Accounting for comorbidity improves prediction of outcome trajectories in biliary acute pancreatitis

Introduction Outcome prediction in acute pancreatitis remains difficult. We aimed to identify simple predictors of a clinically significant outcome trajectories in biliary acute pancreatitis.

Material and Methods In this retrospective, multicenter cohort study data from electronic health-records of patients with biliary acute pancreatitis between 2018 and 2021 were extracted. Predictors of outcome were tested using univariable analyses. Outcome categories were defined hierarchically as: (i) death, (ii) severe pancreatitis and/or ICU admission, (iii) early or late interventions (e.g., endoscopic, surgical), (iv) moderately-severe pancreatitis, (v) mild pancreatitis.

Results Of 569 cases of acute pancreatitis, 217 (38.1%) patients with biliary acute pancreatitis, mean age 65.9 years (SD 17.4), median length of stay (LOS) 7 days (IQR 4;11), were included (see [Table 1]). Overall, 62.2% of patients experienced mild, 30.0% moderately severe, and 7.8% severe acute pancreatitis. The all-cause 90-day mortality was 2.3%. Individually, the Bedside Index of Severity in Acute Pancreatitis (BISAP) score and Charlson Comorbidity Index (CCI) classified patients reasonably well, however, large “outcome grey zones” existed (see [Table 2]). When combining BISAP and CCI, 5 distinct risk groups were identified, ranging from low (group 5) to very-high risk (group 1). High health-care resource use and worse outcomes (i-iii) were prevalent in 62.5%, 60%, 27.3%, 9.5%, 2.4% in groups 1-5. Also, LOS was significantly longer in higher risk groups (p<0.001). Importantly, 97.6% of patients in group 5 experienced a mild-to-moderate pancreatitis without ICU admission, persistent organ dysfunction, surgical or endoscopic interventions, and no fatality, and 90.5% in group 4, with groups 4 and 5 comprising approximately 80% of the entire cohort.

Table 1 Baseline characteristics of initial search and biliary acute pancreatitis cohort

Initial search
Acute pancreatitis cases, n	569
Age, mean (SD)	60.3 (17.2)
Sex female, n (%)	251 (44.1%)
LOS, median (IQR)	7 (4;12)
Etiology, n (%)
Biliary	217 (38.1%)
Alcohol-related	139 (24.4%)
Idiopathic	130 (22.8%)
Biliary acute pancreatitis cohort				p-value
Cases, n	217
Age, mean (SD)	65.9 (17.4)			<0.001*
Sex female, n (%)	107 (49.3%)			0.05*
LOS, median (IQR)	7 (4;11)			0.34*
BISAP, median (IQR)	1 (0;2)
CCI, median (IQR)	3 (1;4)
MODS, median (IQR)	0 (0;1)
Suspected/confirmed cholangitis, n (%)	40 (18.4%)
Underwent ERCP, n (%)	148 (68.2%)
Antibiotic treatment, n (%)	133 (61.3%)
Severity of pancreatitis
mild	135 (62.2%)
moderately-severe	65 (30.0%)
severe	17 (7.8%)
Mortality 90 day all-cause, n (%)	5 (2.3%)
Characteristics across severity groups	Mild	Moderately-severe	severe
Age, mean (SD)	64.8 (18.5)	66.2 (15.8)	74.2 (13.2)	0.10
LOS, median (IQR)	6 (3;9)	9 (6;13)	17 (8.5;31.5)	<0.001
BISAP, median (IQR)	1 (0;1)	1 (0;2)	2 (2;3.75)	<0.001
CCI, median (IQR)	3 (1;4)	3 (2;5)	6 (4.5;7)	<0.001
MODS, median (IQR)

*vs. other etiologies/initial search; BISAP=Bedside Index of Severity of Acute Pancreatitis, CCI=Charlson Comorbidity Index, ERCP=Endoscopic retrograde cholangiopancreatography, IQR=interquartile range, LOS=length of stay, MODS=multi-organ dysfunction score (adj. Marshall score), SD=standard deviation

Table 2 Outcome predictors and groups

Outcomes, n (%)	BISAP 0		BISAP 1-2			BISAP 3-5
Mortality 90d all-cause	0 (0.0%)		0 (0.0%)			4 (30.8%)
Severe pancreatitis or ICU admission	2 (3.3%)		12 (9.3%)			3 (23.1%)
Moderately-severe pancreatitis	16 (26.2%)		40 (31.0%)			5 (38.5%)
Mild pancreatitis	44 (72.1%)		81 (62.8%)			1 (7.7%)
	CCI 0-2		CCI 3-5			CCI≥6
Mortality 90d all-cause	0 (0.0%)		0 (0.0%)			5 (14.7%)
Severe pancreatitis or ICU admission	2 (2.2%)		9 (9.7%)			6 (17.6%)
Moderately-severe pancreatitis	27 (30.3%)		25 (26.9%)			13 (38.2%)
Mild pancreatitis	62 (69.7%)		61 (65.6%)			11 (32.4%)
	Outcome groups*
	Group 1	Group 2		Group 3	Group 4		Group 5
Risk	Very-high	High		Mod.-high	Mod.-low		Low
BISAP-class	3-5			0-2
CCI-class	≥6	0-5		≥6	3-5		0-2
Cases, n (%)	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%)
Moderately-severe pancreatitis	1 (12.5%)	0 (0%)		0 (0%)	2 (2.4%)		0 (0%)
Mild pancreatitis	2 (25%)	2 (40%)		7 (31.8%)	18 (21.4%)		24 (28.9%)

*Outcome groups 1-5 according to BISAP & CCI-classification: Group 1=BISAP 3-5 & CCI≥6, Group 2=BISAP 3-5 & CCI 0-5, Group 3=BISAP 0-2 & CCI≥6, Group 4=BISAP 0-2 & CCI 3-5, Group 5=BISAP 0-2 & CCI 0-2; BISAP=Bedside Index of Severity of Acute Pancreatitis, CCI=Charlson Comorbidity Index, IQR=interquartile range, LOS=length of stay, MODS=multi-organ dysfunction score, SD=standard deviation

Conclusion Outcome prediction does not necessarily demand complicated or hard to come by parameters. This study supports the combined use of BISAP and CCI, both readily and early-on available scores, in stratifying biliary acute pancreatitis patients.

Publikationsverlauf

Artikel online veröffentlicht:
13. Mai 2025