Acute pancreatitis is a sudden inflammation of the pancreas, often seen in clinical practice and known to follow a variable course. While most cases of acute pancreatitis resolve with minimal intervention, approximately 20% of cases develop into severe forms that are associated with substantial morbidity and a mortality rate reaching up to 20%. Since its first descriptions by physicians like Nicholaes Tulp in 1652, the pathophysiology and classifications of acute pancreatitis have evolved significantly. Notably, Reginald Fitz in 1889 categorized acute pancreatitis into hemorrhagic, suppurative, and gangrenous forms, laying the groundwork for subsequent understanding. The "common channel hypothesis" by Eugene Opie in 1901 suggested a critical mechanism by which gallstones obstruct the bile and pancreatic ducts, inducing inflammation by triggering pancreatic enzyme activation within the pancreas itself. These early insights have led to increasingly sophisticated classification systems over time, including the widely used Atlanta Classification of 1992 and its revised form in 2012.[1-4]

Gallstones remain a primary cause of acute pancreatitis, accounting for a substantial proportion of cases alongside alcohol abuse and other factors like hypertriglyceridemia, hypercalcemia, and drug-induced causes. As a result, identifying reliable prognostic markers for gallstone-induced acute pancreatitis is crucial to enable timely and effective treatment. Gallstone-induced pancreatitis presents a particular challenge, as complications from severe cases, such as pancreatic necrosis or systemic inflammatory response, can rapidly increase the risk of mortality. Symptoms include acute upper abdominal pain often radiating to the back, nausea, and vomiting. Physical indicators, like Gray Turner or Cullen signs, can signify severe disease but are rare. For clinicians, the Modified Atlanta Classification, developed to standardize severity assessment of acute pancreatitis and improve inter-clinician communication, categorizes cases as mild, moderate, or severe based on bedside assessments and hematological parameters. Early severity assessment is essential in these cases to guide treatment, as severe acute pancreatitis can progress to multi-organ dysfunction.[5-7]

Traditionally, contrast-enhanced computed tomography (CECT) has served as the gold standard in assessing the severity of acute pancreatitis through the Modified CT Severity Index (CTSI). While effective, this imaging technique is typically performed around two weeks after the onset of symptoms to confirm necrosis, often delaying necessary interventions in critical cases. The Modified Marshall Score within the Revised Atlanta Classification, however, provides a bedside tool that facilitates early severity assessment using clinical and laboratory findings, allowing for faster intervention. Implementing the Modified Atlanta Classification scoring at admission and again at 48 hours may enable more accurate identification of patients who require intensive management, thus potentially reducing mortality and complication rates.[8-10]

This study aims to evaluate the prognostic value of the Modified Atlanta Classification compared to the Modified CTSI in assessing the severity of acute gallstone-induced pancreatitis. By comparing these two scoring systems at early stages, the study intends to identify which method offers better accuracy in predicting severe outcomes, supporting clinicians in tailoring interventions and improving patient outcomes in cases of acute pancreatitis induced by gallstones.

Source of Data: This prospective study was conducted in the Department of General Surgery at Indira Gandhi Medical College, Shimla. Patients presenting to the surgical emergency or outpatient department with acute abdominal pain secondary to gallstone-induced pancreatitis were selected. Selection was based on clinical history, physical examination, biochemical investigations, and imaging findings from abdominal ultrasound and contrast-enhanced computed tomography (CECT).

Inclusion Criteria

1. Patients aged 18 years and above.

2. Patients diagnosed with acute gallstone-induced pancreatitis.

Exclusion Criteria

1. Patients with acute pancreatitis from etiologies other than gallstones.

2. Cases of recurrent pancreatitis.

3. Patients with a known allergy to contrast agents.

4. Patients who had already commenced treatment for pancreatitis before presenting to the hospital.

Diagnosis of acute pancreatitis (AP) was confirmed at admission if two of the following three criteria were met:

1. Acute onset of persistent, severe epigastric pain radiating to the back.

2. Serum amylase or lipase levels elevated to at least three times the upper limit of normal.

3. Imaging findings characteristic of gallstone-induced pancreatitis observed on ultrasound.

Upon admission, a detailed medical history and thorough physical examination were conducted, followed by the necessary biochemical and imaging investigations. Initial severity assessment was done using the Modified Marshall scoring system. Patients were classified as follows based on their Modified Marshall score:

• Mild: Score of 0 or 1.

• Moderate: Score of ≥2.

