Wang CY, Ma L, Zhao Y, Zhang XJ, Li S, Liu YG, Guo HM, Qi JG, Wang JQ, Ye WX, Li JZ, Zhang T. Clinical characteristics of colorectal polyps in patients with non-alcoholic fatty liver disease in high altitude areas. World J Gastrointest Oncol 2025; 17(12): 112761 [DOI: 10.4251/wjgo.v17.i12.112761]
Corresponding Author of This Article
Tao Zhang, Diagnosis and Treatment Center of High Altitude Digestive Disease, Xining Second People’s Hospital, No. 892 Qilian Road, Chengbei District, Xining 810003, Qinghai Province, China. zhangtaoqh@163.com
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (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: http://creativecommons.org/licenses/by-nc/4.0/
Dec 15, 2025 (publication date) through Dec 14, 2025
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World Journal of Gastrointestinal Oncology
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1948-5204
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Wang CY, Ma L, Zhao Y, Zhang XJ, Li S, Liu YG, Guo HM, Qi JG, Wang JQ, Ye WX, Li JZ, Zhang T. Clinical characteristics of colorectal polyps in patients with non-alcoholic fatty liver disease in high altitude areas. World J Gastrointest Oncol 2025; 17(12): 112761 [DOI: 10.4251/wjgo.v17.i12.112761]
Chun-Yan Wang, Department of Gastroenterology, Tianjin Second People’s Hospital, Tianjin Institute of Hepatology, Clinical School of the Second People’s Hospital, Tianjin Medical University, Tianjin 300110, China
Lin Ma, Ying Zhao, Xiao-Jiang Zhang, Graduate School, Tianjin Medical University, Tianjin 300070, China
Shuang Li, Endoscopy Center, Tianjin Second People’s Hospital, Tianjin 300110, China
Yong-Gang Liu, Department of Pathology, Tianjin Second People’s Hospital, Tianjin 300110, China
Hai-Ming Guo, Jun-Guo Qi, Jian-Quan Wang, Wei-Xin Ye, Jian-Zhou Li, Tao Zhang, Diagnosis and Treatment Center of High Altitude Digestive Disease, Xining Second People’s Hospital, Xining 810003, Qinghai Province, China
Co-corresponding authors: Jian-Zhou Li and Tao Zhang.
Author contributions: Wang CY and Ma L wrote the manuscript; Zhang XJ, Li S, Guo HM and Qi JG contributed to data collation; Zhao Y and Ma L contributed to statistical analysis; Liu YG contributed to liver pathology reading; Wang CY, Wang JQ and Ye WX contributed to manuscript revision; Wang CY, Li JZ and Zhang T contributed to research supervision; Wang CY contributed to project design. All authors have read and approve the final manuscript. Wang CY and Ma L contributed equally to this work as co-first authors. Li JZ, as the primary academic supervisor and the originator of the core research concept, was instrumental in the study's design, intellectual direction, and data interpretation. They will be the primary point of contact for inquiries related to the methodological framework and scientific hypotheses. Concurrently, Zhang T, as the principal investigator providing the essential clinical platform and financial support, oversaw the project's execution, ensured resource availability, and contributed significantly to the final critical revision of the manuscript. They will primarily address questions concerning the overall project governance, clinical implications, and resource management. We believe that this dual corresponding authorship structure ensures that all scholarly inquiries, from specific methodological details to broader project-related questions, can be addressed most comprehensively and efficiently during the peer-review process.
Supported by Tianjin Key Medical Discipline Construction Project, No. TJYXZDXK-3-019B.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of the Tianjin Second People’s Hospital.
Informed consent statement: Patients were not required to provide informed consent for the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment via written consent.
Conflict-of-interest statement: We have no financial relationships to disclose.
Data sharing statement: No additional data are available.
