Comparative study of Balthazar Computed Tomography Severity Index and Modified Computed Tomography Severity Index in predicting the outcome of acute pancreatitis
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Comparative study of Balthazar Computed
Tomography Severity Index and Modiﬁed
Computed Tomography Severity Index in
predicting the outcome of acute pancreatitis
Shalabh Jain a,
*, Swarna Gupta a
, A.S. Chawla b
, Yatish Agarwal c
B.B. Thukral d
Senior Resident, Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, India
Consultant and Associate Professor, Department of Surgery, VMMC & Safdarjung Hospital, New Delhi, India
Professor, Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, India
Head of Department, Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, India
a r t i c l e i n f o
Received 8 November 2013
Accepted 20 March 2014
Available online 29 April 2014
CT Severity Index
Modiﬁed CT Severity Index
a b s t r a c t
Objective: To compare the Balthazar CT Severity Index and Modiﬁed CT Severity Index in
predicting the outcome of acute pancreatitis.
Materials and methods: 150 cases of acute pancreatitis, underwent CECT. The scans were
reviewed and scored using both CT indices. Severity parameters included length of hospital
stay, need for intervention, occurrence of organ failure, evidence of infection, and mor-
tality. Descriptive statistics were used for baseline characteristics. Chi-square or Fisher’s
exact tests were used to compare the two indices.
Results: Using Balthazar CTSI with the patient outcome, statistically signiﬁcant correlation
was found between the grades and the length of hospital stay (p ¼ 0.011), development of
infection (p ¼ 0.018), occurrence of organ failure (p ¼ 0.027), and mortality (p ¼ 0.019). No
correlation, however, was obtained between the score and the need for an interventional
procedure (p ¼ 0.126). In contrast, the correlation between the grades under the Modiﬁed
CT Severity Index and outcome was much stronger (p ¼ 0.000 for length of hospital stay,
p ¼ 0.004 for development of infection, p ¼ 0.024 for occurrence of organ failure
and p ¼ 0.013 for mortality). It could also accurately predict the need for interventions
(p ¼ 0.030).
Conclusion: The modiﬁed CTSI correlates more closely with patient outcome than the CTSI.
Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
* Corresponding author. Tel.: þ91 9999672570 (mobile).
E-mail address: email@example.com (S. Jain).
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4 e8 3
0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
Acute pancreatitis is a diffuse inﬂammatory process, which
may remain localized within the pancreas, spread to regional
tissues, or involve adjacent or remote organs, and may run a
highly unpredictable clinical course with a variable outcome.
Broadly classiﬁed into two subtypes: one, edematous or
mild acute pancreatitis and two, a necrotizing or severe acute
pancreatitis, its course in majority (80%) of patients is mild,
self-limiting and calls for a short hospital stay. However, in
approximately 20% of the patients it may become severe and
result in various complications.1
As early treatment of pa-
tients with severe acute pancreatitis result in less morbidity
and mortality, it is essential to identify accurately the patients
with severe disease. Therefore, the stratiﬁcation of severity of
acute pancreatitis at the time of admission is essential to
permit triage, determine prognosis, decide treatment, and
allocate resources judiciously.2,3
In general, physical examination and laboratory ﬁndings
carry a fair accuracy in their ability to help diagnose acute
pancreatitis. However, an accurate prediction of the severity
of disease is more difﬁcult. Since 1974, several clinical and
radiological scoring systems have been developed for this
purpose, including Ranson’s criteria,4
Simpliﬁed Acute Physiology score (SAP score)7
Computed Tomography Severity Index (CTSI).8,9
The CTSI, designed by Balthazar et al, in 1990, is the most
widely adopted for clinical and research settings. The CTSI is a
numeric scoring system that combines a quantiﬁcation of
pancreatic and extrapancreatic inﬂammation with the extent
of pancreatic necrosis. It was found to have a better prognostic
accuracy than the earlier score but it, too, was found to have
some limitations. First, the score obtained with the index did
not incorporate the presence of organ failure,10
atic parenchymal complications11,12
and their correlation with the ﬁnal
outcome. Secondly, as documented in some studies, inter-
observer agreement for scoring the CT scans using the CTSI
was only moderate, with a reported agreement of approxi-
The source of this variability possibly relates
to the subjective and multiple categorization of the extent of
pancreatic inﬂammation and necrosis.
