58269831 Balthazar Scale Pancreatitis

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76 7

.4, Emi l J . B aithazar , M .D .

John H .C Ranson , BM ., B .C h .

D av id P . N a id ich , M .D .

A lec J . M egibow , M .D .

I’ R obert C accava le , M .D .

M atth ew M . C ooper , M .D .

Acu te P anc rea titis : P rognos tic Va lu e

o f C T1

In 83 patien ts w ith a cu te pancreatitis , th e

in itia l com pu ted tom og raph ic (C T ) ex -

A am ination s w ere c lassif ied by degree o fd isease sev erity (g rades A -E ) an d w ere

correla ted w ith th e c lin ica l fo llow -up ,

ob jective p rognostic signs , and com p lica -

. tion s and dea th . Th e leng th o f ho sp ita l-

iza tion corre la ted w ell w ith th e severity

o f th e in itia l CT find ing s. Ab scesses oc -

.4 curred in 21 .6% of th e en tire g roup , com -

pared w ith 60 .0% of grade E patien ts.

P leu ra l e ffu sion s w ere a lso m ore comm on

in g rade E pa tien ts . G rades A and B pa-

, tien ts d id no t hav e ab sces ses , and none

d ied , rega rd les s o f th e n um ber o f p rog -

F no stic sign s. A bscesse s w ere seen in 8 0 .0%

I ‘ of pa tien ts w ith six to e ig h t p rog nostics igns, com pared w ith 1 2 .5% of th ose w ith

zero to tw o. T he u se o f p rogno stic sign s

w ith in it ia l CT find ings resu lts in im -

prov ed prognostic accuracy . E a r ly C T ex-

am ination of pa tien ts w ith a cu te pancrea-

titis is a usefu l p rog nos tic in d icato r o f

m o rb id ity and m orta lity .

‘ In dex te rm s : Pancre as, com pu ted tom og rap hy ,

77.1211 #{149}an cre atit is , 7 7 .2 91

R ad io logy 1985; 156:767-772

F rom th e D ep artm ents of R adio log y (E .J.B ., D .P .N .,

A .J.M .) and Su rge ry (J .H .C .R ., R .C ., M .M .C .), N ew

Y ork U niv ers ity M ed ica l C en ter , B elle vue H o spita l

M ed ica l C enter, N ew Y ork C ity . R ec eiv ed Jan uary 10 ,

19 85; acc ep ted an d rev ision reque ste d M arch 18 , 198 5;

re v is ion rece ived A pr il 3 . 1 985 .c RSNA , 1985

T HE degree , du ra tion , and typ e of trea tm en t o f acu te pancrea titis

a re based on the early eva lua tion of the in itial a ttack ’s severity .

U n til recen tly , th is eva lua tion re lied m ain ly o n the p resence on

absence o f varied c lin ica l pa ram eters such as tachycard ia , fever,

d ysp nea , o ligun ia , p ro trac ted ileus , and ten se abdom en . S evera l

m ethods of a m ore ob jec tive eva lua tio n have been rep orted (1 -7 )

tha t po ten tia lly im prov e prog nostic ab ility an d pred ic tion of com -

p lica tion s. A m ong them , the s ta tis tica l ana ly sis o f ea rly ob jec tive

m easu rem en ts o f m ultip le risk fac to rs , descr ib ed by R anson (2 , 3 ),

has rece iv ed w id e a tten tion and h as been consid ered a re liab le

p ro gnos tic in d ica to r o f the d iseases ’s severity . T h ese ob jec tive p rog-

no stic s igns (g rav e signs o r risk fac to rs ) h ave sign if ican tly im -

pro ved the in itia l assessm en t based on c lin ica l c rite ria a lone an d are

used as gu ide lin es in the d ecis io n -m ak ing pro cess o f se lec tin g

pro per m ed ica l o r su rg ica l trea tm en t in ou r ins titu tion .

