Why Do Some GI Problems Hide from Every Test? (Ep 153)

Transcripts are auto-generated and may contain errors

Dr. Zachary Spiritos: [00:00:00] I don't empirically put people on a gluten-free diet, although I'm hearing more and more that like maybe I should, you don't wanna overly restrict people when there's not a lot of data to support that. It, it helps a lot of folks, like it certainly helps some people, but not everybody. So that's where I think keeping a very detailed symptom diary is really helpful, along with like a food diary to understand what your triggers are.

Dr. Linda Bluestein: Welcome back every bendy body to the Bendy Bodies podcast with your host and founder, Dr. Linda Bluestein, the Hypermobility md. Today we'll be talking with Dr. Zachary Spiritos, who is a neuro gastroenterologist. I'm really excited about this conversation because I have had lifelong gastrointestinal problems.

Now, I have not really been having any recently, knock on wood, but when I was a child, I had lots of problems, [00:01:00] and when I was in my residency at the Mayo Clinic, I would get such severe episodic abdominal pain. They were working me up for all kinds of bizarre things, including porphyria. Later, of course, I had an irritable bowel diagnosis, and after I had my two children, my lower esophageal sphincter just decided to give way one day, and I started having horrible, horrible reflux and ended up having a surgery called Aisin fundoplication, and that's where they wrap the.

The top part of your stomach, around the bottom part of your esophagus so that you don't get that reflux anymore. So my NIS and fundoplication has opened a little bit, uh, because I, I've vomited a number of times. But anyway, this is about you, not me, but I just wanted to share that I've had lots and lots of GI issues as well.

So, Dr. Zachary Spiritos is a neuro gastroenterologist and founder of Ever Better Medicine, a specialty clinic focusing on treating complex digestive conditions, DYS adenoma, including pots and mast cell activation syndrome. He trained at Duke for [00:02:00] gastroenterology and now works with patients who often have overlapping conditions such as disorders of the.

Brain gut interaction. EDS MCAS and Dysautonomia, his approach combines conventional care with a strong focus on lifestyle, nutrition, and patient education. I'm so excited to have this conversation because I know that you are so likely to have gastrointestinal concerns. This is such a common thing that I see in my practice, so I think this is gonna be a really important episode.

As always, this information is for educational purposes only, and it's not a substitute for personalized medical advice. Stick around until the very end so you don't miss any of our special hypermobility hacks. Here we go.

Okay. I am here with Dr. Zach Spiritos. Did I pronounce that right? I should have asked you before we started. You nailed it. Okay. It's good. It's a coin 

Dr. Zachary Spiritos: toss whether people get it right, but you got it. 

Dr. Linda Bluestein: Okay. Okay. I have to tell you, we got over 200 questions. When I asked on Instagram what people wanted to know from you, I could not believe [00:03:00] it.

I was blown away by the number of questions that I got. And so we have a lot to cover today. In fact, I wanna tell you some of the things that, just to give you like a little bit of a heads up, okay. We're gonna talk about motility dumping syndrome, gastroparesis, which of course is a motility problem. Uh, sibo, visceral hypersensitivity, leaky gut gluten intolerance, pots, visceral ptosis compression syndromes, micro microbiome problems, malabsorption, um, inflammatory bowel disease, pelvic floor dysfunction, and of course, like, you know, treatment and diagnosis.

We're not gonna get to all of this, obviously, but I'm just trying to give you like the big is that. Yeah, I'm trying to give you the big picture of like what people asked about. So tons and tons of questions. Um, of course lots of questions on medications and diet and all kinds of things, but I have to tell you the really funny thing first before, before we even launch into this, somebody actually put in the questions this year, A real doctor, he's too photogenic and great in front of the camera.

Seems suss.[00:04:00] 

Dr. Zachary Spiritos: Oh boy. Alright. 

Dr. Linda Bluestein: So I just had to mention that, I mean, these 

Dr. Zachary Spiritos: degrees you can get from Kinko's. Like you can really just like, you can do, you can do amazing things in Photoshop. So 

Dr. Linda Bluestein: Photoshop. Exactly. Exactly. So, um, so yeah, so this is gonna be such a great conversation. I know you've been doing such fabulous work in social media, really trying to raise awareness, which is really, really wonderful 'cause we know that so many people are getting gaslit and they're just not getting the care that they need.

So this is so important. So thank you so much for, for joining me today. 

Dr. Zachary Spiritos: I'm such a big fan of yours that this is like, you know, I just started the social media journey like last year and I've been listening to you for, I mean, this is how I started to learn about hypermobility when I saw it in a clinical, this is like, you provide such great, you know, I guess, um, digestible information about how these patients present and talk about the challenges that they face and how to deal with them and kind of hooking me up with other experts in the field so I can reach out to [00:05:00] them.

I think I told you about Dr. Hanson before the slipping rib patient and just you've helped me make sense of this patient population that is now my entire clinic. And so I really, you've been my mentor from afar, even though you have no idea who I was until a couple weeks ago. So it's, uh, I'm grateful for you and I'm happy to be here.

Dr. Linda Bluestein: Oh, well thank you. That's, that's great. I mean, that's the whole goal is to have as many, you know, patients of course, um, you know, get as much information as they need. But also I love hearing from physicians that have stories like that because I. You obviously are helping a lot of patients. So it's, it has such a, a bigger, you know, butterfly effect, uh, when we can, you know, really help with, uh, physician education like that.

So, so how did you get interested in this population of people? 

Dr. Zachary Spiritos: Well, I, uh, I'm a neuro gastroenterologist by training, so I went to Duke, um, and early on in my attending career, so I've been out of TR fellowship training for about five years. 

Mm-hmm. 

I, um, I did, I did a lot of d GBIs, which are disorders of the brain gut interaction, so IBS gastroparesis, functional dyspepsia, [00:06:00] visceral hypersensitivity, pelvic floor dysfunction.

And then as I kind of grew my practice, I realized I was inheriting a lot of patients with this auto autonomia and, and hypermobility, but I didn't know a lot about it. This is a couple years ago. And then I would kind of, we'd work on the bowel issues and their GI sensations and all of that, but then they still, and we were making progress there, but then people.

Still couldn't stand up. They'd be, and they'd have all these complaints that I couldn't, I couldn't figure out, and their PCPs didn't have any I idea either. So I just started to look things up and, you know, I'd try to send patients to the local POTS cardiologist, but he was booked out for centuries, and that's at UNC and the Duke cardiologist booked out Century.

So I'm pretty savvy at cardiology. You know, I, I went to a residency program with Dr. Cuttin, who's, who's amazing. Um, and at Emory, and they train me to be effectively a defacto cardiologist. I was like, I can do this. And so I read and I read and I read, and I spoke to a lot of people and I have amazing mentors in the field.

[00:07:00] And so I started to treat dysautonomia. And in that I started to acknowledge a lot of the challenges that people with, um, hypermobility face as well. So I've, I diagnosed a cult tethered cord and cranio cervical instability and slipping rib. And obviously there's the malls and the, you know, vascular compression.

So once you start learning about these things, these patients start to make a lot more sense. And then mm-hmm you start introducing yourself to the, the wild world of MCAS. 'cause that, you know, plays a, a big factor in all this, this pathophysiology. So that just adds another, adds another wrinkle to everything.

But, um, so it's been a, a learning process and it was just a natural progression of I think my neuro gastroenterology, um, uh, kind of path in the patients that I see. 

Dr. Linda Bluestein: Yeah, and that's so fascinating because I think, you know, maybe we have heard about the connection between the nervous system and the digestive system, but it sounds like it's much more extensive than most of us realize.

And treating the gut requires often more than just medications. [00:08:00] 

Dr. Zachary Spiritos: Absolutely, absolutely. Especially, you know, there's, when patients come to clinic, uh, with a whatever GI problem, and you know, the first kind of the, the kind of the, the, the price of admission is, is usually an endoscopy or imaging of some sort.

And when all the tests come back normal and the hardware stuff is normal, so there's no cancer or Crohn's disease, or peptic ulcer disease or h pylori, then you enter the neuro GI world. And that's where, you know, there is some disconnect between how the gut, the immune system and the brain are, are communicating.

So, you know, our gut sends signals to our brain, our spinal cord, and then the BA brain receives those signals and then propagates signals back to our gut informing how to, how it moves. And so if there's any disruption there, you can have not only disturbed sensation, like heightened pain, but also altered motility as well.

Hmm. 

So you gotta connect, you gotta, you know, get a focus on the gut essential nervous system. There's a lot of different ways to do that. Um, but it can be [00:09:00] tricky. 

Dr. Linda Bluestein: Yeah. Oh, definitely, definitely. And so let's start by talking about this population of people. Like you said, you already mentioned dysautonomia and one of the, you know, uh, types of dysautonomia of course is POTS or postural orthostatic tachycardia syndrome.

And we know that, um, you know, people with EDS, like you said, often have mast cell activation, mast cell activation disorders, or mast cell activation syndrome, sometimes mastocytosis even. So, so let's talk about what are some of the most common gastrointestinal problems that this population faces? And, you know, I'm sure we could talk about this for like, you know, 20 hours or, or more.

So, uh, if you could give us kind of a rundown of some of the most common things that you see. 

Dr. Zachary Spiritos: Yeah. Uh, slow motility and pain for sure. Um, I kind of kept it broad because there's so many different ways in which this can play out, but, uh, I think we could start, start with the slow motility first. Okay. So.

