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Original Article

Comparative study of Balthazar ComputedTomography Severity Index and ModifiedComputed Tomography Severity Index inpredicting the outcome of acute pancreatitis

Shalabh Jain a,*, Swarna Gupta a, A.S. Chawla b, Yatish Agarwal c,B.B. Thukral d

aSenior Resident, Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, IndiabConsultant and Associate Professor, Department of Surgery, VMMC & Safdarjung Hospital, New Delhi, IndiacProfessor, Department of Radiodiagnosis, VMMC & Safdarjung Hospital, New Delhi, IndiadHead 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

* Corresponding author. Tel.: þ91 9999672570E-mail address: drshalabh003@yahoo.co.i

http://dx.doi.org/10.1016/j.apme.2014.03.0020976-0016/Copyright ª 2014, Indraprastha M

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.

(mobile).n (S. Jain).

edical Corporation Ltd. All rights reserved.

Table 1 e (a) Balthazar CTSI. (b) Balthazar CTSI necrosisscoring.

(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 4e8 3 75

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

andmortality, 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 � 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 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 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 4e8 376

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 pancreatitiswas 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.

Table 3 e Distribution of cases according to age ofpatients.

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

� 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 500mL/24 h or less than 180mL/

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 distributionThe 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 distributionThe study group had a male to female ratio of 2. (Table 4).

3.1.3. Etiological distributionAlcoholic 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).

Inmales, alcohol was found to bemost 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 5 e Etiological distribution of acute pancreatitis.

Cause No. ofcases

% Malecount

% Oftotal

Femalecount

% Oftotal

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 ofacute pancreatitis.

Finding(s) No. ofcases

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

a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4e8 3 77

3.1.4. Clinical presentationEpigastric 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 pseudoaneurysmwere

found, four of splenic artery and another two arising from

branch of hepatic artery (Table 7).

3.3. Scoring and grading of acute pancreatitis withBalthazar 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 withmodified 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).

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

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 wasþ0.815 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 formof intervention, 21 developed infection, 18

had organ failure and 15 succumbed to the disease (Table 10).

Table 8 e Comparison of Balthazar CTSI versus ModifiedCTSI in grading patients of acute pancreatitis.

Grading No. of casesaccording to CTSI

No. of casesaccording to MCTSI

Mild 66 27

Moderate 33 57

Severe 51 66

Table 9eMeasure 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 patientoutcome.

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 12 e Length of hospital stay in relation to CTSI andMCTSI.

Grading Average length ofhospital 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 andMCTSI.

Grading Need for intervention

CTSI MCTSI

Mild 6 0

Moderate 6 6

Severe 18 24

a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4e8 378

3.8. Modified CT Severity Index and patient outcome

When theModified CT Severity Indexwas 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 BalthazarCT Severity Index and Modified CT Severity Index

3.9.1. Length of hospital stayThe length of the hospital stay correlated well with both

Balthazar CT Severity Index and Modified CT Severity Index.

Table 11 e Modified CT Severity Index and patientoutcome.

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

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 interventionsA 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 infectionThe 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 failureThe development of organ failure had a significant correlation

with both Balthazar CT Severity Index (p¼ 0.027) andModified

CT Severity Index (p ¼ 0.024). However, a stronger correlation

was found with Modified CT Severity Index (Table 15).

3.9.5. MortalitySignificant 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 14 e Development of infection in relation to CTSIand MCTSI.

Grading Development of infection

CTSI MCTSI

Mild 3 0

Moderate 6 3

Severe 21 27

Table 15 e Development of organ failure in relation toCTSI 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

a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4e8 3 79

4. Discussion

The present study compares the Balthazar’s Computed To-

mographySeverity IndexwithModifiedComputedTomography

Severity IndexofMortele todetermine their relativestrengths in

pronouncing the prognosis of patients with acute pancreatitis.

Some of the illustrative cases are shown in Figs. 1e4.

Fig. 1 e AeD CECT shows focal enlargement of distal body and

and one ill-defined fluid collection. Calcified gall stones are also

acute pancreatitis was graded as mild (CTSI score [ 3). In contra

placed in the moderate pancreatitis group (MCTSI score [ 4).

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 theModified 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,

tail of pancreas with peripancreatic inflammatory changes

noted. When Balthazar CT Severity Index was employed,

st, when using the Modified CT Severity Index, patient was

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 4e8 380

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. 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 4e8 3 81

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 toBalthazar CTSI and Modified CTSI

4.3.1. Mild pancreatitisIn 66 (44%) patients graded asmild 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 pancreatitisIn 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. 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 4e8 382

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 pancreatitisIn 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 patientoutcome

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

a p o l l o m e d i c i n e 1 1 ( 2 0 1 4 ) 7 4e8 3 83

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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