Liver Cirrhosis: Classification, Surveillance

Child-Pugh Classification

Child-Pugh classification of the severity of cirrhosis

  1 2 3
Total bilirubin, mg/dL (μmol/L) < 2 (< 34) 2-3 (34-50) > 3 (> 50)
Serum albumin, g/L (μmol/L) > 35 (> 507) 28-35 (406-507) < 28 (< 406)
INR < 1.7 1.71-2.20 > 2.20
Ascites None Mild/Moderate
(diuretic responsive)
(diuretic refractory)
Hepatic encephalopathy None Grade I-II
(or suppressed with
Grade III-IV
(or refractory)


i 5-6 points: Class A
7-9 points: Class B
10-15 points: Class C

Surveillance Algorithm

Algorithm for surveillance for varices and primary prophylaxis

Based on Baveno VI consensus (EASL) and guideline on portal hypertension (AASLD)

*LSM, liver stiffness measurement;
**NSBB, non-selective beta-blocker e.g. propranolol 80-160 mg/day or carvedilol 6.25-50 mg/day

Persons with compensated cirrhosis without varices on screening endoscopy should have endoscopy repeated every 2 years with ongoing liver injury, obesity or alcohol use or every 3 years if liver injury is quiescent, e.g., after viral clearance, alcohol abstinence Hepatic Venous Pressure Gradient (HVPG) when available, allows a direct measure of portal hypertension and prognostic stratification of persons with compensated cirrhosis

HVPG < 6 mmHg: no portal hypertension
HVPG 6-9 mmHg: portal hypertension non clinically significant
HVPG ≥ 10 mmHg: clinically significant portal hypertension
In primary and secondary prophylaxis for variceal bleeding HVPG measurement allows to monitor efficacy of beta-blockers