In view of these limitations, a modiﬁed and simpliﬁed CT
scoring system was proposed in 2004 by Mortele et al15
is easier to calculate, reproduce and correlates more closely
with the patient outcome measures.
The Modiﬁed CTSI in relation to earlier CTSI includes fea-
tures reﬂecting organ failure and extrapancreatic complica-
tions for predicting course. This index includes presence or
absence of acute ﬂuid collection rather than count of collec-
tions, it scores necrosis as absent, <30% or >30%, and it takes
into consideration extrapancreatic ﬁndings such as pleural
ﬂuid, ascites, extrapancreatic parenchymal abnormalities,
peri-pancreatic vascular involvement or involvement of the
Few studies have evaluated the prognostic value of Modi-
ﬁed CT Severity Index in acute pancreatitis. Hence, the pre-
sent study was conducted to correlate the Balthazar CTSI
(1990) and Modiﬁed CTSI (2004) with clinical outcome in
patients with acute pancreatitis in a bid to determine their
respective strengths and limitations.
2. Materials and methods
We performed a prospective study involving 150 patients of
acute pancreatitis admitted in our institution. Informed con-
sent of each patient was obtained. The diagnostic criteria of
acute pancreatitis were the presence of atleast two of the
following three manifestations: Acute abdominal pain and
tenderness in upper abdomen, Serum Amylase ! 3 times
normal or imaging ﬁndings (Ultrasound and/or CT) suggestive
of acute pancreatitis. CECT was performed in all the patients
between 48 and 120 h of the onset of symptoms.
2.2. CT technique
All patients underwent Spiral Computed Tomography (CT)
examination of the abdomen using PHILIPS BRILLIANCE 40 CT
UNIT. Contrast-enhanced CT scans (collimation, 4 Â 2.5 mm;
reconstruction section thickness, 5 mm; reconstruction in-
tervals, 5 mm) were obtained 40e50 s after IV injection of
100 mL of iopamidol 300, injected at a rate of 3.0 mL/s, using a
mechanical power injector. Opaciﬁcation of the digestive tract
was achieved with oral administration of approximately
1000 mL of 2% sweetened Urografﬁn suspension.
2.3. Image analysis
All the CT images were reviewed and all pancreatic, peri-
pancreatic, and extrapancreatic ﬁndings and complications
were recorded. Pancreatic ﬁndings included pancreatic
enlargement and presence and extent of areas lacking
enhancement. Peripancreatic ﬁndings included peripancre-
atic fat stranding and number of ﬂuid collections. Extrap-
ancreatic complications included ascites, pleural effusion,
pericardial effusion, vascular complications (venous
Table 1 e (a) Balthazar CTSI. (b) Balthazar CTSI necrosis
Prognostic indicator Points
Normal Pancreas 0
Focal or diffuse enlargement of the pancreas 1
Intrinsic pancreatic abnormalities with
inﬂammatory changes in peripancreatic fat
Single, ill deﬁned ﬂuid collection or phlegmon 3
Two or more poorly deﬁned collections or
presence of gas in or adjacent to the pancreas
30% Necrosis 2
30e50% Necrosis 4
>50% Necrosis 6
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4 e8 3 75
thrombosis, hemorrhage, and arterial pseudoaneurysm for-
mation), gastrointestinal complications (ileus [adynamic ileus
or mechanical obstruction], signs of ischemia, marked bowel-
wall thickening, perforation, and intramural ﬂuid collection),
and extrapancreatic parenchymal complications (infarction,
hemorrhage, and subcapsular ﬂuid collection). The severity of
the pancreatitis for each case was assessed using the CTSI
developed by Balthazar et al (Table 1(a) and (b)), and the
severity of pancreatitis was categorized as mild (score, 0e3
points), moderate (4e6 points), or severe (7e10 points). Sub-
sequently, the severity of the pancreatitis was assessed during
the same interpretation session using a Modiﬁed CT Severity
Index (Table 2), and was again categorized as mild (0e2
points), moderate (4e6 points), or severe (8e10 points)
2.4. Outcome parameters
Clinical follow-up of the patients was done in terms of
Occurrence of organ failure
Cardiovascular failure: systolic blood pressure
90 mmHg in the absence of hypovolemia with signs of
peripheral hypoperfusion or by the need for continuous
infusion of vasopressor or inotropic agents to maintain a
systolic blood pressure of more than 90 mm Hg.
