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We read with interest the study by Katoonizadeh et al1 of acute-on-chronic (alcoholic) liver failure (ACLF) and the accompanying Editorial 2 which cites our report3 of liver histology in decompensated alcoholic liver disease (ALD). We found features of alcoholic hepatitis (intralobular neutrophils, Mallory bodies and ballooning) to be more frequent and more severe in patients biopsied within a month of first onset of decompensation, compared with those biopsied before decompensation or later, and argued for a causal relationship. We acknowledge the strengths of the prospective study of Katoonizadeh et al1 but would interpret their results differently.
Their definition of ACLF1 excludes patients with no prior liver disease and also those without cirrhosis on biopsy. It thus excludes many patients with first presentation …