What is the correct nomenclature for liver cirrhosis, including functional stage (compensated versus decompensated), Child‑Pugh class or MELD score, and underlying etiology?

Nomenclature for Liver Cirrhosis

Liver cirrhosis should be documented using a structured format that includes: (1) functional stage (compensated versus decompensated), (2) severity scoring (Child-Pugh class A/B/C and/or MELD score), and (3) underlying etiology. 1

Functional Stage Classification

The most critical distinction in cirrhosis nomenclature is between compensated and decompensated disease, as this fundamentally determines prognosis and management 1:

• Compensated cirrhosis: Absence of clinically evident complications (no ascites, variceal hemorrhage, or hepatic encephalopathy). Median survival exceeds 12 years 1
• Decompensated cirrhosis: Presence of any overt clinical complication including ascites, variceal bleeding, or hepatic encephalopathy. Median survival is only 1.8 years 1

Substaging Compensated Cirrhosis

Compensated cirrhosis should be further substaged based on portal hypertension severity 1:

• Mild portal hypertension: HVPG <10 mm Hg, with 90% probability of not developing decompensation over 4 years 2
• Clinically significant portal hypertension (CSPH): HVPG ≥10 mm Hg, present in 50-60% of compensated patients, associated with increased risk of varices, decompensation, and hepatocellular carcinoma 1, 2

Severity Scoring Systems

Child-Pugh Classification

The Child-Pugh score stratifies patients into three prognostic classes using five parameters (bilirubin, albumin, INR/PT, ascites, encephalopathy), each scored 1-3 points 1, 3:

• Child-Pugh Class A (5-6 points): Compensated cirrhosis with perioperative mortality of 5-10% 1, 3
• Child-Pugh Class B (7-9 points): Decompensated cirrhosis with 68% seven-year survival and perioperative mortality up to 30-50% 1, 3
• Child-Pugh Class C (10-15 points): Severely decompensated cirrhosis with only 25% seven-year survival and perioperative mortality up to 30-50% 1, 3

The Child-Pugh score remains the most practical bedside tool for prognostic assessment and should be documented for all cirrhotic patients 3, 4. However, it has limitations including subjective components (ascites and encephalopathy grading) and inability to assess clinically significant portal hypertension 3.

MELD Score

The MELD score uses three objective laboratory parameters (bilirubin, creatinine, INR) and is the best predictor of short-term (3-month) mortality in decompensated cirrhosis 1:

• MELD <10: Low risk of decompensation 1
• MELD ≥10: Increased likelihood of decompensation and liver-related outcomes 1
• MELD ≥14: Threshold where transplant benefit emerges; minimal listing criterion 1

MELD should be reserved primarily for patients with decompensated cirrhosis, as it has limited prognostic value in compensated disease with low scores 4. The MELD-Na variant (incorporating serum sodium) has the highest accuracy for predicting mortality in decompensated cirrhosis 4.

Comparative Use of Scoring Systems

• Child-Pugh score: Superior for surgical candidacy assessment, particularly for hepatic resection 1, 3. Remains effective for bedside prognostic assessment in all cirrhotic patients 4
• MELD score: Superior for transplant allocation and predicting short-term mortality in decompensated disease 1. Less useful in compensated cirrhosis 4
• Both scores perform similarly in predicting 6-month mortality (AUC 0.866-0.882 for whole population, 0.796-0.800 for decompensated subgroup) 4, 5

Underlying Etiology

The etiology must be specified as it influences prognosis and management 1:

• Alcohol-related cirrhosis: Document current drinking status, as persistent alcohol consumption is the strongest predictor of mortality and liver-related outcomes 1
• Viral hepatitis: Specify HCV or HBV, and treatment status (e.g., post-SVR) 1
• Metabolic dysfunction-associated: NAFLD/NASH, often with metabolic syndrome components 1
• Mixed etiologies: Common, particularly alcohol with NAFLD or viral hepatitis 1

Critical Pitfalls to Avoid

• Never use Child-Pugh or MELD scores alone without documenting compensated versus decompensated status, as this is the most important prognostic distinction 1
• Do not apply cut-offs developed for untreated disease to post-treatment populations (e.g., post-SVR HCV patients) 1
• Recognize that MELD does not capture clinical decompensation events (ascites, encephalopathy) that significantly impact prognosis 6
• Document specific decompensating events when present, as ascites is the predominant pattern in alcohol-related cirrhosis with one-year mortality of 49% 1

Recommended Documentation Format

Example: "Decompensated alcohol-related cirrhosis, Child-Pugh Class B (8 points), MELD 16, with ascites as initial decompensating event, currently abstinent from alcohol."

This format provides complete prognostic information and guides management decisions including transplant evaluation (Child-Pugh B/C or MELD ≥14 warrant immediate evaluation) 1, 3.