The Modified Pancreatitis Activity Scoring System Shows Distinct Trajectories in Acute Pancreatitis: An International Study

Published:September 17, 2021DOI:

      Background & Aims

      The aims of this study were to: (1) assess the performance of the Pancreatitis Activity Scoring System (PASS) in a large intercontinental cohort of patients with acute pancreatitis (AP); and (2) investigate whether a modified PASS (mPASS) yields a similar predictive accuracy and produces distinct early trajectories between severity subgroups.


      Data was prospectively collected through the Acute Pancreatitis Patient Registry to Examine Novel Therapies In Clinical Experience (APPRENTICE) consortium (2015-2018) involving 22 centers from 4 continents. AP severity was categorized per the revised Atlanta classification. PASS trajectories were compared between the three severity groups using the generalized estimating equations model. Four mPASS models were generated by modifying the morphine equivalent dose (MED), and their trajectories were compared.


      A total of 1393 subjects were enrolled (median age, 49 years; 51% males). The study cohort included 950 mild (68.2%), 315 (22.6%) moderately severe, and 128 (9.2%) severe AP. Mild cases had the lowest PASS at each study time point (all P < .001). A subset of patients with outlier admission PASS values was identified. In the outlier group, 70% of the PASS variation was attributed to the MED, and 66% of these patients were from the United States centers. Among the 4 modified models, the mPASS-1 (excluding MED from PASS) demonstrated high performance in predicting severe AP with an area under the receiver operating characteristic curve of 0.88 (vs area under the receiver operating characteristic of 0.83 in conventional PASS) and produced distinct trajectories with distinct slopes between severity subgroups (all P < .001).


      We propose a modified model by removing the MED component, which is easier to calculate, predicts accurately severe AP, and maintains significantly distinct early trajectories.


      Abbreviations used in this paper:

      AP (acute pancreatitis), APPRENTICE (Acute Pancreatitis Patient Registry to Examine Novel Therapies In Clinical Experience), AUC (area under the receiver operating characteristic curve), CI (confidence interval), GEE (generalized estimating equation), IQR (interquartile range), IRB (institutional review board), MED (morphine equivalent dose), mPASS (modified Pancreatitis Activity Scoring System), PASS (Pancreatitis Activity Scoring System), RAC (Revised Atlanta Classification), SIRS (systemic inflammatory response syndrome), U.S. (United States)
      To read this article in full you will need to make a payment
      AGA Member Login
      Login with your AGA username and password.
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Yadav D.
        • Lowenfels A.B.
        The epidemiology of pancreatitis and pancreatic cancer.
        Gastroenterology. 2013; 144: 1252-1261
        • Garg S.K.
        • Singh D.
        • Sarvepalli S.
        • et al.
        Incidence, admission rates, and economic burden of adult emergency visits for chronic pancreatitis: data from the National Emergency Department Sample, 2006 to 2012.
        J Clin Gastroenterol. 2019; 53: e328-e333
        • Vaughn V.M.
        • Shuster D.
        • Rogers M.A.M.
        • et al.
        Early versus delayed feeding in patients with acute pancreatitis: a systematic review.
        Ann Intern Med. 2017; 166: 883-892
        • Vege S.S.
        • DiMagno M.J.
        • Forsmark C.E.
        • et al.
        Initial medical treatment of acute pancreatitis: American Gastroenterological Association Institute Technical Review.
        Gastroenterology. 2018; 154: 1103-1139
        • Singh H.
        • Gougol A.
        • Mounzer R.
        • et al.
        Which patients with mild acute pancreatitis require prolonged hospitalization?.
        Clin Transl Gastroenterol. 2017; 8: e129
        • Francisco M.
        • Valentin F.
        • Cubiella J.
        • et al.
        Factors related to length of hospital admission in mild interstitial acute pancreatitis.
        Rev Esp Enferm Dig. 2013; 105: 84-92
        • Wu B.U.
        • Batech M.
        • Quezada M.
        • et al.
        Dynamic measurement of disease activity in acute pancreatitis: the Pancreatitis Activity Scoring System.
        Am J Gastroenterol. 2017; 112: 1144-1152
        • Buxbaum J.
        • Quezada M.
        • Chong B.
        • et al.
        The Pancreatitis Activity Scoring System predicts clinical outcomes in acute pancreatitis: findings from a prospective cohort study.
        Am J Gastroenterol. 2018; 113: 755-764
        • Paragomi P.
        • Tuft M.
        • Pothoulakis I.
        • et al.
        Dynamic changes in the pancreatitis activity scoring system during hospital course in a multicenter, prospective cohort.
        J Gastroenterol Hepatol. 2021; 36: 2416-2423
        • Papachristou G.I.
        • Machicado J.D.
        • Stevens T.
        • et al.
        Acute pancreatitis patient registry to examine novel therapies in clinical experience (APPRENTICE): an international, multicenter consortium for the study of acute pancreatitis.
        Ann Gastroenterol. 2017; 30: 106-113
        • Pothoulakis I.
        • Paragomi P.
        • Archibugi L.
        • et al.
        Clinical features of hypertriglyceridemia-induced acute pancreatitis in an international, multicenter, prospective cohort (APPRENTICE consortium).
        Pancreatology. 2020; 20: 325-330
        • Machicado J.D.
        • Gougol A.
        • Tan X.
        • et al.
        Mortality in acute pancreatitis with persistent organ failure is determined by the number, type, and sequence of organ systems affected.
        United European Gastroenterol J. 2021; 9: 139-149
        • Harris P.A.
        • Taylor R.
        • Thielke R.
        • et al.
        Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Marshall J.C.
        • Cook D.J.
        • Christou N.V.
        • et al.
        Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome.
        Crit Care Med. 1995; 23: 1638-1652
        • Singh V.K.
        • Wu B.U.
        • Bollen T.L.
        • et al.
        Early systemic inflammatory response syndrome is associated with severe acute pancreatitis.
        Clin Gastroenterol Hepatol. 2009; 7: 1247-1251
        • Banks P.A.
        • Bollen T.L.
        • Dervenis C.
        • et al.
        Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus.
        Gut. 2013; 62: 102-111
        • Rosner B.
        Fundamentals of biostatistics.
        8th edition. Cengage Learning, Boston, MA2016
        • R Core Team. R
        A language and environment for statistical computing.
        R Foundation for Statistical Computing, Vienna, Austria2017
        • de-Madaria E.
        • Sanchez-Marin C.
        • Carrillo I.
        • et al.
        Design and validation of a patient-reported outcome measure scale in acute pancreatitis: the PAN-PROMISE study.
        Gut. 2021; 70: 139-147
        • Fisher J.M.
        • Gardner T.B.
        The “golden hours” of management in acute pancreatitis.
        Am J Gastroenterol. 2012; 107: 1146-1150
        • Matta B.
        • Gougol A.
        • Gao X.
        • et al.
        Worldwide variations in demographics, management, and outcomes of acute pancreatitis.
        Clin Gastroenterol Hepatol. 2020; 18: 1567-1575.e2
        • Herzig S.J.
        • Rothberg M.B.
        • Cheung M.
        • et al.
        Opioid utilization and opioid-related adverse events in nonsurgical patients in US hospitals.
        J Hosp Med. 2014; 9: 73-81
        • Okie S.
        A flood of opioids, a rising tide of deaths.
        N Engl J Med. 2010; 363: 1981-1985
        • Wells N.
        • Pasero C.
        • McCaffery M.
        Improving the quality of care through pain assessment and management.
        in: Hughes R.G. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Advances in Patient Safety. Agency for Healthcare Research and Quality (US), Rockville (MD)2008