When Low Stomach Acid is Caused by Autoimmune – SIBO Risk: Always looking for the root cause of SIBO. When to investigate low stomach acid, a known root cause for SIBO, for an autoimmune condition: Autoimmune Gastritis (AIG) – which is at least 2-4x more prevalent than Celiac, but often overlooked.

Podcast Highlights

6:26 Low stomach acid or hypochlorhydria can result in Small Intestinal Bacterial Overgrowth (SIBO), which is the cause of IBS in the majority of cases. Low stomach acid can be caused by chronic stress or hypothyroidism. There are pathogens that come into the digestive tract through your food and we need hydrochloric acid and a pH of 3 to kill such pathogens. Such acidity also signals gastric emptying, a release of digestive enzymes, and a release of bile, all of which help to reduce bacteria in the small intestine. And when it comes to treating SIBO, it is easy to just think that we have to kill the bacteria. However, to really fix the gut, we need to help reset and rebalance and reseed to cure SIBO and get someone to a negative breath test.

12:17 There are certain symptoms that might make you suspect that your SIBO patient has low stomach acid, such as when they feel that food is just sitting there and does not move through their stomach normally of if they say that they’re not breaking down their food. You might also suspect low stomach acid if there are intact pieces of food in their stool or if they have peanut butter stool that is very sticky and requires multiple wipes. We can also look at a Spectracell Micronutrient test and look at nutritional deficiencies like iron or B12, which might be trending lower if they have low stomach acid.

13:38 Once you suspect a patient may have low stomach acid, Angela will rule out H. pylori as a cause and she recommends looking at the urea breath test for H. Pylori and she also likes to order a GI Effects stool test and include a stool H. pylori antigen test. She finds that more sensitive than the blood antigen test for H. pylori. Interestingly, if H. pylori grows in the antrum or lower portion of the stomach, H. pylori can cause increased hydrochoric acid production and ulcers. But if the H. pylori grows in the fundus or upper portion of the stomach or in the body, or corpus, the areas where the parietal cells are that make the hydrochloric acid, it can lead to decreased acid production. If there is chronic burping or you have any kind of burning or warmth in the stomach or a sense of fullness, we need to rule out H. Pylori. If you suspect it is a chronic case of hypochlorhydria, then Angela will look at advanced markers, like anti-parietal cell or anti-intrinsic factor antibodies to see if it is a case of atrophic autoimmune gastritis. If there is no H. pylori, then we should see what can be done with diet, lifestyle, and supplements. If they are stressed and in sympathetic mode, then we need to work on stress reduction and this could include the Wim Hof breathing technique.

18:55 When Gastroenterologists do an endoscopy and biopsy for H. Pylori they usually biopsy the antrum and the duodenum to look for celiac. They will miss H. pylori in the fundus or the body of the stomach.

20:33 When it comes to Atrophic Gastritis, one cause is H. Pylori and the other cause is autoimmmune gastritis, in which you get antibody production against the parietal cells. We routinely check of celiac, despite the fact there is only a prevalence in the US of .5 to 1%, whereas autoimmune atrophic gastritis has a prevalence of 2 to 8% and we hardly ever screen for this and the rate is going up. These parietal cells that produce stomach acid also produce intrinsic factor, which is required to absorb B12. And if they are not making stomach acid, then they will not be breaking down their proteins to be able to absorb B12. If you suspect a patient of having low stomach acid you can send them for a Heidelberg test.

27:26 When you are treating a patient who has low stomach acid because they have been on PPIs, Angela will work with their MD to slowly wean them off the PPIs. Angela likes to add in bitters, like Bitters 9 or Bitters X from Quicksilver Scientific, to stimulate their own production of digestive enzymes and hydrochloric acid production. She has them use the Bitters X and do one or two pumps and hold it in their mouth for 90 seconds, swishing it around, before swallowing it. She will also have them cook all their vegetables and eat smaller, more frequent meals, and chew their food three times more than they think they need to. She will also sometimes add digestive enzymes. She will have them use a little baking soda in water if they need to to take the edge off.

31:10 Angela treats autoimmune atrophic gastritis by treating both the gastritis and also by treating the underlying autoimmune condition. We have to look for the triggers for the autoimmune condition, whether they are stress, environmental toxins, food sensitivities, etc. We need to treat the nutritional deficiencies that result, including vitamin B12 and iron. They may initially need iron and B12 injections. Such patients may need hydrochloric acid supplementation for life.

Angela Pifer is one of nation’s foremost Functional Medicine nutritionists in Seattle, Washington with a focus on Gastrointestinal Disorders like SIBO and IBS. Angela is known as the SIBO Guru. Her website is SIBO Guru, she has launched a gut prescription recipe site, Gut Rx Gurus and a FODMAP-free line of bone broths, Gut Rx Gurus Bone Broth.

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.

