Assessment of Decompensated Hepatitis C
Decompensated hepatitis C is defined by a Child-Turcotte-Pugh (CTP) score ≥7, which includes clinical evidence of ascites, hepatic encephalopathy, total bilirubin >2.0 mg/dL, albumin <3.5 g/dL, or INR ≥1.7. 1
Calculate the Child-Turcotte-Pugh Score
The CTP score is the primary tool to differentiate compensated (CTP class A) from decompensated cirrhosis (CTP class B or C). 1
Required laboratory parameters:
- Total bilirubin (>2.0 mg/dL indicates decompensation) 1
- Serum albumin (<3.5 g/dL indicates decompensation) 1
- INR (≥1.7 indicates decompensation) 1
Required clinical assessments:
- Ascites (presence indicates decompensation) 1
- Hepatic encephalopathy (presence indicates decompensation) 1
A CTP score ≥7 or any history of prior decompensation confirms decompensated cirrhosis. 1
Clinical Evaluation for Decompensation Events
Assess for the four cardinal manifestations of decompensation:
- Ascites is the most frequent first decompensation event (occurring in 44.9-47.2% of patients), and should be evaluated clinically and confirmed with ultrasound imaging to detect subclinical ascites 1, 2
- Upper gastrointestinal bleeding from varices (occurs in 15.7-23.6% as first decompensation) requires assessment for esophageal and gastric varices via endoscopy 2, 3
- Spontaneous bacterial peritonitis (occurs in 18.0-20.2% as first decompensation) should be suspected in patients with ascites and fever, abdominal pain, or altered mental status 2
- Hepatic encephalopathy (occurs in 7.9-11.2% as first decompensation) requires clinical grading and assessment 2
Imaging Assessment
Ultrasound of the liver within the prior 6 months is mandatory to:
- Evaluate for hepatocellular carcinoma (HCC) 1
- Detect subclinical ascites 1
- Assess for liver nodularity and splenomegaly as clinical evidence of cirrhosis 1
Laboratory Panel for Decompensation Assessment
Complete blood count (CBC):
- Platelet count <150,000/mm³ suggests cirrhosis and portal hypertension 1, 4
- Platelet count ≤140,000/mm³ has 83% sensitivity and 85% specificity for detecting cirrhosis 4
Hepatic function panel:
- AST/ALT ratio ≥1 suggests cirrhosis (39% sensitivity, 92% specificity) 4
- Elevated bilirubin >2.0 mg/dL indicates decompensation 1
- Albumin <3.5 g/dL indicates decompensation 1
Coagulation studies:
- INR ≥1.7 indicates decompensation 1
- Prolonged prothrombin time is an early indicator of cirrhosis and portal hypertension 5
Additional markers:
- Globulin/albumin ratio ≥1 suggests cirrhosis (43% sensitivity, 98% specificity) 4
Endoscopic Evaluation
Upper endoscopy is essential to:
- Screen for esophageal and gastric varices, as their presence independently correlates with survival 2
- Assess variceal size, as large esophageal varices predict failure to recompensate (adjusted hazard ratio 0.4) and portal hypertension progression (adjusted hazard ratio 2.9) 3
Prognostic Assessment
Key predictors of poor outcomes in decompensated HCV cirrhosis:
- Presence of esophageal and gastric varices independently correlates with survival 2
- Elevated bilirubin independently correlates with worse survival 2
- Low bilirubin, low INR, and absence of large varices predict recompensation after antiviral therapy 3
Common Pitfalls to Avoid
Do not rely solely on transaminase levels (ALT/AST), as approximately 50% of patients with chronic viral hepatitis can have normal transaminase values despite ongoing liver disease, and routine liver tests correlate poorly with necroinflammatory and fibrosis scores. 6, 5
Do not skip ultrasound imaging, as subclinical ascites may be present without obvious clinical signs and HCC surveillance is critical in cirrhotic patients. 1
Recognize that decompensation can occur with any single criterion met (ascites, encephalopathy, bilirubin >2.0, albumin <3.5, or INR ≥1.7), not just a cumulative CTP score ≥7. 1