Hidden Causes of Abdominal Pain in EDS with Dr. Pradeep Chopra (Ep 163)

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Dr. Pradeep Chopra: [00:00:00] It's a lot like post hepatic neuralgia. They'll come in with their shirts, clothes, not touching them, even their shirt off, and it's very painful to touch.

Dr. Linda Bluestein: Welcome back every bendy body to the Bendy Bodies podcast with your host and founder, Dr. Linda Bluestein and the Hypermobility md. This is going to be a great conversation with Dr. Pradeep Chopra. This is part two of our Gastrointestinal Problems and abdominal pain series. This is going to be really, really important because so many of us have suffered from abdominal symptoms that have been really, really difficult to diagnose.

And we are so incredibly fortunate to have Dr. Chopra back on Bendy Bodies. Dr. Chopra is world renowned for his [00:01:00] incredible work in EDS and HSD pots, mast Cell Activation Syndrome, CRPS and Central Sensitization Disorders. Dr. Chopra is a Harvard trained board certified pain medicine specialist with over 25 years of experience.

We'll link all of Dr. Chopra's prior episodes in these show notes for Easy access. As always, this information is for educational purposes only and is not a substitute for personalized medical advice. Here we go.

Okay, well, I am so excited to be back with Dr. Chopra once again, Dr. Chopra, I think that maybe you get the prize for the most guest appearances. I probably should have added this up before this conversation, but uh, it's probably seven or eight, something like that now. So we'll link all of those in the show notes, of course.

But thank you so much for coming in, talking with me again today. 

Dr. Pradeep Chopra: Thank you very much. I really enjoy coming up here and talking. 

Dr. Linda Bluestein: Of course, of course. And, and last time we talked, we were talking about the GI tract and we started [00:02:00] with the upper GI tract and we even started with the teeth, which was a, a very interesting conversation.

And we kind of left off at, with compression syndromes. We got through the esophagus, we got through the small intestine, and, um, and that's pretty much where we left off. So today we're gonna try to cover the rest, which is kind of a lot. So we'll see how well we do. Um, but we wanna talk about like the, the large intestine, and we wanna talk about things like prolapses and also like abdominal wall type problems.

Things that can happen in, in the vagina and in the pelvis. So I thought maybe we would start with the, the, the colon and the large intestine. Does that sound okay with you? 

Dr. Pradeep Chopra: Sure. Um, yeah, absolutely we can do that. Um, so it's still inside the abdomen and. So we, you know, we we're, we talked about all the compression syndromes, the small intestine, and as for our listeners, um, [00:03:00] our, our intestines are about 20 feet and 10 inches long.

And, um, the small intestine is the major part of it. The part about the intestine that we need to understand is it's mobile. It moves because it has to move food along just like a toothpaste. And so it has to move food along. And, um, when it slows down, you start having problems like, uh, bloating, pain, uh, and you know, and then you can alternate between constipation and diarrhea, and then of course absorption.

So people have absorption issues because it's slowing down of the movement of the intestines. One of the things that, uh, people, when with EDS can see is what is called as visceral ptosis. Being spelt as P-T-O-S-I-S. What that means is that it drops down. So my concept is the [00:04:00] intestine is, has three layers of walls on it.

You know, it has muscles on it. Uh, but what if the muscles was thin? What if the intestine was thin? And so any food in it where the weight of the food and the fluids would make the intestines drop down. And that's called visceral ptosis. Or you can, viscera means whatever's inside the abdomen. So we'll talk about the intestines dropping down, and then we'll talk a little bit about, uh, kidney ptosis because the kidneys can drop down also.

Usually the problem that we see in patients with, um. That is dropping down of the intestines is with the transfer colon. So the colon goes up from one side of the abdomen, and that's called the ascending colon. And then so it goes up the right side of, of the abdomen, so it goes up, the right side goes across, which is called the transfer colon, and then it goes down, which is the descending colon on the left side.

Now the transverse colon is kind of loose. It's the, [00:05:00] the ascending colon and the descending colon are fixed, but the transverse colon kind of is, is in there flapping around. Normally it'll descend a little bit with the weight of the food and fluids, but in EDS it can descend a, because they have loose connective tissue, it can descend a lot more.

And so I've seen x-rays of patients where the, the transfer colon is so loaded that it falls into the pelvis. Now when it falls under the pelvis, obviously there are intestinal issues and extraintestinal issues, intestinal issues being bloating, diarrhea, constipation, et cetera. But if it's really loaded and it pushes into the pelvis, it can press on the bladder and a rectum.

And so now they have, again, another reason for constipation and, uh, you know, frequent urination. I don't know how common this is, uh, but it's, it's known to happen in ed. So obviously these conditions have not been studied in great [00:06:00] detail, but it's just something to keep in mind for, in patients with abdominal issues, in patients with EDS, with abdominal issues, one of the things that is thought about is that these patients have what is called dolly colon.

Dolly colon means the, their gut is elongated. And so it's really long and it's thin world. So the weight of the food and the fluids make the, make the transfer colon drop. It doesn't happen to the ascending colon because it's fixed. The descending colon is fixed. But then the, the last part of the, of the descending colon is called the sigmoid colon.

This has shaped, and that is also, uh, loose and kind of flappy. And this, this is a problem that I suspect I see quite often is because what happens is the sigmoid colon is the last part of the, well before the rectum is the last part. And then when it gets loaded, it kind of falls over [00:07:00] and can cause severe constipation.

And the only way I know this is because patients will tell me like if side. Can have a bowel movement. And so that tells me it's a mechanical problem. You know, the diagnosis is pretty simple. They, you can do an, you can diagnose it by x-rays and a dye and you can see where it is. 

Dr. Linda Bluestein: Do you have to be standing up in order for the, for the imaging in order to show the effect of gravity?

Dr. Pradeep Chopra: Correct. Exactly. But here's the thing, I mean, oftentimes I've asked patients like, do you want me to do something about it? 'cause it might involve surgery and we don't know how effective it is. And most patients are quite used to it and they're like, okay, no thanks, the surgery. Um, but it's something to think about that, um, this constipation is a kind of a mechanical constipation and sort of adjusting your position sites can help.

So we're on the subject of ptosis. Ptosis, meaning dropping [00:08:00] down. So the organs in our body, like the kidneys, the kidneys are kind of fixed at the back of our abdomen. They're kind of plastered to the back of the abdomen. But in patients with EDS, they can have ptosis of the kidney, so the kidney can drop down.

Um, it's often known as the official term is nephroptosis, but it's also known as floating kidney. And the diagnostic criteria is that if the kidney des descends more than five centimeters, which is about the height of two vertebra, then it's considered to be, uh, when you move from a, from a lying position to a standing position and it drops by five centimeters or two vertebral, uh, bodies, then it's considered as a floating kidney.

Now most patients don't have any problems. The reason being that we do, we have two kidneys. So one, you know, one kidney has a problem, the other kidney takes over the job. We never get to know that. [00:09:00] And so, uh, and then oftentimes it's, it's, the kidney is working fine, but if they, there is a, there is a problem, um, it's usually a very sharp pain in the flank.

