Cirrhosis classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Charmaine Patel, M.D. [2]Sudarshana Datta, MD [3]

Overview

Cirrhosis of the liver may be classified using two classification methods based on etiology and morphology. Currently, classifying cirrhosis based on morphology is not recommended, as it requires an invasive procedure to examine the gross appearance of the liver, and provides little diagnostic value. Classifying cirrhosis according to etiology is a more acceptable form of classification, as it may be attained through non-invasive laboratory testing, and has a higher diagnostic value.

Classification Based On Etiology

Cirrhosis may be classified on the basis of etiology. This is the most widely accepted method of classification.

(a) Alcoholic cirrhosis

• Most common cause of cirrhosis
• Caused by continuous and prolonged alcohol abuse
• According to American Academy of Family Physicians (AAFP), approximately 60-70 percent of all cases of cirrhosis are due to alcohol abuse

(b) Post-necrotic cirrhosis

• Occurs after a massive event causes liver cell death
• Viral hepatitis is the most common cause
• Agents that are toxic to the liver may also be a cause

(c) Biliary cirrhosis

• Results from any disease that leads to biliary obstruction
• May be due to a blockage in the bile duct and inflammation
• Excess bile in the liver may cause tissue destruction, resulting in jaundice

(d) Cardiac cirrhosis

• Caused by congestive heart failure leading to poor circulation of oxygenated blood to the liver
• Poor circulation may result in liver cell death, and subsequent replacement of dead cells by fibrous tissue.

(e) Cirrhosis due to genetic disorders

• Caused by genetic disorders such as hemochromatosis, Wilson's disease, or alpha-1 antitrypsin deficiency.

(f) Cirrhosis due to malnutrition

• Cirrhosis caused by various forms of malnutrition, particularly chronic starvation.

Classification Based On Morphology

Cirrhosis has historically been classified based upon the nodular morphology that is seen on upon the gross appearance of the liver. Accurate assessment of the liver morphology can only be obtained through surgery, biopsy, or autopsy, therefore more recently, more non-invasive means of classifying and determining the causes of cirrhosis are used.

Micronodular	Macronodular	Mixed
Micronodular cirrhosis is characterized by nodules that are less than 3mm in diameter	Macronodular cirrhosis is characterized by nodules that are more than 3mm in diameter	Micronodular cirrhosis can often progress into macronodular cirrhosis. During this transformation, a mixed form of cirrhosis may be seen.
Causes: Alcohol Hemochromatosis Cholestatic causes of cirrhosis Hepatic venous outflow obstruction Nutritional causes of cirrhosis	Causes: Chronic viral hepatitis Hemochromatosis Wilson's disease Post-necrotic cirrhosis	Mixed nodular cirrhosis is also seen in Indian childhood cirrhosis.

Classification Based On Severity

• Child-Pugh scoring system is used for predicting the risk of complications and severity of cirrhosis.
• The Child-Pugh score employs five clinical measures of liver disease. Each measure is scored 1-3, with 3 indicating most severe derangement.

Measure	1 point	2 points	3 points	units
Bilirubin (total)	<34.2 (<2)	34.2-51.3 (2-3)	>51.3 (>3)	μmol/l (mg/dL)
Serum albumin	>35	28-35	<28	g/L
INR	<1.7	1.71-2.3	> 2.3	no unit
Ascites	None	Suppressed with medication	Refractory	no unit
Hepatic encephalopathy	None	Grade I-II (or suppressed with medication)	Grade III-IV (or refractory)	no unit

• It should be noted that different textbooks and publications use different measures. Some older reference works substitute PT prolongation for INR.
• If the PT is <4 seconds than control, it is assigned 1 point.
• If the PT is 4-6 seconds over control, then it scores 2 points and if PT is >6 seconds over control, it scores 3 points.
• In primary sclerosing cholangitis (PSC) and primary biliary cirrhosis (PBC), the bilirubin references are changed to reflect the fact that these diseases feature high conjugated bilirubin levels:
  • The upper limit for 1 point is 68 μmol/l (4 mg/dL) and the upper limit for 2 points is 170 μmol/l (10 mg/dL).

Interpretation

• Chronic liver disease is classified into Child-Pugh class A to C:

Points	Class	One year survival	Two year survival
5-6	A (Compensated cirrhosis)	100%	85%
7-9	B (Failing)	80%	60%
10-15	C (Decompensated cirrhosis)	45%	35%

• Child-Pugh scores may be used to predict development of complications of cirrhosis.
• A Child-Pugh class C indicates higher chance of developing bleeding varices than those with class A.