# Balthazar CTSI — Balthazar grade and original CT Severity Index for acute pancreatitis

> Combines Balthazar morphologic grade A-E (0-4 points) with the extent of nonenhancing pancreatic necrosis on contrast-enhanced CT (0, 2, 4 or 6 points) into an original CTSI total of 0-10.

**Situação:** vigente · **Órgão:** Pâncreas · **Órgão emissor:** Balthazar et al. / Radiology · **Versão:** 1990 · **Ano:** 1990

## Procedência e vigência
- Família: léxico
- Tipo de lógica: score
- Modalidade: CT
- Fonte primária: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641
- Última verificação: 2026-07-24
- Última checagem: 2026-07-24

## Lógica de decisão
Calculate the original 1990 CTSI only: preserve both components, their points and the exact 0-10 total. Keep modified CTSI and Revised Atlanta severity explicitly separate.

## Categorias

| Código | Rótulo | Critérios | Conduta | Risco | Localizador | Verificado |
| --- | --- | --- | --- | --- | --- | --- |
| A | Balthazar grade A, 0 morphologic points | Balthazar morphologic grade A: normal pancreas and no peripancreatic inflammatory abnormality on CT; contributes 0 morphologic points to the original CTSI. | This component does not prescribe treatment. Combine its 0 points with the necrosis component, report the exact CTSI total, and use the result as one prognostic imaging input alongside the patient's clinical status. | Grade A contributes the minimum morphologic burden, but grade A alone is not a mortality or complication estimate because the total CTSI also depends on pancreatic necrosis. | Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: normal pancreas=0 points; PMID 2296641. | ✓ |
| B | Balthazar grade B, 1 morphologic point | Balthazar morphologic grade B: focal or diffuse enlargement of the pancreas, contributing 1 morphologic point to the original CTSI. | This component does not prescribe treatment. Combine its 1 point with the necrosis component, report the exact CTSI total, and use the result as one prognostic imaging input alongside the patient's clinical status. | Grade B contributes 1 point to CT severity, but it is not a standalone outcome-risk estimate; overall risk depends on the complete CTSI and clinical course. | Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: focal or diffuse enlargement=1 point; PMID 2296641. | ✓ |
| C | Balthazar grade C, 2 morphologic points | Balthazar morphologic grade C: intrinsic pancreatic abnormality with inflammatory change in the peripancreatic fat, contributing 2 morphologic points to the original CTSI. | This component does not prescribe treatment. Combine its 2 points with the necrosis component, report the exact CTSI total, and separately describe the current morphology and clinical severity. | Grade C contributes 2 points to CT severity, but it is not a standalone outcome-risk estimate; overall risk depends on the complete CTSI and clinical course. | Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: pancreatic abnormality plus peripancreatic inflammation=2 points; PMID 2296641. | ✓ |
| D | Balthazar grade D, 3 morphologic points | Balthazar morphologic grade D: one ill-defined peripancreatic fluid collection or phlegmon in the original terminology, contributing 3 morphologic points to the original CTSI. | This component does not prescribe treatment. Combine its 3 points with the necrosis component and describe the collection using current acute-pancreatitis morphology and timing rather than relying on the historical term alone. | Grade D contributes 3 points to CT severity, but it is not a standalone outcome-risk estimate; the complete CTSI and clinical course determine prognostic context. | Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: single ill-defined collection or phlegmon=3 points; Revised Atlanta consensus, Gut 2013, section on pancreatic/peripancreatic collections, for current terminology. | ✓ |
| E | Balthazar grade E, 4 morphologic points | Balthazar morphologic grade E: two or more poorly defined peripancreatic fluid collections, or gas in or adjacent to the pancreas, contributing 4 morphologic points to the original CTSI. | This component does not prescribe treatment. Combine its 4 points with the necrosis component; explicitly describe collections, necrotic content and gas because those findings require clinical interpretation beyond the historical grade. | Grade E contributes the maximum 4 morphologic points, but it is not a standalone outcome-risk estimate; the complete CTSI and clinical course determine prognostic context. | Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: multiple collections or gas=4 points; Revised Atlanta consensus, Gut 2013, infected-necrosis and collection definitions. | ✓ |
| N0 | No pancreatic necrosis, 0 necrosis points | No pancreatic parenchymal necrosis on an adequately enhanced contrast CT; the pancreatic gland enhances and the necrosis component contributes 0 points. | Add 0 necrosis points to the morphologic points. Absence of visible necrosis does not itself determine disposition or treatment, particularly when examination timing or contrast enhancement is suboptimal. | In the original cohort, patients without necrosis had markedly lower morbidity and no deaths, but this historical cohort result is not an individual prediction. | Balthazar et al. 1990, PMID 2296641 abstract: necrosis was defined by lack of gland enhancement; patients without necrosis had 6% morbidity and 0% mortality. Original CTSI table assigns 0 points for no necrosis. | ✓ |
| N<30 | Pancreatic necrosis below 30%, 2 necrosis points | More than 0% but less than 30% of the pancreatic parenchyma lacks enhancement on contrast CT; contributes 2 necrosis points to the original CTSI. | Add 2 necrosis points to the morphologic points and report the estimated percentage category. The component quantifies prognostic imaging burden and does not by itself mandate an intervention. | Any pancreatic necrosis increases concern compared with no necrosis, but this component must be interpreted through the total CTSI and the patient's evolving clinical status. | Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: below 30%=2 points; PMID 2296641 abstract defines necrosis by lack of enhancement and evaluates extent. | ✓ |
| N30-50 | Pancreatic necrosis 30-50%, 4 necrosis points | From 30% through 50% of the pancreatic parenchyma lacks enhancement on contrast CT; contributes 4 necrosis points to the original CTSI. | Add 4 necrosis points to the morphologic points and report the estimated percentage category. The component quantifies prognostic imaging burden and does not by itself mandate an intervention. | The original study associated more than 30% necrosis with serious complications, but the percentage remains one component of a broader clinical assessment. | Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: 30-50%=4 points; PMID 2296641 abstract states serious complications occurred when more than 30% necrosis was present or developed. | ✓ |
| N>50 | Pancreatic necrosis above 50%, 6 necrosis points | More than 50% of the pancreatic parenchyma lacks enhancement on contrast CT; contributes the maximum 6 necrosis points to the original CTSI. | Add 6 necrosis points to the morphologic points and report the estimated percentage category. The component indicates substantial imaging severity but does not itself specify treatment. | This is the highest necrosis-point category and contributes strongly to a high CTSI; individual prognosis still depends on organ failure, infection and the clinical course. | Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: greater than 50%=6 points; PMID 2296641 abstract describes the prognostic impact of pancreatic necrosis. | ✓ |
| CTSI-0-3 | Original CTSI total 0-3, lower CT severity band | Original CTSI total from 0 through 3 after adding Balthazar morphologic points and pancreatic-necrosis points; lower CT severity band. | Use the exact total as a prognostic imaging input, not as a treatment algorithm. A lower CTSI does not override organ failure, infection, worsening symptoms or other clinical indicators. | The original study's low-index group had 2% morbidity and no deaths; these cohort figures provide historical context and are not calibrated patient-specific probabilities. | Balthazar et al. 1990, PMID 2296641 abstract: low CT severity index group had 2% morbidity and no mortality; original CTSI total combines morphologic and necrosis points. | ✓ |
| CTSI-4-6 | Original CTSI total 4-6, intermediate CT severity band | Original CTSI total from 4 through 6 after adding Balthazar morphologic points and pancreatic-necrosis points; intermediate CT severity band. | Use the exact total as a prognostic imaging input, not as a treatment algorithm. Clinical severity and management require assessment of organ failure, complications, infection and trajectory. | This intermediate band lies between the low and high CT-burden groups; the original abstract does not provide a separate patient-level probability for every score in this range. | Balthazar et al. 1990, Radiology 174:331-336, original 0-10 CTSI construction and prognostic stratification; PMID 2296641. | ✓ |
| CTSI-7-10 | Original CTSI total 7-10, high CT severity band | Original CTSI total from 7 through 10 after adding Balthazar morphologic points and pancreatic-necrosis points; high CT severity band. | Use the exact total as a high-burden prognostic imaging input, not as a treatment algorithm. Escalation decisions require the patient's organ failure, infection, complications and overall clinical course. | The original study's high-index group had 92% morbidity and 17% mortality; these historical cohort figures are context rather than individualized probabilities. | Balthazar et al. 1990, PMID 2296641 abstract: high CT severity index group had 92% morbidity and 17% mortality; original CTSI total combines morphologic and necrosis points. | ✓ |

