Child-Pugh severity of liver cirrhosis

Cirrhosis is a chronic liver disease, which is characterized by damage to specific liver tissue and its replacement by a connective structure. Replacement tissue cannot perform a wide range of liver cell functions. This leads to a deterioration in liver function, an increased susceptibility to toxins is observed in the body, and metabolism worsens.

In economically developed countries, cirrhosis is one of the 6 diseases that lead to the largest number of deaths in the CIS, and is in 4th place in this row in the United States. It is estimated that about 40 million people around the world at the age of 35-60 die from this disease every year; 1% of the population in the post-Soviet space suffers from cirrhosis.

Depending on the characteristics of the lesions of the liver areas, the severity of the disease is determined for the patient – this is called the Child-Pugh category. Child-Pugh is a statistical document that allows you to individually analyze the picture of the disease and predict life expectancy, determine the need for liver transplantation, and more.

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Classification of liver cirrhosis

The first variant of the division of cirrhosis of the liver was proposed back in 1956 at the congress of gastroenterologists in Havana, it assumed the differences of 3 types of the disease:

  • postnecrotic,
  • biliary,
  • portal.

This system turned out to be very incorrect and contained a lot of inaccuracies, missing additional factors of liver necrosis. This system was replaced by a new order of species identification in 1974: the International Conference on the Unification of Medical Nomenclature decided to highlight the etiological principle and morphological bases of cirrhosis. Even then, the concept of micronodular (the diameter of the nodes does not exceed 3 mm) and macronodular (the diameter of the nodes is more than 3 mm) and mixed type of regenerative formations were introduced.

At the moment, liver cirrhosis is classified according to several criteria: the cause of development (etiology), features of the lesion (morphology of the disease). In addition, according to the modern statistical accounting of Child-Pugh, according to the characteristic features of an individual disease, the patient is determined by the level of development of cirrhosis in the body. According to Child-Pugh, according to some criteria, the overall score of cirrhosis is determined, and the higher it is, the more severe and neglected the disease.

Despite the three main methods of delimiting the features of the disease, it has not yet been possible to create a unified classification, but the following criteria are used in medicine:

  • Etiology:
  • caused by exposure to ethanol,
  • under the influence of viral diseases,
  • toxic cirrhosis of the liver,
  • caused by genetic metabolic disorders,
  • provoked by disturbances in the work of the bile ducts,
  • cryptogenic origin.
  • Depending on the activity of development, cirrhosis is:
  • subacute (caused by exposure to hepatitis),
  • rapidly progressing,
  • slowly progressing
  • sluggish (development is slowed down by the immune system and exposure to medications),
  • latent (discovered by chance, the activity of neurosis is frozen, the liver is not impaired, life expectancy does not depend on such cirrhosis – no treatment is required).
  • Morphological signs:
  • small-nodular cirrhosis,
  • large nodular cirrhosis,
  • mixed form,
  • incomplete septal form.
  • Existing complications:
  • internal bleeding of the gastrointestinal tract,
  • hepatic failure, falling into a coma, development of stage 0-3 encephalopathy,
  • spontaneous ascites and peritonitis,
  • development of hepatocellular carcinoma or hepatorenal syndrome,
  • the formation of blood clots in the portal vein.
  • Child-Pugh stage of cirrhosis:
  • A-degree (compensated),
  • B-degree (compensated),
  • C-degree (decompensated),

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Etiology

Etiology is the causes of the development of the disease and the factors accompanying this process. For liver cirrhosis, there are certain points that significantly accelerate the replacement of the normal lobular structure of the organ with connective scars. Additional criteria that speed up this process include:

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  • hepatitis of viral origin of categories B, C, D and G, including autoimmune hepatitis,
  • schistosomiasis,
  • alcohol (the second factor that significantly increases the rate of degradation of liver tissue),
  • some industrial toxins, poisons and medications,
  • stagnation of venous blood due to heart failure of the right ventricle, disturbances in the vascular system of the liver, impaired blood flow to small branches and capillaries of the hepatic structure,
  • hereditary metabolic disorders, in particular: iron, copper, changes in the chains of carbohydrate transformation, deficiency of β 1-antitrypsin.

There are no cases when the cause of cirrhosis was syphilis, tuberculosis, malaria, other infectious diseases, or the activity of parasites inside the body.

In about 25% of cases, it is not possible to establish the cause of the disease – such cirrhosis is called cryptogenic.

Alcoholic, viral and toxic cirrhosis

The most common types of liver cirrhosis are alcoholic, viral and toxic. But the leading among them is ethanol cirrhosis of the liver.