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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Tao Zhang, Diagnosis and Treatment Center of High Altitude Digestive Disease, Xining Second People’s Hospital, No. 892 Qilian Road, Chengbei District, Xining 810003, Qinghai Province, China. zhangtaoqh@163.com
Received: August 5, 2025 Revised: September 14, 2025 Accepted: November 10, 2025 Published online: December 15, 2025 Processing time: 128 Days and 6.7 Hours
Abstract
BACKGROUND
Colorectal cancer has high global incidence and mortality rates. Colorectal polyps are relatively common, with adenomatous polyps having a higher risk of malignant transformation. Non-alcoholic fatty liver disease (NAFLD) has been identified as a risk factor for the development of colorectal adenomas. Here, inpatients with NAFLD from the Second People's Hospital of Xining, in Qinghai Province, and the Second People's Hospital of Tianjin were investigated, comparing the biochemical indicators, colonoscopy findings, and pathological results of polyps between patients from low-altitude (Tianjin) and high-altitude (Qinghai Province) areas. Risk factors associated with the occurrence of adenomatous polyps in NAFLD patients from high-altitude areas were also explored.
AIM
To investigate the clinical characteristics of colorectal polyps in NAFLD patients from high-altitude areas.
METHODS
A total of 848 patients with NAFLD were enrolled. Of these, 118 underwent colonoscopy between January 2021 and January 2024 at the Second People's Hospital of Tianjin (low-altitude), while the remaining 730 patients were assessed during the same period at the Second People's Hospital of Xining, Qinghai (high-altitude). All enrolled patients met the diagnostic criteria for NAFLD, and the excised colorectal polyps were analyzed pathologically.
RESULTS
Colorectal polyps were found in 585 cases (80.1%) in the Qinghai cohort and 91 patients (77.1%) in the Tianjin group, indicating a slightly higher incidence in the Qinghai group, although the difference was non-significant (P = 0.449, P > 0.05). The two groups showed no significant difference in sex (P = 0.153, P > 0.05) but differed significantly in the proportion of younger patients (P < 0.01), although no differences were seen in terms of middle-aged and elderly patients (P > 0.05). No differences in polyp numbers were observed between the two regions (P > 0.05), while significant differences were found between the ≤ 0.5 cm and > 1 cm and ≤ 2 cm proportions in both regions (P < 0.05), with no differences in other size categories (P > 0.05). Polyp locations (proximal colon, distal colon) also differed significantly (P < 0.05). Patients in Qinghai were more prone to adenomatous polyps, accounting for 89.2% of polyps, compared to those from Tianjin (P < 0.05). Patients in Qinghai had a higher incidence of tubular adenomas with low-grade dysplasia, while tubular adenomas with high-grade dysplasia predominated in patients from Tianjin (P < 0.05). Patients in Tianjin had a significantly higher proportion of mixed hyperplastic-adenomatous polyps (P < 0.05), as well as greater proportions of mixed hyperplastic-adenomas with low-grade dysplasia (P < 0.05). The incidence of hyperplastic polyps was markedly higher in Tianjin, accounting for 58.4% (P < 0.05). Multivariate logistic regression indicated that sex [OR = 1.693, 95% confidence interval (CI): 1.131-2.536], smoking (OR = 0.604, 95%CI: 0.406-0.897), hypertension (OR = 0.683, 95%CI: 0.471-0.991), and white blood cell counts (WBC) (OR = 1.091, 95%CI: 1.015-1.173) were risk factors for the occurrence of adenomatous polyps in patients with NAFLD in high-altitude areas (Qinghai Province).
CONCLUSION
Patients with NAFLD from high-altitude regions have a higher incidence of colorectal polyps, with a significantly higher incidence of adenomatous polyps compared to other polyp types. Sex, smoking, hypertension, and WBC are risk factors for adenomatous polyps in NAFLD patients in high-altitude regions.
Core Tip: This retrospective study explored the incidence and characteristics of colorectal polyps in patients with non-alcoholic fatty liver disease (NAFLD) from high-altitude (Qinghai) and low-altitude (Tianjin) regions in China. Patient data were analyzed using SPSS 26.0. It was found that NAFLD patients from high-altitude regions had a higher incidence of colorectal polyps, of which the proportion of adenomatous polyps was significantly higher. Sex, smoking, hypertension, and white blood cell counts were observed to be risk factors for the development of adenomatous polyps. Proactive colonoscopy screening is recommended for NAFLD patients with these risk factors living at high altitudes to mitigate the risk of colorectal cancer.
