Gastric acid

# Overview
Gastric acid is, together with several enzymes and intrinsic factor, one of the main secretions of the stomach. Chemically it is an acid solution consisting mainly of hydrochloric acid (HCl), and small quantities of potassium chloride (KCl) and sodium chloride (NaCl).

# Physiology
Gastric acid is produced by parietal cells (also called oxyntic cells) in the stomach. Its secretion is a complex and relatively energetically expensive process. Parietal cells contain an extensive secretory network (called canaliculi) from which the gastric acid is secreted into the lumen of the stomach.  These cells are part of epithelial fundic glands in the gastric mucosa. The pH of gastric acid is 2 to 3 in the human stomach lumen, the acidity being maintained by the proton pump H+/K+ ATPase. The parietal cell releases bicarbonate into the blood stream in the process, which causes the temporary rise of pH in the blood, known as alkaline tide.
The resulting highly acidic environment in the stomach lumen causes proteins from food to lose their characteristic folded structure (or denature). This exposes the protein's peptide bonds.The chief cells of the stomach secrete enzymes for protein breakdown (inactive pepsinogen and renin). The gastric acid activates pepsinogen into pepsin - this enzyme then helps digestion by breaking the bonds linking amino acids, a process known as proteolysis. In addition, many microorganisms have their growth inhibited by such an acidic environment which is helpful to prevent infection.

### Secretion
The gastric acid secretion happens in several steps. Chloride and hydrogen ions are secreted separately from the cytoplasm of parietal cells and get combined into HCl only in their canaliculi. Gastric acid is then secreted into the lumen of the oxyntic gland and gradually reaches the main stomach lumen.
The highest concentration that it reaches in the stomach is 160 mM in the canaliculi. This is about 3 million times that of arterial blood, but almost exactly isotonic with other bodily fluids. The lowest pH of the secreted acid is about 0.8, but the acid gets diluted in the stomach lumen to the pH between 2 and 3.
At first, negative chloride ions and sodium ions get secreted actively from the cytoplasm of the parietal cell into the lumen of the canaliculus. This creates a negative potential of -40 mV (millivolts)to -70 mV across the membrane that enables the diffusion of potassium ions and a small number of sodium ions from the cytoplasm into the canaliculus.
Another step is the production of hydrogen ions in the cytoplasm of parietal cells. The enzyme carbonic anhydrase catalyses the reaction between carbon dioxide and water, in which carbonic acid is produced. This acid immediately dissociates into hydrogen ions and hydrogen carbonate ions. The hydrogen ions leave the cell by the aid of H+/K+ ATPase antiporter.
At the same time sodium ions are actively reabsorbed. This means the largest amount of secreted K+ and Na+ ions return into the cytoplasm. In the canaliculus, secreted hydrogen and chloride ions combine into HCl and are then secreted into the lumen of the oxyntic gland.
There are three phases in the secretion of gastric acid:
1. The cephalic phase: 30% of the total gastric acid to be produced is stimulated by anticipation of eating and the smell or taste of food
2. The gastric phase: 60% of the acid secreted is stimulated by the distention of the stomach with food. Plus, digestion produces proteins, which causes even more gastrin production
3. The intestinal phase: the remaining 10% of acid is secreted when chyme enters the small intestine, and is stimulated by small intestine distention.

## Regulation of secretion
Gastric acid production is regulated by both the autonomic nervous system and several hormones. The parasympathetic nervous system, via the vagus nerve, and the hormone gastrin stimulate the parietal cell to produce gastric acid, both directly acting on parietal cells and indirectly, through the stimulation of the secretion of the hormone histamine from enterochromaffine-like cells (ELC). Vasoactive intestinal peptide, cholecystokinin, and secretin all inhibit production.
The production of gastric acid in the stomach is tightly regulated by positive regulators and negative feedback mechanisms. Four types of cells are involved in this process: parietal cells, G cells, D cells and enterochromaffine-like cells. Besides this, the endings of the vagus nerve (X) and the intramural nervous plecus in the digestive tract influence the secretion significantly.
Nerve endings in the stomach secrete two stimulatory neurotransmitters: acetylcholine and gastrin-releasing peptide. Their action is both direct on parietal cells and mediated through the secretion of gastrin from G cells and histamine from enterochromaffine-like cells. Gastrin acts on parietal cells directly and indirectly too, by stimulating the release of histamine.
The release of histamine is the most important positive regulation mechanism of the secretion of gastric acid in the stomach. Its release is stimulated by gastrin and acetylcholine and inhibited by somatostatin.

### Neutralization
In the duodenum, gastric acid is neutralized by sodium bicarbonate. This also blocks gastric enzymes that have their optima in the acid range of pH. The secretion of sodium bicarbonate from the pancreas is stimulated by secretin. This polypeptide hormone gets activated and secreted from so-called S cells in the mucosa of the duodenum and jejunum when the pH in duodenum falls below 4.5 to 5.0. The neutralization is described by the equation:
The carbonic acid instantly dissociates into carbon dioxide and water, then gets eliminated through urine.

### Safety mechanisms
There are several safety mechanisms that prevent the damage of gastric epithelium.  Nonetheless, when due to different reasons these fail (e.g. because of excess acid production), this can lead to heartburn or peptic ulcers.

# Role in disease
In hypochlorhydria and achlorhydria, there is low or no gastric acid in the stomach, potentially leading to problems as the disinfectant properties of the gastric lumen are decreased.  In such conditions, there is greater risk of infections of the digestive tract (such as infection with Vibrio or Helicobacter bacteria).
In Zollinger-Ellison syndrome and hypercalcemia, there are increased gastrin levels, leading to excess gastric acid production, which can cause gastric ulcers.
In diseases featuring excess vomiting, patients develop hypochloremic metabolic alkalosis (decreased blood acidity by H+ and chlorine depletion).

# Pharmacology
The proton pump enzyme is the target of proton pump inhibitors, used to increase gastric pH in diseases which feature excess acid. H2 antagonists indirectly decrease gastric acid production. Antacids neutralize existing acid.