Use of Modified Balthazar Grades for the Early Prediction of Acute Pancreatitis Severity in the Emergency Department

Abstract

Objective: To develop a new approach based on Balthazar grades of acute pancreatitis (AP) and to assess this modified method as a tool for the early prediction of AP severity in the emergency department (ED). Methods: Data pertaining to AP patients ≥18 years old that had undergone computed tomography (CT) scanning within 24 h following ED admission between January 1, 2017 and September 30, 2017 were retrospectively analyzed. Patients were separated into two groups based on the length of time between the onset of their AP symptoms and the completion of CT scanning (Group 1: <72 h; Group 2: ≥72 h). Modified Balthazar grades for these patients were then assessed, with the concordance between these modified grades and the 2012 revised Atlanta classification being assessed using the Kappa (κ) statistic. The modified grade with the largest κ value was evaluated based on performance traits including Harrell’s concordance index (C-index), area under the receiver operating characteristic curve (AUC) analyses, calibration curves, and decision curve analyses (DCA) in comparison with bedside index for severity in AP (BISAP) scores. Results: In total, 372 patients were included in the present analysis. These patients were regraded according to six methods, with the method yielding the largest κ value consisting of regraded Balthazar grades A–C, D, and E, respectively, corresponding to mild, moderate, and severe AP. The κ values for this method were 0.786 (95% CI, 0.706–0.853) in Group 1 and 0.907 (95% CI, 0.842–0.955) in Group 2, exhibiting nearly complete agreement with the latest Atlanta classification of AP. AUROC values for these modified Balthazar grades when used to predict SAP were significantly higher than those for BISAP scores in Group 1, Group 2, and the overall cohort (P < 0.05). The DCA curves for Group 1, Group 2, and the overall patient cohort exhibited substantial net benefits when using these modified grades across a range of POFs relative to BISAP scores. The calibration curve for this modified approach to predicting POF in AP patients revealed good agreement in this cohort. Conclusion: Modified Balthazar grades exhibited substantial to near-total agreement with the 2012 revised Atlanta classification of AP patients, and this modified method can thus be used for the early prediction of AP severity in the ED.