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Hypochlorhydric Stomach: a Risk Condition for Calcium Malabsorption and Osteoporosis?

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Hypochlorhydric Stomach: a Risk Condition for Calcium Malabsorption and Osteoporosis? Scandinavian Journal of Gastroenterology, 2010; 45: 133–138 REVIEW ARTICLE Hypochlorhydric stomach: a risk condition for calcium malabsorption and osteoporosis? PENTTI SIPPONEN1 & MATTI HÄRKÖNEN2 1Repolar Oy, Espoo, Finland, and 2Department of Clinical Chemistry, University of Helsinki, Helsinki, Finland Abstract Malabsorption of dietary calcium is a cause of osteoporosis. Dissolution of calcium salts (e.g. calcium carbonate) in the stomach is one step in the proper active and passive absorption of calcium as a calcium ion (Ca2+) in the proximal small intestine. Stomach acid markedly increases dissolution and ionization of poorly soluble calcium salts. If acid is not properly secreted, calcium salts are minimally dissolved (ionized) and, subsequently, may not be properly and effectively absorbed. Atrophic gastritis, gastric surgery, and high-dose, long-term use of antisecretory drugs markedly reduce acid secretion and may, therefore, be risk conditions for malabsorption of dietary and supplementary calcium, and may thereby increase the risk of osteoporosis in the long term. Key Words: Achlorhydria, atrophic gastritis, calcium carbonate, calcium salt, hypochlorhydria, malabsorption, osteoporosis, proton-pump inhibitor, stomach acid For personal use only. Introduction acid for calcium absorption and emphasize that the in vitro water solubility of calcium salts is not associated Malabsorption of dietary calcium is a risk factor for with their in vivo absorbability [1–3]. This may cer- osteoporosis. Acid induces dissolution of the calcium tainly be true in subjects with a healthy stomach and in the stomach as a calcium ion (Ca2+). If the stomach normal acid secretion. However, in subjects with an does not secrete acid, calcium salts may not be effec- hypochlorhydric stomach, and with failure of the tively dissolved and ionized, and may be poorly “gastric acid machine”, this may no longer be the absorbed in the proximal small intestine. There are case. Most studies on the absorption of calcium salts three major conditions that significantly decrease acid have been done in subjects or animals with normal acid secretion in human beings. These are the use of secretion. Very little is known about the absorbability potent acid inhibitors in high doses, resections and of micronutrients, including calcium, in subjects with bypasses of the stomach, including bariatric surgery, a permanently acid-free or hypochlorhydric stomach. Scand J Gastroenterol Downloaded from informahealthcare.com by University Of Washington on 08/26/10 and the development of atrophic gastritis in the gastric corpus and fundus. All result in a decrease in gastric acid secretion and may thereby influence calcium Active and passive absorption of dietary calcium homeostasis in the longer term. In the normal stomach, the “acid machine” converts In addition to gastric acid, the bioavailability of die- poorly soluble calcium salts (including calcium car- tary calcium salts depends on several factors, includ- bonate) to calcium chloride (CaCl2) which easily ing the physiological function of the stomach and dissociates to Ca ion (Ca2+) and is, thereby, highly intestine, levels of vitamin D in the tissues and cir- water-soluble, even in the pH-neutral milieu of the gut. culation, diet and the chemical structure and quantity However, some reports and opinions have also been of the calcium compounds ingested [4–12]. Active published which dispute the significance of stomach vitamin D-promoted transcellular absorption of Correspondence: Pentti Sipponen, MD, PhD, Repolar Oy, Box 26, 02101 Espoo, Finland. E-mail: [email protected] (Received 23 June 2009; accepted 11 September 2009) ISSN 0036-5521 print/ISSN 1502-7708 online Ó 2010 Informa UK Ltd. DOI: 10.3109/00365520903434117 134 P. Sipponen & M. Härkönen calcium ion in the duodenum and proximal small 100 ml of water, which provides maximally 25 mg intestine is obviously the most important physiolog- of elemental calcium (Ca2+) dissolved in solution. ical pathway for absorption of the calcium, although Correspondingly, maximal dissolution of calcium car- passive paracellular and transepithelial absorptions of bonate at neutral pH provides much less than 10 mg calcium by vesicles and diacytosis of soluble com- of elemental calcium in 100 ml of aqueous solution. plexes of calcium with tissue or food-derived proteins These solubilities cannot be improved by adding may also occur, even in the colon [7,8,12–18]. calcium salts to the solution. However, when hydro- The net absorption of calcium is certainly the sum chloric acid is present or added, solubility is markedly of the active and passive absorptions, the latter being improved. proportional to the gradient of the calcium concen- Complete dissolution of calcium requires an equiv- tration between the gut lumen and circulation, and alent amount of hydrochloric acid to be secreted into possibly being prominent when active absorption is the gastric juice as calcium is ingested. For example, saturated or