kathmandu medical college, department of surgery

1. Predictive accuracy of Severe Acute Pancreatitis
using Neutrophil to Lymphocyte ratio in
Kathmandu Medical College, Sinamangal
Laudari U, Bohara TP,Parajuli A, Rupakheti SR, Joshi MR
Department of Surgery, Kathmandu Medical College
Teaching Hospital, Sinamangal, Kathmandu
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XIII th International Conference of the Society of Surgeons of Nepal

2. Overview
• Background
• Objective
• Methodology
• Findings
• Discussion
• Recommendations
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3. Background..
• Acute Pancreatitis is usually a self-limiting process
• 25 % of patients present with or subsequently develop a
severe form of the disease
• Severe pancreatitis is associated with mortality of 50%
Darren Taichman et all Annals In theClinic. Clin. 2010
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4. Background..
• Severity of AP is assessed by many standardized scoring
systems
• Most score are not suitable for stratifying patients at the time
of admission or shortly thereafter
• Cumbersome, time consuming, expensive, inaccessible
Singh VK et al. Clin Gastroenterol Hepatol 2009
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and services

5. Background
• NLR score would be one of such tool which would be cheap,
easy to perform and universally accepted
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6. Background..
• Total leucocyte count (TLC) is marker of inflammation and
infection
• It is part of many AP prognostic scoring systems including
Ranson’s, Imrie, APACHE II and Simplified Acute Physiology
Score (SAPS II).
• Neutrophils and lymphocyte are important measure of the TLC
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7. Background..
• Poor outcome of severe AP is due to the uncontrolled SIRS
and multiple organ dysfunction syndromes and TLC is again a
part of SIRS score.
• An increase in neutrophil numbers corresponds with the
development of SIRS and progression to MODS, which are
hallmarks of SAP
Singh VK et al. Clin Gastroenterol Hepatol 2009
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8. Background..
NLR
• The NLR measures the divergence of two leucocyte
components
• Neutrophilia and Lymphopenia are the common physiological
response to any physiological or biochemical stress.
• Few studies have investigated the predictive value of NLR in
AP
Suppiah A et al. J Gastrointest Surg 2013 17(4):675–81
Azab B et al,Pancreatology ,2011 Jan 11(4):445–52
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9. Objective
Primary objective
• To predict the severity of AP using Neutrophil to Lymphocyte
ratio in patients admitted with diagnosis of acute pancreatitis.
Secondary Objective
• To find out optimal cut off value of NLR to predict severity in
AP
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10. Methodology
• Design-prospective observational
• Population and sample- Consecutive patient with Acute
pancreatitis within study duration in
Kathmandu Medical college
• Study duration- June 1st 2015- November 30 2015
• Data collection and analysis
– Consent, Proforma, SPSS 20
– Fischer Exact test, Sensitivity, specificity, NPV, PPV
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11. Methodology….
• Inclusion Criteria
– All the patients admitted with the diagnosis of acute pancreatitis in
Department of Surgery, KMCTH were included in study
• Exclusion Criteria
– Pancreatitis associated with other infective and inflammatory diseases
– Postoperative and post ERCP pancreatitis
– Patient’s on current steroid or chemotherapy for any reason
– Patient already diagnosed as severe pancreatitis
– Patient who has concomitant malignancy
– Patient not willing to participate in the study
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12. Methodology….
• Diagnosis of AP was made if two of the following three
features were present
(1) Abdominal pain consistent with AP
(2) Serum amylase (or lipase) more than three times
normal value
(3) Characteristic findings of AP on AUS, computed
topography or magnetic resonance imaging
Classification of acute pancreatitis—2012: revision of the Atlanta
classification and definitions
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13. Methodology….
• NLR was evaluated at admission
• Severity of AP was made according to Revised Atlanta
Classification 2012
• The correlations were made between the NLR and Modified
Marshall scoring system for organ dysfunction
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14. Methodology….
• The optimal NLR were calculated which reflected the
average Neutrophil to Lymphocyte changes at time of
admission causing organ dysfunction.
• The sensitivity, specificity and predictive value of Neutrophil
to lymphocyte ratio to predict AP were calculated.
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15. Sex distribution
P-0.811- not significant
66.7
33.3
male
female
40
20
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16. Age higher in severe groups but of no statistical significance
P -0.295
51.54
