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It is usually not until development of advanced liver disease that stigmata of chronic liver disease become apparent. Early ALD is usually discovered during routine health examinations when liver enzyme levels are found to be elevated.
These usually reflect alcoholic hepatic steatosis. Microvesicular and macrovesicular steatosis with inflammation are seen in liver biopsy specimens. These histologic features of ALD are indistinguishable from those of nonalcoholic fatty liver disease.
Steatosis usually resolves after discontinuation of alcohol use. Continuation of alcohol use will result in a higher risk of progression of liver disease and cirrhosis. In patients with acute alcoholic hepatitis, clinical manifestations include fever, jaundice, hepatomegaly , and possible hepatic decompensation with hepatic encephalopathy, variceal bleeding, and ascites accumulation.
Tender hepatomegaly may be present, but abdominal pain is unusual.
Occasionally, the patient may be asymptomatic. Furthermore, alcohol metabolite—induced injury of hepatic mitochondria results in AST isoenzyme release. Folate level is reduced in alcoholic patients due to decreased intestinal absorption, increased bone marrow requirement for folate in the presence of alcohol, and increased urinary loss.
The magnitude of leukocytosis white blood cell depletion reflects severity of liver injury.
Histologic features include Mallory bodies , giant mitochondria, hepatocyte necrosis , and neutrophil infiltration in the area around the veins. Mallory bodies, which are also present in other liver diseases, are condensations of cytokeratin components in the hepatocyte cytoplasm and do not contribute to liver injury.
Liver transplantation remains the only definitive therapy. The requirements for transplant listing are the same as those for other types of liver disease, except for a 6-month sobriety prerequisite along with psychiatric evaluation and rehabilitation assistance i. Relapse to alcohol use after transplant listing results in delisting. Re-listing is possible in many institutions, but only after 3—6 months of sobriety.
There are limited data on transplant survival in patients transplanted for acute alcoholic hepatitis, but it is believed to be similar to that in nonacute ALD, non-ALD, and alcoholic hepatitis with MDF less than Even in those who drink more than g daily, only Nevertheless, alcohol-related mortality was the third leading cause of death in in the United States.
This condition has also been linked to asthma, bronchitis, chronic rhinitis, sinusitis, and otitis media. Researchers have reported potential associations between acid reflux and esophageal, oropharyngeal, and hypopharyngeal neoplasms .
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Studies have found that approximately half of the patients with mild LPR can avoid symptoms by implementing changes in their lifestyle . These lifestyle changes are related to eating, drinking, and other habits. For example, raising the bed at the head side has been shown to prevent LPR symptoms. It is also recommended that patients quit smoking, lose weight, and wear loose clothing.
Dietary Modifications LPR symptoms may be reduced by changing dietary habits. Patients are advised to eat food early at least two hours before bedtime to allow time for digestion before lying down . Moreover, patients with acid reflux diseases are also advised against ingesting too much coffee  or carbonated drinks, which are known to affect acidity and cause reflux .
Spicy foods irritate the lower esophageal mucosa leading to heartburn and a burning sensation in their chests. High-fat foods and chocolate are known to prolong gastric emptying, and high-fat foods take longer to digest and have been associated with higher incidences of GERD and erosive esophagitis .
Note that some studies have reported that a high-fat diet has no effect on esophageal acid exposure or transient relaxation of lower esophageal sphincter . Nonetheless, patients should be advised to avoid fatty diets to facilitate digestion and promote overall health. A high-calorie diet can also affect esophageal acid exposure.
One study found that a high-calorie diet was associated with prolonged acidity in the stomach, which could aggravate reflux symptoms . Lifestyle Changes Reflux diseases are known as lifestyle diseases. Patients are therefore advised to avoid smoking, as it is known to cause acid production . Smoking cigarettes is directly correlated with acid retention leading further to slow clearance of esophageal acid.
Smokers have also been shown to have a higher incidence of reflux symptoms, compared to non-smokers [69,70]. Researchers have identified a direct link between the consumption of alcoholic drinks and acid exposure and reflux. Alcoholic drinks of all types are a direct cause of heartburn. Consuming large quantities of alcohol poses the same risks, regardless of whether it was beer, wine, or spirits. Wine and beer have also been found to cause reflux, even in small quantities.
Endoscopic studies have revealed that white wine and beer have similar effects on reflux esophagitis and abnormal pH levels. White wine has a more pronounced effect on acid exposure than does red wine .
Researchers have shown a strong relationship between obesity and acid reflux , and a high body mass index BMI is directly related to acid reflux [76,77]. Weight gain can aggravate reflux symptoms and weight loss can have the reverse effect, allowing patients to reduce taking reflux medications [78,79]. Exercise Patients are advised to participate in exercise sessions of at least 30 minutes each day as a guard against reflux symptoms.
