改良客观性BISAP评分对急性胰腺炎严重程度及预后的预测价值

唐豪佑; 刘胜; 胡程俊; 马林; 李建水

doi:10.3969/j.issn.1001-5256.2021.06.032

改良客观性BISAP评分对急性胰腺炎严重程度及预后的预测价值

DOI: 10.3969/j.issn.1001-5256.2021.06.032

唐豪佑^{1, 2},
刘胜^{1, 2},
胡程俊^{1, 2},
马林^{1, 2},
李建水^{1, 2, ,}

1.
川北医学院附属医院肝胆外科，四川南充 637000
2.
川北医学院肝胆胰肠研究所，四川南充 637000

基金项目:

南充市市校科技战略合作项目 (18SXHZ0332)

利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。

作者贡献声明：唐豪佑、李建水负责设计研究思路，论文撰写；刘胜、胡程俊负责收集临床资料，统计分析；马林协助论文修改。

详细信息

作者简介:
唐豪佑(1995—)，男，主要从事急性胰腺炎基础与临床研究

通信作者:
李建水，ljs2005doctor@126.com

中图分类号: R576
计量
- 文章访问数: 688
- HTML全文浏览量: 162
- PDF下载量: 74
- 被引次数: 0
出版历程
- 收稿日期: 2020-11-15
- 录用日期: 2020-12-18
- 出版日期: 2021-06-20

Value of modified objective Bedside Index for Severity in Acute Pancreatitis score in predicting the severity and prognosis of acute pancreatitis

Haoyou TANG^{1, 2},
Sheng LIU^{1, 2},
Chengjun HU^{1, 2},
Lin MA^{1, 2},
Jianshui LI^{1, 2
, ,}

1.
Department of Hepatobiliary Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan 637000, China
2.
Institute of Hepatobiliary, Pancreatic, and Intestinal Diseases, North Sichuan Medical College, Nanchong, Sichuan 637000, China

