In medicine (gastroenterology), the Child-Pugh score (sometimes the Child-Turcotte-Pugh score) is used to assess the prognosis of chronic liver disease, mainly cirrhosis. Although it was originally used to predict mortality during surgery, it is now used to determine the prognosis, as well as the required strength of treatment and the necessity of liver transplantation.
The score employs five clinical measures of liver disease. Each measure is scored 1-3, with 3 indicating most severe derangement.
|Measure||1 point||2 points||3 points|
|Total bilirubin, μmol/l (mg/dl)||<34 (<2)||34-50 (2-3)||>50 (>3)|
|Serum albumin, g/dl||>3.5||2.8-3.5||<2.8|
|PT INR||<1.7||1.71-2.30||> 2.30|
|Ascites||None||Mild||Moderate to Severe|
|Hepatic encephalopathy||None||Grade I-II (or suppressed with medication)||Grade III-IV (or refractory)|
Different textbooks and publications use different measures. Some older reference works substitute PT prolongation for INR.
In primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC), the bilirubin references are changed to reflect the fact that these diseases feature high conjugated bilirubin levels. The upper limit for 1 point is 68 μmol/l (4 mg/dl) and the upper limit for 2 points is 170 μmol/l (10 mg/dl).
Chronic liver disease is classified into Child-Pugh class A to C, employing the added score from above.
|Points||Class||One year survival||Two year survival|
Other scoring systems
Although the Child-Turcotte scoring system was the first of its kind in stratifying the seriousness of end-stage liver disease, it is by no means the only one. The Model for End-Stage Liver Disease (MELD) is used increasingly to assess patients for liver transplantation, although both scores seem to be more or less equivalent. The MELD score is perhaps a more accurate assessment of perioperative mortality in patients with hepatic dysfunction. The score is derived from a linear regression model based on serum bilirubin, creatinine levels, and the international normalized ratio (INR). It is more accurate than the Child classification in that it is objective, gives weights to each variable, and does not rely on arbitrary cut-off values. Clinicians can use a website to calculate the 7-day, 30-day, 90-day, 1-year, and 5-year surgical mortality risk on the basis of the patient’s age, ASA class, INR, serum bilirubin, and creatinine levels. Taken together, the Child classification and the MELD score complement each other and provide an accurate assessment of the risk of surgery in cirrhotic patients.
Dr C.G. Child and Dr J.G. Turcotte of the University of Michigan first proposed the scoring system in 1964. It was modified by Pugh et al in 1972. They replaced Child's criterion of nutritional status with the prothrombin time or INR, and thus eliminated the most subjective part of the score.
- (Teh et al., 2007)
- (O’Leary and Friedman, 2007; O’Leary et al., 2009)
- Child CG, Turcotte JG. Surgery and portal hypertension. In: The liver and portal hypertension. Edited by CG Child. Philadelphia: Saunders 1964:50-64.
- Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R (1973). "Transection of the oesophagus for bleeding oesophageal varices". The British journal of surgery 60 (8): 646–9. doi:10.1002/bjs.1800600817. PMID 4541913.