Podcast Transcripts

Dr. Weitz: This is Dr. Ben Weitz with the Rational Wellness Podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to Rational Wellness Podcast on iTunes and YouTube, and sign up for my free e-book on my website by going to drweitz.com. Let’s get started on your road to better health. Hello Rational Wellness podcasters. Thank you so much for joining me again today. And for those of you who enjoy the Rational Wellness Podcast, please go to iTunes and give us a ratings and review so more people can find out about the Rational Wellness Podcast.

So on this episode of the Rational Wellness Podcast, we are going to focus on low stomach acid as a cause of SIBO. Small Intestinal Bacterial Overgrowth, abbreviated as SIBO, is the cause of irritable bowel syndrome in the majority of cases. While the large intestine or colon is lined with trillions and trillions of bacteria, the small intestine is relatively free of bacteria. This is because this is where most of the absorption of nutrients from our food occurs, and if there were a lot of bacteria lining the small intestine, it would interfere with that important function.

There are a number of mechanisms that prevent more than a small amount of bacteria from growing in the small intestine. These include the migrating motor complex, which are the peristaltic waves that occur when you haven’t eaten for more than three or four hours, when you hear your stomach gurgling. These help to sweep out any bacteria out of the small intestine. There’s also the GALT, or GI-Associated Lymphoid Tissue, which is the immune system that surrounds the digestive tract. This tends to remove pathogens that enter our body with the food. Then there is the hydrochloric acid secretion from the stomach, and this also serves to kill unnecessary bacteria as well as help us digest our protein. Bile, which is secreted by the liver and stored in the gall bladder, which not only helps us digest fat, but has an antiseptic function, and stands to scrub away bacteria from the small intestine. You also have digestive enzymes, which besides helping us digest our food, have an antimicrobial function. And then we also have the ileocecal valve, which is a protective barrier to stop bacteria from migrating from the colon back up into the small intestine. When any of these processes and structures fail, it can facilitate the growth of SIBO. Today, we’re going to focus on what happens when you have inadequate amounts of hydrochloric acid produced by the stomach.

Our special guest is one of the nation’s foremost functional medicine nutritionists, Angela Pifer, who practices in Seattle, Washington. Angela specializes in treating patients with functional gastrointestinal disorders like SIBO and IBS, and she’s known as the SIBO guru. She lectures around the world on such topics, and has launched a gut prescription recipe site, Gut RX Gurus, and a FODMAP free line of bone broths, Gut RX Guru Bone Broth. Angela, thank you so much for taking time out of your busy schedule to speak to me and our listeners.

Angela Pifer: Thank you, Ben. Thanks for having me.

Dr. Weitz: Great. So how did you get interested in treating patients with gastrointestinal disorders?

Angela Pifer: Gosh, you know, I’ve been in practice about 13 years, and it was just out of the gate, the gut has always fascinated me. There was never anything else. It wasn’t even a thought, and I loved it. To me, there’s some other things going on with the body. We can look at the brain and everything, but we start with the gut in so many cases, don’t we? Like you know, how we’re digesting, how are bowel movements moving along, is digestion working from top down? Like we have to look at all of that to see how we can then support the body and the system with almost everything else. So it’s really kind of this hub, and working with people with functional or chronic gut presentations has always just fascinated me. And honestly, I think that population as a whole, my lovely patients and anyone out there who’s listening who has a functional gut disorder being in that chronic state, they need help. They need support. They need hand-holding, and they really need someone to sometimes step in and be that hub between all their other specialists, because everyone seems to be going off in a different direction sometimes when they’re seeing different specialists, and to have somebody pull everything together is really really helpful.

Dr. Weitz: Yeah, absolutely. You know, if you deal with Functional Medicine, the gut has got to be one of the starting places for almost everything. I just saw a patient this week, and her big complaint is that she’s having unexplained seizures, one after the other, and she’d been to the neurologist and nobody could figure anything out. So we did some stool tests, and she’s got all kinds of things going on in her gut. You can’t even believe the things happening there. Layers and layers. And it turns out, she’s had all these gut symptoms which she was really sort of used to and not even complaining about, and now she’s doing so much better just by fixing her gut.

Angela Pifer: Yeah. And I say the word complacency with so much love and respect and empathy for a person, but I think they have this known sense of norm. “This is what I deal with day in and day out, this is just how it is,” and over time, they adapt to it. Never liking it, but adapt to it, and it isn’t until you show them what it really feels like to not have to sit with that, it’s mind-blowing sometimes what they’ve had to deal with, right?

Dr. Weitz: Yeah, no, absolutely.

Angela Pifer: Yeah.

Dr. Weitz: Yeah, they don’t know what it’s like not to be constipated or not to have gas.

Angela Pifer: Yep. Yeah yeah.

Dr. Weitz: So can you explain how low stomach acid can be a cause of SIBO, which is the cause of IBS in a majority of cases?