摘要

摘要: 目的探讨改良客观性BISAP评分(MBISAP)对急性胰腺炎(AP)严重程度及预后的预测价值。方法回顾性分析2018年6月—2020年6月川北医学院附属医院收治的313例AP患者资料，将BISAP评分中精神状态这一主观性指标去除，再根据CTSI(CT严重指数)评分标准，将胰腺坏死程度分为4类(0、0~30%、30%~50%、＞50%)，并给予相应的赋值(0~3分)，MBISAP评分由上述指标赋值相加可得，最高为7分。根据受试者工作特征(ROC)曲线将313例胰腺炎患者分为MBISAP低级别组(MBISAP＜3分)和MBISAP高级别组(MBISAP≥3分)2组。比较2组基线资料、临床结局，非正态分布的计量资料2组间比较采用Mann-Whitney U秩和检验；计数资料2组间比较采用χ²检验或Fisher精确检验。ROC曲线下面积(AUC)分析比较MBISAP评分、BISAP评分、CTSI评分对AP病情严重程度、预后的预测价值。结果 2组患者在年龄(Z=-5.480，P＜0.001)、病因(χ²=36.536，P＜0.001)、住院时间(Z=-6.038，P＜0.001)、病死率(P＜0.001)、胰周感染(P＜0.001)、多器官功能障碍综合征(MODS)(P＜0.001)、BISAP评分(χ²=215.320, P＜0.001)、CTSI评分(P＜0.001)之间存在明显差异。随着MBISAP评分的增加，AP病情严重程度、病死率、胰周感染、MODS的发生呈增加趋势(P值均＜0.001)。在预测SAP方面，MBISAP评分AUC=0.898(95%CI: 0.859~0.929，P＜0.001)，敏感度为71.43%，特异度为90.53%；当MBISAP≥3时为最佳临界值，优于BISAP评分(AUC=0.868，P＜0.05)、CTSI评分(AUC=0.827，P＜0.05)。在预测AP患者死亡方面，MBISAP评分AUC=0.925(95%CI: 0.890~0.952，P＜0.001)，敏感度为88.89%，特异度为82.89%；当MBISAP≥3时为最佳临界值，与BISAP评分(AUC=0.915，P＞0.05)、CTSI评分(AUC=0.879，P＞0.05)相似。在预测AP胰周感染方面，MBISAP评分AUC=0.842(95%CI: 0.796~0.880，P＜0.001)，敏感度为72.22%，特异度为84.07%；当MBISAP＞2时为最佳临界值，优于BISAP评分(AUC= 0.776，P＜0.05)，但比CTSI评分(AUC=0.932，P＜0.05)较差。在预测AP患者合并MODS方面，MBISAP评分AUC=0.874(95%CI: 0.832~0.909，P＜0.001)，敏感度为76.19%，特异度为84.93%，当MBISAP＞2时为最佳临界值，与BISAP评分(AUC=0.855，P＞0.05)、CTSI评分(AUC=0.829，P＞0.05)相似。结论 MBISAP评分在预测AP患者的严重程度及胰周感染方面优于BISAP评分，预测AP患者死亡及MODS方面也有较好的价值，相比BISAP评分能够更准确、客观地评估AP患者情况。
- 胰腺炎 /
- BISAP评分 /
- CTSI评分
Abstract: Objective To investigate the value of modified objective Bedside Index for Severity in Acute Pancreatitis (BISAP) score (MBISAP) in predicting the severity and prognosis of acute pancreatitis (AP). Methods A retrospective analysis was performed for the data of 313 patients with AP who were treated in Affiliated Hospital of North Sichuan Medical College from June 2018 to June 2020, and the subjective indicator of mental state in BISAP score was removed. According to the scoring criteria for Computed Tomography Severity Index (CTSI), the degree of pancreatic necrosis was classified as 4 grades (0%, 0%-30%, 30%-50%, and > 50%) and was assigned a score of 0-3 points, respectively, and MBISAP score was determined by adding the above points, with the highest score of 7 points. According to the receiver operating characteristic (ROC) curve, the 313 patients with pancreatitis were divided into low-level MBISAP group (MBISAP < 3) and high-level MBISAP group (MBISAP ≥3). The two groups were compared in terms of baseline data and clinical outcome. The Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups, and the chi-square test or the Fisher's exact test was used for comparison of categorical data between two groups. The area under the ROC curve (AUC) was used to analyze an compare the value of MBISAP score, BISAP score, and CTSI score in predicting the severity and prognosis of AP. Results There were significant differences between the two groups in age (Z=-5.480, P < 0.001), etiology (χ²=36.536, P < 0.001), length of hospital stay (Z=-6.038, P < 0.001), mortality rate (P < 0.001), peripancreatic infection (P < 0.001), multiple organ dysfunction syndrome (MODS) (P < 0.001), BISAP score (χ²=215.320, P < 0.001), and CTSI score (P < 0.001). Severity of AP, mortality rate, and incidence rates of peripancreatic infection and MODS tended to increase with the increase in MBISAP score (P < 0.001). In predicting severe AP, MBISAP score had an AUC of 0.898 (95% confidence interval [CI]: 0.859-0.929, P < 0.001), with a sensitivity of 71.43% and a specificity of 90.53%; at the optimal cut-off value of ≥3, MBISAP score was significantly better than BISAP score (AUC=0.868) and CTSI score (AUC=0.827) (both P < 0.05). In predicting the mortality of patients with AP, MBISAP score had an AUC of 0.925 (95% CI: 0.890-0.952, P < 0.001), with a sensitivity of 88.89% and a specificity of 82.89%; at the optimal cut-off value of ≥3, MBISAP score was similar to BISAP score (AUC=0.915) and CTSI score (AUC=0.879) (both P > 0.05). In predicting peripancreatic infection in AP, MBISAP score had an AUC of 0.842 (95% CI: 0.796-0.880, P < 0.001), with a sensitivity of 72.22% and a specificity of 84.07%; at the optimal cut-off value of > 2, MBISAP score was better than BISAP score (AUC=0.776) and was inferior to CTSI score (AUC=0.932) (both P < 0.05). In predicting MODS in patients with AP, MBISAP score had an AUC of 0.874 (95% CI: 0.832-0.909, P < 0.001), with a sensitivity of 76.19% and a specificity of 84.93%; at the optimal cut-off value of > 2, MBISAP score was similar to BISAP score (AUC=0.855) and CTSI score (AUC=0.829) (both P > 0.05). Conclusion MBISAP score is better than BISAP score in predicting the severity of AP patients and peripancreatic infection, and it also has a good value in predicting mortality and MODS in patients with AP. MBISAP score can evaluate the conditions of AP patients more accurately and objectively than BISAP score.
- Pancreatitis /
- BISAP Score /
- CTSI Score

