What Does Child-Pugh Score 9/B Mean?
A Child-Pugh score of 9 indicates Class B (moderate) cirrhosis, representing moderately decompensated liver disease with significant functional impairment and increased mortality risk. 1
Understanding the Child-Pugh Classification System
The Child-Pugh score stratifies the severity of cirrhosis using five clinical and laboratory variables, with total scores ranging from 5 to 15 points 1:
Scoring Components (1-3 points each):
- Hepatic encephalopathy: None (1 point), Grade 1-2 (2 points), Grade 3-4 (3 points) 1
- Ascites: None (1 point), Slight (2 points), Moderate (3 points) 1
- Total bilirubin: <2 mg/dL (1 point), 2-3 mg/dL (2 points), >3 mg/dL (3 points) 1
- Albumin: >3.5 g/dL (1 point), 2.8-3.5 g/dL (2 points), <2.8 g/dL (3 points) 1
- INR: <1.7 (1 point), 1.7-2.2 (2 points), >2.2 (3 points) 1
Classification Categories:
- Child-Pugh Class A (mild): 5-6 points - compensated cirrhosis 1
- Child-Pugh Class B (moderate): 7-9 points - moderately decompensated cirrhosis 1
- Child-Pugh Class C (severe): 10-15 points - severely decompensated cirrhosis 1
Clinical Implications of Child-Pugh Class B (Score 9)
Mortality and Prognosis
Patients with Child-Pugh Class B have significantly worse outcomes than Class A patients. In the context of acute variceal bleeding, Class B patients with active bleeding have a 3-fold higher mortality than Class B patients without active bleeding, though still lower than Class C patients 1. The score effectively separates patients into groups with significantly different median survivals and survival curves 2.
Treatment Considerations
Portal Hypertension Management:
- For acute variceal bleeding: Child-Pugh B patients with scores >7 and active bleeding at endoscopy qualify as high-risk and should receive preemptive TIPS within 72 hours (ideally <24 hours) 1
- Standard therapy mortality: Approximately 28% of high-risk patients (including Child-Pugh B with active bleeding) die when treated with standard therapy alone 1
Anticoagulation in Atrial Fibrillation:
- Oral anticoagulation is reasonable in Child-Pugh Class B patients without clinically significant coagulopathy or thrombocytopenia 1
- DOACs preferred over warfarin: Apixaban, dabigatran, or edoxaban are reasonable choices 1
- Rivaroxaban is contraindicated in Child-Pugh Class B due to increased bleeding risk 1
Surgical Considerations:
- Liver resection: Highly selected Child-Pugh B patients may be considered for limited resection only if liver function tests are normal and clinical signs of portal hypertension are absent 1
- Elective surgery: Child-Pugh Class B patients undergoing major elective procedures (including orthopedic surgery) face substantially elevated mortality risk, with some studies showing up to 64% early mortality in Class B/C combined 3
Common Pitfalls and Caveats
The Child-Pugh score has inherent limitations due to subjective components (ascites and encephalopathy grading) and does not include renal function, which is a critical prognostic factor 1. The MELD score may provide more objective risk stratification in certain contexts, particularly for transplant allocation and TIPS procedures 1, 4, 5.
Portal hypertension assessment is crucial beyond the Child-Pugh score alone, as clinically significant portal hypertension substantially increases surgical mortality and postoperative decompensation risk 1.
A score of 9 represents the upper range of Class B, placing the patient closer to Class C severity. These patients warrant careful monitoring, as they may decompensate more readily than those with lower Class B scores 1, 6.
Transplant Evaluation
Liver transplantation evaluation should be considered for Child-Pugh Class B patients, particularly those with complications of cirrhosis or MELD scores ≥15 6. The transition from compensated to decompensated cirrhosis (which Class B represents) marks a critical juncture where transplant assessment becomes appropriate 1, 6.