Angela Pifer: Yeah, absolutely. So when we look at SIBO, we really have to always consider that SIBO is a secondary condition. It’s never a primary condition. It was set up because something else has happened, some other thing or things have happened. And so we have to try to get at the root of what is setting this up for the person. You know, SIBO needs to be addressed, but we have to look at everything else as well to fix that root cause. So SIBO doesn’t continue or come right back or be reoccurring because you’re not fixing the real correct thing here. So one of the very big contributors can be low stomach acid. Low stomach acid can be caused by a few different things. Low stomach acid could be caused by really really really chronic stress, it could be caused by hypothyroidism as well. So it’s this spiderweb of connections that we have to get in and try to figure out this root cause for people. And we’re starting to look at low stomach acid, I mean this is, you know, it’s like not chewing your food. This is like a major component and stuck within the digestive tract, and if you can’t use low stomach acid to actually break your food down properly … And really the main thing is we’re talking about SIBO is to clear up pathogens that are coming in. You know, we need that proper really acidic pH that’s under three pH to actually clear everything off, otherwise we’re just gonna get bombarded with things that we’re taking in by mouth multiple times a day. We want that first step, it’s a really big line of protection there.

We also have to look at, we’ve got a pH at that acidity for a reason, and it signals gastric emptying properly, it signals the proper release bile, it signals the proper release of digestive enzymes. So as you were talking about in your intro, bile being needed as well to clear out the intestinal tract. We have a lot of conjugated bile with our intestinal tract. It actually acts as a detergent. And every time we eat some fat, your gall bladder goes squish squish. It’s like a stress ball, squish squish. And it’s gonna release some bile, and with that, that will help your emulsify your fats. Then it’s also coming through as a detergent and clearing out that small intestine. And it also happens in between meals, so it doesn’t just happen that you get a bile release with your meals, you also get it in between meals, and that’s gonna piggyback the migrating motor complex and those cleansing waves that come down.

So in your intro, I’m going to disagree just a little bit here because I think it plays into the conversation we have about what the heck to do with SIBO. I think if we start to compare the trillions of organisms that are in the large intestine, there’s so many massive amounts of organisms in the large intestine that when you look at the small intestine, it seems quite minuscule. And yet if we look at the small intestine just by itself, we’re looking at millions and upwards of billions of microorganisms per milliliter, per teaspoon of fluid. So it’s not sterile by any means, there’s lots of organisms there. But we also have forward-moving matter. Everything’s moving forward, it’s not hanging out like it does in the large intestine where everything hangs out there and ferments and we get all this beautiful relationship with our microbiota in that area. Things are moving through a lot faster, so we don’t get this big buildup of organisms in the small intestine. And we’ve got bile moving through, like there’s lots of mechanisms to help keep the organism load at a specific load.

When one of those mechanisms, or multiple mechanisms, goes wrong, of course, then we get a buildup. And then we get fermentation happening in the small intestine and lots of other things that could come with SIBO that’s quite debilitating, because that small intestine is not meant to stretch, and that causes a lot of pain. And we don’t get as much gas movement of course, out or just spilling across the intestinal lining. So why I say that is so many people think SIBO, “I gotta kill it.” And we can’t Drano that small intestine, we want to look at this as a re-balancing. Really fixing the underlying issue, getting on the mechanisms and what’s going on there, but then re-balancing and just taking the person to that level. Not “kill kill kill,” and then stepping back, because that’s not gonna work either. We’ve got to help reset and re-balance and reseed, affect change with the immune system, and there’s so much that goes into play with this even once you get somebody to a negative breath test. There’s so much healing on the other side to make all this beautiful work that you’ve just done stick.

Dr. Weitz: Do you sort of use the four R or five R program as kind of a backbone of your approach?

Angela Pifer: Yeah, you know, I don’t. Not with SIBO specifically. There’s so many other things I do. I mean as we start to look at autoimmune and others, I know we’re gonna talk about an autoimmune condition as we talk here. But in terms of SIBO, I don’t … There’s so many beautiful things that that four R program does, and there’s bits and pieces filled in along the work that is done, that really it’s more, you know, stabilize the patient and whatever that means. We’ve gotta evoke change with the diet, oftentimes. We don’t always have to go drastically low, but we wanna adjust the diet to make sure they’re nourished, adjust it to how they’re digesting and absorbing, adjust it to make sure their symptoms are somewhat calmed down so they can hang out in this period of time as we treat properly, you know. So there’s a lot of change that happens with the diet. And in terms of kind of that whole repletion, we’ve got to get on the other side of actually treating SIBO to get to that point where we can start to work on more of that reseeding of the gut, a lot of immunoregulatory support at that point. And it’s bits and pieces, but not the perfect four R.

Dr. Weitz: Okay. Sounds good. So when would you suspect low stomach acid as a cause for a patient with SIBO?

Angela Pifer: You know, I would say that I actually assess that with every patient. It kind of comes out of the gate when you’re doing the intake with the patient, and they start to talk about different symptoms that they have,

Dr. Weitz: What symptoms would make you think about low stomach acid?

