What is the Child-Pugh (Child-Pugh score) class for a patient with liver cirrhosis, presenting with moderate ascites, mild encephalopathy, hypoalbuminemia (low albumin), hyperbilirubinemia (elevated bilirubin), and elevated International Normalized Ratio (INR)?

Child-Pugh Classification for Liver Cirrhosis

The patient's clinical and laboratory findings correspond to Child-Pugh Class C.

Calculation of Child-Pugh Score

The Child-Pugh classification system assesses the severity of liver cirrhosis using five parameters. Let's calculate the score for this 42-year-old female patient:

1. Encephalopathy: Mild confusion (Grade I-II) = 2 points 1
2. Ascites: Moderate = 2 points 1
3. Bilirubin: 30 micromol/L (between 34-51 micromol/L range) = 2 points 1
4. Albumin: 30 g/L (between 28-35 g/L range) = 2 points 1
5. INR: 1.9 (>1.5) = 3 points 1

Total score: 11 points

Child-Pugh Classification

According to the British Society of Gastroenterology guidelines:

• Class A: Score of 5-6 points
• Class B: Score of 7-9 points
• Class C: Score of 10-15 points 1

With a total score of 11 points, this patient falls into Child-Pugh Class C.

Clinical Significance

Child-Pugh Class C indicates severe liver dysfunction with significant implications:

• Mortality risk: Patients with Child-Pugh Class C have approximately 50% mortality over one year following variceal hemorrhage 1
• Surgical risk: Perioperative mortality can be as high as 30-50% in Child-Pugh Class B or C patients compared to only 5-10% in Class A 1
• Treatment decisions: The classification guides therapeutic interventions, including candidacy for surgical procedures, TIPS placement, and liver transplantation

Important Considerations

• The Child-Pugh score is widely used due to its simplicity, availability, low cost, and good discriminatory power 2
• For patients with cirrhosis and hepatic encephalopathy, the combination of albumin-bilirubin grade with serum ammonia levels can provide additional diagnostic value 3
• Some studies suggest that including serum creatinine as a sixth parameter can improve the prognostic value of the Child-Pugh classification, particularly for Class B patients 4
• For variceal bleeding risk assessment, Child-Pugh Class C patients have significantly higher mortality (35.6%) compared to Class B (11.7%) 5

Common Pitfalls to Avoid

1. Misclassifying bilirubin levels: Be careful with unit conversions (micromol/L vs. mg/dL)
2. Subjective assessment of encephalopathy: Mild confusion corresponds to Grade I-II encephalopathy
3. Overlooking INR: Some older versions use prothrombin time instead of INR
4. Confusing ascites grading: Moderate ascites is clinically detectable but not tense

The Child-Pugh classification remains a cornerstone in the assessment of liver disease severity and guides critical treatment decisions in patients with cirrhosis.