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Clouston AD, Gouw ASH, Tiniakos D, Bedossa P, Brunt EM, Callea F, Dienes HP, Goodman ZD, Hubscher SG, Kakar S, Kleiner DE, Lackner C, Park YN, Roberts EA, Schirmacher P, Terracciano L, Torbenson M, Wanless IR, Zen Y, Burt AD. Severe acute liver disease in adults: Contemporary role of histopathology. Histopathology 2024. [PMID: 38773813 DOI: 10.1111/his.15212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/11/2024] [Accepted: 05/02/2024] [Indexed: 05/24/2024]
Abstract
Liver biopsies have consistently contributed to our understanding of the pathogenesis and aetiologies of acute liver disease. As other diagnostic modalities have been developed and refined, the role of biopsy in the management of patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and acute hepatitis, including acute liver injury (ALI), has changed. Liver biopsy remains particularly valuable when first-line diagnostic algorithms fail to determine aetiology. Despite not being identified as a mandatory diagnostic tool in recent clinical guidelines for the management of ALF or ACLF, many centres continue to undertake biopsies given the relative safety of transjugular biopsy in this setting. Several studies have demonstrated that liver biopsy can provide prognostic information, particularly in the context of so-called indeterminate hepatitis, and is extremely useful in excluding conditions such as metastatic tumours that would preclude transplantation. In addition, its widespread use of percutaneous biopsies in cases of less severe acute liver injury, for example in the establishment of a diagnosis of acute presentation of autoimmune hepatitis or confirmation of a probable or definite drug-induced liver injury (DILI), has meant that many centres have seen a shift in the ratio of specimens they are receiving from patients with chronic to acute liver disease. Histopathologists therefore need to be equipped to deal with these challenging specimens. This overview provides an insight into the contemporary role of biopsies (as well as explant and autopsy material) in diagnosing acute liver disease. It outlines up-to-date clinical definitions of liver injury and considers recent recommendations for the diagnosis of AIH and drug-induced, autoimmune-like hepatitis (DI-AIH).
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Affiliation(s)
- Andrew D Clouston
- Centre for Liver Disease Research, School of Medicine (Southern), University of Queensland, Princess Alexandra Hospital, Ipswich, Australia
| | - Annette S H Gouw
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, the Netherlands
| | - Dina Tiniakos
- Department of Pathology, Aretaieion Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Elizabeth M Brunt
- Pathology and Immunology, Washington University School of Medicine, St Louis, MO, USA
| | | | - Hans-Peter Dienes
- Institute of Pathology, Meduniwien, Medical University of Vienn, Wien, Austria
| | - Zachary D Goodman
- Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Stefan G Hubscher
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Sanjay Kakar
- Department of Pathology, University of California, San Francisco, CA, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Carolin Lackner
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Young N Park
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Eve A Roberts
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Luigi Terracciano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Michael Torbenson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ian R Wanless
- Department of Pathology, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Yoh Zen
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Alastair D Burt
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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2
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Joshi R, Parkhi M, Gupta A, Susngi T, Kumar A, Dhibar DP, Mitra S. Alcoholic foamy degeneration: an unusual presentation of the alcoholic liver disease diagnosed on autopsy. Autops Case Rep 2023; 13:e2023446. [PMID: 38034523 PMCID: PMC10688259 DOI: 10.4322/acr.2023.446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/14/2023] [Indexed: 12/02/2023]
Abstract
Alcoholic foamy degeneration (AFD) is an uncommon presentation of alcoholic liver disease (ALD) with characteristic histologic findings of foamy-looking hepatocytes due to the presence of abundant microvesicles of fat within the cytoplasm predominantly in perivenular and midzonal regions without inflammation and fibrosis. It is underdiagnosed as the patients quickly recover after alcoholic abstinence and are rarely caught on biopsies. AFD has better prognosis than alcoholic hepatitis, and the injury mechanism is different, warranting a different diagnosis. We present an uncommon case of AFD incidentally diagnosed during autopsy in a chronic alcoholic and diabetic man.