With this auto autonoma, right. It's not, it's a, it's an imbalance in your, [00:10:00] in your parasympathetic and your sympathetic nervous systems. Mm-hmm. And so you're more driven towards the sympathetic line of things, and your parasympathetic is a little bit more dampened, um, for a variety of reasons. And when we're in sympathetic, when we're, you know, our parasympathetic nervous system is rest and digest, it, it, it helps your stomach squeeze and your sphincters relax.

And to push that food distally to where it ultimately reaches the rectum. And then your anal sphincter relaxes and you can defecate. But when you're in, you're in kind of more in that sympathetic kind of drive. It just, things don't move as well. And so you can develop slow motility. So gastroparesis what some proximally ineffective esophageal motility of the esophagus.

So when studies, we can often see the esophagus doesn't as well. Gastroparesis, um, uh, small bowel dysmotility, which we have a tough time measuring. Um, there's certainly tools to do so, but I don't do that in my practice. And then, you know, a clo inertia, we're slow moving colon. Um, and there's def dysfunctions, which [00:11:00] is kind of a different animal altogether, but pelvic floor dysfunction, which we often see in, in hypermobility.

Um, and then pain. And so when we talk about dysautonomia, right, we, oh, let me talk really quickly about the hypermobility folks. So they also have a, a relative neuropathy as well. Um, I'm not quite sure why it happens. Maybe I could pick your brain about that and how I make sense of it is this the kind of the disrupted collagen in turn, you know, you get more lax tissue and that disrupt the endings, but you get this relative neuropathy, so they also are suffering from a, even if.

Full on pots. 

Mm-hmm. 

Um, and then let's talk about pain. Okay. So when we talk about dysautonomia, right? So the vagus nerve conveys our parasympathetic afer and efferent nerves. So our afer nerves take signals from the gut to the central nervous system. And efer nerves take signals from our brain to our intestines.

And so there's not only issues with movement, right? So where [00:12:00] the brain sends efferent signals to the gut in terms of how to move, but also the afferent signals are perturbed as well. So there's a disruption in pain signaling. So you have intense nociception, so more pain than you should, which we often cause visceral, we call hypersensitivity.

So in gastropare, right, they get a lot of, they sometimes get a lot of pain. That pain is unique in the sense that you can give them pro motility agents, agents that help the stomach move and squeeze. And that should make their pain better, but it doesn't. So you give these patients pro motility agents, right?

You can document that the stomach is squeezing better on imaging, but their pain is still there, right? So it's more nuanced than just getting things to move. There's also a pain sensory disorder as well. You also have to be aware of everything else that can uniquely affect this, this patient population.

So MCAS can cause a lot of GI pain as well. So you have to tease out whether there's a mast cell disorder at play because those mast cells really can hypers, sensitize those, these nerves. So they can, when they, they live in the GI tract as well [00:13:00] as like everywhere else in the fricking body. And they release not only histamine, which can sensitize nerves, but TNF, so pro-inflammatory markers that can cause local inflammation and really sensitize those nerves.

Um, so that can cause pain. And then, you know, so the patients who have, you know, pain with gastroparesis, you're like, well, do they also have mals? That's also, you get postprandial pain. So you just have to be aware of these things. All these conditions, you know, have different. Um, ways in which they present.

So there's certain questions that you can use to tease it out, but really it's, you know, a little bit's trial and error. You know, we try certain things. We obtain some diagnostic, uh, data points, and then we touch base, you know, like every week I touch base with patients every seven to 10 days to be like, is this working?

'cause that's also informative in terms of what the, the underlying pathophysiology may be. I know that was pretty longwinded, but hopefully that was, 

Dr. Linda Bluestein: and it's a good a way to kind of, you know, think about things in a, um. You know, putting them into kinda some bigger buckets if, if you will. And so I [00:14:00] really, I really like that.

So that's, so that's really interesting. The visceral hypersensitivity problem. I, I was scoped and, you know, I've had a lot of GI problems throughout my life, knock on wood. Not, not now. Um, but I have had in the past, and I think it's really tough when you get told, well, you have visceral hypersensitivity.

'cause a lot of us, you know, we, we gaslight ourselves as well as other people gaslighting us. And we, even if it's explained to us that no, this is a real phenomenon, you know, we tend to think, oh, it's, I'm just not strong enough or I'm just not able to cope with this adequately. So I feel like there's a lot of misunderstanding around that and that it's very challenging for people to deal with that as a diagnosis.

I feel like there's certain diagnoses that are a lot easier for people to accept and wrap their heads around and, and maybe part of it is because it's easier for their families and, you know, if they go to another physician and they say, oh, well I have. You know, this particular thing that can be, that can be measured that, um, they tend to get more respect for that.

Dr. Zachary Spiritos: Yeah. I mean, we could measure it if we did functional [00:15:00] MRIs, like, you can really pick this up on, we don't do them because they cost an arm and a leg and they don't really change treatments. But, you know, it's, it is really challenging. And then I think it's compounded when I think a lot of providers don't know how to explain it.

Mm-hmm. And so they're like, it's, you know, if you just, you know, just take a load off just stre, just destress a little bit. Right. And that's problematic for a couple reasons. One, it oversimplifies the problem because, and it just, it is, and it's, it's multifactorial. Just if you do, I'm a big fan of diaphragmatic breathing, but it won't solve all of these issues.

Mm-hmm. Um, and then also puts the onus on the patient like, you're doing something wrong. Mm-hmm. Like, if you, you're too stressed out, you're doing something, you just, you, you aren't in tune with yourself. Fix it and all this will get better. And it's like, I think it's very misleading and inappropriately puts a lot of blame on the patient, which is not great.

Dr. Linda Bluestein: A lot of people who have, uh, gastrointestinal problems in this population. They've been to a gastroenterologist, they've done probably some labs, they do celiac testing and a maybe a variety of different things. And then, like you said, the, the ticket to [00:16:00] admission is, is an upper endoscopy and or a lower endoscopy depending on where your symptoms are.

Right. So, um, what is your approach though? 'cause I imagine that your approach is quite different to, uh, working people up. 

Dr. Zachary Spiritos: Yeah, I mean, it starts with the interview, right? Mm-hmm. Like I, I always have to start with when did things begin? Um, and it really is informative. Like was it a huge GI bug, right? Was it an infection?

Like post viral, post COVID IBS is very, very real. Was it puberty? And then you developed right. Was pregnancy and post. Postpartum s and so mm-hmm. I think that's really helpful in terms of putting this all together because our data tests aren't perfect and so the clinical history inform of a lot of where I'm gonna go.

And then, you know, I think understanding like your biggest symptom is really helpful. Um, because that really tells me like what organ system we we're gonna start with. Um, I also gotta make sure you're pooping well because a lot of people have a lot of issues and constipation is really challenging. It really is.

And people come to me and they're [00:17:00] like, I think I'm dying. I think I have cancer. And we just realized they a huge stool burden. I don't mean just like when you're not, when it can really be quite painful, so. 

Mm-hmm. 

Um. Yeah, no, it's tricky. But I definitely, I spend a lot of time with patients, um, and getting understand, like the, understand the cadence of everything.

What makes things worse, what things, what, what makes things better. We talk about stress and sleep and your job and your relationships and your diet and your medications and all the symptoms, right? You have to do the whole review of systems, right? Mm-hmm. To really understand, you know, if MCA is at play, if hypermobility is at play and then you do the physical exam, right?

And you do the biting soer, but also don't really love the biting score. And yeah, I've made some posts about that because I've had so many patients where I'm like, clearly your hypermobile, but their biting score is like underwhelming, right? And they're like, their skin is like, you know, heat, like up the fear and then they have MALS and they have THO syndrome.

I don't. 

Dr. Linda Bluestein: Right. Right. And I, and I do wanna just quickly interject, mals median, [00:18:00] arcuate ligament syndrome for that is one of the compression syndromes. And we'll get into that more in just a little bit. So, okay. So you're, you're starting with a very, sorry. No, no, no, that's okay. I just like to make sure that, you know, people, people who are not familiar with, uh, certain terms that we, that we define them.

So it's really important. This, uh, who was it, was it Osler who said, listen to the patient. They're telling you the diagnosis. And I feel like now this is such a huge problem, especially like in cardiology, right? That, you know, we, I'm a lot older than you are, so like, when I. Was going through my, you know, medical school and residency and everything.

And I, as an anesthesiologist, you know, you spend three months in cardiology in your intern year. And so, you know, you're taught all these things about, you know, how to determine what's causing this murmur. Right. But now you're just like, oh, there's a murmur, I'm gonna get an echo. So it's just, you know, the, the art of the physical exam even I feel like is, uh, you know, just not what it used to be.

Dr. Zachary Spiritos: Absolutely. Absolutely. Yeah. We, we've, we've come to stop trusting patients. Because I think we were taught a certain way, and you know, my [00:19:00] textbook, there's, you know, in GI there's dozens of pages on Crohn's disease and Peptic Ulcer disease and irritable bowel syndrome is given two pages. But it's infinitely more complex than all of those other pathophysiologies.

We just don't, we have a tough time understanding it. 

Mm-hmm. And 

so when someone comes to you similarly with like MCAS or hypermobility, which goodness, there are diagnoses there that I hadn't heard about until I started reading about them. Like Credo Cervical Instability was not on my board exams. 

Dr. Linda Bluestein: No.

Tether cord was a new 

Dr. Zachary Spiritos: diagnosis to me. Right. And so if people come to you with challenges and symptoms that don't fit within your paradigm of what you understand about medicine, then oftentimes it's dismissed. Like this doesn't exist, or it's stress or it's anxiety. And people stop becoming curious about why people's symptoms are what they are.