All patients received conservative management following standard treatment protocols. The Modified Marshall score was reassessed at 48 hours to observe changes in severity:

• Patients with an initial score of ≤1, and a repeat score of ≤1, were classified as mild pancreatitis according to the Revised Atlanta Classification.

• Patients with an initial score of ≥2 that decreased to ≤1 upon reassessment were classified as moderate pancreatitis.

• Patients with a persistent Modified Marshall score of ≥2 at 48 hours were classified as severe pancreatitis.

CECT of the chest and abdomen was performed 72 hours after presentation to allow accurate assessment of pancreatic necrosis. Using these CECT findings, a Modified CT Severity Index (CTSI) score was calculated for each patient. The modified CTSI was used as the gold standard to categorize patients as having mild, moderate, or severe pancreatitis.

Sample Size Calculation: The sample size was calculated based on a study [11], which demonstrated that the Modified Atlanta Classification has a sensitivity and specificity of 89.47% and 85.71%, respectively, in the context of gallstone-induced pancreatitis, with gallstones identified as the cause in 38% of cases (p = 0.38). Using this as a reference, with a precision of 10%, a 95% confidence interval, and an expected dropout rate of 10%, the calculated sample size for the study was 110 patients.

A total of 110 patients with acute gallstone-induced pancreatitis were included in the study. The severity of pancreatitis was assessed at admission and after 48 hours using the Modified Atlanta Score (MAS) and compared with the Modified CT Severity Index (MDCTSI) at 72 hours.

This table-1 presents the distribution of patients by age and gender. Patients ranged from 21 to 85 years, with a mean age of 50.47 ± 15.92 years. The age group with the highest representation was 41–50 years (22.72%), followed closely by 51–60 years (20.9%) and 61–70 years (20%). This shows that middle-aged and older adults are more commonly affected by gallstone-induced acute pancreatitis. Gender distribution indicates a higher prevalence among females (64.55%) compared to males (35.45%), with a female-to-male ratio of approximately 1.82:1.

Table 1: Age and Gender Distribution of Patients

This table-2 summarizes key clinical parameters, including pulse rate, systolic blood pressure, and Glasgow Coma Score (GCS) at admission. The mean pulse rate was recorded at 91.49 beats per minute (SD = 14.86), and the mean systolic blood pressure was 139.37 mm Hg (SD = 90.83). All patients had a GCS of 13–15, indicating that they were neurologically stable on admission. These clinical findings provide baseline data on the physiological state of the patients at the onset of treatment.

Table 2: Clinical Parameters and Glasgow Coma Score (GCS)

Table 3 details the biochemical parameters of patients at admission, which help assess organ function and the severity of inflammation. The mean total leukocyte count was 10.53 x 10^9/L, reflecting a possible inflammatory response. The platelet count averaged 248.66 x 10^9/L, suggesting generally normal coagulation. Renal function was assessed via blood urea (mean = 30.74 mg/dl) and serum creatinine (mean = 0.78 mg/dl), both within or near normal ranges, indicating no significant renal impairment on admission. Liver function, evaluated by total and direct bilirubin, showed slightly elevated values, potentially related to biliary obstruction from gallstones. The mean amylase and lipase levels were markedly elevated, with amylase at 1112.94 units/L and lipase at 1066.54 units/L, confirming the diagnosis of acute pancreatitis. The pH (7.42) and PaO2/FiO2 ratio (268.94) values reflect stable acid-base balance and respiratory function in most patients.

Table 3: Biochemical Parameters at Admission

This table presents radiological findings from ultrasound and MDCTSI, which provide insights into the pancreas's condition and the extent of necrosis. All patients (100%) had gallstones on ultrasound, confirming the etiology of pancreatitis as gallstone-induced. In terms of pancreatic morphology, 33.64% of patients had a normal pancreas on ultrasound, while 66.36% had a bulky pancreas, suggesting inflammation or edema. MDCTSI findings on pancreatic necrosis revealed that 91.81% of patients had necrosis of 0–30%, while 8.18% had 30–50% necrosis, indicating that most patients had minimal necrotic involvement.

Table 4: Radiological Findings and Pancreatic Necrosis on MDCTSI

This table-5 shows the severity classification of pancreatitis according to the Modified Atlanta Score (MAS) at admission and 48 hours later. At admission, 70.9% of patients were classified as mild, and 29.09% as moderate, with no cases categorized as severe. After 48 hours, the distribution changed slightly: 70.9% remained mild, 15.4% were moderate, and 13.63% progressed to severe. This change in classification highlights the dynamic nature of the disease and the importance of reassessment within 48 hours for timely intervention in worsening cases.

