant-Based Classification of Acute Pancreatitis Severity (DCAP). This scoring system is used in the clinical setting to classify the severity of acute pancreatitis in patients. The DCAP calculator is particularly useful in predicting the clinical course and prognosis of patients with acute pancreatitis, which can guide treatment decisions and patient management. 

The DCAP calculator takes into account local complications (such as necrosis, abscess, or pseudocyst), systemic complications (such as organ failure), and the persistence of these complications over time. Based on these factors, acute pancreatitis is classified as mild, moderate, or severe. 

This calculator is not applicable to patients with chronic pancreatitis or those with pancreatitis due to causes other than acute pancreatitis, such as post-ERCP pancreatitis. It is also not suitable for use in patients with insufficient clinical data to accurately assess the presence or absence of local or systemic complications.

Determinant-based classification of acute pancreatitis severity

This tool calculates the risk score for postoperative pancreatic fistula by evaluating four clinical factors related to the patient's condition and surgical experience. Each input factor is assigned a numerical score, and the sum of these scores determines the overall risk, which is then classified into a specific interpretation category ranging from negligible to high risk.

Inputs and their corresponding scoring:

1. Gland Texture:
   - Firm: 0 points
   - Soft: 2 points

2. Pathology:
   - Pancreatic adenocarcinoma or pancreatitis: 0 points
   - Ampullary, duodenal, cystic, islet cell: 1 point

3. Pancreatic Duct Diameter:
   - >= 5 mm: 0 points
   - 4 mm: 1 point
   - 3 mm: 2 points
   - 2 mm: 3 points
   - <= 1 mm: 4 points

4. Intraoperative Blood Loss:
   - <= 400 mL: 0 points
   - 401-700 mL: 1 point
   - 701-1,000 mL: 2 points
   - > 1,000 mL: 3 points

The total score is computed by summing the scores from each of the four inputs. Once the total score is calculated, it is interpreted according to the following scale:

- Score of 0: The risk of fistula is negligible.
- Score from 1 to 2: The risk of fistula is low.
- Score from 3 to 6: The risk of fistula is intermediate.
- Score of 7 or more: The risk of fistula is high.

The procedure collects the user's inputs for gland texture, pathology, pancreatic duct diameter, and intraoperative blood loss, assigns predefined scores to each based on the specified categories, and sums these scores to produce a total score. This total score is then matched against interpretation criteria to provide a risk assessment, which includes both the numerical score and a descriptive interpretation of the risk level. 

This system provides a structured approach to evaluate postoperative fistula risk, helping inform clinical decisions by categorizing risk into clearly defined levels based on standard inputs.

The calculator in question is the Risk Score for Postoperative Pancreatic Fistula (POPF). This scoring system is specifically designed for patients undergoing pancreatic surgery, particularly pancreaticoduodenectomy, distal pancreatectomy, and other pancreatic resections. The clinical utility of this calculator is to predict the likelihood of a patient developing a postoperative pancreatic fistula, a serious and potentially life-threatening complication. 

The risk score takes into account various factors including patient characteristics, disease characteristics, and operative details. It helps clinicians to stratify patients into low, moderate, and high-risk categories, thereby guiding postoperative management and potentially reducing morbidity and mortality.

Exclusion criteria for its use would include patients not undergoing pancreatic surgery, those with pre-existing pancreatic fistulas, or those with contraindications to surgery. It's also important to note that this risk score may not be applicable in cases where intraoperative findings or postoperative course significantly deviate from the norm.

Risk score for postoperative pancreatic fistula

Acute pancreatitis

Aspiration of peripancreatic fluid collections

Evaluation for underlying cause

Endoscopic retrograde cholangiopancreatography

ERCP, prevention of post-ERCP pancreatitis

Nutrition support

Nutrition support, parenteral nutrition

Distal pancreatectomy

Nutrition support, oral feeding

Supportive care

Supportive care, general principles

Antibiotic therapy

Antibiotic therapy, therapeutic

Supportive care, fluid therapy

Magnetic resonance cholangiopancreatography/endoscopic ultrasound

MRCP/EUS

Serum lipase and amylase

Mechanical ventilation

Diagnostic criteria

Brief intervention for alcohol misuse

Antibiotic therapy, prophylactic

Percutaneous/endoscopic drainage

Percutaneous/endoscopic drainage, pancreatic necrosis

Nutrition support, enteral feeding

Risk assessment

Pancreatic necrosectomy

ERCP, indications

Specific pharmacotherapy

Abdominal imaging

Abdominal imaging, ultrasound

Patients with obesity

C-reactive protein

Setting of care

Setting of care, tertiary care

Abdominal imaging, CT/MRI

Antifungal therapy

Cholecystectomy

Open abdomen

Additional laboratory tests

ERCP

Setting of care, ICU

General principles

Percutaneous/endoscopic drainage (gallstone pancreatitis)

Follow-up imaging

Management of pancreatic pseudocysts

Supportive care (pain management)

Surveillance for diabetes

Updated 2024 ACG guidelines for the diagnosis and management of acute pancreatitis


Acute pancreatitis

Background

Overview

Guidelines

Key sources