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Alcoholic cirrhosis

It is in the first place in terms of prevalence among other types of cirrhosis. The disease develops in 20% of those suffering from alcohol dependence, and often, cirrhosis is preceded by alcoholic hepatitis. Great damage is done to the liver cells, because ethanol is almost completely destroyed in the liver and has a detrimental effect on this organ.

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For the alcoholic type of the disease, there are risk groups:

  • overweight people
  • girls and women, since they have an increased sensitivity of liver tissue to alcohol (this is due to hormonal background)
  • carriers or suffering from hepatitis B, C or D. It is believed that C-hepatitis provokes the development of cirrhosis, and when it appears, it aggravates the overall picture and aggravates the course of the disease,
  • alcohol addicted. In order for alcoholic liver disease to develop, it is enough to consume 40 or more grams per day for a long time (10 years),
  • people whose close relatives suffered from this ailment.

Despite the absence of specific symptoms that could clearly distinguish this type of cirrhosis from others, there are some characteristic features:

  • The face is a little swollen, small capillaries are visible through the skin. In other areas of the skin, spider veins are present.
  • Atrophied muscles of the thoracic and cervical vertebra.
  • Increased size of the parotid glands.

Alcoholic cirrhosis is called an irreversible process of changes in the structure of the liver caused by alcohol abuse, but with the rejection of intoxicating drinks and effective therapy, there is a chance that it will be possible to preserve existing healthy cells and significantly slow down the replacement process. It is important not to start the disease, but to start treatment at an early stage, because each subsequent stage is more difficult than the previous one:

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  • Disease period.
  • Features.
  • Compensation.
  • Sometimes liver enlargement is possible, other signs are absent.
  • Subcompensation
  • The patient has a worsening appetite, frequent nausea and vomiting, and a general weight loss.
  • Decompensation
  • Liver failure, portal hypertension, and sometimes bacterial infections develop. The body is completely depleted.

This type of cirrhosis is often observed in men over the age of 40, who already have ethanologic diseases: pancreatitis, neuritis, encephalopathy and others.

Viral cirrhosis

The development of such cirrhosis is provoked by B, C, D – hepatitis, which has entered the body through the roof or the secretions of the mucous membrane (the mode of transmission is hematogenous). Cirrhosis occurs due to the fact that an infection causes hepatocytes to mutate, and the immune system, considering the altered structures to be foreign, attacks and destroys them. As a result, necrosis develops and damaged hepatocytes are replaced by connective tissue.

Depending on the type of hepatitis, the characteristics of transmission and its effect on the body change:

  • hepatitis B is resistant to temperatures and adapts well to the environment, therefore it is often transmitted through household items, during sexual intercourse, and medical manipulations. Has no hepatotoxic effect.
  • Hepatitis C in combination with the D-type is poorly adapted to the environment, sensitive to temperatures, and therefore transmission is mainly blood-to-blood. It has a hepatotoxic effect.

Symptoms include: deterioration in general health, enlarged liver, discoloration of feces and urine, headache and frequent dizziness, fever and constant drowsiness. Nausea, abdominal pain and vomiting are common.

Toxic cirrhosis

Toxic cirrhosis of the liver is a non-treatable disease, the development of which is provoked by their exposure to exogenous toxins. Once in the body, they aggressively affect the hepatocytes and cause their death – multiple necrosis develop, and as a result, allergic hepatitis is formed, and then – liver cirrhosis of toxic genesis. The main feature of this type of liver cirrhosis is that its appearance depends only on external factors. This means that with inflammation, hepatitis or other liver diseases, the process of the development of the disease does not occur.

According to the International Classification of Diseases 10 revision (ICD 10), toxic liver lesions are in the range of K 71-K71.9 XI class codes.

Substances that can cause the development of a toxic type of disease:

  • Medicines of regular intake, to which the patient has an increased sensitivity of the body.
  • Mushroom poison.
  • Heavy metals,
  • Some herbal medicines. Phytopreparations.

Most often, this disease affects people working in a chemical industry or taking drugs with strong hepatic effects. The main symptom of toxic cirrhosis is abdominal pain after each drug intake, receiving a dose of some substance, etc.

Cardiac

Cardiac cirrhosis is a type of cirrhotic liver disease, the etiological basis of which was not the initial pathology of the organ, but a disease of another structure – the heart. This is often heart failure of any origin. Cardiac cirrhosis of the liver is characterized by:

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  • increased body temperature,
  • jaundice,
  • weight loss,
  • internal intestinal bleeding,
  • decreased performance,
  • changes in the composition of the blood.

