Tiny Tip: BISAP for Pancreatitis

In Medical Concepts, Tiny Tips by Doran Drew3 Comments

EDITOR’S NOTE: I often struggle with determining whether the presentation is pancreatitis or whether it’s PANCREATITIS. There are a number of scoring systems to help evaluate this question but one in particular is nicely suited to the Emergency Department. I like Doran’s Tiny Tip that can help you remember some of the key features to consider. – EP

The severity and sequelae of acute pancreatitis range wildly, from mild epigastric pain with a benign natural history to multiple organ dysfunction necessitating ICU admission[1]. This variability poses a dilemma for emergency physicians, as diagnosis does not clearly dictate disposition. While Ranson, APACHE II, and CTSI scoring systems have been validated for risk-stratification, these tools are geared towards evaluation of the pancreatitis inpatient after extensive workup and are not amenable to use in the emergency department[2].

This conundrum has led to development of the Bedside Index of Severity in Acute Pancreatitis (BISAP), a simple tool ideal for rapid risk-stratification[2,3]. The tool is based on a 5-point score, derived from 5 parameters collected within a patient’s first 24 hours in hospital. Conveniently, the parameters of the BISAP score can be used to spell BISAP, making for an easy-to-remember mnemonic.

Blood Urea Nitrogen > 8.92 mmol/L

Impaired mental status,

≥2 SIRS Criteria,

Age > 60 years

Pleural effusion on chest X-ray or CT

BISAP

References

[1] E.L. Bradley, A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992., Arch. Surg. 128 (1993) 586–90.

[2] G.I. Papachristou, V. Muddana, D. Yadav, M. O’Connell, M.K. Sanders, A. Slivka, et al., Comparison of BISAP, Ranson’s, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis., Am. J. Gastroenterol. 105 (2010) 435–41; quiz 442. doi:10.1038/ajg.2009.622.

[3] B.U. Wu, R.S. Johannes, X. Sun, Y. Tabak, D.L. Conwell, P.A. Banks, The early prediction of mortality in acute pancreatitis: a large population-based study., Gut. 57 (2008) 1698–703. doi:10.1136/gut.2008.152702.

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Doran Drew

Doran Drew

Queen's University, BScH, MD Candidate (2017)
Doran Drew
- 8 months ago
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  • R. S. Sahsi

    BISAP provides a scoring system that predicts chance of mortality, but how to we best incorporate this risk-stratification into practice? Is it sufficient to guide disposition decisions? Do 0-1 scores warrant outpatient management, vs. 4-5 who may require more intensive setting than a ward bed?

    • Thomas Low

      As an intensivist and emergency physician working in a community hospital, I have seen many patients with pancreatitis admitted to the floor deteriorate and become critically ill. Unfortunately, there is often a delay in recognition for such cases. A busy general hospitalist may not have always have the experience or time to recognize how sick their patients with pancreatitis can become.

      I don’t think scoring systems over physician judgement are all that useful to determine what initial disposition a patient gets in the real world (this is just too simplistic). Furthermore, in Canada, we also don’t have the resources (nor is it our practice) to admit most patients to an ICU that are “at risk” of deterioration or higher mortality (unlike in the States). It is my experience that scoring systems are MOST important as a PROMPT and communication tool for forewarning admitting physicians who take care of patients with pancreatitis in a non-monitored floor setting.

      It is these patients who day 2-3 of their admission ‘suddenly’ deteriorate and require rapid resuscitation. Scoring systems (to supplement physician judgement and experience) can help prompt the admitting physicians to patients at risk. IT then helps them prioritize these patients among their roster of patients and tasks. This is particularly helpful to avoid neglect of patients who don’t look too sick but score higher (with BISAP/RANSON/APACHE II). The admitted patient with pancreatitis may then get more frequent nursing vitals, may become the first patient rounded on, more expedited and frequent blood work – a more intense ‘tracking’ of the patient’s progress and earlier identification of a need for more aggressive care. We sometimes forget when talking about disposition that the intensity of care and attention by physicians for admitted patients is a gradient and is often more important than whether one is admitted to a monitored or non-monitored setting.