Balthazar score

Last revised by Jeremy Jones on 20 Sep 2021

The Balthazar score is a subscore within the CT severity index (CTSI) for grading of acute pancreatitis

The CTSI sums two scores:

  • Balthazar score: grading of pancreatitis (A-E)
  • grading the extent of pancreatic necrosis

The Balthazar score was originally used alone, but the addition of a score for pancreatic necrosis improved correlation with clinical severity scores.

The CTSI has since been updated to the modified CTSI (2004).


Grading of pancreatitis (Balthazar score)
  • A: normal pancreas: 0
  • B: enlargement of pancreas: 1
  • C: inflammatory changes in pancreas and peripancreatic fat: 2
  • D: ill-defined single peripancreatic fluid collection: 3
  • E: two or more poorly defined peripancreatic fluid collections: 4
Pancreatic necrosis 
  • none: 0
  • ≤30%: 2
  • >30-50%: 4
  • >50%: 6

The maximum score that can be obtained is 10.

Stratification of pancreatitis severity
  • mild pancreatitis (interstitial pancreatitis): Balthazar B or C, without pancreatic or extrapancreatic necrosis
  • intermediate (exudative pancreatitis): Balthazar D or E, without pancreatic necrosis; peripancreatic collections are due to extrapancreatic necrosis
  • severe pancreatitis (necrotizing): necrosis of the pancreas (non-enhancing areas in the pancreas on contrast-enhanced CT)

Treatment and prognosis

There is good correlation of clinical pancreatitis scores and current CT pancreatitis severity scores (such as the CTSI and modified CTSI) so imaging is not always necessary to assess the severity of pancreatitis 3.

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Cases and figures

  • Case 1: Balthazar E
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  • Case 2: Balthazar E
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  • Case 3: Balthazar C
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  • Case 4: Balthazar E
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