Table 5: Modified Atlanta Score (MAS) at Admission and After 48 Hours

This table-6 compares the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the Modified Atlanta Score (MAS) against the Modified CT Severity Index (MDCTSI) for different severity categories (mild, moderate, severe). For mild cases, MAS shows high sensitivity (98.63%) and NPV (96.77%), indicating its reliability in identifying mild cases accurately. In moderate cases, MAS has a specificity and PPV of 100%, meaning it effectively identifies moderate cases with minimal false positives. For severe cases, MAS has both high sensitivity (92.86%) and specificity (98.96%), suggesting it closely aligns with MDCTSI in identifying severe pancreatitis. This comparison demonstrates MAS’s effectiveness in predicting the severity of acute pancreatitis, showing it to be a useful tool for early-stage assessment when compared to the CT-based gold standard.

Table 6: Comparison of Modified Atlanta Score (MAS) and Modified CT Severity Index (MDCTSI) in Predicting Severity

Acute pancreatitis is a common ailment encountered by the physicians and surgeons in all parts of the world, and forms a good proportion of emergency admissions in emergency unit . The most common cause of AP in many western and Asian countries is cholelithiasis , accounting for 35% to 60% of cases [12] . It is of utmost importance to make an early diagnosis and assess the severity of AP and prompt management . This study was conducted for comparison of modified Atlanta classification at 48 hrs with modified CTSI in acute gallstone induced pancreatitis 

The patients in this present study were in the age range of 21 – 85 years . Mean age was 50.47 +-15.92 . [13] included patients with age range of 18 – 93 years with median age of 61.5 years. [14] included patients with mean age of 42.9 +=15.9 years ( range : 18 -80 years ). [15] reported mean age of 50 years similar to the present study.  In our study, Female patients outnumbered males with ratio of 1.82:1. Female to male ratio which was similar to findings of [16-18] respectively . In the present study, 2 patients i.e 1.81% of total patients were categorised by MDCTSI as severe pancreatitis due to pancreatic necrosis but these patients were in mild state of severity clinically without any organ failure . These patients improved dramatically on conservative treatment and were discharged in 4 – 5 days. 

Modified Atlanta classification was performed at admission and 48 hrs using mainly the modified Marshall scoring for organ failure . This scoring may change the categorisation of patient at presentation to a better or worse category as per scoring at 48 hrs . Mild AP is identified by the absence of organ failure at time of admission . It needs further 48 hr to observe organ failure and its reversal to normal function in order to classify in moderate and severe category. In the present study , 78 patients ( 70.9%) patients diagnosed as mild AP by modified Atlanta classification at admission and 32( 29.09%) patients as moderate AP . However on reevaluating after  48 hrs , 78 patients ( 70.09%) out of 110 patients were diagnosed as mild AP , 17 (15.4%) as moderate and 15 ( 13.63%) as severe AP by modified Atlanta classification. These findings are similar to the study done [11] who also found the distribution of AP as 73.1% , 15.4 % and 11.5% as mild , moderate and severe AP respectively , as per revised modified Atlanta classification. 

Modified CTSI was considered as the gold standard scoring system to objectively categorise the patients into AP into mild , moderate and severe AP . Out of 110 patients 73 ( 66.36% ) were having mild , 23 ( 20.09%) moderate and 14 ( 12.72%) as severe pancreatitis according to Modified CTSI . This corresponds with the study conducted [19]in which out of 196 patients , 136  ( 66.9%) patients showed mild pancreatitis , 41 ( 21%) patients had moderate , and 19 patients ( 10%) had severe pancreatitis . In study done [11] , as per MCTSI out 0f 26 patients , 18 patients (69.23%) classified as mild and 5 patients ( 19.23%) , 3 patients ( 11.54%) as moderate and severe respectively which correlate with results of our study . Specificity and sensitivity of mild and moderate AP as per Modified Atlanta classification come out to be 73.91% and 100% respectively which is comparable to 75.00% and 90.91% as per study of [11].