Citation: Wang CY, Ma L, Zhao Y, Zhang XJ, Li S, Liu YG, Guo HM, Qi JG, Wang JQ, Ye WX, Li JZ, Zhang T. Clinical characteristics of colorectal polyps in patients with non-alcoholic fatty liver disease in high altitude areas. World J Gastrointest Oncol 2025; 17(12): 112761
Colorectal polyps are a common disorder of the digestive tract and are classified as benign tumors. Of these, adenomatous polyps are more common and are associated with a higher risk of malignant transformation. Colorectal cancer (CRC), one of the most prevalent tumors of the digestive tract, originates predominantly from adenomatous polyps. The progression from benign polyp to CRC typically follows an adenoma-carcinoma pathway. CRC is relatively common throughout the world, ranking high in terms of overall cancer incidence and mortality. Therefore, the early identification and treatment of adenomatous polyps in the colon are crucial to reducing both the incidence and mortality rates of CRC.
Non-alcoholic fatty liver disease (NAFLD) has been found to be a risk factor for the development of colorectal adenomas[1-3]. The average altitude of Tianjin is 3.5 m above sea level, making it one of the lowest-altitude provincial-level administrative regions in China. Qinghai Province is located on the Qinghai-Tibet Plateau, with an average altitude of 4058.4 m above sea level, where the low-oxygen environment may have significant adverse effects on human health. This study selected Qinghai Province and Tianjin Municipality as representative high-altitude and low-altitude regions, respectively, for comparison, to investigate the clinical characteristics and pathology of colorectal polyps in patients with NAFLD from these regions. The results indicated a relatively higher incidence of adenomatous polyps in NAFLD patients from the high-altitude region. The risk factors associated with the development of adenomatous polyps were also explored. The findings will provide a reference for the timely prevention and treatment of this condition, thereby reducing the risk of cancer development.
MATERIALS AND METHODS
Subjects
A total of 848 patients with NAFLD were enrolled. Of these, 118 patients underwent colonoscopy at the Second People's Hospital of Tianjin between January 2021 and January 2024, and 730 patients received colonoscopy at the Second People's Hospital of Xining, in Qinghai Province, during the same period. All enrolled patients met the diagnostic criteria for NAFLD, as outlined in the "Diagnosis and Treatment Guidelines for NAFLD (2018 Edition)"[4]. These guidelines state that “the diagnosis of NAFLD requires evidence of diffuse hepatic steatosis from academic imaging or histological studies, and the exclusion of ethanol (alcohol) abuse and other causes leading to hepatic steatosis”. Colorectal polyps were evaluated pathologically. The inclusion criteria for patient enrollment were: (1) Patients diagnosed as having NAFLD through examination; (2) Newly diagnosed colorectal polyps, first-time treatment; and (3) Aged between 18 and 80 years. Exclusion criteria: (1) Co-morbid viral hepatitis (hepatitis B virus or hepatitis C virus), autoimmune liver disease, alcoholic liver disease, or other liver diseases; (2) Progression to cirrhosis or hepatocellular carcinoma; (3) Polyps that had not been examined pathologically; (4) Incomplete clinical data; (5) Progression to CRC; and (6) History of colorectal diseases (including polyp resection history, inflammatory bowel disease, familial adenomatous polyposis) (Figures 1 and 2). All patients provided written informed consent. The study was approved by the Ethics Committee of the Second People's Hospital of Xining (Ethics Approval Number: 2025001) and by the Ethics Committee of the Second People's Hospital of Tianjin, Ethics Approval Number: [2025]8.
Figure 2 Flowchart of patient admission from Qinghai.
NAFLD: Non-alcoholic fatty liver disease; HBV: Hepatitis B virus; HCV: Hepatitis C virus.
Data collection
General information was collected for all the enrolled patients, including sex, age, body mass index (BMI), personal habits (smoking and drinking), medical history (diabetes, hypertension, coronary heart disease), and biochemical indicators, such as the levels of alanine aminotransferase, aspartate aminotransferase (AST), γ-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), total bilirubin (TBIL), albumin, high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol (TC), triglycerides (TG), and uric acid. Information on routine blood parameters, including white blood cell count (WBC), red blood cell count (RBC), hemoglobin (HGB), and platelet count (PLT), as well as the levels of the tumor markers carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and alpha-fetoprotein (AFP), was also obtained.
