Introduction
Acute pancreatitis (AP) remains a leading gastrointestinal cause of hospital admission and emergency department visits worldwide. Characterized by the premature activation of pancreatic enzymes leading to autodigestion and systemic inflammation, the clinical course of AP is highly variable. While approximately 80% of cases are mild and self-limiting, the remaining 10–20% progress to severe acute pancreatitis (SAP). These severe cases are defined by persistent organ failure and carry a significant mortality risk, ranging from 10% to 25%, often arise as 50% in the presence of infected necrosis or multi-organ dysfunction [1].
The clinical diagnosis of AP is established by fulfilling at least two of three criteria: characteristic upper abdominal pain, serum amylase or lipase levels exceeding three times the upper limit of normal, and radiological evidence of pancreatic inflammation [2] According to the 2012 Revised Atlanta Classification, the disease is categorized into mild, moderately severe (transient organ failure <48 hours), and severe (persistent organ failure >48 hours) [3]. Given that early, aggressive intervention can reduce mortality from 50% to under 10%, the ability to accurately triage patients during the golden window of admission is a clinical imperative [4-5].
Predicting the trajectory of AP remains a significant challenge. Established scoring systems including Ranson’s criteria, APACHE II, and the Bedside Index for Severity in Acute Pancreatitis (BISAP) offers valuable prognostic data but are often hindered by complexity. Many require 48 hours of observation, extensive laboratory panels, or multiple physiological variables, which limits their utility in rapid-response emergency settings or resource-constrained environments [6].
Radiological assessment, specifically the Computed Tomography Severity Index (CTSI) and its modified version (MCTSI), is currently the gold standard for evaluating local complications and pancreatic necrosis. However, contrast-enhanced CT (CECT) is most accurate when performed 72 hours after symptom onset, as earlier imaging may underestimate the extent of tissue damage [6-7]. Furthermore, the reliance on CECT presents barriers in patients with renal impairment or in rural healthcare facilities where advanced imaging is not readily accessible [8].
In response to the need for a more streamlined prognostic tool, the PANC 3 scoring system was developed. This model utilizes three easily obtainable parameters: a hematocrit level 44%, a body mass index (BMI) 30 kg/m², and the presence of pleural effusion on initial imaging (such as a chest X-ray or ultrasound). By focusing on markers of hemo-concentration, adiposity-driven inflammation, and systemic fluid shift, PANC 3 aims to identify high-risk patients immediately upon arrival [9].
In regions like India, where the clinical burden of AP is high and access to high-end diagnostics may be inconsistent, validating simpler tools is essential. This study evaluates the predictive accuracy of the PANC 3 score in comparison to the CTSI. By determining whether this bedside tool can match the prognostic value of advanced imaging, we aim to provide clinicians with a reliable, cost-effective method for early risk stratification, potentially improving outcomes through timely intervention and optimized resource allocation.
Materials and Methods
Study Setting and Design
This prospective observational study was conducted in the Department of General Surgery at Sri Guru Ram Das Institute of Medical Sciences and Research (SGRDIMSR), hospital in Amritsar, Punjab. The study spanned an 18-month period from July 2024 to December 2025. Ethical clearance was obtained from the Institutional Research and Ethics Committee (SGRD/IEC/2024-) prior to the commencement of the study.
Patient Selection and Eligibility
Patients presenting to the surgical emergency department with clinical features suggestive of acute pancreatitis (AP) were screened for enrollment.
Inclusion Criteria: Patients aged 12 years and above with clinical presentation of acute abdominal pain consistent with AP were included in the study.
Exclusion Criteria: Patients presenting with organ failure at admission or within the first 24 hours (pre-classified as severe) as well individuals with a history of pancreatic malignancy, chronic pancreatitis, or recurrent acute episodes.
Diagnostic Criteria and Clinical Assessment
The diagnosis of acute pancreatitis was confirmed by the presence of at least two of the following:
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Acute onset of persistent, severe epigastric pain radiating to the back.
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Serum amylase or lipase levels 3 times the upper limit of normal.
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Characteristic radiological findings of AP on transabdominal ultrasonography.
Upon enrollment, a comprehensive clinical history was documented, focusing on demographics, symptom duration, and etiology (e.g., alcohol consumption or biliary disease). A baseline physical examination and laboratory workup-including complete blood counts and biochemical profiles-were performed for all participants.
Severity Scoring Protocols
PANC 3 Score: The PANC 3 score was determined at the time of admission based on three specific criteria: Hematocrit >44%; Body Mass Index (BMI) >30 kg/m2; Radiological evidence of pleural effusion on chest X-ray. A PANC 3 score was considered "positive" for severe disease only if all three parameters were present.