And they blame it on anxiety 'cause it's, they just, they're not taking the next step. And it's, um, really challenging for patients. And so we, people started to just not trust patients. And it's, again, as you've mentioned, they'll tell you the story, they'll tell you what's going on. You just have to listen. 

Dr. Linda Bluestein: I think as our labs and imaging have become, you know, more and more [00:20:00] sophisticated, so many people think if it's not showing up in the labs and it's not showing up in the imaging, then therefore it does not exist.

Which we know there's lots of things that don't show up on, you know, I mean, I, I've had people say to me so many times, I had every lab test known to mankind, like ev everything, they tested for everything. And then I look at what they tested for and it's like, there's just, obviously there's like an infinite number of tests almost.

So it's like, you know, we should, we should always be saying. You know, the tests that we ran didn't come up with anything conclusive, but we'll keep looking. And I, and I wish that more people were in a position that they, that they could do that. Um, so I wanna talk more about these, uh, motility problems because I feel like this is such a common problem that a lot of people face.

And, you know, you see a lot of people who end up on, you know, uh, eventually they might end up on tube feeds and things like this, and it's, and it's, or TPN even, um, you know, peripheral nutrition. And that's often, you know. Because they started with [00:21:00] kind of a motility problem. And obviously that's a tragic outcome.

You can end up with all kinds of, you know, you can get sepsis and clots forming on the line and things like that. So, you know, we really wanna try to use the gut right. As much as we possibly can. And so can you run us through, like, within the category of motility? Um, maybe I start with slow motility.

'cause obviously there's also the opposite, although it sounds like that's less, less common. But, you know, how do you kind of distill that out and what kind of things actually can be done for that? 

Dr. Zachary Spiritos: Yeah, so, you know, I think the most common thing that I see is, is gastroparesis. 

Mm-hmm. 

Right? And it's really, it's really tricky.

Um, and, you know, we, it's a very elegant pathophysiology, but we just have very elementary tools that we have. We just, we don't get it right. And so, you know, it always starts with, you know, you gotta understand the diagnosis first. So is it gastroparesis? Are, they're not eating because of SMA syndrome, which is, um, superior, uh, mesenteric artery syndrome, where the fat pad [00:22:00] is lost between the aortic aorta and the SM a clamping, the duodenum, do they have media ar ligament syndrome making it really challenging to eat?

Do they have IBS and central sensitization where it's really, it, it hurts to eat? But if we're focusing more on, okay, they have slow motility, they have gastroparesis, like what do we do? So we start with diet first, and that's kind of the, the ground floor of, of, of where we start. And it moves the needle for a lot of people, but for more severe cases, it's, it's not doing a whole heck of a lot.

And they've tried everything, but we talk about, you know, um, kind of small frequent meals, um, trying to introduce fiber that is kind of blended up, seeded deep healed, not any of that kind of hard soluble fibers. Um, la you know, low, you know, um, less seeds, less nuts, kind of a blenderized diet. Right? Our stomach is, is a, is a, is a blender more or less.

And if our, if the blenders, um, uh. Spiral. What am word am I looking for? What turns up the food, like the blade is dull. The, like, [00:23:00] the blade. I've never used that analogy before, so now I'm just, I was like, I jumped into that one head first. I, when the blade is a little bit dull, right. And gastroparesis, you just have to do it a favor, right?

So if you wanna eat carrots, you blend it up. If you wanna eat apples, blend it up, take the skin off. Um, so I work kind of hand in hand with the dietician there, not only to identify what you should and should eat, but also calorie counting to make sure that we, you're getting enough, enough food and we don't have to go to parental nutrition with tpn.

Mm-hmm. Um, and let's talk about, you know, medications, right? So there's a, this is tough. Um, so we use pro motility agents kind of very apprehensively because they're not great and they have some side effects. Mm-hmm. So reglan is the most notable one. Um, and it really just helps the move the food move. But studies show that it doesn't work very well.

It just doesn't. So it works mechanistically, but it doesn't help with patient patient symptoms. But if you do regularly with diet. It does, it does move the needle. If you use Reglan diet and a neuromodulator, it even helps a little bit more. So the [00:24:00] neuromodulator is for the pain element of it. 

Hmm. Okay. 

So, um, you can use, you know, amitriptyline at no low doses, nortriptyline at no doses.

Um, and what they do is that works at the level of spinal cord to help, um, tune out some of these pain inappropriate pain signaling from the gut. Um, but you have to be careful there because it also can slow down motility in the colon, and if you have dysautonomia, it can lead to more orthostasis. So you're balancing all these things, but fortunately you can get away with like low doses.

Um, you can use, you know. Spar, which helps with gastric accommodation. Um, you can use Cymbalta kind of less commonly, but, um, Cymbalta also can worsen pots in some regards 'cause it increases your norepinephrine at the, at the synaptic terminal. So it, you just have to, there's a balance there. Um. Mm-hmm. Uh, and then, you know, to go back to pro motil agents, you know, you can use erythromycin mm-hmm.

Which is an antibiotic that help, that increases your motilin, which is, you know, it's usually stimulated by M cells. Um, and so, but [00:25:00] that has tachyphylaxis and that kind of doesn't work in a couple months and has QTC prolongation. So you're kind of, but I, I usually blend a pro motility agent. Um, you can also use, um, PCAL Pride oeg, which works not only proximally but distally as well.

And in these dysautonomia patients where you're generally dealing with kind of global dismotility, it's, it's not a bad agent. And it's, it's now available on GoodRx for a reasonable price because it is kind of a pain to get. Yeah, so I use, I mogra is a good one. Low side effects, hits the serotonin receptors in your gut.

Um, and then I'll use kind of a, a neuromodulator as well to help with the pain too. But everybody's different. Some people don't wanna take pain medications, right? And so mm-hmm. How can you help with the, the, the pain nociception centrally? And you can also use hypnosis. Like hypnosis has pretty good data for it.

You can use cognitive behavioral therapy if you have a lot of kind of thoughts around like if, uh, a lot of kind of cata uh, catastrophic thoughts about what, what's gonna happen. Like if I eat this, I'm gonna have pain all day. And GBT kind of enables you to challenge those thoughts to understand whether they're real or not.

[00:26:00] Um, and then there's like functional dyspepsia, which is kind of a, a cousin of gastroparesis where actually the stomach is moving okay, but you have a lot of pain and that's kind of a different conversation. But generally speaking, we talk about diet. I use some pro motility agent if we need to compliment it with some, um, some agent to help with central pain processing.

And then we always talk about sleep. Stress, stress, getting outside relationships, exercise. And I recognize there are, you know, not everybody can get outside. Not everybody can work out and sleep well. Mm-hmm. But we tackle all these things. 'cause it does, it all blends together. Right. And I always tell patients that like, this is really tricky and I'm not you, when I see in a couple weeks, we're not gonna be a hundred percent better, but I'm looking for like 10%, right?

Mm-hmm. And we're gonna be working together for a long time to understand your body and what works for you. And so it's, um, it's a dance and we, we, we work hard, we work at it together. Oh, another gastroparesis tip, you gotta poop everything. A [00:27:00] gastroparesis is worse when you can't poop. So if there's a backup on 95, right?

You gotta fix where the flames and the car crash is first. And then everything doesn't always rectify itself altogether, but it gets better. So you gotta get people pooping, but you're dealing with the same issues. Like, why aren't you pooping? Like people wanna poop. Like, it's not just like, oh, go poop.

It's, you have to get into that too. So it's, um, it is still, it's a, it's still a tube. It's an elegant tube, it's still a tube. And you gotta block the distal. You gotta address the distal blockage first before you can confront anything proximately. Okay. But that's how we think about gastroparesis. 

Dr. Linda Bluestein: Okay.

That's a super helpful tip. And what I find, uh, happening very, very commonly with my patients, and maybe because, you know, my p practice is much more focused on pain on the whole, and you're obviously a neuro gastroenterologist, so you're focused on more the GI aspect of course. But what I find is people don't necessarily bring up to me about how often they're pooping.

So I have to ask them specifically. And then sometimes they'll be like, oh yeah, once a week. I'm like, [00:28:00] once a week. That's, that's not okay. Um, so, and, and I actually have, but they have so many 

Dr. Zachary Spiritos: other bigger things to talk to you about. Right? Exactly. 

Dr. Linda Bluestein: Exactly. And so it's 

Dr. Zachary Spiritos: like that's, that's it gets lost in the shuffle.

Yeah. Yeah. I wanna say make sure a patients have.

You know, before saying, okay, you gastroparesis, there's a pain element to that we have to treat, or you have to make sure there's no MCAS, make sure there's no mals because malls can cause postprandial abdominal pain. And we can talk in, I dunno if you wanna dive into the pathophysiology there or talk about the rectum and how challenging is the poop.

We can, we can jump around anatomically. Yeah. Um, I'll let you drive the ship though. 

Dr. Linda Bluestein: Yeah. It's really hard not to kind of jump around a little bit. So, uh, hopefully people are gonna bear with us with, with, with that. Um, I did have a question. Oh, okay. So, so const, uh, uh, bowel movements, how fre, what is the goal?

What is the goal for bowel movements? So I feel like that's a good Yeah. Important 

Dr. Zachary Spiritos: thing if whatever makes you comfortable, right? Mm. Fecal stasis doesn't cause any [00:29:00] problems if you're not.

