CC: Gastroenterology: Hypo- (common) and A-chlorhydria (rare)
HYPOCHLORHYDRIA = pH greater than 1
ACHLORHYDRIA = pH of 6 ? basal HCl levels are 0, no HCl secreted with food stim
decr stomach acid very common problem in developed world
esp in elders, along with B12 def
up to 20% of Westerners have hypoHCl
not recognized by mainstream medicine
there is no recommended treatment
hypochlorhydria (hypoHCl) often dt acid blocking drugs
gastrin = gastric acid = HCl
STIMULI FOR GASTRIN
thinking about, smelling, tasting food
hypoglycemia
anger, epinephrine
proteins, calcium, milk, coffee
EFFECTS OF HCL ON GI HORMONES
acid enters duodenum-->CCK release--> many reactions:
mucosal and pancreatic growth
gall bladder contraction
pancreatic enzyme, bicarb and insulin release
relaxation of sphincter of Oddi
decreased appetite
decreased GI immunity???
decreased gastric emptying
MEDICINES THAT LOWER ACID
drugs: proton pump inhibitors (PPI), pepto and other acid neutralizers
common practice of suppressing or neutralizing acid-->negative health effects
this not recognized in mainstream medicine
cimetidine-->increased gastric cancer dt gastric dysbiosis (incr H pylori)
NORMAL HCl
healthy men produce approx 80 grains/day, females 60
normal aging involves a gradual INCREASE in stomach acid, but not in the west
lowering of acid levels in elders in west mbdt high H pylori infx rates
MAJOR FX OF GASTRIC ACID
converts pepsinogen to pepsin
keeps bacteria and parasites down
aids in digestion of B12, folic
aids mineral digestion
stimulates release of CCK-->gall bladder constrxn
stims release of secretin
activates leukocytes, the reason for adding HCl to Meyer's cocktail
(SSL Pneumo tx: Meyer's cocktail and nebulized allicin)
NUTRIENT MALABSORPTION DT LOW HCl
cationic minerals: zinc, chromium, selenium, magnesium, iron
medicated Zollinger Ellison syndrome pts-->iron def dt acid blocking drugs
calcium: carbonates less well absorbed, citrates are still absorbed w/ low HCl
proteins not hydrolyzed: aa def
B vitamins esp B3 and B12
phytochemicals (which?)
INCIDENCE OF HYPOCHLORHYDRIA
more common than pancreatic insufficiency
prob very common in west dt sympathetic overload, poor diet, lack of bitters
COMPLICATIONS OF HYPOCHLORHYDRIA
malnutrition esp of minerals, proteins
nutrients poorly absorbed w/o acid: zinc, iron, chromium, copper, magnesium, cobalamin, folic acid, possibly niacin
calcium absorption was thought to be dependent on acid but this has been 2x disproven
research goes on
dysbiosis in SI dt lack of acid barrier to incoming pathogens
may induce AI dz by cross rxn
incr toxicity dt microbial production
incr intestinal permeability dt inflam from dysbiosis
S/SX OF A- OR HYPOCHLORHYDRIA
(visible sx only seen in more extreme cases)
pyrosis cc/pc (burning sensation with meals, after meals)
indigestion cc/pc: gas, bloat, eructation
delayed gastric emptying: heavy/full sensation in stomach pc, easy satiety
soft brittle peeling nails
diffuse hair loss in women (thyroid, PCOS)
maxillary telangiectasia
coated tongue
halitosis
yeast overgrowth
Riddler's point tenderness
Lowenberg's test mb + (cramp in leg, should be able to get to 210, mb low mineral)
Lowenberg's test = pressure applied to musculature using cuff, record pressure at which pt reports pain, usu a test for DVT
DISEASES ASSOCIATED W/ HYPOCHLORHYDRIA
diabetes mellitus
childhood asthma
hypo/hyperthryoidism (esp AI, Grave's dz)
RA, SLE, myasthenia gravis, Sjogren's syndrome, celiac dz
cholecystitis, cholelithiasis (dt low CCK)
osteoporosis (poor mineral absorption)
(under question: calcium absorption now shown to be acid independent)
adrenal fatigue/Addison's dz
chronic hepatitis
