Bedside Index for Severity in Acute Pancreatitis (BISAP) score for assesing prognosis in Acute Pancreatitis
Date First Published:
July 5, 2012
Last Updated:
July 8, 2012
Report by:
Adam Ting, Medical Student (University of Manchester)
Three-Part Question:
In [adult patients with a diagnosis of acute pancreatitis], [is the Bedside Index of Severity in Acute Pancreatitis (BISAP) score] accurate in [determining disease severity]?
Clinical Scenario:
Following the diagnosis of acute pancreatitis, a 50 year old man awaits treatment in the emergency department. With advantages of being simple to perform with only 5 parameters to consider and a quick prediction at 24 hours following admission, you are unsure if BISAP score is accurate in predicting clinical severity in acute pancreatitis when compared with the more established Ranson's/modified Glasgow score.
Search Strategy:
OVID MEDLINE 1946 to June Week 3 2012
EMBASE 1974 to 2012 July 03
EMBASE 1974 to 2012 July 03
Search Details:
[(exp Pancreatitis, Acute Necrotizing/ OR exp Pancreatitis/ OR exp Pancreatitis, Chronic/ OR exp Pancreatitis, Alcoholic/ OR pancreatitis.mp.) AND (bedside index for severity in acute pancreatitis.mp. OR BISAP.mp.)] LIMIT to Human AND English Language.
Outcome:
20 paper were found 10 were relevant
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis. R. Mounzer et al Jun-12 United States | 2 Prospective Cohort: Training Cohort (University of Pittsburgh Medical Center) - 256 patients Validation Cohort (Brigham and Women's Hospital, Boston)- 397 patients |
Prospective Cohort Study | BISAP Score with cut-off at 2 for Training Cohort at admission | Sensitivity - 0.61 (±0.2) | Complex study addressing all 9 clinical scores and 2 laboratory markers. Did not address unavailable data/information that indicates severity. |
| BISAP Score with cut-off at 2 for Validating Cohort at admission | Specificity - 0.84 (±0.4) | ||||
| BISAP Score with cut-off at 2 for Training Cohort 48 hrs after admission | PPV - 0.54 (± 0.10) | ||||
| BISAP Score with cut-off at 2 for Validating Cohort 48 hrs after admission | NPV - 0.87 (± 0.07) | ||||
| AUC - 0.72 (± 0.10) | |||||
| Sensitivity - 0.62 (± 0.20) | |||||
| Specificity - 0.76 (±0.4) | |||||
| PPV - 0.20 (± 0.60) | |||||
| NPV - 0.96 (± 0.04) | |||||
| AUC - 0.69 (± 0.11) | |||||
| Sensitivity - 0.72 (±0.17) | |||||
| Specificity - 0.83 (±0.9) | |||||
| PPV - 0.60 (± 0.16) | |||||
| NPV - 0.89 (± 0.06) | |||||
| AUC - 0.77 (± 0.09) | |||||
| Sensitivity - 0.59 (±0.26) | |||||
| Specificity - 0.81 (±0.04) | |||||
| PPV - 0.23 (± 0.10) | |||||
| NPV - 0.95 (± 0.04) | |||||
| AUC - 0.70 (± 0.13) | |||||
| Procalcitonin and BISAP score versus C-reactive protein and APACHE II score in early assessment of severity and outcome of acute pancreatitis M. Bezmarevic et al. 2012 Serbia | 51 patients: 29 patients with severe acute pancreatitis |
Diagnostic study comparing predictive value of BISAP score when compared to APACHE II score and serum procalcitonin when compared to serum CRP. Severity was first determined using Atlanta classification by the presence of organ failure. | BISAP score at 24h of admission with cut-off at 3 | 74% sensitive; 59% specific | Technical errors: spelling and grammatical mistakes. Small study conducted at single specialist center. |
| APACHE II score at 24h of admission with a cut-off at 8 | 89% sensitive; 69% specific | ||||
