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Gastric (Stomach) Acid Secretion

Gastric Acidity

The pH of an empty stomach in healthy individuals ranges from 1.5 to 3.5 [1]. During and after a meal, the stomach pH rises and returns to basic levels in about three hours [2]. The greatest increase of gastric pH (up to ~5) has been observed after fatty meals [3].

Achlorhydria and Hypochlorhydria

Achlorhydria refers to absent and hypochlorhydria to reduced secretion of gastric acid in the stomach [4]. Achlorhydria is defined as pH in the stomach greater than 5.09 in men and 6.81 in women after maximal stimulus for acid secretion [5].

Causes

  • Old age [5,6]
  • Stomach disorders:
    • Chronic atrophic gastritis [8,9] or acute gastritis [10] caused by the bacterium Helicobacter pylori
    • Gastric carcinoma [23]
    • Autoimmune atrophic gastritis with or without pernicious anemia [8,11,12], which can be associated with diabetes type 1 [8,13], autoimmune thyroiditis [8], adrenal insufficiency (Addison’s disease), vitiligo, hypoparathyroidism, primary biliary cirrhosis [128], Sjögren’s syndrome [14], or “watermelon stomach” with vascular malformations [15]
    • Crohn’s disease [19]
    • Partial surgical removal of the stomach (partial gastrectomy) [5] with or without removal of the vagus nerve (vagotomy) in treatment of gastric ulcer or gastric carcinoma, and gastric bypass (bariatric surgery) in treatment of obesity [5]
  • Drugs: proton pump inhibitors or PPIs (omeprazole) [8,16], H2 blockers (ranitidine, cimetidine) [17] and misoprostol (an analog of prostaglandin E2) [18]
  • Diabetic autonomic neuropathy [20]
  • Sarcoidosis [21]
  • Iron deficiency [22]
  • Common variable immunodeficiency disorder [24]
  • HIV/AIDS [28]
  • Menetrier’s disease [25]
  • Tumors: VIPoma and somatostatinoma (rare pancreatic tumors) [26,27]

Symptoms

Achlorhydria by itself usually does not cause any symptoms or physical signs [8].

Complications

  • Impaired absorption of:
    • Vitamin B12 [49,50] and folate [51] resulting in macrocytic anemia
    • Vitamin C [52]
    • Calcium, possibly resulting in osteoporosis (due to a long-term (>1 year) use of high doses of proton pump inhibitors) [5,11,48,74,75]
    • Non-heme iron (from plant foods, milk products and eggs) resulting in microcytic anemia [53,54,55,56,74]
    • Magnesium (in long-term–>1 year–proton pump inhibitors users) resulting in hypomagnesemia, hypoparathyroidism and hypocalcemia [57,58,74]
    • Zinc [4,59]
  • Impaired protein digestion [63-p.420] possibly resulting in food allergies in susceptible individuals [40,41]
  • Delayed gastric emptying [39]
  • Overgrowth of bacteria in the stomach [6,43,44,45]
  • Small intestinal bacterial overgrowth (SIBO) [42]
  • Increased risk of bacterial gastrointestinal infections [4,16,46,47]
  • Bezoars, clusters of indigestible food ingredients, mostly fiber [60]
  • Carcinoid tumors in the stomach [61]

During sustained achlorhydria, Helicobacter pylori infection can spontaneously heal [62].

Hypochlorhydria Management

  1. Treatment of the underlying cause
  2. Acidic beverages can lower gastric pH and thus help to absorb certain supplements, for example, cranberry juice can improve the absorption of vitamin B12 [50].
  3. Coke, which is acidic ( pH ~ 2.5), can help dissolve clusters of fiber stuck in the stomach (bezoars) [109,110].
  4. Hypnosis may help increase gastric acid secretion [35,36].

Hyperchlorhydria

Hyperchlorhydria is defined as presence of excessive gastric acid in the stomach [64].