Colonoscopy
After preparation of the bowel with a polyethylene glycol electrolyte solution, colonoscopy was performed by experienced gastroenterologists from the Endoscopy Centers at the two hospitals, documenting the numbers, locations, and sizes of the polyps, which were then biopsied or removed endoscopically for pathological examination. Polyp numbers were categorized as solitary (single) or multiple (≥ 2), while sizes were classified according to diameter, namely, ≤ 0.5 cm, > 0.5 and ≤ 1 cm, > 1 and ≤ 2 cm, and ≥ 2 cm, with multiple polyps sized according to their maximum diameter. Two experienced pathologists from the Pathology Department analyzed and summarized the polyp pathology for diagnostic consensus. The polyps were further categorized by location, as follows: (1) Proximal colon (ascending colon, cecum, hepatic flexure, transverse colon); (2) Distal colon (splenic flexure, descending colon, sigmoid colon, rectum); and (3) Present in both proximal and distal regions.
Based on the results of the pathological examination, the polyps were classified as: (1) Hyperplastic polyps; (2) Adenomatous polyps; (3) Mixed hyperplastic-adenomatous polyps; (4) Hamartomas; and (5) Inflammatory polyps.
Statistical analysis
Data were analyzed using SPSS 26.0. Categorical data are presented as n (%) and were compared using χ2 tests. Normally distributed continuous data are presented as mean and standard deviation (mean ± SD) and were compared using t-tests. Univariate and multivariate regression were used for identifying potential risk factors for colorectal polyps in patients with NAFLD, with factors showing significance (P < 0.05) in the univariate analysis incorporated in the multivariate analysis for identification of independent risk factors for the development of colorectal polyps in patients with NAFLD.
RESULTS
Incidence of colorectal polyps in patients with NAFLD in the two groups
Among the 730 NAFLD patients in the Qinghai cohort, 585 (80.1%) were found to have colorectal polyps. Among the 118 patients with NAFLD from Tianjin, 91 (77.1%) were found to have colorectal polyps. The incidence of colorectal polyps was thus slightly higher among NAFLD patients in Qinghai Province, although the difference was not statistically significant (P = 0.449, P > 0.05).
Comparison of the general characteristics of the two groups
Of the 585 cases from Qinghai with colorectal polyps, 416 (71.1%) were male and 169 (28.9%) were female. 91 cases of colorectal polyps were identified in Tianjin, involving 58 (63.7%) male and 33 (36.3%) female patients; the difference between the sexes was non-significant (P = 0.153, P > 0.05). The patients were also classified as young (aged < 45 years), middle-aged (45-60 years), and older (aged > 60 years)[5]. There was a statistically significant difference in the proportions of young patients between the Qinghai and Tianjin cohorts (P < 0.01), while no significant difference was observed in terms of middle-aged and older patients (P > 0.05) (Table 1). Compared to the patients from Qinghai, those from Tianjin had higher BMI values, a higher prevalence of drinking history, and a higher prevalence of hypertension, all of which were statistically significant (P < 0.05) (Table 2).
Table 1 Comparison of gender and age between two groups of non-alcoholic fatty liver disease patients, n (%).
A comparison of the biochemical parameters between the two patient groups showed significant differences in the levels of AST, GGT, TBIL, direct bilirubin, glucose, TG, TC, total bile acids, blood urea nitrogen, HDL, and LDL (all P < 0.05). Comparison of RBC, HGB, and PLT levels also showed significant differences between the groups (all P < 0.05), with patients in Qinghai having higher RBC and HGB levels (Table 3).
Table 3 Analysis of biochemical results for two groups of patients.
Comparison of tumor markers between the two groups
The AFP, CA19-9, and CEA levels in both groups were within the normal ranges. The levels of AFP and CA19-9 in NAFLD patients from Tianjin were significantly higher than in those from Qinghai (P < 0.05) (Table 4).