That's where the kidney is. And this pain, uh, goes from, it's called the classical loin to groin pain. Uh, it gets worse when you stand, obviously, because that's when the kidney drops down. It does cause a nausea and vomiting. And because the renal artery gets constricted, because the blood flow to the kidney gets constricted, it can cause high, uh, blood pressure.

Um, it can cause bleeding in the urine. And there's a kind of a heaviness in the, in the abdomen on that side. Now, I don't know if there's, um, we don't know if people who have floating kidneys have it on both sides or they can have it on one side. It's something to think about if everything else has been ruled out.

And this, I wanted to, I sort of wanted to put a little disclaimer. [00:10:00] Um, just because somebody has EDS don't think about fancy abdominal problems. You can have normal other problems like an appendicitis or a cocy gallbladder problem or something like that. And, and I don't want people to think that, oh, I have pain in my loin and you know, it could be just a kidney stone.

I don't want you to think that your kidney's dropping down or something. 

Dr. Linda Bluestein: Right, right. And, and things like diverticulosis that are more common in people with EDS, that, that something like, that's gonna be much more common. I, I was gonna ask you, as you were talking about the renal, uh, ptosis or nephroptosis, um, my husband is a urologist, so he's operated on lots and lots of kidneys, and I don't recall him ever mentioning that he has done any kind of a pxi surgery for, for kidneys.

Is that, have you had patients that have had to have surgery for that or, or anything, or have you seen this very often? 

Dr. Pradeep Chopra: No, I haven't. But see, here's the thing. I mean, it's, I suspect it's commonly missed, number one. Number two, I, I [00:11:00] think in most cases it's probably asymptomatic. Mm-hmm. Because, you know, these people are born with it and the, and, and, and the blood vessels and the ure, the u the ureter and everything has adjusted to it.

I dunno, I haven't seen this, actually, I don't think I've ever seen it. 

Dr. Linda Bluestein: Okay. 

Dr. Pradeep Chopra: But the only tos that I've seen is the sigmoid colon causing. Constitution that I have seen. I've seen that too. Yeah. But I don't think I've ever seen, but it's something we, since we're discussing abdominal issues, it's just something to keep in the back of the mind for especially our physician listeners, um, that this can be a issue.

One of the things that, um, is a big, kind of a concern, especially in patients with vascular radius, they always bring it up as bowel perforation. 

Dr. Linda Bluestein: Mm-hmm. Right. 

Dr. Pradeep Chopra: And, but I just wanna make sure that this is not limited to patients with vascular radius. So there's always, in, in SLO syndrome, [00:12:00] there is an overlap of symptoms, uh, or overlap of pathology.

So, so I know patients with vascular a DS we know are prone to having vascular anomalies like aneurysms, but that doesn't mean that a patient with hypermobile a DS can't have an aneurysm. And so we can just rule out like, okay, you've got hypermobile EDS, you can't have an aneurysm, 

Dr. Linda Bluestein: right? 

Dr. Pradeep Chopra: Um, that is still there on the table.

And so bowel perforation, uh, or rupture is a common, I'm not sure, it's not common, but it is seen more often in vascular EDS. But it can be seen in hypermobile, a ds, and it is a serious emergency condition. You know what happens is, uh, there's a hole in the intestine or part of the intestine, there's a rupture.

And so the contents of the intestine come out such as bacteria, food or bile. And so these patients present with severe sudden abdominal pain, it's very sudden. It's very severe, [00:13:00] and it is, and of course, um, there's infection. So there's fever, uh, and because there's infection. Inflammation. The abdomen becomes really tender and rigid.

They start to breathe faster and this fever and nausea and vomiting. But this is an ER thing. Mm-hmm. This is a completely er thing. If you, if you have any of these symptoms, head to the ER and they can diagnose it pretty easily. 

Dr. Linda Bluestein: And 

Dr. Pradeep Chopra: that 

Dr. Linda Bluestein: could also be related to, not, to, not to bring this up already again, but a ruptured tick from diverticulosis.

Right? So, I mean, even in a quote unquote normal person, normal connective tissue person, one of the causes of bowel perforation is a ruptured diverticula. So that's, uh, but that's super important to to point this out because I think sometimes it's really hard for people who have abdominal pain on a regular basis and then, you know, they get, uh, an episode that maybe it does seem more extreme than usual, but they're not sure.

Do I go to the er? Do I not go to the er? 'cause they, they've been gaslit so [00:14:00] many times. So I think it is very important to point out what are the things that you should definitely go to the ER for. So if you do have that sudden onset or, or significant worsening of abdominal pain, especially if it is associated with a fever, um, or, you know, sweating or chills, right?

Or those are some things to be, uh, very, very concerned 

Dr. Pradeep Chopra: about. Absolutely. If it is sudden onset. Fever, there's chills head to the er, no question. Yeah, absolutely. And it can be from diabetic colitis profession from diabetic colitis, so that's non EDS reason, plus an EDS reason. And then there can be a rupture.

And most er physicians are really adapted or diagnosing that it's not a big deal on the large intestine. I don't think we have anything else to, uh, go through that I can think of right now. Moving into the pelvis. Um, there is something called a pelvic congestion syndrome, and I suspect [00:15:00] it's more often than we diagnose it.

And so, you know, we know that in, in people with hyper, with EDS, they tend to pool blood. And a large part of this pooling is in the abdomen and the pelvis, uh, especially when they stand. And so. The, the veins in the pelvis, there are big, huge veins in the pelvis, and so they tend to pull a lot of blood there.

And this causes, uh, they technically present classically will present with chronic pelvic pain. It's not sharp, it's kind of a dull, achy pain. But the, but the typical point is that it gets worse with being upright. So when you move from, uh, from supine to upright position or standing position, it gets worse.

That's kind of the classical sensation. And of course when you lie down, it gets better. They can have varicose veins in their pelvis, the vulva or the [00:16:00] legs, but there is typically a very heavy. A foggy feeling like there's something loading into the pelvis. Um, they, it may be associated with, uh, lower back pain because it's tugging on the structures attached to the, the lo the lumbar spine.

So it's putting pressure on the, on the pelvic floors, pushing, you know, so it can cause uh, back pain. But the main one that I want to stress on is this pain comes on with being upright and gets better with lying down. That's the classical symptom. And obviously, uh, these patients are also have pots. 

Dr. Linda Bluestein: I did wanna talk a little bit more about diverticulosis, just because it's common in the general population, but it's so much more common with EDS that I feel like, you know, again, 'cause that can affect your dietary requirements, right?

Like the foods that you might be recommended to eat. Um, and it's my understanding that especially in classical, like, um, EDS, that the [00:17:00] prevalence of diverticulosis is a lot greater. Um, there was a study recently that showed 80% of patients that had classical, like EDS type one, 80% of them had diverticulosis, and two thirds of those people experienced spontaneous intestinal perforations.

Speaking of, you know, other nonvascular types of EDS, um, having, you know, per, uh, intestinal perforations. So that type of EDS we know is of course, you know, quite rare. But I just wanted to point that out. That is huge. 81%. 80% in this study. Yep. 80%. Yep. 80% I can, uh, wow. Yeah. So I, I can include the study in the show notes so people can see what the study was.