If they're okay with it and they're not bloated and not uncomfortable, then that's totally fine. You know, there's this kind of like three, like, you know, poop three times a day or once every three days. But I find there's great variability there. Mm-hmm. And look, once you get to like the seven, eight days, like people generally are pretty symptomatic or if you probe, they're like, yeah, I get full a little early and I failed for colonoscopies in a row, and I'm bloated.

And you're like, okay, well maybe we have to deal with this. Um 

mm-hmm. 

But you know, generally speaking, if you're bloated and uncomfortable and have discomfort, like we should address it. 

Dr. Linda Bluestein: So the goal of like going every day is not necessarily something that we should have for everybody. 

Dr. Zachary Spiritos: No. It's like saying like, I like my haircut, but if I had Dr.

Bruce's hair in my, my head, like, I don't want that. I think your hair is fantastic. I don't want your hair in my head. Like, you're pooping the amount that you need poop. Don't anybody else? Okay. Um. 

Dr. Linda Bluestein: Okay, well [00:30:00] that's, that's really good. And, and 

Dr. Zachary Spiritos: also like women and men have huge, you know, disparities in how well their colon.

So men's colons move a lot faster than women's. Mm. Estrogen tends to be the stop break on the colon. 

Mm. And 

that's why postmenopausal, a lot of women get a little mean. They, in that perimenopause postmenopausal phase, you, you can get a little more constipated 'cause the estrogen isn't there. Um, there's also more twists and turns.

Right. And, um, and the pelvic organs are just, they have an impact on, on the relative movements of the colon too. So, yeah, you just, everybody's different. 

Dr. Linda Bluestein: Before we move on to, um, compression syndromes and SIBO and viscera, ptosis, all these other things that we wanna try to cover, um, while we're, while we're still on the, on the motility problems, what are your thoughts about, uh, mestinon or proto TIG mean for pots and how that might potentially impact the motility?

Dr. Zachary Spiritos: Yeah, so I use Mestinon for pots for sure. Mm-hmm. Um, it is not the first thing I go to, but if we need kind of a relative [00:31:00] reduction in your heart rate, um, without compromising your blood pressure and there's concomitant GI issues like slim motil, then I will use it. Mm-hmm. I don't think it like, is a game changer.

I think it's an adjunct therapy. Mm-hmm. Like I don't think I've ever put anybody on it. And then everything turned around because, you know, if you think mechanistically, and I'm probably oversimplifying it, is that, you know, you have this kind of, uh, kind of, uh, autonomic imbalance in postural orthostatic tachycardia syndrome where your sympathetic is a little bit more, is higher than your parasynthetic and the meson just kind of does this, but does it really mm-hmm.

Does it really dampen your sympathetic job? Like, I don't think so. Mm-hmm. I think it just increases your parasympathetic arm so it can take the edge off, but I don't think it's, I don't think it's, um, it's everything. Like it mechanistically, it, theoretically it should work better, but I don't, I don't find it to be a complete game changer, but it is a weapon or not a weapon, a tool that I have, and I think I'll certainly use.

Dr. Linda Bluestein: Last question about the, uh, motility issue or comment or whatever was that I had a patient the other day who [00:32:00] had such bad colonic inertia. I can't remember how old she was when she had this surgery, but she had a massive amount of her colon actually, uh, removed. And she said it dramatically helped her from the standpoint of, you know, having bowel movements.

But Wow. That seems like really, you know, that's pretty aggressive. Right? And then you have all kinds of other problems, I would think after that. 

Dr. Zachary Spiritos: Yeah. You know, it, that's a tough one. Um, I've only sent one patient to surgery and she had some mitochondrial deficit that was just horrendous and just said we couldn't overcome it.

Um, but you can throw the kitchen sink at these patients, you know, you wanna have to make sure there's no outflow obstruction, that there's no pelvic floor dys synergia. 

Mm-hmm. 

So make, you know, we, you know, you wanna kind of ask the right questions to, to tease that out. And then, you know, diet some kind of low fermentable fiber.

Laxative so you can throw some pretty hardcore medications at these patients' physiology and hopefully move the needle. I, you know, and when we're [00:33:00] getting really desperate, I'll combine, you know, a secretagogue like glide, which effectively pulls water into the intestines and makes this stool softer, combined with a pro, uh, stimulant agent like Moeity, which helps the colon squeeze.

So you're making the stool soft simultaneously, helping the colon squeeze, increasing water movement, uh, making sure that you have the proper pooping position. Um, so it's kind of an all hands on deck approach. 

Dr. Linda Bluestein: Yeah. And I, I certainly hope that, uh, more gastroenterologists become interested in helping this populations of patients.

'cause I'm sure, you know, you can't see everybody. And so, you know, there's, there's way, way more people that need help than there are clinicians that can help them. It's a huge problem. 

Dr. Zachary Spiritos: Yeah, it's a, it's such a fascinating field. It really is. And you get to really connect with people as opposed to just connecting with their colons.

Like when I was just, you know, I'm doing my general GI days and I'm fixing dysphasia and taking out polyps. You're like, I did have a relationship with the mucosal layer of your colon. Like, that's all I [00:34:00] know about you. Um, but you get to, you know, 'cause, but you get to, you know, that's a, you know, the, the challenging thing, but also the beautiful thing is that there's so many different levers to pull.

Like, you can talk about the mental health and the diet and the movement, and there's so many different inputs to your GI health and how you perceive it. So you can, you can either think of this as very overwhelming or think of this as an opportunity to positively affect GI health through all of these, these avenues.

Dr. Linda Bluestein: Yeah. Yeah. No, that, I think that's great. 'cause like I had my colonoscopy screening, colonoscopy, just, you know, routine not that long ago. And I never saw the gastroenterologist beforehand. It was all scheduled. I got all my instructions and everything showed up at the hospital. Same thing for my husband. We had different gastroenterologist, but literally showed up at the hospital and met this person for the first time right before the procedure.

I'd already done the prep and, you know, everything. And so, yeah, it's a completely different relationship that you're, that you're talking about. 

Dr. Zachary Spiritos: It's pretty strange, isn't it, being such a [00:35:00] vulnerable person. I'm like, Hey, I'm Dave, I'm gonna take a look in your colon and I'll probably never see you again.

Dr. Linda Bluestein: Yeah, yeah. It's, it's very strange. It is very strange. Very strange. When I was, when I was having more GI problems, um, back when I was living in Wisconsin. And I remember I was going to be having a screening colonoscopy and I tried to start talking about some of the issues that I had. Like, here, I'm gonna be having this colonoscopy.

Is there anything additional that we should be doing for diagnostic purposes? And this is before I knew about MCAS. 'cause otherwise I would've said, Hey, could you do mast cell, could you do biopsies and look for mast cells and see if there are more Yeah. Abnormally shaped or whatever. But anyway, so, um, so yeah, it's, I think there's different ways that people practice and, um, different, different interests that people have.

Of course. So, so we're gonna take a quick break and when we come back, we are going to try to tackle the other, I don't know how many things on the list, uh, sibo. Gluten intolerance, Viser Proptosis. We'll see. We'll see what we get to, so we'll be right back.[00:36:00] 

This episode of the Bendy Bodies podcast is brought to you by EDS guardians, paying it forward in the Aler Danlos Syndromes community patient to patient for the common good. I am proud to serve on the inaugural board of directors for EDS Guardians, a small charity with a big mission and a big heart now seeking donors, volunteers, and partners, patient advocacy and support programs available now.

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Okay, we are back with Dr. Spiritos. Uh, this is such a great conversation and I know [00:37:00] that there's so many things that we could talk about, and I feel like we just have to kind of like pick the most important ones. And I do want people to be able to walk away with some pearls. And already you've given us tons.

You've already given us a bunch of different ideas of things that can be done for, uh, motility problems. We kind of covered that a little bit more in detail in the, in the first part, I was wondering if maybe we could talk about sibo. I hate to say briefly, but um, I guess when do you suspect it, what kind of workup do you do and how do you treat it in five minutes or less?

Just kidding. 

Dr. Zachary Spiritos: Yeah. So small intestinal bacterial overgrowth is where there's a superfluous amount of, uh, bacteria in the intestines. Uh, mark Pimentel is, is a thought leader here. I kind of follow his lead. If you wanna learn more, I would look up his talks. He's just, he's dedicated his whole life to this tricky phenomenon.

Um, he describes it more of as an infection, right? It's like an overgrowth, uh, in, in a small bowel as opposed to previously we thought that there was kind of, the bacteria should be in the [00:38:00] colon mm-hmm. Where it's more alkaline and, and they kind of propagate up to the small bowel. But we're realizing that it's, it's, it's just an overgrowth.

It's, it's almost like an infection. Um, we're starting to understand the exact bacterial strains that cause SIBO as well, which is kind of cool. Um, biggest risk factors are really, you know, where the, the small bowel can't clear adequately. Mm-hmm. So the small bowel has kind of regulatory mechanisms like the migrating motor complex to kind of clear it's like the Zamboni to clear the small bowel bacteria because it shouldn't be there.

Mm-hmm. Or it should be there in relatively small amount. Um, and so risk factors for kind of that not working so well is dysautonomia because that vagal input in your small bowel just isn't as effective as it should be. So it's either. Poorly coordinated or kind of dampen down kind of, um, peristalsis. So the small bowel can't clear the bacteria.

Narcotics is a big one. Um, just because the small bowel, just narcotics are a stop, stop break for the entire GI [00:39:00] system. Um, prior GI surgeries just 'cause you can get kind of adhesions and stasis of certain areas. 'cause once you have a kind of, you have your abdomen open, whether it's a cholecystectomy, a um, kind of hysterectomy, et cetera, you'll get adhesions there from the prior inflammation and that just kind of distorts the way the bowel can move sometimes.