Table 4 Analysis of tumor marker results for two groups of patients.
Comparison of polyp numbers, sizes, and locations between the two groups
Polyp numbers did not differ significantly between patients from the two regions (P > 0.05). In terms of polyp sizes, marked differences were seen between the groups in the polyp sizes of ≤ 0.5 cm and > 1 and ≤ 2 cm (P < 0.05), while no differences were seen in polyps of other sizes (P > 0.05). There was a statistically significant difference in the incidence of polyps between the proximal and distal colons of patients from the two locations (P < 0.05) (Table 5).
Table 5 Comparative analysis of the number, size, and location of polyps found during colonoscopy for two groups of patients, n (%).
Comparison of polyp pathology between the two groups
A total of 409 colorectal polyps from 585 patients in the Qinghai region were examined pathologically, compared with 77 polyps from the 91 patients in Tianjin. The findings showed that patients from the Qinghai region had a markedly higher incidence of adenomatous polyps (89.2% vs 24.7% for the Tianjin group, P < 0.05). Patients in Qinghai had a significantly higher incidence of tubular adenomas with low-grade dysplasia, while those from Tianjin had a significantly greater proportion of tubular adenomas with high-grade dysplasia (P < 0.05). Patients in Tianjin had a significantly higher number of mixed hyperplastic-adenomatous polyps (P < 0.05), as well as a greater proportion of mixed hyperplastic-adenomas with low-grade dysplasia (P < 0.05). The incidence of hyperplastic polyps in patients in Tianjin was significantly higher than in those from Qinghai (58.4% vs 10.0%; P < 0.05) (Table 6).
Table 6 Comparative analysis of polyp pathology between two groups of patients, n (%).
Risk factors for adenomatous polyps in patients in the Qinghai region
The overall prevalence of adenomatous polyps in patients from the Qinghai region was 89.2%. Therefore, factors contributing to the increased risk of adenomatous polyp development in this region were analyzed. Multivariate logistic regression revealed that sex [OR = 1.693, 95% confidence interval (CI): 1.131-2.536], smoking (OR = 0.604, 95%CI: 0.406-0.897), hypertension (OR = 0.683, 95%CI: 0.471-0.991), and WBC (OR = 1.091, 95%CI: 1.015-1.173) were independently associated with the risk of adenomatous polyp development (Tables 7 and 8).
Table 7 Univariable analyses of risk factors for adenomatous polyps occurrence in patients in Qinghai region.
The term “colorectal polyp” refers to any lesion protruding into the lumen of the colorectal tract. China has a high incidence of colorectal polyps. Adenomatous polyps are closely linked to the development of CRC. The adenoma-cancer sequence has been established as a recognized pattern in CRC development. It is estimated that between 70 and 90% of adenomatous colorectal polyps will transform into CRC. The high incidence of colorectal polyps, therefore, represents a serious threat to human health that requires monitoring and timely intervention. The transformation from benign adenoma to malignancy typically takes approximately 10 to 15 years, providing a window for early diagnosis and the implementation of preventive measures. Timely diagnosis and treatment of pre-cancerous lesions can effectively prevent progression to CRC, thereby reducing patient mortality.
The prevalence of colorectal polyps in patients with NAFLD is significantly higher than that in the non-NAFLD population[6]. Increases in altitude are associated with linear decreases in the absolute oxygen content[7]. Chronic intermittent hypoxia in high-altitude environments may exacerbate metabolic disorders and inflammatory states in patients with NAFLD[8], thereby contributing to the development and progression of colorectal polyps. The results of the present study showed that a greater number of colorectal polyps were detected in NAFLD patients in Qinghai Province compared to those in Tianjin. Furthermore, 89.2% of the detected polyps in patients from Qinghai Province were adenomatous polyps, suggesting that the incidence rate of adenomatous polyps in the NAFLD population in high-altitude areas is significantly higher than that in low-altitude areas. A study from Ecuador[9] showed individuals living at high altitudes had higher incidence rates of gastric, colorectal, liver/bile duct, and breast cancers, as well as lymphatic/hematopoietic malignancies, all of which were associated with more rapid progression. The chronic hypoxic environment in high-altitude regions may exacerbate insulin resistance, inflammatory responses, and dysbiosis of the gut microbiota in patients with NAFLD, thereby increasing the risk of developing colorectal polyps and CRC[10-12]. In terms of polyp size, the present study observed higher proportions of polyps measuring > 0.5 cm in NAFLD cases from the Qinghai region, while in Tianjin, more polyps measuring ≤ 0.5 cm were found relative to Qinghai. This may be related to the activation of hypoxia-inducible factors by chronic hypoxic environments, leading to increased levels of inflammation and oxidative stress, altered cellular metabolism and proliferation, and impairment of the intestinal barrier[13-15].