Angela Pifer: Yeah, absolutely. Food just feels like it’s just sitting there and not moving through their stomach. A little bit bit of food makes them feel full fast. It could be that we start to look at, you know, they’re not breaking down their food, they see a lot of intact pieces of food in the stool, or even peanut butter stool, I call it. So it’s really sticky stool, it takes a lot of wipes. They’re probably not breaking their proteins down, so then we would look back upstream and figure out what’s going on there, which low stomach acid is oftentimes a culprit at that point. I would say what I see with a lot of patients is a lot of burping. Food just feels like it’s a heavy weight in their stomach. They need to space their food out because they don’t feel like they’re digesting at a quick enough clip that they can eat a little bit more consistently than that. And then as we step back and look at labs, you know, Spectracell and nutritional markers, we can look at different things to see if their iron is trending lower or B12 is trending lower, and we would see that if they have low stomach acid.

Dr. Weitz: Okay. Once you suspect that a patient has low stomach acid, how would you figure out what is causing the low stomach acid, whether it be a H. pylori infection or autoimmune-related or something else?

Angela Pifer: Yeah. I think we always are gonna start with the basics, I mean unless somebody presents with a really chronic case where they’ve had just chronic low B12 over time, I’m gonna start to step into some of those advance markers, looking for anti-parietal cell or anti-intrinsic factor antibodies to see if there’s actually something going on more as an autoimmune front. But once we start to look at this, you know, how are they digesting their food, what is their diet presenting like, can we correct this with supplements, and then what is also going on in terms of their lifestyle? If they’re, you know, really in a sympathetic state, we work a lot on stress reduction because a sympathetic state, being more stressed chronically over time, is really gonna drive digestive chemicals away from the digestion, from top-down. So there’s a lot of lifestyle effect that we can have as we start to see people move away from that. But really, and again, I say this with great love for the patient that is sitting there feeling like this is just … ‘Cause chronic presentation, and they deal with this all the time. Most people with functional gut disorders like this feed forward cycle, stress is always gonna contribute to that, but then once it’s present, they’re having to deal with these symptoms all the time. And so stress is almost always some sort of factor that’s adding to that, and so I think there’s a lot of … You know, I introduce people to the Wim Hof breathing method, I have them make sure they’re walking an hour a day …

Dr. Weitz: Wim Hof is when you take a cold shower?

Angela Pifer: No, Wim Hof is actually … So that’s more contrast hydrotherapy. Wim Hof is actually a breathing technique. You should look him up on YouTube, he’d be interesting to have on your podcast. I don’t even know if I’ll explain it correctly. It’s this beautiful way of actually really taking in almost this hyper amount of oxygen into your blood, and huge diaphragmatic breathing technique, and then you actually ride that out a little bit. But in terms of oxygenation and capacity, people aren’t using the full lung that they have, or lungs, and moving it up. And so it’s a really interesting breathing technique to get them to use that entire space and diaphragm. Yeah, it’s very very cool. So yeah. So I think there’s a lot that we can do in terms of just the stress piece, you know, to really help people out. So as we’re starting to look at the low stomach acid piece, you know, we’ve gotta really listen to the patient, and SIBO is going to contribute. Once SIBO is set up in terms of … And where SIBO is at the small intestine. So the further SIBO is up, and the worse SIBO is with all those contributing factors, it can start to break down digestive enzymes in that brush border, uncoupled bile. It can really interfere with a lot of nutritional absorption that we’re doing in that area. So it just depends on the patient as we’re working on, to what degree we need to come in and do any kind of intervention at that point.

Dr. Weitz: So how would you rule out H. pylori? What tests do you like to use for H. pylori?

Angela Pifer: Yeah. I actually prefer the breath test for H. Pylori. I really do. The urea breath test.

Dr. Weitz: Okay. Why is that?

Angela Pifer: That’s my favorite one. Oftentimes I want to see a GI Effects so I’ll add that on, as we look at a stool antigen for that.

Dr. Weitz: Yeah.

Angela Pifer: You know, if they’ve never been diagnosed with H. Pylori, then we’ll do a blood antigen, but I really like the breath test. I know there’s a like controversy on SIBO’s presence, sometimes you’ll get a false positive. I’ve not seen that line up. And of course we have endoscopy, right, is where rather referring over to the GI doctor. But I think the urea breath test is really pretty straightforward to me. I think the antigen test with the stool antigen actually misses it a lot more than when we see that breath test.

Dr. Weitz: So the notes you sent me over before we did this podcast, it was really interesting that you talked about how if H. Pylori grows in one part of the stomach, it’s associated with increased hydrochloric acid. For those of you who aren’t aware, H. Pylori is often an undiagnosed cause of ulcers because you get this bacteria that burrows into the wall of the stomach, and then the stomach produces more and more acid to try and get rid of it, and so it can often be the true cause of ulcers. On the other hand, if that H. Pylori grows in another part of the stomach where the cells that make the hydrochloric acid are, it actually destroys those parietal cells, and you end up with less hydrochloric acid from H. Pylori.

