Dynamic Guidelines: Scoring Appendicitis, GI Bleeds, and Pancreatitis, Study notes of Computed Tomography

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Dynamic Practice Guidelines for

Emergency General Surgery

18 Committee on Acute Care Surgery, Canadian Association of General Surgeons

RISK PREDICTION

Daniel Ben Lustig, MD, MSc, Monique Marguerie, MSc, Melissa Hanson MD, Jacinthe Lampron MD Committee on Acute Care Surgery, Canadian Association of General Surgeons Dynamic Practice Guidelines for Emergency General Surgery

Prediction Scoring

Return to Table of Contents Addiss, Shaffer, Fowler, and Tauxe. 1990. Am J Epidemiol Acute appendicitis remains one the most common global causes of acute abdominal pain requiring emergent surgical intervention. Approximately 7% will have acute appendicitis in their lifetime. Early recognition reduces the morbidity and mortality associated with complications including perforations or appendiceal abscesses (Addis et al. 1990). Definition:

Prediction Scoring

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Alvarado Score (Acute Appendicitis)

The Alvarado Score for acute appendicitis is a validated scoring system that uses 8 predictive signs, symptoms and laboratory data to determine the likelihood that a patient in the emergency department presenting with abdominal pain has appendicitis. Addiss, Shaffer, Fowler, and Tauxe. 1990. Am J Epidemiol

Prediction Scoring

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Alvarado Score (Acute Appendicitis)

McKay R, and Shepherd J. 2007. Am J Emerg Med Several studies have evaluated the Alvarado score for ruling in or ruling out an appendicitis using different cut off scores with similar results. Low Risk: A score of 3 or lower had a sensitivity of 96% for ruling out and thus there is no indication for CT. If no other cause is found they can generally be discharged if stable and advised to return to hospital if there is no improvement. Moderate Risk: Scores between 4 to 6 (sensitivity 35.6% and specificity 94%); CT scans in this clinically equivocal group improves the sensitivity and specificity to 90.4% and 95% respectively. If clinically suspicious, admission is warranted for observation and serial examinations. High Risk: Individuals with a score of 7 or higher typically requires surgical consultation and likely an appendectomy.

Acute upper gastrointestinal bleeds (UGIB) are potentially life-threatening depending on the severity of the hemorrhage. Risk stratification for upper GI bleeding is important as it allows to identify patient’s who would benefit from closer monitoring or more urgent investigation from those who may be safely discharged home and managed as outpatients. Image adapted from: Link

Prediction Scoring

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Glasgow-Blatchford Score (Upper GI Bleed)

Hyett BH, Abougergi MS, Charpentier JP et al. 2013. Gastrointest Endosc. Risk Factor Score BUN (mg/dL) 18.2-22.4 2 22.4-28.0 3 28.0-70.0 4

70.0 6 Hgb (g/L) 120 - 130 1 (0 for women) 100 - 120 3 (1 for women) <100 6 SBP (mmHg) 100 - 109 1 90 - 99 2 <90 3 HR >100bpm 1 Melena 1 Syncope 2 Hepatic diseases 2 Heart Failure 2 Score: 0: Low Risk - Consider Outpatient Management (99.6% sensitive meaning most can be safely discharged home) 1: High risk requiring hospital admission, consider ICU admission and urgent endoscopy <2: 98% sensitive in ruling out death, re- bleeding and the need for intervention

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Acute Pancreatitis

Wu BU, Johannes RS, Sun X, et al. 2008. Gut Acute pancreatitis is characterized by severe abdominal pain and elevated pancreatic enzymes. It is a leading cause of abdominal related hospitalizations and can lead to significant morbidity and mortality if left undiagnosed and untreated. The BiSAP scoring system is a set of criteria used to predict the mortality risk in patients with acute pancreatitis based on 5 variables. Patients with 0 risk factors have a <0.1% risk of mortality, while people with all 5 risk factors have a 22.5% mortality risk.

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Bedside Index for Severity of Acute Pancreatitis (BISAP) Score

Wu BU, Johannes RS, Tabak Y, et al. 2008. Gut

Indicator Parameters

B UN > 25 mg/dL (8.9 mmol/L) I mpaired Mental Status Abnormal mental status with a Glasgow coma score <15 (1 point) S IRS Evidence of SIRS (1 point) A ge (^) >60 years old (1 point) P leural Effusion Imaging study reveals pleural effusion (1 point) Score: 0 - 2 Points = Lower Mortality (< 2%) 3 - 5 Points = Higher Mortality (>15%)

Prediction Scoring

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Advantages of BiSAP Score in Acute Pancreatitis

Papachristou GI, Muddana V, Yadav D, et al. 2010. Am J Gastroenterol The BiSAP scoring system has been found to have similar accuracy when compared to the widely accepted APACHE-II through multiple independent studies showing its validity. The Ranson and APACHE II scoring systems are limited due to their complexity and numerous parameters that may not be routinely collecting during hospital admission.

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Computed Tomography Severity Index (Pancreatitis)

Bathazar EJ. 2002. Radiology. Pancreatitis Grading (Balthazar Score) Score Normal pancreas 0 Enlargement of pancreas 1 Inflammatory changes in pancreas and peripancreatic fat 2 Ill-defined single peripancreatic fluid collection 3 Two or more poorly defined peripancreatic fluid collections 4 Pancreatic Necrosis Score None 0 < 30% 2 30 - 50% 5

50% 6

Score: 0 - 3 Mild Acute Pancreatitis 4 - 6 Mod. Acute Pancreatitis 7 - 10 Severe Acute Pancreatitis

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Ranson’s Criteria (Non-Gallstone Pancreatitis)

Score:

• 0 - 2 = 2% Mortality
• 3 - 4 = 15% Mortality
• 5 - 6 = 40% Mortality
• 7 - 8 = 100% Mortality Ranson JH, Rifikind KM, Roses DF, et al. 1974. Surg Gynecol Obstet Ranson’s Criteria on admission
• Age > 55 yrs
• WBC > 16,000/uL
• Glucose > 11 mmol/L
• Serum LDH > 250 IU/L
• Serum AST > 250 IU/L Ranson’s Criteria after 48 hours of admission
• Fall in HCT by more than 10%
• Fluid sequestration of >6L
• Hypocalcemia (Serum Ca < 2.0 mmol/L)
• Hypoxemia (PO2 < 60 mmHg)
• Increase in BUN to > 1.98 mmol/L (>5mg/dL) after IV fluid hydration/resuscitation
• Base deficit of > 4 mmol/L

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Sequential Organ Failure Assessment (SOFA) Score

Ferreira FL, Bota DP, Bross A, et al. 2001. JAMA. Click to Continue to Evaluation of SOFA Score

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Sequential Organ Failure Assessment (SOFA) Score

Ferreira FL, Bota DP, Bross A, et al. 2001. JAMA. Evaluation of the SOFA Score