S in ce m o rb id ity and m o rtality depen d in g rea t m easu re o n the

loca l pancrea tic an d p en ip ancreatic com plications (i.e., abscess,

pseudocys t, hem orrhag e) , com puted tom ograph ic (CT ) exam ina-

tion cou ld p lay an im portan t ro le in the in itia l assessm en t o f the

severity o f acu te p an cneatitis. Fo r th is reaso n , in the past 4 years w e

have em barked on a com p rehens iv e stud y designed to assess the

pro gnos tic va lue of the in itia l CT exam ina tion in pa tien ts w ith

acu te pancrea titis. O ur o b jec tives are (a ) to desc ribe , c lassify , an d

analyze the early CT find in gs in acu te pancrea titis ; and (b ) to assess

the ir p red ic tive va lue based on co rre lation of ear ly CT find ings

w ith c lin ica l and o b jective pro gnos tic sign s.

M ATERIALS AND M ETHODS

O ur stu dy is ba sed o n a de tailed analysis o f CT , c lin ica l, and lab ora to ry

find ings of 83 p atie n ts w ith acu te pan cre ati tis adm itte d to o ur inst itu t ion in

th e p ast 4 ye ars . T here w e re 63 m en and 20 wom en , aged 17-7 9 years , w ith a

m ean age of 4 5 years. The c lin ical d ia gno sis w as based on ty p ic al sym ptom s

su ch a s nau sea , vom itin g , abd om ina l pa in , a nd eleva tion o f serum am y lase

le vels abo ve 200 Som ogy i un its. T he etio log y o f pancreati tis w a s ch ron ic

a lco hol ab use in 51 p atie n ts , ch o le lith ias is in 11 , ga llstone s and a lco hol in

fiv e, hyp erl ip id em ia in tw o, an d m isc ella neo us o r u nknow n in 1 4 . T he re

w ere no case s o f traum atic p anc rea titis inc lud ed in th is series.

W e used the prev io usly repor ted o bje ctiv e p rog nos tic sig ns (2 , 3 , 6 , 7 ),

lis ted in Table 1 , to assess th e sever ity of the attack an d its po ssib le com p li-

ca tio ns. A ll pat ien ts w e re in i tia l ly treated by nasog astr ic su ctio n , in trav e-

no us f lu id , and su ppo rtiv e th erapy . W e drain ed in fected flu id co lle ctio ns

(absc esses) in 1 8 p atien ts (21 .7% ), som e upon in itia l e valuat ion and others a s

com p lic atio ns dev elo ped . T he clin ic al co urse , com plica tion s, tre atm ent ,

an d re spo nse to trea tm ent w ere record ed for al l ind iv id uals, un t il d ea th o r

d isch arg e from th e ho sp ita l.

CT exam inations w ere p erfo rm ed on a G E 8800 sc ann er (M ilw auk ee )

us ing stand ard te chn ica l p aram e ters . D ilu te d 2% barium sulfa te (E -Z -CA T ,

E -Z -EM , W estb ury , N .Y .) w as used as o ral c on tras t m a teria l, and a rap id

in trav eno us d rip in fus ion o f 30% d iatr izo ate m eg lum ine (R eno-M -D IP

[S qu ibb ]) w as sta rted im m ediate ly b efo re scan nin g u nle ss con tra ind icated .

B olus in je ctions w e re n ot used in th is stu dy .

A to ta l o f 152 C T scan s w e re ob tain ed , e ithe r a s a sin g le exam in atio n o r as

co nse cu tive , fo llow -up ex am ina tion s ap pro x im ate ly every 2 w eeks. Th e



1 . CT scan o f no rm al pancreas in pa tie n t w ith clin ica l pan -

c reat itis (g rade A ) .

2. D iffuse en largem en t o f th e pancreas w itho u t per ipan -

c reat ic in flam m a tory chan ge s (grade B ).

3 . E nla rged p an cre as associate d w ith h azines s and in -

c rea sed densi ty o f per ipancre atic fa t (g rade C) . No te

p resenc e of d iffu se fatty in f iltra tio n o f l ive r.

I

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8.

