eMedicine Specialties > Gastroenterology > Stomach

Achlorhydria: Follow-up

Author: Timothy R Koch, MD, Professor of Medicine (Gastroenterology), Georgetown University School of Medicine
Coauthor(s): Hiral Shah, MD, Chief Resident, Department of Internal Medicine, Georgetown University Hospital at Washington Hospital Center
Contributor Information and Disclosures

Updated: Nov 9, 2009

Follow-up

Further Outpatient Care

  • Patients with achlorhydria may develop ECL cell hyperplasia and gastric carcinoids. However, most experts believe that regular upper endoscopic surveillance is not justified.
  • Achlorhydria leads to hypergastrinemia. The trophic effect of gastrin leading to colorectal adenocarcinoma has been observed in knockout mouse models.
  • Patients on long-term PPI treatment may develop drug-induced achlorhydria. These patients have been observed to have reduced serum vitamin B-12 (cobalamin) levels. Vitamin B-12 injections may be indicated in this subgroup.
  • Bacterial overgrowth and subsequent micronutrient deficiencies can occur in patients with achlorhydria. Patients with a history of gastric bypass surgery or long-term PPI use are predisposed to bacterial overgrowth. These patients should be tested for various nutrient deficiencies, including thiamine levels and calcium levels. Patients should undergo hydrogen breath testing. If the test results are positive, these patients should be treated with antimicrobial therapy for bacterial overgrowth. The patients should receive appropriate supplements to correct deficient nutrients. However, this supplementation may not be sufficient to maintain adequate nutrient levels without the treatment of the bacterial overgrowth.

Inpatient & Outpatient Medications

  • Parenteral vitamin B-12 may be important in selected patients.

Complications

  • Atrophic gastritis (and associated achlorhydria) has been considered to be a potential precursor to gastric carcinoma.

Prognosis

Small bowel bacterial overgrowth is a chronic condition. Retreatment may be necessary once every 1-6 months. There are reports of cycling of antibiotics to reduce the risk of antibiotic resistance.

Miscellaneous

Medicolegal Pitfalls

  • Long-term PPI therapy has been associated with the following 2 major complications: (1) as described previously, there is an association with hip fractures in patients with achlorhydria on PPI therapy, and (2) current use of gastric acid suppressive therapy has been associated with an increased risk of community-acquired pneumonia.
  • Sustained achlorhydria has been observed after PPI treatment in a patient with Zollinger-Ellison syndrome, starting soon after treatment began and becoming complete within 6 months.
  • Gastric resection, leading to surgically induced achlorhydria, has been associated with severe postoperative infections. It has been observed in humans that the lack of an acidic environment may favor bacterial overgrowth. This, in turn, can lead to various nutrient deficiencies with significant clinical manifestation.
  • According to a study from the Netherlands by Janssen et al, patients with achlorhydria who take nonsteroidal anti-inflammatory drugs (NSAIDs) develop upper GI ulcers during NSAID use in a similar fashion as patients who produce acid normally.7
  • Drug-induced achlorhydria is a particularly important situation in elderly patients, in whom it may be associated with secondary bacterial overgrowth.
  • Patients with pernicious anemia and achlorhydria may demonstrate impaired absorption of iron and may be screened for iron deficiency.
 


More on Achlorhydria

Overview: Achlorhydria
Differential Diagnoses & Workup: Achlorhydria
Treatment & Medication: Achlorhydria
Follow-up: Achlorhydria
References
Further Reading
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References

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Further Reading

Clinical guidelines
pH testing. Laboratory medicine practice guidelines: evidence-based practice for point-of-care testing.
National Academy of Clinical Biochemistry - Professional Association. 2006. 6 pages. NGC:005646

American Gastroenterological Association medical position statement: evaluation of dyspepsia.
American Gastroenterological Association Institute - Medical Specialty Society. 1997 Nov 8 (revised 2005 Nov). 3 pages. NGC:004711

Clinical trial
Clinical Experiment of H. Pylori Transmission

Related eMedicine topics
 Diarrhea
Pernicious Anemia
Somatostatinomas
VIPomas
WDHA Syndrome

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Keywords

achlorhydria, adenocarcinoma, pernicious anemia, gastric carcinoma, carcinoid tumor, carcinoid tumors, adenocarcinomas, hypochlorhydria intragastric pH, parietal cell, hypergastrinemia, mucolipidosis type IV, proton pump inhibitors, basal acid secretion, stimulated acid secretion, gastric atrophy, gastric polyps, atrophic gastritis

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Contributor Information and Disclosures

Author

Timothy R Koch, MD, Professor of Medicine (Gastroenterology), Georgetown University School of Medicine
Timothy R Koch, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Physiological Society
Disclosure: Nothing to disclose.

Coauthor(s)

Hiral Shah, MD, Chief Resident, Department of Internal Medicine, Georgetown University Hospital at Washington Hospital Center
Hiral Shah, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

David Greenwald, MD, Fellowship Program Director, Associate Professor, Department of Medicine, Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine
David Greenwald, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

James L Achord, MD, Professor Emeritus, Department of Medicine, Division of Digestive Diseases, University of Mississippi School of Medicine
James L Achord, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Mississippi State Medical Association, New York Academy of Sciences, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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