Angela Pifer: Yeah. So you really can’t go off of … There’s some symptoms that are present that we need to investigate if H. Pylori is present. I mean to me, if any kind of burping, if they’re chronic burping, I think H. Pylori should be ruled out. But any kind of burning, any kind of warmth in the stomach, a really early sense of fullness, we really should be ruling out H. Pylori and stepping through the sequence from there.

Dr. Weitz: And you also mentioned in your notes that GI docs, when they do an endoscope, they’re often looking in at that part of the GI tract where H. Pylori leads to ulcers, but not the … What’s the other part of the stomach where …?

Angela Pifer: Yeah, so if you think about the stomach like a kidney bean, like up on it’s end, you’ve got the fundus is up top, the body is kind of in the middle, and then the antrum is on the bottom. When we start to look at parietal cells, which produce stomach acid, they’re in the fundus and the body, so in this upper two thirds part. And then in the bottom part is the antrum, and if you look on almost every single endoscopy, they’re doing biopsies on the antrum. They’re looking for H. Pylori, and they’re gonna miss if there’s an autoimmune issue with parietal cells. And they’re also doing biopsies in the duodenum to see if there’s celiac. So I feel like, especially as we’re gonna get into it here, we really should be assessing the whole stomach and looking a little bit beyond this. But it’s interesting that even when recommended that, it doesn’t come back as the biopsy in that area. I think they’re just on … And I say it with great respect, they do things none of us can, but that’s just where they’re looking, and they’re not looking in the fundus or the body.

Dr. Weitz: Yeah, interesting. Yeah, you have to try to develop a relationship. There’s not many integrative GI docs around.

Angela Pifer: Yeah.

Dr. Weitz: Fortunately we have Dr. Rhabar in LA, so …

Angela Pifer: Yeah. Yeah, and Dr. Mullen. Yep.

Dr. Weitz: Yeah. Is he in LA?

Angela Pifer: No, Dr. Mullen, Jerry Mullen up in …

Dr. Weitz: Yeah yeah yeah yeah.

Angela Pifer: Yeah.

Dr. Weitz: Yeah. So let’s talk about autoimmune atrophic gastritis. What are some of the symptoms associated with that in particular, and how do we assess for that?

Angela Pifer: Yeah, absolutely. Well I think when we start to look at autoimmune, there’s a lot of conversation around the CDTB toxin and autoimmunity coming from that, and that being a cause of this IBS-C or SIBO. What we have to look at is that’s definitely a percent, that can set SIBO up, but when we’re starting to look at the population that has low stomach acid and trying to get to the root of what’s going on with SIBO, there’s going to be a small percentage there that we really do have to have, you know, a keen eye on to see if any of those people have autoimmune atrophic gastritis. And basically what that is is you’ve got some atrophy of the stomach, and you have gastritis, which is inflammation. So we’ve got atrophy and inflammation, and then you’ve got this autoimmune involvement. So atrophic gastritis, there’s two types. One is caused by H. Pylori, and the other is autoimmune atrophic gastritis. And so basically you’ve got the autoimmune involvement and you’ve got antibody production against the parietal cells. And so as we start to tuck deeper into low stomach acid and its implications, when we start to look at autoimmune atrophic gastritis, this is everything that we’ve just talked about tenfold because this isn’t simply more stress induced or a bit of hyperthyroid pushed in in terms of setting that metabolic rate and how much stomach acid you’re producing, or you’ve got a zinc deficiency. All of those can be recovered fairly easily, depending on the case. But what we’re really talking about is an autoimmune connection here with low stomach acid.

I think to discuss this, we kind of have to talk first about prevalence, because I think it seems like kind of a foreign term, and yet when we start to look at prevalence, everyone’s pretty much heard about celiac. Almost everything is screened for celiac, especially if there’s digestive stuff going on. So even as practitioners, we’re so quick to jump on that. But when we look at celiac disease, it’s .5 to 1% prevalence in the U.S. Very, very small percent of people, and if you have it, it’s a very big deal. But it’s a small percent of people, and yet, as practitioners, we’re fairly quick to rule that out. When we look at autoimmune atrophic gastritis, we’re actually looking at a 2 to 8% prevalence. So even if we just take the 2%, it’s 2 to 4 times more likely present than celiac. And so we really have to kind of stand up and pay attention to this.

When we look at atrophic gastritis caused by H. Pylori, that’s actually going down in America because it’s being screened for. But when we look at autoimmune atrophic gastritis, it’s going up. It’s starting to increase as are a lot of the autoimmune conditions, right? People are becoming more susceptible, and we can have a whole ten shows over why we think that is, right? But when we’re starting to look at the autoimmune atrophic gastritis, basically what we’re looking at is, we’ve got inflammation of the stomach, atrophy of the stomach, we see a breakdown of the parietal cells because you’re making antibodies against those. And when we look at the parietal cells, those make stomach acid, and they also make intrinsic factor. And intrinsic factor is what binds to your vitamin B12, and that coupling, as it moves through the intestines, is absorbed together. If you’re not making intrinsic factor, you’re not gonna absorb your B12, and if you’re not making stomach acid, you’re not gonna break down your proteins to get to your B12 in the first place.