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A

RESULTS

O f the 83 p a tien ts su rvey ed , 6 3 m e-

covered w ith m ed ica l trea tm en t a lone

and w ere d ischarged , w hile 18 p a-

tie n ts (21 .7% ) becam e sep tic and m e-

Figures 1, 2, a nd 3

76 8 #{149}ad io logy S ep tem ber 1 985

in it ia l ex am ina tion s w ere pe rform ed

w ith in the first 3 h osp ita l d ay s in 40 pa -

tie n ts an d b etw een day 4 and 10 in 43 pa -

tie n ts. In gen era l, se ve rely il l pa tien ts m e -

ceived p rio rity fo r CT examination ,

m akin g th is sam ple un rep resen tative of

all p atie n ts w ith acu te pan cre atit is a d-

m it ted to o ur in sti tu tion .CT scan s w ere in terp rete d w ith out p rio r

know ledg e of c lin ical f ind ing s or ob jec -

tive pro gn ost ic signs . Th e fo l low ing con -

d it ion s w e re spe cif ica lly lo ok ed fo r and

reco rded : p resenc e of fat ty live r, g allb lad -

den pa tho log y , p eri ton eal effu sio n , a nd

pleu ral ef fus ion s.

In add itio n , w e cla ssif ied the type of

pan cre atic in flamm ation se en on CT scans

in to five ca teg orie s. Th is cla ssifica tio n w as

based on an overall a sse ssm en t o f siz e ,

con tou r, a nd d ens ity of the g land and per -

ipan cre atic abn orm ali ties . S pe cific m ea -

surem ents w e re n ot used in th is as sess -

m en t. W e u sed th e fo llow in g grades ,

w hich are s im ilar to tho se rep orte d in the

lite ratu re (8 ): g rad e A , n orm al pan cre as

(F ig . 1 ); g rade B , foc al o r d iffuse en large-

m en t of the pancreas (F ig . 2 ) (in clu d in g

con tou r irregu lar itie s, no nhom ogeneo us

attenu atio n of the g lan d , d ila ta t ion o f the

pan cre atic du ct, an d fo ci of sm a ll flu id co l-

le ctions w ith in the g lan d , as lo ng a s the re

w as no ev idence of p eripan cre atic d is-

ease ); g rade C, in trin sic p anc rea tic abn or-

m alitie s as soc iate d w ith haz ine ss and

streak y den sit ies re pre sen tin g inflam m a -

to ry change s in th e pe rip anc rea tic fat (F ig .

3); grad e D , sin g le , i ll-d efin ed flu id co lle c-

tion (p h legm on ) (F ig . 4 ) ; g rade E , tw o o r

m ultip le , poo rly def ined flu id co llec tio ns

2.

(F ig . 5 ) o r presen ce of gas in or ad ja cen t to

the pancrea s (Fig. 6).

quired su rg ic al d ra inag e of abscesses .

O n e pa tien t un derw en t su rgery to m e-

m ove a persis ten t pseudo cy st. F ive

pa tien ts w ith abscesses d ied , and on e

oth er p atien t d ied o f h ep a tic and

ren al fa ilu re w ith ou t ev id en ce of pan -

creatic ab scess . T he re la tio nsh ip of

the ob jec tive prognos tic signs to the

clin ica l c ou rse is show n in T ab le 2 .

4

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A



Figure 4

V olum e 156 N um ber 3 Radio logy #{149}69

a. b.

CT scan of en la rged body and ta il o f the pan creas (a ) w ith assoc ia ted flu id co llection in left an te rio r para rena l space (b ) (a rrow s) (g rade D ).

r Figure 5

a. b.

CT scan show ing la rge flu id co llec tions in the lesser sac and an ter io r pa rarena l sp ace in p atie n t w ith g rad e E pancreati tis . N ote com p res sion

. w ith par tia l ob stru ction o f th e du odenum and sligh t th icken in g of ga llb ladd er w all (a rrow s) .

Seco nda ry C T F ind in gs

Second ary C T find ing s tha t m ay

corre la te w ith th e severity o f acu te

pancrea titis w ere record ed . W e ob-

se rved fa tty in filtration of the live r in

21 p atien ts (25 .3% ) (F ig . 3 ) f rom all

five g rades of pancrea titis. G a llstones

w ere seen on CT scans in 1 2 p atien ts

(14 .5% ), bu t w ere m issed in a num ber

of o ther pa tien ts w ho pro ved to have

ch o le lith iasis on sonognam s o r during

su rg ical exp lo ration . W e observed

ga llb ladd en s w ith th ick ened w alls in

five pa tien ts , none of w hom had ga ll-

ston e pancreatitis (F ig . 5 ). S ix p atien ts

(7 .2% ) had fre e flu id in the pem ito ne al

cav ity , five w ith grade D or E pancrea -

titis. W e d e tec ted p leu ra l e ffusion s in

27 p atien ts (32 .5% ). E ffu sions w ere

presen t in 41% o f the 12 pa tien ts w ith

grade D and 65% o f th e 23 p atien ts

w ith grade E pan crea titis . B ila te ra l e f-

fus io ns w ere seen in 22% o f p atien ts

w ith grade E pan crea titis .