HTML全文

图 1 不同评分系统预测AP患者严重程度、死亡、胰周感染、MODS的ROC曲线

注：a, 预测SAP的ROC曲线；b, 预测死亡的ROC曲线；c, 预测胰周感染的ROC曲线；d, 预测MODS的ROC曲线。

下载: 全尺寸图片幻灯片

表 1 MBISAP评分系统赋值表

变量	0分	1分	2分	3分
尿素氮(mmol/L)	≤9	＞9
SIRS	无	有
年龄(岁)	≤60	＞60
胸腔积液	无	有
胰腺坏死面积	0	0~30%	30%~50%	＞50%
注：SIRS，全身炎症反应综合征。至少具备以下2项确诊：(1)体温＜36 ℃/＞38 ℃；(2)呼吸频率＞20次/min或PCO₂＜32 mm Hg；(3)脉搏＞90次/min；(4)WBC＞12×10⁹/L或＜4×10⁹/L。

下载: 导出CSV

表 2 2组患者基线资料比较

项目	MBISAP低级别组(n=253)	MBISAP高级别组(n=60)	统计值	P值
年龄(岁)	49.0(41.0~57.5)	62.5(52.25~73.75)	Z=-5.480	＜0.001
性别[男(%)]	141(55.73)	28(46.67)	χ²=1.604	0.205
吸烟[例(%)]	59(23.32)	21(35.00)	χ²=3.477	0.062
饮酒[例(%)]	60(23.72)	19(31.67)	χ²=1.625	0.202
糖尿病[例(%)]	46(18.18)	15(25.00)	χ²=1.437	0.231
高血压[例(%)]	50(19.76)	13(21.67)	χ²=0.109	0.741
病因[例(%)]			χ²=36.536	＜0.001
胆源性	111(43.87)	45(75.00)
高脂血症	89(35.18)	5(8.33)
酒精	25(9.88)	0
饮食	16(6.32)	1(1.67)
不祥	12(4.74)	9(15.00)
住院时间(d)	10.00(7.00~13.00)	16.00(12.00~20.75)	Z=-6.038	＜0.001
死亡[例(%)]	1(0.40)	8(13.33)		＜0.001
胰周感染[例(%)]	5(1.98)	13(21.67)		＜0.001
MODS[例(%)]	5(1.98)	16(26.67)		＜0.001
BISAP评分(轻/重，例)	252/1	15/45	χ²=215.320	＜0.001
CTSI评分(轻/中/重，例)	215/38/0	17/42/1		＜0.001

下载: 导出CSV

表 3 根据MBISAP评分分层的SAP、病死率、胰周感染、MODS患者数量及其比例

MBISAP评分	总例数	SAP[例(%)]	死亡[例(%)]	胰周感染[例(%)]	MODS[例(%)]
0分	101	0	0	0	0
1分	85	4(4.71)	0	2(2.35)	1(1.18)
2分	67	10(14.93)	1(1.49)	3(4.48)	4(5.97)
3分	29	13(44.83)	2(6.90)	6(20.70)	7(24.14)
4分	26	17(65.38)	3(11.54)	6(23.08)	7(26.92)
5分	5	5(100)	3(60.00)	1(20.00)	2(40.00)
6分	0
7分	0

下载: 导出CSV

表 4 根据BISAP评分分层的SAP、病死率、胰周感染、MODS患者数量及其比例

BISAP评分	总例数	SAP[例(%)]	死亡[例(%)]	胰周感染[例(%)]	MODS[例(%)]
轻(0~2分)	267	21(7.87)	1(0.37)	8(3.00)	8(3.00)
重(3~5分)	46	28(60.87)	8(17.39)	10(21.74)	13(28.26)

下载: 导出CSV

表 5 根据CTSI评分分层的SAP、病死率、胰周感染、MODS患者数量及其比例

CTSI评分	总例数	SAP[例(%)]	死亡[例(%)]	胰周感染[例(%)]	MODS[例(%)]
轻(0~3分)	232	13(5.60)	1(0.43)	0	4(1.72)
中(4~6分)	80	35(43.75)	7(8.75)	17(21.25)	16(20.00)
重(7~10分)	1	1(100)	1(100)	1(100)	1(100)

