An overlooked cause of dyspepsia?


Discussion of a common cause of dyspepsia was missing from your September article, “Dyspepsia: A stepwise approach to evaluation and management” (J Fam Pract. 2021;70:320-325). After more than 25 years of practice, I have found that most people with dyspepsia have hypochlorhydria1—a condition that results in the inability to produce adequate amounts of hydrochloric acid, or stomach acid. With lower amounts of stomach acid, food does not break down but ferments instead, producing gas and discomfort.

I use a simple test to diagnose patients with hypochlorhydria. The patient takes a capsule of hydrochloric acid directly after eating a meal; failure to experience epigastric burning within 30 minutes of ingesting the capsule indicates a need for additional stomach acid with a meal. If they do experience a burning sensation within 30 minutes, it indicates they do not need additional stomach acid. The burning sensation is relieved by drinking 2 teaspoons of baking soda in 4 oz of water to neutralize the excess acid.

In my experience, most people who take the test do not experience a sense of burning. I find that once these patients with hypochlorhydria start taking betaine hydrochloride with their meals, they no longer need the many over-the-counter or prescription antacids and their dyspepsia disappears. Many of my patients find that after a few months, they begin to experience burning and can discontinue the supplement, without facing a return of their dyspepsia.

Marianne Rothschild, MD
Mount Airy, MD

1. Iwai W, Abe Y, Iijima K, et al. Gastric hypochlorhydria is associated with an exacerbation of dyspeptic symptoms in female patients. J Gastoenterol. 2012;48:214-221. doi: 10.1007/s00535-012-0634-8

Editor’s note

After reading Dr. Rothschild’s letter, I decided to do a little digging to find out if there is any research evidence to support her approach to dyspepsia. I carefully searched PubMed and found only 2 observational studies showing an association between dyspepsia and hypochlorhydria. There are no randomized trials of dyspepsia treatment with hydrochloric acid to support her clinical observations. Placebo effect? Until there is a good, randomized trial, we will not know. But who would have guessed that H pylori causes peptic ulcers?

John Hickner, MD, MSc
Editor-in-Chief, The Journal of Family Practice

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