Pulmonary insufﬁciency (on FiO2 ¼ 0.2): PaO2 60 mmHg
or need for ventilator support.
Renal failure: creatinine 2 mg/dl after rehydration, or
urine output of less than 500 mL/24 h or less than 180 mL/
8 h, or by the need for hemo- or peritoneal dialysis.
Hepatic failure: Serum bilirubin levels greater than
100 mmol/L or alkaline phosphatase levels greater than
three times the upper limit of the normal range.
Hematologic system failure: Hematocrit level of less than
20%, WBC of less than 2000/mm3
, or platelet count of less
Evidence of infection based on:
Combination of a fever 100*F and an elevated WBC
Positive results on gram stain of aspirate or
Positive results on culture
Need for intervention (Surgical or Percutaneous) due to
pancreatic or extra-pancreatic complications
Length of hospital stay
2.5. Data analysis
Descriptive statistics were used for baseline characteristics,
outcomes of interest, and extrapancreatic ﬁndings. Chi-
square or Fisher’s exact tests were used to assess relation-
ships between outcomes and morphologic severity of CTSI
and MCTSI. P value 0.05 was considered signiﬁcant.
3.1. Demographic proﬁle of the subjects
3.1.1. Age distribution
The age of the patients in the study group was in the range of
18e80 years. Maximum patients were in the age group 41e50
years (42.0%). The mean age was 43.66 years (Table 3).
3.1.2. Gender distribution
The study group had a male to female ratio of 2. (Table 4).
3.1.3. Etiological distribution
Alcoholic pancreatitis was found to be most common etio-
logical factor for acute pancreatitis in 42% cases. Cholelithi-
asis was seen in 38% of cases. Together cholelithiasis and
alcoholism accounted for 72% of cases (Table 5).
In males, alcohol was found to be most common etiological
agent accounting for 50% of cases. In females, cholelithiasis
was found to be most common etiological agent accounting
for 57.8% of cases.
Table 2 e Modiﬁed CTSI.
Prognostic indicator Points
Normal pancreas 0
abnormalities with or
Pancreatic or peripancreatic
ﬂuid collection or
peripancreatic fat necrosis
One or more of following: pleural
effusion, ascites, vascular
complications, or gastrointestinal
Table 3 e Distribution of cases according to age of
Age group (in years) No. of patients Percentage (%)
11e20 3 2
21e30 21 14
31e40 33 22
41e50 63 42
51e60 12 8
61e70 15 10
71e80 3 2
Total 150 100
Table 4 e Gender distribution of patients.
Gender No. of patients (n ¼ 150) Percentage (%)
Female 51 34
Male 99 66
Total 150 100
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4 e8 376
3.1.4. Clinical presentation
Epigastric pain was present in all the patients. Triad of
epigastric pain, nausea and vomiting was present in 75% of
patients. Jaundice was noted in only in 3 cases (Table 6).
3.2. Extra-pancreatic complications
Pleural effusion was the most common extra-pancreatic
complication. Left pleural effusion was more common than
the right, and in none of the cases, isolated right sided pleural
effusion was found.
Ascites was the second most common complication seen
in 36% cases.
