Retrospective Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Apr 27, 2023; 15(4): 564-576
Published online Apr 27, 2023. doi: 10.4254/wjh.v15.i4.564
Peptic ulcer disease in non-alcoholic fatty liver disease hospitalizations: A new challenge on the horizon in the United States
Dushyant Singh Dahiya, Vinay Jahagirdar, Hassam Ali, Manesh Kumar Gangwani, Muhammad Aziz, Saurabh Chandan, Amandeep Singh, Abhilash Perisetti, Aakriti Soni, Sumant Inamdar, Madhusudhan R Sanaka, Mohammad Al-Haddad
Dushyant Singh Dahiya, Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI 48601, United States
Vinay Jahagirdar, Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO 64110, United States
Hassam Ali, Department of Internal Medicine, East Carolina University, Greenville, NC 27858, United States
Manesh Kumar Gangwani, Department of Internal Medicine, The University of Toledo, Toledo, OH 43606, United States
Muhammad Aziz, Department of Gastroenterology, The University of Toledo, Toledo, OH 43606, United States
Saurabh Chandan, Division of Gastroenterology and Hepatology, CHI Creighton University Medical Center, Omaha, NE 68131, United States
Amandeep Singh, Madhusudhan R Sanaka, Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
Abhilash Perisetti, Division of Gastroenterology and Hepatology, Kansas City Veterans Affairs Medical Center, Kansas City, MO 64128, United States
Aakriti Soni, Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, United States
Sumant Inamdar, Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
Mohammad Al-Haddad, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
Author contributions: Dahiya DS, Ali H, Inamdar S, Sanaka MR, and Al-Haddad M were responsible for the conception and design; Dahiya DS, Inamdar S, Sanaka MR, and Al-Haddad M provided administrative support; Dahiya DS and Ali H were responsible for provision, collection, and assembly of data; all authors were responsible for review of literature, drafting the manuscript, and revision of key components of the manuscript; and all authors have read and approve the final version of the manuscript.
Institutional review board statement: The National Inpatient Sample database contains numerous safeguards to protect patient privacy. It also lacks patient- and hospital-specific identifiers. Therefore, our study was exempt from Institutional Review Board (IRB) evaluation as per guidelines put forth by our institutional IRB for analysis of HCUP databases.
Informed consent statement: The data for this study was collected from the National Inpatient Sample (NIS) database. As the NIS database lacks patient-specific and hospital-specific identifiers, this study did not require informed consent.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The National Inpatient Sample is a publicly available database that can be accessed at Due to the availability of a large sample size within the NIS database, it is an ideal choice for the estimation of national trends and clinical outcomes.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Dushyant Singh Dahiya, MD, Doctor, Department of Internal Medicine, Central Michigan University College of Medicine, 1015 S Washington Ave, Third Floor, Saginaw, MI 48601, United States.
Received: January 7, 2023
Peer-review started: January 7, 2023
First decision: February 21, 2023
Revised: February 24, 2023
Accepted: March 27, 2023
Article in press: March 27, 2023
Published online: April 27, 2023
Research background

The association between peptic ulcer disease (PUD) and liver cirrhosis has been thoroughly investigated. However, there are knowledge gaps on PUD in non-alcoholic fatty liver disease (NAFLD) hospitalizations. As the prevalence of NAFLD continues to rise across the globe and in the United States, it is vital to identify individuals with NAFLD at high risk of adverse clinical outcomes from PUD.

Research motivation

In current literature, there is a knowledge gap on PUD in NAFLD hospitalizations. Hence, this study was designed to help fill the knowledge gaps that currently exist in this subset population.

Research objectives

Our main objective was to identify national trends in hospitalization characteristics, clinical outcomes, and complications for NAFLD hospitalizations with PUD. We also performed a comparative analysis between NAFLD and non-NAFLD hospitalizations with PUD to assess the influence of NAFLD on PUD.

Research methods

The National Inpatient Sample was used from 2009-2019 to identify all adult (≥ 18 years) NAFLD hospitalizations with PUD in the United States. Furthermore, a control group of all adult PUD hospitalizations without NAFLD were identified for comparative analysis. Statistical analysis was conducted using SAS 9.4. To test for the trend for proportions of binary variables, the Cochran-Armitage trend test was implemented. The trend for the averages of continuous variables in years was examined using linear regression. The Rao-Scott design-adjusted chi-square test examined the association between two categorical variables.

Research results

NAFLD-PUD hospitalizations increased from 3745 (2009) to 3805 (2019). Racial differences were noted as NAFLD hospitalizations with PUD increased for Whites and Hispanics, while a decline was observed for Blacks and Asians. There was an increase in all-cause inpatient mortality for NAFLD hospitalizations with PUD from 2% in 2009 to 5% in 2019 (P < 0.001). However, the rates of Helicobacter pylori (H. pylori) infection and upper endoscopy decreased during the study period. Despite a high comorbidity burden, we observed lower inpatient mortality, mean length of hospital stay, and mean total healthcare cost (THC) for NAFLD-PUD hospitalizations vs the non-NAFLD-PUD cohort. Perforation of the gastrointestinal tract, coagulopathy, alcohol abuse, malnutrition, and fluid and electrolyte disorders were identified as independent predictors of inpatient mortality for NAFLD hospitalizations with PUD.

Research conclusions

Between 2009-2019, inpatient mortality for NAFLD hospitalizations with PUD increased. However, there was a significant decline in H. pylori infections and esophagogastroduodenoscopy for NAFLD-PUD hospitalizations. After a comparative analysis, NAFLD-PUD hospitalizations had lower rates of mortality, mean length of hospital stay, and mean THC vs the non-NAFLD-PUD cohort despite a higher comorbidity burden.

Research perspectives

This is one of the few national studies which investigates trends, clinical outcomes, and complications of NAFLD hospitalizations with PUD, using one of the largest, multi-ethnic databases in the United States. Future research should be directed toward identifying the underlying cause of racial disparities for this subset population.