That is, that is huge. That's in classical, like EDS type one. 

Dr. Pradeep Chopra: I think we can go on to neurological causes of abdominal pain. Okay. So in the neurological causes, let's talk about the spine. One [00:18:00] of the things is we'll start from the top of the spine. So we start with the cervical spine and we talk about cranio cervical instability, which means, um, instability of the neck.

Um, what that can do is, uh, it can cause compression of the spinal cord and it cause compression of the arteries and the veins as well as the neuro system, including the famous vagus nerve. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: Now, the vagus nerve plays a really important role in digestion and so a need dysfunction of the vagus nerve can cause.

GI problems. So yes, uh, instability. The cervical spine can contribute to GI problems. Um, but I don't know if I've seen a patient who had cranio cervical instability had a fusion done and their, all their abdominal issues went away. It could be contributing to it, but may not be the only reason. 

Dr. Linda Bluestein: Ha. Have you seen people where their GI symptoms got [00:19:00] substantially better though after they had their fusion surgery?

Dr. Pradeep Chopra: Yes, I've seen them. I mean better but not gone. So there are other reasons why they would have GI issues, and so that's one of the things to think about. So autonomic dysfunction like pots, um, can also contribute because remember the entire GI tract moves on the autonomic nervous system. Um, and the sympathetic nervous system is pretty much the entire intestine, whereas the.

Parasympathetic nerve only goes up to the transfer colon. And so hearts, people with pots or autonomic dysfunction, uh, dysautonomia can also have lots of GI issues. And this is the confusing part, Linda, is that these, you know, when a patient comes in and you, you, they have all these abdominal issues and you, you're left wondering, is this mts or is this POTS 

Dr. Linda Bluestein: right?

Or 

Dr. Pradeep Chopra: what is causing this? And it's probably a [00:20:00] few of them and you just sort of have to chip away at it one by one. 

Dr. Linda Bluestein: Yeah. That's where it's really tricky with the symptom overlap between the connective tissue disorders, mast cell disorders, dysautonomia, like the, the, the symptom overlap is so huge. So Yeah.

But at the end of the day, the big thing is what are you gonna do? How are you gonna help the person feel better? Right. So, um, knowing exactly the cause of course would be nice, but, uh, I think, you know, sometimes it's really figuring out. What are the best, what are the right, uh, you know, I'm, I'm thinking of like a toy like that.

You kind of pull a string and then it starts to spin. Like what's the, what's the thing that you're gonna do that's gonna have the, the greatest impact? So we would love to hear your hacks. 'cause of course we always love to hear your, your hacks are very, very popular. So, uh, as you're talking about these things, if you have additional hacks, be sure to throw those in.

Dr. Pradeep Chopra: Here's the thing, like we talked about, you know, how, how different things can cause different prob issues can cause different problems in the GI [00:21:00] system. And in my own mind, I sort of try to differentiate, um, if it's painful. Um, you know, so when you feel the abdomen and it's tender everywhere, um, I think more of inflammation in the GI tract.

Dr. Linda Bluestein: Hmm. 

Dr. Pradeep Chopra: And if they still have, if they, if they have bloating and it's not as tender when you, when you feel around on the abdomen, it's not that super tender. I think more of, okay, maybe this is DYS anno, but at the end of the day, they, is both of them contributing to this. Um, the only thing with MCAS is that MCAS is a pretty nasty condition to have.

It does cause a lot of abdominal pain. It can not does. It can because mast cells like to accumulate at the surfaces of the body. And so the surf, one of the surfaces is, is the intestine. And, and so it cause inflammation of the lining of the intestine. And what the intestine does is it doesn't, like [00:22:00] when it's inflamed, it doesn't like anything touching it.

And so when you eat food, it stops moving and then it starts to brought up and then you wind up with diarrhea, constipation, but it's severe cramping, abdominal pain. 'cause now you have an inflamed gut and is trying to push food along, and that's predominantly MCAS pain. And of course the diagnosis of mast cell depends on, um, on other, other things.

But as far as the abdomen is concerned, it's, uh, it's quite painful. Um, and, and as for us, for us, uh, physicians, we, when we feel around and they have a diffused tenderness everywhere, that I think more of MA than, uh, dysautonomia. 

Dr. Linda Bluestein: Mm. 

Dr. Pradeep Chopra: Okay. I know if you guys have discussed this before, but Heather cord can cause a lot of GI issues.

Dr. Linda Bluestein: We, we have not discussed that before. Yeah. Okay. Interesting. Tell me more. 

Dr. Pradeep Chopra: So [00:23:00] this I have seen, and it has been surprising because, uh, oftentimes, you know, I tell patients, Hey, listen, you're going to see your bladder symptoms improve. You're gonna see your back pain, your leg symptoms improve. And then lo and behold, they come back and then they'll say, my GI symptoms got better and I have been, not everyone I don't want to sound like, okay, that is the only reason.

But I have seen this before and you know, when I did a search of this and I found out that yes, it's possible because after all, at the end of the day, all your nerves pass through your spinal cord. And if you spinal cord is being stretched, it's going to affect everything. So expect to see some improvement in the GI system after a tethered cord release.

So the tension of the spinal cord causes a disruption of the signals going up to the, uh, brain and control of the bowel and bladder function. And so when you release the tethered cord, that function gets better. I know for a fact that the bladder function improves within, [00:24:00] within 24 hours as soon as they wake up.

But GI symptoms also get better, like constipation and all that gets better after tethered cord surgery. So one more reason to have that released. But again, uh, like I said, uh, caught maybe just one of those dots in the whole conundrum of right GI issues, you know? Right. Autonomic dysfunction. Okay. Mass cell activation, and then you have tethered cord, and then you have cranio cervical instability and a whole slew of other things that can contribute to this.

Dr. Linda Bluestein: Don't you think? I, at least, I think based on my personal and clinical experience, that it also is not necessarily even that exact same combination of things on any given day, on every day. So some days maybe one thing is playing a bigger role, maybe some foods that you ate and your mast cells are unhappy, and then another day, maybe [00:25:00] there's something else that's more predominant.

Um, I, I think there's a lot of variability from day to day in a lot of our symptoms because there's so many different contributing factors and it's a, it's a constant moving target. I feel like 

Dr. Pradeep Chopra: ab Absolutely. So, you know, that's why we don't look at, we don't look at diseases, um, as, uh, as a straight line.

It's always. Some days are worse than other days. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: And some symptoms are worse than other symptoms. So someday your MCAS might be out of control and some, your pot is out of control. The way I look at it is, um, in terms of treatment outcomes, I look at as more good days than bad days. 

Dr. Linda Bluestein: Mm-hmm. Right.

Dr. Pradeep Chopra: And then finally at the end of it, even the bad days are not as bad or manageable. That's how we look at it. But it's not on a straight line. It's never a, it's always a, a baby curve. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: So, as we were on the subject of, uh, [00:26:00] inflammation of the GI tract, so the GI tract is loaded with nerves. In fact, there's so many nerves in it that it's called the second brain.