Patients who are less active physically are more at risk of developing reflux problems [80,81]. H2-receptor antagonists H2AT , prokinetic agents, and mucosal cytoprotectants e.
Neuromodulators e. LPR treatment generally requires an aggressive approach, including high doses of PPIs over long periods twice daily for months [10,12,14].
Surgery Surgery is usually a last resort in LPR treatment [11,]. Patients should be warned that the response of their laryngeal symptoms to surgery is uncertain. Surgery should only be used in cases where patients responded to PPI therapy but did not achieve complete relief of LPR symptoms.
Recommended Approaches to Reflux Assessment There are, as yet, no multidisciplinary approaches to the assessment and management of LPR . There is also some controversy about the routine use of endoscopy for patients with reflux disorder on their initial visit. Based on previous research, we developed the algorithm shown in Figure 2, with the aim of streamlining the assessment and management of reflux disorders, including LPR and GERD. Patients with symptoms suggestive of complications or malignancies e.
Chest pain is seldom a symptom indicative of LPR; therefore, it is important to differentiate between cardiac from non-cardiac chest pains before considering LPR as a potential culprit. Chest X-rays may be required to exclude the possibility of lung disorders for patients presenting with chronic cough 2 or more weeks.
Hoarseness is sometimes associated with uncomplicated LPR; however, lingering hoarseness for more than 2 weeks warrants an investigation of potential complications, including underlying vocal cord paralysis or lesions.
This would involve referral to an otolaryngologist for laryngoscopic examination. In primary care units, the diagnosis may be based primarily on LPR-associated symptoms and a therapeutic trial that includes lifestyle changes, dietary modifications, and the short-term use of PPIs.
If LPR-related symptoms can be resolved within weeks of a therapeutic trial using PPIs or H2AT, titrating therapy at the lowest dosage may be required for months.
Patients who show a less than complete improvement in symptoms may require a maintenance regimen for months before initiating titrating pharmacologic treatment. It is suggested that patients are referred to specialists in the event that short-term therapeutic trials fail. Figure 2. Algorithm for assessment and management of reflux disease. LPR is very common, particularly among the elderly.
Numerous existing methods provide useful diagnostic information on LPR, including endoscopic evidence of mucosal damage, demonstration of reflux events by multichannel impedance and pH-monitoring studies, radiography, esophageal manometry, spectrophotometric measurement of bile reflux, and mucosal biopsy. Nonetheless, there remains some controversy regarding the appropriate course of action in the diagnosis of LPR, and no test is considered conclusively reliable.
LPR symptoms can be alleviated or eliminated by adopting changes in lifestyle, such as dietary, behavioral, and lifestyle habits. Patients are also advised to avoid sweet and fried foods, refrain from smoking and drinking, and wear loose comfortable clothing.
They should also try to reduce stress in their lives and reduce their weight. Further investigations into alternative causes of laryngeal symptoms, including allergy, sinusitis, or pulmonary disorders, should be considered for patients who fail to respond to LPR treatments. The risk of misdiagnosis based on reliable medical history records is relatively small. When the diagnosis is in question or the therapeutic response to PPIs is unsatisfactory, referral to a specialist is required to confirm the diagnosis of LPR.
Laryngeal and pharyngeal complications of gastroesophageal reflux disease. GI Motility online DOI: Laryngopharyngeal reflux: diagnosis, treatment, and latest research. Int Arch Otorhinolaryngol ;18 2 Laryngopharyngeal reflux is different from classic gastroesophageal reflux disease.
Alcoholic liver disease
Ear Nose Throat J ;81 9 Suppl 2 American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease. Gastroenterology ; 4 , e1-e5. Management of laryngopharyngeal reflux: an unmet medical need. Neurogastroenterol Motil ;22 2 Review article: reflux and its consequences--the laryngeal, pulmonary and oesophageal manifestations.
Aliment Pharmacol Ther ;33 Suppl Linking laryngopharyngeal reflux to otitis media with effusion: pepsinogen study of adenoid tissue and middle ear fluid. J Otolaryngol Head Neck Surg ;37 4 Correlation between allergic rhinitis and laryngopharyngeal reflux. Biomed Red Int ; Curr Allergy Asthma Rep ;7 3 JAAPA ;18 8 Laryngopharyngeal reflux. Accessed March 30, Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery.
Otolaryngol Head Neck Surg ; 1 Evaluation and management of laryngopharyngeal reflux. JAMA ; 12 Med Arch ;71 3 J Neurogastroenterol Motil ;16 1 Functional anatomy and physiology of the upper esophageal sphincter. The otolaryngologic manifestations of gastroesophageal reflux disease GERD : a clinical investigation of patients using ambulatory hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury.
