1. Top of page
  2. Summary
  3. Introduction
  6. Discussion
  8. References

Background Studies using consecutive liver biopsies constitute an attractive approach to gaining insight into the pathogenesis of alcoholic liver disease.

Aim To analyse histological factors at baseline, which are predictive of fibrosis progression and recurrence of alcoholic hepatitis.

Results A total of 193 drinkers underwent consecutive biopsies at an interval of 4 years. At baseline, 20 had normal livers, 135 steatosis, five fibrosis and 33 alcoholic hepatitis. The fibrosis score increased from 1.07 ± 0.07 to 1.7 ± 0.94 (P < 0.001). In multivariate analysis, only steatosis (P = 0.04), alcoholic hepatitis (P = 0.0004) and stage of fibrosis (P < 0.0001) were independent predictive factors of the fibrosis score at the second biopsy. Cirrhosis developed more frequently in patients with steatosis (11%) and alcoholic hepatitis (39%) than in others (0%, P < 0.0001). Alcoholic hepatitis recurred more frequently in patients with alcoholic hepatitis at baseline: 58% vs. 15%, P < 0.0001. In multivariate analysis, alcoholic hepatitis at the first biopsy was the only predictive factor of its recurrence (P < 0.0001).

Conclusions In a large cohort of drinkers with consecutive biopsies, steatosis, fibrosis stage and alcoholic hepatitis at baseline were independent predictive factors of fibrosis progression. In terms of mechanisms, we propose a novel concept of multiple hits of alcoholic hepatitis occurring in the same patient.


  1. Top of page
  2. Summary
  3. Introduction
  6. Discussion
  8. References

Mortality associated with alcohol-induced liver injury is related to cirrhosis and its complications.1, 2 Progress in the natural history of alcoholic liver disease constitutes an important challenge for clinicians; it should enable them to focus on a specific subgroup of patients with high risk of developing significant liver fibrosis.3

Most studies evaluating risk factors for fibrosis in patients with alcoholic liver disease have used cross-sectional observational data.4 Those studies showed that age,4–6 female gender,5–8 overweight6 and alcoholic hepatitis9, 10 were risk factors for cirrhosis. However, cross-sectional studies comport several limitations.3 For example, they are unable to analyse the impact of steatosis on the progression of liver fibrosis; this has been demonstrated only in longitudinal studies.11

Conversely, studies using consecutive liver biopsies constitute an attractive approach towards gaining additional insight into the mechanisms of fibrosis progression.12 In alcoholic liver disease, studies using a design of repeated biopsies have provided valuable information,13–18 and suggest steatosis as a risk factor for development of cirrhosis.17 However, in those studies, the number of patients with repeated liver biopsies, ranging from 16 out of 7619 to 39 out of 8817 was not sufficient to determine the evolution of patients according to their initial histological diagnosis.

Alcoholic fatty liver, a lesion initially considered to be a benign condition, is now believed to be a risk factor in progression to liver fibrosis and/or cirrhosis.11, 17 However, it is still uncertain as to whether the severity of steatosis predicts fibrosis progression; indeed, in one study, the significance of this variable disappeared upon multivariate analysis.17 In addition to steatosis, controversy remains concerning the influence of perivenular fibrosis on progression to liver fibrosis.14, 15, 18, 20

Conversely, the major impact of alcoholic hepatitis on subsequent development of cirrhosis has been clearly established.9, 11, 13, 16, 19 However, whether exacerbation of fibrosis progression occurs after the initial episode of alcoholic hepatitis or is related to the development of multiple episodes of alcoholic hepatitis during alcohol consumption remains unknown. The hypothesis of multiple hits of alcoholic hepatitis is attractive; to our knowledge, however, no studies to date using consecutive biopsies have determined whether patients in whom alcoholic hepatitis is revealed on initial biopsy run the risk of having recurring episodes of alcoholic hepatitis. Such a demonstration would support the hypothesis that a specific host profile is required in the pathogenesis of alcoholic hepatitis, and would provide strong data supporting multiple hits of alcoholic hepatitis as the main contributor to exacerbated progression to liver fibrosis in a subgroup of heavy drinkers.