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: Um, and there's, and, and this inflammation is eventually get to the nerves and the nerves are gonna get inflamed. So the, so the GI tract actually has its own nervous system. So we have a nervous system that I can control so I can scratch my head. That's under my control. And then we have the autonomic nervous system that controls autonomic functions like breathing or your heart rate and all that stuff.

But then the GI tract has its own nervous system called the enteric nervous system. And what happens is that inflammation, constant inflammation from MCAS or whatever, can cause inflammation of these nerves, and that can cause sensitization of the, of the nerves, the tric nerves in the GI tract. It's quite a nasty condition.

I've seen it on many occasions. So what [00:27:00] happens is they'll eat food. Uh, they won't have pain right away, but they'll have pain after, say two hours or after an hour or something later on. And that's when the food, as it moves down the GI tract and hits that sensitive area, that's when they feel it. Um, it's called visceral hyperalgesia.

Uh, and it's really, obviously it's painful. And then there's. Cross sensitization. So cross sensitization is, for example, you have pain from the bladder that inflammation and of the nervous system in the bladder can cause, uh, cross inflammation or crosstalk as it's called crosstalk with the nervous system in the GI tract.

Dr. Linda Bluestein: Mm-hmm. And 

Dr. Pradeep Chopra: so that can cause, uh, GI pain also, and that's called cross sensitization. So different organs, um, as they cross paths in the spinal cord. Cause these pain signals to be mixed up and other structures can trigger pain. 

Dr. Linda Bluestein: Yeah. I, I was [00:28:00] diagnosed with visceral hypersensitivity. I, I was getting scoped and my doctor said, well if, if we don't find anything, then the only explanation.

Like, you know, this is before I knew really anything about EDS, uh, or MCAS, but what I was told was really the only explanation would, would have to be visceral hypersensitivity. And I remember at that time I was having difficulty with, um, swallowing any kind of water or food that was a little bit warmer or a little cooler than normal.

I would get like pain in my esophagus as the food would be coming down. And fortunately, fortunately, it's way, way better. I, I, knock on wood quick. Uh, but, but yeah, I think a lot of people probably fall into that spectrum of at least some degree of visceral hypersensitivity, don't you think? I mean, it might not be like the primary cause of their symptoms, but they, they might be more aware of what's going on in their GI tract, whereas I feel like, I feel like I have family members or [00:29:00] friends who they don't have any clue what's going on in their body at all.

Like relative to me. I can feel everything. They can feel nothing. 

Dr. Pradeep Chopra: That's true. I've always wondered about that. People with EDS live in a different universe 

Dr. Linda Bluestein: mm-hmm. 

Dr. Pradeep Chopra: From people without EDS. They've had pains for so long, they think that it's normal part of their life. Uh, they have light, they're lightheaded.

It's normal part of their life. And oftentimes kids come in and they're like, you're not supposed to feel dizzy when you stand. And so, yes. The other thing is that your friend in the GI system is the vagus nerve. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: Okay. We love the vagus nerve. It's, it's a really long nerve. Uh, but unfortunately for some reason, uh, God decided to not let it go all the way.

So it stops at, I believe the two third and one third of the transfer score on it stops kind of, so it provides innovation to the upper, uh, the for good. [00:30:00] Actually, 

Dr. Linda Bluestein: mm-hmm. 

Dr. Pradeep Chopra: Patients with, um, this autonomia, which is dysfunction of the autonomic nervous system, they have low vagal tone. That means their vagus nerve is not working as well.

Um, or they can have damaged, uh, vagus nerve, uh, for whatever reason that caused gastroparesis. Now gastroparesis is slowing down the stomach, not the intestines. So, and that's where the vagus nerve supplies, there is some work. And, and of course it contributes a lot to our, um, to, to denomi. And so there's a lot of work going on in terms of vagal nerve stimulation and stimulators.

And there are implantable stimulators. There are some external stimulators, and there is this one drug that I know of, um, it's called, um, TIG or Mastin. Um, it's not a, I wish it was a better drug. Yeah, I wish it doesn't really have a lot of side effects, uh, and you, [00:31:00] you know, but you have to give it a pretty high doses to get that nerve, uh, work to be done.

But it's, it's a good drug for pots and gi, uh, issues. 

Dr. Linda Bluestein: I've had some pretty good results with it. You've had? Yeah. Uhhuh. Yeah, I've definitely had some patients do really well with it. 

Dr. Pradeep Chopra: They, no, the patients like it, but I just wish it would solve even better, the problem entirely, right? Yeah. Right. Yeah, of course.

Patients love it. Yeah. 

Dr. Linda Bluestein: Yeah, of course. Um, we're, and I, I'm aware of needing to take a quick break in a second here, but I wanna ask you one quick question before we take the break. Um, when you were talking about the vagus nerve and those of us with EDS and Dysautonomia ex et cetera, of whatever, whatever combination of these things that we might have, is this also why I've made this observation?

And I don't know if this has been actually studied, but so many of us startle so easily. Um, you know, I have family members who like, I'll, I'll, you know, totally surprise them. And they, and they're just like, what? And, and, and my husband has walked around the corner before and I jump [00:32:00] and he's like, I live here.

Dr. Pradeep Chopra: So just think of this, okay. A person with EDS has say dysautonomia, right? Mm-hmm. This autonomia is function of your dys, of your autonomic nervous system, which means your sympathetic nervous system is revved up and your sympathetic nervous system is the nerve of flight or fright. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: And at baseline, people with parts, their heart is often in the high nineties and even getting into the hundreds, which means that you're already in a flight or fight state.

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: So for example, you, for me, if I look at a snake now, my nervous system, my sympathetic nervous system is revved up. Right? I'm meant fight or fright. And now somebody in, somebody in the back comes and says, boo, I'm gonna jump around my skin. And that's the thing with people with Mia, is they're already revved up.

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: And all it takes is a little bit of a startle, and then they. Uh, go over. [00:33:00] 

Dr. Linda Bluestein: Mm-hmm. Mm-hmm. 

Dr. Pradeep Chopra: Yeah, absolutely. Vagus nerve is your friend. Some, some days sometime we may have an awesome vagus nerve, uh, treatment. 

Dr. Linda Bluestein: We're gonna take a quick break. I wanna make sure that we talk about abdominal wall type problems and also issues with the lower ribs.

And we are going to also, I guess we talked about ptosis pretty well. I don't know if there's anything you wanna come back to that mesenteric ischemia. Um, we need to talk more about, uh, pelvic floor and things like that. So we are going to come right back. We're gonna take a quick break and those are some topics we will cover when we come back.

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Okay, we're back with Dr. Chopra and we are talking about a whole host of things that can go on in a body with a connective tissue disorder like EDS that can contribute to abdominal type, uh, symptoms or gastrointestinal type symptoms and can make the picture quite confusing. So we've covered a lot of things already.

Um, do you want to move on to the abdominal wall and lower [00:35:00] ribs or do you wanna go to a different area next? 

Dr. Pradeep Chopra: You know, I like to kind of focus on the more commonly missed reasons for abdominal pain. Yes. Costochondritis, which is inflammation of the rib or pain from the rib is common in EDS. I mean, universally common in fact is so common that people with EDS, like a lot of them are like, yeah, it hurts.

