Beyond scoring: a modern interpretation of disease progression in chronic liver disease

[...]complexity has been introduced by the recent description of the entity termed 'acute on chronic liver failure' (ACLF) which refers to a very rapid progression of liver injury and multiorgan failure in cirrhotic patients at all stages following a defined or an undefined precipitating illness. 3 The aetiology of chronic liver disease has a profound impact on the pattern of fibrotic evolution and on the relative predominant mechanism It is increasingly clear that different CLDs are characterised by different predominant profibrogenic mechanisms and, while cirrhosis is the common result of progressive fibrogenesis, there are distinct patterns of fibrosis development in different and even within the same CLD ( figure 1 ). For these and other reasons (sampling error, lack of adequate standards, etc), the value of liver biopsy as a gold standard slowly became questionable for clinicians and pathologists particularly when biopsy started to be used almost exclusively for the identification of 'disease stage', that is, the extent of tissue fibrosis and, accordingly, fibrosis and stage have been confused in histological staging systems.\n 75 A hyperdynamic circulation is a hallmark of advanced cirrhosis. 76 Norfloxacin partially reversed the hyperdynamic circulation in cirrhotic patients. 74 Similar observations were made with rifaximin, which resulted in an improvement in systemic haemodynamics in patients with alcoholic cirrhosis and ascites, 77 which also reduced portal pressure in animal models.