Assessment of Severity of Acute Pancreatitis Using Modified Computed Tomography Severity Index and Revised Atlanta Classification and Their Association with Clinical Outcome Parameters

Jain Swasti; Malhotra, Ankur; Chandak, Shruti; Arora, Deepti; Taneja, Aman

Acta Medica InternationalActa Medica International. 12:p 38-46, Jan–Apr 2025.

doi: 10.4103/amit.amit_121_24

Author Information

Department of Radiodiagnosis, Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India

¹Department of Pathology, Teerthanker Mahaveer Medical College and Research Centre, Moradabad, Uttar Pradesh, India

Address for correspondence: Dr. Ankur Malhotra, Department of Radiodiagnosis, Teerthanker Mahaveer Medical College and Research Centre, Moradabad - 244 001, Uttar Pradesh, India. E-mail: drankur.m7@gmail.com

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License (http://creativecommons.org/licenses/by-nc-sa/4.0/), which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

Abstract

Acute pancreatitis (AP) is a serious gastrointestinal condition with significant morbidity and mortality. It can lead to various complications and is commonly diagnosed using laboratory tests and contrast-enhanced computed tomography (CT) scans. This study evaluates the efficacy of the Modified CT Severity Index (MCTSI) and the neutrophil-to-lymphocyte ratio (NLR) in predicting the severity of AP compared to the Revised Atlanta Classification (RAC). In addition, we will also assess concordance of MCTSI and RAC with NLR.

After approval from IEC, this prospective observational study, conducted over 18 months at Teerthanker Mahaveer Medical College Hospital, Moradabad, Uttar Pradesh, included 65 adult patients clinically diagnosed with AP. All participants satisfying the inclusion criteria were enrolled after taking a written informed consent and they underwent standard laboratory tests (including a complete blood count) and radiological evaluation (including CT scan performed using 128-slice scanner Ingenuity CT, Philips Healthcare) during their hospital stay. The primary outcome measures were the sensitivity, specificity, and accuracy of NLR and MCTSI, as well as their alignment with the RAC for assessing AP severity.

In this study of 65 patients with clinically diagnosed AP, the mean age was 38.82 ± 15.82 years with a range of 15–85 years of age, with a male predominance (61.5%) and male to female ratio of 1.6:1. The study evaluated the effectiveness of MCTSI, NLR, and RAC methods for predicting the severity of AP. Severe AP cases, as classified by all methods, were associated with higher rates of surgical intervention (up to 45.5%), infection (up to 66.7%), persistent organ failure (up to 100%), mortality (up to 36.4%), and longer hospital stays (mean of up to 20.21 days), highlighting the need for accurate severity assessment in managing AP. The sensitivity, specificity, and accuracy of NLR were 67%, 90.9%, and 76%, respectively, while MCTSI had sensitivity of 95%, specificity of 13.6%, and accuracy of 62%. NLR showed a high area under the curve (0.855) compared to MCTSI (0.645). NLR was found to be a viable alternative for predicting severity, especially in resource-limited settings.

The Modified Computed Tomography Severity Index (MCTSI) is a well-established tool for assessing the severity of AP, demonstrating ease of calculation and a close correlation with clinical outcomes. Our study confirmed that MCTSI has superior predictive ability for moderately severe and severe cases, showing high sensitivity and positive predictive value. It aligns well with the RAC, with both scoring systems significantly correlating with clinical outcomes such as the need for surgical intervention, infection, organ failure, mortality, and hospital stay duration. More adverse outcomes were observed in moderate and severe grades compared to mild cases. Additionally, NLR which is a novel parameter demonstrates strong concordance with RAC in assessing moderate-to-severe AP and offers a cost-effective alternative to MCTSI and traditional radiological methods. It can effectively predict disease severity and guide early diagnosis and treatment, particularly in settings with limited resources.

