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Predicting the severity of acute pancreatitis

Santhi Swaroop Vege, MD
Section Editor
David C Whitcomb, MD, PhD
Deputy Editor
Shilpa Grover, MD, MPH, AGAF


Approximately 15 to 25 percent of all patients with acute pancreatitis (AP) develop severe AP. Between 1988 and 2003, mortality from acute pancreatitis decreased from 12 percent to 2 percent, according to a large epidemiologic study from the United States [1]. However, mortality rates remain much higher in subgroups of patients with severe disease. The ability to predict its severity can help identify patients at increased risk for morbidity and mortality, thereby assisting in appropriate early triage to intensive care units and selection of patients for specific interventions.

This topic review will summarize methods for predicting the severity of AP. The clinical manifestations, diagnosis, and treatment of AP are discussed separately. (See "Clinical manifestations and diagnosis of acute pancreatitis" and "Management of acute pancreatitis".)


A multitude of predictive models have been developed to predict the severity of AP based upon clinical, laboratory, and radiologic risk factors, various severity grading systems, and serum markers [2]. Some of these can be performed on admission to assist in triage of patients, while others can only be obtained after the first 48 to 72 hours or later.

However, these predictive models have low specificity (ie, high false positive rates), which, when coupled with the low prevalence of severe AP (15 to 25 percent), results in low positive predictive values [3]. Future predictive models will need to incorporate additional factors (eg, biomarkers, genetic polymorphisms and mutations, and proteomic and metabolomic patterns) and methods of analyses [4].


The revised Atlanta classification system divides acute pancreatitis into two broad categories (table 1) [5,6]:

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Literature review current through: Nov 2017. | This topic last updated: Jul 14, 2016.
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  1. Fagenholz PJ, Castillo CF, Harris NS, et al. Increasing United States hospital admissions for acute pancreatitis, 1988-2003. Ann Epidemiol 2007; 17:491.
  2. Windsor JA. Search for prognostic markers for acute pancreatitis. Lancet 2000; 355:1924.
  3. Robert JH, Frossard JL, Mermillod B, et al. Early prediction of acute pancreatitis: prospective study comparing computed tomography scans, Ranson, Glascow, Acute Physiology and Chronic Health Evaluation II scores, and various serum markers. World J Surg 2002; 26:612.
  4. Chauhan S, Forsmark CE. The difficulty in predicting outcome in acute pancreatitis. Am J Gastroenterol 2010; 105:443.
  5. Bradley EL 3rd. 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.
  6. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62:102.
  7. Marshall JC, Cook DJ, Christou NV, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med 1995; 23:1638.
  8. Larvin M. Assessment of clinical severity and prognosis. In: The Pancreas, Beger HG, Warshaw AL, Buchler MW, et al (Eds), Blackwell Science, Oxford 1998. p.489.
  9. Banks PA, Freeman ML, Practice Parameters Committee of the American College of Gastroenterology. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006; 101:2379.
  10. Frey CF, Zhou H, Harvey DJ, White RH. The incidence and case-fatality rates of acute biliary, alcoholic, and idiopathic pancreatitis in California, 1994-2001. Pancreas 2006; 33:336.
  11. Papachristou GI, Papachristou DJ, Morinville VD, et al. Chronic alcohol consumption is a major risk factor for pancreatic necrosis in acute pancreatitis. Am J Gastroenterol 2006; 101:2605.
  12. Lankisch PG, Assmus C, Pflichthofer D, et al. Which etiology causes the most severe acute pancreatitis? Int J Pancreatol 1999; 26:55.
  13. Lankisch PG, Blum T, Maisonneuve P, Lowenfels AB. Severe acute pancreatitis: when to be concerned? Pancreatology 2003; 3:102.
  14. Martínez J, Johnson CD, Sánchez-Payá J, et al. Obesity is a definitive risk factor of severity and mortality in acute pancreatitis: an updated meta-analysis. Pancreatology 2006; 6:206.
  15. Isenmann R, Rau B, Beger HG. Early severe acute pancreatitis: characteristics of a new subgroup. Pancreas 2001; 22:274.
  16. Buter A, Imrie CW, Carter CR, et al. Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis. Br J Surg 2002; 89:298.
  17. 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.
  18. Brown A, Orav J, Banks PA. Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis. Pancreas 2000; 20:367.
  19. Lankisch PG, Mahlke R, Blum T, et al. Hemoconcentration: an early marker of severe and/or necrotizing pancreatitis? A critical appraisal. Am J Gastroenterol 2001; 96:2081.
  20. Baillargeon JD, Orav J, Ramagopal V, et al. Hemoconcentration as an early risk factor for necrotizing pancreatitis. Am J Gastroenterol 1998; 93:2130.
  21. Remes-Troche JM, Duarte-Rojo A, Morales G, Robles-Díaz G. Hemoconcentration is a poor predictor of severity in acute pancreatitis. World J Gastroenterol 2005; 11:7018.
  22. Muddana V, Whitcomb DC, Khalid A, et al. Elevated serum creatinine as a marker of pancreatic necrosis in acute pancreatitis. Am J Gastroenterol 2009; 104:164.
  23. Büchler M, Malfertheiner P, Schoetensack C, et al. Sensitivity of antiproteases, complement factors and C-reactive protein in detecting pancreatic necrosis. Results of a prospective clinical study. Int J Pancreatol 1986; 1:227.
  24. Wilson C, Heads A, Shenkin A, Imrie CW. C-reactive protein, antiproteases and complement factors as objective markers of severity in acute pancreatitis. Br J Surg 1989; 76:177.
  25. Leese T, Shaw D, Holliday M. Prognostic markers in acute pancreatitis: can pancreatic necrosis be predicted? Ann R Coll Surg Engl 1988; 70:227.
  26. Wu BU, Johannes RS, Sun X, et al. Early changes in blood urea nitrogen predict mortality in acute pancreatitis. Gastroenterology 2009; 137:129.
  27. Wu BU, Bakker OJ, Papachristou GI, et al. Blood urea nitrogen in the early assessment of acute pancreatitis: an international validation study. Arch Intern Med 2011; 171:669.
  28. Lankisch PG, Weber-Dany B, Maisonneuve P, Lowenfels AB. High serum creatinine in acute pancreatitis: a marker for pancreatic necrosis? Am J Gastroenterol 2010; 105:1196.
  29. Forsmark CE, Baillie J, AGA Institute Clinical Practice and Economics Committee, AGA Institute Governing Board. AGA Institute technical review on acute pancreatitis. Gastroenterology 2007; 132:2022.
  30. Papachristou GI, Whitcomb DC. Predictors of severity and necrosis in acute pancreatitis. Gastroenterol Clin North Am 2004; 33:871.
  31. Blum T, Maisonneuve P, Lowenfels AB, Lankisch PG. Fatal outcome in acute pancreatitis: its occurrence and early prediction. Pancreatology 2001; 1:237.
  32. Buddingh KT, Koudstaal LG, van Santvoort HC, et al. Early angiopoietin-2 levels after onset predict the advent of severe pancreatitis, multiple organ failure, and infectious complications in patients with acute pancreatitis. J Am Coll Surg 2014; 218:26.
  33. Kylänpää-Bäck ML, Takala A, Kemppainen E, et al. Procalcitonin strip test in the early detection of severe acute pancreatitis. Br J Surg 2001; 88:222.
  34. Talamini G, Uomo G, Pezzilli R, et al. Serum creatinine and chest radiographs in the early assessment of acute pancreatitis. Am J Surg 1999; 177:7.
  35. Block S, Maier W, Bittner R, et al. Identification of pancreas necrosis in severe acute pancreatitis: imaging procedures versus clinical staging. Gut 1986; 27:1035.
