Hypochlorhydria (Low Stomach Acid): Causes, Symptoms & Functional Medicine Management

The combination of hydrochloric acid, lipase, and pepsin combine to create the acidic gastric juices found in the stomach. These healthy stomach acid levels serve as a first line of defense for the gastrointestinal system, preventing infectious agents from reaching the intestines. A normal gastric pH is considered to be present with pH values >3, with values below 4 capable of killing bacterial invaders within 15 minutes. Gastric juices with a pH >3 mark the beginning stages of hypochlorhydria. As the pH increases above 4, there is an increased prevalence of bacterial overgrowth. Achlorhydria is defined as a pH > 7.

There are two main categories of hypochlorhydria: iatrogenic and acquired. Iatrogenic hypochlorhydria is the most common, resulting from the use of medications to reduce gastric acid secretions. Proton pump inhibitors (PPIs) are one of the top ten most prescribed drugs in the world, contributing to the rise in iatrogenic hypochlorhydria. Malnutrition is the leading cause of acquired hypochlorhydria.

Individuals taking PPIs generally have a pH between 5-7. Individuals with hypochlorhydria are at an increased risk for infection and disease due to a loss of this protective barrier. Research conducted by Martinsen, Fossmark, and Waldum (2019) demonstrated that individuals with hypochlorhydria were at an increased risk of various infections, including bacterial, fungal, and parasitic infections. One study they reviewed reported a significant decrease in Shannon’s diversity of the GI microbiome and changes in 20% of the bacterial taxa in PPI users versus non-users.

The increased use of PPIs makes it necessary to review current medications, both prescribed and over-the-counter, at each patient encounter. Nutritional status should also be evaluated utilizing blood labs, anthropometrics, diet diaries, food allergies/sensitivities, etc. Other useful factors in screening a patient for gastric hypoacidity include assessing gender, age, stress levels/eating behaviors, geographic origin/nationality, testing of stomach acid levels, and labs to rule out concurrent diseases such as Helicobacter pylori, chronic gastritis, parietal cell autoantibodies, hypothyroidism, etc. Keep in mind that there can be discrepancies between different testing methods and cutoff values depending on the labs used.

Malnutrition can be the cause of or the result of hypochlorhydria. Malnutrition that leads to a deficiency in the nutrients needed to make HCL can cause hypochlorhydria. These include chloride, sodium, potassium, zinc, and iodine. Malnutrition can also develop as a result of hypochlorhydria. Decreased gastric acidity impairs nutrient absorption, resulting in possible nutrient deficiencies for most of the essential vitamins and minerals, including protein, iron, calcium, magnesium, zinc, vitamins A and E, copper, and all the B vitamins. The presence of both malnutrition and hypochlorhydria increases the risk of enteric infections. There is also an increased prevalence of food allergies in individuals with reduced gastric acidity as they lose the ability to sufficiently denature proteins. With hypochlorhydria, larger protein peptides remain, which can trigger an immune system response, resulting in allergic symptoms. Therefore, screening for hypochlorhydria should be conducted in individuals that suffer from malnutrition and/or food sensitivities/allergies.

There is also an increased prevalence of food allergies in individuals with reduced gastric acidity as they lose the ability to sufficiently denature proteins. With hypochlorhydria, larger protein peptides remain, which can trigger an immune system response, resulting in allergic symptoms. Therefore, screening for hypochlorhydria should be conducted in individuals that suffer from malnutrition and/or food sensitivities/allergies.

Stress management is also important in regulating gastric acid secretion. This is due to the digestive inhibition created by the sympathetic nervous system and the splanchnic nerves. Splanchnic nerve activation inhibits digestive activity (suppression of gastric juices and HCL production), pancreas, and gallbladder. It is therefore necessary to evaluate an individual’s eating environment. Recommendations may need to be made that decrease sympathetic stimulation during mealtime, such as Facebook, reading/listening to news, controversial discussions, etc.

Reduced gastric acidity can impair the absorption of some prescription medications, in effect reducing the dosage needed for a given condition. The decreased gastric acidity caused by PPI usage can impair the absorption of pH-dependent, weakly basic drugs. A study by Yago et al. (2013) showed that 1500 mg of betaine HCL was able to lower gastric acid pH levels to < 3 within a mean time of 6.3 (+ 4.3) minutes. The healthy gastric pH was short-lived with reacidification lasting ~ 75 minutes.

The authors also noted that serum gastrin levels remained unchanged and did not show a correlation with the measured pH changes observed. This lack of correlation between serum gastrin levels and gastric pH decreases the validity of using serum gastrin as a marker for hypochlorhydria.

Yago et al. (2014) went on to prove that betaine HCL increased absorption of a drug with pH-dependent solubility. Betaine HCL is well tolerated and easy to administer, offering a viable treatment option for those with hypochlorhydria. The recommended dosage is 1500 mg per meal. This dosage was shown to work nearly as fast as higher dosages (3000 mg and 4500 mg) and with less risk of irritation and with fewer pills to swallow.

Recommended: 500 mg capsules

Please consult your doctor before taking Betaine HCL.
500 mg per capsule.
Dose is dependent on the size of the meal and how much protein is being consumed. A large steak requires more HCL compared with beans and rice.
Taking niacin or niacinamide (> 500 mg) can have a buffering effect on stomach pH, requiring higher doses of HCL.