The results of the multivariate logistic regression analysis showed that sex, smoking, hypertension, and WBC were significant risk factors for the development of adenomatous polyps. Men are more likely to suffer from colorectal adenomas and CRC, which may be related to lifestyle habits[5,16]. A study from Japan showed a 55.0% incidence of adenomatous polyps in men 55.0%, compared to 38.3% in women[17]. This may be related to the protective effects of estrogen in women[18]. Studies have shown that the risk of colorectal adenomatous polyps is 5.244 times higher in smokers than in non-smokers[19], while other studies found that the duration of smoking history is associated with the risk of colorectal polyp development, with a dose-dependent relationship between them. This relationship was found to apply to colorectal polyps of various pathological types[20,21]. This may be linked to the large number of carcinogens in tobacco. At the same time, smoking can also lead to oxidative stress and DNA damage[22], which can, in turn, cause irreversible damage to the colorectal mucosa. Kaneko et al[23] analyzed a national database of health claims collected between 2005 and 2018, and found that after multivariate adjustment, compared with normal blood pressure, elevated blood pressure was associated with CRC (HR = 0.93, 95%CI: 0.85-1.01). Other studies have also shown a positive correlation between hypertension and CRC risk[24], and hypertension is also documented to increase the overall prevalence of colorectal adenomas[25]. Additionally, it has been found[26] that hypertension is predictive of colorectal adenoma recurrence. Inflammation is known to promote the malignant transformation of colonic adenomas, as it affects the microenvironment and signaling within the intestinal mucosa[27]. Cancer cells can evade immune surveillance and promote the formation of a tumor microenvironment, leading to exacerbation of inflammation and ultimately tumorigenesis[28,29]. Studies[30-32] have shown that changes in the proportions of inflammatory cell types and factors during this process can be used for both diagnosis and prognosis prediction, these changes include elevated proportions of leukocytes, peripheral blood neutrophils, monocytes, and platelets, along with decreased levels of lymphocytes.
Although some studies have shown that age is a risk factor for colorectal adenoma, as the incidence tends to increase gradually with age[33], and others have suggested a significant association between diabetes and colorectal adenomas[34], the present study did not reach consistent conclusions. These issues require further investigation in larger samples using different methods.
There are several limitations to this study. Information on the dietary habits and lifestyles of patients in the high-altitude region was lacking. Information on demographic factors, apart from sex and age, was also lacking, including data on income, educational level, family structure, and ethnicity. A prospective multicenter study is planned for further verification of the present results, with colonoscopy screening for high-risk patients to detect, diagnose, and treat potentially malignant polyps. The pathogenesis of adenomatous polyps in the Qinghai region will also be explored further, contributing to reducing the incidence of CRC.
CONCLUSION
Patients with NAFLD in high-altitude regions of China were found to have a higher incidence of colorectal polyps, together with a significantly higher incidence of adenomatous polyps compared to other polyp types. Sex, smoking, hypertension, and WBC were determined to be risk factors for the development of adenomatous polyps in NAFLD patients in high-altitude regions.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Oncology
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade C, Grade C, Grade C
Novelty: Grade C, Grade C, Grade C
Creativity or Innovation: Grade C, Grade C, Grade C
Scientific Significance: Grade C, Grade C, Grade C
P-Reviewer: El-Shabrawi MHF, MD, Professor, Egypt; Moyana T, MD, Professor, Canada S-Editor: Qu XL L-Editor: A P-Editor: Zhang YL
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