Child-Pugh Scores for Cirrhosis
| Variable | 1 Point | 2 Points | 2 Points |
| encephalopathy | absent | mild-moderate | severe to coma |
| ascites | absent | slight | moderate |
| bilirubin | <2 | 2-3 | >3 |
| albumin | >3.5 | 2.8-3.5 | <2.8 |
| prothrombin time | 1-4 | 4-6 | >6 |
Class A = 5 points, class B=7-9 points, class C=10 or more points
Ascites:
- Reduce dietary sodium, restrict fluid to 1.5 L/day
- Diuretics – furosemide and spironolactone
- No amount of weight restriction if edema, but if not 0.5 kg/day loss
- Monitoring for electrolyte imbalances, renal impairment or gynecomastia (spironolactone causes).
- Add midodrine (increases effective circulating blood volume and renal perfusion by increasing systemic and splanchnic blood pressure) and rifaximixin (lowers ammonia production in the bowel) as add-on to diuretics for enhanced diuresis in refractory ascites with improved systemic, renal hemodynamics and short-term survival.
Hepatic Encephalopathy:
Remember liver ABCs
- A: Airway support. Remove precipitating factors
- B: Bowels – reduce nitrogen load in gut
- C: If class C treat with:
- Lactulose – may continue long-term to prevent reoccurrence
- Antibiotics – reduce nitrogen producing bacteria in the gut: neomycin, metronidazole or rifaximin
- Can use polyethylene glycol instead of lactulose. If benzo overdose suspected, get flumazenil. Supplement with zinc if needed.
Gastroesophageal Varices:
- Fluid resuscitation and hemodynamic stabilization. May need sclerotherapy
- Reduce splenic flow and portal pressure with vasopressin drip or octreotide (octreotide preferred)
- Flouquinonlone (Cipro preferred) for 7 days. Alternative: ceftriaxone 1 g daily
- Non-selective beta-blockers prevent a repeat (propranolol, nadolol, carvedilol). Titrate to HR of 55 bpm or a 55% reduction in baseline.