Herbal Bitters

Bitters provide an excellent option for those who cannot take HCL. Bitters promote digestion by stimulating the secretion of stomach acid, digestive enzymes, and bile.

Cephalic Vagal Reflex—Stimulation of oropharyngeal bitter receptors increases saliva and vagal stimulation to the digestive organs.
Local reflex—Stimulation of oropharyngeal and gastrointestinal bitter receptors acts locally to increase digestive secretions.
Alcohol—can improve digestion (rather than the bitter taste)
Hyperemia—the major influence of bitters on digestion is improved blood circulation in the abdominal organs.

Proper Bitters Dosing

Recommended—David Winston’s Original Bitters

Please consult your doctor before taking bitters.
30 drops—taken straight or in a small amount of water before meals
Ideally take bitters 15-20 minutes before a meal.
Take for at least two months
Use caution with GERD, gastric ulcers, or gastritis
Do not use in hyperchlorhydria

Coffee

Boekema et al. (1999) found that coffee, caffeinated and decaffeinated, stimulated HCL production. Rubach et al. (2014) found that higher-caffeine coffees (market blends) had a quicker reacidification time versus lower-caffeine coffees (dark French roast).

Vitamin C

O’Connor et al. (1989) found that individuals with hypochlorhydria (pH > 4) had low fasting levels of gastric vitamin C. They noted a significant correlation between gastric juice and plasma concentrations of vitamin C (p = 0.002).

Proper Vitamin C

Recommended: Buffered vitamin C 500 mg

Please consult your doctor before taking vitamin C.
1 twice a day
Use vitamin C along with HCL. Improves iron absorption, important in the production of HCL
Reduces the conversion of nitrites to carcinogenic nitrosamines at both acidic and neutral pH
Effective against H. pylori

How to Assess and Manage Hypochlorhydria (Quick Reference Guide)

Assess:

Review current medications at each patient encounter
Screen for the use of PPIs.
Evaluate diet for imbalances/deficiencies/food allergies
Evaluate for signs and symptoms of hypochlorhydria (see below).
Assess stress levels in general and mealtime behaviors/environment.
Assess geographic origin/nationality, gender, and age.
Note: Gastric HCL levels increase during the follicular phase and decrease during the luteal phase of the menstrual cycle.
In general, aging is associated with a decrease in stomach acid production. There is a large variance in fasting hypochlorhydria in the elderly, with one study reporting it to be less common in Americans (10%) compared with Japanese (>60%) or Norwegians (80%).

Test:

Radio-telemetric capsules—Heidelberg pH Diagnostic System
Anti-parietal cell antibodies
Intrinsic factor antibodies
H. Pylori
Iron/ferritin levels
Thyroid panel
Rule out other anemias

Signs and Symptoms

Belching after meals
Bloating
Gas
Morning diarrhea
Diarrhea after heavy meals
Constipation
Muscle cramping
Oral symptoms-dentures
Rosacea
Dilated capillaries around the maxilla and nose
Early satiety
Weight loss
Anemia
Heartburn
Indigestion
Sensation of food sitting in the stomach
Halitosis
Fatigue
Depression
Poor-quality fingernails
Brittle hair
Hair loss
Symptoms tend to be worse with meat

Miscellaneous Information

Adverse Effects of Proton Pump Inhibitors

Alteration of gastrointestinal microbiome—SIBO, dysbiosis, candidiasis, etc.
Increased risk of infection—C. difficile infection, other enteric bacterial infections, colitis, pneumonia, etc.
Impaired absorption of nutrients and drugs. Nutrient deficiencies—iron, calcium, magnesium, B vitamins, protein
Gastric cancer
Osteoporosis
Kidney injury/disease
Impaired drug absorption
Overall mortality

Causes of Hypochlorhydria

Atrophic gastritis due to antibodies against parietal cells
Stomach cancer
Stress
H. pylori—eradication of infection restores normal HCL levels
Severe iron deficiency
Antacids, PPIs, histamine blockers
Post gastroenteritis
Hypothyroidism
Pernicious anemia
Radiation therapy involving the stomach
Gastric bypass surgery
Vasoactive intestinal peptides and somatostatinomas—both are islet cell tumors of the pancreas.
Pellagra, caused by niacin deficiency
Chloride, sodium, potassium, zinc, and/or iodine deficiency. These are all elements needed to produce adequate levels of stomach acid.
Sjogren’s Syndrome
Menetrier’s disease, characterized by hyperplasia of mucous cells in the stomach, also causes excess protein loss leading to hypoalbuminemia. Presents with abdominal pain and edema

Pathogens involved with Hypochlorhydria

Bacterial infections:

Non-typhoid salmonellosis
Cholera
Campylobacter jejuni
Diarrhoeagenic Escherichia coli
Clostridium difficile
Shigellosis
Listeriosis
Brucellosis
H. pylori

Parasitic infections:

Strongyloides
Giardia
Entamoeba histolytica

Fungal infections:

Candida albicans

Other Infections:

Yersinia enterocolitica
Enteroviruses
Prions—Creutzfeldt-Jakob
Strep
Staph
Enterococcus

References

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