Conditions, Cystitis

The Importance of Stomach Acid for (Bladder) Health

The stomach and its acid secretion may seemingly be unrelated to bladder health but as a matter of fact, stomach acid plays an important role in overall health – as a first line of defense for our immune system, in protein digestion and nutrient absorption.

Many may think of stomach acid in relation to heartburn/GERD, which affects up to 27 % of adults [1] and has risen recent years. As a result, antacids are the 7th most popular personal care product in the US alone, with sales of many million dollars [2].

However, the symptoms for low and high stomach acid are very similar. While high stomach acid can definitely be very irritating, low stomach acid may have more far reaching consequences.





Why do we even need stomach acid?

Stomach acid, or hydrochloric acid (HCl) is one of the most vital secretions to help us digest and absorb food and also to help protect our bodies from disease.

HCl is one of the key components for efficient digestion and the body’s first line of defence against pathogenic viruses, bacteria and yeasts. Pathogens thrive in a more alkaline environment and cannot normally survive the harsh acidity of the stomach.

Low levels of HCl may cause an array of problems and may be the root cause of various seemingly unrelated disorders.

One of the key functions of HCl is to acidify the environment in the stomach. This sterilizes the food, which is important to prevent the food from putrefying and thus becoming a source of toxicity for the body.

Furthermore, HCl can kill off any pathogenic bacteria, viruses or yeasts that might be entering the body through food. It acts as a first line of defence for our immune system.

The next key function of HCl is to ‘unravel’ the chains of amino acids present in proteins in order to prepare them for digestion. Moreover, it activates the protein-digesting enzyme pepsin.

This starts the digestion of proteins that we need as building blocks to keep our bodies healthy and to produce enzymes and hormones.

We also need HCl to absorb vitamin B12 and toionize’ certain minerals, such as calcium, magnesium and zinc, which is important for their efficient absorption.

What happens if we don’t have enough stomach acid?

Because HCl has so many important functions, low levels (hydrochloridia) may lead to unwanted symptoms.

First of all, proteins are hard to break down without sufficient HCl and may start to rot and putrefy in the stomach. This could produce a lot of gas, potentially leading to bloating, indigestion and belching.

Protein could also sit undigested in the stomach, causing a feeling of fullness and sometimes nausea. Amino acids from protein may not arrive where they are needed, potentially leading to a shortness of enzymes, neurotransmitters or and hormones, which can affect the whole body.

When food leaving the stomach is not acidic enough, it may fail to trigger hormones to secrete pancreatic enzymes and bile. This could affect digestion and absorption in the intestines. The small intestine may also ‘reject’ the food and push it back up, potentially resulting in heartburn.

With low HCl, nutrient absorption may be compromised, even if they are supplemented.

The vitamins B12, B6 and folate all need HCl for absorption and are potentially deficient in people suffering from low HCl [3]. Absorption of other nutrients such as vitamin C, iron [4], magnesium and calcium [5] could also be impaired. Chronic nutrient deficiencies in turn may have a negative impact on all aspects of health.

With age, stomach acid levels drop and with it the potential for stomach problems.  This may sometimes be due to an infection with the H. pylori bacterium, which can take hold in the stomach when acid levels are low and then survive HCl even if it levels are raised subsequently [3, 6].

Without adequate stomach acid, we are more prone to a variety of infections as our first line of defence is not in place [7, 8].

The effect of Low Stomach Acid on Bladder Health

Without adequate stomach acid to kill invading microbes, pathogens such as E. coli [7] can enter the body through food and find their way into the bladder and cause urinary tract infections (for example from contaminated chicken).

Calcium and magnesium are needed for normal muscle function, so if they aren’t absorbed well this could have consequences for the bladder muscle potentially resulting in issues such as incontinence or an overactive muscle.

Also, materials to repair bladder cells may not be getting through.

Risks of taking Antacid Medications

Many people who suffer from indigestion and heartburn might reach for antacid medication. There are two types of these medications: antacids, which consist of alkalizing minerals that neutralize acid and Proton Pump Inhibitors (PPIs), which inhibit the secretion of stomach acid.

Studies have shown that the use of PPIs to suppress HCl production raises the risk of catching serious infections, including the antibiotic resistant C. Difficile bug, which can lead to severe diarrhoea that can be fatal [9], and pneumonia [10] amongst others [7, 8].

Moreover, people using PPIs may develop SIBO (small intestinal bacterial overgrowth) [11, 12] or SIFO (small intestinal fungal overgrowth) [12]. Changes of pH in the stomach due to low levels of HCl can also change the pH in the remainder of the digestive tract which can allow bacteria to live in places they would not normally be present.

So we can see that low levels of stomach acid has the potential of creating an array of problems and symptoms.