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INTRODUCTION

Acute pancreatitis (AP) is a medical emergency characterized by the sudden onset of severe abdominal pain, often accompanied by nausea and vomiting. The most common causes include alcohol abuse and gallstones. Diagnosis is typically based on clinical presentation, elevated serum amylase and lipase levels (with lipase being more specific), and imaging studies. The prevalence of AP varies globally, with a range of 4.9% to 73.4% per 100,000 individuals. There lies a high probability of survival for most of the patients, as they experience a moderate illness. Nevertheless, a severe clinical course is experienced by 15–20% of AP patients, resulting in a 20–30% increase in mortality and morbidity and both local and systemic consequences.[¹⁻³]

The Atlanta classification, introduced in 1992, initially divided pancreatitis into mild and severe categories. The classification was updated in 2012, further categorizing the disease into mild, moderate, and severe, based on a modified Marshall scoring system.[⁴,⁵] This revision also considered the presence of local complications and organ failure.[⁵]

Several scoring systems are routinely used to predict morbidity and mortality in AP, including the Ranson score, the Marshall score, APACHE II, BISAP, SOFA, and the Glasgow Coma Scale.[⁶] These systems are often complex and rely heavily on laboratory tests, increasing resource demands. Some also require reassessment over time.[⁶]

Recently, the neutrophil-to-lymphocyte ratio (NLR) has emerged as a predictor of disease severity and outcome in AP, as well as in other conditions.[⁷] An elevated NLR indicates a heightened inflammatory response, with an increased neutrophil count reflecting acute inflammation and a decreased lymphocyte count indicating a decline in overall health.[⁸] NLR has shown a sensitivity of 78.12% and a specificity of 70.27% for predicting the severity of AP, with a normal NLR ranging from 1 to 3, mild stress from 6 to 9, moderate stress from 9 to 18, and severe stress at levels >18.[⁸]

Imaging techniques, including ultrasound and computed tomography (CT) scans, are also crucial in diagnosing and determining the severity of pancreatitis. Contrast-enhanced CT is considered the gold standard for diagnosing AP, as it is highly sensitive in detecting pancreatic necrosis and extrapancreatic complications.[⁹] Among radiological scoring systems, the CT severity index (CTSI) and the modified CT severity index (MCTSI) are widely used in both clinical practice and research. MCTSI assesses AP severity based on radiological findings, including the presence of pancreatic inflammation, necrosis, and extrapancreatic complications. MCTSI has been reported to have a sensitivity of 100%, specificity of 92.3%, positive predictive value (PPV) of 94.4%, and accuracy of 96.7% in identifying moderate to severe disease.[⁹]

The MCTSI has yet to be fully validated as a reliable and accurate tool for assessing the severity of AP when compared to the Revised Atlanta Classification (RAC) and the NLR. There is a notable lack of studies in Indian literature that compare MCTSI (a radiological measure), RAC (a clinicoradiological measure), and NLR (a laboratory measure) to evaluate their correlation with clinical outcomes. Only a few anecdotal studies have explored this relationship.[⁹⁻¹⁴] In response to this gap, the current study aims to assess the concordance between MCTSI and RAC in predicting the severity of AP and associated clinical outcomes. In addition, the study will investigate the alignment between MCTSI, RAC, and NLR as a laboratory parameter.

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MATERIALS AND METHODS

This prospective observational study was conducted in the Department of Radiodiagnosis at Teerthanker Mahaveer Medical College Hospital in Moradabad, U.P., over 18 months (December 2023 to May 2024), focusing on assessing the severity of AP using the MCTSI and RAC and their association with clinical outcomes. This was a time bound study and included 65 adult patients clinically diagnosed with AP, who underwent contrast-enhanced CT (CECT) scans. Ethical approval was obtained from institutional ethical committee (TMMC and RC/IEC/2021-22/08 dated November 23, 2022). The written informed consent was obtained from all the enrolled patients. The procedures used follow the guidelines laid down in the Declaration of Helsinki.

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Inclusion criteria

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Exclusion criteria

Patients satisfying the inclusion criteria were subjected to the computed tomography (CT) examination performed using 128-slice scanner (Ingenuity CT, Philips Healthcare) followed by laboratory tests including, i.e., total leukocyte count (TLC), differential leukocyte count (DLC), and NLR. A history of the patients was recorded regarding age, sex, and any familial history of similar diseases. All eligible patients were properly counseled and explained about the nature and purpose of the study. Secrecy and confidentiality were maintained. After informed written consent, patients were recruited into the study.

All studies were performed using 128-slice scanner (Ingenuity CT, Philips Healthcare). Patients were asked to remove clothes and any metallic objects, and were asked to wear a gown. Scan was performed in supine position sometimes in right lateral decubitus position. A scanogram was obtained and plain and postcontrast series of the abdomen and pelvis were taken. Oral contrast was given as per requirement and patient clinical condition.

