Features |
MAP |
MSAP and SAP |
P value |
n=133 |
n=34 |
||
Gender, % |
|||
Male |
90 (67.7) |
24 (70.6) |
0.74 |
Female |
43 (32.3) |
10 (29.4) |
|
Age, years |
39.8 ± 11.0 |
39.7 ± 11.0 |
0.95 |
ALT (U/L) |
29.1 ± 20.0 |
27.0 ± 20.1 |
0.59 |
AST (U/L) |
27.0 ± 20.1 |
32.1 ± 31.8 |
0.49 |
TG (mmol/L) |
13.1 ± 8.2 |
23.3 ± 11.9 |
<0.01 |
TC (mmol/L) |
8.5 ± 4.0 |
12.0 ± 8.9 |
0.03 |
Amylase (U/L) |
304.7 ± 336.7 |
349.2 ± 306.2 |
0.46 |
BISAP |
0.9 ± 0.8 |
2.5 ± 0.9 |
<0.01 |
MCTSI |
2.9 ± 1.4 |
4.8 ± 1.8 |
<0.01 |
Hospitalization days |
8.3 ± 2.7 |
13.0 ± 4.8 |
<0.01 |
Local complication, % |
|||
0 |
94 (70.7) |
9 (26.5) |
<0.01 |
1 |
39 (29.3) |
25 (73.5) |
|
Hypertension, % |
|||
0 |
105 (78.9) |
24 (70.6) |
0.3 |
1 |
28 (21.1) |
10 (29.4) |
|
Hyperuricemia, % |
|||
0 |
106 (79.7) |
30 (88.2) |
0.25 |
1 |
27 (20.3) |
4 (11.8) |
|
Type 2 diabete, % |
|||
0 |
87 (65.4) |
21 (61.8) |
0.69 |
1 |
46 (34.6) |
13 (38.2) |
|
Fatty liver, % |
|||
0 |
66 (49.6) |
6 (17.6) |
0.01 |
1 |
67 (50.4) |
28 (82.4) |
Scoring system |
MAP |
MSAP and SAP |
P value |
n=133 |
n=34 |
||
BISAP |
|||
?3 |
6 (4.5%) |
25 (73.5%) |
<0.01 |
<3 |
127 (95.5%) |
9 (26.5%) |
|
MCTSI |
|||
?4 |
53 (39.8%) |
27 (79.4%) |
<0.01 |
<4 |
80 (60.2%) |
7 (20.6%) |
Table 3. Analysis between BISAP and MCTSI in predicting local complication of HLAP
Scoring system |
No Local complication |
Local complication |
P value |
n=103 |
n=64 |
||
BISAP |
|||
?3 |
7 (6.8%) |
24 (37.5%) |
<0.01 |
<3 |
96 (93.2%) |
40 (62.5%) |
|
MCTSI |
|||
?4 |
22 (21.4%) |
58 (90.6%) |
<0.01 |
<4 |
81 (78.6%) |
6 (9.4%) |
As seen in Table 4, Fig. 1, Fig. 2. The AUC for BISAP and MCTSI predicting severe HLAP respectively were 0.89, 0.78, sensitivity were 73.5%, 79.4%, specificity were 95.5%, 60.2%, PPV were 80.6%, 33.8%, NPV were 93.4%, 92.0%. In predictionig local complications, the AUC of BISAP and MCTSI respectively were 0.73, 0.87, sensitivity were 37.5%, 90.1%, specificity were 93.2%, 78.6%, PPV were 77.4%, 72.5%, NPV were 70.6%, 93.1%.