How to know if you have low stomach acid?

The most obvious symptoms could include (note that they are very similar to high stomach acid symptoms):

  • digestive discomfort shortly after eating a meal
  • bloating
  • wind
  • burping
  • burning
  • inability to eat large portions
  • acid reflux
  • feeling of fullness
  • nausea
  • diarrhea
  • constipation
  • GERD or GORD

Many other chronic ailments may also be indirectly linked to low levels of stomach acid (however, they are non-specific and could have a different cause). These can include (but are not limited to):

  • Anemia
  • Hair loss
  • Brittle nails
  • Acne
  • Nutrient deficiencies
  • Calcium deposits
  • SIBO
  • C. Diff
  • Dysbiosis
  • H. Pylori
  • Hormonal imbalances
  • Neurotransmitter imbalances

How to test for stomach acid levels?

The gold-standard functional test for HCl levels is the Heidelberg Capsule Test. A small radio transmitter capsule is swallowed and measures resting HCl levels, alternating with an alkaline bicarbonate challenge. The physician then checks how well the stomach returns to an acid condition, which determines whether or not adequate levels of HCl are produced. As far as I know there is no private lab in the UK offering this test and I don’t know if it is available in NHS hospitals.

The VEGF Test is a lab test that measures ‘vascular endothelial growth factor’ (VEGF) in the saliva, which is proportionate to the amount of HCl produced in the stomach. This non-invasive test is available privately in the UK and costs around £80.

The Bicarbonate Challenge Test is an easy and cheap test that can be done at home. It is based on the idea that an alkaline bicarbonate solution would react with the acidic HCl in the stomach, causing burping. As all DIY tests, it is probably not 100% accurate. In the morning a solution of ¼ tsp bicarbonate plus 250 ml of water is consumed on an empty stomach. Belching should occur if HCl is present. The time it takes until belching occurs is then measured:

  • 1-2 minutes: normal HCL
  • 2-3 minutes: normal to slightly low HCl
  • 3-5 minutes: low HCl
  • 5+ minutes: potentially no HCl

What to do about low stomach acid

Eat enough protein: Without sufficient protein in the diet the production of HCl and pepsin may be very low. Long-term vegetarians and vegans (including me) often develop low levels as production of HCl diminishes with the lack of protein in the diet.

Chew well: The first stage of digestion is chewing. Chewing and tasting food triggers HCl to be produced in the stomach.

Don’t eat when stressed: When the body is stressed, the sympathetic side of the nervous system favours the functioning of vital organs that would be needed in a ‘fight or flight’ situation and lowers secretions of the digestive system, including HCl.

Don’t drink with your meals: Consuming too many liquids with food can dilute stomach acid, no more than a small glass would be recommended. Try to leave at least 30 mins on either side.

Apple cider vinegar: A tsp of ACV mixed into an equal amount of water taken right before a meal may help to acidify stomach contents (it does not stimulate HCl production however)

Betaine HCL: This is a supplemental form of stomach acid. You should consult a health practitioner before taking these supplements.

Bitters: Herbal bitters may help to stimulate digestive secretions and have been used traditionally.

 

Do you think you have problems with low stomach acid? Have you been taking antacids? Let me know in the comments!





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 Sources:

