I have another curious pondering if anyone is interested to chip in...
Is it correct that PA is a consequence of low stomach acid? And perhaps, as we all invariably age, the stomach is unable to produce enough acid to transport B12 or create IFAB's?
I only ask because, after two years of analysing what went wrong, I realise now that I ended up severely B12 deficient along with a systemic breakdown of several body organs (saliva gland tumour, thyroid nodule, colon polyps, gastro problems in general). I'd had a low meat intake but certainly not full vegan or even vegetarian...just irregular meat intake along with regular fish. And my body breakdown followed a period of chronic and intense work-related stress.
So, if chronic stress has the ability to lower stomach acid to such a degree, can it actually CAUSE PA? Or could it be that it mimics PA, if the mechanisms are still working?
Because it may be that I still have IFABs (never tested) but due to persistent stress and a lack of enough B vitamins, I had a temporary imitation of PA in the form of megaloblastic anemia and low stomach acid for a prolonged period. Add to that alcohol consumed with food on fairly regular occasions (often as a means to manage stress).
Please excuse my ignorance but could low stomach acid from stress and inadequate diet be the final cause of B12 deficiency? And if so, I wondered how it exacly it could cause B12 deficiency if it isn't PA.
Many thanks in advance 😀
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Pickle500
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As we age , we do produce less stomach acid . This can be magnified enormously by taking PPIs for acid reflux , caused by imperfect closure of the oesophageal sphincter, due to low acid content . ( proton pump inhibitors which annihilate stomach acid ) This can result In Achlorhydria . This in turn results in poor absorption of all vitamins and minerals . . Can be helped by taking supplementary vitamin and mineral tablets . BUT , if you have Pernicious Anaemia, that will not help your B12 absorption, because B12 requires not only stomach acid , but also the Intrinsic Factor. which P.A. patients lack . The answer for P.A. patients is B12 injections which by-pass the stomach .
There are many more causes for B12 deficiency , and you will find them listed on the Internet.
Thank you for explaining Wedgewood, that's very helpful to this piece of research!
So, in effect, stomach acid reduction--from any cause but in particular PPIs, metformin, general aging, chronic stress, and lack of dietary balance--risks malabsorption of B12 and reducing levels. Then, of course, if someone has PA there is no chance of absorption at all due to missing Intrinsic Factor?
For me, then, I think there should be at least four stated causes/reasons for B12 deficiency:
1. Pernicious Anemia: A lack of Intrinsic Factor causing permanent malabsorption and lifelong injections.
2. Lack of B12 intake from the diet: Rare as a stand-alone cause but can be attributable to veganism and some strict vegetarianism that doesn't include lacto-ovarian, pescetarian or reduced meat intake.
3. Severely low levels of stomach acid: Caused by long term use of PPIs, Metformin, or combinations of other imbalances such as stress, lack of B vitamin intake, poor sleep or lifestyle factors that reduce stomach acid and impair absorption.
4. Lack of intestinal absorption: IBD conditions such as Crohn's, celiac, and SIBO where B12 absorption and transportation is still possible from the stomach but not from the intestines/illeum as a final stage for recirculation of B12.
I say this because, for me, I didn't fit into the diet or PA category. So I think there should be four categories for investigation of B12 deficiency. And there could also be overlaps between each one that require testing.
The B12 absorption process is SO complicated, isn't it? There's a lot that could go wrong. I still can't understand how this isn't covered in general medical training, but hopefully we can start to change that.
Perhaps B12 is a regulator of estrogen levels - but not entirely clear how?
It's never mentioned as a cause. Perhaps because it's not well understood? But there is clearly some link particularly as it's implicated in pregnancy too.
I also left out Nitrous Oxide use or heavy alcohol/drug use, but I believe this would have to be at addiction levels to be a principal cause.
The list is almost endless. Perhaps it's why there's so much hostility amongst medics whenever we bring the subject up? Because it's just patently clear that B12 is an essential nutrient that we need for survival yet no-one really knows this or talks about it? Doctors becoming 'plant-based' because they say this reduces heart attacks etc.
We just need better, more regular testing don't we. It should be done without thought really.
Wow, yes. Postnatal depression as a reaction to low B12? That's really interesting.
So maybe the lack of B12 could lead to reduced hormonal activity, which would make sense. But the reduced B12 maybe came from increased demand in terms of hormonal activity during childbirth or menopause. More B12 needed to regulate body systems.