Um, so those are the general risk factors. You know, some people think prior cholecystectomy is a risk factor or PPI use, but I don't, the data isn't quite there, but I understand kind of theoretically how that can happen so that, that always up a little bit. Um, you know, the is bloating. It just like, it's tough to get beyond, like really look for it if you're, if you're not bloated.

But I sometimes do, if, if the shoe fits. Um, and then you can either have constipation, if you have m smithy eye, which is an archaea, which is not really a bacteria, but an archaea that increases your methane production, which can slow down colonic motility. So that sibo, where it's called IMO, intestinal Meth Nova Earth can cause constipation.

Traditional SIBO is, I believe it's an e [00:40:00] coline, Klebsiella species that cause, um, that cause a lot of bloating and, and, and diarrhea or loose stools. So that's where I start. So risk factors for it symptoms, bloating and bowel, um, abnormalities. Um, and I test for it. So I use a, a hydrogen breath test or a lactulose breath test.

Um, I usually, I use lactulose. It's a little bit more sensitive, so you'll get more false positives, but I'd love to have more false positives and false, false negatives. Mm-hmm. Um, and then we treat it, I, I go with the data and I use rifaximin a lot for, you know. Hydrogen producing produc or um, sibo, um, that's a traditional type.

Um, axin works well. It's a ubi, it's not an antibiotics, it doesn't work everywhere in the body. It just shifts the bacteria to a healthier one. So, you know, getting insurance approvals kind of a beast sometimes. That's kind of unfortunate, but it, it works well and it's 14 days. Um, some people do want herbs though, so I do have herbal remedies.

Um, there's just not a lot of studies for it. There's a couple, right? But they're, they're in a handful of patients, so it hasn't been reproduced on [00:41:00] a larger scale in a randomized control fashion. So I'm a little bit hesitant to do so. I always choose Sure facts, but I always try to meet a patient where they are.

So if they wanna do herbs, let's do some herbs. And I, you know, I have my own pro, not my own protocols, but I've looked up and I've researched in terms of what Berberine does and what garlic does and what all these other agents do. I'm not integrated trained, but I certainly embrace it when, when people want me to go down that route.

So, um, but I always say that like, it just, it's not as, the data has to show that it's as effective as rif. Um, and then there's different treatments for, there's also a hydrogen sulfide, SIBO variant that Dr. Pimentel has recently identified. Um, so that's kind of a new agent. And then for intestinal meth antigen overgrowth, it's a combination of, um, of, uh, it's, uh, neomycin and rif.

So a different antibiotic choice there. Um, so yeah, I treat it when I see it, but there's also false positives. So when we treat it, I'll say like, this may not be it. This may not be it. Mm-hmm. Um, and we may have to continue to fight. Uh, occasionally we'll treat people when [00:42:00] everything gets better. Um, but it's usually in someone who has had a recent bariatric surgery and then they develop tons of bloating and then we treat it and it gets better and it's really not, it's.

Sometimes it's um, there is a high recurrence rate about 40% just because you can't really fix the underlying pathophysiology unless this ball is slow due to narcotics and then you just wean off narcotics, which obviously easier said than done. But if you have underlying dysmotility or stasis from prior batch bariatric surgery, like it certainly can come back.

There are a couple approaches there. You just kind of continue to treat it when it comes back and people don't love that for obvious reasons. Um, but if you do have recurrence or just like I treated, I got treated once, I never wanna go through this again. Then we can talk about pro motility agents to kind of keep the, the bowel going.

And so moeity is my first choice there. Um, 'cause it does work throughout the entire GI tract, but proximally in distally tell the colon squeeze and allow the small bowel to kind of get rid of that, those excess bugs. Um, someone me about garlic, fine. [00:43:00] You know, if you, if you have IBS, you know, garlic has a lot of, it's a FODMAP bomb.

So you gotta have to take that into consideration. It's also just not well studied. Right. And so that's where I always have a little bit of a hangup with these. 'cause it's just, there's not long-term data for use of this and how effective it is, how to dose it, how long do you use it for. And there are, there's information out there, it's just not incredibly well validated to what I've seen.

And if I, if I'm wrong, please send me data. Um, so I always, um, but mot is my, my go-to, and you can use mo erythromycin as well, but there's also those, those issues that I spoke about before with the tachyphylaxis where in six months to stop the work as well. Um, and there's also QTC prolongation issues. So you just gotta take all this into consideration.

And, 

Dr. Linda Bluestein: and what about patients that are taking, um, Zofran or Ondansetron for their nausea and that, 'cause that also slows transit, right? So could that contribute or. 

Dr. Zachary Spiritos: I think so I don't think there's that many, you know, in these studies. You know, that's a great question. [00:44:00] Um, because Zofran can definitely cause constipation and hit on, you know, the way that Moeity works.

Zofran works in the opposite way. It still works in the serotonergic um, receptors. So I imagine, so I don't know how many people are on Zofran chronically, like obviously we wanna get, we wanna stop that as, as soon as possible. Well, I dunno if that's well studied, but it certainly would make sense. Um, I met, when you're doing the SIBO test, you have to, it's very protocolized.

You have to follow a specific diet, remove certain medications before you take it to not alter kind of your native GI motility. So, um, I imagine you'd probably take someone off Zofran before testing for it, but at the same time, if you're on it chronically and that's why you have sibo, maybe you just test while on it.

But it's a really good question. Yeah. 

Dr. Linda Bluestein: Yeah, and it's, it's really interesting 'cause I have a lot of patients who take, who do take it quite regularly because they have nausea from their, from their pots. And so we try to, you know, get to the root cause and try to see if we can get their pots better some other way, because that can also cause headaches and that also causes, uh, QT problems as well.

So, anyway, I was just, I was [00:45:00] just curious about that little side note and then, uh, I had never heard the term before biotics. That's fascinating. And I know there's home tests for sibo and I was wondering if those home tests for SIBO are as accurate? The direct to consumer tests? Yeah. Okay. 

Dr. Zachary Spiritos: I don't think so.

I don't think so. I haven't, I haven't, I haven't sniff it out, but I, the t know I've, he's such leader and t. Brain of SIBO testing that I use because it also picks up on hydrogen sulfide variant of sibo, which isn't picked up on the other tests. Um, sometimes in the other tests, if you have like flat lines of both hydrogen methane, it could be like, this could be hydrogen sulfide, but it's not.

It's, it's pretty, it's, it's, it's guessing. Um, so I use the mark 'cause it, it has all three, uh, it tests for all three. Okay. I wanna talk about chronic nausea really quickly. Okay. So it can happen, um, for sure. And I have a lot of patients with dysautonomia and not [00:46:00] with dysautonomia. You have chronic nausea and they get sent to a GI doctor even though chronic nausea.

So postprandial nausea is different after eating. Nausea is ulcers, dys, motility, gastroparesis. But chronic nausea that is around the clock and often worse in the morning, often find that's due to an overly active sympathetic drive. Right. And the nausea receptor, the, the signal for nausea is in the hind brain.

It's not actually in the GI tract. And so Zofran works primarily in the brain, doesn't work peripherally. Ion works in both areas. So. I use a medication called Mirtazapine a lot for that. Obviously you wanna kind of work on sleep and work on cerebral profusion if someone has dysautonomia. Um, but reglan really, I'm sorry, um, mirtazapine works really well to dampen down those, those, um, those, those, um, nausea receptors in the brain.

Interesting. And I often find these patients have a difficult time sleeping as well and it helps with sleep, helps with appetite a little bit. Um, it's really, really safe. You know, it was used as an antidepressant many, many years ago, but you're using it sub therapeutic doses at seven and a half or 15 at night.

Hmm. So I think it's a really [00:47:00] nice adjunct to at least get people off Zofran just because of the qtc. And, you know, you just in your're handcuffed to taking a medication a couple times a day. Does it work all the time? It doesn't, but is a, it's a nice option to try to make that change to something a little safer.

Dr. Linda Bluestein: Okay. No, that's, that's excellent to know. 'cause yeah, the chronic nausea, like you said, with or without dysautonomia is uh, a common thing that, uh, seems like we, we see. So thank you for sharing that. So, so, uh, would it be okay to move on to compression syndromes? 

Dr. Zachary Spiritos: Yeah. 

Dr. Linda Bluestein: For sure. So what should we, because you know, I wanna be respectful of your time, so I'm like watching the clock and making sure, okay, what do we, what do we wanna make sure we cover in the time that we have left?

So, so what should we know about compression syndromes in, in terms of, um, how they, and I understand that this is a very big question, obviously, because there's multiple different ones and, and what symptoms they present with are DA little bit different. But, you know, if you could give us a kind of a 10,000 foot overview in terms of who should be evaluated for these and, uh, what kind of workup and, [00:48:00] and treatment might be considered.

Dr. Zachary Spiritos: Yeah, in terms of compression syndromes that cause GI symptoms, like not talking about mayner or Nutcracker 

mm-hmm. 

Um, which is a little bit different that can affect people with dysautonomia and affect their volume status. Um, but for compression syndromes that affect the GI tract, you know, the first one we talk about is median arcuate ligament syndrome.

And so the median ar ligament is this ligament that comes, um, that kind of originates from the diaphragmatic cura. So where the kind of the, the crosshatch of where our diaphragm lives. And it's supposed to sit superior or above our celiac artery in a celiac ganglion. And so the traditional teaching was that.