For treatment, the development of heart failure is initially blocked – and then therapy is carried out to inhibit the development of cirrhosis.

Genetic

Congenital cirrhosis – a pathology that develops in the fetus in utero, is a severe form of the disease. It is impossible to do without liver transplantation – even modern medicine provides an extremely low life expectancy. The reason for the development is maternal diseases: hepatitis, syphilis, HIV and some others, hereditary liver diseases from both sexes and congenital pathologies.

Morphological classification of cirrhosis

In the formation of the characteristics of the disease, its etiology plays a significant role: the changes that occur in the liver lobules in cirrhosis directly depend on it.

This means that the morphology of cirrhosis is a consistent characteristic, which is mostly determined by etiology. Depending on the characteristics, several morphological types of the disease are distinguished:

  • Type of disease.
  • Features.

By the size of the nodes and their features:

  • macronodular cirrhosis of the liver,
  • small-nodular cirrhosis,
  • septal lesion
  • mixed type.
  • The nodes are unevenly separated by connective tissue, the size of the nodes is from 3 mm to 5 cm.
  • The size of the nodes does not exceed 3 mm, the bridles are interconnected by small partitions (threads).
  • It is the initial stage of nodular cirrhosis of the liver: before the appearance of nodules, fibrous septa develop.
  • The middle stage is between large-nodular and small-nodular lesions.

By the speed of development + reasons:

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  • portal cirrhosis,
  • postnecrotic cirrhosis of the liver,
  • biliary,
  • mixed look.
  • Slowly fading cirrhosis, gradually depressing liver activity. Usually, manifestations of the portal appearance are present in fatty hepatosis and viral hepatitis.
  • It develops against the background of toxic damage to the hepatic structure, develops rapidly, with the formation of large nodes. In this case, the liver is reduced.
  • Causes of occurrence: degradation of the tissue of the biliary tract and changes in the gallbladder itself, which worsen the output of bile.
  • Medium between portal and postnecrotic cirrhosis.

According to the characteristics of the nodes:

  • monobular,
  • multilobular cirrhosis,
  • mixed.
  • The node consists of one hepatic lobule, channels are absent.
  • The node consists of several lobules, veins and ducts are present.
  • There are two types of nodes of approximately the same size.
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In small-nodular cirrhosis at the beginning of decompensation, manifestations of jaundice, hemorrhagic syndrome prevail, internal bleeding may open, hepatic encephalopathy is noted. With this stage of cirrhosis, 40% of the total live just over 3 years, 60% – less. Treatment at this stage involves only the fight against the symptoms of the disease and the use of artificial blood filters, because it is no longer possible to significantly slow down the development of cell neurosis.

Postnecrotic cirrhosis of the liver is a common disease characterized by the presence of signs inherent in other subspecies. In fact, this is the same large-nodular cirrhosis of the liver with the manifestation of a multilobular structure, arises as a complication from viral hepatitis or toxins in the body. The main feature is a reduced liver, with a predominance of the nodular structure.

Forms and stages

Depending on the stage of the disease, treatment is prescribed and predictions are made. Cirrhosis is characterized by three stages of development:

  • Compensated cirrhosis of the liver.
  • Subcompensated liver cirrhosis.
  • Decompensation stage.

The stage of compensation is the first stage in the development of the disease, in fact, this is the initial cirrhosis, when the functionality of the liver is not yet disturbed, but irreversible tissue fibrosis has begun. The main problem of diagnosis is the absence of symptoms of early cirrhosis. The disease is often diagnosed with blood tests for other diseases. Key Features:

  • weight loss,
  • yellowish tint of the eyeballs,
  • the stomach is slightly enlarged,
  • sometimes there is pain under the ribs on the right side,
  • body temperature rises to 37,5,
  • the quality of the skin deteriorates: darkening and the appearance of dermatous spots.

What is the compensated stage? – This is a mild form of the disease, which allows you to make very favorable predictions. Treatment is based on preventing further development into a chronic form or transition to a new stage.

The subcompensated stage is the second stage of cirrhotic changes. Already there are disturbances in the functioning of the liver, one feels heaviness after eating, pain in the right hypochondrium, etc., the level of bilirubin and enzymes in the blood rises in the blood. The main symptoms that give the right to suspect the second stage of cirrhosis:

  • weight loss,
  • diarrhea, flatulence, abdominal enlargement,
  • jaundice, dermatitis,
  • dilated veins, a venous mesh appears,
  • the appearance of internal bleeding, their degree increases.
  • impaired performance, impaired sleep, decreased muscle tone, general weakness.