  36. Bollen TL, Singh VK, Maurer R, et al. A comparative evaluation of radiologic and clinical scoring systems in the early prediction of severity in acute pancreatitis. Am J Gastroenterol 2012; 107:612.
  37. Tsuji Y, Yamamoto H, Yazumi S, et al. Perfusion computerized tomography can predict pancreatic necrosis in early stages of severe acute pancreatitis. Clin Gastroenterol Hepatol 2007; 5:1484.
  38. Tsuji Y, Takahashi N, Fletcher JG, et al. Subtraction color map of contrast-enhanced and unenhanced CT for the prediction of pancreatic necrosis in early stage of acute pancreatitis. AJR Am J Roentgenol 2014; 202:W349.
  39. Merkle EM, Görich J. Imaging of acute pancreatitis. Eur Radiol 2002; 12:1979.
  40. Lecesne R, Taourel P, Bret PM, et al. Acute pancreatitis: interobserver agreement and correlation of CT and MR cholangiopancreatography with outcome. Radiology 1999; 211:727.
  41. Morgan DE, Baron TH, Smith JK, et al. Pancreatic fluid collections prior to intervention: evaluation with MR imaging compared with CT and US. Radiology 1997; 203:773.
  42. Hirota M, Kimura Y, Ishiko T, et al. Visualization of the heterogeneous internal structure of so-called "pancreatic necrosis" by magnetic resonance imaging in acute necrotizing pancreatitis. Pancreas 2002; 25:63.
  43. Arvanitakis M, Delhaye M, De Maertelaere V, et al. Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis. Gastroenterology 2004; 126:715.
  44. Mounzer R, Langmead CJ, Wu BU, et al. Comparison of existing clinical scoring systems to predict persistent organ failure in patients with acute pancreatitis. Gastroenterology 2012; 142:1476.
  45. Wang X, Xu Y, Qiao Y, et al. An evidence-based proposal for predicting organ failure in severe acute pancreatitis. Pancreas 2013; 42:1255.
  46. Corfield AP, Cooper MJ, Williamson RC, et al. Prediction of severity in acute pancreatitis: prospective comparison of three prognostic indices. Lancet 1985; 2:403.
  47. Ranson JH, Rifkind KM, Roses DF, et al. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet 1974; 139:69.
  48. Agarwal N, Pitchumoni CS. Simplified prognostic criteria in acute pancreatitis. Pancreas 1986; 1:69.
  49. Ranson JH. The timing of biliary surgery in acute pancreatitis. Ann Surg 1979; 189:654.
  50. De Bernardinis M, Violi V, Roncoroni L, et al. Discriminant power and information content of Ranson's prognostic signs in acute pancreatitis: a meta-analytic study. Crit Care Med 1999; 27:2272.
  51. Johnson CD, Toh SK, Campbell MJ. Combination of APACHE-II score and an obesity score (APACHE-O) for the prediction of severe acute pancreatitis. Pancreatology 2004; 4:1.
  52. Papachristou GI, Papachristou DJ, Avula H, et al. Obesity increases the severity of acute pancreatitis: performance of APACHE-O score and correlation with the inflammatory response. Pancreatology 2006; 6:279.
  53. Domínguez-Muñoz JE, Carballo F, García MJ, et al. Evaluation of the clinical usefulness of APACHE II and SAPS systems in the initial prognostic classification of acute pancreatitis: a multicenter study. Pancreas 1993; 8:682.
  54. Williams M, Simms HH. Prognostic usefulness of scoring systems in critically ill patients with severe acute pancreatitis. Crit Care Med 1999; 27:901.
  55. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 1992; 101:1644.
  56. Mofidi R, Duff MD, Wigmore SJ, et al. Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis. Br J Surg 2006; 93:738.
  57. Singh VK, Wu BU, Bollen TL, et al. Early systemic inflammatory response syndrome is associated with severe acute pancreatitis. Clin Gastroenterol Hepatol 2009; 7:1247.
  58. Wu BU, Johannes RS, Sun X, et al. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut 2008; 57:1698.
  59. Papachristou GI, Muddana V, Yadav D, et al. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol 2010; 105:435.
  60. Windsor JA. A better way to predict the outcome in acute pancreatitis? Am J Gastroenterol 2010; 105:1671.
  61. Lankisch PG, Weber-Dany B, Hebel K, et al. The harmless acute pancreatitis score: a clinical algorithm for rapid initial stratification of nonsevere disease. Clin Gastroenterol Hepatol 2009; 7:702.
  62. Bollen TL, van Santvoort HC, Besselink MG, et al. The Atlanta Classification of acute pancreatitis revisited. Br J Surg 2008; 95:6.
  63. Vege SS, Chari ST. Organ failure as an indicator of severity of acute pancreatitis: time to revisit the Atlanta classification. Gastroenterology 2005; 128:1133.
  64. Goris RJ, te Boekhorst TP, Nuytinck JK, Gimbrère JS. Multiple-organ failure. Generalized autodestructive inflammation? Arch Surg 1985; 120:1109.
  65. Bernard GR, Doig G, Hudson L, et al. Quantification of organ failure for clinical trials and clinical practice. Am J Respir Crit Care Med 1995; 151:A323.
  66. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996; 22:707.
  67. Le Gall JR, Klar J, Lemeshow S, et al. The Logistic Organ Dysfunction system. A new way to assess organ dysfunction in the intensive care unit. ICU Scoring Group. JAMA 1996; 276:802.
  68. Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990; 174:331.
  69. Tenner S, Sica G, Hughes M, et al. Relationship of necrosis to organ failure in severe acute pancreatitis. Gastroenterology 1997; 113:899.
  70. Simchuk EJ, Traverso LW, Nukui Y, Kozarek RA. Computed tomography severity index is a predictor of outcomes for severe pancreatitis. Am J Surg 2000; 179:352.
  71. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013; 13:e1.
  72. Tenner S, Baillie J, DeWitt J, et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013; 108:1400.