The study demonstrates that the Modified Atlanta Score (MAS) is a reliable and practical tool for early severity assessment in acute gallstone-induced pancreatitis, performing comparably to the Modified CT Severity Index (MDCTSI). While MDCTSI remains the imaging-based gold standard, MAS offers a cost-effective, bedside alternative that enables timely identification of severe cases, facilitating rapid and effective treatment planning. This scoring system allows clinicians to make informed decisions early in the disease course, supporting appropriate interventions and resource allocation. MAS proves particularly valuable in settings where imaging resources are limited or rapid response is essential, making it an excellent substitute for CECT in the prognostic assessment of acute pancreatitis severity and enhancing patient outcomes by enabling prompt, targeted care.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Indira Gandhi Medical College, Shimla (H.P)

1. Toouli, J., et al. "Guidelines for Management of Acute Pancreatitis." Journal of Gastroenterology and Hepatology, vol. 17, suppl., 2002, pp. S15–S39. DOI: 10.1046/j.1440-1746.2002.02842.x

2. Fitz, R. H. "Acute Pancreatitis: A Consideration of Pancreatic Hemorrhage, Suppuration, Gangrenous Pancreatitis, and Disseminated Fat Necrosis." Boston Medical and Surgical Journal, vol. 120, 1889, pp. 181–235.

3. Opie, E. L. "The Etiology of Acute Hemorrhagic Pancreatitis." Johns Hopkins Hospital Bulletin, vol. 12, 1901, pp. 182–188. No DOI available.

4. O’Reilly, D. A., and A. N. Kingsnorth. "A Brief History of Pancreatitis." Journal of the Royal Society of Medicine, vol. 94, 2001, pp. 130–132. DOI: 10.1258/jrsm.94.3.130

5. Banks, P. A., et al. "Classification of Acute Pancreatitis–2012: Revision of the Atlanta Classification and Definitions by International Consensus." Gut, vol. 62, no. 1, 2013, pp. 102–111. DOI: 10.1136/gutjnl-2012-302779

6. Kota, S. K., et al. "Metabolic Pancreatitis: Etiopathogenesis and Management." Indian Journal of Endocrinology and Metabolism, vol. 17, 2013, pp. 799–805. DOI: 10.4103/2230-8210.120257

7. Williams, N., P. R. O'Connell, and A. McCaskie. Bailey and Love's Short Practice of Surgery. 27th ed., CRC Press, 2018, pp. 1221–1224. 

8. Shah, D., et al. "Burden of Gastrointestinal and Liver Disease in India, 1990–2016." Indian Journal of Gastroenterology, vol. 37, 2018, pp. 239–245. DOI: 10.1007/s12664-018-0854-0

9. Salomone, T., et al. "Coagulative Disorders in Human Acute Pancreatitis: Role for the D-Dimer." Pancreas, vol. 26, no. 2, 2003, pp. 111–116. DOI: 10.1097/00006676-200303000-00001

10. Agarwal, N., and C. S. Pitchumoni. "Acute Pancreatitis: A Multifaceted Disease." Gastroenterologist, vol. 1, no. 2, 1993, pp. 115–128. 

11. Padu, G., et al. "Comparison of Modified Atlanta Classification with CT Severity Index." MAMC Journal of Medical Sciences, vol. 5, no. 2, 2019, pp. 63–67. 

12. The, F., and Y. Yuan. "Early Routine Endoscopic Retrograde Cholangiopancreatography Strategy Versus Early Conservative Management Strategy in Acute Gallstone Pancreatitis." Cochrane Database of Systematic Reviews, no. 5, 2012, p. CD009779. DOI: 10.1002/14651858.CD009779.pub2

13. Carnovale, A. "Mortality in Acute Pancreatitis: Is It an Early or Late Event?" JOP, vol. 6, 2005, pp. 438–444.

14. Raghu, M. G. "Lung Complications in Acute Pancreatitis." J Pancreas, vol. 8, 2007, pp. 177–185. 

15. Uhl, W., et al. "A Randomized Double-Blind, Multicentric Trial of Octreotide in Moderate to Severe Acute Pancreatitis." Gut, vol. 45, 1999, pp. 97–104. DOI: 10.1136/gut.45.1.97

16. Malik, A. M. "Acute Pancreatitis: A More Common and Severe Complication of Gallstones in Males." International Journal of Health Sciences (Qassim), vol. 9, 2015, pp. 141–145. 

17. Sandblom, G., T. Bergman, and I. Rasmussen. "Acute Pancreatitis in Patients 70 Years of Age or Older." Clinical Medicine Insights: Geriatrics, vol. 1, 2008, pp. 27–30. DOI: 10.4137/CGS.S513

18. Ugane, S. P., et al. "A Study of Gallstones Associated with Acute Pancreatitis and Its Management in Rural India." International Journal of Current Research and Review, vol. 4, 2012, pp. 146–150. 

19. Bollen, T. L., et al. "Comparative Evaluation of the Modified CT Severity Index and CT Severity Index in Assessing Severity of Acute Pancreatitis." American Journal of Roentgenology, vol. 197, no. 2, 2011, pp. 386–392. DOI: 10.2214/AJR.10.4897