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Affiliation(s)
- Rashmi Joshi
- Post Graduate Institute of Medical Education and Research, Department of Histopathology, Chandigarh, India
| | - Mayur Parkhi
- Post Graduate Institute of Medical Education and Research, Department of Histopathology, Chandigarh, India
| | - Anjali Gupta
- Post Graduate Institute of Medical Education and Research, Department of Histopathology, Chandigarh, India
| | - Terence Susngi
- Post Graduate Institute of Medical Education and Research, Department of Internal Medicine, Chandigarh, India
| | - Ashwani Kumar
- Post Graduate Institute of Medical Education and Research, Department of Histopathology, Chandigarh, India
| | - Deba Prasad Dhibar
- Post Graduate Institute of Medical Education and Research, Department of Internal Medicine, Chandigarh, India
| | - Suvradeep Mitra
- Post Graduate Institute of Medical Education and Research, Department of Histopathology, Chandigarh, India
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3
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Forrest E, Goldin R. Letter: the value of quality liver biopsy before initiation of corticosteroids for severe alcoholic hepatitis-authors' reply. Aliment Pharmacol Ther 2022; 55:1072. [PMID: 35362124 DOI: 10.1111/apt.16890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Ewan Forrest
- Glasgow Royal Infirmary and University of Glasgow, UK
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4
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Spahr L, Lanthier N, Tihy M, Frossard JL, Rubbia-Brandt L, Goossens N. Clinical Presentation and Gene Expression of Acute Alcohol-Induced Microvesicular Steatosis Mimicking Alcoholic Hepatitis. Hepatol Commun 2021; 5:618-628. [PMID: 33860120 PMCID: PMC8034579 DOI: 10.1002/hep4.1669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/03/2020] [Accepted: 12/17/2020] [Indexed: 12/14/2022] Open
Abstract
Acute alcoholic microvesicular steatosis (MIC) may complicate heavy alcohol intake and present as alcoholic hepatitis (AH) syndrome. However, detailed clinical, biological, and histologic data associated with MIC are scarce. We compared the clinical presentation, histologic features, and hepatic transcriptomic of patients presenting with AH due to either MIC or severe alcoholic steatohepatitis (ASH). In this case-control study, patients who drank heavily (>100 g/day) with the AH syndrome were included either in the MIC group (>50% severe microvesicular steatosis, no inflammation) or in the severe ASH group (polynuclear neutrophil infiltration, macrosteatosis, ballooned hepatocytes). All patients received standard supportive care plus steroids for those with severe ASH and were followed up for 3 months. Whole-liver transcriptome profiling was performed on liver snap-frozen biopsies. Compared to ASH (n = 24, mean age 49.3 years), patients in the MIC group (n = 12, mean age 49.1 years) had a higher reported alcohol intake (P < 0.01), lower Model for End-Stage Liver Disease score (P < 0.05), lower hepatic venous pressure gradient (P < 0.01), higher alanine aminotransferase (P < 0.02) and gamma-glutamyltransferase (P < 0.001), higher triglycerides (P < 0.001) and total cholesterol (P < 0.002), but similar bilirubin levels (P = 0.54). At histology, patients with MIC had a lower fibrotic stage compared to those with ASH (P < 0.001). A higher density of megamitochondria was seen in MIC compared to ASH (P < 0.05). During follow-up, death or transplantation occurred in 4/12 (33%) patients with MIC and 7/24 (29%) patients with severe ASH. Differential hepatic gene expression in MIC compared to ASH included down-regulation of genes related to inflammation and fibrosis and up-regulation of genes involved in lipid metabolism and mitochondrial function. Conclusion: MIC is an acute, noninflammatory, potentially severe alcoholic liver injury mimicking ASH, is associated with a lower fibrosis stage, and has a distinct gene expression profile.
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Affiliation(s)
- Laurent Spahr
- Gastroenterology and HepatologyUniversity Hospitals of Geneva and Faculty of MedicineGenevaSwitzerland
| | - Nicolas Lanthier
- Gastroenterology and HepatologyUniversity Hospitals of Geneva and Faculty of MedicineGenevaSwitzerland.,Gastroenterology and HepatologySaint-Luc University HospitalUniversité Catholique de LouvainBrusselsBelgium
| | - Mathieu Tihy
- Clinical PathologyUniversity Hospitals of Geneva and Faculty of MedicineGenevaSwitzerland
| | - Jean-Louis Frossard
- Gastroenterology and HepatologyUniversity Hospitals of Geneva and Faculty of MedicineGenevaSwitzerland
| | - Laura Rubbia-Brandt
- Gastroenterology and HepatologySaint-Luc University HospitalUniversité Catholique de LouvainBrusselsBelgium
| | - Nicolas Goossens
- Gastroenterology and HepatologyUniversity Hospitals of Geneva and Faculty of MedicineGenevaSwitzerland
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Kwong S, Meyerson C, Zheng W, Kassardjian A, Stanzione N, Zhang K, Wang HL. Acute hepatitis and acute liver failure: Pathologic diagnosis and differential diagnosis. Semin Diagn Pathol 2019; 36:404-414. [PMID: 31405537 DOI: 10.1053/j.semdp.2019.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute hepatitis and acute liver failure are severe medical conditions that require early clinical intervention. Histopathologic findings on a liver biopsy or a liver explant may help identify the underlying etiology or provide an important direction for further clinical, laboratory and radiographical investigation. This review is divided into two main portions. The first portion concentrates on various etiologies and discusses unique histologic features that can be associated with specific etiologies. The second portion describes the general morphologic features based on which the diagnosis of acute hepatitis and acute liver failure are made. Histopathologic distinction between collapse and cirrhosis and limitations of histopathologic assessment for underlying etiologies are addressed in this portion. Another focus of this review is non-necrotic acute liver failure, which typically features diffuse microvesicular steatosis secondary to various etiologies causing mitochondrial dysfunction. Molecular testing serves an increasingly important role in the diagnosis and management of this group of disorders.