CT Severity Index (CTSI): Contrast-enhanced computed tomography (CECT) of the abdomen was performed during the first week of admission (typically after 72 hours of symptom onset) to evaluate local complications and necrosis. Severity was graded according to the Modified CT Severity Index (MCTSI) and categorized as Mild: 0-2 points; Moderate: 4-6 points; Severe: 8-10 points
Data Management and Statistical Analysis
All data were meticulously recorded in a structured proforma and subsequently tabulated using Microsoft Excel. Continuous variables are presented as mean ±standard deviation (SD), while categorical variables are reported as frequencies and percentages. The Chi-square test or Fisher’s exact test was utilized to evaluate the association between categorical variables. Mean comparisons between groups were conducted using the independent sample t-test. The predictive performance of the PANC 3 score was compared against the CTSI to determine its diagnostic accuracy. A p-value <0.05 was defined as the threshold for statistical significance.
Results
Demographic and Etiological Profile
The study cohort comprised 50 patients, predominantly young adults, with 72% (n=36) aged 40 years. A male predominance was observed (62%, n=31), with a male-to-female ratio of 1.63:1 (Table 1). Gallstones were the primary etiology (68%), followed by alcohol consumption (24%) and hyperlipidemia (8%). Anthropometric assessment revealed that 26% (n=13) of the participants were obese (BMI 30 kg/m²).
| Parameter | Category | Frequency (n=50) | Percentage (%) |
| Age Group | ≤40 years | 36 | 72.0 |
| 41–60 years | 7 | 14.0 | |
| >60 years | 7 | 14.0 | |
| Gender | Male | 31 | 62.0 |
| Female | 19 | 38.0 | |
| BMI | <25 (Normal) | 24 | 48.0 |
| 25–29.9 (Overweight) | 13 | 26.0 | |
| ≥30 (Obese) | 13 | 26.0 | |
| Etiology | Gallstones | 34 | 68.0 |
| Alcohol | 12 | 24.0 | |
| Hyperlipidemia | 4 | 8.0 |
Clinical Presentation and Severity Scoring
Healthcare-seeking behavior was prompt, with 80% of patients presenting within 6 hours of symptom onset. At admission, 16% (n=8) were PANC 3 positive. Subsequent radiological evaluation via CTSI classified 30% (n=15) of cases as severe (Table 2).
| Scoring System | Parameter/Category | Frequency (n) | Percentage (%) |
| PANC 3 Components | Hematocrit >44% | 8 | 16.0 |
| BMI >30 kg/m² | 13 | 26.0 | |
| Pleural Effusion | 15 | 30.0 | |
| PANC 3 Status | Positive (All 3 criteria) | 8 | 16.0 |
| Negative (0–2 criteria) | 42 | 84.0 | |
| CTSI Classification | Mild (0–2) | 8 | 16.0 |
| Moderate (4–6) | 27 | 54.0 | |
| Severe (8–10) | 15 | 30.0 |
Clinical Outcomes and Complications
Significant morbidity was noted, with 42% (n=21) of patients requiring ICU admission. Local or systemic complications occurred in 28% (n=14) of the cohort. Organ failure was observed in 6% (n=3) of patients, with cardiac failure being the most frequent (66.6% of failure cases). The overall mortality rate was 6% (Table 3).
| Outcome | Category/Duration | Frequency (n=50) | Percentage (%) |
| ICU Admission | Required | 21 | 42.0 |
| ICU Stay (n=21) | 4–6 Days | 13 | 26.0 |
| Hospital Stay | >10 Days | 14 | 28.0 |
| Morbidity | Any Complication | 14 | 28.0 |
| Organ Failure | 3 | 6.0 | |
| Mortality | Expired | 3 | 6.0 |
Predictive Accuracy and Statistical Association
Both PANC 3 and CTSI demonstrated strong associations with adverse outcomes (Table 4). Notably, all patients who developed organ failure or expired were PANC 3 positive (p=0.001). Similarly, higher mean CTSI scores were significantly correlated with increased mortality (9.33±1.15 vs 5.19±2.19; p=0.002).
| Outcome | PANC 3 Positive (n=8) | PANC 3 Negative (n=42) | CTSI Score Mean±SD |
| ICU Admission | 8 (100%) | 13 (31%) | 7.52±1.76 |
| Organ Failure | 3 (37.5%) | 0 (0%) | 8.40±1.67 |
| Complications | 5 (62.5%) | 9 (21.4%) | 7.43±1.98 |
| Mortality | 3 (37.5%) | 0 (0%) | 9.33±1.15 |
Discussion
The present study revealed a significant demographic shift toward a younger population, with 72% of patients aged ≤40 years (Table 1). This aligns with contemporary trends in developing regions where urbanization and early exposure to risk factors-such as high-fat diets and alcohol are lowering the age of onset (Yadav and Lowenfels,[10]). This shift suggests an increasing long-term socioeconomic burden on healthcare systems.