Among vascular complications, venous thrombosis was
the most common (6 in portal vein, 3 in superior mesenteric
vein and 3 in splenic vein). Six cases of pseudoaneurysm were
found, four of splenic artery and another two arising from
branch of hepatic artery (Table 7).
3.3. Scoring and grading of acute pancreatitis with
Majority of patients (44%) had a CTSI score between 0 and 3
and were, hence, categorized as mild pancreatitis. Another
24% of patients had a CTSI score of 4e6 and fell under the
category of moderate pancreatitis, while 34% cases had a CTSI
score of 7e10 and were categorized as severe
pancreatitis (Table 8).
3.4. Scoring and grading of acute pancreatitis with
Majority of patients were categorized as severe pancreatitis
(44%). 38% patients were grouped into moderate pancreatitis
and 18% were categorized in mild pancreatitis (Table 8).
3.5. Comparison of Balthazar CTSI versus modiﬁed CTSI
Majority of patients had mild pancreatitis according to CT
Severity Index. However, according to Modiﬁed CT Severity
Index, majority were categorized as severe pancreatitis. The
Spearman rank correlation between CT Severity Index and
Modiﬁed CT Severity Index was þ0.815 with signiﬁcance value
3.6. Outcome parameters
The average duration of hospital stay in the study was 9 days
with a range from 0 to 16 days. Thirty (20%) patients under-
went either percutaneous or surgical intervention. Thirty
(20%) patients had evidence of infection. Organ failure
occurred in 24 (16%) patients. A total of 18 (12%) patients
succumbed to acute pancreatitis (Table 9).
3.7. Balthazar CT Severity Index and patient outcome
When the Balthazar CT Severity Index was applied, the
average duration of hospital stay in patients categorized as
mild pancreatitis was 4.8 days, in moderate pancreatitis 10.4
days and in severe pancreatitis 13.5 days.
Of the patients categorized as mild pancreatitis, 6 patients
required interventional procedure, 3 had infection, and 3 had
organ failure. No mortality was recorded in this group.
In the patients categorized as moderate pancreatitis, 6
patients required intervention, 6 developed infection, 3 had
organ failure and 3 patient died.
In the patients categorized as severe group, 18 patients
required some form of intervention, 21 developed infection, 18
had organ failure and 15 succumbed to the disease (Table 10).
Table 6 e Clinical presentation of acute pancreatitis.
Symptoms No. of cases Percentage (%)
Epigastric Pain 150 100
Nausea 135 90
Vomiting 111 74
Fever 15 10
Constipation 18 12
Jaundice 3 2
Dyspnea 6 4
Table 5 e Etiological distribution of acute pancreatitis.
Cause No. of
Cholelithiasis 57 38 24 16 33 22
Alcohol 63 42 54 36 9 6
Trauma 3 2 3 2 0 0
Post ERCP 3 2 0 0 3 2
Idiopathic 39 26 27 18 12 8
Table 7 e Extrapancreatic complications in patients of
Finding(s) No. of
Pleural effusion 84 56
Left only 48 32
Right only 0 0
Bilateral 36 24
Ascites 54 36
Infarction 3 2
Hemorrhage 0 0
Subcapsular collection 15 10
Venous thrombosis 12 8
Pseudoaneurysm 6 4
GI Involvement 39 26
Table 8 e Comparison of Balthazar CTSI versus Modiﬁed
CTSI in grading patients of acute pancreatitis.
Grading No. of cases
according to CTSI
No. of cases
according to MCTSI
Mild 66 27
Moderate 33 57
Severe 51 66
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4 e8 3 77
3.8. Modiﬁed CT Severity Index and patient outcome
When the Modiﬁed CT Severity Index was applied, the average
duration of hospital stay in patients categorized as mild
pancreatitis was 1.6 days, in moderate pancreatitis 7 days and
in severe pancreatitis 13.7 days.
None of the patients categorized as mild pancreatitis had
an adverse or fatal outcome.
The majority (80%) of patients requiring interventional
procedure fell in the severe pancreatitis group. Likewise, 27
out of 30 patients who developed infection, and 21 out of 24
patients who developed organ failure belonged to this group.