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Affiliation(s)
- Stanley Kwong
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States.
| | - Cherise Meyerson
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Wei Zheng
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Ari Kassardjian
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Nicholas Stanzione
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Kuixing Zhang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States.
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Ma M, Falloon K, Chen PH, Saberi B, Pustavoitau A, Ozdogan E, Li Z, Philosophe B, Cameron AM, Gurakar A. The Role of Liver Transplantation in Alcoholic Hepatitis. J Intensive Care Med 2019; 34:277-291. [PMID: 29879862 DOI: 10.1177/0885066618780339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute alcoholic hepatitis is a syndrome of jaundice and hepatic decompensation that occurs with excessive alcohol consumption. The diagnosis can be made with a combination of clinical characteristics and laboratory studies, though biopsy may be required in unclear cases. Acute alcoholic hepatitis can range from mild to severe disease, as determined by a Maddrey discriminant function ≥32. Mild forms can be managed with supportive care and abstinence from alcohol. While mild form has an overall good prognosis, severe alcoholic hepatitis is associated with an extremely high short-term mortality of up to 50%. Additional complications of severe alcoholic hepatitis can include hepatic encephalopathy, gastrointestinal bleeding, renal failure, and infection; these patients frequently require intensive care unit admission. Corticosteroids may have short-term benefit in this group of patients if there are no contraindications; however, a subset of patients do not respond to steroids. New emerging therapies, which target hepatic regeneration, bile acid metabolism, and extracorporeal liver support, are being investigated. Liver transplantation for alcoholic liver disease was traditionally only considered in patients who have achieved 6 months of abstinence, in part due to social and ethical concerns regarding the use of a limited resource. However, the majority of patients with severe alcoholic hepatitis who fail medical therapy will not live long enough to meet this requirement. Recent studies have demonstrated that early liver transplantation in carefully selected patients with severe alcoholic hepatitis who fail medical therapy can provide a significant survival benefit and yields survival outcomes comparable to liver transplantation for other indications, with 6-month survival rates ranging from 77% to 100%. Alcohol relapse posttransplantation remains an important challenge, and heavy consumption can contribute to graft loss and mortality. Future investigation should address the substantial post-liver transplantation recidivism rate, from improving selection criteria to increasing posttransplantation substance abuse treatment resources.
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Affiliation(s)
- Michelle Ma
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katie Falloon
- 2 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Po-Hung Chen
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Behnam Saberi
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aliaksei Pustavoitau
- 3 Department of Anesthesiology and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elif Ozdogan
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zhiping Li
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Benjamin Philosophe
- 4 Division of Transplant Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrew M Cameron
- 4 Division of Transplant Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmet Gurakar
- 1 Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
Excessive alcohol consumption can lead to a spectrum of liver histopathology, including steatosis, steatohepatitis, foamy degeneration, fatty liver with cholestasis, and cirrhosis. Although variability in sampling and pathologist interpretation are of some concern, liver biopsy remains the gold standard for distinguishing between steatohepatitis and noninflammatory histologic patterns of injury that can also cause the clinical syndrome of alcohol-related hepatitis. Liver biopsy is not routinely recommended to ascertain a diagnosis of alcohol-related liver disease in patients with an uncertain alcohol history, because the histologic features of alcohol-related liver diseases can be found in other diseases, including nonalcoholic steatohepatitis and drug-induced liver injury.
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Affiliation(s)
- Nitzan C Roth
- Sandra Atlas Bass Center for Liver Diseases Department of Medicine Northwell Health, 400 Community Drive, Manhasset, NY 11030, USA.
| | - Jia Qin
- Department of Pathology, The Department of Veteran Affairs New York Harbor Healthcare System, 800 Poly Place, Brooklyn, NY 11209, USA
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Lieber SR, Rice JP, Lucey MR, Bataller R. Controversies in clinical trials for alcoholic hepatitis. J Hepatol 2018; 68:586-592. [PMID: 28966126 PMCID: PMC6709528 DOI: 10.1016/j.jhep.2017.09.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 08/18/2017] [Accepted: 09/20/2017] [Indexed: 12/13/2022]
Abstract
Alcoholic hepatitis (AH) is the most severe form of alcoholic liver disease, contributing to significant morbidity and mortality. Yet, the only available therapies that improve survival are corticosteroids and liver transplantation, with no new drugs successfully developed for decades. This article briefly describes the current state of affairs in AH therapy and examines the practical and ethical challenges of conducting controlled trials in patients with severe AH. While prednisolone is considered standard of care in severe AH, this recommendation remains controversial given the marginal benefits and questionable long-term safety of steroids. Placebo-controlled trials without steroids may be necessary and ethically justified in certain populations with AH who have not been adequately investigated. Ultimately, we suggest that the field will advance with the development of a plausible animal model of true AH, a consensus on a composite clinical endpoint that does not rely solely on mortality, as well as the adoption of the NIAAA Alcoholic Hepatitis Consortia recommendations regarding standard definitions and when to request a liver biopsy prior to study entry.
