What is the Child-Pugh score?

The Child-Pugh score classifies chronic liver disease into three classes: A (5–6 points, well-compensated), B (7–9 points, significant functional compromise), and C (10–15 points, decompensated). Each of five parameters is scored 1–3 points.

How does Child-Pugh differ from MELD?

Child-Pugh uses both objective (labs) and subjective (ascites, encephalopathy) criteria and classifies patients into three broad classes. [MELD](/tools/meld-score) uses only objective lab values and provides a continuous numerical score. MELD is preferred for transplant allocation; Child-Pugh is widely used for surgical risk assessment and prognosis.

What are the survival rates by class?

Child-Pugh Class A: ~100% 1-year survival, ~85% 2-year survival. Class B: ~81% 1-year survival, ~57% 2-year survival. Class C: ~45% 1-year survival, ~35% 2-year survival. These are general estimates and vary by specific liver disease and comorbidities.

When should the Child-Pugh score be used?

Common uses include: assessing operative risk in cirrhotic patients (Class C patients have very high surgical mortality), guiding decisions about interventions (e.g., variceal banding, TIPS placement), monitoring disease progression, and as an entry criterion for clinical trials.

What is the perioperative mortality by class?

For abdominal surgery: Class A: ~10%. Class B: ~30%. Class C: ~50-80%. These rates vary by procedure type. Cardiac surgery and emergency surgery have even higher mortality. Most surgeons avoid elective surgery in Class C.

What are the West Haven criteria for encephalopathy?

Grade 0: No abnormality. Grade I: Lack of awareness, shortened attention span, sleep disturbance. Grade II: Lethargy, disorientation, asterixis. Grade III: Somnolent but arousable, marked confusion. Grade IV: Coma.

How is ascites graded?

Grade 1 (mild): Detectable only by ultrasound. Grade 2 (moderate): Moderate symmetrical abdominal distension. Grade 3 (severe): Large or tense ascites with marked abdominal distension. For Child-Pugh, none = 1 point, mild/moderate = 2 points, severe = 3 points.

What is the history of Child-Pugh?

Child and Turcotte developed the original score in 1964 for surgical risk in cirrhosis. Pugh modified it in 1973, adding INR and changing to the current format. It's been the standard cirrhosis classification for decades.

Is Child-Pugh valid for all liver diseases?

It's most validated for cirrhosis from various etiologies. It may be less accurate for cholestatic diseases (PBC, PSC) where bilirubin rises early, and for acute liver failure where synthetic function declines rapidly.

What drugs require Child-Pugh-based dosing?

Many hepatically metabolized drugs require adjustment. Prescribing information often says 'avoid in Child-Pugh C' or 'reduce dose by 50% in Child-Pugh B.' Examples include opioids, benzodiazepines, many antibiotics, and some cardiovascular drugs.

Can Child-Pugh predict variceal bleeding risk?

Yes, indirectly. Child-Pugh B/C patients have higher portal pressures and greater risk of variceal hemorrhage. Class guides decisions about primary prophylaxis (beta-blockers, band ligation) and surveillance intervals.

What is compensated vs. decompensated cirrhosis?

Compensated = no history of ascites, encephalopathy, or variceal bleeding (typically Child-Pugh A). Decompensated = any of these complications (typically Child-Pugh B or C). Decompensation marks a key prognostic turning point.

How often should Child-Pugh be reassessed?

At minimum, annually for stable patients. More frequently (every 3-6 months) for patients near class boundaries, recent decompensation, or undergoing treatment that might affect liver function.

Is there a minimum score?

The minimum is 5 (all five parameters at 1 point each), which is Class A. The maximum is 15 (all five at 3 points each), which is Class C. You cannot have a score below 5.

What about portal vein thrombosis?

Portal vein thrombosis worsens prognosis and increases portal hypertension but isn't directly captured in Child-Pugh. It's an important consideration for TIPS candidacy and transplant evaluation.

Online Medical Tools — Child-Pugh Score

Printed on 8/14/2026

For informational purposes only. This is not medical advice.

Clinical

Child-Pugh Score

The Child-Pugh score (also known as the Child-Turcotte-Pugh score) classifies the severity of chronic liver disease and cirrhosis. It combines five clinical and laboratory parameters — total bilirubin, serum albumin, INR, ascites, and hepatic encephalopathy — to classify patients into Class A (well-compensated), B (significant compromise), or C (decompensated). It is widely used for surgical risk assessment and prognosis in cirrhosis.

Formula: Child-Pugh = Bilirubin(1–3) + Albumin(1–3) + INR(1–3) + Ascites(1–3) + Encephalopathy(1–3)

Total Bilirubin

Serum Albumin

INR

Ascites

Hepatic Encephalopathy

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How It Works

Gather laboratory values

Obtain recent bilirubin, albumin, and INR. These should be from the past few days and reflect the patient's current hepatic synthetic function.

Assess clinical parameters

Evaluate for ascites (none, mild/controlled, moderate-severe) and hepatic encephalopathy grade (none, grade I-II, grade III-IV).

Calculate class and interpret

Sum the five scores (5-15 total). Class A (5-6): compensated. Class B (7-9): significant compromise. Class C (10-15): decompensated with high surgical risk.

Who Uses the Child-Pugh Score

Pre-Operative Risk Assessment

Surgeons, anesthesiologists

Assess whether a cirrhotic patient can safely undergo elective surgery. Class C patients have ~50-80% perioperative mortality for abdominal surgery.

Prognosis Discussion

Hepatologists, palliative care

Communicate disease severity to patients and families. Class correlates with survival: A ~100%, B ~81%, C ~45% at 1 year.