atrophic gastritis
chronic urticaria, eczema, vitiligo, rosacea
gastric ulcers (H pylori)
gastric carcinoma (a case illustrating a possible mechanism: pt w/ PA developed carcinoid tumor, perhaps achlorhydria-->prolonged stim of antral G cells and fundic argyrophilic cells-->hyperplasia-->cancer)
(H-pylori produce carcinogenic nitrites, N-nitrosos compounds from nitrate)
(acid lowering drugs ie cimetidine may incr H-pylori pop-->incr cancer risk)
salmonellosis
giardiasis
depression (one study showing link with malabsorption)
CORRELATIONS
most hypoHCl pts do NOT have AI gastritis or pernicious anemia (PA)
sig % of pts have anti-parietal cell ABs
chronic ASx H pylori infx related to impaired acid secretion in some studies
tx of H pylori infx does not lead to consistent change in acid
one study says H pylori gastritis severity correl w/ lower acid
other study shows H pylori incr AB production-->possible cross reactive AI dz
ABs in line above: vs secretory canniculi of parietal cells
AUTOIMMUNE ASSOCIATION WITH LEAKY GUT WELL KNOWN TO NATUROPATHS
parietal cells are frequently and early attacked by ABs in pts with chronic AI dz
some naturopaths consider Addison's dz(adrenal fatigue) to be part of hypochlorhydria
the mechanism, as I understand it:
low acid-->dysbiosis-->inflam-->breakdown of intestinal tight junctions-->leaky gut
leaky gut-->antigenic particles get into mucosa associated lymphatic tissue (MALT)
antigen in MALT-->systemic immune response to foods that leaked from intestine
systemic response to antigen that we should not have responded to-->possible x rxn
cross reaction of immune response to food-->autoimmune disease
if our guts don't leak we don't have food antigen provoking an immune response
and hence have less AI disease
ETIO/RISK FACTORS
taking PPIs
chronic unremitting stress, sympathetic overdrive/dominance, poor vagal tone
H pylori (esp first 3 mo of overgrowth)
chronic overeating
devitalized diet, lack of bitters
deficiency of Cl-
AI dz (thyroid, adrenal, gastritis with ABs vs parietal cells or IF)
salt restrictive diet (why???)
genetic issue with acid production (native/Pima, Hispanic, NE Eur)
ABOUT THE PIMA
(my opinion here, not what's found in books or lectures)
studies have shown that Pima tribe all have low acid
a study found Pima have:
low duodenal ulcer rates and high gastric cancer rates
low acid and delayed gastric emptying
H pylori not considered in this study
in my view this finding does not support a genetic link
poor HCl production mbdt sympathetic overdrive
delayed gastric emptying mbdt poor diet/high DM rates
the Pima reservation is deeply embedded in Phoenix, Arizona
PHX = a particularly corporatized and unhealthy city in a demolished desert
hence this tribe is different from most who live more separate from white man
the Pima (my apologies) are more sedentary, eat a more SAD diet
and are more distressed by modern plasticized city life, AC, cars, fences, etc
a comparison study of Pima vs surrounding caucasian Phoenicians is needed
DDX
dyspepsia
peptic ulcer dz (PUD)
hyperchlorhydria (rare)
chronic gastritis (common)
GI cancer
DIAGNOSIS
HEIDELBERG TEST IS DIAGNOSTIC
Heidelberg testing
Gene Bowman on 62nd and Stark does it
swallow a a tethered pH meter with radio transmitter on board
wear a belt that detects radio signals
do a series of bicarb challenges (up to six)
see how long it takes stomach to re-acidify
healthy teen can repeatedly neutralize 1sp bicarb in 15-20 mins "without fail"
will show hidden hypoHCl
HEIDELBERG TEST SHOWS ALL 3 TYPES OF HYPOCHLORHYDRIA:
1) reserve hypochlorhydric: can neutralize first challenges but runs out of acid