And really there can't be much of a way to avoid this, even if someone eats alot of B12.
It's just so obvious that B12 is like petrol or gas to the body's engine.
Hi Wedgewood. I read with interest your above comments, as I have PA and have b12 injections 3 monthly. Also have breast cancer and treated with exemestane and alondronate for my osteoporosis, caused by my first cancer 20years ago. I saw GP recently, re indigestion probably caused by alondronate, had upper gi endoscopy all ok. Positive stool test for HPylori. However due to being on alondronate and clopidogrel, he prescribed lomprozole. After about a week I experienced awful intermittent stabbing pain behind navel and loose stools.l. I stopped the lomprozole and pain stopped but still have loose stool. Has anyone else been prescribed a PPI having a PA dianosis and had similar issues.
If you are being treated for Pernicious Anaemia with B12 injections , then the PPI ( in your case Iomprazole ) will not affect your B12 supply to your body , but obviously will impede your absorption of other vitamins and minerals, so a vitamin and mineral would be a goo£ idea . But
But a lack of stomach acid will upset the flora , the good bacteria , in your stomach , which can result in stomach pain . A probiotic may help to establish beneficial bacteria . Also an acidic drink, say diluted Organic cider vinegar with mother before meals
. Eat smaller meals more often and CHEW THOROUGHLY . This gives the enzymes in the saliva chance to start the breakdown of the food , enabling better absorption, which is impeded by lack of stomach acid.
Your loose stools should soon get better .
As you tested positive for Helicobacter Pylori , are you being treated with antibiotics , which can also upset the stomach flora ?
Thanks Wedgewood for your prompt reply. Though I had a +h pylori stool test, the Consultant took a sample from my stomach and said it tested negative, so said I didn't need the antibiotic treatment. I'm speaking with my GP sometime soon a d will ask him to explain how one can have +tv stool test but endoscopy says -tv.Thanks for prebiotic advice, have started yacult. But will buy some from chemist.
As I understand it, PA is a double whammy whereby antibodies attack the stomach lining which causes reduced stomach acid and intrinsic factor. Just to make doubly sure that you can’t absorb B12 you also have antibodies to IF.
So reduced stomach acid is a symptom rather than a cause of PA.
I don’t know the answer to that but just to say that the older I get the more goes wrong! Whether it’s PA, thyroid, glaucoma, teeth, aches and pains…..!
Don’t know if this helps Pickle500 but this is part of a reply I wrote five years ago after what seemed a ‘lightbulb moment’ in my own particular journey through autoimmune disease 🤩
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If the cause of B12 def. is dietary and not an autoimmune condition, oral supplementation and a nutritious diet will usually suffice but, if you have an autoimmune condition, H/Pylori, or problems with digestion (coeliac, Crohns, gastritis, gastric surgery etc.), the condition is more complex as B12 from food is not likely to be absorbed, depletes over time and oral supplements are not usually absorbed either.
There is further risk for those over the age of 60, as hydrochloric acid (which begins the process of extracting B12 from food) is more likely to reduce leading to severe deficiency, especially as this age group is even more likely to be on various medications which deplete vitamin B12 further.
Researchers now believe leaky gut/intestinal disease/gastric atrophy is the source of autoimmune disease, and this is likely to eventually lead to low hydrochloric acid needed to begin the process of absorbing B12 as well as other essential vitamins and minerals. I believe this is at the bottom of all our own family autoimmune/Hashimoto's thyroid/PA/B12 problems.
Dr Marc Ryan's excellent article on his Hashimoto's Facebook page was a lightbulb moment for me in the search for answers to the cause of, not just Hashi's autoimmune disease but B12 def. in particular:
…………….
"Hashimoto's Health Tip: The Little Paint Brushes in Your Tummy"
"Anyone who has lived with Hashimoto's knows that this is so much more than a thyroid problem. The biggest axis of trouble is often found in the thyroid-brain-gut connection. And one common problem that causes this is leaky gut or intestinal permeability.
Many researchers believe that this is ground zero for autoimmune disease. It is the place that autoimmune disease is born and the place that makes it get worse and worse. And when things get worse in the gut, problems in the thyroid and brain often follow. In this post, I wanted to shed light on some little known but very helpful enzymes called brush border enzymes :
The small intestines are the place where leaky gut often happens. And the walls of the small intestines are lined with tiny little hair like protrusions called microvilli. On a regular microscope they kind of look like a tiny, fuzzy paint brush. This fuzzy appearance is why they came up with the term "brush border" to describe them. This is the place where absorption happens. And many people with Hashimoto's suffer from deficiencies of important vitamins and nutrients (like vitamin D, vitamin B12 and B6, zinc, selenium, magnesium, iron, etc.)