You press on their rib and they'll say, yeah, it hurts, but they don't really care much about it. But if the lower ribs. The lower part of your chest, the lowest, most ribs, if they start to hurt, it almost feels like abdominal pain. 

Dr. Linda Bluestein: Hmm. 

Dr. Pradeep Chopra: Diagnosis is pretty easy. And that's why a, a physical exam in abdominal pain is so crucial is that, you know, if they complain of pain in their abdomen and you palpate around and then you just kind of push on the rib and they go, ouch.

And then you can, then I ask them like, is this the pain you're complaining about? And then that's [00:36:00] from the ribs osteo. 

Dr. Linda Bluestein: And, and so is that usually costochondritis or is that sometimes slipping rib syndrome, 

Dr. Pradeep Chopra: slipping rib syndrome. So I think of slipping rib syndrome more of a, uh, rib Subluxation. But, uh, I'm not sure if, uh, slipping, that's what, that's my impression.

But cost, uh, rib Subluxation can cause pretty severe chest wall pain. And that's like you, it's almost like you're getting a heart attack. It's that bad. Buton of the lower ribs, uh, can mimic abdominal pain. And so when you feel around and you kind of apply a light pressure on the ribs, the lower ribs, they'll complain of pain.

And oftentimes it's like make sure, like is this the pain that you're talking about? 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: Um, obviously you have to at the same time look for other common reasons for abdominal pain. You're not missing something else, but it's reproducible [00:37:00] pain. That's what I'm trying to say. 

Dr. Linda Bluestein: Yeah. No, that's great. 'cause Costochondritis is definitely super common.

This is something that I also have had, I haven't had all of these things, but I've had, I've had quite a few, uh, with Costochondritis. Uh, what can we do about that? 

Dr. Pradeep Chopra: Um, it's a tough one. Um, so. The first thing is, you know, as in treatment for pain, you have to know the cause of the pain. And we know the, the reason for the pain here is a rib inflammation.

And you know, between the ribs there are muscles, there are actually three layers of muscles. And, and so when the ribs get inflamed, the muscles also tighten up a little bit. And so they get, they have pretty severe pain there. Uh, the, the question that I cannot answer is why do people develop costochondritis?

And this is not an EDS thing. This is, I've seen this in non EDS patients. It's predominantly common in women. Uh, and they'll have this severe excruciating rib pain. So what I'll do is I'll go and inject [00:38:00] steroid locally over the rib. I haven't done it in that many EDS patients, um, but I have done it in non EDS patients and they do get a good response.

But it's kind of a, it's not a very fun experience getting shots on your ribs, but you do it along and then. After a few visits, they start to get better. But why do they have inflammation on the ribs? I have no idea. And I've looked at the literature and nobody really knows Why. 

Dr. Linda Bluestein: Is it related to more motion of the ribs, even if it's not like a full Subluxation?

I mean, like you said, it's something that's common in the general population as well. So, 

Dr. Pradeep Chopra: but here's the thing, the lower ribs don't really move that much. 

Dr. Linda Bluestein: Mm. 

Dr. Pradeep Chopra: That's the thing. So this, the ribs on the right side cover the liver and the left, they hide the spleen even 

Dr. Linda Bluestein: though they're floating. 

Dr. Pradeep Chopra: They're, and then there's some floating ribs there.

But, um, I'm not sure, honestly, I don't know. But, but the diagnosis is, you know, it gets worse if they [00:39:00] say, for example, take a deep breath or cough, have a big hearty cough that'll make the pain worse. Uh, and obviously is reproducible. And that should make you think of troponitis. And I just wanna say it's a very benign thing.

It's nothing to worry about. Uh. It's as long as everything else has been rule out. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: So almost all patients that I've seen at least have tenderness of the rib. And if you press on the rib, it hurts and you know, they go out. But other than that, they're like okay with it. But it sometimes it can mimic abdominal pain.

Dr. Linda Bluestein: Mm-hmm. Mm-hmm. 

Dr. Pradeep Chopra: The other pain I wanna talk about was, um, two kinds of pain. Let's talk about the first one, which is called acnes. The full form is A-C-N-E-S, or also known as anterior compartment nerve entrapment syndrome. So anterior compartment, nerve entrapment syndrome. Is it 

Dr. Linda Bluestein: compartment or cutaneous?

Dr. Pradeep Chopra: It's, I'm sorry. Cutaneous. Oh, sorry. Um, yeah, my [00:40:00] bad. It just, it's cutaneous. So, um, so you know the ribs, sorry. The nerves do, are the nerves travel along the sides of the body. So they come from behind and then they come on, sort of travel along to the front over here. And in the front you have the six pack muscle.

So they, when they reach the, when they reach the border of the six pack muscle, uh, they, the tiny little tunnel and they go through under that tunnel and they go into the muscle and, and then they can break, break off. And for whatever reason, we'll get into the reasons later on, this tunnel becomes narrow and it compresses the nerve.

And these patients present with abdominal, uh, pain, uh, it's pretty severe. Uh, the characteristics of these pain, this pain is that it's kind of localized. So they'll [00:41:00] say it's mostly, it's in the upper abdomen, they'll see it over here. Uh, and it's can be lower abdomen also. And then I've seen this in both non EDS and edss and the non EDS patients is usually people who, um, it's because of trauma.

So, boxers, wrestlers, plumbers. I've seen it in plumbers. So, so this, they, what they do is, you know, when they're working on some plumbing stuff, they have something kind of pushing into their abdomen. They're holding their pipe, I think, and it's pushing in there. And then they're working on the pipe and eventually they start to develop the narrowing, the nerve, the, the tunnel gets narrowed down and they develop this pain.

Sometimes surgery can do it. So chole cyst, we don't, you don't see it in cholecystectomies nowadays because we do laparoscopic most of it. But you can see it in hysterectomies or cesarean sections. Um, you can see it after pregnancy. So the abdomen kind of blots up and then it goes [00:42:00] down, and then the nerve entrapment.

You can see that there, there are a couple of ways you can diagnose it. Uh, one is you simply have them, you simply start pressing on that. Edge of the, the six pack muscle. You press on the edge and you've hit a tender spot. The other one is, I have them do is you can have them do a little sit up, partial sit up and you'll find that exact, it'll be a spot, it'll be that one spot that hurts.

Um, there is this, there is something called a connet sign, which is the other round. You, you lie back and then you lift your leg up, you lift your leg up, which tightens the six pack muscle. And then again, you can find a tender spot. The diagnosis is kind of difficult. Uh, you have to, you, you have to go in there and find that exact tender spot and inject a tiny bit of numbing medicine.

And if it takes away the pain, then you know that that's what it's, and it's kind of hard to do that. 

Dr. Linda Bluestein: You [00:43:00] maybe you were just gonna say what I was gonna say, which is if they're not sensitive to local anesthetics in the typical way, then that's gonna confuse your result as well. 

Dr. Pradeep Chopra: Of course, I mean, yeah. Uh, I mean, you'd have to check with the, with the patients if they're responsive to lidocaine or not.