impaired. The transit time of the dietary complete dissolution of a single 500-mg (approxi- bolus in the small intestine is up to 1–3 h, during mately 5 mmoles) tablet of calcium carbonate into which most of the active and passive absorption will ionic form (Ca2+) consumes 10 mmoles of hydro- obviously occur. This time window is relatively short chloric acid (for the physiochemical background and may require optimal physiological conditions, see: http://en.wikipedia.org/wiki/calcium_carbonate). e.g. effective ionization of the calcium compounds This will provide 200 mg of elemental calcium in the ingested, for both active and passive absorption phe- gastric juice from 500 mg of calcium carbonate. Basal nomena. Regarding the passive absorptions, it is con- acid output in the healthy stomach is 0.2–5 mmol/h ceivable that these pathways also require the into approximately 100–200 ml of gastric juice. Post- dissolution and ionization of calcium salts, and that prandially, the peak and maximal acid outputs the calcium salts are minimally absorbed as whole increase 10–20-fold for a short period of time. molecules neither passively nor actively, e.g. as In order to ensure the presence of maximal intra- carbonate salts. gastric acidity, calcium carbonate tablets are recom- The complex cycle of active calcium absorption in mended to be taken with food [4]. It is believed that the the intestinal epithelial cells involves specific molecular dissolution of calcium salts is better postprandially, mechanisms for binding of the calcium ion (Ca2+) when the acid output is maximal, than under fasting to carrier proteins and transmembrane channel conditions. However, the use of proton-pump inhibi- For personal use only. molecules in the enterocytes, some of these protein tors (PPIs) or the presence of atrophic gastritis decrease bindings being vitamin D-dependent [13–17]. These both the basal and maximal outputs of acid, and will, absorption phenomena take place in the pH-neutral therefore, diminish the quantity of acid available for milieu of the intestinal epithelium, are no longer dissociation of calcium salts postprandially. Further- influenced by stomach acid, and are hence outside more, it is conceivable that the simultaneously ingested the scope of this review. Complex mechanisms also food also needs and consumes acid for various digestive occur during the metabolism of calcium in bone processes in the postprandial phase, and that this acid is tissues but these phenomena are also beyond the no longer available for dissolution of the calcium salts. scope of this paper. We will focus on phenomena In addition, acid may be needed and consumed in the and mechanisms related to the influence of stomach postprandial phase for dissolution of many dietary acid on dissolution, ionization and absorption of the micronutrients other than calcium, such as, for Scand J Gastroenterol Downloaded from informahealthcare.com by University Of Washington on 08/26/10 dietary calcium. example, iron, magnesium and zinc. The need for elemental calcium is ‡ 800 mg/day, the amount which has to be dissolved and ionized Solubility of calcium salts from the dietary calcium salts within a relatively short period of time (the normal stomach will empty within Supplementary calcium is usually given as calcium 1–2 h after ingestion of food). It may be estimated that carbonate tablets in most commercially available the acid required for fully dissolution of 800 mg of medications. At neutral pH, calcium carbonate is elemental calcium from 2 g of calcium carbonate is practically insoluble in water. Calcium ascorbate, about 40 mmoles of hydrochloric acid, which corre- calcium citrate, calcium lactate, and calcium gluco- sponds to the amount of acid secreted maximally in nate dissolve somewhat better than carbonates and 1–2 h by a normal healthy stomach. Therefore, the phosphates, whereas calcium oxalate is largely insol- quantity of acid needed is high, which may mean that uble under any biological condition [7,8,19]. The acid secretion must be normal or nearly normal to maximal solubility of calcium citrate at room temper- ensure a physiologically effective dissolution of all ature and neutral pH is approximately 100 mg in nutrients ingested. Acid and calcium malabsorption 135 As a simplified summary, hydrochloric acid (the Atrophic gastritis “stomach acid machine”) ionizes calcium salts, e.g. calcium carbonate, to one Ca2+ ion and two Cl– ions in Atrophic gastritis (loss of normal glands in the the stomach, resulting in the production of water and mucosa) in the gastric corpus results in a permanently hypochlorhydric or achlorhydric stomach. Atrophic CO2, the latter being mostly exhaled in the breath. Small amounts of soluble bicarbonates may also be gastritis is a human, in vivo model of all disease conditions associated with a persistently low intragas- formed by the reaction of dissolved CO2 with calcium tric acidity. The significance of atrophic gastritis to the carbonate. Thus, calcium chloride (CaCl2) is formed, which is highly water-soluble in neutral and even in malabsorption of vitamins, micronutrients and med- alkaline milieu. At pH 7, some 50–70 g of calcium icines has, however, been surprisingly poorly studied.
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