One of the reasons for this is the breakdown of these brush borders.
Foods high in lectins or other inflammatory substances (like gluten, and other grains, beans and nightshades) can actually cause these brush borders to get crushed and destroyed. The microvilli (little hairs) that make up the brush border have enzymes for this final part of digestion anchored into their membrane as membrane proteins. These enzymes are found near to the transporters that will then allow absorption of digested nutrients."..............
…………..
Personally, I take daily spoonfuls of sauerkraut (more good bacteria than any other probiotic I'd tried) and avoid gluten, in the hope that this will help heal these microvilli lining the digestive system, enabling better absorption and thereby strengthening the immune system.
This did work for quite a while but, being over 60 years old (when hydrochloric acid had obviously begun to reduce) as well as having had Hashimoto's, H. Pylori and gastric problems for years, I found myself having to begin self injecting every other day after two viruses led to the onset of neurological problems (crippling fatigue, dizziness, memory problems, pins and needles etc.)
My symptoms have hugely improved but stress or overdoing exercise, etc can often bring them on again.
Thank you so much for sharing that is very helpful. Yes, I do suspect I suffered with leaky gut too. I think it was triggered by stress and may be inherited since my late father found terminal colon cancer shortly after redundancy in the late eighties. He had a healthy lifestyle but perhaps struggled to manage the impact.
My problems all arrived at the same time including 3 colon polyps. So I feel that that is the genetic link, exacerbated by a lowered meat intake (believing it had caused my polyps) a lack of sleep, ongoing stress from the pandemic and my own job loss. Then two bouts of nitrous oxide during operations and colonoscopy plus alcohol sort of stripped it all away.
I took a course of 12 Symprove and that did change things. Not a single remedy to recover but many and ongoing. Good food, good sleep, no interactions with stressful people.
More scientific research behind leaky gut is needed I think.
I feel it’s likely I have a leaky gut and indeed this was suggested by an NHS allergy specialist as being the reason why I suffered anaphylaxis after eating a peach (along with low stomach acid causing the peach proteins to not be digested).
I’ve often see people mention the advisability of a gluten free diet but have dismissed this for me, partly out of laziness/ unwillingness to change and partly because the NHS blood test showed no reaction to gluten.
Can I ask if you were diagnosed as gluten intolerant?
I’m wondering if I should give it a go given my PA, thyroid problems and potential for allergies.
I was never officially diagnosed as allergic to gluten but my tum is obviously better without it. My dad, brother and son all have similar stomach/colon problems but no autoimmune disease - seems only the female line affected by autoimmune issues so far 🤔
This research paper, originally posted by ‘Diogenes’, (Dr J Midgeley) on Thyroid UK about six years ago, for some reason always stayed in my mind and was really helpful in eventually making sense of my own PA/B12 deficiency when eventually found to have borderline microcytic anaemia. (PA/B12 def. is more usually diagnosed by having large red blood cells - macrocytic anaemia!) :
“Hashimoto’s thyroiditis (HT) is the most frequent autoimmune disease, and it has been reported to be associated with gastric disorders in 10–40% of patients while about 40% of patients with autoimmune gastritis also present HT. Some intriguing similarities have been described about the pathogenic mechanism of these two disorders, involving a complex interaction among genetic, embryological, immunologic, and environmental factors.
CAG (Chronic Autoimmune Gastritis) is characterized by a partial or total disappearance of parietal cells implying the impairment of both hydrochloric acid and intrinsic factor production.
The clinical outcome of this gastric damage is the occurrence of a hypochlorhydric-dependent iron-deficiency anemia, followed by pernicious anemia concomitant with the progression to a severe gastric atrophy.
Malabsorption of levothyroxine may occur as well.
We have briefly summarized in this mini review the most recent achievements on this peculiar association of diseases that, in the last years, have been increasingly diagnosed."
"(3) The natural history of HT is the progressive reduction of thyroid function till overt hypothyroidism (24) with a rate of progression of 2–4% per year (23), while that of gastric atrophy features the progressive reduction, till disappearance, of parietal cells, leading to reduced or absent acid production (3, 22). These alterations interfere with absorption of essential nutrients leading, at first to iron-deficiency anemia, followed by PA".
