Achlorhydria Treatment & Management

  • Author: Jennifer (Zone-En) Lee, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Aug 18, 2011
 

Medical Care

Achlorhydria and the physiologic consequences of this condition have the following treatments.

  • Achlorhydria associated with H pylori infection may respond to H pylori eradication therapy, although resumption of gastric acid secretion may only be partial.
    • The standard, first-line therapy for gastric H pylori is as follows: PPI (20 mg bid) plus clarithromycin (500 mg bid) plus amoxicillin (1 g bid). For patients who are allergic to penicillin, amoxicillin can be replaced by levofloxacin (250 mg bid).
    • There is some minor disagreement on the duration of treatment. US guidelines recommend a 14-day course, while in Europe, a 7-day course is considered to be sufficient. A meta-analysis reveals a 12% advantage for a longer course of treatment, but this is at an added expense and a greater risk of adverse effects. Patient compliance is also more difficult with a longer course of treatment (ie, 14 d vs 7 d).
  • In immune-mediated diseases (eg, pernicious anemia), acid secretion cannot be restored after destruction of the gastric secretory mucosa.
    • Treatment of gastritis that leads to pernicious anemia consists of parenteral vitamin B-12 injection. It is not clear whether intranasal vitamin B-12 therapy is adequate in individuals who have been diagnosed with pernicious anemia. Parenteral vitamin B-12 treatment may reverse hematologic abnormalities. However, it may have little effect on preexisting neurologic abnormalities. This treatment does not affect the underlying gastric atrophy, inflammation, or the possible development of gastric carcinoma and should be followed with these risks in mind.
    • Associated immune-mediated conditions (eg, insulin dependent diabetes mellitus, autoimmune thyroiditis) should also be treated. However, treatment of these disorders has no known effect in the treatment of achlorhydria.
  • The normal indigenous intestinal microflora consists of about 1015 bacteria that mainly reside in the lower gut. Bacterial overgrowth implies abnormal bacterial colonization of greater than 100,000/mL in the upper gut.
    • Small intestinal bacterial overgrowth can result in recurrent diarrhea with malabsorption, D-lactic acidosis, and an increased risk of endogenous infection.
    • Other conditions associated with small bowel bacterial overgrowth include steatorrhea, macrocytic anemia, and, less commonly, protein-losing enteropathy.
    • Microecological changes are accompanied by vitamin B-12 deficiency anemia, hypovitaminosis, protein deficiency, translocation of bacteria and their toxins from the intestine into the bloodstream, emergence of endotoxinemia, and possible generalization of infection. Bacterial overgrowth is diagnosed by concentration of hydrogen in expiratory flow (glucose-hydrogen breath test) or by bacteriological study of aspirate from the proximal part of the small intestine.
    • Antimicrobial agents, including metronidazole, amoxicillin/clavulanate potassium, ciprofloxacin, and rifaximin, can be used to treat bacterial overgrowth.
  • Achlorhydria resulting from long-term PPI use may be treated by dose reduction or withdrawal of the PPI.
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Surgical Care

Hypergastrinemia due to achlorhydria secondary to PPI therapy or resection of the gastric fundus is known to cause ECL cell hyperplasia and gastric carcinoids. Surgery is the only potentially curative therapy for carcinoid tumors.[11]

Surgical antrectomy results in normalization of serum gastrin levels and disappearance of multicentric gastric carcinoids. In a study by Hirschowitz et al, antrectomy resulted in normalization of serum gastrin levels within 8 hours and disappearance of carcinoids in 6-16 weeks.[12]

Gladdy et al examined the efficacy of endoscopic surveillance versus surgical resection in the treatment of patients with type I GI carcinoid tumors.[11] In the study, 46 patients underwent endoscopic surveillance with polypectomy, while 19 patients were treated with gastric resection. (The latter treatment was used in patients with larger-sized tumors, increased depth of invasion, and solitary tumors.) The 5-year recurrence-free survival rate was 75% in the surgical resection patients, but the disease-specific survival rate was 100% in both patient groups. Concomitant adenocarcinoma was found in 4 of the patients who underwent resection, with the detection made through preoperative biopsy in 2 of these individuals. (The carcinoid tumors were bigger and the carcinoid disease was more advanced in all patients with coexisting gastric adenocarcinoma.)

The authors recommended that resection be considered for patients with more advanced carcinoid disease, owing to the increased adenocarcinoma risk associated with the advanced disorder. They also concluded that endoscopic surveillance is appropriate for determining the status of carcinoid tumors and for the assessment of the dysplasia or adenocarcinoma that can arise in association with type I GI carcinoid tumors.

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Contributor Information and Disclosures
Author

Jennifer (Zone-En) Lee, MD  Fellow, Section of Gastroenterology, Georgetown University School of Medicine, Washington Hospital Center

Jennifer (Zone-En) Lee, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society of Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Coauthor(s)

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.

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.

Specialty Editor Board

David Greenwald, MD  Associate Professor of Clinical Medicine, Fellowship Program Director, 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, American Society for Gastrointestinal Endoscopy, and New York Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Alex J Mechaber, MD, FACP  Senior 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

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 & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

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