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It happens during things that push on your belly and bladder, like coughing, laughing, sneezing, or lifting something heavy

10.1016/j.jnutbio.2021.108634 34 JinL.SunS.RyuY.PiaoZ

Terminal endpoints included plasma biomarkers alanine/aspartate aminotransferase (ALT/AST), metallopeptidase inhibitor 1 (TIMP-1) and amino terminal peptide of type III procollagen (PIIINP), liver biochemistry, NAFLD Activity Score (NAS), fibrosis stage and quantitative liver histology

Another mechanism by which pepsin can perpetuate its harmful effects is by reducing carbonic anhydrase-III levels, which play a fundamental role in local protection against the deleterious effects of stomach acid content (Reference Gill, Johnston and Buda34)