Child-Turcotte-Pugh Score
The Child-Pugh scoring system, initially developed by Child and Turcotte in 1964, aimed to predict mortality in cirrhosis patients and guide surgical decision-making. Originally, it utilized five criteria, including serum bilirubin, serum albumin, ascites, neurological disorder, and clinical nutrition status. ¹ Pugh et al. later modified the system by replacing clinical nutrition status with prothrombin time. This adaptation enhanced the accuracy of the scoring system in assessing the severity of liver disease. ²
| Clinical and Lab Criteria | 1 Point | 2 Point | 3 Points |
|---|---|---|---|
| Hepatic Encephalopathy | None | Mild to Moderate (Grade 0 or 1) | Moderate to Severe (Grade 3 or 4) |
| Ascites | None | Mild to Moderate (Diuretic responsive) | Severe (Diuretic refractory) |
| Bilirubin (mg/dl) (µmol/L) | < 2 < 34.2 | 2-3 34.2 - 51.3 | > 3 > 51.3 |
| Albumin (g/dl) (g/L) | > 3.5 > 35 | 2.8 - 3.5 28 - 35 | < 2.8 < 28 |
| Prothrombin time Seconds prolonged International Normalized Ratio | <4 <1.7 | 4-6 1.7 - 2.3 | >6 >2.3 |
| Child-Turcotte-Pugh Class | Score | Disease Severity |
|---|---|---|
| Child A | 5-6 | Good Hepatic Function |
| Child B | 7-9 | Moderately Severe Liver Disease |
| Child C | 10-15 | Advance Liver Disease |
Clinical Significance of Child Turcotte Pugh Score
The Child-Pugh score has undergone validation as a reliable predictor of postoperative mortality in portocaval shunt surgery and has also demonstrated its ability to assess the mortality risk linked to other significant surgical procedures. ³
| Child A | Child B | Child c | |
|---|---|---|---|
| Mortality Rate after abdominal surgery | 10% | 30% | 70%-80% |
| Elective Surgery | Safe Candidate | Surgery after medical optimization | Contraindicated |
Limitation of Child Turcotte Pugh Score
1) Two subjective grading are included in final score – ascites and encephalopathy
2) There is no inclusion of renal function, and
3) Patient with the same Child class can have significantly different clinical parameters, for eg: a patient with INR of 3 and S. Bilirubin level of 6 g/dl can potentially have a same Child Pugh Score as another patient with INR 6 and S. Bilirubin level of 12.3 g/dl.
To address the above mentioned limitations, The MELD (Model for End-stage Liver Disease) Score was developed which included broader range of continuous variables like bilirubin, creatinine, INR, and Liver disease etiology. MELD Score has since evolved to consider Serum Sodium levels and dialysis status while excluding the cause of disease.
- Child CG, Turcotte JG. Surgery and portal hypertension. Major Probl Clin Surg. 1964;1:1-85.
- Pugh RN, Murray‐Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. British journal of surgery. 1973 Aug;60(8):646-9.
- Tsoris A, Marlar CA. Use of the Child Pugh score in liver disease.