Nonalcoholic Steatohepatitis Is Associated With a Higher Risk of Advanced Colorectal Neoplasm

Yuri Cho; Soo-Kyung Lim; Sae Kyung Joo; Dong-Hyong Jeong; Jung Ho Kim; Jeong Mo Bae; Jeong Hwan Park; Mee Soo Chang; Dong Hyeon Lee; Yong Jin Jung; Byeong Gwan Kim; Donghee Kim; Kook Lae Lee; Won Kim


Liver International. 2019;39(9):1722-1731. 

In This Article

Abstract and Introduction


Background & Aims: Nonalcoholic fatty liver disease (NAFLD) is known to increase the risk of adenomatous colonic polyps. However, the role of screening colonoscopy in patients with biopsy-proven NAFLD in detecting advanced colorectal neoplasm is not clearly evidence-based. Therefore, we investigated whether the histological severity of NAFLD is associated with advanced colorectal neoplasm.

Methods: This study included patients ≥18 years old who underwent screening colonoscopy between 2013 and 2018 within a biopsy-evaluated prospective NAFLD cohort. Advanced colorectal neoplasm was defined as an adenomatous polyp greater than 10 mm in diameter and/or with villous histology and/or with high-grade dysplasia or adenocarcinoma.

Results: Among the 476 patients with clinically suspected NAFLD, 379 patients were diagnosed with biopsy-proven NAFLD and 97 patients had no evidence of NAFLD histologically, who were analyzed as healthy controls. The prevalence of advanced colorectal neoplasm was 11.1% (n = 53). Patients with advanced colorectal neoplasm had higher grade of steatosis (P = 0.004) and higher stage of hepatic fibrosis (P = 0.044) than those with normal colonoscopic findings or low-grade adenomatous polyp. Multivariable logistic regression analysis revealed that the presence of nonalcoholic steatohepatitis (NASH) was an independent risk factor for both colorectal polyp (odds ratio [OR], 2.08; 95% confidential interval [CI], 1.12-3.86; P = 0.020) and advanced colorectal neoplasm (OR, 2.81; 95% CI, 1.01-7.87; P = 0.049).

Conclusions: The presence of biopsy-proven NASH was significantly associated with an increased risk of advanced colorectal neoplasm among patients with NAFLD. This finding may alert physicians to conduct screening colonoscopy in patients with NASH to detect advanced colorectal neoplasm early.


Nonalcoholic fatty liver disease (NAFLD) has become the most common form of liver disorders and may progress to nonalcoholic steatohepatitis (NASH), advanced fibrosis, cirrhosis, or hepatocellular carcinoma.[1] Because the prevalence of NAFLD is increasing, metabolic syndrome with insulin resistance is becoming an important focus of research.[2] Similarly, colorectal cancer (CRC) is one of the most common forms of cancer, and some clinical studies have suggested that metabolic syndrome is an important risk factor for CRC.[3,4] Accordingly, the role of screening colonoscopy to identify the risk of developing CRC in patients with NAFLD is also of paramount importance as a component of a comprehensive therapeutic process.

NAFLD has a wide histological spectrum that ranges from simple steatosis to NASH. Within this spectrum, NASH with advanced fibrosis was shown to have higher morbidity and mortality resulting from liver-related outcomes, cardiovascular disease with type 2 diabetes mellitus, and malignancies such as CRC.[5,6] Recent studies using non-invasive diagnostic tools such as abdominal ultrasound to assess NAFLD, have shown an association between NAFLD and an increased risk of CRC.[7–9] However, the gold standard for diagnosis of NAFLD is liver biopsy. Thus, assessing the risk of CRC according to the histological severity of NAFLD would be valuable.

As the most common cause of chronic liver disease, NAFLD is likely to be associated with inflammation-mediated colorectal adenomatous polyp or colorectal neoplasm.[10,11] However, to date, few studies have shown the relationship between the histological severity of NAFLD and colorectal neoplasm.[12,13] In this prospective cohort study, we aimed to investigate the association between the histological severity of NAFLD and the prevalence of advanced colorectal neoplasm.