TIPS Candidacy

Interventional radiologists, hepatologists

Evaluate candidacy for transjugular intrahepatic portosystemic shunt. Child-Pugh B/C patients have higher post-TIPS encephalopathy risk.

Clinical Trial Stratification

Researchers, study coordinators

Stratify patients by disease severity for hepatology research. Child-Pugh class is a common inclusion/exclusion criterion.

Drug Dosing Guidance

Pharmacists, prescribing physicians

Many drugs require dose adjustment in hepatic impairment. Prescribing information often references Child-Pugh class for dosing recommendations.

Disease Monitoring

Hepatology clinics

Track Child-Pugh class over time to monitor disease progression or improvement with treatment (e.g., after alcohol cessation, HCV cure).

Pro Tips

Class A vs. B boundary is most clinically important

The transition from A to B marks decompensation onset. Class A patients generally tolerate procedures well; Class B/C require careful risk-benefit analysis. Watch for patients with 6 vs. 7 points.

Ascites and encephalopathy are subjective — be consistent

Different examiners may grade these differently. Use standardized definitions: mild ascites = detectable only on imaging or shifting dullness; moderate = obvious on exam; severe = tense ascites. Document your grading.

Treatment affects the score

Diuretics can control ascites (scoring 2 vs. 3). Lactulose can control encephalopathy (scoring 2 vs. 3). A patient on medications may score lower than their true disease severity without treatment.

Compare to MELD for different purposes

Use Child-Pugh for surgical risk and prognosis; use [MELD](/tools/meld-score) for transplant prioritization. They capture different aspects: MELD is purely lab-based; Child-Pugh includes clinical assessment.

Hepatocellular carcinoma doesn't change Child-Pugh

HCC can kill patients with well-preserved liver function. A Class A patient with HCC may have worse prognosis than their Child-Pugh suggests. Consider HCC separately.

INR can be affected by anticoagulation

If a patient is on warfarin, INR doesn't reflect hepatic synthetic function. Some experts use a baseline INR of 1.0 or estimate what INR would be off warfarin.

Albumin reflects nutrition too

Low albumin isn't solely hepatic; malnutrition, nephrotic syndrome, and inflammation also lower albumin. Consider the clinical context when interpreting.

Class C patients rarely tolerate elective surgery

Perioperative mortality for Class C abdominal surgery approaches 50-80%. Most surgeons decline elective procedures. Emergency surgery has even higher mortality but may be unavoidable.

Track class over time

A patient progressing from A to B, or B to C, has clinically meaningful decompensation. This progression should trigger intensified management and transplant evaluation if appropriate.

Modified Child-Pugh exists for PBC/PSC

Primary biliary cholangitis and primary sclerosing cholangitis may have disproportionately high bilirubin relative to synthetic function. Some modified scoring systems exist but aren't widely used.

Common Questions About Your Results

Evidence-Based Methodology

Child-Pugh originated from Child and Turcotte (1964) for surgical risk assessment, modified by Pugh (1973). It remains the most widely used cirrhosis classification system. Survival estimates are from the original studies and subsequent validations. Perioperative mortality data is compiled from multiple surgical series.

Clinical Content Trust

Last reviewed:: April 21, 2026
Guideline version:: General evidence framework v2026.04
Source set version:: Primary-source set v1

How to Interpret Your Result

The Child-Pugh score ranges from 5 to 15 and classifies patients into three classes. Class A (5–6 points) indicates well-compensated cirrhosis with approximately 100% one-year survival and low operative risk. Class B (7–9 points) indicates significant functional compromise with approximately 81% one-year survival and moderate surgical risk. Class C (10–15 points) indicates decompensated cirrhosis with approximately 45% one-year survival and very high operative risk.

The classification helps predict perioperative mortality: Class A patients generally tolerate surgery well, Class B patients have increased but potentially acceptable surgical risk depending on the procedure, and Class C patients have prohibitively high mortality for most elective surgeries (approaching 50–80% for abdominal operations). The score also guides management decisions regarding variceal prophylaxis, transplant referral timing, and overall prognosis.

When to Use This Tool

Use the Child-Pugh score to classify the severity of chronic liver disease in patients with known or suspected cirrhosis. It is particularly valuable for preoperative risk assessment — surgeons and anesthesiologists rely on it to determine whether a cirrhotic patient can safely undergo elective surgery. Class C patients are generally considered too high-risk for most elective procedures.

The score is also used to guide clinical management decisions, such as determining whether to initiate primary prophylaxis for variceal bleeding, assessing the timing of liver transplant referral, and as an entry criterion or stratification variable in clinical research. It provides a quick bedside assessment that combines laboratory data with clinical findings.

Limitations

The Child-Pugh score includes two subjective components — ascites severity and hepatic encephalopathy grade — which can vary between examiners and are influenced by treatment. A patient on diuretics with controlled ascites and one on lactulose with controlled encephalopathy may score differently depending on how the examiner interprets their current status. This subjectivity reduces inter-rater reliability compared to purely objective scores like [MELD](/tools/meld-score).

The score classifies patients into only three broad categories, which limits its ability to differentiate within groups. Two patients both classified as Class B (one with 7 points and another with 9 points) may have meaningfully different prognoses. The continuous [MELD score](/tools/meld-score) provides finer discrimination and is preferred for transplant allocation.

The score does not account for several important factors in liver disease, including the presence of hepatocellular carcinoma, portal vein thrombosis, hepatorenal syndrome, or the specific etiology of cirrhosis. It was originally developed for predicting surgical risk and may be less accurate for other prognostic applications.

Disclaimer: This tool is for educational and informational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about your health.

Changelog

April 21, 2026 · trust-baseline
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