Scan parameters were as follows:

The images were analyzed in all views (axial, coronal and sagittal), Multiplanar reformation was done. Maximum intensity projection images were reformatted for evaluation of vessels. The severity of AP was graded using the MCTSI and RAC, with findings recorded on a predesigned pro forma.

MCTSI[¹⁵] [Table 1] – The sum of the values was used to determine the AP, which was subsequently classified as:

Severity grading as per Modified CT severity index in patients of Acute pancreatitis

RAC defines AP as either interstitial edematous pancreatitis (IEP) or necrotizing pancreatitis (NP), and it differentiates between an early phase (1st week) and a late phase (after the 1st week). The first phase is distinguished by clinical parameters, while the second phase is defined morphologically by contrast-enhanced CT findings in conjunction with clinical staging. The severity was classified into three categories based on clinical and morphologic finding[¹⁴] [Table 2].

Severity categories as per Revised Atlanta Classification

Laboratory tests, including TLC, DLC, and NLR, were also conducted to assess disease severity. A rise in the neutrophil count suggests an acute inflammatory response, while a decrease in the lymphocyte count indicates a decline in overall health. Normal values was defined as an NLR of 1–3, mild derangement as 6–9, moderate derangement as 9–18, and severe derangement as >18.[¹⁶]

Clinical follow-up data were collected for all patients until their discharge or demise. The parameters comprised the duration of hospitalization, the occurrence of organ failure, presence of infections, the necessity for intervention (surgical or percutaneous) following pancreatic or extra-pancreatic complications, and mortality. Evidence of infection was defined as the following: A fever exceeding 1000°F and an elevated white blood cell count exceeding 15,000/m3, positive results on a gramme stain of aspirate, or positive results on a culture. The Modified Marshall score was used to define organ failure in the following manner[¹⁷] [Table 3].

Modified Marshall Scoring System for organ failure in patients of Acute pancreatitis

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Statistical analysis

The statistical analysis was performed using “SSPS statistical software version 21.0” after the raw data were inputted into Microsoft Excel. Descriptive and inferential statistics were utilized to analyze the data. Profiling of the patients on varied demographic and anatomic parameters was done. The quantitative variables will be represented as the mean (SD), whereas qualitative variables were represented in terms of frequencies/percentages. “Chi-Square test” was used to correlate Qualitative variables. A diagnostic procedure was implemented for calculation of “sensitivity, specificity, PPV, negative predictive value (NPV), and accuracy.” P < 0.05 was considered as significant.

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RESULTS

In this study of 65 patients with clinically diagnosed AP, the mean age was 38.82 ± 15.82 years with a range of 15–85 years of age, with a male predominance (61.5%) and male to female ratio of 1.6:1. The most common presenting symptom was pain (100%), followed by vomiting (87.7%), fever (49.2%), jaundice (30.8%), abdominal distension (20.0%), and dyspnea (20.0%). Past medical history revealed that gallstones were the most common cause of AP (41.5%), followed by idiopathic (32.3%), alcohol (24.6%), post-ERCP (6.2%), and trauma (1.5%) [Table 4]. Laboratory findings showed that 67.7% of patients had a normal TLC, while 32.3% had deranged TLC. NLR categorization revealed that 44.6% of patients had moderate grading, 20% had normal grading, 18.5% had severe grading, and 16.9% had mild grading [Table 5].

Clinicodemographic profile of study patients

Distribution of study population on Basis of Laboratory values

The most common imaging finding was peripancreatic fat stranding/inflammation (93.85%), followed by peripancreatic fluid (76.92%), pancreatic enlargement (55.38%), and pancreatic necrosis (30.77%). The study reported that 70.8% of cases showed no evidence of necrosis, while 15.4% had <30% necrosis and 13.8% had more than 30% necrosis [Table 6].

Distribution of study population on Basis of Imaging Findings

Extra pancreatic complications were observed, with ascites being the most common (50.8%), followed by bilateral pleural effusion (27.7%), vascular thrombosis (21.54%), and pleural effusion on only one side (23.1%). The study found that the majority of patients (67.69%) had IEP, while NP was present in 32.31% of cases [Table 7 and Figure 1].