The specific aims of the present study, involving the largest cohort to date of heavy drinkers with consecutive liver biopsies, were (i) to analyse independent histological factors predicting fibrosis progression; and (ii) to determine whether multiple hits of alcoholic hepatitis occur in a particular subgroup of patients.


  1. Top of page
  2. Summary
  3. Introduction
  6. Discussion
  8. References


We retrospectively identified 193 patients with consecutive liver biopsies recruited from the Hepatogastroenterology Units of Antoine Béclère and Jean Verdier Hospitals. All patients continued drinking during the period between the two biopsies. Patients with consecutive liver biopsies were recruited if they fulfilled the following criteria: consumption of at least 50 g of alcohol per day over the previous year; negative status for the presence of hepatitis B surface antigen and antibodies to HCV and HIV virus; and the absence of other liver diseases including autoimmune hepatitis and primary liver cirrhosis. Patients with stage 4 fibrosis (cirrhosis) on the first biopsy were excluded. At each biopsy, patients were questioned about the total duration of their alcohol intake over the 5 years preceding hospitalization. The daily intake of alcoholic beverages was expressed in pure ethanol. Factors assessed at the time of the two biopsies included gender, age, alcohol consumption in grams per day, duration of alcoholism and body mass index (BMI). A blood sample was obtained to perform measurements of bilirubin, prothrombin time, mean corpuscular volume, albumin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), γ-glutamyl transpeptidase (GGT), creatinine, apolipoprotein-A1, alpha 2 macroglobulin and fasting levels of glucose, cholesterol and triglycerides.

Histological study

All patients underwent liver biopsy during the 2 weeks following admission for each hospitalization. Biopsy samples were routinely processed. The staining procedure included haematoxylin–eosin, Masson’s trichrome, reticulin according to Gordon and Sweet’s method and Perls staining. All biopsies were evaluated by two pathologists (FB and DS) who had had several years of experience in liver pathology and who were not aware of the identity of the patient, the order of the biopsy (first or second), clinical and biological data or the amount and duration of alcohol intake. For each biopsy sample, the pathologist filled out a previously validated questionnaire that had been simplified.21 The median lengths of the first and second liver biopsies were 2 cm (95% CI: 1.7–2 cm) and 1.8 cm (95% CI: 1.6–2 cm), with a number of portal tracts of 13 (95% CI: 12–14) and 15 (95% CI: 12–14), respectively.

The primary endpoint fibrosis score was assessed by using the Metavir score.22 Several scores have been proposed for staging of hepatic fibrosis in alcoholic liver disease. A highly detailed scoring system was proposed by Chevallier et al.23 but has not been used in routine practice because it includes as many as 18 potential variables. The Metavir system for scoring hepatic fibrosis has been validated on a large cohort of patients with alcoholic liver disease.20, 24 The correlation between the Metavir score and the area of fibrosis was higher in alcoholic liver disease (r = 0.87) than in viral chronic hepatitis (r = 0.66).20 Multiple regression analysis showed that the area of fibrosis was explained only by the Metavir score of fibrosis.20 Those authors slightly modified the original Metavir score via the addition of F4a for potential cirrhosis and F4b for definite fibrosis. The addition of F4a was designed for small biopsies obtained by transjugular biopsy. In the present study, we did not use this modification for two reasons: (i) over 95% of patients underwent percutaneous liver biopsies; and (ii) in addition, the authors showed that the good correlation observed between the area of fibrosis and the Metavir score was not dependent on the addition of the F4a grade. Therefore, the use of the Metavir score in alcoholic liver disease is a validated approach to determining progression of hepatic fibrosis in heavy drinkers. Fibrosis was coded as follows: fibrosis: 0, no fibrosis; 1, portal fibrosis without septa; 2, portal fibrosis with few septa; 3, portal fibrosis with many septa and 4, cirrhosis.

