Balthazar Score For Pancreatitis Calculator

How does this Balthazar score for pancreatitis calculator work?

This health tool examines the computed tomography findings in pancreatitis and the degree of necrosis in order to delineate the severity of AP.

The Balthazar score is another name used for the Computed Tomography Severity Index (CTSI) and the two components are:

I) Balthazar Grade

■ 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.

II) Necrosis Score

■ No necrosis;

■ 0 to 30% necrosis;

■ 30 to 50% necrosis;

■ Over 50% necrosis.

CTSI has proven to be more accurate than the other pancreatitis assessments, including the CRP (C-reactive protein) level. However, this doesn’t mean that it carries the same sensibility in each of the components taken individually. This means that it is not such an accurate predictor of prognosis in patients with pancreatic necrosis.

The following represents the common stratification of pancreatitis severity:

■ Mild pancreatitis – also known as interstitial pancreatitis and characterized by a Balthazar grade B or C, without pancreatic or extrapancreatic necrosis;

■ Moderate or exudative pancreatitis – characterized by a Balthazar grade D or E, without pancreatic necrosis;

■ Severe pancreatitis – is the type that presents significant necrosis (visualized on contrast enhanced CT).

Balthazar score interpretation

Each of the two sections has a different grading of CT and necrosis that is awarded a different number of points, increasing proportionally with the severity of AP.

CT severity index = CT grade points + Necrosis points

The maximum score obtainable, the sum of the maximum Balthazar grade points and pancreatic necrosis points is 10.

There are three score ranges suggestive of different degrees of AP severity:

■ 0 – 3: score consistent with mild AP;

■ 4 – 6: score consistent with moderate AP;

■ 7 – 10: score is consistent with severe AP.

Computed tomography in pancreatitis

CT remains one of the essential investigation and diagnosis methods, along blood and urine tests. There are certain criteria which, if present upon admission, require CT:

■ Abdominal distension and tenderness present;

■ Fever and/or leukocytosis;

■ Uncertain diagnosis;

■ 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 (here presented with some examples of findings):

1. Intrapancreatic – edema, pancreatic pseudocysts and/ or abscesses;
2. Peripancreatic or extrapancreatic – irregular pancreatic outline, retroperitoneal edema;
3. Locoregional – thickening of inflamed Gerota's fascia, pancreatic ascites or pleural effusion.

Acute pancreatitis diagnosis and mortality assessment tools

The Balthazar score is one of the many severity and complication tools available in the monitoring of acute and severe pancreatitis. These are some other examples:

■ Acute physiology and chronic health examination APACHE II can provide further insight and help establish severe pancreatitis diagnosis.

■ The BISAP pancreatitis score calculator addresses 5 criteria consistent with increased risk of complications in acute pancreatitis admission.

■ The Ranson criteria for pancreatitis predicts mortality risk based on results from samples collected within 24 and 48 hours from admission.

■ Glasgow prognostic criteria (Imrie's criteria) consists of laboratory values collected during the first 48 hours upon pancreatitis admission.

References

1) Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. (1990) Acute pancreatitis: value of CT in establishing prognosis. Radiology; 174(2):331-6.

2) Leung TK, Lee CM, Lin SY, Chen HC, Wang HJ, Shen LK, Chen YY. (2005) Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II scoring system in predicting acute pancreatitis outcome. World J Gastroenterol; 11(38):6049-52.

3) Chatzicostas C, Roussomoustakaki M, Vardas E, Romanos J, Kouroumalis EA. (2003) 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; 36(3):253-60.

4) Lautz TB, Turkel G, Radhakrishnan J, Wyers M, Chin AC. (2012) Utility of the computed tomography severity index (Balthazar score) in children with acute pancreatitis. J Pediatr Surg; 47(6):1185-91.

5) Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A, Whitcomb DC. (2010) Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol; 105(2):435-41.