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Child-Pugh and liver function before surgery: what the grade means for you | CION Cancer Clinics
The Child-Pugh score grades how well a scarred liver is working, using three blood tests and two things the doctor checks by examining you. Grade A livers are the ones in which resection is normally considered. Grade B usually allows only a small operation, and grade C rules resection out. This page explains what goes into the score, what else the team checks, and what to ask. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
MI
Medically reviewed by Dr. Mohammed ImaduddinConsultant Surgical Oncologist · MBBS, MS (General Surgery), MCh (Surgical Oncology) · last reviewed September 2026, next review due September 2027
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On this page
- What is the Child-Pugh score, and why does it decide surgery?
- The five things the score is made from
- The grade and what it usually means for surgery
- What else does the team look at?
- From the first blood test to a decision
- What families say about liver function tests, and what is true
- What can this page not tell you?
- Common questions about liver function before surgery
The short answer
What is the Child-Pugh score, and why does it decide surgery?
The Child-Pugh score is a simple grade of how well a scarred liver is working. It is built from three blood tests and two things the doctor checks by examining you. The result is a grade of A, B or C. Surgeons use it because a liver that is already struggling cannot afford to lose more tissue, however small the tumour.
How the score is built
Each of the five items is given 1, 2 or 3 points depending on how abnormal it is, and the points are added up. A total of 5 or 6 is grade A, coping well. A total of 7 to 9 is grade B, under strain. A total of 10 to 15 is grade C, failing. Your report may show the letter, the number or both.
What each grade usually means for an operation
Grade A is the group in which liver resection is normally considered, including larger operations if the remnant is big enough. In grade B, only a small operation is usually contemplated, and the team often suggests something other than surgery. In grade C, resection is not offered, because the liver left behind would very likely fail.
The score describes the liver, not the cancer. A grade A liver with a large tumour and a grade B liver with a tiny one are two different problems.On your report
The five things the score is made from
- Bilirubin
- The yellow pigment the liver clears from the blood. When it rises, the skin and eyes turn yellow. A high level means the liver is not keeping up.
- Albumin
- A protein the liver makes. A low level means the liver's factory is running slow, and it is one reason fluid collects in the belly and legs.
- INR or prothrombin time
- How quickly the blood clots. The liver makes the clotting factors, so a slow result points to a weak liver, and to more bleeding during surgery.
- Ascites
- Fluid collecting inside the belly. Found by examination or on the scan. None, a little that responds to tablets, or a lot, each scores differently.
- Encephalopathy
- Confusion, sleepiness or a change in behaviour because the liver is not clearing toxins from the blood. Even a mild episode adds points.
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The grade and what it usually means for surgery
Grade on the report
What the surgical team usually does
Grade A: the liver is coping well
Resection is considered, with the remnant measured for anything larger than a small operation
Grade B: the liver is under strain
Only a small resection is usually contemplated; heat treatment or transplant often preferred
Grade C: the liver is failing
Resection is not offered; transplant, other treatments or supportive care are discussed
Any grade with raised portal pressure
Surgery becomes less likely whatever the letter, because bleeding and liver failure risks rise
Beyond the score
What else does the team look at?
Child-Pugh is a starting point. It was designed for people with cirrhosis, and it misses things a surgeon needs to know.
Portal pressure
Blood backing up through a scarred liver raises pressure in the portal vein. A low platelet count, a large spleen or swollen veins in the food pipe all point to it. It matters even in grade A.
Remnant volume
The scan is used to measure how much liver would remain after the planned cut. A scarred liver needs a larger remnant than a healthy one because each gram does less work and regrows slowly.
Dye clearance test
Some centres inject a green dye and measure how fast the liver clears it from the blood. It gives a live reading of liver function that the blood tests alone cannot.
Usually written as
- ICG clearance
- ICG retention
MELD score
Another score built from bilirubin, clotting and kidney function. It is used mainly to rank people for a transplant, but surgeons also read it alongside Child-Pugh before a resection.
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The pathway
From the first blood test to a decision
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Blood tests
Liver function, clotting, platelets, kidney function and hepatitis tests. These give the three numbers in the score and flag portal pressure.
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Examination and scan
The doctor checks for fluid in the belly and any confusion. A contrast CT or MRI shows the tumour, the spleen and any fluid the examination missed.
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The grade is worked out
The five items are scored and added. If the grade is A and the tumour looks removable, the team goes on to measure the remnant and may add a dye clearance test.
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Endoscopy, if pressure is suspected
A camera down the food pipe looks for swollen veins. Finding them changes the plan even when the score is good.
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Tumour board
Surgeons, liver physicians, oncologists and radiologists set the score, the pressure, the remnant and the tumour side by side and agree what to propose. You are told the reasoning, not just the answer.
