Acute Pancreatitis Balthazar Score

Evaluates the severity of AP based on the Balthazar grading and necrosis percentage.

In the text below the calculator there is in depth information about the score and its interpretation.


The Balthazar score is used to evaluate disease severity in patients with acute pancreatitis. The model is also known as the Computed Tomography Severity Index (CTSI) and has two components:

■ Balthazar grade: from A to E, increasing in severity;

■ Necrosis Score: from no necrosis to over 50% necrosis.


The three severity stages of acute pancreatitis are described below:

Pancreatitis stage Description
Mild or interstitial Is characterized by a Balthazar grade B or C, without pancreatic or extrapancreatic necrosis.
Moderate or exudative Is characterized by a Balthazar grade D or E, without pancreatic necrosis.
Severe Presents significant necrosis (visualized on contrast enhanced CT).

1

Balthazar Grade

2

Necrosis Score

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The scoring system explained

The Balthazar score or the Computed Tomography Severity Index (CTSI) as it is also known, evaluates the pancreatitis grade and necrosis to determine a severity score. This is then associated with mild, moderate or severe AP.

The Balthazar Grade component of the score is:

■ Grade A – Normal CT;

■ Grade B – Focal or diffuse enlargement of the pancreas (Edematous Pancreas);

■ Grade C – Pancreatic gland abnormalities and peripancreatic inflammation;

■ Grade D – Fluid collection in a single location;

■ Grade E – Multiple or extensive fluid collections and / or gas bubbles in or adjacent to pancreas.

The Necrosis score component of the model is:

■ No necrosis;

■ 0 to 30% necrosis;

■ 30 to 50% necrosis;

■ Over 50% necrosis.

The common stratification of pancreatitis severity can be found in the below table:

Pancreatitis stage Description
Mild or interstitial Is characterized by a Balthazar grade B or C, without pancreatic or extrapancreatic necrosis.
Moderate or exudative Is characterized by a Balthazar grade D or E, without pancreatic necrosis.
Severe Presents significant necrosis (visualized on contrast enhanced CT).

CTSI, designed after a study by Balthazar in 1994 has proven to be more accurate than the other pancreatitis assessments and laboratory determinations, such as the C-reactive protein level.

Individual components do not carry the same sensibility as the full score and in some cases (i.e. patients with pancreatic necrosis), it may not be an accurate predictor of disease severity and prognosis.

Four clinical models for diagnosis, evaluation or prognosis of acute pancreatitis are summarised in the following table:

Pancreatitis model Description
APACHE II (Acute physiology and chronic health examination) Helps establish diagnosis.
BISAP pancreatitis score Evaluates 5 criteria consistent with increased risk of complications in acute pancreatitis admission.
Ranson criteria for pancreatitis Predicts mortality risk based on patient data and laboratory tests at 24 and 48h after admission.
Glasgow prognostic criteria (Imrie's criteria) Evaluates laboratory test results in the first 48h after admission with AP.
 

Result interpretation

Each of the two components of the score is awarded a number of points, depending on the severity aspect. The score varies between 0 and 10 and increases proportionally with the severity of AP.

CT severity index = CT grade points + Necrosis points

The results are correlated with the three degrees of acute pancreatitis severity:

■ 0 – 3 points indicate mild AP;

■ 4 – 6 points indicate moderate AP;

■ 7 – 10 points indicate severe AP.

 

CT investigations in AP

Computed tomography is the main investigation in the diagnosis of AP, along laboratory tests (blood and urine). There are certain clinical criteria that indicate the patient should undergo CT:

■ Abdominal distension and tenderness present;

■ Uncertain diagnosis;

■ Fever and/or leukocytosis;

■ No improvement after 72 hours of conservative medical therapy;

■ Acute change of status, entering fever or shock.

CT findings are usually classed in three categories:

CT finding Examples
Intrapancreatic Edema, pancreatic pseudocysts and/or abscesses
Peripancreatic or extrapancreatic Irregular pancreatic outline or retroperitoneal edema
Locoregional Thickening of inflamed Gerota's fascia, pancreatic ascites or pleural effusion
 

Original source

Balthazar EJ, Freeny PC, vanSonnenberg E. Imaging and intervention in acute pancreatitis. Radiology. 1994; 193(2):297-306.

Other references

1. Balthazar EJ. Acute pancreatitis: assessment of severity with clinical and CT evaluation. Radiology. 2002; 223(3):603-13.

2. Bollen TL, Singh VK, Maurer R, Repas K, van Es HW, Banks PA, Mortele KJ. A comparative evaluation of radiologic and clinical scoring systems in the early prediction of severity in acute pancreatitis. Am J Gastroenterol. 2012; 107(4):612-9.

3. Chatzicostas C, Roussomoustakaki M, Vardas E, Romanos J, Kouroumalis EA. Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II and III scoring systems in predicting acute pancreatitis outcome. J Clin Gastroenterol. 2003; 36(3):253-60.

4. Raghuwanshi S, Gupta R, Vyas MM, Sharma R. CT Evaluation of Acute Pancreatitis and its Prognostic Correlation with CT Severity Index. J Clin Diagn Res. 2016; 10(6): TC06–TC11.


App Version: 1.0.1

Coded By: MDApp

Specialty: Gastroenterology

System: Digestive

Objective: Evaluation

Type: Score

No. Of Items: 2

Year Of Study: 1994

Article By: Denise Nedea

Published On: June 7, 2017 · 10:52 AM

Last Checked: June 7, 2017

Next Review: June 7, 2018