2) total hypochlorhydric: cannot neutralize the first challenge in an hour
3) achlorhydric: zero basal acid secretion and no response to bicarb challenge
GASTRIC STRING TEST
just a screening test
will show achlorhydria
string with reagent added will be green if pH 6-7, red is pH of 1
take lowest pH that you find on string
REFLEX POINTS
Chapmans point = Riddler pt above
indicator: 1' inf to tip of xyphoid on inf L costal border
found by Dr Riddler
document tenderness on 0-4 scale
compare with pancreatic pt on R
CLINICAL PICTURE
more evident in extreme achlorhydria cases
soft brittle or peeling nails
parallel ridges on fingernails indicate aa malabsorption
dry skin on lower leg dt lipid malabsorption
diffuse hair loss in women
maxillary telangiectasia
coated tongue
halitosis
most pts don't report digestive issues but may have "normal"s that are abn
(they are used to abnormal bloating, flatus, etc)
food allergies mbdt hypo
muscle cramps (esp those relieved by mineral supps)
dysbiosis as determined by stool sample or indicanuria
pyrosis cc/pc
indigestion cc/pc: gas, bloat, eructations
delayed gastric emptying: heavy, full sensation pc, easy satiety
gastric acid riddler's point tenderness
lowenberg's test mb positive
CHALLENGE TESTING AKA TITRATION
take HCl capsules, slowly increasing dose
careful! HCl may be overdosed by some naturopaths, there is risk
if no response by time of max dox then sign of hypo
max dose/day should not exceed natural/optimal production levels
max: 80 grains for average white guy, woman 60 grains
burning pain in abdomen, pyrosis, dyspepsia or other sx indicate normochlorhydria
I'm not sure about this as a strong indicator
burning mbdt gastritis, not too much acid
doesn't distinguish btw reserve and total hypochlorhydric
Dr Davis Lamson protocol:
take 1 10 grain cap after 2 bites at a meal for 3 days
then 2 caps at one meal and one at the next for 3 days
then 3 and 2 for 3 days
if discomfort from start might not be hypoHCl, might be gastritis
*NEVER TAKE HCL AT END OF MEAL, much more risk of pyrosis esp if lie down after
*DO NOT COMBINE HCL WITH ENZYME SUPP, THE ACID WILL TEAR UP THE ENZYMES
LABS (Yarnell)
MCV >91 in 85%
serum Cl- >105
serum Ca/Phos ratio <2.3 or >2.7
serum TGs <70
BUN <13
none of the serum findings is diagnostic alone
LABS (SSL)
SERUM
Low TP, globulin, ferritin, Ca, Mg, BUN
B12 below 350 pg/ml
neutrophilic hypersegs >10% (recheck after giving folate)
hair analysis: 5-6 low minerals (other than Na, K)
CBC: MCV over 93.0
Stool Testing: dysbiosis (persistent, excessive) incl yeast
ALLOPATHIC TX
there is none
this disorder not usu recognized among allopaths
NATUROPATHIC TREATMENT
for the mental emotional component: reduce sympathetic overload
food hygiene
psychophysio of digestion:
calm down before meals, smellfood prep, think about food, slow deep breathing
bfast like a queen lunch like a princess and dinner like a pauper
before meal
bitter herbs or vinegar pc to stim HCl and tonify GI tract
at meal
chew food until liquid (Fletcherize)
simplify meals (fewer ingredients)
avoid overeating (typical stomach can hold 1.5L but it stretches over time)
avoid fluid esp cold w/meals; cold slows motility, hot incr motility
avoid excess fat, sugar
food combining (??? top recommendations?)
between meals
consider walks pc
consume plenty of fluids (minimum 2L/day)
in evening
light snax after 8pm
*lots more on notes
TREATMENT FOR ACHLORHYDRIA
immediate hydrochloric acid replacement
supplementation to address nutritional deficiencies
possible nutritional IVs
look for pernicious anemia: ABs vs parietal cells?
tx for AI dz
SOURCES:
SSL lecture on 1/6/2010
Naturopathic Gastroenterology by Eric Yarnell, ND