The other histological features were coded as follows:21 (i) fibrosis of the centrilobular vein: 0, no vein; 1, enlargement of the centrolobular vein; 2, fibrous septa between centrilobular veins; (ii) steatosis: 0, steatosis <10%; 1, 10–30%; 2, 30–50%; 3, 50–80%; 4, 80–100%; (iii) cholestasis: 0, none; 1, moderate or marked; (iv) necrosis or ballooning: 0, none; 1, moderate or marked and (v) intensity of alcoholic hepatitis: 0, absence; 1, discrete; 2, moderate or marked.25

A final pathological diagnosis was made for each liver biopsy sample based on the principal pathological abnormality according to the different items: normal liver (fat amount <10% and fibrosis score at 0–1), fatty liver (fat amount ≥10%), fibrosis alone, alcoholic hepatitis and cirrhosis.

Statistical analysis

The fibrosis score on the second liver biopsy was used as the endpoint for assessing progression of liver fibrosis. We analysed the relationship between the fibrosis score on the second liver biopsy and clinical and histological risk factors at baseline using univariate comparison followed by multivariate regression. The quantitative variables are expressed as means ± S.E. of the mean. Univariate analysis was performed by using parametric tests (Student’s t-test and Fischer’s exact test) and non-parametric tests (Mann–Whitney test). To test quantitative variables in univariate analysis, the cut-off level chosen was the median value. Variables at baseline that reached a P-value of ≤0.1 in univariate analysis were included in multiple regression analysis. In multiple regression analysis, the fibrosis score on the second liver biopsy was the dependent variable. Regression coefficients were expressed with their S.E. and 95% CI.


  1. Top of page
  2. Summary
  3. Introduction
  6. Discussion
  8. References

Clinical, biochemical and histological characteristics at baseline

A total of 193 heavy drinkers who had undergone consecutive biopsies were included in the study: 182 were recruited from Antoine Béclère Hospital and 11 from Jean Verdier Hospital (Table 1). At Antoine Béclère Hospital, liver biopsy was systematically proposed to hospitalized patients who drank at least 50 g of alcohol per day. Patients with consecutive liver biopsies were extracted from the computer system of Beclere Hospital. Between 1985 and 1997, this system logged all heavy drinkers having undergone liver biopsy. Between 1985 and 1997, a total of 2848 heavy drinkers were admitted to the Unit of Antoine Béclère Hospital. Among these, 1244 were excluded, including 596 for whom no liver biopsy was performed, 313 because of missing data and 335 because of serological markers of hepatitis B or C virus. Thus, 1604 patients were analysed: 608 had cirrhosis and, based on the liver biopsies, 996 patients had no cirrhosis. 194 (19%) had normal liver histology, 683 (69%) had steatosis (with or without fibrosis) and 119 (12%) had alcoholic hepatitis. One hundred and eighty-two of those 996 patients underwent consecutive liver biopsies between 1985 and 2003 and were included in the present study. Patients with consecutive liver biopsies did not differ from the total cohort of 996 patients in terms of gender (female 20% vs. male 22%), age (45.4 ± 10.22 years vs. 47 ± 11 years), alcohol intake (134 ± 56 g/day vs. 125 ± 84 g/day) or histological lesions [normal liver (10% vs. 19%), steatosis (70% vs. 69%) and alcoholic hepatitis (17% vs. 12%)]. At Jean Verdier Hospital, patients were identified by checking all those who had undergone consecutive biopsies from the Hepatology Unit. In this Unit, liver biopsy was not systematically proposed to heavy drinkers, but rather, according to the clinician’s decision. Clinical, biological and histological characteristics of the study population at baseline are given in Table 1. At baseline, histological lesions were classified as follows: 20 cases of normal livers (10%), 135 cases of steatosis (70%), five cases of fibrosis (2%) and 33 cases of alcoholic hepatitis (17%). The mean fibrosis score was 1.06 ± 0.073. There were no significant differences between the groups having normal liver, steatosis, fibrosis or alcoholic hepatitis in terms of male gender (95% vs. 79% vs. 78.8% vs. 60%), age (43.9 ± 2.3 years vs. 44.7 ± 0.9 years vs. 48.2 ± 1.8 years vs. 49.9 ± 4.6 years), duration of alcohol consumption (17.1 ± 3 years vs. 17.5 ± 1.2 years vs. 20.4 ± 2.5 years vs. 18.5 ± 6.6 years) or tobacco consumption (26.1 ± 4.2 packs-year vs. 22 ± 1.6 packs-year vs. 15.2 ± 3.3 packs-year vs. 24 ± 8.3 packs-year). The alcohol intake was significantly different among the four groups: (102.9 ± 12.2, 142.1 ± 4.7, 123.8 ± 9.7, 108 ± 24.5 g/day, P = 0.01). Mean corpuscular volume (P = 0.3), platelet count (P = 0.1), AST/ALT ratio (P = 0.4) and GGT (P = 0.3) were not correlated with the amount of daily alcohol intake.

