Liver Cirrhosis: Causes, Child-Pugh Score and Complications

Cirrhosis is the end stage of chronic liver damage. Normal liver tissue is replaced by fibrous scar tissue and regenerative nodules, which disturbs liver function and blood flow through the liver. It can remain "compensated" for years before complications appear.

Causes

• Chronic viral hepatitis B and C — major causes in South Asia.
• Alcohol-related liver disease.
• Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly called NAFLD — rising with obesity and diabetes.
• Autoimmune causes: autoimmune hepatitis, primary biliary cholangitis and primary sclerosing cholangitis.
• Genetic causes: haemochromatosis, Wilson's disease and alpha-1 antitrypsin deficiency.
• Other causes: drugs, Budd–Chiari syndrome and chronic heart failure.

Clinical features

General symptoms: fatigue, weight loss and muscle wasting.

Signs of chronic liver disease:

• jaundice
• spider naevi
• palmar erythema
• clubbing and leukonychia
• Dupuytren's contracture (especially in alcohol-related disease)
• gynaecomastia
• testicular atrophy
• easy bruising

Signs of portal hypertension:

• splenomegaly
• ascites
• caput medusae

Investigations

• Liver function and clotting:
  • raised bilirubin
  • low albumin
  • prolonged prothrombin time / INR
• Full blood count: low platelets from hypersplenism.
• Tests for the cause:
  • viral serology
  • autoantibodies
  • ferritin and transferrin saturation
  • caeruloplasmin in young patients
  • alpha-1 antitrypsin
• Imaging: ultrasound (a small, nodular liver, splenomegaly, ascites) and elastography (FibroScan).
• Upper GI endoscopy: screens for oesophageal varices.
• Liver biopsy: occasionally, if the diagnosis is uncertain.

Assessing severity

The Child–Pugh score (classes A, B and C) uses five features:

• bilirubin
• albumin
• INR
• ascites
• encephalopathy

The MELD score (based on bilirubin, INR and creatinine, with sodium in MELD-Na) predicts short-term mortality and guides transplant listing.

Major complications and their management

• Ascites:
  • salt restriction
  • diuretics (spironolactone, with or without furosemide)
  • large-volume paracentesis with albumin for tense ascites
  A serum–ascites albumin gradient (SAAG) of 11 g/L or more indicates portal hypertension.
• Spontaneous bacterial peritonitis (SBP): diagnosed when the ascitic fluid neutrophil count is above 250 cells/mm³. Treat with IV antibiotics and albumin. Do a diagnostic tap in every patient with ascites admitted to hospital.
• Variceal bleeding: a medical emergency. Management:
  • resuscitation
  • terlipressin
  • prophylactic antibiotics
  • urgent endoscopic band ligation
  Non-selective beta-blockers (for example carvedilol or propranolol) or banding prevent first and recurrent bleeds.
• Hepatic encephalopathy: confusion, drowsiness and a flapping tremor (asterixis). Find and treat the trigger, such as infection, GI bleeding, constipation, electrolyte disturbance or sedatives. Give lactulose, with rifaximin to prevent recurrence.
• Hepatocellular carcinoma: ultrasound surveillance about every 6 months.
• Hepatorenal syndrome and malnutrition.

General care

• Treat the cause: antivirals, stopping alcohol, weight loss.
• Nutrition, with adequate protein and a late-evening snack.
• Vaccination.
• Avoid NSAIDs and sedatives.
• Early referral for liver transplantation when appropriate.

Exam pearls

• Any patient with cirrhosis who deteriorates: consider SBP, a GI bleed or infection.
• Lactulose works by reducing ammonia absorption from the gut.
• Avoid NSAIDs in cirrhosis, because they cause kidney injury and bleeding.

See also Hepatitis B, Hepatitis C, Upper GI Bleeding and our Clinical Eye Series: Abdominal Signs.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. Ascitic fluid neutrophils 400 cells/mm³ in cirrhosis. Diagnosis?

   1. Malignant ascites
   2. Pancreatic ascites
   3. Normal
   4. Spontaneous bacterial peritonitis
   5. Heart failure
   Show answer

   Answer: D. Spontaneous bacterial peritonitis
   Ascitic neutrophils above 250/mm³ diagnose SBP; treat with IV antibiotics and albumin.

2. A SAAG of 11 g/L or more indicates:

   1. Pancreatitis
   2. Portal hypertension
   3. Peritoneal TB
   4. Nephrotic syndrome only
   5. Peritoneal cancer
   Show answer

   Answer: B. Portal hypertension
   A high serum–ascites albumin gradient (≥11 g/L) points to portal hypertension.

3. Which drug pair is given in suspected variceal bleeding before endoscopy?

   1. Steroids and insulin
   2. Aspirin and heparin
   3. Omeprazole only
   4. Terlipressin and prophylactic antibiotics
   5. Propranolol IV and NSAID
   Show answer

   Answer: D. Terlipressin and prophylactic antibiotics
   Terlipressin reduces portal pressure; antibiotics reduce infection and rebleeding and improve survival.

4. First-line treatment for hepatic encephalopathy:

   1. NSAIDs
   2. High-protein restriction to zero
   3. Diuretics
   4. Lactulose (plus treating the trigger)
   5. Sedatives
   Show answer

   Answer: D. Lactulose (plus treating the trigger)
   Lactulose reduces ammonia absorption; rifaximin prevents recurrence. Always find the trigger.

5. Which is NOT part of the Child–Pugh score?

   1. Creatinine
   2. Encephalopathy
   3. Albumin
   4. INR
   5. Bilirubin
   Show answer

   Answer: A. Creatinine
   Child–Pugh: bilirubin, albumin, INR, ascites, encephalopathy. Creatinine is part of MELD.

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Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.