In median ARCA ligate syndrome, one, it just never happens. It's just incredibly rare in Zebra, which to be fair, it is in patients that probably don't have dysautonomia and don't have hypermobility. Um, but the pathophysiology is that that ligament starts to compress the celiac artery. And so when you eat, you get relative ischemia of your stomach.

So it just hurts. It's like a heart attack of your gut, um, [00:49:00] because the celiac already peruses a good part of the stomach and so you tend to get pain after eating pain with exercising. And there's certain ways that people can kind of manipulate their body to relieve that pressure. So like leaning forward kind of downward dog, um, exhalation, um.

Um, that's the teaching, but it behaves certainly differently. Um, but there's also another school of thought, which I very much believe in, is that the, it's not only the, that art, that ligament compressing the artery, but compressing the celiac ganglion, which is the, the nerve, the family of nerves that innervate the stomach.

So it's kind of, it can be an ischemic presentation or ischemic etiology where it's compressing the, the artery. But I think, I think that the majority of patients that have pain, it's from, it's a neuropathy where it's pressing the nerve bundle. So it's kind of like a complex regional pain syndrome of the gut.

Mm-hmm. Um, and so the traditional testing we use for MALS is an ultrasound with inhalation and expiration to [00:50:00] see if kind of during inhalation, that ligament squeezes the artery. But if it's negative, it doesn't really touch on whether it's how it interacts with the celiac ganglion. And from what I've seen is that even like.

CT scans, I can somehow see this hooking sign of mals, which is pathognomonic for that, or an MRI. It's tough to see the relation between the celiac ganglion and the um, the ligament. So, um, if we have a high degree of suspicion for this, you are the right person. The symptoms fit, we cannot describe, we cannot account for your symptoms with any other pathophysiology or not responding to treatments that treat any other, anything else.

Then we'll um, send you for a celiac ganglion, uh, plexus block. Um, but it can be tough because it's hard to get it approved because I believe the. Kind of approved indications is for pancreas cancer, like pain due to that, right? Is it completely benign? I think it's a pretty safe procedure. So it's, but it's all, um, kind of a risk benefit conversation.

But if you're really having a tough time with this and we're, [00:51:00] we don't really have any other options and the testing is negative, I'll empiric, can we send you for this, um, after a thoughtful discussion with the patient to see if this makes you feel better? And it is a proof of concept. If it does get better, then we could talk about, um, identifying a surgeon that can take care of it by kind of peeling that, that ligament off of the plexus.

Dr. Linda Bluestein: Okay. Yeah. I, I used to do celiac plexus blocks when I was in my, in my residency, uh, you know, doing my pain rotations. And like you said, it's, it's not a completely benign procedure, not, not super high risk now with our imaging that we're able to do and things like that. But definitely you don't wanna be just doing that willy-nilly, you know, like you said, you wanna be very, very selective for a wide variety of reasons.

Also, it is expensive, you know, it's a, it's an invasive kind of thing, so. Okay. That's, that's super helpful. And then what about, um, SMAS? 

Dr. Zachary Spiritos: Yeah, so s. Superior mesenteric artery syndrome, which is where the second part of the duodenum. So how we're constructed is our esophagus, our stomach, the duodenal bulb, first part of the duodenum, second part of the duodenum, third, fourth du.

[00:52:00] So, um, the second part of the duodenum as it crosses Medline, um, lives between the bifurcation of the aorta and superior mesenteric artery. So the traditional thinking is that people lose that fat pad. Um, so there's a fat pad that kind of lines this, um, this kind of the joining of these two arteries. And if you lose a lot of weight quickly, or you have some kind of spinal manipulation, cervical spinal manipulation that can close.

And so it just shuts that, that D two. Um, so you get a lot of, um, obstructive symptoms like what you see with gastric outlet obstruction. So nausea, inability to eat a lot, um, some pain. But the, I think the nausea element is, is pretty strong. And so you, it can behave somewhat like gastroparesis. Um, but. Can happen to people with hypermobility outside of the circumstances with which I described the rapid weight loss, the cervical manipulation, just because they're hypermobile hypermobile, the, the kind of, uh, the takeoff [00:53:00] from the SMA from the aorta is a little bit different.

Everything sat, there's ptosis of everything more, not only of the organs, but the vasculature. And that can kind of compress the, the duodenum as well, that's a little bit more easy to diagnose. Um, so obviously the, the clinical history, negative endoscopy, normal gastric emptying study. And then, um, you can get this kind of small bowel follow through where people drink contrast.

Then it passes through your stomach into your small bowel. If there's hangup between D two and three, that could be s for and the treatment. It's kind of build up that fat pad so that angle becomes a little bit more obtuse. And so sometimes we have to do TPN, um, uh, you can certainly do, if you can get a GJ tube past the obstruction, which is easier said than done.

And sometimes, uh, an advanced endoscopist can do that. Um, so it's just, it's, again, it's a tricky situation. You just kinda have to weigh the options and what the patient wants to do and what resources are available locally. 

Dr. Linda Bluestein: That's, that's great. That's great to have those two syndromes, uh, pretty clearly defined and [00:54:00] what, what our options are.

So, so let's also talk about something. Let's, let's back up, just something that's a little bit more, I don't wanna say mundane, but like super common. I think, um, glucose intolerance, um, not, not celiac, but you know, it seems like this is something that a lot of people are, are dealing with when they have, you know, mast cell activation.

Um, and this complex of conditions, I. 

Dr. Zachary Spiritos: Yeah, no, that's a, it's a good point. So, um, gluten intolerance is, is tricky. Um, so obviously you wanna make sure that people don't have celiac disease, which is a distinct autoimmune condition. Mm-hmm. And then, um, you know, you kind of take the patient's lead to see how they feel after eating gluten.

Um, some people, there's kind of non-celiac gluten sensitivity where people not only get GI symptoms, but they get brain fog fatigue, muscle aches. And the question is, is that mast cell or is that non-celiac gluten sensitivity? You know, we're quickly learning that some of these conditions that are previously [00:55:00] poorly defined, like interstitial sitis have a mast cell component to it.

So, is non like gluten sensitivity, is that just gluten that's irritating your mast cells? Like, I don't think we know just yet. Mm-hmm. Um, and then in cases of irritable bowel syndrome, some people think that they are gluten intolerant, but it's the FODMAPs that really cause a lot of bloating, distension, and pain.

Mm-hmm. So a FODMAP is a fermentable oligosaccharide and polyol, where it's a stupidly long name for a poorly absorbed, uh, carbohydrate. Um, that kind of makes its way, um, it evades digestion. The small intestine comes into the colon and the kind of native bacteria there turn that into a lot of gas and that distension cause pain in patients with irritable bowel syndrome.

But those are, those symptoms are more localized to the GI tract. Um, and it's not gluten per se, but it's the FRS and wheat. So wheat simultaneously has frs, gluten tease. You know, I, I [00:56:00] don't empirically put people on a gluten-free diet, although I'm hearing more and more that like, maybe I should, um, you know, again, you don't wanna overly restrict people.

Mm-hmm. And I hate to restrict people when there's not a lot of data to support that. It, it helps a lot of folks. Like it certainly helps some people, but not everybody. And so that's where I think keeping a very, kind of very detailed, um, symptom diary is really helpful, along with like a food diary to understand what your triggers are.

Because you know, when you eat something, it can affect you 30 minutes later, like in like histamine intolerance, but in, you know, IBS or non like gluten sensitivity, like it can, it can be six to eight hours later. Mm-hmm. 

So, 

um, I'm a big proponent of keeping a strict food and symptom diary to understand what's what.

But you know, it's, it's a really, it's a hot button topic. I think I gave a very like, nebulous answer there. Um, but if it makes you feel better, great. Stop it. Um, we gotta make sure you don't have celiac disease 'cause that portends, like, you really have to be incredibly strict there. 'cause there's a risk for, you know, vitamin deficiencies, nutrient deficiencies, small bowel [00:57:00] lymphoma.

Um, but um, for the most part, if it makes you feel better, then you know, by all means cut it out. But I have an incomplete understanding of gluten, I think, and how it works in the body. 

Dr. Linda Bluestein: I feel like it's so complicated and I feel like, you know, so much of what you were talking about earlier feeds into this.

Like you said, people, you know, if you eat certain things and then they're trying to figure out what it was that caused those symptoms, and then you're, okay, well I'm gonna eliminate this and I'm gonna eliminate that. And next thing you know, I mean I've, I've had people that, you know, come to me and they're eating literally three things.

It's like, you know, and that, that obviously Yeah. Yeah. It's 

Dr. Zachary Spiritos: called a, um, avoid a restrictive food and take disorder. It's really tricky. Um, 'cause there's so much anxiety around eating, like eating should bring us together. It should be a happy moment and it should be shared and enjoyed. And so, you know, I think one of the, the challenges, but the kind of great pleasures that I get in clinic is identifying underlying pathophysiology.

So we can definitively say, okay, this is what you can eat. This is what you can eat. And then working with a, a GI savvy dietician to reintroduce foods in a safe way. And I think that [00:58:00] partnership is really, IM important as well, is identifying a dietician on your team that can really help these people. Not only.

Identifying the foods to eat, not to eat, but also talking about the anxieties around eating. And that's a mm-hmm. It's, it's, it's tough. It's really challenging. 

Dr. Linda Bluestein: So you do have a dietician on your team? 

Dr. Zachary Spiritos: I do. 

Dr. Linda Bluestein: Okay. Yeah, that, I think that is so important because that, um, you know, I get so many questions about that.