Table 1.   Clinical, biological and histological characteristics of the 193 patients at the first biopsy
Male sex: n (%)155 (80)
  1. AST, aspartate aminotransferase; ALT, alanine aminotransferase.

Body mass index (kg/m2): mean ± S.E.22.6 ± 0.28
Daily alcohol intake (g/day): mean ± S.E.134.3 ± 4
Tobacco consumption (pack-year): mean ± S.E. 21.3 ± 1.4
AST (IU/L): mean ± S.E.51.8 ± 4.1
AST/ALT ratio: mean ± S.E.1.43 ± 0.07
γ-Glutamyl transpeptidase (IU/L): mean ± S.E.230.4 ± 27.4
Bilirubin (μmol/L): mean ± S.E.18.5 ± 1.3
Mean corpuscular volume (fl): mean ± S.E.104.1 ± 0.6
Platelet count (103/mm3)238 ± 12.6
Prothrombin time (%): mean ± S.E.93.1 ± 0.8
Glycemia (mmol/L): mean ± S.E.5.84 ± 0.17
Cholesterolemia (g/L): mean ± S.E.4.86 ± 0.16
Serum triglyceride (g/L): mean ± S.E.1.25 ± 0.07
Apolipoprotein A1: mean ± S.E.1.84 ± 0.06
Histological analysis
 Normal liver: n (%)20 (10.4)
 Steatosis: n (%)135 (70)
 Alcoholic hepatitis: n (%)33 (17)
 Isolated fibrosis5 (2.6)
Mean fibrosis score1.06 ± 0.073

Histological and clinical factors at baseline associated with fibrosis stage at second liver biopsy

Univariate analysis

The mean delay between the two biopsies was 3.5 ± 0.18 years. At the second biopsy, patients still disclosed high levels of mean corpuscular volume (104 ± 0.7 fL), GGT (104.1 ± 0.6 IU/L), AST (56 ± 4.5 IU/L), AST/ALT ratio (1.6 ± 0.07) and normal platelet levels (220 ± 97 103/mm3). The percentage of patients with symptomatic disease (detectable jaundice with bilirubin ≥25 μmol/L) was similar at the first and second biopsy: 17% vs. 19%. Intervals between the first and second biopsy were not significantly different among patients according to initial histological diagnosis: normal liver group, 4.04 ± 0.6 years; steatosis group, 3.51 ± 0.22 years; alcoholic hepatitis group, 3.2 ± 0.45 years; and isolated fibrosis group, 3.8 ± 1.16 years. Groups having normal liver, steatosis, fibrosis and alcoholic hepatitis were not significantly different at first and second biopsy in terms of evolution of biological features indicative of an acute change in the patient’s disease, such as differences in bilirubin (3 μmol/L vs. 0 μmol/L vs. 0 μmol/L vs. 3 μmol/L), AST (6 IU/L vs. 0 IU/L vs. −5 IU/L vs. 14 IU/L ) and prothrombin times (0% vs. 0% vs. −3% vs. 0%). The BMI of patients with steatosis or alcoholic hepatitis were higher than in patients with normal livers: 23.03 ± 2.98 vs. 22.7 ± 3.91 vs. 19.6 ± 3.35, P = 0.002. Overall, the mean fibrosis score increased between the first and second biopsy: 1.07 ± 0.07 vs. 1.7 ± 0.94, P < 0.001. At second biopsy, daily alcohol intake was 121.3 ± 4.3 g/day. The daily alcohol intakes at first and second biopsy were highly correlated (P ≤ 0.0001). Between the two biopsies, patients mentioned that their daily alcohol intake had decreased, was unchanged or had increased in 53%, 22% and 27% of cases, respectively. Comparison of patients according to their evolution of alcohol intake showed that this did not impact on fibrosis progression (1.6 ± 0.14 vs. 1.76 ± 0.22 vs. 1.84 ± 0.2, NS) or on the development of cirrhosis (14% vs. 22% vs. 27%, NS). At the second biopsy, platelet count (P = 0.003), AST/ALT (P ≤ 0.0001) and GGT (P = 0.01) were correlated with fibrosis progression. In univariate analysis, the following variables reached a P-value <0.05 as predictive factors of fibrosis at the second liver biopsy (Table 2): duration of alcoholism (P = 0.04), age (P = 0.004), steatosis P = 0.002, alcoholic hepatitis (P < 0.0001) and stage of fibrosis (P < 0.0001). Interestingly, steatosis persisted in 88% of patients who had had steatosis on the first biopsy. The relationship between evolution of fibrosis and extent of steatosis at baseline was complex. Patients with a steatosis score at baseline >2 (corresponding to the median score of extent of steatosis at baseline) revealed a higher fibrosis score on the second liver biopsy than patients with a steatosis score ≤2 (<30%): 1.99 ± 0.15 vs. 1.53 ± 0.12, P = 0.02. However, progression of fibrosis was not significantly different in patients with the highest steatosis score (>50%) than in others: 1.75 ± 0.46 vs. 1.70 ± 0.1. As expected, all morphological criteria of alcoholic hepatitis were significantly associated with a higher fibrosis score on the second liver biopsy: ballooned hepatocytes or necrosis (P < 0.0001), neutrophil infiltration (P < 0.0001) and the presence of Mallory bodies (P < 0.0001). Evolution of fibrosis was not influenced by the intensity of alcoholic hepatitis (2.69 ± 0.24 in discrete alcoholic hepatitis vs. 3.25 ± 0.44 in moderate/severe alcoholic hepatitis, P = 0.27), nor by the intensity of the different morphological features of alcoholic hepatitis (data not shown).

