MetALD Was a More Notable Independent Risk Factor for Reflux Esophagitis Than MASLD: A Multicenter Cohort Study Using Directed Acyclic Graphs

Aim Metabolic abnormalities are recognized as risk factors for reflux esophagitis. Recently, the definition of MASLD and MetALD has been proposed. However, the effect of moderate alcohol consumption on its development remains unclear. We aimed to investigate independent risk factors for reflux esophagitis, including MASLD and MetALD. Methods The present multicenter observational cohort study enrolled 5441 consecutive health check‐up examinees between 2008 and 2021. Participants were classified into the non‐SLD, MASLD, or MetALD groups. Independent risk factors for reflux esophagitis were evaluated using multivariate Cox regression analysis. Directed acyclic graphs were constructed to identify direct risk factors for reflux esophagitis. Results Age, male sex, and hiatus hernia were independent risk factors for reflux esophagitis. MASLD (HR 1.1534, 95% CI 1.0069–1.3213, p = 0.0395) and MetALD (HR 1.9026, 95% CI 1.3554–2.6707, p = 0.0002) were also identified as independent risk factors compared to non‐SLD. Furthermore, the MetALD group showed a significantly higher risk than the MASLD group (HR 1.6495, 95% CI 1.1668–2.3319, p = 0.0046). The cumulative incidence in the MetALD group was significantly higher than in the MASLD group (85.1/1000 vs. 55.8/1000 person‐years, p = 0.0111). Directed acyclic graphs revealed that moderate alcohol consumption was identified as a direct risk factor for reflux esophagitis. Conclusions MASLD and MetALD were independent risk factors for reflux esophagitis. Patients with MetALD had a higher risk than patients with MASLD. Furthermore, moderate alcohol consumption was a direct risk factor for reflux esophagitis in patients with SLD. These findings highlight the importance of both MASLD and moderate alcohol consumption in the pathogenesis of reflux esophagitis.