Assessment

Scottish Palliative Care Guidelines
Healthcare Improvement Scotland

Cirrhosis represents the irreversible advanced stage of chronic progressive liver disease. This may be relatively asymptomatic and individuals may live for many years with compensated cirrhosis. Progression to decompensated cirrhosis is characterised by the development of one or more of the following liver-related complications:

  • variceal haemorrhage
  • ascites
  • spontaneous bacterial peritonitis
  • hepatic encephalopathy
  • hepatorenal or hepatopulmonary syndrome
  • portopulmonary hypertension.

Decompensated cirrhosis requiring admission to hospital is associated with a 50% mortality rate at 12 months. It is therefore recommended that any patient who has decompensated cirrhosis is managed comprehensively, including an assessment of their supportive care needs. This may include referral to the local specialist palliative care team if there are complex physical, psychosocial or spiritual needs identified.

The Child-Turcotte-Pugh score

The Child-Turcotte-Pugh score is a clinical classification of severity of liver disease and prognosis:

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Factor 1 point 2 points 3 points
>Total bilirubin (μmol/L) <34 34 to 50 >50
>Serum albumin (g/L) >35 28 to 35 <28
>PT INR <1.7 1.71 to 2.30 >2.30

 

Ascites None Mild Moderate to Severe
Hepatic
encephalopathy*		 None Grade 1 to 2
(or suppressed
with medication)		 Grade 3 to 4 (or refractory)*

 

  Class A Class B Class C
Total points 5 to 6 7 to 9 10 to 15
1-year survival 100% 80% 45%

*Refer to guidance on hepatic encephalopathy.

 

Mild, moderate and severe hepatic impairment may be equated pragmatically with Child‑Pugh class A, B and C respectively, and it can be assumed that patients for whom this guideline is intended will have Child‑Pugh class B or C disease. There are limited data on the safety of medications according to grade of liver disease. There is no biochemical marker or specific formula that may accurately predict drug metabolism in hepatic impairment, so liver function tests are an unreliable way of determining how a patient with cirrhosis will tolerate a particular drug.