In our m o rpho log ic eva lua tion , w e

no ted a d iffuse inv o lvem ent o f the

pancreas in 68 of 83 cases and a seg-

m en ta l d istribu tion in the rem ain ing

15 cases (18 .1% ). In n ine pa tien ts



.

a. CT scan sh ow ing increased den sity of the p eripan cre atic retrop eri ton eal fa t associated w ith ex tra lum in al air (arrow ) in p atien t w ith

pem ipancrea tic ab scess .

b . B ila te ra l, ill-de fined , re troperitonea l flu id co llec tions w ith m u ltip le g as bu bb les in pa tie n t w ith absces s (g rad e E ).

r

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Figur e 6

77 0 #{149}adio logy Sep tem ber 1985

(10 .8% ), th e in f lamm atory pro cess in -

vo lved exc lusiv ely or p redom inan tly

the head o f the pancreas (F ig . 7 ) ; in

f iv e, th e b ody and ta il; and in one ,

o n ly th e tail o f the pancreas. Sw elling

o f on ly the head of the pancreas w as

p resen t in th ree of the 1 1 pa tien ts

w ith g allston e p an crea titis (2 7 .3% )

bu t in on ly s ix cases o f a ll o the r types

o f pancrea titis (8 .3% ). Tw o pa tien ts

w ith h is to ries o f p rev ious pan crea titis

h ad p an crea tic d uc ta l ca lcifica tio ns

d em onstra ted o n CT scan s.

T h e p a tien ts w ere d iv ided accord -

ing to th e f iv e grades , an d the m ela -

tionsh ips b etw een d iffe ren t g rades

and the c lin ical course and prognos tic

s igns w ere an a ly zed . T h ere w ere 12

pa tien ts (1 4 .5% ) in grad e A , 19 (22 .9% )

in g rade B , 17 (20 .5% ) in grad e C , 12

(1 4 .5% ) in grad e D , and 23 (2 7 .7% ) in

grade E.

CT and C lin ica l C ourse

The re la tion sh ip be tw een ear ly CT

find in gs and c lin ica l course is sum -

m anized in T ab le 3 . T he av erag e n um -

ben of fas ting d ay s (n o th ing by

m ou th ) and days in th e ho sp ita l com e-la ted rough ly w ith the severity o f the

in itial C T find ing s. E xcep tio ns to the

genera l trend , how ever, o ccu rred ,

w ith som e pa tien ts in g rade B requ ir-

ing 4 w eeks of hosp ita lization and

som e in g rade D requ ir in g less than 2

w eek s of trea tm en t. N o pa tien t w ith

grad e A pancrea titis w as ser io usly ill,

and a ll five p atien ts w ho d ied because

of local com plications (abscesses ) m i-tially h ad grade D or E pancm ea titis.

R e tropem itonea l, ex tra lum ina l a ir

w as seen in four pa tien ts (F ig . 5 ) w ho

a ll p rov ed a t su rg ery to have in fected

abscesses . In th ree cases , g as bu bb les

w ere de tec ted on C T scan s in p atien ts

with on ly one to th ree prog nos tic

s igns w ith in the f ir st 2 4 hours o f hos-

pitalization.

F lu id co llec tion s w ere in itia lly seen

in 35 pa tien ts in g rades D and E (o r

45 .7% of these com bined g rades). F o l-

low -u p C T scan s show ed tha t in 19

pa tien ts (5 4 .3% ), flu id co llec tio ns m e-

so lved w itho u t fu rthe r com plications ,

w h ile in 1 6 pa tien ts (45 .7% ), they d id

n o t and even tua lly b ecam e in fec ted .