So as we start to look at this patient population … This isn’t everyone that needs to be screened for this, but we have to start to look at if there’s a chronic digestive presentation here. And we really want to start to key into this is if somebody’s taking massive handfuls of HCl Betaine and they’ve been doing that for a really long time or they don’t digest their food, this is something that we should be screening them for. When we start to look at this, you know, we kind of have this …

Dr. Weitz: By the way, do you ever use that HCl challenge test as a way to screen for this?

Angela Pifer: You know, I don’t as a way to screen for this. I refer people over for the Heidelberg test if we’re suspecting low stomach acid, especially if I see them on this level of HCl Betaine.

Dr. Weitz: Okay.

Angela Pifer: I feel for a time, that was really working for me. So setting aside autoimmune atrophic gastritis, it was working for me in terms of getting people on a certain load, and it was making a difference, and then I feel like it just didn’t work as well anymore.

Dr. Weitz: Right. By the way, for people that aren’t aware of what we’re talking about, this is where you give a patient one HCl tablet taken before a meal, and then you give them two or take it after a meal, and then three, and you keep increasing it until they get a burning sensation, and then you back off.

Angela Pifer: Yeah. Or a warming sensation, but yes.

Dr. Weitz: Warming, yeah.

Angela Pifer: Yeah. So I’ve seen that work for some people. I’ve seen other people … A lot of times when people come to me, they’ve been to quite a few practitioners, and they’ve already done that test in the past, so you know, we just kind of learn from what they’ve already been working through.

Dr. Weitz: Yeah.

Angela Pifer: Yeah. So it’s pretty interesting. So I would just go off more symptoms of what we would expect. Again, you know, total protein’s low in a lab. You’ve got B12 that’s chronically low. Iron is low with no really good cause for it, and when you’re recovering. You know, they’re kind of the slight, not life-long, but say for the last few years at least this has kicked in at some point, they’ve been trending more towards meat, yeah, they’re not quite getting it recovered.

Dr. Weitz: What tests do you like for B12 and for iron?

Angela Pifer: I do serum B12. And then when we’re looking at iron, it’s just the full panel. Serum, TIBC, saturation, ferritin. And then of course looking at all the rest of the CBC, looking up, you know…

Dr. Weitz: You don’t find the need to do like methylmalonic acid or homocysteine for B12 status?

Angela Pifer: I actually like both of those when looking at folate and B12.

Dr. Weitz: Okay.

Angela Pifer: Yes yes. I look a little bit more at that, and of course it depends on what I see in terms of supplementation that they’ve been on, you know, for a really long time. I’m also looking at that more for folate and B12 status, and methylating. Yeah.

Dr. Weitz: Okay, cool. So let’s talk about treating a patient with low stomach acid. How do you approach that?

Angela Pifer: Yeah, absolutely. Well I think low stomach acid and autoimmune atrophic gastritis are gonna be really two different things in terms of approaching that.

Dr. Weitz: Okay, so let’s start with a few different cases. With somebody who’s got low stomach acid because they’ve been taking proton pump inhibitors for years, how do you handle that?

Angela Pifer: Yes, absolutely. So with their doctors approval for coming off of medication, of course, I actually will start to add in bitters. I’ll have them cook all their vegetables. I’ll have them eat more frequent meals just to start, and then we’re really gonna work on stress management, setting the tone for the meal, and chewing their food three times more than they think they need to. We might need to address fat load a bit, just depending on how well their gastric emptying is going. We might need to adjust things that way. I work a lot with that. I love bitters, I love them.

Dr. Weitz: And bitters are designed to stimulate your own digestive enzymes and acid secretion, right?

Angela Pifer: Yeah, absolutely. Our food, I mean it’s kind of crazy to think about, even our broccoli and brussel sprouts are bred for sweetness. All of like the bitterness, the different species within those, they’re all bred more sweet. We’re like setting aside anything that has more bitter because the masses don’t trend towards that, right, in terms of what we’re choosing at the supermarket. So when we give somebody bitters, it literally is bitter. Your mouth has these beautiful taste receptors back here that just light up when you give somebody bitters, and if you even think about it if you’ve done it, it makes your mouth water. Like it’s really stimulating digestion from the top down. So I have people … I like Quicksilver Scientific, their Bitters 9.

Dr. Weitz: Oh, okay.