下载: 导出CSV

表 6 MBISAP评分与BISAP、CTSI评分系统对AP严重程度及预后的预测效果比较

项目	AUC	95%CI	敏感度(%)	特异度(%)	最佳临界值	约登指数	P值
SAP
MBISAP评分	0.898	0.859~0.929	71.43	90.53	≥3	0.620	＜0.001
BISAP评分	0.868	0.826~0.904	83.67	77.27	≥2	0.610	＜0.001
CTSI评分	0.827	0.780~0.867	73.47	82.95	＞3	0.564	＜0.001
死亡
MBISAP评分	0.925	0.890~0.952	88.89	82.89	≥3	0.718	＜0.001
BISAP评分	0.915	0.879~0.944	88.89	87.50	≥3	0.764	＜0.001
CTSI评分	0.879	0.838~0.913	88.89	75.99	＞3	0.649	＜0.001
胰周感染
MBISAP评分	0.842	0.796~0.880	72.22	84.07	＞2	0.563	＜0.001
BISAP评分	0.776	0.726~0.821	55.56	87.80	≥3	0.434	＜0.001
CTSI评分	0.932	0.902~0.960	100.00	78.64	＞3	0.786	＜0.001
MODS
MBISAP评分	0.874	0.832~0.909	76.19	84.93	＞2	0.611	＜0.001
BISAP评分	0.855	0.811~0.892	90.48	71.92	≥2	0.624	＜0.001
CTSI评分	0.829	0.782~0.869	80.95	78.08	≥4	0.590	＜0.001

下载: 导出CSV

参考文献(25)