Table 4. Comparision between BISAP and MCTSI in predicting severity and local complications of HLAP
Scoring system |
sensitivity (%) |
specificity (%) |
PPV (%) |
NPV (%) |
Youden index |
AUC |
MSAP and SAP |
||||||
BISAP |
73.5 |
95.5 |
80.6 |
93.4 |
0.69 |
0.89 |
MCTSI |
79.4 |
60.2 |
33.8 |
92 |
0.4 |
0.78 |
Local complication |
||||||
BISAP |
37.5 |
93.2 |
77.4 |
70.6 |
0.31 |
0.73 |
MCTSI |
90.1 |
78.6 |
72.5 |
93.1 |
0.69 |
0.87 |
Figure 1. ROC curve of BISAP and MCTSI about the severity of HLAP
Figure 2. ROC curve of BISAP and MCTSI about local complications of HLAP
Figure 3. Correlation between BISAP and TG of HLAP
Discussion
In 1952, Klatskin (Klatskin et al., 1952) initially proposed that hyperlipidemia may be the underlying cause for AP. It was widely known that gallstones (up to 60%) and excess alcohol consumption (30%) were the leading contributing factors of AP, while hyperlipidemia (HTG) was less frequency, accounting for 4-10% (Adiamah et al., 2018). Nowadays excess high-sugar and high-fat food intake, overweight, and absent regular physical exercise bring about the elevated incidence for HLAP. A study about the trend for etiological distribution of AP during the period of five years in Beijing by Zheng et al (Zheng et al., 2015), found that the proportion of patients with HLAP was increasing year by year and HTG had taken place of the alcohol as the second common factors of AP. Compared to other etiological AP, HLAP had more complicated pathological mechanism, faster aggravation, easier relapse, higher mortality rate as high as 30% (Valdivielso et al., 2014). Therefore, it is imperative to understand the etiology and predict the severity at early stage for better individualized treatment and management.
Our study highlighted that there were more man patients than woman patients with HLAP [(67.7% vs 32.3%) in MAP, (70.6% vs 29.4%) in MSAP and SAP] with the similar ages (39.8 ± 11.0 in MAP, 39.7 ± 11.0 in MSAP and SAP ), which was in line with the report of Li et al (Li et al., 2018). These outcomes above probably were responsible for strong work and life pressure, smoking, absent exercise, high-calorie food, and irregular sleeping schedule in young man patients. Additionly, TG in MSAP and SAP group was higher than in MAP group [(23.3 ± 11.9) vs (13.1 ± 8.2) mmol/L, P<0.01]. Consistently, an analysis carried by Wang, et al. (Wang et al., 2016) indicated that when TG > 20.0mmol/L, MSAP and SAP patients accounted for 63.1%, which was greatly higher than MAP petients. Oh et al (Oh et al., 2007) and Yadav et al (Yadav et al., 2003) believed that the occurrence and mortality rate of AP would decrease when TG was controlled under 5.65mmom/L. A study concluded (Xiao et al., 2012) that patients with fatty liver was 59% in MAP group and 100% in MSAP and SAP group. Similar to previous study, the proportion of fatty liver in our research were 50.4% in MAP group and 82.4% in MSAP and SAP group respectively.
BISAP was derived on data collected from 17992 cases of AP from 212 hospitals in 2000–2001 and validated by 18256 AP cases from 177 hospitals in 2004-2005. Wu et al concluded that BISAP was as effective as APACHE II to evaluate in-hospital mortality (Wu et al., 2008). Prior research demonstrated that the accuracy of BISAP for severity assessment of AP were not worse than “traditional” scoring systems (Ranson score, APACHE II, MCTSI et al) (G. I. Papachristou et al., 2010). A study by Qiu, et al. (Qiu et al., 2015) indicated that the AUC (0.604), sensitivity (0.905), and specificity (1.000) of BISAP were higher in the prediction of SAP compared to MCTSI. In our study, BISAP also performed better in predicting the severity of HLAP than MCTSI. Moreover, we found that BISAP was positive correlation with TG, both of which were important prognostic marker for HLAP.
MCTSI is a major clinical imaging scoring system showed strongly correlation with morbidity and local complications of AP (Aoun et al., 2009; Balthazar et al., 2002). It was modified and simplified based on CTSI that was put forward by Balthazar and colleagues (Mortele et al.; Balthazar and Robinson et al., 1990). A study revealed that MCTSI manifested higher accuracy for the local complications and death of HLAP patients compared with nonhyperlipidemic acute pancreatitis (NHLAP) (G. I. Papachristou et al., 2010). According to the retrospective research from Yang, et al. (Yang et al., 2016), MCTSI had outstanding performance in the prediction of local complications but poor in severity accessment compared to BISAP. That conformed to our study.
There were two limitations of the study. Firstly, the study was respective with small sample. Secondly, lack of comparision with other else traditional scoring systems.
Conclusions
Our study demonstrated that the level of TG and the incidence of fatty liver were higher in severer patients. TG was positively correlated with BISAP. Furthermore, BISAP may be a useful prognostic marker to predict the severity of AP.
