To compare the Balthazar CT Severity Index and Modified CT Severity Index in predicting the outcome of acute pancreatitis.

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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. 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. 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. 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. 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. 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. 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. 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. 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. 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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