Table 2.   Factors at baseline predictive of fibrosis on the second liver biopsy (univariate analysis)
Explicatory variablesFibrosis scoreSignificant P-value
Age <45 years1.43 ± 0.14P = 0.004
Age ≥ 45 years1.97 ± 0.127
Male1.71 ± 0.11P = 0.8 (NS)
Female1.8 ± 0.21
Body mass index (BMI) <22 kg/m21.74 ± 0.14P = 0.97 (NS)
BMI ≥ 22 kg/m21.74 ± 0.14
Fasting blood glucose < 4.9 mmol/L1.61 ± 0.16P = 0.39 (NS)
Fasting blood glucose ≥ 4.9 mmol/L1.79 ± 0.13
Daily alcohol intake < 100 g/day1.94 ± 0.16P = 0.1 (NS)
Daily alcohol intake ≥ 100 g/day1.61 ± 0.12
Duration of alcoholism < 15 years1.48 ± 0.13P = 0.04
Duration of alcoholism ≥ 15 years1.95 ± 0.14
Tobacco consumption < 25 packs/year1.86 ± 0.12P = 0.08 (NS)
Tobacco consumption ≥ 25 packs/year1.49 ± 0.16
Absence of steatosis0.92 ± 0.25P = 0.002
Presence of steatosis1.82 ± 0.10
Absence of alcoholic hepatitis1.50 ± 0.10P < 0.0001
Presence of alcoholic hepatitis2.73 ± 0.21
Absence of significant fibrosis on the first biopsy1.27 ± 0.10P < 0.0001
Presence of significant fibrosis on the first biopsy2.67 ± 0.15
Absence of perivenular fibrosis on the first biopsy1.47 ± 0.13P = 0.08 (NS)
Presence of perivenular fibrosis on the first biopsy1.80 ± 0.14

The percentage of patients developing cirrhosis at the second liver biopsy was significantly higher in patients with steatosis (11%) and alcoholic hepatitis (39%) than in patients without those lesions (0%, P < 0.0001).