And most, a lot of the, a DSS do not respond. They're insensitive to lidocaine. I, I generally use, uh, Marcaine or BP Akin uh, nowadays if I am doing any kind of, uh, injection on any IDS patient, I go straight for maring. It's just much better that way. You're not confusing things, but yes, you can inject a local anesthetic like maring or, or Lidocaine, and then you sort of see whether they get relief from it and it has to be pretty significant relief.

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: And sometimes you can repeat it just to be 

Dr. Linda Bluestein: sure. And then what do you do if that test is positive? If you do the, if you do that, and then what do you do? 

Dr. Pradeep Chopra: Um, we've tried everything. They do say in the literature, weight loss and [00:44:00] all kinds of things, but at the end of the day, they need a surgical release.

That's the only thing that I have seen that helps out finding a surgeon to do it is a hard part. 

Dr. Linda Bluestein: I was just gonna say, I bet that's not easy to find a surgeon to do that. 

Dr. Pradeep Chopra: Yeah. Because, you know, I don't blame them because it's kind of hard. Like there are these fine nerves here and where you're gonna identify which nerve and then you release that and it's, it's sort of hard.

Um, so, but yes, and the reason I bring up, uh, acnes or anterior, uh, cutaneous nerve entrapment syndrome is because it's not all that rare. It's not. That's the thing. So easily, if you press on the six at the edge of the six pack muscle, they're very tender there. You do a sit up and you press, it hurts a lot.

You can have them raise their leg and press it hurts and that it has to be a very localized pain. And then of course, um, you can numb it up, but [00:45:00] it works. Then your shorts, 

Dr. Linda Bluestein: acnes, if like with the costochondritis. Now I understand that's an itis. So that's, uh, an inflammatory condition. And there you're using the local anesthetic and steroid.

And here you're talking about using just a local anesthetic, I believe. But is there some, uh, that's diagnostic. It sounds like doing those injections, but is there any therapeutic benefit? Like if you did that a few times, um, you know, with some kind of frequency, would that potentially help with their symptoms as well?

Or it's just for diagnostics? 

Dr. Pradeep Chopra: It's only for diagnostics. Um. I have tried, uh, radiofrequency ablation of that. Oh, really? Cutaneous nerve. Uh, but I have to admit, uh, I've stopped doing it because it's just not that easy to do it. Um, it's very difficult to identify the nerve, you know, if it's against a bony landmark like we do for other issues, then it's fine.

You can, you know where the nerve is, right. But in here, it's kind of floating [00:46:00] around, so we don't, I did it years ago and then I, I wasn't impressed, so I stopped doing it. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: I think it's just trying to release it is, is surgically is the best way to do it. 

Dr. Linda Bluestein: Uh, what about abdominal migraines? Is that something that you see, uh, fairly commonly?

I mean, I, I 

Dr. Pradeep Chopra: have seen some. You know, but you know, when you're, when you're looking at a patient with the EDS, the migraine part, you, when they come and tell you they have abdominal migraines, I kind of leave it to the, uh, neurologist who are already treating them for it. But these patients present with very severe sudden onset abdominal pain.

It's just cramping. And it's usually the cramping is around the belly button area. Um, they have nausea, vomiting. They can alternate between diarrhea and constipation, but they have a headache at the same time. And that's what makes it an abdominal migraine. 

Dr. Linda Bluestein: So do you have to have a headache at the same time?

Dr. Pradeep Chopra: Um, no. Not have to. Uh, but they often have, [00:47:00] and they also have sensitivity to light and sound just like a migraine. 

Dr. Linda Bluestein: Hmm. And 

Dr. Pradeep Chopra: so it's often, that's one of the reasons why they call it abdominal migraine, but the usual migraine medicines don't work for this. That's the thing. So it's more common in children. I haven't seen it in adults, and oftentimes it goes away.

So they'll say, yeah, when I was younger I got diagnosed, but it's gone now. So I don't know if that's, if it's another condition that they grew out of and it's just being labeled as abdominal migraines. But the usual migraine trip, like the Triptans and the CGRP antagonists don't work. 

Dr. Linda Bluestein: And what about CRPS?

Can you get CRPS of the abdomen? 

Dr. Pradeep Chopra: Yes, you can. Um, so CRPS is complex regional pain syndrome. It's a, it's an awfully painful condition. So for the longest time we thought that you can only have CRPS in the limbs. In fact, up until recently it was said that, [00:48:00] um, you can, you know, it happens only in the limbs, uh, the either the arms or the legs.

But we've seen, uh, patient, uh, patients develop CRPS of their abdomen. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: Presents classically as CRPS symptoms. So they have pain to soft touch known as allodynia. Now, they may or may not have color change because one of the diagnostic criteria of CRPS is color difference. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: Which is easy in an extremity, but in the abdomen it's a little more difficult.

And again, there has to be a temperature difference. And so with the temperature difference, um, you know, in the past we, you know, the standard criteria for CRPS, the was the Budapest criteria, right? I mean, it's still the Budapest criteria, but they have now what is called the Valencia consensus. So in the Valencia consensus, they, um, came up and they sort of, um, ironed out a few kinks in the Budapest criteria.

So they said, well, if you have pain in an area where [00:49:00] the temperature can be, or say for example, you have CRPS in both legs. In that case, you measure temperature in a different part of the body, an unaffected part of the body. So for example, if you have it in the CP in the abdomen, you measure the temperature on the abdomen and then say you'd measure it on the forehead.

And, and the, the criteria is there should be a one degree difference. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: In reality, you see like five, 10 degrees difference. Um, but yes, you can have CRPS, uh, of the abdomen. It's a lot like post hepatic neuralgia. They'll come in with their shirts, clothes, not touching them, even the shirt off, and it's very painful to touch.

Dr. Linda Bluestein: And, and if someone has CRPS of the abdomen, does that often? 'cause you know, as, as obviously we know CRPS can travel, so it can start in one extremity and then travel to other parts of the body. Do you know if CRPS of the abdomen more often follow [00:50:00] CRPS of extremities or if it can. Just start in the abdomen itself.

Dr. Pradeep Chopra: So most, most times that I've seen CRPS as the abdomen has been after trauma. Like I had this patient who, uh, developed CPS, they had put EKG leads on his chest and his abdomen and, um, without realizing it, um, they, he was put through an MRI scanner. 

Dr. Linda Bluestein: Oh no. And so 

Dr. Pradeep Chopra: he had all these burn marks. 

Dr. Linda Bluestein: Oh no. 

Dr. Pradeep Chopra: Yeah. He had these burn marks and that resulted in him developing CRPS over there.

So it's usually after a trauma that you'll see this, uh. It's become a lot less now because most of the abdominal surgeries are laparoscopic. So you have a tiny incision, not like in the old days, they would slice the person open, so this lost less nerve damage. But you do still see it. Um, car accidents, especially when the airbag, [00:51:00] uh, explodes and that hits your, if it hits your abdomen, it can cause CRPS symptoms.

Dr. Linda Bluestein: Interesting. And, and what about, uh, bladder problems? What can happen with the bladder that we should be aware of? 

