Introduction
Acute biliary pancreatitis (ABP) has been shown to be associated with increasing incidence and health-care costs, and possibly higher mortality than other etiologies. Despite the existence of various scoring systems, early and accurate risk stratification remains difficult. Due to heterogeneity of populations, focusing on one etiology might reveal important insights concerning predictors of outcome.
Aims & Methods
We conducted a retrospective, multicenter cohort study including all patients admitted with ABP between 2018 and 2021 at two hospitals. Epidemiological, clinical, and outcome data were analyzed. The main clinical outcome of interest was a hierarchical composite endpoint of five mutually exclusive clinical states: (i) death (90-day all-cause mortality), (ii) severe AP and/or admission to the intensive care unit (ICU), (iii) endoscopic, interventional radiological, or surgical interventions, (iv) moderately-severe AP, (v) mild AP. Univariable logistic regression identified parameters associated with worse outcomes, which were then tested in multivariable models. Emphasis was placed on early availability and clinical practicality of predictors. We aimed to stratify patients into outcome trajectories reflecting both health impact and healthcare resource utilization.
Results
Out of 569 total acute pancreatitis cases, 217 (38.1%) patients had ABP (mean age 65.9 ±17.4 years; median length of stay (LOS) 7 days, IQR 4;11) Mild, moderately-severe, and severe disease occurred in 62.2%, 30.0%, and 7.8% of patients. All-cause 90-day mortality was 2.3%. Several parameters were significantly (p<0.05) associated with worse outcomes, including BISAP and the Charlson comorbidity index (CCI) (p<0.001). Individually, BISAP and CCI classified patients reasonably, however, wide prognostic uncertainty persisted. When combining BISAP and CCI (BISAP-C), 5 discrete risk groups were identified, ranging from low (group 1, BISAP 0-2 & CCI 0-2) to very-high risk (group 5, BISAP 3-5 & CCI ≥6) (see Table 1). The prevalence of severe outcomes (i–iii) increased across these strata: 2.4% (Group 1), 9.5% (Group 2), 27.3% (Group 3), 60% (Group 4), and 62.5% (Group 5), with LOS also significantly longer in higher-risk groups (p<0.001). Mortality was 50% in group 5, while, importantly, 97.6% of patients in group 1 experienced mild-to-moderate AP without ICU admission, persistent organ dysfunction, surgical or endoscopic interventions, and no fatality, supporting potential early discharge. This also occurred in 90.5% of group 2. Notably, Groups 1 and 2 together comprised nearly 80% of the cohort.
Table 1. Outcome trajectories
| Outcome groups*
|
| Group 5
Very-high
| Group 4
High
| Group 3
Mod.-high
| Group 2
Mod.-low
| Group 1
Low
|
BISAP
CCI
| 3-5
≥6
| 3-5
≤5
| 0-2
≥6
| 0-2
3-5
| 0-2
≤2
|
Cases, n (% of cohort)
| 8 (4.0%)
| 5 (2.5%)
| 22 (10.9%)
| 84 (41.6%)
| 83 (41.1%)
|
LOS, median (IQR)
| 5 (3;10)
| 15 (9;106.5)
| 10 (6;14.25)
| 7 (4;11)
| 5 (3;9)
|
Mortality, 90d all-cause
| 4 (50%)
| 0 (0%)
| 0 (0%)
| 0 (0%)
| 0 (0%)
|
Severe pancreatitis or ICU admission
| 0 (0%)
| 3 (60%)
| 6 (27.3%)
| 6 (7.1%)
| 2 (2.4%)
|
Intervention (endosc., IR, surgical)
| 1 (12.5%)
| 0 (0%)
| 0 (0%)
| 2 (2.4%)
| 0 (0%)
|
Moderately-severe pancreatitis
| 2 (25.0%)
| 2 (40%)
| 7 (31.8%)
| 18 (21.4%)
| 24 (28.9%)
|
Mild pancreatitis
| 1 (12.5%)
| 0 (0%)
| 9 (40.9%)
| 58 (69.0%)
| 57 (68.7%)
|
Conclusion
Comorbidity seems to play a major role concerning worse outcomes in ABP. The combination of CCI and BISAP (BISAP-C), both comprised of early-on and easily available parameters, offers improved early prognostic discrimination and may provide tailored, individualized management and healthcare resource utilization.