Author Contributions
L N conceived the study; L N and QM W participated in the design and drafted the manuscript;L N, SR W, F Y, XM F, H L and Y C collected the data and performed statistical analyses.QM W, Y C, M L and JJ Z edited and checked the manuscript. All of the authors have read and approved the final manuscript.
References:
Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, Tsiotos GG, Vege SS. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111.
Fan J, Ding L, Lu Y, Zheng J, Zeng Y, Huang C. Epidemiology and Etiology of Acute Pancreatitis in Urban and Suburban Areas in Shanghai: A Retrospective Study. Gastroenterol Res Pract 2018; 2018: 1420590.
Zheng Y, Zhou Z, Li H, Li J, Li A, Ma B, Zhang T, Liao Q, Ye Y, Zhang Z, Yang Y. A multicenter study on etiology of acute pancreatitis in Beijing during 5 years. Pancreas 2015; 44: 409-414.
Mortele KJ, Wiesner W, Intriere L, Shankar S, Zou KH, Kalantari BN, Perez A, VanSonnenberg E, Ros PR, Banks PA, Silverman SG. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. AJR Am J Roentgenol 2004; 183: 1261-1265.
Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut 2008; 57: 1698-1703.
Ranson J, Rifkind KM, Turner JW. Prognostic signs and nonoperative peritoneal lavage in acute pancreatitis. Surg Gynecol Obstet 1976; 143: 209 - 219
Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE-acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 1981; 9: 591-597.
Klatskin G. Relationship between relapsing pancreatitis and essential hyperlipemia. Am J Med 1952; 12: 3-23.
Adiamah A, Psaltis E, Crook M. A systematic review of the epidemiology, pathophysiology and current management of hyperlipidaemic pancreatitis. Clin Nutr 2018; 37: 1810-1822.
Valdivielso P, Ramírez-Bueno A, Ewald N. Current knowledge of hypertriglyceridemic Pancreatitis. Eur J Intern Med 2014; 25: 689-694.
Li X, Ke L, Dong J, Ye B, Meng L, Mao W, Yang Q, Li W, Li J. Significantly different clinical features between hypertriglyceridemia and biliary acute pancreatitis: a retrospective study of 730 patients from a tertiary center. BMC Gastroenterol 2018; 18: 1-89.
Wang SH, Chou YC, Shangkuan WC, Wei KY, Pan YH, Lin HC. Relationship between Plasma Triglyceride Level and Severity of Hypertriglyceridemic Pancreatitis. PLoS One 2016; 11: e0163984.
Oh RC and Lanier JB. Management of hypertriglyce ridemia. Am Fam Physician 2007; 75: 1365-1371?
Yadav D. Issues in hyperlipidemic pancreatitis. J Clin Gastroenterol 2003; 36: 54-62.
Xiao B, Zhang XM, Jiang ZQ, Tang W, Huang XH, Yang L, Feng ZS. Fatty liver in acute pancreatitis: characteristics in magnetic resonance imaging. J Comput Assist Tomogr 2012; 36: 400-405.
Papachristou GI, Muddana V, Yadav D, O’Connell M, Sanders MK, Slivka A, Whitcomb DC. 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: 435-441.
Qiu L, Sun RQ, Jia RR, Ma XY, Cheng L, Tang MC, Zhao Y. Comparison of Existing Clinical Scoring Systems in Predicting Severity and Prognoses of Hyperlipidemic Acute Pancreatitis in Chinese Patients: A Retrospective Study. Medicine (Baltimore) 2015; 94: e957.
Aoun E, Chen J, Reighard D, Gleeson FC, Whitcomb DC, Papachristou GI. Diagnostic accuracy of interleukin-6 and interleukin-8 in predicting severe acute pancreatitis: a meta-analysis. Pancreatology 2009; 9: 777-785.
Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology 2002; 223: 603-613.
Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990; 174: 331-336.
Yang L, Liu J, Xing Y, Du L, Chen J, Liu X, Hao J. Comparison of BISAP, Ranson, MCTSI, and APACHE II in Predicting Severity and Prognoses of Hyperlipidemic Acute Pancreatitis in Chinese Patients. Gastroenterol Res Pract 2016; 2016: 1834256.