Causes

  • Increased secretion of the hormone gastrin [65,66,67,68,69]:
    • Chronic gastritis (inflammation of the stomach) caused by Helicobacter pylori
    • Gastric outlet obstruction due to:
      • Congenital pyloric stenosis in infants
      • Congenital duodenal webs
      • Gastric ulcer, polyps or cancer that obstruct the pylorus
      • Ingestion of caustics that results in scarring of the pylorus
      • Pancreatic, duodenal or gallbladder cancer pressing upon pylorus from outside
      • Bezoars, clusters of undigested food or other swallowed material in the stomach
    • Short-bowel syndrome (SBS) after extensive surgical removal of the small intestine [65]
    • Retained gastric antrum syndrome due to recurrent gastric ulcer after partial surgical removal of the stomach [65]
    • Gastrinoma (a tumor that secretes gastrin) with multiple peptic ulcers (Zollinger-Ellison syndrome) [65]
    • Chronic renal failure (rare) [65]
  • Increased secretion of histamine, for example, in in systemic mastocytosis or basophilic granulocytic leukemia [70]
  • Uncertain mechanism [65]:
    • Tumors other than gastrinomas [65]
    • Rebound gastric acid hypersecretion after withdrawal of H2 blockers [70] or proton pump inhibitors (PPIs) [70,71]
    • Stress, such as strenuous exercise [33,34,72], psychological stress [7], severe injury, head trauma, surgery, burns, sepsis or shock, “stress ulcers” (“Curling’s ulcer” after burns [73] or “Cushing’s ulcer” due to a brain tumor or injury [113]
    • Hyperparathyroidism [76]
    • Cystic fibrosis [65]
    • Chronic pancreatitis [77]
    • Hypertrophic, hypersecretory gastropathy [65]
    • Idiopathic hypersecretion of gastric acid [70]
    • Drugs:
      • Stimulators of salivation: pilocarpine, cevimeline
      • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin [78] and indomethacin [79,80]
      • Oral corticosteroids [81]
    • Calcium supplements [82]
    • Treatment with cysteamine in children with cystinosis [65]

What else can stimulate gastric acid secretion:

  • Chewing gum [83]
  • Proteins and aromatic amino acids [29,30]
  • Milk (whole and low-fat) [84]
  • Soft drinks [84]; they are usually acidic themselves [85,86]
  • Caffeine and coffee (including decaffeinated coffee) [84,95]; tea [84,96]; cola (kola) nuts [97,98]
  • Red pepper [99], black pepper [32], cinnamon [32] and paprika [32]
  • Alcohol (ethanol). Pure ethanol up to 4 vol%, but not higher, moderately stimulates gastric acid secretion. Maleic and succinic acid and possibly other substances in fermented beverages, such as beer, wine, champagne, sherry and martini, strongly stimulate gastric acid secretion, while distilled alcoholic beverages, such as whiskey, cognac, rum, calvados and campari, usually do not stimulate or can even inhibit acid secretion [84,100,101,102,103,104]. Chronic alcoholics may have increased, decreased or unaltered gastric acid secretion [101].
  • In various studies, smoking stimulated, inhibited or had no effect on gastric acid secretion [105,106].
  • Hypoglycemia caused by insulin injection [107,108]

Chili [112] or glucose meals [30] probably do not significantly affect gastric acid secretion.

TABLE: pH values of common foods and beverages:

FOOD pH
Mineral water 4.0-11.6
Tap water 6.5-8.5
SOFT DRINKS
Cola – regular [94] 2.65
Cola – diet [94] 2.9
Ginger ale 2.0-4.0
Iced tea 2.8-3.6
Root beer 4.0-4.8
FRUIT and VEGETABLE JUICES
Apple juice 3.3-5.6
Apricot nectar 3.8
Carrot juice 6.4
Cranberry juice 2.3-2.5
Grape juice 3.3-3.5
Grapefruit juice, canned 2.9-3.3
Lemon juice 2.0-2.6
Lime juice 2.0-2.4
Mango juice 4.6
Orange juice 3.3-4.3
Pear juice 3.7
Pineapple juice 3.2-3.9
Pomegranate juice 3.5
Prune juice 3.7-4.0
Tomato juice 4.1-4.6
Vegetable juice 3.9-4.3
SPORT DRINKS  [94,129] 2.8-6.6
ENERGY DRINKS [94] 2.8
ALCOHOLIC BEVERAGES
Bacardi breezer 2.6
Beer 4.1-4.3
Cider 2.9-3.5
Kombucha tea [90,91] 2.4-4.5
Rum 4.8
Tequila, desperados 3.2
Vodka 6.0-7.0
Whisky 9.0
Wine [129] 2.7-4.0
FRUITS
Apples 3.2-4.0
Apricots 3.3-4.8
Banana 4.5-5.3
Blackberries 3.2-4.5
Blueberries 3.1-3.7
Cherries 3.2-4.1
Currants, red 2.9
Dates 4.1-6.6
Gooseberries 2.8-3.1
Grapes 2.8-4.5
Grapefruits 3.0-3.8
Lemon 2.2-2.4
Lime 1.8-2.8
Mango, ripe 3.4-4.8
Nectarines 3.9-4.2
Oranges 3.1-4.3
Peaches 3.3-4.1
Pears 3.5-4.6
Pineapple 3.2-5.2
Plums 2.8-4.6
Pomegranate 3.0
Prunes 3.1-5.4
Quince 3.1-3.3
Raisins 3.8-4.1
Raspberries 3.2-4.0
Strawberries 3.0-3.9
Tangerines 3.3-4.5
VEGETABLES
Artichokes, canned 4.3-6
Asparagus 4.0-6.0
Cucumbers, dill pickles 3.2-3.7
Olives, green 3.6-3.8
Onions 5.3-5.6
Potatoes 5.4-5.9
Rhubarb 3.1-3.4
Sauerkraut 3.3-3.6
Tomatoes 4.3-4.9
DAIRY PRODUCTS
Acidophilus 4.0
Butter cream [92] 4.0-4.6
Buttermilk 4.5
Cheese 4.1-6.6
Kefir: fresh > 72 hours [132] 6.7 > 3.8
Milk 6.4-6.8
Sour cream [133] 4.5
Sour milk [122] 4.7-5.7
Whey drink, acid [93] 4.0-5.0
Yogurt [111] 4.5-4.7
SAUCES
Chili sauce, acidified 2.8-3.7
Ketchup 3.9
Mayonnaise 4.2-4.5
Mustard 3.5-6.0
Soy sauce 4.4-5.4
Vinegar 2.0-3.4
OTHER
Bread 5.0-6.2
Fish 5.0-7.0
Honey 3.7-4.2
Jams, jellies, marmalades 2.9-4.5
Yeast 3.0-3.5

Chart sources: [85,86,87,88,89,122,129]

Hyperchlorhydria Symptoms

Symptoms of increased gastric acid secretion in individuals with Zollinger-Ellison syndrome can include abdominal pain, heartburn, diarrhea, steatorrhea (fats in stool due to fat malabsorption), weight loss and rectal bleeding [114].

Complications

  • Diarrhea [70,115]
  • Hyperchlorhydria due to Helicobacter pylori infection or other causes is associated with duodenal ulcer [65,67,116,117] and esophageal ulcer [117]. Individuals with gastric hyperacidity can have refractory peptic ulcers, gastric or duodenal ulcers that do not heal after 8 weeks of standard treatment [118,119].
  • Gastric hyperacidity may increase the risk of gastro-esophageal reflux disease (GERD) [70,120,121].
  • Vitamin B12 deficiency [70]
  • Iron deficiency [70]
  • In individuals with cystic fibrosis [123,124] or gastrinoma (Zollinger-Ellison syndrome) [125], excessive amount of acid produced in the stomach enters the duodenum and may deactivate pancreatic lipase (the enzyme that breaks down fats) and bile acids, which may result in impaired fat digestion and steatorrhea (fatty diarrhea).

Hyperchlorhydria Treatment

  • Proton pump inhibitors (omeprazole)
  • H2 blockers (ranitidine)
  • Antacids (calcium carbonate or citrate, aluminum hydroxide)
  • Ginger extract [31,126]
  • Momordica dioica Roxb. fruit [127]
  • Capsaicin (an active ingredient in red pepper) [37,38]

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