Distribution of study population on Basis of Basis of Extra Pancreatic Complications, type of pancreatitis and type of collection

A 45-year-old female presented with complaints of acute onset severe epigastric pain radiating to back, vomiting & fever. NLR was 24 (Severe). (a) CECT revealed heterogeneously enhancing pancreas (Black arrow). (b) shows more than 30% necrosis, peripancreatic fluid and extensive fat stranding. (c) shows filling defect (thrombus) in right hepatic vein (White arrow). (d) shows air foci (*) in necrotic areas of pancreas. MCTSI score was 10 (Severe). Patient developed persistent organ failure and RAC grade was severe. Unfortunately, Patient died after being admitted for 22 days in hospital

The severity of AP was most commonly moderate, as assessed by NLR (44.6%), MCTSI (55.4%), and RAC (47.7%) [Table 8 and Figures 2-4]. Surgical intervention was required in 16.9% of cases, and infection was found in 30.8%. Organ failure occurred in 53.9% of patients, with a mortality rate of 9.2%.

Distribution of study population on Basis of different grading systems (NLR, MCTSI and RAC)

A 68-year-old male presented with complaints of acute onset epigastric pain and history of gallstone disease. NLR was 2 (normal). (a) NCCT shows bulky pancreas with mild peripancreatic fat stranding. (b) On contrast CT pancreas shows homogeneous postcontrast enhancement (white arrow). MCTSI score was 2 (Mild). Patient did not develop any organ failure and severity grade according to RAC was also mild. Patient was discharged in 6 days without any adverse clinical outcomes

A 25-year-old male presented with complaints of acute onset pain epigastrium, fever and history of gallstone disease. NLR was 10 (moderate). (a) On CECT imaging pancreas was bulky (white arrow) with homogeneous parenchymal enhancement. (b) shows peripancreatic fluid (black thick arrow) & adjacent moderate peripancreatic fat stranding. (c) shows associated left sided pleural effusion (*). (d) shows mild ascites (black thin arrow). MCTSI score was 6 (moderate). There was transient organ failure and RAC grade was moderately severe. Patient developed infection and was discharged in 12 days

A 39-year-old male presented with complaints of acute onset severe epigastric pain, fever and vomiting and history of alcohol intake. NLR was 26 (severe). (a) On CECT diffuse pancreatic enlargement (white arrow) with ill-defined non-enhancing parenchymal hypodensities (black thick arrow) were noted in distal body & tail suggestive of necrosis < 30% with peripancreatic fluid collection, fat stranding. (b) shows bilateral pleural effusion (*). (c) shows ascites (black thin arrow). MCTSI score was 8 (severe). Patient developed transient organ failure and RAC grade was moderately severe. Patient developed infection during the hospital stay and was discharged in 24 days

Surgical intervention was required in 16.9% of cases, while 83.1% did not require any surgical intervention. Infection was noted in 30.8% of patients, while 69.2% had no evidence of infection. Organ failure was observed in 53.8% of patients, with 35.4% having transient organ failure and 18.5% having persistent organ failure. The mortality rate was 9.2% [Table 9].

Distribution of study population on Basis of Clinical Outcome parameters

The study evaluated the effectiveness of MCTSI, NLR, and RAC methods for predicting the severity of AP. The MCTSI method demonstrated a sensitivity of 100%, specificity of 84%, PPV of 65.22%, NPV of 100%, and accuracy of 87.96% when compared to the RAC method [Table 10]. The NLR method, compared to RAC, showed a sensitivity of 90.48%, specificity of 92.68% [Table 11], PPV of 86.96%, NPV of 83.33%, and accuracy of 89.23%. When NLR was compared to MCTSI, it had a sensitivity of 82%, specificity of 100%, PPV of 100%, NPV of 62.50%, and accuracy of 86.16% [Table 12].

Association between RAC method and MCTSI method

Association between RAC Method and NLR Method

Association between MCTSI method and NLR method

Severe AP cases, as classified by all methods, were associated with higher rates of surgical intervention (up to 45.5%), infection (up to 66.7%), persistent organ failure (up to 100%), mortality (up to 36.4%), and longer hospital stays (mean of up to 20.21 days), highlighting the need for accurate severity assessment in managing AP.

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DISCUSSION

The present hospital-based prospective observational study was conducted at Teerthanker Mahaveer Medical College Hospital, Moradabad, Uttar Pradesh, involving 65 clinically diagnosed cases of AP who underwent CECT abdomen in the Radiology Department aimed to compare two scoring systems, the MCTSI and the RAC, to predict the severity of AP and correlate them with clinical outcomes and the NLR, a laboratory parameter.