Multivariate analysis

In multivariate analysis, only the delay between the two biopsies (P = 0.02), steatosis (P = 0.04), alcoholic hepatitis (P = 0.0004) and stage of fibrosis (P < 0.0001) were independent predictive factors of the fibrosis score on the second liver biopsy (Table 3). In multivariate analysis restricted only to patients with standardized protocol of liver biopsy (from Béclère Hospital), the delay between the two biopsies, steatosis, alcoholic hepatitis and stage of fibrosis were still independent predictive factors of fibrosis progression.

Table 3.   Independent predictive factors at baseline of fibrosis on the second liver biopsy (multiple regression analysis)
VariablesRegression coefficient (95% CI)S.E.Significant P-value
Age at first biopsy0.002 (0.01–0.02)0.008P = 0.80 (NS)
Daily alcohol intake at first biopsy−0.0004 (−0.003–0.002) 0.001P = 0.74 (NS)
Duration of alcoholism0.007 (−0.01–0.02)0.008P = 0.37 (NS)
Tobacco consumption−0.004 (−0.01–0.004)0.004P = 0.3 (NS)
Delay between the two biopsies in years0.07 (0.007–0.13)0.03P = 0.03
Perivenular fibrosis at first biopsy−0.23 (−0.52–0.06)0.147P = 0.12 (NS)
Steatosis at first biopsy0.42 (0.014–0.83)0.21P = 0.04
Alcoholic hepatitis at first biopsy0.74 (0.34–1.13)0.20P = 0.0004
Fibrosis at first biopsy0.69 (0.54–0.84)0.08P < 0.0001

Histological and clinical factors at baseline predictive of alcoholic hepatitis on the second liver biopsy

In univariate analysis, steatosis (P = 0.001), fibrosis (P = 0.04) and alcoholic hepatitis (P < 0.0001) at baseline were predictive factors for disclosing alcoholic hepatitis on the second liver biopsy. Age (P = 0.5), sex gender (P = 0.8), alcohol intake (P = 0.4), tobacco consumption (P = 0.6) and BMI (P = 0.6) were not associated with the presence of alcoholic hepatitis on the second liver biopsy. Patients with alcoholic hepatitis on the first biopsy had a higher probability of revealing alcoholic hepatitis on the second biopsy: 58% vs. 15%, P < 0.0001. According to the initial pathological diagnosis, the probability of disclosing alcoholic hepatitis on the second liver biopsy was as follows: 0% for patients with normal liver, 18% for patients with steatosis, 58% for patients with alcoholic hepatitis and 0% for patients with isolated fibrosis (P < 0.0001).

In multivariate analysis, using alcoholic hepatitis on second liver biopsy as the dependent variable (logistic regression), only the presence of alcoholic hepatitis at baseline (regression coefficient 1.79, P < 0.0001) was an independent predictive factor (even after adjustment for the centre), whereas steatosis and fibrosis stage were not (Table 4).

Table 4.   Independent predictive factors of the presence of alcoholic hepatitis on the second liver biopsy (logistic regression)
VariablesRegression coefficient (95% CI)S.E.Significant P-value
Steatosis at first biopsy0.23 (−0.072–0.536)0.16P = 0.13
Alcoholic hepatitis at first biopsy1.79 (0.92–2.66)0.44P < 0.0001
Fibrosis at first biopsy0.31 (−0.07–0.68)0.19P = 0.11


  1. Top of page
  2. Summary
  3. Introduction
  6. Discussion
  8. References

To our knowledge, the present study is the largest published cohort of heavy drinkers with consecutive liver biopsies focusing on histological features that predict progression of fibrosis. All patients continued to drink during the period separating the two biopsies. We agree that the retrospective design of the present study may have induced a potential bias in selection. However, this bias does not seem to have affected results as (as in previous studies) we showed that alcoholic hepatitis, steatosis and extent of fibrosis were independent predictive factors of fibrosis progression. Among these histological features, alcoholic hepatitis was associated with the highest risk of fibrosis progression, leading to the development of cirrhosis in 40% of cases. Moreover, we have shown for the first time that recurrence of alcoholic hepatitis is a common event in patients with alcoholic hepatitis on the first biopsy. However, in the absence of longitudinal determination of biological markers of inflammation such as C-reactive protein or pro-inflammatory cytokines [tumour necrosis factor-alpha, interleukin 6 (IL-6), IL-8], we cannot exclude the possibility of ‘chronic alcoholic hepatitis’ with continuous liver injury. The considerable time lapse between the two biopsies (4 years) lends support to our data indicating a novel concept of ‘multiple hits of alcoholic hepatitis’ or of ‘chronic alcoholic hepatitis’ occurring in the same patients.