Mortality was also only reported in this group (Table 11).
3.9. Comparison of outcome parameters with Balthazar
CT Severity Index and Modiﬁed CT Severity Index
3.9.1. Length of hospital stay
The length of the hospital stay correlated well with both
Balthazar CT Severity Index and Modiﬁed CT Severity Index.
However, the Modiﬁed CT Severity Index (p ¼ 0.000) out-
performed the Balthazar CT Severity Index (p ¼ 0.011)
3.9.2. Need for interventions
A signiﬁcant correlation (p ¼ 0.030) was found between the
grades of modiﬁed Severity Index score and the need for an
interventional procedure. In contrast, the Balthazar CTSI
scoring system failed to predict such a need (p ¼ 0.126)
3.9.3. Development of infection
The development of infection in the subjects correlated well
with both Balthazar CT Severity Index and Modiﬁed CT
Severity Index. However, the Modiﬁed CT Severity Index
(p ¼ 0.004) had a stronger correlation than the Balthazar CT
Severity Index (p ¼ 0.018) (Table 4) Table 14.
3.9.4. Development of organ failure
The development of organ failure had a signiﬁcant correlation
with both Balthazar CT Severity Index (p ¼ 0.027) and Modiﬁed
CT Severity Index (p ¼ 0.024). However, a stronger correlation
was found with Modiﬁed CT Severity Index (Table 15).
Signiﬁcant correlation between mortality and the severity of
pancreatitis was found both with Balthazar CT Severity Index
(p ¼ 0.019) and the Modiﬁed CT Severity Index (p ¼ 0.013).
However, the Modiﬁed CT Severity Index had a stronger cor-
relation than Balthazar CT Severity Index (Table 16).
Table 9 e Measure of outcome parameters in the subjects.
Outcome parameters No. of cases Percentage (%)
Duration of hospital
stay (in days)
0e5 30 20
6e10 54 36
11e15 60 40
16e20 6 4
Infection 30 20
Organ failure 24 16
Death 18 12
Table 10 e Balthazar CT Severity Index and patient
Outcome factor Balthazar CT Severity Index
Mild Moderate Severe
No. of patients 66 33 51
Avg. length of hospital
stay in days
4.8 10.4 13.5
Intervention 6 6 18
Infection 3 6 21
Organ failure 3 3 18
Death 0 3 15
Table 11 e Modiﬁed CT Severity Index and patient
Outcome factor Modiﬁed CT Severity Index
Mild Moderate Severe
No. of patients 27 57 66
Avg. length of hospital
stay in days
1.6 7 14.2
Intervention 0 6 24
Infection 0 3 27
Organ failure 0 3 21
Death 0 0 18
Table 12 e Length of hospital stay in relation to CTSI and
Grading Average length of
hospital stay in days
Mild 4.8 1.5
Moderate 7.3 6.9
Severe 13.5 14.2
Table 13 e Need for intervention in relation to CTSI and
Grading Need for intervention
Mild 6 0
Moderate 6 6
Severe 18 24
Table 14 e Development of infection in relation to CTSI
Grading Development of infection
Mild 3 0
Moderate 6 3
Severe 21 27
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4 e8 378
The present study compares the Balthazar’s Computed To-
mographySeverity Index with Modiﬁed ComputedTomography
Severity Index ofMortele to determine their relativestrengthsin
pronouncing the prognosis of patients with acute pancreatitis.
Some of the illustrative cases are shown in Figs. 1e4.
4.1. CT grading of severity of pancreatitis
In this series, when Balthazar CT Severity Index was
employed, acute pancreatitis was graded as mild in 44% (66/
150), moderate in 22% (33/150) and severe in 34% (51/150) pa-
tients. In contrast, when using the Modiﬁed CT Severity Index,
a much larger number, viz. 66/150 (44%) patients were placed
in the severe pancreatitis group. Mild pancreatitis was present
in 18% (27/150) and moderate pancreatitis in 38% (56/150)
The Balthazar CT Severity Index graded 66 (44%) patients
into the mild group while the Modiﬁed CT Severity Index,
only considered 27 (18%) of these patients to be in this group.