### Citações por categoria
- **A**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: normal pancreas=0 points; PMID 2296641.
- **B**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: focal or diffuse enlargement=1 point; PMID 2296641.
- **C**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: pancreatic abnormality plus peripancreatic inflammation=2 points; PMID 2296641.
- **D**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: single ill-defined collection or phlegmon=3 points; Revised Atlanta consensus, Gut 2013, section on pancreatic/peripancreatic collections, for current terminology.
- **E**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original CTSI morphologic component: multiple collections or gas=4 points; Revised Atlanta consensus, Gut 2013, infected-necrosis and collection definitions.
- **N0**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, PMID 2296641 abstract: necrosis was defined by lack of gland enhancement; patients without necrosis had 6% morbidity and 0% mortality. Original CTSI table assigns 0 points for no necrosis.
- **N<30**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: below 30%=2 points; PMID 2296641 abstract defines necrosis by lack of enhancement and evaluates extent.
- **N30-50**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: 30-50%=4 points; PMID 2296641 abstract states serious complications occurred when more than 30% necrosis was present or developed.
- **N>50**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original necrosis component: greater than 50%=6 points; PMID 2296641 abstract describes the prognostic impact of pancreatic necrosis.
- **CTSI-0-3**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, PMID 2296641 abstract: low CT severity index group had 2% morbidity and no mortality; original CTSI total combines morphologic and necrosis points.
- **CTSI-4-6**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, Radiology 174:331-336, original 0-10 CTSI construction and prognostic stratification; PMID 2296641.
- **CTSI-7-10**: Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis (1990) — https://doi.org/10.1148/radiology.174.2.2296641 · Balthazar et al. 1990, PMID 2296641 abstract: high CT severity index group had 92% morbidity and 17% mortality; original CTSI total combines morphologic and necrosis points.

## Referências cruzadas
- _fronteira compartilhada_ → [Revised Atlanta — Revised Atlanta classification of acute pancreatitis](https://radcommons.laudos.ai/systems/atlanta-pancreatitis.md) — Balthazar CTSI is a 0-10 imaging prognostic index. Revised Atlanta uses organ failure and local/systemic complications for current clinical severity; identical words such as mild or severe do not make the systems interchangeable.

## Histórico de versões

| Data | Evento | Detalhe | Situação |
| --- | --- | --- | --- |
| 2002-06-01 | revised | CT Severity Index for acute pancreatitis described. | confirmed |
| 1990-02-01 | published | Original CT Severity Index for acute pancreatitis published. | confirmed |


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> Conteúdo de referência reescrito. Confira a publicação primária vigente. Não é dispositivo médico nem substitui o julgamento clínico. O radiologista responsável pelo laudo permanece o autor e o responsável.

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