It has been reported that patients with perivenular fibrosis show rapid fibrosis progression.14, 15, 18 However, the importance of perivenular fibrosis in the pathogenesis of alcohol-induced liver injury remains unknown, as studies evaluating this lesion were performed on a small cohort and multivariate analysis was not performed. In the present study, perivenular fibrosis did not predict fibrosis progression, as the trend towards significance in univariate analysis disappeared in multivariate analysis. Our results are in accordance with a recent study showing that perivenular fibrosis did not add any independent information concerning fibrosis.20 Therefore, we suggest that the presence of perivenular fibrosis may no longer be considered as a risk factor in fibrosis progression. However, although the length of biopsies was sufficient, we cannot exclude a bias in histological analysis, as the count centrolobular areas were not recorded.

In a previous study, we showed that excess weight was a risk factor for cirrhosis, alcoholic hepatitis and steatosis, and we proposed the concept of a possible potential role of the metabolic effects of ethanol ingestion caused by excess weight in patients with alcoholic liver disease.6 In the present study, we observed that patients with steatosis or alcoholic hepatitis had a higher BMI than those with normal liver. Intriguingly, the present study did not observe a correlation between excess weight and fibrosis progression because of the small number of patients suffering from obesity (n = 4). Such a low prevalence of overweight patients is at least in part explained by the exclusion of patients with cirrhosis at inclusion. Indeed, in our previous cross-sectional study showing excess weight as a risk factor for cirrhosis,6 11% of patients were overweight, and among them 60% were cirrhotic. Conversely, only 3% of patients without cirrhosis were overweight,6 which is very close to the present study. In addition, it is important to note that overweight patients with cirrhosis were older than non-overweight patients (56 years vs. 46 years).6 Therefore, longitudinal studies focusing on patients without cirrhosis at inclusion would require a huge sample size and a follow-up period of at least 10 years to explore the role of overweight. The present longitudinal study was not designed to answer this question.

Experimental data from animal models point to steatosis as a continuous phenomenon, and an important histological feature of alcohol-induced liver injury.26–28 The present study supported steatosis as an independent predictive factor for a higher fibrosis score, and it was responsible for cirrhosis in 11% of cases. In a study of 88 patients with pure alcoholic fatty liver, fibrosis progression was observed in 19% of cases and, as in our study, cirrhosis occurred in approximately 10% of patients.17 Conversely, data concerning the impact of the severity of steatosis on fibrosis progression remain controversial.11, 17, 19, 29 Like others,19, 29 we observed that the severity of steatosis did not seem to influence fibrosis progression.

The major impact of alcoholic hepatitis on fibrosis progression is clearly established, but its natural history remains poorly elucidated. Several studies showed that alcoholic hepatitis may no longer be considered as an acute process,13, 16, 19 but none of these compared the evolution of alcoholic hepatitis based on the presence or absence of such a lesion on initial biopsy. The present study demonstrated that alcoholic hepatitis at baseline is an independent predictive factor in disclosure of this lesion on subsequent biopsy. Our data supported the hypothesis of multiple hits of alcoholic hepatitis rather than persistence of the phenomenon. Indeed, if persistence of the same process were, in fact, the underlying mechanism, alcoholic hepatitis would be observed in almost all patients with this lesion on the first biopsy, as we observed for steatosis, a continuous phenomenon which persisted in 90% of cases. Thus, the present study supported the hypothesis that in a particular subgroup of patients, the persistence of alcoholic hepatitis over a long period via multiple hits or ‘a chronic process’ may explain at least, in part, the exacerbation of fibrosis progression.


  1. Top of page
  2. Summary
  3. Introduction
  6. Discussion
  8. References

We thank Mrs Jerri Bram for revision of the manuscript.

Declaration of personal and funding interests: None.


  1. Top of page
  2. Summary
  3. Introduction
  6. Discussion
  8. References
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