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Affiliation(s)
- Sarah R. Lieber
- Division of Gastroenterology and Hepatology and 3Biochemistry Departments of Medicine and Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - John P. Rice
- Division of Gastroenterology and Hepatology, Departments of Medicine and Public Health, University of Wisconsin, WI, USA
| | - Michael R. Lucey
- Division of Gastroenterology and Hepatology, Departments of Medicine and Public Health, University of Wisconsin, WI, USA
| | - Ramon Bataller
- Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh Liver Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Roth NC, Saberi B, Macklin J, Kanel G, French SW, Govindarajan S, Buzzanco AS, Stolz AA, Donovan JA, Kaplowitz N. Prediction of histologic alcoholic hepatitis based on clinical presentation limits the need for liver biopsy. Hepatol Commun 2017; 1:1070-1084. [PMID: 29404443 PMCID: PMC5721404 DOI: 10.1002/hep4.1119] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/01/2017] [Accepted: 10/09/2017] [Indexed: 12/17/2022] Open
Abstract
The clinical presentation of alcoholic hepatitis (AH) can be mimicked by other alcoholic liver diseases. The aim of this study was to identify clinical features that predict AH on liver biopsy. Biopsies from patients hospitalized for presumed severe AH were used to identify a derivation cohort (101 patients) and validation cohort (71 patients). Using histologic scores for hepatocyte ballooning, Mallory-Denk bodies, and lobular inflammation, 95 patient biopsies (55%) were classified as definite AH, 55 (32%) as possible AH, and 22 (13%) as no AH. Survival was similar among the groups, but mortality was significantly increased for patients with fatty change ≤50% on initial liver biopsy. An analysis limited to uninfected patients with definite AH or no AH in the derivation cohort identified a greater leukocyte count at admission and radiographic evidence of liver surface nodularity as independent predictors of definite AH on biopsy (P < 0.05). In the derivation cohort, the leukocyte count thresholds for ensuring 100% specificity for diagnosing definite AH were 10 × 109/L if the liver surface was nodular and 14 × 109/L if the liver surface was smooth, with a sensitivity of 76% and an area under the receiver operator characteristic curve of 0.88. In the validation cohort, these thresholds had a specificity of 86%, a sensitivity of 59%, and an area under the receiver operator characteristic curve of 0.72. Conclusion: The combination of an elevated leukocyte count and a nodular liver surface in the absence of active infection retrospectively identified patients with a high likelihood of histologic AH for whom liver biopsy may not be necessary. For patients with suspected severe AH who do not fulfill these criteria, liver biopsy is important to exclude other variants of alcoholic liver disease. (Hepatology Communications 2017;1:1070-1084).
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Affiliation(s)
- Nitzan C. Roth
- Keck School of MedicineDivision of Gastrointestinal and Liver Diseases, University of Southern CaliforniaLos AngelesCA
| | - Behnam Saberi
- Division of Liver DiseasesIcahn School of Medicine at the Mount Sinai HospitalNew YorkNY
| | - Jared Macklin
- Keck School of MedicineDivision of Gastrointestinal and Liver Diseases, University of Southern CaliforniaLos AngelesCA
| | - Gary Kanel
- Department of PathologyUniversity of Southern CaliforniaLos AngelesCA
| | - Samuel W. French
- Department of Pathology and Laboratory Medicine, Harbor‐University of CaliforniaLos Angeles Medical CenterTorranceCA
| | - Sugantha Govindarajan
- Department of Pathology and Laboratory Medicine, Harbor‐University of CaliforniaLos Angeles Medical CenterTorranceCA
| | - Anthony S. Buzzanco
- Department of Pathology and Laboratory Medicine, Harbor‐University of CaliforniaLos Angeles Medical CenterTorranceCA
| | - Andrew A. Stolz
- Keck School of MedicineDivision of Gastrointestinal and Liver Diseases, University of Southern CaliforniaLos AngelesCA
| | - John A. Donovan
- Keck School of MedicineDivision of Gastrointestinal and Liver Diseases, University of Southern CaliforniaLos AngelesCA
| | - Neil Kaplowitz
- Keck School of MedicineDivision of Gastrointestinal and Liver Diseases, University of Southern CaliforniaLos AngelesCA
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