| Comparison of BISAP, Ranson’s, APACHE-II, and CTSI Scores in Predicting Organ Failure, Complications, and Mortality in Acute Pancreatitis Papachristou et al. Feb-10 | Total of 185 patients included in the study; 40 patient were classified as severe acute pancreatitis based on the presence of organ failure for more than 48h. |
Prospective Cohort Study comparing predicting values of various scoring systems in acute pancreatitis: BISAP score, Ranson's score, APACHE-II score and CTSI score | AUC of scoring systems in outcome prediction | BISAP: SAP 0.81 (CI 0.74-0.87); Pancreatic Necrosis 0.78 (CI 0.69-0.85), Mortality 0.82 (CI 0.67-0.91) | Some values of patient transferred were not available. With SAP defined by organ dysfunction, this can explain the better performance of Ranson's score as its variable are weighted towards detecting organ failure. |
| Accuracy of studies in predicting SAP | Ranson's: SAP 0.94 (CI 0.89-0.97); Pancreatic Necrosis 0.85 (CI 0.79-0.90), Mortality 0.95 (CI 0.90-0.98) | ||||
| Accuracy of studies in predicting SAP | APACHE-II: SAP 0.78 (CI 0.71-0.84); Pancreatic Necrosis 0.72 (CI 0.64-0.78), Mortality 0.94 (CI 0.89-0.97) | ||||
| CTSI: SAP 0.94 (CI 0.89-0.97); Pancreatic Necrosis 0.85 (CI 0.79-0.90), Mortality 0.95 (CI 0.90-0.998) | |||||
| BISAP: Sens 37.5 (CI 24.2-53.0), Spec - 92.4 (CI 86.9-95.7), PPV - 57.7 (CI 38.9-74.5), NPV - 84.3 (77.8-89.1) | |||||
| Ranson's: Sens 84.2 (CI 69.6-92.6), Spec - 89.8 (CI 83.6-93.8), PPV - 69.6 (CI 55.2-80.9), NPV - 95.3 (90.2-97.9) | |||||
| APACHE-II: Sens 70.3 (CI 54.2-82.5), Spec - 71.9 (CI 83.6-93.8), PPV - 69.6 (CI 55.2-80.9), NPV - 90.1 (83.1-94.4) | |||||
| CTSI: Sens 85.7 (CI 70.6-93.7), Spec - 71.0 (CI 61.5-79.0), PPV - 50.8 (CI 34.4-63.2), NPV - 93.4 (CI 85.5-97.2) | |||||
| Ranson's: SAP 0.94 (CI 0.89-0.97); Pancreatic Necrosis 0.85 (CI 0.79-0.90), Mortality 0.95 (CI 0.90-0.98) | |||||
| APACHE-II: SAP 0.78 (CI 0.71-0.84); Pancreatic Necrosis 0.72 (CI 0.64-0.78), Mortality 0.94 (CI 0.89-0.97) | |||||
| CTSI: SAP 0.94 (CI 0.89-0.97); Pancreatic Necrosis 0.85 (CI 0.79-0.90), Mortality 0.95 (CI 0.90-0.998) | |||||
| BISAP: Sens 37.5 (CI 24.2-53.0), Spec - 92.4 (CI 86.9-95.7), PPV - 57.7 (CI 38.9-74.5), NPV - 84.3 (77.8-89.1) | |||||
| Ranson's: Sens 84.2 (CI 69.6-92.6), Spec - 89.8 (CI 83.6-93.8), PPV - 69.6 (CI 55.2-80.9), NPV - 95.3 (90.2-97.9) | |||||
| APACHE-II: Sens 70.3 (CI 54.2-82.5), Spec - 71.9 (CI 83.6-93.8), PPV - 69.6 (CI 55.2-80.9), NPV - 90.1 (83.1-94.4) | |||||
| CTSI: Sens 85.7 (CI 70.6-93.7), Spec - 71.0 (CI 61.5-79.0), PPV - 50.8 (CI 34.4-63.2), NPV - 93.4 (CI 85.5-97.2) | |||||
| Predicting the severity of acute pancreatitis. V. Petsimeri et al. Oct-11 Greece | 17 patient | Cohort Study looking at prognostic value to various severity score. A cut-off of >2 in the BISAP score was considered severe acute pancreatitis. | Predictions of outcome above the cut-off for BISAP scores | Mortality - 33%; Complications - 33.3% | Only Journal Abstract available. Small sample size. |
| A Comparative Evaluation of Radiologic and Clinical Scoring Systems in the Early Prediction of Severity in Acute Pancreatitis T Bollen et al. Dec-11 United States | A total of 346 episodes of AP in 307: 159 episodes of AP in 150 patients where CT was performed on admission were included in the study, the other 187 episode did not meet the exclusion criteria and were not included. |
Prognostic Cohort study comparing the accuracy of seven CT scoring systems and two clinical scoring system in predicting mortality and clinical severity. | Accuracy of BISAP score 24h after admission with a cut-off of ≥3 at predicting clinical severity | Sens 48(95% CI 29-67); Spec 82(75-88); PPV 38(33-55); NPV 81(81-93) | |