Blood tests or ultrasound and biopsy can confirm the stage.

Decompensated cirrhosis is the last and most dangerous stage of the disease. Almost the entire structure of the liver consists of pseudo-lobules and scars, the functionality of the organ is undermined, the prognosis is extremely poor. Features of the disease:

  • portal hypertension,
  • hemorrhoids,
  • yellow skin and eyeballs,
  • severe frequent pains in the abdomen: not only the liver hurts, but also the enlarged spleen,
  • large asterisks of varicose veins appear,
  • the stomach greatly increases in size,
  • severe jaundice
  • complete exhaustion, loss of strength and deterioration in morale, general weakness.

If untreated, death occurs very quickly: depending on the severity and activity of the disease – within 2-3 years, at best.

In addition, there are forms of the disease such as stagnant and mixed type of ailment.

Stagnant appearance – chronic cirrhosis caused by blood stasis due to disturbances in the circulatory system. Reason for development: oxygen starvation of hepatocytes and their death. It develops against the background of toxicity or alcohol exposure.

The mixed type of cirrhosis is a morphological sign of the disease, when the scars are micro- and macronodular in size at the same time, their number is approximately equal.

Child-Pugh scale

The classification of liver cirrhosis by child pugh involves determining the severity of cirrhosis and making predictions depending on various concomitant factors, these are: bilirubin level, blood counts, abnormalities in the liver, the presence of hepatitis, lifestyle and nutrition characteristics, etc. Each such factor has its own index, these indices are eventually summed up, and the overall disease score is obtained. It is this point that allows you to make some predictions and adjust the course of treatment.

At the moment, the Child-Pugh classification is the most accurate available, and is able to characterize how developed liver failure is, its features, a description of the general condition and an assessment of the chances of recovery.

Scale-based survival assessment

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The Child-Pugh classification of liver cirrhosis allows predicting the life span of a person with a certain degree of cirrhosis.

  • With a compensated degree, the remainder of life is approximately 7 years or more. Without treatment, about 50% of all patients reach this figure.
  • For a subcompensated species, the lifespan is

5 years.

  • At the last stage of decompensation, only 11-40% live for 3 years at best, 60 to 89% die within a year. This is explained by the development of serious complications and complete degradation of the liver tissue.
  • Explanation of results

    Small-nodular cirrhosis, large-nodular, mixed type, incomplete septal form – all of them can have their own severity, which determines the characteristics of therapy and procedures.

    In order to assess the situation yourself, you can use the parameters expressed in the following table:

    Criteria1 score2 points3 points
    AscitesNoEasy formPronounced, sharp
    Prothrombin index,%> 60+403,52,8- 3,550 (> 3)

    Depending on the amount of points received, a diagnosis is made:

    • Compensated stage (Class “A”) – 5-6 points.
    • Subcompensation (Class “B”) – 7-9 points.
    • Decompensation (Class “C”) – 10-15 points.

    An important feature of the decompensation degree is that with criteria of 13 points and an active form of the disease, there are indications for liver transplantation, but this question is very controversial, because the mortality rate on the surgical table is very high.

    Additional morphological and etiological parameters

    For morphological classification, there is an addition: there are two types of cirrhosis, depending on the speed of its spread:

    • Active (very high rate of necrosis).
    • Passive (the immune system successfully copes with the spread of scars and counteracts neuroses).

    In addition, there are etiological features of the post-cirrhotic effect, that is, the development of complications. Often, as a result of liver failure, portal hypertension develops in different stages:

    • pre-symptomatic stage (no signs),
    • clinical (the volume of the liver increases, the symptoms increase),
    • acute (ascites develops, all symptoms are pronounced, the condition is severe),
    • stage with complications (development of related diseases, persistence of symptoms, profuse internal bleeding appears).

    Svetlana Borszavich

    General practitioner, cardiologist, with active work in therapy, gastroenterology, cardiology, rheumatology, immunology with allergology.
    Fluent in general clinical methods for the diagnosis and treatment of heart disease, as well as electrocardiography, echocardiography, monitoring of cholera on an ECG and daily monitoring of blood pressure.
    The treatment complex developed by the author significantly helps with cerebrovascular injuries and metabolic disorders in the brain and vascular diseases: hypertension and complications caused by diabetes.
    The author is a member of the European Society of Therapists, a regular participant in scientific conferences and congresses in the field of cardiology and general medicine. She has repeatedly participated in a research program at a private university in Japan in the field of reconstructive medicine.

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