  1. El-Serag HB, Sweet S, Winchester CC, et al Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review Gut 2014;63:871-880. http://gut.bmj.com/content/63/6/871
  2. Statista Sales growth of leading brands of antacid tablets in the United States in 2016 (change to prior sales year) 2017 https://www.statista.com/statistics/194547/us-sales-growth-of-antacid-tablet-brands-in-2013/
  3. Lovat, L. B. Age related changes in gut physiology and nutritional status. Gut 1998 [cited 38: 306-309] Available from: http://gut.bmj.com/content/38/3/306.full.pdf
  4. Kenneth E L McColl Effect of Proton Pump Inhibitors on Vitamins and Iron The American Journal of Gastroenterology 104, S5-S9 (March 2009) https://www.nature.com/ajg/journal/v104/n2s/full/ajg200945a.html
  5. Horn, E. et al A Case Series of Proton Pump Inhibitor–Induced Hypomagnesemia American Journal of Kidney Diseases [Volume 56, Issue 1, July 2010, Pages 112-116] http://www.sciencedirect.com/science/article/pii/S027263860901600X
  6. Marshal BJ et al. Pyloric Campylobacter infection and gastroduodenal disease Med J Aust. 1985 Apr 15;142(8):439-44. http://www.ncbi.nlm.nih.gov/pubmed/3982346?dopt=Abstract&holding=f1000,f1000m,isrctn
  7. Bavishi, C. and DuPont, H. L. (2011), Systematic review: the use of proton pump inhibitors and increased susceptibility to enteric infection. Alimentary Pharmacology & Therapeutics, 34: 1269–1281. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2011.04874.x/full
  8. Gianluca Terrin et al Ranitidine is Associated With Infections, Necrotizing Enterocolitis, and Fatal Outcome in Newborns Pediatrics Jan 2012, 129 (1) e40-e45 http://pediatrics.aappublications.org/content/129/1/e40
  9. Tleyjeh IM, Abdulhak AAB, Riaz M, Garbati MA, Al-Tannir M, et al. (2013) Correction: The Association between Histamine 2 Receptor Antagonist Use and Clostridium difficile Infection: A Systematic Review and Meta-analysis. PLOS ONE 8(4): 10.1371/annotation/56f8945c-33f6-45bf-87ce-dd512f7c25b0. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0056498
  10. de Jager, C. P. C., Wever, P. C., Gemen, E. F. A., van Oijen, M. G. H., van Gageldonk-Lafeber, A. B., Siersema, P. D., Kusters, G. C. M. and Laheij, R. J. F. (2012), Proton pump inhibitor therapy predisposes to community-acquired Streptococcus pneumoniae pneumonia. Aliment Pharmacol Ther, 36: 941–949. http://onlinelibrary.wiley.com/doi/10.1111/apt.12069/full
  11. Lombardo L et al Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy. Clin Gastroenterol Hepatol. 2010 Jun;8(6):504-8 https://www.ncbi.nlm.nih.gov/pubmed/20060064
  12. Jacobs, E. et al Dysmotility and proton pump inhibitor use are independent risk factors for small intestinal bacterial and/or fungal overgrowth Aliment Pharmacol Ther 2013; 37: 1103–1111 http://onlinelibrary.wiley.com/doi/10.1111/apt.12304/full

24 Comments

  • Reply

    Cathy Chester

    November 1, 2017

    I do have SIBO and I want to know NOW WHAT? Since the diagnosis I’ve eliminated gluten, sugar and dairy. My stomach still bothers me. So I’m overwhelmed with reading materials, suggestions, and what to do to feel “normal” again? Suggestions are appreciated!

    Glad to “meet” you from the FB Chronic Illness Bloggers thread.

    Best to you,
    Cathy Chester

    • Reply

      Layla

      November 1, 2017

      Hi Cathy, nice to ‘meet’ you too! TBH I still struggle slightly with these things as well, SIBO is a really tough one. Starting with the stomach would be important, making sure there is enough acid and gut motility is triggered – this sterilizes the small intestine. The pH in the colon is also important, so trying to balance the gut flora (again, extremely hard). I’ve heard some promising research on a product called Atrantil but have not tried it myself.
      I’ve had some good success with the elemental diet in the past (very promising research) but it is so horrible that I cannot recommend it. I’m working on my stomach now, which seems a good starting point. Stress is also a major factor, so that’s another thing to look into.

  • Reply

    Sheryl

    November 1, 2017

    Fascinating article as always, Layla! I really appreciate how you dig beyond the surface knowledge to show how one thing impacts everything else.

    • Reply

      Layla

      November 2, 2017

      Thanks, Sheryl!

  • Reply

    Lisa Ehrman

    November 2, 2017

    Really good info. I take Hydrochloric Acid, but also am being treated for MCAS. One thing we take is Zantac, which is not a PPI. I’m trying to replace this, though, because it’s bad for my kidneys.

    • Reply

      Layla

      November 2, 2017

      So are you taking hydrochloric acid to make up for the antacid effect of zantac? As far as I understand it, zantac blocks histamine and histamine actually plays a role in controlling stomach acid output. I don’t know if other antihistamines would have the same effect? I hadn’t thought of that connection before but had seen zantac pop up in the research I used.

  • Reply

    Diane

    November 2, 2017

    Thank you so, so much for this article. There’s so much actionable info for me to work with here!!

    • Reply

      Layla

      November 2, 2017

      Thanks, I hope it’s useful!

      • Reply

        Diane

        November 5, 2017

        Quite! I’m curious, have you read anything about a “breaking-in” process when you change habits and increase your stomach acid?

        Just cutting out the water when I eat seems to be giving me all sorts of heartburn and nausea, and I can’t tell if it’s a coincidence or not. It certainly makes logical sense but I suppose it would be nice to see a little validation haha.

        • Reply

          Layla

          November 6, 2017

          Sometimes this could be due to a thin stomach lining/not enough mucus around the stomach – when acid levels rise, this could then lead to burning. Have you ever been tested for stomach ulcers/H. pylori? This can also cause symptoms like that, which are often relieved by antacids, water etc. (not saying you have this, just something you could look into). I certainly still struggle with a burning stomach sometimes. Popular home remedies for this include slippery elm, aloe vera, cabbage juice, marshmallow root, licorice (mucilage).