Laryngoscope ; 4 Pt 2 Suppl 53 Laryngopharyngeal reflux symptoms improve before changes in physical findings. Laryngoscope ; 6 The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus.
Am J Gastroenterol ; 8 ; quiz Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol ; 3 ; quiz Prevalence of laryngopharyngeal reflux in a population with gastroesophageal reflux. Laryngoscope ; 8 Pepsin and carbonic anhydrase isoenzyme III as diagnostic markers for laryngopharyngeal reflux disease. Laryngoscope ; 12 Pepsin promotes proliferation of laryngeal and pharyngeal epithelial cells. Bile-induced laryngitis: is there a basis in evidence?
Ann Otol Rhinol Laryngol ; 3 Role of the components of the gastroduodenal contents in experimental acid esophagitis. Surgery ;92 2 Diagnosis and management of chronic laryngitis associated with reflux. Laryngopharyngeal sensory deficits in patients with laryngopharyngeal reflux and dysphagia. Ann Otol Rhinol Laryngol ; 11 Laryngoscope ; 11 Distribution of V-ATPase in rat salivary glands. Eur J Morphol ; 36 Suppl Heterotopic gastric mucosa inlet patch in a patient with laryngopharyngeal reflux LPR and laryngeal carcinoma: a case report and review of literature.
Dis Esophagus ;22 4 :E Heterotopic gastric mucosal patch of the esophagus is associated with higher prevalence of laryngopharyngeal reflux symptoms. Eur Arch Otorhinolaryngol ; 11 The role of the larynx in chronic cough. Acta Otorrinolaringol Esp ;64 5 Chronic cough and irritable larynx.
J Allergy Clin Immunol ; 2 Management of recurrent laryngeal sensory neuropathic symptoms. Laryngeal pseudosulcus as a predictor of laryngopharyngeal reflux. Laryngoscope ; 10 Perspectives in laryngopharyngeal reflux: an international survey. Laryngoscope ; 8 Pt 1 Globus pharyngeus: a review of its etiology, diagnosis and treatment. World J Gastroenterol ;18 20 An evidence-based appraisal of reflux disease management--the Genval Workshop Report.
Gut , 44 Suppl 2:S Should patients with pH-documented laryngopharyngeal reflux routinely undergo oesophagogastroduodenoscopy?
A retrospective analysis. J Laryngol Otol ; 12 Laryngeal signs and symptoms and gastroesophageal reflux disease GERD : a critical assessment of cause and effect association.
Clin Gastroenterol Hepatol ;1 5 Correlation between symptoms and laryngeal signs in laryngopharyngeal reflux. Association of oral antireflux medication with laryngopharyngeal reflux and nasal resistance.
Laryngopharyngeal reflux has negative effects on taste and smell functions. An assessment of olfactory function in patients with laryngopharyngeal reflux disease.
Acta Otolaryngol ; 1 Associations between peripheral vertigo and gastroesophageal reflux disease. Med Hypotheses ;85 3 Association between otitis media and gastroesophageal reflux: a systematic review. Otolaryngol Head Neck Surg ; 3 Laryngopharyngeal reflux in children with chronic otitis media with effusion. J Neurogastroenterol Motil ;22 3 Comparison between the reflux finding score and the reflux symptom index in the practice of otorhinolaryngology.
Int Arch Otorhinolaryngol ;20 3 Validity and reliability of the reflux symptom index RSI. J Voice ;16 2 Prevalence of laryngeal irritation signs associated with reflux in asymptomatic volunteers: impact of endoscopic technique rigid vs. Symptoms, laryngeal findings, and hour pH monitoring in patients with suspected gastroesophago-pharyngeal reflux.
The reliability of the assessment of endoscopic laryngeal findings associated with laryngopharyngeal reflux disease. The validity and reliability of the reflux finding score RFS.
Impact of h esophageal pH monitoring on the diagnosis of gastroesophageal reflux disease: defining the gold standard.Australian Journal of Oto-Laryngology ;3 3 The reflux components, which contain hydrochloric acid, pepsin, and bile acids, can irritate the laryngeal mucosa [2,].
Figure 1. Recommended Approaches to Reflux Assessment There are, as yet, no multidisciplinary approaches to the assessment and management of LPR .
Laryngoscope ; 9 Curr Allergy Asthma Rep ;7 3 Nonetheless, patients should be advised to avoid fatty diets to facilitate digestion and promote overall health.
Wine and beer have also been found to cause reflux, even in small quantities. Diagnosis and management of chronic laryngitis associated with reflux.
Laryngoscope ; 11
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