In the present study, patients ranged from 15 to 85 years old, with a mean age of 38.82 ± 15.82 years. This is consistent with Sahu et al.[¹³] (36.6 ± 9.8 years), Bhanou NM et al.[¹] (39.5 years), and Tahir et al.[⁹] (43.7 ±16.67 years). Padu et al.[¹⁴] reported a mean age of 44.73 ± 11.61 years, while Carnovale A et al.[¹⁸] found a median age of 61.5 years. Raghu et al.[¹⁹] observed an average age of 42.9 ± 15.9 years in their patients. The study observed a male preponderance with a ratio of 1.6:1, possibly due to the rural setting affecting female patient turnout. Similar male predominance was reported by Sahu et al.[¹³] (3:1), Tahir et al.[⁹] (64.45% male), and Bhanou NM et al.[¹] (5:1), whereas Padu et al.[¹⁴] showed a higher proportion of females (5.2:1). Other studies by Malik et al.,[²⁰] Sandblom et al.,[²¹] and Ugane et al.[²²] reported varying female- to-male ratios of 2:1, 1:0.6, and 3:2, respectively.

The most common presenting complaint was pain (100%), followed by vomiting (87.7%), fever (49.2%), jaundice (30.8%), abdominal distension (20.0%), and dyspnea (20.0%). These findings align with studies by Sahu et al.,[¹³] Tahir et al.,[⁹] and Kokulu et al.,[⁷] who also reported abdominal pain as the most prevalent symptom. The most common etiological factor was gallstones (41.5%), consistent with studies by Raghuvanshi et al. [²³] and Bhanou NM et al.,[¹] who reported gallstones as the most prevalent cause, although Bhanou NM et al.[¹] found a higher prevalence of alcohol intoxication (65.8%).

Laboratory findings showed that 67.7% of patients had a normal TLC, while the NLR categorized most patients as moderate (44.6%). Studies by Zahorec et al.[²⁴] and Li et al. [²⁵] highlight the prognostic significance of NLR in various diseases, including acute pancreatitis.

Imaging findings revealed that peripancreatic fat stranding/inflammation was the most common, seen in 93.85% of patients, consistent with findings by Banday et al.[¹⁵] Peripancreatic fluid was observed in 76.92% of patients, similar to findings by Sahu et al.[¹³] 29.2% of patients had pancreatic parenchymal necrosis, with 15.4% showing less than 30% necrosis and 13.8% showing more than 30%.

In terms of complications, ascites was the most common extra-pancreatic complication (50.8%), followed by bilateral pleural effusion (27.7%). These results align with studies by Sahu et al.[¹³] and Kokulu et al.,[⁷] who also reported pleural effusion and ascites as common complications. The study found that interstitial edematous pancreatitis (IEP) was more common (67.69%) than necrotizing pancreatitis (NP), which was observed in 32.31% of cases, aligning with findings by Sahu et al.[¹³]

In this study, acute peripancreatic fluid collection was the most common type, accounting for 46.15% of cases, followed by acute necrotic collection (16.92%), walled-off necrosis (13.85%), and pseudocyst (10.77%). Kokulu et al.[⁷] reported different local complications in 10% of patients with pancreatic necrosis, including pancreatic pseudocyst (3%), intraabdominal abscess (1%), ascites (7%), and splenic vein thrombosis (1%).

Regarding NLR grading, the majority of cases (44.6%) were classified as moderate, 20.0% as mild, 18.5% as severe, and 16.9% had normal NLR. Bhanou NM et al.[¹] found a higher proportion of patients with mild NLR grading (50) compared to moderate (24) and severe (32) cases. Tahir et al.[⁹] reported an average NLR of (11.72 ± 9.52), with significant variations between mild (5.88 ± 2.115) and more severe cases (19.15 ± 10.102). No significant gender differences were observed in NLR values, but higher levels were noted in severe cases among females compared to males.

In this study, as per Modified Computed Tomography Severity Index (MCTSI) 55.4% of cases had moderate grading, 23.1% had mild grading, and 21.5% had severe grading. This contrasts with studies of Sahu et al.[¹³] who found 43.3% patients with severe grading, and Padu et al.[¹⁴] who noted 69.23% with mild pancreatitis. The possible reason could be due to differences in the demography. The Revised Atlanta Classification (RAC) revealed 47.7% with moderately severe grading, 35.4% with mild grading, and 16.9% with severe grading. This is similar to study done by Pongprasobchai et al.[²⁶] study, which found 72% mild, 16% moderate, and 12% severe cases of AP.