Dr. Pradeep Chopra: Yes, let's talk about bladder pain. Okay. Often diagnosed as inter lumped into interstitial cystitis, and we really don't know why people develop interstitial cystitis. I mean, there are lots of theories, uh, but basically it boils down to inflammation or the lining of the bladder.

That's what it boils down to. Um, some people have even called it fibromyalgia of the bladder and all, all of these things. Um, you know, when a condition has many names, that means none of them are right. Yeah. You know, so, um, the bladder pain, uh, they have inflammation of the bladder, uh, often diagnosed as, 'cause we have to give all our con conditions a fancy [00:52:00] name.

So we call it interstitial cystitis, but the key word here is cystitis, which means inflammation of the bladder. And I've talked to, uh, gynecologists a lot and they've, they all think, and I've said like, you think it can be MCAS and they all think it can be. Um, and. But I haven't been able to convince anyone to put Chromin in the bladder.

Dr. Linda Bluestein: Yeah. I tr I tried to talk to my husband about that. In fact, one of our colleagues from Masterminds, we were having dinner at her house and, uh, she tried to convince my husband that, well, this when my husband was still in clinical practice. And she was like, oh, come on. Just try it. 

Dr. Pradeep Chopra: I tried it. Yeah, 

Dr. Linda Bluestein: you have 

Dr. Pradeep Chopra: tried it.

I mean, you can drink it, right? You can put it in your eyes. Why can't you put it in the bladder? So you have tried it? No. Oh. Oh, I haven't. I've tried convincing the local urologist. They all agree, but the, you know, hospital policies and all sorts of things, but yes. Um, it can cause um, and [00:53:00] so it's very simple to think that, okay, well you're taking chromin, right?

You're, you're drinking chromin, it's a liquid. You drink it and it'll eventually get into the blood and get into the bladder. But here's the problem with coline. It doesn't get absorbed that well. Absorption is not that great, and that's the problem. I don't think a lot of it gets into the bladder. Now, fin might be a different drug that can help, um, but most, most, uh, people who treat interstitial cystitis go on to a kind of a low histamine drug diet to avoid irritation of the bladder.

Or they try to, uh, you know, like one of the thinking is that the bladder is the spasm of the bladder muscle. And so they try to distend it, like they sort of loosen up, uh, it's, uh, muscle. And so they do a, what is called A-D-M-S-O, um, installation. Um, so they [00:54:00] expand the bladder hoping that the muscle will sort of stretch out.

Uh, and I think it does help. But bladder inflammation is common in EDS. And if it's an EDS patient who has obvious signs of M-C-A-S-I, I attribute that to mostly MCAS. 

Dr. Linda Bluestein: Yeah, I, I do too. And I've had some really good results with resolution of bladder symptoms with addressing their MCAS for sure. 

Dr. Pradeep Chopra: Yeah, absolutely.

One of the, we on abdominal wall pain, I just wanna talk about abdominal muscle spasms. Um, it's usually after a trauma, like a surgical trauma, so you might have had a, a hysterectomy or a, um, cesarean section or something where there's been a long incision. Think of the abdomen as a, as a bag with muscles all around it.

Bag is made up of muscles. And so some of these muscles, when they're sliced open and then they heal up, they don't heat up that well. And there's localized spasms of these muscles. [00:55:00] And oftentimes, and I, most of the time I've seen it in the lower abdomen. It'll be after inin hernia surgery opening, inguinal hernia surgery, or a hysterectomy or cesarean section.

And again, it's the same thing. You have them do a little sit up and you press on that muscle. You can literally feel muscle knots there. In the old days, I used to inject, do lidocaine injections, uh, numbing medicine injections, like trigger point injections. But now I, uh, I, I just skip that step and I go straight for Botox.

Oh. And it does help. Oh, interesting. It does help. 'cause it's not inflammatory, it's just clear muscle spasm. So I might do a few trigger point injections with, uh, an an local anesthetic numbing medicine, and if they have a decent response, then I go on Botox injections for these muscle spasms. So yes, patients with abdominal pain can have.

Outside the abdomen pain and they can have [00:56:00] inside the abdomen pain. 

Dr. Linda Bluestein: Okay. And I wanna make sure that, uh, before we wrap up, I, I feel like there's a couple of things that I wanted to touch on that we haven't hit yet. So if I can tell you what those are and then you can pick which one we do first. Um, I think you and I had talked a little bit about rectal evacuation disorders, food intolerances, which we've kind of touched on MCAS of course, but we haven't really talked more specifically about, about maybe some of those that we might want to talk about.

Pelvic floor dysfunction, endometriosis, ovarian cysts, or torsion and dyspareunia related pain. This is the list that, you know, you and I had talked about that you had given me before we started. So, um, are there some of those that we can try to touch on in the last few minutes here? 

Dr. Pradeep Chopra: Sure. Um, just before we go onto that, I just wanna say that endometriosis is very, very, very common in ds.

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: And. Uh, that's one thing. So, you know, if you are having pelvic pain, you think of don't miss out on endometriosis, which is pretty standard. When you're, when you have your cycle, the pain gets, uh, [00:57:00] extraordinarily worse. That's one thing to look at. Um, rectal dysfunction is, um, when patients are trying to have a bowel movement and they can't empty it completely, so they ha they have pain and they have difficulty emptying it completely.

They might do partially, but not all of it. And, um, it can be for different reasons. Uh, we don't really quite know. Uh, it could be because of the pelvic floor muscles being weak. Mm-hmm. Um, or they could be, like I said, remember the sigmoid colon getting loaded and then it kind of flips over. Mm-hmm. And that can cause some of this.

Um, and just chronic constipation, um, can cause rectory dysfunction. Uh, they. Figure this out by doing a manometry. So they put a balloon in there and they look at the pressure, and that's how they figure it out. Vaginal pain, uh, in EDS is actually very common. Um, and the [00:58:00] thing is a lot of, uh, women are, don't really wanna talk about it.

Um, they don't, they want don't bring it up. And so I sometimes bring it up again. It's a lot of, it's, I think it's related to MAS, uh, like everything else, the lining of the vagina is, is a, is a lining and it gets inflamed. And so that causes, um, pretty, it causes inflammation of the vaginal lining. Um, it can also come from, uh, pelvic floor dysfunction.

And, and I think that pelvic floor dysfunction is, you know, the pelvis is like a ring, right? Mm-hmm. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Pradeep Chopra: And the pelvic floor is a, is a little floor on the bottom of this rink. If the ring is not, is not steady, then the pelvic floor is being stretched and that can cause pelvic floor spasm and uh, vaginal pain.

So these are some other [00:59:00] reasons. Uh, there are a lot of, a lot of other reasons also that can cause, like recurrent urinary tract infections that can cause pain in these patients. And that's usually when that happens, I think of tethered cord syndrome, uh, because the sphincter to the, to the urethra is not closing properly and now you have organisms going up the wrong way.

Uh, but it can be for other reasons to look at. Um, sometimes bladder, inter interstitial cystitis or bladder inflammation can get mis uh, misdiagnosed, uh, as a urinary recurrent urinary tract infections. 

