Use Of The Child Pugh Score In Liver Disease


Article Author:
Andrea Tsoris


Article Editor:
Clinton Marlar


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
5/28/2019 10:41:59 AM

Definition/Introduction

The Child-Pugh scoring system (also known as the Child-Pugh-Turcotte score) was designed to predict mortality in patients with cirrhosis.  Originally conceptualized by Child and Turcotte in 1964 to guide the selection of patients who would benefit from elective surgery for portal decompression, it broke down patients into three categories: A - good hepatic function, B - moderately impaired hepatic function, and C - advanced hepatic dysfunction.  Their original scoring system used 5 clinical and laboratory criteria to categorize patients: serum bilirubin, serum albumin, ascites, neurological disorder, and clinical nutrition status.[1]  The scoring system was modified later by Pugh et al. substituting prothrombin time for clinical nutrition status.  Additionally, they introduced variable points for each criterion based on increasing severity [2]

  • Encephalopathy: None = 1 point, Grade 1 and 2 = 2 points, Grade 3 and 4 = 3 points
  • Ascites:  None = 1 point, slight = 2 points, moderate = 3 points
  • Bilirubin: under 2 mg/ml = 1 point, 2 to 3 mg/ml = 2 points, over 3 mg/ml = 3 points
  • Albumin: greater than 3.5mg/ml = 1 point, 2.8 to 3.5mg/ml = 2 points, less than 2.8mg/ml = 3 points
  • Prothrombin Time* (sec prolonged): less than 4 sec = 1 point, 4 to 6 sec = 2 points, over 6 sec = 3 points

*Frequently INR will be used as a substitute for PT, with INR under 1.7 = 1 point, INR 1.7 to 2.2 = 2 points, INR above 2.2 = 3 points

The severity of cirrhosis: primary

  • Child-Pugh A: 5 to 6 points
  • Child-Pugh B: 7 to 9 points
  • Child-Pugh C: 10 to 15 points

Issues of Concern

Historically the Child-Pugh classification was used for liver transplant allocations.  However, there were three primary limitations to its use:  1) grading ascites and encephalopathy require a subjective assessment, 2) the classification system does not account for renal function, and 3) there are only ten different scores (based on points) available.  This last limitation was significant because patients were not able to be adequately differentiated based on the severity of disease and therefore wait time had a considerable impact on prioritization.[3]  Practically speaking, a patient with an INR of 6 and bilirubin of 14 could potentially have the same Child-Pugh score as a patient with an INR of 2.3 and bilirubin of 4.0.  The MELD score, which has a wider range of more continuous variable values, was created to account for these differences.  The original MELD score was calculated using the patient's bilirubin level, creatinine level, INR, and cause of liver disease.[4]  Since then, it has evolved to exclude causes of disease and takes into account the serum sodium level and whether the patient is on dialysis.

Clinical Significance

The Child-Pugh score has been validated not only as a predictor of postoperative mortality after portocaval shunt surgery but also predicts mortality risk associated with other major operations.  After abdominal surgery, Child class A patients have a 10% mortality rate; Child class B patients have a 30% mortality rate, and Child class C patients have a 70 to 80% mortality rate[5][6] Child class A patients are generally considered safe candidates for elective surgery.  Child class B patients can proceed with surgery after medical optimization but still have increased risk.  Elective surgery is contraindicated in Child class C patients.  The Child-Pugh score can help predict all-cause mortality risk and development of other complications from liver dysfunction, such as variceal bleeding, as well.   In one study, overall mortality for these patients at 1 year was 0% for Child class A, 20% for Child class B, and 55% for Child class C.[7]


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Use Of The Child Pugh Score In Liver Disease - Questions

Take a quiz of the questions on this article.

Take Quiz
A 65-year-old male with a history of alcoholic liver disease is brought to the emergency department for altered mental status. He is immediately intubated for GCS less than 8. The family is concerned about his prognosis. Which of the following statements is most accurate regarding the Child-Pugh scoring system?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 68-year-old man presents to the emergency department with hematemesis. He does not regularly see a doctor and drinks 1 liter of vodka daily. On exam, he has a slight hand tremor. He has a large abdomen with a fluid wave. His INR is 2.0, total bilirubin is 2.0 mg/dL, and albumin is 3.0 g/dL. Which of the following most accurately describes his estimated mortality after abdominal surgery?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 56-year-old is admitted to the hospital with bleeding rectal varices. She is on the liver transplant list with a MELD score of 30 with a 3-month predicted mortality of 52.6%. Her Child-Pugh score is 8, making her a Child B with a 1-year mortality of 20%. Which of the following, if present, best explains the difference in mortality predicted by the two scoring systems?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Use Of The Child Pugh Score In Liver Disease - References

References

Child CG,Turcotte JG, Surgery and portal hypertension. Major problems in clinical surgery. 1964;     [PubMed]
Pugh RN,Murray-Lyon IM,Dawson JL,Pietroni MC,Williams R, Transection of the oesophagus for bleeding oesophageal varices. The British journal of surgery. 1973 Aug;     [PubMed]
Cholongitas E,Burroughs AK, The evolution in the prioritization for liver transplantation. Annals of gastroenterology. 2012;     [PubMed]
Malinchoc M,Kamath PS,Gordon FD,Peine CJ,Rank J,ter Borg PC, A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology (Baltimore, Md.). 2000 Apr;     [PubMed]
Mansour A,Watson W,Shayani V,Pickleman J, Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery. 1997 Oct;     [PubMed]
Garrison RN,Cryer HM,Howard DA,Polk HC Jr, Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis. Annals of surgery. 1984 Jun;     [PubMed]
Infante-Rivard C,Esnaola S,Villeneuve JP, Clinical and statistical validity of conventional prognostic factors in predicting short-term survival among cirrhotics. Hepatology (Baltimore, Md.). 1987 Jul-Aug;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of PA-Hospital Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for PA-Hospital Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in PA-Hospital Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of PA-Hospital Medicine. When it is time for the PA-Hospital Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study PA-Hospital Medicine.