Commonly believed
What families say about liver function tests, and what is true
"His liver tests are normal, so there is no cirrhosis."
Ordinary liver enzyme tests can be near normal in a badly scarred liver. Child-Pugh uses different measures, and the scan, the platelet count and an examination fill in the rest. Normal enzymes are reassuring but not proof.
"Grade A means the liver is healthy."
Grade A means a scarred liver is coping well. It is still a scarred liver, with less reserve than a healthy one. That is why the surgeon also measures the remnant and checks the portal pressure before agreeing to anything large.
"We can improve the score with tonics before the operation."
Some items do respond to treatment. Fluid in the belly can be controlled and hepatitis can be suppressed, and the team will do both. But herbal tonics do not repair scar tissue, and some harm the liver. Tell the team about everything you are taking.
"A bad score means nothing can be done."
A bad score means a resection is unsafe. It does not rule out heat treatment, treatment through the artery, or in some cases a transplant. Those are real treatments, not consolation prizes.
Being straight with you
What can this page not tell you?
It cannot tell you your own grade, or whether you or your parent will be offered surgery. The score is one input among several, weighed against the tumour, the portal pressure and the remnant volume. Two people with the same letter can be given different advice for good reasons.
What the score is not
It is not a measure of how serious the cancer is, and it says nothing about what will happen after treatment. It was designed decades ago for people with cirrhosis and was never meant to be the last word on surgery, which is why the other tests on this page exist.
Questions worth asking
Ask what your grade is and which items pushed it up, and whether any of them can be treated before a decision is made. Ask whether portal pressure has been checked and how. Ask how much liver would remain. And ask what the team would recommend if surgery were ruled out, so you hear the whole picture at once.
Bring every earlier blood report to the appointment. A change over time tells the team more than one result on its own.Questions we are asked
Common questions about liver function before surgery
Is Child-Pugh done for everyone having liver surgery?
It is most useful where there is cirrhosis or another long-standing liver disease. In someone with a healthy liver, for example bowel cancer that has spread to the liver, the ordinary liver tests and the remnant measurement carry more weight.
Can the grade change?
Yes, in both directions. Fluid in the belly can be controlled, hepatitis can be suppressed and albumin can rise with better nutrition, which may move a borderline score. A drinking relapse or an infection can push it the other way. That is why the score is repeated close to the operation date.
Why does a low platelet count matter so much?
Platelets are trapped in a spleen that has swollen because blood is backing up through the scarred liver. So a low count is an indirect sign of raised portal pressure, as well as a direct cause of more bleeding during surgery. It is one of the first numbers a liver surgeon looks at.
What is the ICG test, and does it hurt?
A harmless green dye is injected into a vein and a sensor on the finger or a blood test measures how quickly the liver clears it. It feels like an ordinary injection. Not every centre uses it, and it is usually reserved for borderline cases.
Grade B has been mentioned. Is surgery completely off?
Not always, but it becomes a much harder case to make. A very small tumour near the surface, with no raised portal pressure, is sometimes removed in grade B at experienced centres. More often the team recommends heat treatment or considers a transplant.
Can a transplant be done instead of a resection?
For selected small liver cancers in a cirrhotic liver, yes. A transplant removes the cancer and the scarred liver together. Whether it applies depends on the size and number of tumours, the rest of your health and whether a donor is available. The tumour board will raise it if it is an option.
Should he stop his medicines before the tests?
No. Do not stop or change any medicine, including hepatitis tablets, blood thinners, diuretics or diabetes medicines, unless the surgical team tells you to and tells you when. Bring a list of everything taken, including herbal and Ayurvedic preparations, because some of them affect the liver.
Are these tests covered by Aarogyasri or insurance?
Blood tests and scans done as part of an approved cancer treatment plan are usually covered. Aarogyasri, CGHS, ECHS and EHS are accepted at CION, and most cashless insurers are empanelled. Call the helpline with your scheme or policy details and we will check before you travel.
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Sources
- Cancer Research UK — Surgery for liver cancer
- National Cancer Institute — Adult Primary Liver Cancer Treatment (PDQ), health professional version
- NICE — Cirrhosis in over 16s: assessment and management (NG50)
- American Cancer Society — Surgery for liver cancer
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Liver Surgery With Cirrhosis: Is It Possible?The decision this score feeds intoFuture Liver Remnant ExplainedThe other measurement the team needsLiver Failure After ResectionThe complication the score is trying to predictFitness, Tests and PrehabilitationThe rest of the work-up before any cancer operationMedicines Around Cancer SurgeryWhat to tell the team about tablets and tonics
Talk to us
Have a liver function report you do not understand?
Send it to us or call the helpline. A surgical oncologist will read it with you and explain what it means for the options open to you. One helpline serves every CION centre.