In fact, that's part of the, like, last part of the, the questions. But we're gonna be running out of time, you know, low histamine diet, do you do it forever? And of course the low histamine diet, you know, what, what. It's a problem for some people, it's not a problem for other people. Uh, just because a food is supposed to be, you know, higher in histamine.

I, I I find that there's a lot of individual variation there. Somebody else asked you how do you increase tolerance for TO foods? Other people asked about over restriction about meal timing, you know, a lot of questions related to food, but, you know, it would be really hard to, to get into all of those. And I wanna make sure we kind of focus on the things that are more, um, more specific to what, to what you're [00:59:00] doing.

So can we talk in the last few minutes that we have, can we talk first about PPIs and what your thoughts are about proton pump inhibitors? The good, the bad, the ugly. Um, 'cause people tend to, tend to get started on them right then. Like they never get stopped. 

Dr. Zachary Spiritos: Yeah. So there are clear examples where they are so incredibly helpful and everything in medicine is a risk benefit conversation, right?

And so if you just have some random GI cramp and you're put on a PPI, that's you gotta. Horrible erosive esophagitis from gastroesophageal reflux disease. If you have peptic ulcer disease that is recalcitrant for whatever reason, or have a marginal ulcer, marginal ulcer from bariatric surgery or Barrett's esophagus or eosinophilic esophagitis, there is clear data that has benefit.

Okay. Obviously we wanna get you off it if we can, but it's a safe medication. That's just what the data tells us. So the best studies out there show that it [01:00:00] has it, it can potentially cause two different conditions. One is intestinal infections, and the thought being that, you know, your kind of the, the low pH of your stomach should kill off the, the, you know, you ate Uncle Bob's undercooked chicken and there's some e coli there.

Your, your stomach acid should be able to kill it off. But if you're on a PPI that, you know, that could potentially propagate your colon leading to a colitis, that's one. But I've personally never seen it happen. So, you know, um, but it's definitely a risk out there. Um. And, uh, and then potentially bone density loss.

Mm-hmm. 

And 

so it's not, the studies haven't been consistent in showing that. But if I find that if I have someone who is, who's a post-menopausal woman who is over the age of, you know, who, who has, who's, who's thin, um, definitely is a smoker, then I'm like, okay, we should move towards something else here to not increase that osteoporotic risk.

But, you know, everything that suggests that it causes, you know, mineral loss, Alzheimer's, cancerous, they're [01:01:00] all, you know, they're all correlation studies. So they study these people that have X conditions and say, let's look back and see if they have, they were on a PPI. And it turns out when you study people who have a lot of diagnoses like advanced renal dysfunction and dementia and cancer, that at some point in time they were put on a ppi.

Mm-hmm. But it doesn't suggest causation. And so it's, I think the bottom line isn't this, is, this philosophy is the same for any therapy intervention in medicine. It's just, it's weighing the risks and the benefits. 

Dr. Linda Bluestein: Mm-hmm. 

Dr. Zachary Spiritos: But it is a safe medication. 

Dr. Linda Bluestein: Okay. Um, what about GLP ones? Uh, glucagon-like peptide agonist, uh, receptor medications.

So we know this, this obviously could also be its own like episode, but a lot of people now are, you know, uh, they came across this study where they, it improved mast cell in, uh, one patient in a case study. But I, you know, I've had patients for whom, you know, they've experienced some weight gain and they're really concerned about it and they didn't really have much in the way of symptoms of [01:02:00] gastroparesis and they really, really wanted to try it.

So I've started them on like super, super low dose and I've had some people really feel that they've gotten some improvement from it. Also, some anti-inflammatory effects, et cetera. Is that something that you prescribe at all, or what do you have any 

Dr. Zachary Spiritos: It's a fantastic medication. It really is, um, if used appropriately, right?

Mm-hmm. And so I have people who end of my clinic with. Horrible constipation, horrible nausea, because somebody put them on a medication in the GLP one, GIP family and said, okay, take it, take this dose for four weeks and then you're gonna increase it. And then four weeks after that, you're gonna increase it again.

Mm-hmm. 

It's like the Wolf of Wall Street dialogue with Matthew McConaughey. He is like, in 10 minutes, gimme like another vodka martini. And he, he's like, he kept, and they just like, it's this kind of plan on autopilot, right? And that's just not how it should be used. And it's, it's, it's, this, the, it's analogy is like, you know, if I'm on Amlodipine 10, like let's just increase it every week until I'm gonna feel better, right?

Like, it's just not how, that's just not how medications work. [01:03:00] Um, but they have so many incredible benefits and, you know, obviously weight loss, right? There's people who have, you know, immense kind of, um, food noise where all they do is just their, their brain just tells 'em to eat food, right? Mm-hmm. And it's this kind of real chemical dependency in food.

And it kind of can turn down that and in turn can, you know, it helps with liver health and it decreases. Kind of metabolic associated SS stayat liver disease or, or previously noticed fatty liver disease. And it help, it's now FDA approved for sleep apnea. So it has all these amazing, um, benefits for people with underlying metabolic dysfunction.

Um, but then you, you know, you take it to the MCAS patient population who have, who could have underlying gastroparesis, it gets a little tricky. Mm-hmm. I will say that I have used it in people with gastroparesis without any problems. 

Mm-hmm. So 

does it create delayed gastric emptying? 

Yes. 

If your symptoms are fairly well controlled though, and you can eat, you know, there's some people who have horrible gastroparesis and things just sit there forever and ever and they vomit.

Like that's just not gonna be an option. But Right. For patients with kind of more [01:04:00] mild phenotype or moderate phenotype of gastroparesis, you can say, we we're gonna try it and we're gonna give it a shot at a very low dose. Right. And then we touch base every week or two and see how, we kind of see how you do.

And obviously we can always, we can always keel it off if it's not working for you. So I think it's, um, I think, I don't think. Having gastroparesis is a non-starter for GIS and glp and, um, I think for the right person, it's a really nice option. 

Dr. Linda Bluestein: Okay. Uh, getting to the end of my list of questions. Of course we had to, you know, uh, go through some of these pretty quickly or, well, I wanna come back and talk about Viscera, ptosis at, at some point, maybe, maybe for part two.

Um, what about questions to, uh, finding a good specialist when you have a lot of GI symptoms and questions to ask the gastroenterologist to see if they're a good fit. And Kate specifically asked, one of my followers specifically asked, why do doctors treat GI issues as if they're not connected to EDS?

Which we know that that is a [01:05:00] problem. 

Dr. Zachary Spiritos: I think doctors don't know a lot about EDS, they just don't. I didn't know about it until a couple years ago throughout all of my training, we just, you just didn't, we didn't pay attention to it. That EDS body behaved so differently than someone without. Connective tissue, uh, underlying connective tissue disorder.

Um, there's, there's new, there's new diagnoses, this new pathophysiology. And, you know, traditional GI doctors work with hardware issues. They work with plumbing issues. Right. Is something wrong with the tube? 

Mm-hmm. 

Right. Is there an ulcer here? Is there inflammation here? Can I biopsy and find h pylori or some pathology?

And if I can't, then it's probably IBS, right? 

Mm-hmm. And that's 

where it gets a little tricky, just 'cause I does IBS exist? Not sure. I think IBS is this kind of catchall diagnosis for people have symptoms, but goodness, nothing is showing up on, on testing. So I think to the, to Kate's question is that a lot of people just don't understand EDS.

And I'm trying to learn it. I have an incomplete understanding of it, and I get taught by patients every day mm-hmm. About how their body works. 'cause I just, I think as a medical [01:06:00] compute community, we're just, we fall short in terms of our understanding of this condition. Um, yes. We don't understand that.

We don't understand IBS very well. The majority of GI doctors don't understand IBSI read about IBS and think about IBS. Every day. Every single day. And I'm still learning on a daily basis. Wow. 'cause we're still kind of understanding what connects to what, and everybody's IBS is different. Is it located in the gut?

Is it due to increased too much gut stretch? Is it due to dysbiosis? Is it due to increased serotonin pathways? Is it due to altered, uh, bio salt, uh, metabolism? So it just can get so tricky and so, so heterogeneous. So finding your team is the other part of the question. And this is really tricky. I think finding a neuro GI is really, really helpful, but there's certainly a lot of other people who wanna be creative and think outside the box.

And I think you just have to find someone who's on your team. Right. And so even if they're like, look, I'm not quite sure how this fits together right now. Like, I'm gonna read, or I'm gonna ask questions. We're gonna find you someone [01:07:00] who will, who can help you. Or I'm gonna read and I'll get back to you.

Mm-hmm. Um, but when someone shuts the door and says, Hey, this is IBS, you know, meditate or give you some kind of, but now unoriginal thoughts about. IBS that probably won't move the needle very much. That's when it's time to move on. But I think you just need a partner in this because mm-hmm. Even in someone who, I think I'm relatively savvy in this and I, I read a lot and I think about this all the time, I'm still rather unclear about how this is gonna go with my patients.

And I'm very upfront about that. I'm k is like, a lot of this is trial and error. This is not an opacity on a chest x-ray or a, um, a broken ankle. We're gonna fix it and you're gonna get better. Like this is, we're gonna have to work together. We're gonna start things, we're gonna stop things. You're gonna have to, lemme know how things are going and that's how we're gonna proceed.

So you just need someone who's, who's will listen to you and fight fraud on your behalf. 