45.56
42
44
46
48
50
52
Severe group Non-severe group
Age distribution
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17. BMI
» Mean BMI- 24.18 kg/m2 (S.D-3.91)
25.81
23.68
22
23
24
25
26
severe group Non- severe group
Distribution in respect to Body Mass
Index
(P-0.083)
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18. (P-0.660)
68.3
10
21.7
0
10
20
30
40
50
60
70
80
Mild acute
Pancreatitis
Moderately severe
pancreatitis
severe pancreatitis
Distribution by severity of Pancreatitis
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19. 33
16
11
Biliary Alcohol induced Unknown
0
5
10
15
20
25
30
35
Distribution by etiology %
Pearson chi
square
P=0.424
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20. 45
11
4
0
10
20
30
40
50
no organ failure Persistent organ failure Transient organ failure
Distribution by organ failure
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21. 54
3 1 1 1
0
10
20
30
40
50
60
no local
complications
Acute
pancreatic
necrosis
Acute
pancreatic fluid
collection
Acute
pancreatic
pseudocyst
Acute infected
pancreatic
necrosis
Distribution by local complications
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22. 43
14
2 1
0
5
10
15
20
25
30
35
40
45
50
Conservative
management
Lap
cholecystectomy
Single stage ERCP
and Lap chole
open necrosectomy
Management Strategies
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23. The mean NLR in all three groups had no
statistical significance for severity
5.67
4.9
6.1
0
1
2
3
4
5
6
7
mild group moderately severe
group
severe group
Mean NLR
(P-0.786)
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24. Area under curve of NLR to severity
Not significant
AUC 0.579 P=0.389
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25. Variable Area P value
TLC 0.558 0.524
NLR 0.579 0.389 Higher AUC
No statistical
significance
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26. Comparison of Sensitivity, Specificity, PPV and
NPV of NLR in Predicting Severity of AP
Severe AP NLR (> 3.825)
Sensitivity 84.60 High
Specificity 36.20
PPV 26.80
NPV 89.50 High
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27. • Cut of value of NLR was 3.825 from ROC curve ,as
determined by maximal youden index
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28. Discussion
• The main finding of our study
– NLR was elevated in patient with Severe AP
– able to differentiate between severe and non-severe
pancreatitis at admission,
– higher the NLR at admission, more severe the disease.
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29. Discussion
• The optimal cut off value in our study was 3.825
• Suppia et al NLR =4
• Basem et al. NLR=10
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30. Discussion
compared to which we found more increase in SAP, which is probably
due to larger number of samples in our study
21.00%
12.90%
25%
17%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
our study Bohara et al.
KMCTH
Papachristou et.al I.C Funnel et al.
Prevalence of SAP - According to Revised Atlanta Classification
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31. Discussion
SENSITIVITY SPECIFICITY PPV NPV
APACHE II 83.30 68.90 51.70 91.20
GLASGOW 73.50 71.10 49.00 87.70
RANSON 91.20 74.40 57.40 95.70
Our study
(NLR> 3.825)
84.60 % 36.20% 26.80% 89.50%
Comparison of our studies with standard scoring system
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32. Discussion
Sensitivity Specificity PPV NPV P value
NLR ( Azab et al.)
(NLR>4.7)
85.2 47.7 14.6 89.5 0.0053
NLR( Suppiah et
al.)
(NLR>10.6)
63.6 56.7 21.2 89.5 0.009
Our study
(NLR> 3.825)
84.60 % 36.20% 26.80% 89.50% 0.389
In contradictory to these studies , we had no statistical significance
of NLR for severity , though the results were comparable
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33. Conclusion
• The results of this study showed that NLR can be used as a
prognostic marker of severity of acute pancreatitis.
• This will not replace the currently accepted scoring systems
• but still because of its convenience in assessing repeatedly
without any further cost and discomfort to the patient
• it can be used routinely in every case of acute pancreatitis to
assess its severity and predict complications
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34. Recommendation
We recommend using the NLR ratio at admission as prognostic
tool only at initial level of care for early risk stratification,
referral and for conservative management groups.
It can be done as a part of routine blood investigation, which
won’t add any extra cost to patient
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35. Limitation
• Small sample size
• Single cantered study
• The hematologic parameter varies after resuscitation. So the
investigations are not always sent before starting the
resuscitation, which may have altered the Neutrophil to
lymphocyte ratio.
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36. Thank you
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education and services
XIII th International Conference of
the Society of Surgeons of Nepal