"Iron Deficiency and PA" :
"Chronic atrophic gastritis is clinically silent in most cases and only a small percentage of patients may complain about dyspeptic symptoms. A well-described clinical feature of thyrogastric syndrome is represented by the presence of an iron-deficiency and/or a PA. In fact, it has been demonstrated that an iron-deficient anemia, refractory to oral iron therapy, in patients with HT, may be due to chronic atrophic gastritis (13).
Clinical signs of this disease appear after several years of its onset, when the progressive reduction to disappearance of the parietal cells leads to atrophy of the gastric mucosa, impairing the absorption of iron, vitamin B12 (cobalamin), folate, and other nutrients (22)."
“In the initial phase of the atrophic gastritis, the damage of parietal cells can lead to iron deficient microcytic anaemia as the only clinical sign (38). When the gastric atrophy becomes severe and/or the IFA is no longer produced, even the absorption of cobalamin becomes compromised. "
Many thanks for that info Polaris, I think it’s all pointing to it being sensible that I try a gluten free diet.
I have Graves’ disease (overactive thyroid, in remission) and this pre-dated my PA diagnosis by about 10 years. I also have whichever antibodies it is that point to HT. Luckily my thyroid seems to be holding on without the need for thyroxine at the moment albeit bumping along at the bottom of the range. I was also ‘lucky’ enough to test positive to IFAb and hence received a fairly early PA diagnosis.
Folate and iron levels always seem to have been ok though although I recall zinc was on the bottom of the range when tested
Symprove and other probiotics along with Betaine HCL have helped with digestive discomfort over the last few years but that is nevertheless getting worse and something definitely isn’t right.
I do eat a lot of gluten as I do long distance cycling and a sandwich lunch with morning and afternoon cake stops is all part of it (and a very enjoyable part at that)! I will give it a go though after I’ve researched suitable alternatives.
Sorry for the long message but this thread is very important. Probably repeated myself on other threads but just wanted to write in support of all whats been written here about the stomach, hormones,stress, iron and b12 etc -
I'm pretty sure I've had atrophic gastritis since age 15, my stomach has a bad reaction to any food even yoghurt.
They tested me for coeliac recently and I was negative. I'm 35 now and chronically iron deficient all my life, hair loss, extreme fatigue, autoimmune illnesses and since October have all the classic symptoms of PA for which I self inject as was never taken seriously by gps.
I was found to have H pylori around 9 years ago but 2 back to back pregancies/nursing, move across the country and back and then pandemic meant I ended up leaving it all on the back burner as I was told taking antiobiotics wouldn't neccessarily 'cure' my years of stomach problems and many people have H pylori without an issue. I had repeatedly been going to the gp for my stomach through my teenage years and early 20s to no avail. Tried all the stupid meds for IBS made it 100 times worse.
The top of my stomach blows up like a balloon and feels almost bruised and inflamed internally when I eat, I've been fobbed off for many years with 'IBS' even though my bowel is unaffected. I'm now told after a stool test recently I haven't got H pylori even though I never had treatment and finally after 20 YEARS I'm now being referred to gastro.
The damage is done, life quality is now non existent as I don't leave the house. Since age 15 I've trudged along and feel robbed of my teens and 20s, I would cry with exhaustion and stopped going out as I would suffer for a week if went out for a night out and by the time I got ready I was ready for bed anyway. I looked pregnant, my hair thinned and my teeth have prematurely eroded. I don't know how I've got to 35, looking after 2 children without help (apart from my husband) and homeschooling. I now have to give it all up as my brain is now affected.
1. My stomach issues started in extremely high stress/rubbish diet was also in place age 15
5. Changed diet - good but slow improvement but still stomach issues, exhaustion, hair loss
6. No energy ever, at home most of the time - best times of my life was when I was pregnant/nursing
7. About 5 years ago noticed a decline in cognitive ability - felt I was becoming 'dumber' - put it down to baby brain.
8. 5 years after having my children starting thinking hmm baby brain is lasting a bit long here! Mixing up words without realising, long pauses drawing a blank losing words, memory loss
9. Dizziness, palpitations began all in the pandemic after some changes in menstrual cycle (very heavy blood loss)
10.Leading up to October- felt something was very wrong but put it down to a stressful house move
11. October - honestly feel now looking back I've had a near death experience, every day feeling like I was going to die with all symptoms above increasing 100 fold, starved of air falling into things no balance dizziness like nothing Ive ever known. Loss of speech, feeling spaced out, dementia like symptoms and irregular heart struggling to beat with walking from one room to another
12. Now self injecting, noticed big improvements but still trying to work out how to space injections, tried weekly and bck to square one with the mental abilities plummeting again. Find it hard doing the most basic tasks at times, hard to speak, stuttering.
