Letters to the Editor
To the Editor: The search for an easy-to-use and accurate predictor tool for the measurement of severity in acute pancreatitis is a never-ending quest. In the June 2013 issue of the Journal of Pediatric Gastroenterology and Nutrition, Coffey et al (1) suggested that serum lipase ≥7 × the upper limit of normal (ULN) is a simple predictor of acute pancreatitis severity. Its sensitivity was 85% and specificity 56%. In 2012, we published a study evaluating different scoring systems for acute pancreatitis in a cohort of 48 children (2). Because we had the lipase level for 44 of them, we could test the usefulness of serum lipase in our cohort. Among these 44 children, 11 were classified as having severe pancreatitis and 33 with its mild form, according to the criteria of the Atlanta symposium (3). The median × ULN of serum lipase value was 9.36 (standard deviation [SD] 32) for the whole cohort, 20.83 (SD 19.19) for the severe pancreatitis, and 9.3 (SD 35.36) for the mild pancreatitis. The area under the receiver-operating characteristic (ROC) curve was 0.69 (confidence interval [CI] 95% 0.47–0.91, P = 0.06), the sensitivity 0.72 (95% CI 0.57–0.87), and the specificity 0.43 (95% CI 0.41–0.43).
Unlike previous studies (2,4–6), Coffey et al used a modified version of the Atlanta symposium, excluding pseudocysts from severe pancreatitis. If we exclude pseudocysts from the analysis, the area under the ROC curve is 0.79 (95% CI 0.58–1, P = 0.038), the sensitivity 0.80 (95% CI 0.73–0.87), and the specificity 0.46 (95% CI 0.45–0.46). If we count pseudocyst as mild form, the area under the ROC curve is 0.77 (95% CI 0.56–0.98, P = .049), the sensitivity 0.80 (95% CI 0.73–0.87), and the specificity 0.41 (95% CI 0.40–0.41). In our cohort, the area under the ROC curve of Ranson, DeBanto, and the Glasgow Coma Scale score was 0.846, 0.699, and 0.774, respectively. Thus, we confirm the good sensitivity of ≥7 × ULN lipase as a predictor of the severity of acute pancreatitis; however, because of its low specificity, the area under the ROC curve did not fare better than the other scoring systems and the false-positive rate was 68%. To date, the scoring system for severity of acute pancreatitis in children is sailing between Scylla and Charybdis, in other words, either a good sensitivity or a good specificity, but never both. The challenge remains to find a way to associate both of them.
1. Coffey MJ, Nightingale S, Ooi CY. Serum lipase as an early predictor of severity in pediatric acute pancreatitis. J Pediatr Gastroenterol Nutr
2. Fabre A, Petit P, Gaudart J, et al. Severity scores in children with acute pancreatitis. J Pediatr Gastroenterol Nutr
3. Bradley EL 3rd. 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
4. DeBanto JR, Goday PS, Pedroso MR, et al. Acute pancreatitis in children. Am J Gastroenterol
5. Suzuki M, Fujii T, Takahiro K, et al. Scoring system for the severity of acute pancreatitis in children. Pancreas
6. Lautz TB, Chin AC, Radhakrishnan J. Acute pancreatitis in children: spectrum of disease and predictors of severity. J Pediatr Surg