  • Reply

    Claire

    November 2, 2017

    Really informative post! I love anything with a bit of medicine and research – nursing background I guess. Will share x

    • Reply

      Layla

      November 2, 2017

      Thanks, Claire!

  • Reply

    Deb walker

    November 4, 2017

    Hi, I’ve been on Propranolol for acid reflux for about 10 years. I’m now in the process of being diagnosed with IC. I’m thinking there may be a connection??

    • Reply

      Layla

      November 5, 2017

      Hi Deb, everything in the body is connected so I’d never rule it out. I don’t quite understand the use of Propranolol for acid reflux though, in the medication leaflet it says it’s a beta-blocker mostly used for cardiovascular disease and high blood pressure – the only connection I could find to the stomach was ‘prevent stomach bleeding in patients with high blood pressure in their liver or swollen blood vessels in their gullet’. It is not an antacid or PPI so it wouldn’t act in the same way on stomach acid…

      • Reply

        Diane

        November 5, 2017

        I’ve had a PPI wreck me POTS-wise, and take Propranolol for POTS symptoms. I wonder if the two types of meds work in similar systems somehow… certainly curious to learn more from Deb!

        • Reply

          Layla

          November 6, 2017

          Interesting. I’ve had a little dig into both: PPIs work on inhibiting an enzyme system called ‘proton-pump’ that is needed for production of stomach acid, thereby inhibiting stomach acid production. Propranolol works by blocking beta-receptors in the body, those are mainly receptors for the excitatory neurotransmitter noradrenaline (or norepinephrine in the US). Because these receptors are everywhere in the body, beta-blockers have a wide range of benefits and also side-effects. The only connection to stomach acid I can see here is that it is sometimes used to treat an overactive thyroid, hence it probably slows down the thyroid and this can also reduce stomach acid output.

          • Diane

            November 6, 2017

            This is getting a bit off-topic, I know, but I dug a little more and it looks like a PPI, by inhibiting the acid production, would also inhibit bicarbonate release into the bloodstream (aka alkaline tide), which regulates blood pH. Anyone know where that might tie in with POTS?

          • Layla

            November 6, 2017

            Yes, now that you mention it I had learned that as well. Unfortunately I don’t know much about POTS…

  • Reply

    Michelle

    November 6, 2017

    I have been told I have silent reflux. I also have gastroparesis and Chronic kidney disease along with Sjogrens and intercystitial cystitis. Ive read that D-Liminine could help. My gastroenterologist wanted me to Pepcid and I don’t want to due to all the issues it can cause. I think my next visit Im going to ask about being tested for low acid. Im sure I have an issue with the valve that keeps the food in ti stomach so I get reflux because of it.

    • Reply

      Layla

      November 6, 2017

      I don’t know too much about Sjoergens, but isn’t part of the condition the ‘drying out’ of body tissues? I wonder if it could reduce stomach acid? May be worth to get tested, although Doctors generally seem to mostly treat for high acid but hopefully your doc is open to this. D-Limonene also neutralizes stomach acid (https://www.ncbi.nlm.nih.gov/pubmed/18072821) so I would only used it if it’s confirmed high acid.

      • Reply

        Michelle

        November 7, 2017

        Thanks so much for your reply. Do you know he name of a specific test for low stomach acid? You made absolute sense with the Sjogrens it didn’t even cross my mind.

        • Reply

          Layla

          November 7, 2017

          The tests are all listed in this article.

  • Reply

    Marilyn

    November 14, 2017

    I also have Sjogren’s and Interstitial cystitis. I also suffer weight loss from what I think is malabsorption due to Sjogren’s and probably low stomach acid and poor digestion. I’m currently awaiting an appointment with a gastroenterologist who hopefully can run some of these tests. However, I also wonder if increasing my stomach acid would damage my bladder lining as I am on an alkaline diet as acidic foods are to be avoided with IC. I have been told that my bladder lining looked like “purple grapes” during a cystoscopy. I also have Hunner’s lesions. I am sensitive to many foods which cause IC flares. I have difficulty with fruits, fats, as well as a long list of foods on the IC diet. The only beverage I can tolerate is spring water or filtered water with a pH above 7. I even found that I cannot take probiotics without flaring. It would seem that my IC symptoms would need to improve before I could tolerate taking supplements to increase a low acid condition.

    • Reply

      Layla

      November 14, 2017

      Dear Marilyn,
      It sounds like you’d have to address inflammation and the integrity of connective tissue surrounding the digestive tract and bladder lining first – without that increased acid would cause more problems. Herbs like slippery elm, marshmallow, aloe Vera may be useful, as well as collagen/ bone broth and buffered vitamin C.

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