F lu id co llec tion s deve loped in on ly

th ree pa tien ts w ho d id no t have them

in itia lly and w ere c lass ified as g rade

C pancrea titis . O ne o f these pa tien ts

ended up w ith a pseudocys t an d tw o

w ith abscesses . In 15 pa tien ts, the in -

fec ted flu id co llec tio ns w ere dra ined

be tw een the 5 th and 50 th day hosp i-

ta lized afte r an average stay o f 25

days .

CT and P rognos tic S igns

The re lation sh ip be tw een early CT

find ings and prognos tic sign s is

sh ow n in T ab le 4 . T he re lationsh ip

be tw een the num ber of p rogn ostic



Figure 7

V olum e 156 Num ber 3 Radio logy . 77 1

s ig ns and grad es of pancrea titis va ries

. w ide ly in pa tien ts w ith zero to five

p rogno stic s igns . A ll pa tien ts w ith

m ore than five prognostic sign s w ere

in grade E ; how ever, a few p atien ts

pa w ith four an d five signs w ere in

grades A and B.

W hen the num ber of pa tien ts w ith

ab scesses o r those tha t d ied w ere ana-

lyzed as a func tio n of com bined CT

fin d ings and prog nos tic s igns (T ab le

5 ), the com plica tion ra te and pro gno-

sis co u ld b e be tte r assessed . T h e num -

., ben of pa tien ts w ith abscesses in

g rades C and D is s ign ifican tly la rger

if the num ber of p rognos tic s igns ish igh er . In add ition , the percen tag e of

d ea ths correla ted w ell w ith the num -

b em of prognostic s igns .

DISCUSS ION

The rad io log ic fea tu res and ro le o f

. -. C T scann ing in in itia l d iagn osis o f

acu te pancrea titis an d its com plica -

tions a re w ell es tab lished in the lit-

eratu re (8 -18 ). T he CT appearance of

clin ica l fo rm s o f m ild (edem atou s, in -

te rs titia l) o r severe (necro tiz ing , hem -

om nhag ic ) p an creatitis h as been de-

p scn ibed (8 , 19 , 20). T o our kn ow ledg e ,

how ever, a com p rehensive eva lua-

tion of the prog nos tic va lue o f th e m i-.3 tia l CT exam ina tion based on c lin ica l

fo llow -up , su rg ica l find ings , and con-

S rela tion w ith p rogno stic s igns h as n o t

been perfo rm ed . T h is s tudy a ttem pts

to fill th is gap and estab lish es the va l-

ue of C T scann in g , no t on ly in the

in itia l d iagn osis o f p an crea titis, bu t as

a prog nos tic ind ica to r o f the d isease ’s

sev er ity and its expec ted com plica -

t ions .

Secondary CT F ind ing s

O u r search of the lite ra tu re d id no t

d isclo se a p rev ious assessm en t o f the

secon dary CT find in gs eva lu a ted in

th is study . F a tty in filtra tion of the liv -

en w as seen in 2 1% of our p a tien ts

(F ig . 3 ) and occurred abou t eq ua lly in

pa tien ts w ith m ild , m od era te , o r se-

vene pancrea titis . G a llb lad ders w ith

th ick en ed w alls w ere seen in five

cases (F ig . 5 ), and the s ign ifican ce is

unknow n since the co nd itio n w as

presen t in p atien ts w ithou t c lin ica l

ev idence of cho lecys titis. It m ay m e-

presen t non spec ific edem a assoc ia ted

w ith a lcoho lic live r d isease o r no n-

spec ific in f lamm ation re la ted to pan-

crea titis. P leu ra l e ffu sions w ere la rger

an d m ore comm only seen in pa tien ts

w ith severe p an crea titis. In th is ser ies ,

they w ere presen t in 65% of g rade E

p atien ts and in on ly 1 0% in grades A

and B . B ila te ra l p leu ra l e ffu sions w ere

seen a lm ost ex clus ive ly in grade E pa-

tien ts. T here w as n o corre la tion be-

tw een the severity o f pancrea titis and

its cau se in th is ser ies . F iv e of the 11

cases o f ga lls tone p an creatitis w ere

c lass ified as g rade E , w h ile th e o th er

s ix w ere grad e A , B , o r C .

