Comp
                       
                       
parative st
and Mo
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Original Article
Comparative study of Balthazar Computed
Tomography Severity Index and Modified
Computed Tomography Severit...
1. Introduction
Acute pancreatitis is a diffuse inflammatory process, which
may remain localized within the pancreas, sprea...
thrombosis, hemorrhage, and arterial pseudoaneurysm for-
mation), gastrointestinal complications (ileus [adynamic ileus
or...
3.1.4. Clinical presentation
Epigastric pain was present in all the patients. Triad of
epigastric pain, nausea and vomitin...
3.8. Modified CT Severity Index and patient outcome
When the Modified CT Severity Index was applied, the average
duration of...
4. Discussion
The present study compares the Balthazar’s Computed To-
mographySeverity Index with Modified ComputedTomograp...
upgraded them to the severe group. Three patients identified
as severe on Balthazar CT Severity Index were downgraded to
th...
Infection developed in 30 (20%) patients.
Organ failure occurred in 24/150 (16%) patients. In 15 out of
these 24 patients,...
duration of hospital stay was 7 days, 6 (10.5%) patients
required intervention, while 3 (5.2%) patients each developed
inf...
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...
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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

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To compare the Balthazar CT Severity Index and Modified CT 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

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  2. 2. Original Article 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 a Senior Resident, Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, India b Consultant and Associate Professor, Department of Surgery, VMMC & Safdarjung Hospital, New Delhi, India c Professor, Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, India d Head of Department, Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, India a r t i c l e i n f o Article history: Received 8 November 2013 Accepted 20 March 2014 Available online 29 April 2014 Keywords: Pancreatitis 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: drshalabh003@yahoo.co.in (S. Jain). Available online at www.sciencedirect.com ScienceDirect 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 http://dx.doi.org/10.1016/j.apme.2014.03.002 0976-0016/Copyright ª 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
  3. 3. 1. Introduction 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 Imrie’s score,5 APACHE- II,6 Simplified Acute Physiology score (SAP score)7 and 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 extrapancre- atic parenchymal complications11,12 or peripancreatic vascular complications13 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- mately 75%.11,14 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 which 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 gastro-intestinal tract. 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 2.1. Subjects 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 scoring. (a) Prognostic indicator Points Normal Pancreas 0 Focal or diffuse enlargement of the pancreas 1 Intrinsic pancreatic abnormalities with inflammatory changes in peripancreatic fat 2 Single, ill defined fluid collection or phlegmon 3 Two or more poorly defined collections or presence of gas in or adjacent to the pancreas 4 (b) Necrosis Points None 0 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
  4. 4. 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) pancreatitis. 2.4. Outcome parameters Clinical follow-up of the patients was done in terms of following parameters: 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 than 40,000/mm3 . Evidence of infection based on: Combination of a fever 100*F and an elevated WBC 15,000/mm3 with 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 Mortality 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. Results 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 Pancreatic Inflammation Normal pancreas 0 Intrinsic pancreatic abnormalities with or without inflammatory changes in peripancreatic fat 2 Pancreatic or peripancreatic fluid collection or peripancreatic fat necrosis 4 Pancreatic Necrosis None 0 30% 2 30% 4 Extra pancreatic complications One or more of following: pleural effusion, ascites, vascular complications, parenchymal complications, or gastrointestinal tract involvement 2 Table 3 e Distribution of cases according to age of patients. 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
  5. 5. 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 Balthazar CTSI 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 modified CTSI 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 of 0.01. 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 cases % Male count % Of total Female count % Of total 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 acute pancreatitis. Finding(s) No. of cases Percentage (%) Pleural effusion 84 56 Left only 48 32 Right only 0 0 Bilateral 36 24 Ascites 54 36 Extra-pancreatic parenchymal abnormality Infarction 3 2 Hemorrhage 0 0 Subcapsular collection 15 10 Vascular complication 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
  6. 6. 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) (Table 12). 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) (Table 13). 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). 3.9.5. Mortality 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 Percutaneous or surgical intervention 30 20 Infection 30 20 Organ failure 24 16 Death 18 12 Table 10 e Balthazar CT Severity Index and patient outcome. 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. 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 MCTSI. Grading Average length of hospital stay in days CTSI MCTSI 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 MCTSI. Grading Need for intervention CTSI MCTSI Mild 6 0 Moderate 6 6 Severe 18 24 Table 14 e Development of infection in relation to CTSI and MCTSI. Grading Development of infection CTSI MCTSI 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
  7. 7. 4. Discussion 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) patients. 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 group. 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 CTSI MCTSI Mild 3 0 Moderate 3 3 Severe 18 21 Table 16 e Mortality in relation to CTSI and MCTSI. Grading Mortality CTSI 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
  8. 8. 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 index. 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 collection. 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
  9. 9. 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 intervention. 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
  10. 10. 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 group. 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 outcome 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
  11. 11. 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. r e f e r e n c e s 1. Bradley III EL. 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. 1993;128(5):586e590. 2. Steinberg W, Tenner S. Acute pancreatitis. N Engl J Med. 1994;330:1198e1210. 3. De Beaux AC, Palmer KR, Carter DC. Factors influencing morbidity and mortality in acute pancreatitis; an analysis of 279 cases. Gut. 1995;37:121e126. 4. Ranson JHC, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer FC. Prognostic signs and the role of operative management in acute pancreatitis. Surg Gynecol Obstet. 1974;139:69e81. 5. Imrie CW, Benjamin IS, Ferguson JC, et al. A single-centre double-blind trial of Trasylol therapy in primary acute pancreatitis. Br J Surg. 1978;65:337e341. 6. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818e829. 7. Le Gall JR, Loirat P, Alperovitch A. Simplified acute physiology score for intensive care patients. Lancet. 1983;2:741e745. 8. Balthazar EJ, Robinson DL, Megibow AJ, Ranson JHC. Acute pancreatitis: Value of CT in establishing prognosis. Radiol. 1990;174:331e336. 9. Balthazar EJ, Freeny PC, vannSonnenberg E. Imaging and intervention in acute pancreatitis. Radiol. 1994;193:297e306. 10. Lankish PG, Pflichthofer D, Lehnick D. No strict correlation between necrosis and organ failure in acute pancreatitis. Pancreas. 2000;20:319e322. 11. Mortele KJ, Mergo P, Taylor H, Ernst M, Ros PR. Renal and peri renal space involvement in acute pancreatitis: state of art spiral CT findings. Abdom Imaging. 2000;25:272e278. 12. Wiesner W, Studler U, Kocher T, Degen L, Buitrago-Tellez CH, Steinbrich W. Colonic involvement in non-necrotizing acute pancreatitis: correlation of CT findings with the clinical course of affected patients. Eur Radiol. 2003;13:897e902. 13. Inoue K, Hirota M, Beppu T. Angiographic features in acute pancreatitis: the severity of abdominal vessel ischemic change reflects the severity of acute pancreatitis. J Pancreas. 2003;4:207e213. 14. Lecesne R, Tourel P, Bret PM, Atri M, Reinhold C. Acute pancreatitis: interobserver agreement and correlation of CT and MR cholangiopancreatography with outcome. Radiology. 1999;211:727e735. 15. Mortele KJ, Weisner W, Intriere L, et al. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. AJR. 2004 Nov;183:1261e1265. a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4 e8 3 83
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