Regarding surgical intervention, 83.1% of patients did not require surgery, while 16.9% did. Kokulu et al.[⁷] reported 29% and Sahu et al.[¹³] reported 25% requiring intervention. For infection, 69.2% had no infection, whereas 30.8% did, consistent with findings of study done by Sahu et al.[¹³] reporting 40% infection in their patients.46.2% of cases had no organ failure, 35.4% had transient failure, and 18.5% had persistent failure. Sahu et al.[¹³] found similar results with 41.7% exhibiting orthostatic hypotension. Mortality rates were 9.2% in this study, which are comparable with Sahu et al.[¹³] who reported 11.7% mortality. Infections and persistent organ failure were linked to higher mortality.

Comparative statistical evaluations showed that the NLR method had a sensitivity of 90.48%, specificity of 92.68%, PPV of 86.96%, NPV of 83.33%, and an accuracy of 89.23% when predicting the severity of AP, making it comparable to the RAC method. This finding is consistent with studies by Tahir H et al., [⁹] who reported NLR as a robust predictor of severity in acute pancreatitis, and Kong W et al.,[¹⁶] who reported a sensitivity of 79% and specificity of 71% for NLR. Similarly, the MCTSI method demonstrated high sensitivity (100%) and accuracy (87.96%) in predicting severe cases, comparable to the RAC method, with findings consistent with those of Bollen et al.[⁸] and Padu et al.[¹⁴] Sahu et al.[¹³] and Cazacu SM et al.[²⁷] confirmed that NLR aligns well with clinical outcomes and provides practical benefits in predicting severity. Overall, these findings underscore that severe cases are consistently linked to higher rates of complications, prolonged hospital stays, and increased mortality, regardless of the grading system used.

Based on the preceding analysis, it is evident that current clinical scoring systems and radiological criteria for assessing acute pancreatitis (AP) pose significant challenges, resulting in delays in anticipating disease progression and determining appropriate care levels. Both the Modified Computed Tomography Severity Index (MCTSI) and the Neutrophil-to-Lymphocyte Ratio (NLR) exhibited strong connections with the Revised Atlanta Classification (RAC) for severity grading.

The MCTSI demonstrated exceptional predictive ability for moderately severe and severe cases, with a sensitivity of 100% and a positive predictive value (PPV) of 84%, compared to the RAC method. However, its predictive capability for mild cases was more modest, with a specificity of 65.22% and a negative predictive value (NPV) of 100%. In contrast, the NLR method showed comparable effectiveness to the RAC, with a sensitivity of 90.48% and a PPV of 92.68% for severe cases, and a specificity of 86.96% and NPV of 83.33% for mild cases. This positions NLR as an efficient and resource-effective alternative for predicting AP severity, particularly in resource- limited settings. This was in concurrence with studies done by Bhanou NM et al.,[¹] Kokulu et al.[⁷] and Sahu et al.[¹³]

Overall, the accessibility and effectiveness of NLR make it a valuable tool for early diagnosis and timely treatment initiation in various healthcare environments, potentially reducing morbidity, and mortality rates associated with AP.

The study had few limitations. Notably, it did not include a comparison between CT severity grading and clinical severity scoring systems, such as APACHE. In addition, the small sample size, constrained by time limitations, may have impacted the statistical significance of our findings.

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CONCLUSION

The MCTSI is a well-established tool for assessing the severity of AP, demonstrating ease of calculation and a close correlation with clinical outcomes. Our study confirmed that MCTSI has superior predictive ability for moderately severe and severe cases, showing high sensitivity (100%), and PPV (65.22%). More adverse outcomes were observed in moderate and severe grades compared to mild cases.

In addition, the NLR emerged as a promising predictor of disease severity, showing good concordance with both MCTSI and RAC. NLR demonstrated superior predictive capability for moderately severe and severe cases with high sensitivity (90.48%) and PPV (92.68%) and it provided increased prediction accuracy for mild cases with high specificity (86.96%) and NPV (83.33%). This makes NLR a more efficient and resource-effective method, particularly beneficial in settings with limited resources. Its use can facilitate early diagnosis and prompt treatment, thereby reducing morbidity and mortality rates.

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Financial support and sponsorship

Nil.

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Conflicts of interest

There are no conflicts of interest.

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Keywords:

Acute pancreatitis; modified computed tomography severity index score; neutrophil-to-lymphocyte ratio; Revised Atlanta Classification

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