[1]	HUBER W, PHILLIP V, SCHMID R, et al. Acute Pancreatitis: What is new?[J]. Dtsch Med Wochenschr, 2017, 142(7): 525-529. DOI: 10.1055/s-0042-100233.
[2]	VEGE SS, GARDNER TB, CHARI ST, et al. Low mortality and high morbidity in severe acute pancreatitis without organ failure: A case for revising the Atlanta classification to include "moderately severe acute pancreatitis"[J]. Am J Gastroenterol, 2009, 104(3): 710-715. DOI: 10.1038/ajg.2008.77.
[3]	GUDA NM, TRIKUDANATHAN G, FREEMAN ML. Idiopathic recurrent acute pancreatitis[J]. Lancet Gastroenterol Hepatol, 2018, 3(10): 720-728. DOI: 10.1016/S2468-1253(18)30211-5.
[4]	WANG L, ZENG YB, CHEN JY, et al. A simple new scoring system for predicting the mortality of severe acute pancreatitis: A retrospective clinical study[J]. Medicine (Baltimore), 2020, 99(23): e20646. DOI: 10.1097/MD.0000000000020646.
[5]	Pancreas Study Group, Chinese Society of Gastroenterology, Chinese Medical Association; Editorial Board of Chinese Journal of Pancreatology; Editorial Board of Chinese Journal of Digestion. Chinese guidelines for the management of acute pancreatitis (Shengyang, 2019)[J]. J Clin Hepatol, 2019, 35(12): 2706-2711. DOI: 10.3969/j.issn.1001-5256.2019.12.013. 中华医学会消化病学分会胰腺疾病学组, 《中华胰腺病杂志》编委会, 《中华消化杂志》编委会. 中国急性胰腺炎诊治指南(2019年, 沈阳)[J]. 临床肝胆病杂志, 2019, 35(12): 2706-2711. DOI: 10.3969/j.issn.1001-5256.2019.12.013.
[6]	WU BU, JOHANNES RS, SUN X, et al. The early prediction of mortality in acute pancreatitis: A large population-based study[J]. Gut, 2008, 57(12): 1698-1703. DOI: 10.1136/gut.2008.152702.
[7]	ALHAJERI A, ERWIN S. Acute pancreatitis: Value and impact of CT severity index[J]. Abdom Imaging, 2008, 33(1): 18-20. DOI: 10.1007/s00261-007-9315-0.
[8]	XU HF, LI Y, YAN J, et al. Severity analysis of acute pancreatitis based on etiology[J]. Natal Med J China, 2014, 94(41): 3220-3223. DOI: 10.3760/cma.j.issn.0376-2491.2014.41.005. 徐海峰, 李勇, 颜骏, 等. 急性胰腺炎病因与其严重程度的关系[J]. 中华医学杂志, 2014, 94(41): 3220-3223. DOI: 10.3760/cma.j.issn.0376-2491.2014.41.005.
[9]	CHEN HJ, WANG JJ, TSAY WI, et al. Epidemiology and outcome of acute pancreatitis in end-stage renal disease dialysis patients: A 10-year national cohort study[J]. Nephrol Dial Transplant, 2017, 32(10): 1731-1736. DOI: 10.1093/ndt/gfw400.
[10]	GARG PK, SINGH VP. Organ failure due to systemic injury in acute pancreatitis[J]. Gastroenterology, 2019, 156(7): 2008-2023. DOI: 10.1053/j.gastro.2018.12.041.
[11]	CHEN FY, BAI XY, WU D. The severity scoring system and prognostic biological markers of acute pancreatitis[J]. Chin J Intern Med, 2019, 58(8): 615-619. DOI: 10.3760/cma.j.issn.0578-1426.2019.08.016. 陈方莹, 柏小寅, 吴东. 预测急性胰腺炎严重程度的评分系统及生物标志物[J]. 中华内科杂志, 2019, 58(8): 615-619. DOI: 10.3760/cma.j.issn.0578-1426.2019.08.016.
[12]	TAN Y, RAFI S, TYEBALLY FANG M, et al. Validation of the modified Ranson versus Glasgow score for pancreatitis in a Singaporean population[J]. ANZ J Surg, 2017, 87(9): 700-703. DOI: 10.1111/ans.13139.
[13]	KNOEPFLI AS, KINKEL K, BERNEY T, et al. Prospective study of 310 patients: Can early CT predict the severity of acute pancreatitis?[J]. Abdom Imaging, 2007, 32(1): 111-115. DOI: 10.1007/s00261-006-9034-y.
[14]	YE JF, ZHAO YX, JU J, et al. Building and verifying a severity prediction model of acute pancreatitis (AP) based on BISAP, MEWS and routine test indexes[J]. Clin Res Hepatol Gastroenterol, 2017, 41(5): 585-591. DOI: 10.1016/j.clinre.2016.11.013.
[15]	SAHU B, ABBEY P, ANAND R, et al. Severity assessment of acute pancreatitis using CT severity index and modified CT severity index: Correlation with clinical outcomes and severity grading as per the Revised Atlanta Classification[J]. Indian J Radiol Imaging, 2017, 27(2): 152-160. DOI: 10.4103/ijri.IJRI_300_16.
[16]	RIECHERS RG 2nd, RAMAGE A, BROWN W, et al. Physician knowledge of the Glasgow Coma Scale[J]. J Neurotrauma, 2005, 22(11): 1327-1334. DOI: 10.1089/neu.2005.22.1327.
[17]	BLEDSOE BE, CASEY MJ, FELDMAN J, et al. Glasgow coma scale scoring is often inaccurate[J]. Prehosp Disaster Med, 2015, 30(1): 46-53. DOI: 10.1017/S1049023X14001289.
[18]	HEIM C, SCHOETTKER P, GILLIARD N, et al. Knowledge of Glasgow coma scale by air-rescue physicians[J]. Scand J Trauma Resusc Emerg Med, 2009, 17: 39. DOI: 10.1186/1757-7241-17-39.
[19]	YANG YX, LI L. Evaluating the ability of the bedside index for severity of acute pancreatitis score to predict severe acute pancreatitis: A meta-analysis[J]. Med Princ Pract, 2016, 25(2): 137-142. DOI: 10.1159/000441003.
[20]	SENAPATI D, DEBATA PK, JENASAMANT SS, et al. A prospective study of the Bedside Index for Severity in Acute Pancreatitis (BISAP) score in acute pancreatitis: An Indian perspective[J]. Pancreatology, 2014, 14(5): 335-339. DOI: 10.1016/j.pan.2014.07.007.
[21]	HAGJER S, KUMAR N. Evaluation of the BISAP scoring system in prognostication of acute pancreatitis - A prospective observational study[J]. Int J Surg, 2018, 54(Pt A): 76-81. DOI: 10.1016/j.ijsu.2018.04.026.
[22]	HARSHIT KA, SINGH GM. A comparison of APACHE Ⅱ, BISAP, Ranson's score and modified CTSI in predicting the severity of acute pancreatitis based on the 2012 revised Atlanta Classification[J]. Gastroenterol Rep (Oxf), 2018, 6(2): 127-131. DOI: 10.1093/gastro/gox029.
[23]	BANDAY IA, GATTOO I, KHAN AM, et al. Modified computed tomography severity index for evaluation of acute pancreatitis and its correlation with clinical outcome: A tertiary care hospital based observational study[J]. J Clin Diagn Res, 2015, 9(8): TC01-TC05. DOI: 10.7860/JCDR/2015/14824.6368.
[24]	PETROV MS, SHANBHAG S, CHAKRABORTY M, et al. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis[J]. Gastroenterology, 2010, 139(3): 813-820. DOI: 10.1053/j.gastro.2010.06.010.
[25]	MOFIDI R, SUTTIE SA, PATIL PV, et al. The value of procalcitonin at predicting the severity of acute pancreatitis and development of infected pancreatic necrosis: Systematic review[J]. Surgery, 2009, 146(1): 72-81. DOI: 10.1016/j.surg.2009.02.013.