Made the connection recently that I was suffering with low stomach acid after experimenting with hcl and pepsin but gp proceeded to give me ppis for the second time even though I told them they make things much worse? Told him I'm not absorbing the very healthy organic diet I've been on since age 25 (after getting endometriosis diagnosis managed it with diet- was told that was IBS when i was in horrendous pain told I was 'constipated'). As usual no one listens, now have a referral to gastro but its took 6 months going back and forth and feeling like a pain. Dont know if the fact that I told him I'm self injecting has made him take me a bit more seriously.
Tried cutting back on injections to once a week to see what would happen and back to square one, feeling as though I have dementia and like I'm a shell. Back to self injecting every 2 days, the last 6 months have just sped by in a horrible blur. (I never got a diagnosis I was lucky to meet a PA sufferer and find this forum to confirm it all for me).
It may be important to note that I've had chronic stress throughout my life due to family issues and some pretty big 'shocks' and traumatic experiences in the last 6 years. I have the worst luck! But I am grateful to my Lord and Saviour Jesus Christ because hes brought me through and I'm still here. Needless to say, stress must affect the unfolding of how b12 deficiency develops. I think for those of us who live lives where stress is normal - our bodies sort of adapts and must therefore use up more resources. I'm also interested in how adrenal stress would tie into all of this.
Oh yes my thyroid readings are subclinical tsh just hovering above the base 'range' level !!!! So definately can see the connection there also!!!
Sometimes it ends up being all too much for the system. Our stressful lives, early experiences or traumas, genetic inheritance, and lifestyle pressures have a tipping point.
We seem to live in a world, or did live in a world pre-pandemic, that pretended to care for people's wellbeing but still demanded we act like machines - rise early, get work done, eat on the go, be stressed all day, come home late, eat late, work more....
We have a limit. And in a spooky way I think the pandemic gave us that message too.
It sounds like you maybe have some worries over your injections. Are you finding every other day too much for the system?
To be honest I just hate doing them, they make me so tired afterwards so I do them in the night now which is better. I've been messing the last few up, having to change the needle and start again. I seem to be bruising and bleeding a lot more now and I don't know if I'm doing it right. Sometimes its painless and then sometimes I am dithering and mess it up. I never had bruises in the first few weeks of doing them myself. I have put on some weight since then as I lost a lot and couldn't eat, I'm wondering if that has anything to do with it as my thigh is short but now has a bit more meat on them. I'm wondering if that has messed up my perception of where the needle goes. I watch endless videos before but everyone seems to do it differently. 90 degree angle etc, I dont know if I'm going into the muscle half the time and I suspect that when I do it and mistakenly it is subcutaneously its not as effective for me as intramuscular.
Yes your right, the life that is deemed as normal and efficient in our society is very unnatural to our bodies. Its very different even to what is was 30 years ago, its all very off balance especially for women. It all began in the 60s and has just reached its mad peak now. We've never lived like this EVER and now the multiple autoimmune illnesses which remain a mystery as to their cause and cure are the fruits of living in this extremely unnatural way.
Sorry for late reply here. This is all so complicated isn’t it? Where to start in a 10 minute gp appointment! Enough to bring on a panic attack just thinking about it.
A few random thoughts to add to all your points.
Alcohol alone can cause inflammation of the stomach lining and decreased acid production
Gluten sensitivity could well be due to use of glyphosate, which is systemic in plants and is now everywhere - in the soil as well - and probably affects the health/nutrient status of animals too. Even those that do have access to grazing are probably compromised and many animals hardly see the light of day anyway. That makes my wonder about the nutritional value of meat.
If am pretty sure (correction welcome if this is wrong) that an even a glitch in folate metabolism can affect b12 uptake. This is shown by raised homocysteine and possibly folate level (unmetabolised in the blood). B12 serum/active and MMA can be normal. The answer to this is a combination of b12, b6 and folate.
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Reasons for low B12 correct?
Why does the cause of B12 deficiency matter?
Can PPI'S deplete b12 this much? 
Chronic stomach problems and PA
Serum B12 levels compared to active B12 levels 