W h ile acu te pancrea titis is g en eral-

ly con side red a d if fuse d isease , in th is

ser ies a segm enta l fo rm of p an crea ti-

tis w as observed in 18 .1% of the cases.

(F ig . 7 ). Spec ifically , the head of the

pancreas w as en la rged in a la rger p ro -

portion of pa tien ts w ith ga llston e

pancrea titis (27 .3% ), com pared w ith

the pro portion o f th e to ta l se ries

(8 .3%).

CT and C lin ica l C ourse

The su rvey of the s ta tistica l d a ta

p resen ted show s tha t a c lear com re la -

tio n can be es tab lished b etw een the

severity o f pan crea titis , a s de te rm ined

a t the in itia l CT ex am in ation , and the

c lin ica l course . W e no ted a s teady

trend tow ard an in creased averag e

n um ber o f fasting d ay s and days h os-

p ita lized in pa tien ts w ith m ore sev ere

g rades of pancrea titis (T ab le 3 ). F ive

o f s ix dea ths and 88 .8% of a ll ab scesses

o ccurred in pa tien ts in itia lly c lassi-

fied as hav ing grades D and E pan-

c rea titis . N o p atien ts o rig ina lly c lassi-

fied as hav ing grad e A or B p an -

c rea titis had sub sequ en t abscesses . A ll

p atien ts w ith a norm al p ancreas on

C T scan (g rade A ) had a m ild c lin ical

cou rse w ithou t com p lica tions and

w ere d isch arged in less than 2 w eeks .

A lthough the c lin ica l cou rse w as

co nsis ten t w ith the grade of p an crea-

titis, som e grad e A patien ts m ay no t

h av e had pancrea titis a t a ll. T h ere-

fo re , the exac t percen tage of pa tien ts

w ith acu te pancrea titis and a norm al

CT scan is d if ficu lt to assess. T h is per-

cen tage depend s m ain ly on th e sever-

ity o f acu te pancrea titis and the tim e

of the exam ina tion an d shou ld be ex -

pec ted to vary from series to se ries.

CT and Deve lopm en t o f

Abscesses

A strong re la tio nsh ip ex ists b e-

tw een the in itial p resence of pem ipan-

crea tic f lu id co llec tion s (g rades D and

E ) and th e d ev e lo pm ent o f ab scesses.

A bscesses o ccu rred in 1 8 pa tien ts in

th is se ries (2 1 .7% ), bu t they deve loped

in on ly tw o pa tien ts w ith ou t in itia l

flu id c olle ctio ns.

Th e presence of poorly encapsu la t-

ed p em ipancn ea tic flu id co llec tio ns in

patien ts w ith a cu te p anc rea titis



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77 2 . Rad io logy Sep tem ber 1985

sho u ld no t be regarded casua lly . F lu -

id co llec tions reso lved spon tan eo usly

in 54 .3% of pa tien ts w ho had th em but

lingered on an d even tua lly becam e

in fec ted in th e rem ain ing 4 5 .7% . F o l-

low -up CT exam ina tio ns shou ld be

p erfo rm ed in th ese pa tien ts to assess

the presen ce , size , and loca tion of

these co llec tions u n til they reso lve .

P rev ious ly , ex travasated pancrea tic

sec re tio ns and the deve lo pm ent o f

la rge pem ipancrea tic flu id co llec tions

w ere cons id ered an escap e m echa-n ism , lead ing to a b en ef ic ia l decom -

p ress io n of the pancrea tic duc t sy stem

(12). In ou r study , h ow ev er, based o n

sho rt-te rm CT and c lin ica l fo llow -up

ev a lu ation , w e fa iled to de tec t any ad -

van tages of la rge flu id co llec tio ns fo r

th is g rou p of pa tien ts . W hile w e d id

n o t condu ct long -term eva lua tions ,

w e fo und tha t ex travasa ted flu id w as

asso c ia ted w ith a pro trac ted an d se-

vene c lin ica l course . In p atien ts w ith -

o u t such flu id , the cou rse of pancrea -

titis w as m ild or s ig n ifican tly sh orten

an d less com plica ted .