Gender analysis showed a clear male predominance (62.0%; M:F ratio 1.63:1), consistent with global data identifying higher rates of alcohol-induced pancreatitis in men (Petrov and Yadav,[11]). Conversely, the female cohort is more frequently associated with biliary etiologies linked to gallstone disease (Han et al.,[12]). Ultimately, these distributions reflect a complex interplay between biological susceptibility and behavioral risk factors.
In the present study (Table 1), 52% of patients were overweight or obese, with 26% meeting the obesity threshold (>30 kg/m²). This prevalence is clinically significant as obesity is a key metric in the PANC 3 scoring system and a known driver of systemic inflammation. Adipose tissue functions as an active endocrine organ, releasing cytokines that amplify the systemic inflammatory response syndrome (SIRS) and increase the risk of peripancreatic necrosis (Gu et al.,[13]). Our findings align with global trends where elevated BMI is a critical determinant of AP severity (Aune et al.,[14]).
Etiologically, gallstone disease (68%) predominated, followed by alcohol (24%) and hyperlipidemia (8% Table 1). This distribution mirrors regional trends where biliary etiologies remain the primary driver of AP, likely influenced by local dietary patterns and genetic predispositions (Sindato,[15]). The male-centric trend in alcohol-related cases underscores the role of sociocultural behavioral factors in disease manifestation.
The PANC 3 evaluation showed that 16% of patients were PANC 3 positive, with pleural effusion (30%) being the most prevalent criterion (Table 2). Pleural effusion serves as a critical marker of the systemic inflammatory response and early vascular permeability (Yan et al.,[16]).
In contrast, the CT Severity Index (CTSI) classified 30% of patients as having severe disease, with 54% exhibiting moderate CTSI classification (Table 2). While PANC 3 excelled in the early identification of high-risk patients at admission, CTSI provided a more granular assessment of local complications and necrosis (Foster et al.,[17]). The findings suggest that PANC 3 is an ideal gatekeeper for early triage, while CTSI remains the gold standard for detailed anatomical staging.
The clinical course was significant, with 42% of the cohort requiring ICU admission and 28% developing complications (Table 3). Organ failure occurred in 6%, primarily manifesting as cardiac failure. Mortality was also 6%, with all deaths occurring in the severe disease group. This correlation confirms that while most AP cases follow a mild course, the moderate-to-severe subset incurs a massive healthcare burden, requiring prolonged hospitalization (over 10 days in 28% of cases) and intensive support (Van DIjk et al.,[18]).
The PANC 3 score demonstrated high sensitivity for critical outcomes, with 100% of positive patients requiring ICU admission. All instances of organ failure (37.5%) and mortality (37.5%) occurred exclusively within the PANC 3 positive group, confirming its utility as an effective rule-out tool at admission (Brown et al.,[9]).
Correspondingly, the mean CTSI scores showed a progressive increase correlated with severity: 7.52±1.76 for ICU admission and 9.33±1.15 for mortality (Table 4). While PANC 3 facilitates rapid bedside triage, the CTSI provides necessary anatomical detail to explain the 62.5% complication rate observed in high-risk patients (Bollen et al.,[19]). The absence of mortality and organ failure in the PANC 3 negative group (n=42) highlights its value in optimizing resource allocation and identifying the at-risk minority (Foster et al.,[17]).
Conclusion
The current study identifies a demographic shift in acute pancreatitis (AP) toward younger males, with a high prevalence of obesity and gallstone etiology. Clinically, the PANC 3 score functions as a highly sensitive bedside gatekeeper, demonstrating 100% sensitivity in ruling out mortality and organ failure. While CTSI remains the gold standard for anatomical staging and necrosis assessment, integrating both tools optimizes early triage and resource allocation for high-risk patients.
Declarations
Ethical Approval and Consent to Participate
All procedures performed in this case series were conducted in accordance with institutional ethical standards and the principles of the Declaration of Helsinki. Ethical approval was obtained from the appropriate institutional review board where required. Written informed consent was obtained from all patients or their legal guardians prior to the procedures.
Consent for Publication
Written informed consent for publication of clinical details and images was obtained from the patients or their legal guardians. All identifying information has been anonymized to protect patient confidentiality
Availability of Supporting Data
The data supporting the findings of this study are available from the corresponding author upon reasonable request, subject to institutional and ethical regulations
Competing Interests
The authors declare that they have no competing interests related to this work.
Funding Statement
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Authors’ Contributions
All authors contributed substantially to the conception, data acquisition, analysis, drafting, and critical revision of the manuscript. All authors have read and approved the final version of the manuscript.