| Accuracy of BISAP score 24h after admission with a cut-off of ≥3 at predicting mortality | Sens 89(95% CI 52-100); Spec 81(73-87); PPV 22(10-38); NPV 99(96-100) | ||||
| Assesing mortality in severe acute pancreatitis. Evaluation of the bedside index for severity in acute pancreatitis (BISAP). J. Larino-Nola et al. Jun-10 Sweden | 135 patients in total; 51 patient died. |
Prognostic cohort study evaluating accuracy of BISAP score for predicting mortality in patients with severe acute pancreatitis | Odds ratio of mortality | BISAP score ≥2: 1.07 (95% CI: 0.168- 6.72) | Only conference abstract available. Insufficient data available. |
| Need for mechanical ventilation: 20.7 (95% CI: 4.62-92.33) | |||||
| Organ failure development: 14.9 (95% CI: 4.09-54.30) | |||||
| Age: 7.8 (95% CI: 1.37- 44.0) | |||||
| Mechanical ventilation, age and organ failure are better predictors of mortality in severe acute pancreatitis than BISAP score. | |||||
| Admission SIRS score is better than admission BISAP score in predicting various outcomes in patients with acute pancreatitis. R. Takludar May-11 United States | 284 patients with AP. | Prognostic cohort study comparing accuracy of two clinical scores at predicting seven different outcome at admission, SIRS with a cut-off ≥2 BISAP score with a cut-off ≥3 | Odd ratio of length of hospitalisation >7 days | BISAP - 1.76 (0.45-5.88); SIRS - *4.21 (2.39-7.41) | Only conference abstract available. Limited data available. |
| Odd ratio of the need for ICU care | BISAP - 2.81 (0.41-12.5); SIRS - *4.28 (1.75-12.50) | ||||
| Odd ratio of intra-abdominal infections | BISAP - 1.27 (0.07-7.14); SIRS - *4.92 (1.96-14.39) | ||||
| Odd ratio of pancreatic necrosis | BISAP - *4.02 (1.01-14.29); SIRS - *4.09 (2.04-8.33) | ||||
| Odd ratio of fluid collections | BISAP - 1.98 (0.51-6.67); SIRS - *2.47 (1.39-4.35) | ||||
| Odd ratio of organ failure | BISAP - unavailable; SIRS - *3.76 (0.92-15.39) | ||||
| Odd ratio of mortality | BISAP - 3.28 (0.69-12.50); SIRS - *2.96 (0.64-16.67) | ||||
| * indicates statistically significant | |||||
| SIRS is a better overall predictor of outcomes than BISAP score at admission | |||||
| Prediction of mortality in acute pancreatitis. M.E. Shaileshkumar Feb-11 India | Total of 79 patients in total were included in the study. | Cohort study comparing accuracy of BISAP score with other methods of severity stratification (CTSI, Ranson's and CRP) in predicting mortality and complications in acute pancreatitis. | Area under curve predicting occurrence of pancreatic necrosis | BISAP-0.92; Ranson's-0.82; CRP-0.52 | Only conference abstract available. Limited data available. |
| Area under curve predicting mortality | BISAP-0.93, Ranson's-0.94; CRP-0.59; CTSI-0.84 | ||||
| Area under curve predicting occurrence of pancreatic necrosis | BISAP-0.92; Ranson's-0.82; CRP-0.52 | ||||
| Area under curve predicting mortality | BISAP-0.93, Ranson's-0.94; CRP-0.59; CTSI-0.84 | ||||
| The early prediction of mortality in acute pancreatitis: a large population-based study B. Wu et al Jun-08 United States | 2 groups of patients with acute pancreatitis were analysed: Derivation group included 17992 cases of AP from 212 hospitals; Validation group included 18256 cases of AP from 177 hospitals. |
Cohort study aimed at developing a scoring system for clinical stratification in acute pancreatitis | AUC for predicting in-hospital mortality | BISAP score - 0.82(95% CI 0.79-0.84); APACHE II score - 0.83(95% CI 0.80-0.85 | Withs referred patients included in the study combined with the large number of cases, data were not always available for all cases. Definition of clinical severity were not based on ICD-9 data. |
