Achlorhydria (patient information)

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 * Associate Editor-In-Chief: Mohammed A. Sbeih, M.D.[mailto:msbeih@perfuse.org]; Jinhui Wu, MD

Overview
Achlorhydria refers to nonexistent hydrochloric acid secretion in the stomach. This condition may occur spontaneously as a result of a clinical disorder or from drug administration (iatrogenic). Studies demonstrate that prior gastric bypass surgery, chronic gastric H pylori infection, chronic proton pump inhibitor (PPI) use, or some autoimmune conditions such as diabetes, autoimmune thyroid disease may be associated with achlorhydria. Usual signs and symptoms include indigestion, nausea, bloating, diarrhea or constipation, increased susceptibility to bacterial and parasitic infection in stomach, or nutritional deficiency. There is no spcific test for the diagnosis of achlorhydria. A gastric pH of greater than 3.5 and a serum gastrin levels higher than 500-1000 pg/mL may suggest a diagnosis of achlorhydria. Blood tests such as iron indices, calcium, prothrombin time, vitamin B-12, vitamin D, serum folate, and thiamine levels, endoscopy and biopsy may also be helpful. Treatement options include treatments on underlying condition, surgery, antibacteria therapy, nutritional supplementation and dietary counseling. The prognosis depends on the underlying condition and the complications of achlorhydria.

What are the symptoms of Achlorhydria?
Patients with achlorhyria may have signs and aymptoms as the following:


 * Impaired digestion or indigestion, undigested food in stools
 * Nausea
 * Bloating
 * Diarrhea or constipation
 * Increased susceptibility to bacterial and parasitic infection in stomach
 * Iron deficiency
 * Cracked nails

Other health problems may also cause these symptoms. Only a doctor can tell for sure. A person with any of these symptoms should tell the doctor so that the problems can be diagnosed and treated as early as possible.

What causes Achlorhydria?
This condition may occur spontaneously as a result of a clinical disorder or from drug administration (iatrogenic). Studies demonstrate that prior gastric bypass surgery, chronic gastric H pylori infection, chronic proton pump inhibitor (PPI) use, or some autoimmune conditions such as diabetes, autoimmune thyroid disease may be associated with achlorhydria.

Who is at highest risk?

 * Prior gastric bypass surgery
 * Chronic gastric H pylori infection
 * Chronic proton pump inhibitor (PPI) use
 * Autoimmune conditions, such as diabetes, autoimmune thyroid disease.
 * Elderly individuals

Diagnosis

 * Measurement of basal acid secretion and gastric pH: These are the most important and basic study to prove the presence of the condition of achlorhydria. A pH of greater than 3.5 is commonly used to identify achlorhydria, and more than 50% of them whose initial stomach pH is 4.0 or higher.
 * Gastrin levels: Serum gastrin level in patients with achlorhydria is very high. A serum gastrin levels higher than 500-1000 pg/mL may suggest a diagnosis of achlorhydria.
 * Antiparietal cell antibody testing: Achlorhydria shows a strong association with autoimmune conditions. Many patients with achlorhydria can be detected antiparietal cell antibody.
 * Blood tests: Blood tests such as iron indices, calcium, prothrombin time, vitamin B-12, vitamin D, serum folate, and thiamine levels should be checked to exclude deficiencies and anemia.
 * Endoscopy and biopsy: Endoscopy is an very important test used in patients with suspected achlorhydria. This test can help find the cause of achlorhydria. During the procedure, after you are sedated, an endoscope which is a thin, flexible, lighted tube was passed down your throat. Then the doctor can view the lining of your esophagus, stomach, and first part of the small intestine. If abnormal areas are noted, biopsy can be obtained through the endoscope. The tissue samples will be checked by pathologist under a microscope to see what is the cause of achlorhydria.

When to seek urgent medical care?
Call your health care provider if symptoms of achlorhydria develop.

Treatment options

 * Achlorhydria is often the result of another disease process, so the treatment is usually focused on the underlying condition.
 * For achlorhydria associated with immune-mediated conditions, such as insulin dependent diabetes, autoimmune thyroiditis, treatment of these disorders should also be the first. However, treatment of these diseases has no known effect in the treatment of achlorhydria.
 * The standard therapy for achlorhydria associated with H pylori infection is to eradication H pylori by PPI plus clarithromycin plus amoxicillin. For patients who are allergic to penicillin, amoxicillin can be replaced by levofloxacin.
 * For achlorhydria resulting from anti-inflammatory medications, the treatment is stopping taking the drugs. If anti-inflammatory medications must be taken, the patient may benefit by ingesting them with meals or milk.
 * Treatment of gastritis that leads to pernicious anemia consists of parenteral vitamin B-12 injection.
 * Achlorhydria resulting from long-term PPI use may be treated by dose reduction or withdrawal of the PPI.


 * Surgery: Hypergastrinemia due to achlorhydria secondary to PPI therapy or resection of the gastric fundus is known to cause enterochromaffin-like (ECL) cells hyperplasia and gastric carcinoids. Surgery is the only potentially curative therapy for carcinoid tumors.
 * Antibacteria therapy: Antimicrobials such as metronidazole, amoxicillin-clavulanate potassium, ciprofloxacin, or rifaximin are suggested to treat bacterial overgrowth.
 * Nutritional supplementation
 * Dietary counseling

Diseases with similar symptoms

 * Pernicious anemia
 * VIPomas

Where to find medical care for Achlorhydria?
Directions to Hospitals Treating achlorhydria

Prevention of Achlorhydria

 * Treatment of chronic gastric H pylori infection
 * Avoidance of chronic proton pump inhibitor (PPI) use

What to expect (Outlook/Prognosis)?
The outcome of achlorhydria depends on:


 * The underlying cause of achlorhydria: If achlorhydria results from cancer or a surgical procedure, the prognosis is more guarded.
 * The complications of achlorhydria: Atrophic gastritis, one of the complications of achlorhydria, has been considered to be a potential precursor to gastric carcinoma.

Possible complications
achlorhydria may result in increased bacterial growth in the stomach and duodenum. This increases the risk of several infectious diseases such as salmonellosis, typhoid fever, shigellosis, and various parasitic infections. Stomach acid is important in liberating minerals from food, thereby increasing the risk that individuals with hypochlorohydria or achlorhydria will develop calcium and zinc deficiencies. Loss of acid production may also alter the rate or extent of drug absorption. Atrophic gastritis, one of the complications of achlorhydria, has been considered to be a potential precursor to gastric carcinoma.