Of the remaining 39 patients graded as mild under Balthazar
CT Severity Index, 33 had extrapancreatic complications. The
Modiﬁed CT Severity Index awarded them two extra points
for this reason, and thus, upgraded them to the moderate
The Balthazar CT Severity Index graded 33 (22%) patients as
having moderate pancreatitis while the Modiﬁed CT Severity
Index graded 57 (38%) patients in the moderate pancreatitis
group. Of the 33 patients graded as moderate on Balthazar
CTSI score, 18 patients had one or more extrapancreatic
complications besides demonstrating signs of gland necrosis.
The Modiﬁed CT Severity Index awarded them two extra
points for the extrapancreatic complications, and thus,
Table 15 e Development of organ failure in relation to
CTSI and MCTSI.
Grading Development of organ failure
Mild 3 0
Moderate 3 3
Severe 18 21
Table 16 e Mortality in relation to CTSI and MCTSI.
Mild 0 0
Moderate 3 0
Severe 15 18
Fig. 1 e AeD CECT shows focal enlargement of distal body and tail of pancreas with peripancreatic inﬂammatory changes
and one ill-deﬁned ﬂuid collection. Calciﬁed gall stones are also noted. When Balthazar CT Severity Index was employed,
acute pancreatitis was graded as mild (CTSI score [ 3). In contrast, when using the Modiﬁed CT Severity Index, patient was
placed in the moderate pancreatitis group (MCTSI score [ 4).
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4 e8 3 79
upgraded them to the severe group. Three patients identiﬁed
as severe on Balthazar CT Severity Index were downgraded to
the moderate group under the Modiﬁed CT Severity Index,
since these patients had received lesser points for necrosis in
the modiﬁed index.
The Balthazar CT Severity Index graded 51 (34%) patients
into severe pancreatitis while the Modiﬁed CT Severity Index
graded 66 (44%) patients in the like manner. This increase
was due to the upgradation of 18 patients with extrap-
ancreatic complications into the severe group under the
Modiﬁed CT Severity Index, and downgrading of 3 patients of
the severe group in Balthazar CT Severity Index to the mod-
erate grade under the Modiﬁed CT Severity Index due to
lesser points being awarded for necrosis in the modiﬁed
4.2. Overall patient outcome
The length of hospital stay in the subjects ranged from 0 to 16
days, with an average length of 9 days.
A total of 30 (20%) patients required either a percutaneous
or surgical intervention. Three (2%) patients each required a
pigtail catheter insertion and aspiration under ultrasound
guidance. The breakup for surgical intervention was as fol-
lows: 6 (4%) patients needed a necrosectomy, 6 (4%) patients
required active management for a pseudoaneurysm, three
(2%) patient needed a decompressive laparotomy for abdom-
inal compression syndrome, three (2%) patients were oper-
ated for a ﬁstulous communication with the bowel, and three
patients (2%) required a surgical drainage of an infected psoas
Fig. 2 e AeC CECT demonstrates diffuse enlargement of pancreas with peripancreatic inﬂammatory changes and single
peripancreatic collection in lesser sac. There is no evidence of any pancreatic necrosis or extrapancreatic complication. The
Balthazar CT Severity Index graded patient as having mild pancreatitis (CTSI score [ 3) while the Modiﬁed CT Severity
Index graded patient in the moderate pancreatitis group (MCTSI score [ 4).
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4 e8 380
Infection developed in 30 (20%) patients.
Organ failure occurred in 24/150 (16%) patients. In 15 out of
these 24 patients, more than one organ system failed. Shock
and respiratory failure occurred in 18 patients each, whereas
renal failure developed in 6 patients.
In all, 18 (12%) patients succumbed to disease. Fifteen out
of these 18 patients had one or more organ system failure and
twelve patients had developed infection.