| A Prospective Evaluation of the Bedside Index for Severity in Acute Pancreatitis Score in Assessing Mortality and Intermediate Markers of Severity in Acute Pancreatitis V. K. Singh et al Apr-09 United States | A total of 397 cases of acute pancreatitis was analyzed | Prospective cohort study evaluating the ability of BISAP score at predicting mortality and severity (by looking at organ failure and pancreatic necrosis) in patients with acute pancreatitis. | AUC for mortality | BISAP score - 0.82(95% CI 0.79-0.95); APACHE II score - 0.88(95% CI 0.77-0.99) | Clinical severity were based on clinical judgement rather than standardised definitions. Including patients referred meant the loss of data in the process of collecting. Size of cohort limits extensive evaluation of complications (organ failure and pancreatic necrosis) |
| Odds ratio of complications with BISAP score ≥3 | Organ failure: 7.4 (2.8-19.5) | ||||
| Persistent organ failure: 12.7 (4.7-33.9) | |||||
| Necrosis: 3.8 (1.8-8.5) |
Author Commentary:
Currently the preferred choice of scoring systems include the Ranson's criteria (used primarily in US) and the modified Glasgow/Imrie score (used primarily in the UK). Though extensively validated, the burden of having to collect 11 and 8 parameters for the Ranson's and Imrie criteria respectively complicates it use. Additionally, the 48h delay before a diagnose can be made, impedes the delivery of effective management. Recently, B. Wu et al (9) developed a new clinical scoring system with the aim of accurately identifying clinical severity within 24h of hospital admission. Following the completion of the study, it was concluded that the BISAP score was a reliable prognostic scoring system for use in AP. Since then various studies have been done to evaluate the accuracy of this 5 point system predicting severity, mortality and subsequent pancreatic complications in patients with acute pancreatitis.
Bottom Line:
BISAP score is a reliable method in stratifying clinical severities of acute pancreatitis within 24hours of hospital admission; however, it is unreliable in the prediction of future pancreatic complications.
References:
- R. Mounzer et al. Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis.
- M. Bezmarevic et al.. Procalcitonin and BISAP score versus C-reactive protein and APACHE II score in early assessment of severity and outcome of acute pancreatitis
- Papachristou et al.. Comparison of BISAP, Ranson’s, APACHE-II, and CTSI Scores in Predicting Organ Failure, Complications, and Mortality in Acute Pancreatitis
- V. Petsimeri et al.. Predicting the severity of acute pancreatitis.
- T Bollen et al.. A Comparative Evaluation of Radiologic and Clinical Scoring Systems in the Early Prediction of Severity in Acute Pancreatitis
- J. Larino-Nola et al.. Assesing mortality in severe acute pancreatitis. Evaluation of the bedside index for severity in acute pancreatitis (BISAP).
- R. Takludar. Admission SIRS score is better than admission BISAP score in predicting various outcomes in patients with acute pancreatitis.
- M.E. Shaileshkumar. Prediction of mortality in acute pancreatitis.
- B. Wu et al. The early prediction of mortality in acute pancreatitis: a large population-based study
- V. K. Singh et al. A Prospective Evaluation of the Bedside Index for Severity in Acute Pancreatitis Score in Assessing Mortality and Intermediate Markers of Severity in Acute Pancreatitis