Angela Pifer: And their Bitters X is fantastic, and I just have them do one or two pumps 15 minutes before a meal. They hold it in their mouth for 90 seconds, swishing it around, trying to get it to the back, and then they swallow. We’ve got bitter receptors in our stomach as well, so it’s wonderful. It’s a great way to kind of help stimulate digestion there. In terms of digestive enzymes, one of my favorites is Panplex 2-Phase by Integrative Therapeutics. It has a low-level digestive enzyme, low-level bio-support, and just a little bit of HCl Betaine. So I think less is more. I wanna kind of just start with these lower levels and work up from there. So that’s my way to approach it. I would try to set the tone for the meal, really look at your food, smell your food, think about where it came from, what it’s gonna taste like, put that first bite in your mouth and really set your fork down and taste it. And to me, that sets the tone for the meal and really slows people down.

Dr. Weitz: When you’re weaning patients off of PPIs, you have to be careful about sort of a rebound, right?

Angela Pifer: Yeah, you do. You know, I’ve had really great luck again with, you know, Dr’s approval on this, and really great luck in weaning people off of proton pump inhibitors. There hasn’t really been a case that I haven’t been able to do because we set everything else up first, and then depending on the medication, we might be able to halve that medication, or we just start to slowly take that every other day. And I’ll always aim that around a weekend, because if you’ve ever really watched people’s food journals over the course of a week, like year after year like I have, you realize that hunger is much more increased during the week. Like there’s just more stress going on. So I start to wean them over a weekend, and you know, have just a little bit of baking soda on hand if they need to do like a half teaspoon of baking soda and water just to take the edge off. And then they have the medication. If something comes up, nobody is asking them to sit in misery with heartburn. It’s usually pretty good. I think most people just try to stop cold turkey, and then they realize that didn’t go well, so they feel like they’re really chained to it. So you just have to work with them to get them set up.

Dr. Weitz: Okay. And then how do you treat patients with atrophic gastritis, and is it the same treatment if it’s autoimmune origin or H. Pylori?

Angela Pifer: Yeah, so atrophic gastritis is caused by H. Pylori, and so there’s some great treatments out there for H. Pylori. What we’re talking about is the autoimmune atrophic gastritis, and that’s gonna be more from an autoimmune perspective. So you know, just as if there’s autoimmune thyroid, you’re going to treat the thyroid, but you’re also going to treat the autoimmune condition. So with autoimmune atrophic gastritis, you’re going to treat the autoimmune condition in that you’ve got to work on the whole stress cycle with everybody, getting them sleeping well, calming down the body’s reason for ramping everything up and attacking. You want to calm down and figure out triggers, you know, where triggers are coming from, whether it’s stress, environmental, internal in terms of food and all.

And then we really want to look at treating nutritional deficiencies, making sure that they’re recovering their B12, recovering their iron. So when we look at autoimmune atrophic gastritis, the vast majority of cases aren’t even diagnosed until they’re completely at this end stage of pernicious anemia, and that pernicious anemia is basically you’ve got anemia because you can’t absorb your vitamin B12, and you need B12 along the iron pathway. And then you’ve got this autoimmune component causing this. So pernicious anemia is also an autoimmune condition, but it’s this end stage of autoimmune atrophic gastritis. So most people aren’t diagnosed ’til that point, so we want to catch them before that. We want to catch them when they consistently have B12 levels of under 500, that we see indications of pancreatic insufficiency. So they’ve got this low stomach acid and signaling of the pancreas, you know, we don’t see that and that connection. We wanna look for vitamin B12 deficiency symptoms like peripheral neuropathy. We want to look for even restless leg syndrome, which is strongly connected to this. That you know, again, at that beginning they’re going to have poor gastric emptying, they’re gonna feel full, they’ve got this excessive burping, sometimes they feel a little nauseous ’cause food is sitting there, and all of this has been kind of chronically presenting. We’ve got a store of iron in our system, you know, in our body. It isn’t until we really start to see this very big shift, and same thing with B12, this really big shift with this autoimmune attack. We don’t usually start to see this rear up for a good year and a half, two years, so we wanna catch this earlier on, and it might be that chronic presentation that we get to see that with.

So again, first rule out H. Pylori. Absolutely let’s rule that out, but then let’s start to look at, you know, do we start to see B12 levels dipping down? Which is kind of hard sometimes because everyone’s taking B12. And serum B12 is a really great indication that you’re taking good supplements sometimes, so maybe we need to take people off of things for a couple of weeks to get a better read on that serum level. But we wanna look at that, we want to investigate gastroparesis if that’s there, or again, if gastritis is present, we’re going to look for H. Pylori and then start to look at iron and B12 and start to recover those.

If somebody’s gotten to the point of pernicious anemia, they might need iron shots, they might need intramuscular B12 shots, you know, the supplementation may not do it. And this population of course is interesting because they’ve got lower stomach acid and poor signaling, and oftentimes they’re gonna have slower motility. So if you’re trying to recover iron on a consistent basis, you know, you can really slow things down more because iron can be quite constipating. And iron isn’t necessarily … It can be toxic to the colonocytes as well, so you know, sometimes iron shots are gonna be a better choice depending on that patient and what’s going on there.

Dr. Weitz: Interesting. And of course, trying to heal the gut as well, right?

