Diagnostic Utility of D-Dimer, C-Reactive Protein, and Erythrocyte Sedimentation Rate in Predicting Severity of Acute Pancreatitis: A Prospective Comparative Study.

Acute pancreatitis (AP) is one of the most common gastrointestinal emergencies worldwide and is associated with substantial morbidity and mortality.[1-3] The disease spectrum ranges from mild self-limiting inflammation to severe pancreatitis complicated by pancreatic necrosis, organ failure, and death.[4] Early identification of severe disease is therefore crucial for appropriate triage, intensive monitoring, and timely intervention.

Several prognostic scoring systems, including Ranson’s criteria, APACHE II score, and Glasgow Severity Index, have been developed to predict disease severity.[5-7] Despite their usefulness, these systems require multiple variables and are often cumbersome in routine clinical practice. Consequently, there has been increasing interest in identifying simple biochemical markers capable of providing rapid prognostic information.

D-dimer reflects activation of coagulation and fibrinolysis and has emerged as a potential marker of severe inflammatory states.[8-10] Elevated D-dimer levels have been associated with pancreatic necrosis, organ failure, and mortality in acute pancreatitis. CRP remains one of the most commonly used inflammatory biomarkers; however, its delayed rise may limit early prognostic utility.[11] ESR is an inexpensive and widely available marker of systemic inflammation that may provide additional prognostic information.[12]

This study aimed to evaluate the prognostic significance of D-dimer, CRP, and ESR in patients with acute pancreatitis and determine their association with established severity scoring systems.

Study Design and Setting

This prospective comparative observational study was conducted in the Department of General Surgery, K.R. Hospital, Mysuru, Karnataka, India, between July 2023 and December 2024.

Study Population

Sixty consecutive patients diagnosed with acute pancreatitis according to the Revised Atlanta Classification were included.

Inclusion Criteria

•              Age between 18 and 70 years.

•              Acute pancreatitis diagnosed by clinical, biochemical, and radiological criteria.

•              Presentation within 24 hours of symptom onset.

Exclusion Criteria

•              Chronic pancreatitis.

•              Recurrent pancreatitis.

•              Pancreatic malignancy.

•              Pregnancy.

•              Anticoagulant therapy.

•              Known thromboembolic disorders.

•              Chronic liver disease.

•              Refusal to participate.

Data Collection

Demographic characteristics, clinical findings, laboratory investigations, and radiological findings were recorded. D-dimer, CRP, and ESR were measured serially during hospitalization.

Severity Assessment

Disease severity was assessed using:

•              Revised Atlanta Classification.

•              APACHE II score.

•              Ranson’s criteria.

•              Glasgow Severity Index.

Statistical Analysis

Continuous variables were expressed as median and interquartile range or mean ± standard deviation where appropriate. Comparisons between groups were performed using Mann–Whitney U test. Kruskal–Wallis test was used for multiple group comparisons. Statistical significance was defined as p < 0.05.

Table 1. Demographic Characteristics of Study Population (n = 60)

The majority of patients were males (75%) and belonged to the 40–49 years age group (53.3%).

Table 2. Serial Changes in D-Dimer Levels

D-Dimer levels demonstrated a progressive rise during hospitalization, suggesting increasing coagulation and inflammatory activity.

Table 3. Serial Changes in CRP Levels

CRP levels remained elevated throughout the study period with considerable inter-patient variability.

Table 4. Serial Changes in ESR Levels

ESR showed a consistent upward trend over time, indicating persistent inflammatory activity.

Table 5. Comparison of Biomarkers Between Mild and Severe Acute Pancreatitis

All three biomarkers were significantly higher in severe acute pancreatitis compared to mild disease. D-Dimer and ESR demonstrated particularly strong associations with severity.

Table 6. Correlation of D-Dimer, CRP and ESR with Laboratory Parameters

D-Dimer and ESR showed strong positive correlations with creatinine, TLC, and lipase, while CRP showed strongest correlation with TLC.

Table 7. Biomarker Performance Across Severity Groups

ESR demonstrated the strongest discrimination between severity groups, followed by D-Dimer. CRP did not show statistically significant differences across severity categories.

Results Summary

A total of 60 patients with acute pancreatitis were included in this prospective study. The majority were male (75%) and belonged to the 40–49 years age group (53.3%). Serial measurements revealed progressive increases in D-Dimer and ESR levels over the study period, while CRP remained persistently elevated. Patients with severe acute pancreatitis had significantly higher median D-Dimer, CRP, and ESR values compared to those with mild disease (p < 0.05). D-Dimer and ESR also demonstrated significant differences across severity groups and showed strong correlations with established laboratory markers of disease severity, including creatinine, TLC, and lipase. Among the biomarkers studied, ESR and D-Dimer emerged as the most reliable predictors of disease severity, whereas CRP showed comparatively weaker prognostic performance.

The present study evaluated the role of D-dimer, CRP, and ESR as biomarkers of disease severity in acute pancreatitis. Our findings demonstrate that D-dimer and ESR correlate significantly with disease severity and may serve as useful prognostic indicators.

D-dimer levels increased progressively during hospitalization and were significantly higher among patients with severe acute pancreatitis. These findings are consistent with previous studies demonstrating the association of D-dimer with pancreatic necrosis, multiorgan dysfunction, and mortality.[8-10] Activation of coagulation pathways is an important component of systemic inflammatory response syndrome and may explain the observed relationship between elevated D-dimer levels and disease severity.

ESR also showed progressive elevation and strong association with severe disease. Similar observations have been reported by Xue et al., who demonstrated a significant relationship between elevated ESR and severe acute pancreatitis.[11] ESR remains an attractive biomarker due to its low cost and universal availability.

Although CRP levels were significantly elevated among patients with severe disease, its predictive value was comparatively weaker. Previous studies have similarly reported that CRP is a late-phase reactant and may not adequately identify severe disease during the early phase of illness.[12]

The findings of this study suggest that D-dimer and ESR may complement existing clinical scoring systems and assist in early risk stratification, particularly in resource-limited settings.

Strength

•              Prospective study design.

•              Serial assessment of inflammatory biomarkers.

•              Correlation with multiple validated severity scoring systems.

•              Use of inexpensive and widely available laboratory parameters.

Limitations

•              Single-center study.

•              Small sample size.

•              Lack of receiver operating characteristic analysis.

•              Absence of multivariate regression modeling.

•              Limited follow-up duration.

D-dimer and ESR demonstrated superior performance compared with CRP in predicting disease severity in acute pancreatitis. These inexpensive and readily available biomarkers may facilitate early risk stratification and assist clinical decision-making, particularly in resource-constrained healthcare settings. Larger multicenter studies are warranted to validate these findings and establish clinically useful cutoff values.

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10.    Banks PA, Bollen TL, Dervenis C, et al. Gut 2013;62(1):102-11.

11.    Xue P, Deng LH, Zhang ZD, et al. Clinical significance of elevated erythrocyte sedimentation rate in patients with acute pancreatitis. Pancreas 2012;41(8):1220-4.

12.    Cardoso FS, Ricardo LB, Oliveira AM, et al. C-reactive protein prognostic accuracy in acute pancreatitis. Eur J Gastroenterol Hepatol 2013;25(7):784-9.