4.3. Comparison of patient outcome in relation to
Balthazar CTSI and Modiﬁed CTSI
4.3.1. Mild pancreatitis
In 66 (44%) patients graded as mild pancreatitis with Balthazar
CT Severity Index, the average duration of hospital stay was
4.8 days, 6 (9%) patients required intervention, 3 (4.5%)
developed infection, and 3 (4.5%) had organ failure. No mor-
tality took place in this group. In contrast in the 27 patients
graded as mild pancreatitis with Modiﬁed CT Severity Index,
the average duration of hospital stay was 1.6 days, with no
patient developing infection, organ failure or succumbing to
the disease. At the same time, none of the patients needed
4.3.2. Moderate pancreatitis
In 33 (22%) patients graded as moderate pancreatitis with
Balthazar CT Severity Index, the average duration of hospital
stay was 10.4 days, 6 (18.2%) patients required intervention, 6
(18.1%) developed infection and 3 (9%) developed organ fail-
ure. Three (9%) deaths were recorded in this group. In com-
parison in the 57 (38%) patients graded as moderate
pancreatitis with the Modiﬁed CT Severity Index, the average
Fig. 3 e AeD CECT shows 50% non-enhancing area of pancreatic parenchyma suggestive of necrosis. Peripancreatic
inﬂammatory changes and Ill-deﬁned ﬂuid collection is noted. Extrapancreatic manifestations include left sided pleural
effusion and colonic wall thickening. The Balthazar CT Severity Index (CTSI score [ 9) As well as the Modiﬁed CT Severity
Index (MCTSI score [ 10) graded patient into severe pancreatitis.
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4 e8 3 81
duration of hospital stay was 7 days, 6 (10.5%) patients
required intervention, while 3 (5.2%) patients each developed
infection and organ failure. No mortality was recorded in this
4.3.3. Severe pancreatitis
In the 51 (34%) patients graded as severe pancreatitis with
Balthazar CT Severity Index, the average duration of hospital
stay was 13.5 days, 18 (35.3%) patients required intervention,
21 (41.2%) developed infection, 18 (35.2%) had organ failure
and 15 (29.4%) patients succumbed due to the disease process.
In contrast in the 66 (44%) patients graded as severe pancre-
atitis with the Modiﬁed CT Severity Index, the average dura-
tion of hospital stay was 13.7 days, 24 (36.36%) patients needed
intervention, 27 (41%) patients had infection, and 21 (31.8%)
developed organ failure. All 18 patients who succumbed to the
disease process were from this group.
4.4. Correlation between severity indices and patient
When relating the severity grades of the subjects under the
Balthazar CTSI with their outcome, statistically signiﬁcant
correlation was found between the grades and the length of
hospital stay (p ¼ 0.011), development of infection (p ¼ 0.018),
occurrence of organ failure (p ¼ 0.027), and mortality
(p ¼ 0.019). No correlation, however, was obtained between
the score and the need for an interventional procedure
(p ¼ 0.126). In contrast, the correlation between the grades
under the Modiﬁed CT Severity Index and outcome was much
Fig. 4 e AeD CECT scan reveals diffuse enlargement of pancreas with 30% area of necrosis. Peripancreatic inﬂammatory
changes are present. Single well deﬁned collection is noted near the splenic hilum. Superior mesenteric vein thrombosis,
left pleural effusion and bowel wall thickening are also noted. When Balthazar CT Severity Index was employed, acute
pancreatitis was graded as moderate (CTSI score [ 5). In contrast, when using the Modiﬁed CT Severity Index, patient was
placed in the severe pancreatitis group (MCTSI score [ 8).
a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4 e8 382
stronger (p ¼ 0.000 for length of hospital stay, p ¼ 0.004 for
development of infection, p ¼ 0.024 for occurrence of organ
failure and p ¼ 0.013 for mortality). It could also accurately
predict the need for interventions (p ¼ 0.030).
Conﬂicts of interest
All authors have none to declare.
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