Acute Pancreatitis Balthazar Score

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:

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:

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:

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.