Angela Pifer: Mm-hmm (affirmative). Absolutely, absolutely. I think that’s going to come with it, and I think that comes with a lot of conditions after as well.

Dr. Weitz: And those patients are going to need HCl supplementation probably for the rest of their lives, right?

Angela Pifer: They probably will, and you know, I think it’s again, if somebody has an autoimmune condition, we need to be able to tell them that they have an autoimmune condition, because autoimmune comes in pairs. And also, I would say that autoimmune, you know, as we start to look at this, we need to be able to say like there is a reason that you might need ongoing supplementation, in terms of HCl Betaine, in terms of B12 support, in terms of iron support. There’s a connection to be made there with the patient, because sometimes I think, you know, patients might go from practitioner to practitioner and they’ve got these long laundry lists of supplements, and we don’t know which are necessary and which aren’t. But if we’ve got an autoimmune condition set up for this, they’re going to need to really support their system long-term because of the autoimmune condition that’s present. And the more stressed out they get from wherever this is coming at, the worse the autoimmune cycle can get. And then you get more degradation and targeting of those parietal cells which makes everything downstream worse. So the stress management piece can’t be talked about enough with this population, but then we also have to start to look at how else are we gonna support them, and they’re gonna need supplementation lifelong. They’re going to need it, like absolutely. So they need to know that and be able to connect with that because I think people can fall in and out of favor with supplements, or you know, “I don’t know if these are even doing anything for me” kind of thing. In this case, this is really something that needs to be looked at.

Dr. Weitz: So can you monitor those anti-parietal cell antibodies the way you monitor like TPO antibodies with patients with Hashimoto’s to see to what extent their autoimmune component is active, or?

Angela Pifer: Yeah. You really can, but I think we have to be careful to say, you know, parietal cell antibodies are at 82 and they go to 72, it doesn’t mean that they’re necessarily getting better. You know, antibodies are volatile. They don’t just go up a ladder and down a ladder depending on two things. If we are in a very stressful situation, we can see a shift there. If we are fighting off a cold, we can see a shift. If we …

Dr. Weitz: Right, but maybe are there bigger shifts? Like with TPO, you know, antibodies for thyroid, if they have 500 and it goes up to a thousand, that’s significant, or it’s 1,200 and it goes down to 150, you still have elevated antibodies, but that’s a significant shift, whereas if it goes from 100 to 400, maybe it’s insignificant.

Angela Pifer: I agree. I completely agree, yeah. When there’s

Dr. Weitz: Is there a similar sort of range with the anti-parietal cells?

Angela Pifer: You know, I think it’s going to be based on the person and what we’re looking at with both of those and where they kind of fall into. I think as we start to look at the progression and how long this has been there for people and how advanced they are, they might not be able to get those fully recovered like we’d like. But for the anti-parietal cells, the anti-intrinsic factor antibodies, you know, we’d look at both of those, and of course if there’s a positive test, we’re gonna refer over to a GI doc to get a biopsy. But in the right place, they’ve got to biopsy the fundus or the body of the stomach to be able to actually confirm that.

Dr. Weitz: Cool. Okay, that’s good. Very interesting information. Thank you for informing us about a condition I think most patients and even a lot of practitioners are not aware of, which is autoimmune atrophic gastritis as a cause of low stomach acid leading to SIBO.

Angela Pifer: Yep.

Dr. Weitz: So how can listeners and practitioners get a hold of you if they want to contact you, sign up for your courses, get your bone broth?

Angela Pifer: Yeah, absolutely. So my practice site is siboguru.com, and I’d love to have everybody visit me there. And then SimplySIBODiet.com is a beautiful collection of practitioners and chefs that are in the low-FODMAP realm. And there’s a SIBO-specific category in there, and everything is low-FODMAP. And I’ll say it really quick, I don’t as a whole put every single person that’s ever even, you know, SIBO glaring, on a low-FODMAP diet, but there’s going to have to be some adjustments, and so to be able to have a recipe set that you can go to to really fill in the gaps and give people ideas … Because we’re so used to eating what we eat, and then when we can’t eat that anymore, it’s like chicken on a plate. Like what do you do? So it’s nice to be able to have all these beautiful recipes for sauces and sweets if you need them, and the foods just really tasty. So that’s a subscription site for recipes, simplysibodiet.com.

And then GutRxBoneBroth, the first low FODMAP bone broth to hit the market, and people can order that online. It just ships directly to their door, and we actually ship beautiful high-protein, high-gelling bone broth that tastes absolutely amazing. We’ve got a big plant here in Seattle, and we sell beef and we sell chicken, and it is just absolutely delicious, so it’s just nice to have that to kind of fill in the gaps and have that as a base of a soup, because you can’t just go to a store and get a garlic-free, onion-free anything, right? Everything has it in it. So it’s nice to have a broth that people can really connect to there.

Dr. Weitz: Cool, great. Thank you so much for spending time with us.

Angela Pifer: Of course, thank you!

Dr. Weitz: Okay, I’ll talk to you soon, Angela.