T he d iagno sis o f abscess in m ost o f

our cases w as based on the presence

of a persis ten t f lu id co llec tio n p lu s

seps is u nresp onsiv e to an tib io tic th em -

apy . B ecause of debris and n ecro tic

tis sue , the density o f flu id co llec tions

w as variab le (5 -3 0 H U ) and no t he lp -

fu l in th is d iagnos is. T he ro les o f per-

cu tan eo us asp ira tio n and drainag e of

pancrea tic abscesses have been m e-

ported in th e lite ra tu re (21 , 22 ), b u t

th ese procedu res w ere no t u sed in

th is se ries.

R e tm opem iton eal a ir w as seen in four

patien ts, a ll o f w hom had prov ed ab-

scesses a t su rgery . A s reported in the

lite ra tu re (2 3 , 24 ), flu id co llec tion s

co n ta in in g a ir m ay deve lop seco n-

dam y to en tem ic f is tu las and m ay no t

alw ays in d ica te an ab scess . H ow ever,

th is CT find ing , particu la rly w hen

seen dur in g the in itia l a ttack , stro ng-

ly sugges ts a gas-fo rm ing in fection

an d is ex trem ely va luab le in qu ick ly

iden tify ing th is p o ten tia lly life -

th rea ten ing com p lica tio n . In th ree

pa tien ts , m etropem itonea l a im visu al-

ized on CT scan in th e f ir st 2 4 hou rs

led to a correc t d iagn osis th a t w as no t

suspec ted c lin ica lly . S urgery w as per-fo rm ed w ithou t de lay , and a ll th ree

p atien ts su rv ived .

Prognostic S ign s , CT , and

C lin ica l C ourse

The rela tionsh ip be tw een p rogno s-

tic s igns and severity o f pancrea titis is

docum en ted in T ab le 2 . In fec ted ab-

scesses occurred w ith an increased in -

c idence in pa tien ts w ith sev eral p ro g-

nos tic sign s. A bscesses w ere seen in

80 .0% of pa tien ts w ith s ix to e igh t

sign s, com pared w ith 12 .5% of pa-

tien ts w ith zero to tw o sign s. W e

found tha t using pro gnos tic s igns and

CT fin d ings led to a b e tte r estim ation

of the risk of death in th is se ries. In

g rades A and B p atien ts , n one o f th e

pa tien ts d ied , regard less o f the num -

ben of p rog nos tic s igns , w hich varied

be tw een zero an d five . O n the o th er

hand , the m orta lity o f pa tien ts in itial-

ly c lassified as g rades C , D , on E com e-

la ted w ith the inc reas in g num ber of

p rogn ostic sign s (T ab le 5 ).

W e con clud e tha t in itia l CT ex am i-

n ation in cases o f acu te pancrea titis is

ve ry he lp fu l in estab lish in g on con-

firm ing the c lin ica l d iagnos is, a s w ell

as in dep ic ting assoc ia ted ab nonm ali-tie s. C T can also be used as an ear ly

ind ica to r o f the d isease ’s severity an d

its expec ted m orb id ity and m o rtality .

W e found a good co rre la tion be tw een

the g rades of m ild , m odera te , o r se -

v en e pan crea titis as es tab lished by C T

appearance and the c lin ica l course ,

d ev elo pm ent o f abscesses, and dea th .

T he u se of ob jec tive pro gnos tic s igns

w ith in itia l CT find in gs im prov es the

o rig ina l p rog nos tic es tim ation and

iden tifie s p atien ts in w hom life -

th rea ten ing com plica tio ns m ay deve l-

o p . CT ex am in ations sh ou ld be pen-

fo rm ed in a ll pa tien ts w ith m odera te

o r sev ere c lin ica l fo rm s of pancrea titis

to ev alua te the presence and severity

o f the in itia l a ttack and to assess its

c lin ica l evo lu tion . U

S end co rre spo nd ence and rep rin t req ues ts to :

Em il B altha zar, M .D ., NYU M edic al C enter, B el-

le vue H osp ita l , D epa rtm ent o f R ad io logy , 2 7 th

S tre et and 1 st A venu e, N ew Y ork , N ew Yo rk

10016 .

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Documents

58269831 Balthazar Scale Pancreatitis