Dr. Linda Bluestein: Oh my gosh, lots of, lots and lots of reasons. I, I had a period when I was in residency where I had these horrible episodes of abdominal pain and then in between you would be relatively, uh, fine, but they were trying to work me up for all kinds of different things, including porphyria.

Um, which, you know, all the testing for that [01:00:00] came out negative. And fortunately, now knock on wood, like I don't have this, uh, problem anymore. But, uh, this was such a great conversation because I feel like so many people, well, that it's like with me, right? I was told if I don't see something structural, therefore the only thing that I can possibly think of that could be going on with you as visceral hypersensitivity.

And we just went through this exhaustive list of all kinds of other things that can be contributing to abdominal pain, bloating, constipation, diarrhea, like all kinds of GI symptoms. And so this was such a great conversation. I really appreciate you taking the time to. Go through all of this and tell us all of these things that we should be thinking about.

Thank you. 

Dr. Pradeep Chopra: That's great. There must be at least another dozen conditions, not quite related to EDS that can cause abdominal pain. So people with EDS can have non EDS pain conditions as well as EDS related pain conditions. 

Dr. Linda Bluestein: Right. No, that's a good point. Do you want to rattle some of those off right now so that people just because, because [01:01:00] otherwise people are gonna, I think, email me and they're gonna be like, wait, that was a, that was a cliffhanger.

You know, he said that there are a dis 

Dr. Pradeep Chopra: Okay, so you can have ovarian cyst or ovarian torsion that can do it. Yep. Um, pelvic floor dysfunction, we talked about that. Vous um, or interception. So VOUS is when a part of the intestine does kind of twists on itself. So what happens is the blood flow is restricted, so it becomes really painful.

Interception is when they go into each other. Um, so one of the things I wanted say was, you know. People who have a continuous abdominal pain, it's easier to diagnose than like, you had it came and then it went away. So by the time you get to the doctor's office, there's no pain. And so it's hard to figure out what's causing it.

But if you go in there with actual pain, then you can sort of figure out what's going on. So I suspect some of these people might have vous, [01:02:00] um, that twist and then an untwist. Um, and then you have the, uh, interception. Um, MCAS is a really big reason for GI pain. I just want to, uh, food intolerances. That's a whole, that's like five podcast talk, uh, food intolerances.

Uh, why people with gia, with EDS have food intolerances. We are not sure, but there's lots of food intolerances that can cause this. Um. Then you have, uh, visceral and the neuronal crosstalk that can do it. Um, rupture of the uterus, especially in pregnancies. Uh, uterine rupture. Um, I haven't seen it. I haven't even heard of it, but it's something to keep in mind.

Uh, retroperitoneal hematoma. So blood, um, just blood, like a blood vessel will break in the back of the abdomen and so it causes collection of blood [01:03:00] over there. Metric ischemia or dissection can cause it. So, so there's a part of the intestine that has a, like a flap. Let's just say there's a flap and there's blood vessels in it and some, sometimes that the blood vessels, that's how they travel to the intestine through this flap.

So you have a flap at the end intestine and so blood travels.

And sometimes these blood vessels can get either kinked or blocked or they can just rupture and so there's no blood flow to the intestine. And so they have abdominal pain. Um, then, um, and hernias, um, hernias are hernias. Hernias of course is, you know, there's a weakness in the abdominal wall and the contents of your intestine, your abdomen are poking through it.

Um, if you don't fix it in time, then it can get in, it can get, um, [01:04:00] uh, it can be food can get stuck in it or it can twist on itself. Um, so that's another reason. Get incarcerated. 

Dr. Linda Bluestein: Yeah, 

Dr. Pradeep Chopra: incarcerated. Uh, really, I don't, we haven't, I haven't seen that lately because people are, doctors are pretty good at diagnosing hernias and catching it early on, but it can happen.

Uh, these are some of the. Outliers of go pain and EDS, 

Dr. Linda Bluestein: and we know hernias are more common in EDS, so some of these things, yeah, they're common in regular people, but they also, some of them occur more commonly with, with, uh, connective tissue disorders. 

Dr. Pradeep Chopra: Recurrent hernias is in the diagnostic criteria for hypermobile EDS.

Right. Exactly. Yeah. 

Dr. Linda Bluestein: Well, very good. Well, thank you so much. I was taking notes as we were talking, and I'm gonna recommend about eight other episodes that people are gonna wanna listen to based on, based on this conversation, you know, because they're gonna be like, wait, I want more information about X, Y, Z, you know, so they're gonna wanna check out [01:05:00] the two episodes that, uh, that we did with Dr.

Theo, her, where you, you were the guest. Host for the second one with Dr. Theo Haes, and I've interviewed Dr. Irwin Goldstein and Dr. Andrew Goldstein about, uh, perineal issues, pelvic problems, Dr. Kelly Casper about urologic problems including interstitial cystitis. Um, I interviewed Dr. Zach Spiritos, who's a neuro gastroenterologist about gastrointestinal problems.

So people wanna check that out. And then the last one I wanted to mention is the episode with Dr. Adam Hanson, where we talked about slipping rib syndrome. So we'll link all of those in the show notes as well. But anyway, so this has been such a great conversation and I'm so grateful to you for taking the time again to, uh, to chat with me and, and teach us so many wonderful things that, uh, all of us should know about for EDS and HSD and this, you know, complication that we might experience and, you know, can be easily missed.

Dr. Pradeep Chopra: Thank you for [01:06:00] having me on. It's a pleasure.

Dr. Linda Bluestein: Well, I'm so grateful for Dr. Pradeep Chopra coming on the Bendy Potties podcast once again to share his infinite knowledge with us. It was so great to talk about this part two of Gastrointestinal Problems, and I hope that you'll also check out the other episodes mentioned during this conversation. I had a great conversation with Dr.

Zach Spiritos, two conversations with Dr. Theo Es and so many others that we will link in the show notes that I definitely urge you to check out so you can take an even deeper dive. And thank you so much for listening to this week's episode of the Bendy Bodies. With the Hypermobility MD podcast, you can help us spread the word about joint hypermobility and related disorders by leaving a review and sharing the podcast.

This really helps raise awareness about these complex conditions. Did you also know that I offer one-on-one support for both clients and healthcare professionals? Whether you're living with hypermobility or caring for someone who is, I've got your [01:07:00] back. Check out my coaching and mentorship options on the services page of my website@hypermobilitymd.com.

You can also find me Dr. Linda Bluestein on Instagram, Facebook, TikTok, Twitter, or LinkedIn At Hypermobility MD you can find human content, my producing team at Human Content Pods on TikTok and Instagram. You can also find full video episodes of every week on YouTube at Bendy Bodies Podcast. A quick note, while I'm so glad that you're enjoying the Bendy Bodies podcast and we love bringing on guests with unique perspectives to share, however, these unscripted discussions do not reflect the views or opinions held by me or the Bendy Bodies team.

Although we may share healthcare perspectives on the podcast, no statements shared on bendy bodies should be considered medical advice. Please always consult a qualified healthcare provider for your own care to learn about the Bendy Bodies program, disclaimer and ethics policy submission, verification licensing terms and HIPAA release terms, or reach out with any questions.

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