ORIGINAL SCIENTIFIC ARTICLES
Computed Tomography Severity Index Is an Early
Prognostic Tool for Acute Pancreatitis
Patrick W Vriens,
, Pieter van de Linde,
, Eveline T Slotema,
, Piet E Warmerdam,
Paul J Breslau,
Acute pancreatitis is a severe disease with unpredictable course and outcomes. It is especially
hard to identify early those patients who will have a fulminant course. In a prospective obser-
vational study, we tested the hypothesis that the CT Severity Index (CTSI), established within
48 hours after admission, is prognostic for morbidity and mortality and can predict the necessity
for admission to an ICU.
From January 1994 to October 2002, all patients with the diagnosis of first time acute pancre-
atitis underwent spiral CT with intravenous contrast within 48 hours of admission. The extent
of inflammation and necrosis was assessed to define the CTSI. Patients were initially managed
in an ICU in a standardized fashion. Complications and mortality were registered in a system-
Seventy-nine patients were admitted with acute pancreatitis. The overall complication rate was
57%; mortality was 9%. In patients with a CTSI of 0 to 3, these rates were 42% and 2%,
respectively; in those with CTSI of 4 to 6, 81% and 19%, respectively; and in those with CTSI
of 7 to 10, 100% and 33%, respectively. Outcomes of subsequent CT scans did not alter the
initial prognosis. Early CTSI correlated well with the incidence of complications, sepsis, mor-
tality, and necessity for ICU admission.
Acute pancreatitis is associated with marked morbidity and mortality. Initial admission to an
ICU and standardized conservative treatment are justified for all patients. Early establishment
of the CTSI is an excellent prognostic tool for complications and mortality. Patients with a
CTSI of 0 to 3 can safely be discharged from the ICU. (J Am Coll Surg 2005;201:497–502.
© 2005 by the American College of Surgeons)
Acute pancreatitis embodies a large spectrum of disease
that can range from mild edema to severe necrosis of the
pancreas. Its presentation may vary from a mild, self-
limiting abdominal pain, to a fulminant illness that can
rapidly lead to sepsis, multiorgan failure, and death. The
course of the disease is highly unpredictable at the time
of admission. The fate of a patient with acute pancreati-
tis depends greatly on early recognition of the severity of
the disease. But it is hard to identify in an early phase
those patients that will have an adverse course. Initial
clinical presentation, laboratory findings, and scoring
systems such as the Ranson Criteria
and the Acute Phys-
iology and Chronic Health Evaluation (APACHE) II
might help to differentiate mild versus severe pancreati-
tis within 48 hours of hospital admission, but they do
not accurately predict the prognosis of patients with
Apart from the time period neces-
sary to establish the score, these scoring systems are im-
practical for routine clinical use.
The value of additional radiologic investigations in
the early phase is subject of discussion. The Computed
Tomography Severity Index (CTSI), as proposed by Bal-
thazar and colleagues,
quantifies, in a well-defined scor-
ing system, the extent of inflammation of the pancreas
and the amount of necrosis, which could be important
factors in predicting the clinical outcomes of acute pan-
The full extent of pancreatic necrosis, however,
develops within 96 hours after the onset of the disease.
This could be an argument to perform CT scanning
only in selected patients 4 to 5 days after the onset of
Competing Interests Declared: None.
Abstract presented at the 4th European Congress of the International Hepato-
Pancreatico-Biliary Association, Amsterdam, The Netherlands, May, 2002.
Received August 12, 2004; Revised May 19, 2005; Accepted June 1, 2005.
From the Departments of Surgery (Vriens, van de Linde, Slotema, Breslau)
and Radiology (Warmerdam), Rode Kruis Ziekenhuis, The Hague, The
Correspondence address: Patrick W Vriens, MD, PhD, Sint Elisabeth Ziek-
enhuis, PO Box 90151, 5000 LC Tilburg, The Netherlands.
© 2005 by the American College of Surgeons ISSN 1072-7515/05/$30.00
Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2005.06.269