Mm-hmm. And I 

think you can know pretty quickly in the interview if that person's the right person for you. Mm-hmm. But I do think, like, patient forums are great. I think they'll tell you who's pot savvy, who's EDS savvy, um, uh, obviously like the, the, the [01:08:00] bigger websites like THISNO International, um, there's a ma cell website, EDS society, there's, there's, there's resources there as well.

Dr. Linda Bluestein: Okay, that's great. And as you know, we end every episode with a hypermobility hack. Do you have one for us? 

Dr. Zachary Spiritos: You gotta learn how to poop. Everybody's gotta learn how to poop. That's stupid, stupid toilet that they made, that porcelain thrown. It's a piece of junk and it's not conducive to good, to good pooping.

Uh, so yeah, we, you know, um, a lot of people, you know, with, um, hypermobility, denomi have issues pooping, whether that's slow transit or they can't eat fiber, or they have viscera, ptosis and everything just kind of sags. And they have, or they have pelvic floor dysfunction because in EDS you kind of hyper, you kind of compensate for the collagen laxity.

So all those muscles.

Low hanging fruit, we can all do it. And I'm gonna kind of walk through a couple steps here, if that's okay with you, [01:09:00] because this is Yes, please, a spiel that I like to do. And if I'm, if this is too weird or gross, please tell me to shut up. Um, but so Squatty potty is fantastic. Um, so you wanna get your knees above your waist or your hips when you're pooping to really open up that rectal angle.

There's something called the, uh, pupil rec muscle that's kind of a sling, and it kind of like cuts off the rectum and then it opens when our knees are above our waist. So that's a, that's a kind of, that's where I would start. Um, and then a lot of people have very tense, tense pelvic muscles who are constipated.

And so diaphragmatic breathing on the commode is also really nice as opposed to doom scrolling on Instagram or checking your FanDuel. Um, you really wanna work on relaxing your pelvic floor. So diaphragmatic breathing's a really nice trick there. I like Megan Reel's video. She's from Michigan. She's brilliant.

She's a GI psychologist. Has a great demonstration of gi of diaphragmatic breathing. One hand in your chest, one hand in your belly, breathe. And just push out your belly and make sure this hand in your chest is [01:10:00] really stable. Okay? Practice a couple times a day for five minutes each, and you just want to think about your pelvic floor relaxing.

And then step three is pushing. So you don't wanna strain, but a gentle push, breathe in through your nose and then kind of breathe out through your mouth like you're fogging the mirror, like, and try to feel that rectum evacuate. And that's, and it gets, you know, there's, there's more nuance to it. And I by no means a pelvic floor physical, the physical therapist, but I'd love my pelvic floor physical therapist.

Yes. Um, they are just an invaluable member of the team. And, but that's where I start with everybody. 'cause if you don't assume proper poop inquisition, you're fighting an uphill battle and you can throw all the laxatives and fiber and belly massages in the world that you want. But that's, it's, that's pretty critical.

Dr. Linda Bluestein: Yeah. No, that's great. And we, and we did an episode on pelvic floor PT that I will also link in the show notes so people can, can check that out. No, that's super important. And, and if, can I take three to five more minutes of your time? 

Dr. Zachary Spiritos: Yeah, absolutely. Okay. 

Dr. Linda Bluestein: Because I feel like I, I do want to just, [01:11:00] if you can give me three to five minutes on viscera, ptosis, like, you know, again, what is it?

Why do people with EDS need to know about it and, and how do you work it up and what do you do about it? And I know that that's like an unfair question to say, Hey, can you cover this in three to five minutes? But I feel like we should at least give people something since we did mention it a few times. I mentioned it multiple times, and I feel like it's kind of unfair to not at least give the, give people something to walk away with.

Dr. Zachary Spiritos: Yeah, no, it's, it's a, it's a, it's a diagnosis that we make, but the interventions can be, um, they're tough. They're tough. So it's, ptosis is just sagging, right? Mm-hmm. It's the posis of your eye and myasthenia gravis, your eye sags, right? And so it's just PS of all of your organs because that the architecture, the, the scaffolding of your organs isn't as robust as it should be, just because those innate defects in collagen and hypermobility, so everything's sag.

So a lot of people have like a kind of a more lower belly, 'cause all the organs just kind of sag more, um, kind of lower into their abdominal [01:12:00] cavity. So, you know, one thing that makes people feel better is just kind of abdominal binder, just kind of hold everything up, um mm-hmm. And, you know, ideally you'd wanna hoist everything up, but we can't do that.

It's just we don't have those abilities. And going into doing surgery is, is not generally a good idea. So abdominal binders, um, decreasing the amount of kind of gas load in your intestines. So I generally recommend like a lower FODMAP diet. I'll do a modified lower FODMAP diet. So I'll kind of pick out things that are higher in FODMAPs, which again, these kind of non-absorbable carbohydrates that can cause a lot of gas.

I'll treat sibo 'cause if you have kind of sagging organs, just the motility won't be as robust. So if there's concomitant sea ball, I'll treat that as well. Um, introducing fiber in a safe way. So a lot of these folks have kind of slow motility. So the fiber that you give like gels up, gunks up creates a lot of fermentation, which stinks and is uncomfortable.

So, partially hydrolyzed gu gum is a nice gel. Low fermentation fiber supplement that I often use in these [01:13:00] patients proper pooping position is really, really helpful too. Um, working with a pelvic floor physical therapist, really nice pro motility agents if you need them to kind of help the colon squeeze.

Obviously we can't reverse the posis, but we can alleviate some of the symptoms, the bloating symptoms, the kind of sagging feelings with a, with a kind of abdominal binder. Any, you know, constipation. We can treat that with laxative diet. Um, make proper pooping position working with a pelvic floor physical therapist.

Um, and you know, last resort, you know, you do surgery, um, and some people may need like an end ostomy or an end colostomy, which is not our goal. Mm-hmm. Um, and I've actually never seen that happen in real life. Um, there's often kind of workarounds there, but it's just something that we kind of have to deal with.

I can't reverse it, unfortunately. We don't really, we're not there. We can't do anything to improve your, the, um, kind of the. Your hardware and, and improve your collagen necessarily. But, and then you gotta rule out like rectus seals, which are kind of out pouching in your colon, [01:14:00] into, into your vagina or the associated, um, areas.

Um, 'cause that kind of can hold stool and, and create outflow obstruction. So, but those are kind of, um, that's kind of where I would start. 

Dr. Linda Bluestein: That's fabulous. That, that's so, so helpful because, you know, this is something that does come up for sure in, in my practice. I've had people ask about it. I actually had one person who was going to be going somewhere to Canada or something for, for possible surgery.

And so I, I love some of those ideas, especially something like an abdominal binder, which can also help with people's denomi and, and, uh, at least giving people something that they can think about and, and, uh, consider trying discuss with their doctors and, and everything. So that's, that's wonderful. Um, okay, great.

Well thank you so much. This has been such a great conversation and I know that all of the listeners are. Really like taking notes and, uh, you know, getting so much information. And I just wanna thank you for taking the time. Um, before we hang off, can you tell us, uh, a couple of quick things, [01:15:00] hopefully relatively quick, uh, where people can find you, what kind of practice you're doing now days, and if you can see people from certain states or you know, kind of how that works.

Um, and I think, uh, that's it. And if you have any special projects that you want us to know about. 

Dr. Zachary Spiritos: Yeah. Thank you for, um, for allowing me to give me the platform to say this so you can find me on Instagram at Dr. Zach Spiritos. Uh, we just opened up our new clinic called Ever Better Medicine. I was previously with UNC, um, and Ever Better is a telehealth clinic that is in North Carolina, Illinois.

Aim to treat, you know, we have a weight management division, but also a kind of a dysautonomia. Chronic complex digestive symptoms division as well. Um, so we do treat pots, we treat MCAS, we treat all these tricky GI conditions, whether it's gastroparesis, cyclic, vomiting syndrome, chronic pseudo obstruction, really, you name it.

Um, and we wanna make kind of. Identifying and treating these [01:16:00] complex disorders accessible so you don't have to go to Mayo, you don't have to go to Cleveland Clinic or these amazing motility centers like we can come to you, you can be in your PJ's and we can work through this together. It is a handholding operation.

It is not a set it and forget it. I will never put you on anything and say, see you in six months. We are working together. It is a partnership. We have an amazing dietician. We partner with GI psychologists. We're gonna hire a pelvic floor physical therapy therapist. We're creating exercise plans for core and lower extremity for people with dysautonomia.

So we're trying to create this kind of network of individuals to really support these folks who are misunderstood. Um, your symptoms are minimized and, um, and try to get them, you know, better quality of life. So it's a, it's a general, it's a partnership. Um, and I'm really excited to, to get going. We're starting to see our first patients in the next couple weeks.

If we are not in your states, please send me a message, but where you want us to expand to? 'cause we are gonna expand over time, but we gotta crawl before we can walk and we gotta make sure our EMR works and our website works first, but 

Dr. Linda Bluestein: yeah, 

Dr. Zachary Spiritos: we're excited to get out [01:17:00] there. 

Dr. Linda Bluestein: Yeah, the whole state licensure thing is such a, is such a nuisance.

So right now you can see people from North Carolina and did you say Illinois? 

Dr. Zachary Spiritos: Illinois? 

Yeah. 

Dr. Linda Bluestein: Okay. Okay. Very good. So if there're, if people are in different states, like you said, reach out to you on Instagram and say, Hey, think about getting a licensure in Colorado so I can send you all my Colorado patients.

Dr. Zachary Spiritos: Yeah, we're super receptive to that. And you don't have to be a resident of either these states. You just have to be, if you wanna take, you know, a vacation in Wilmington or Chicago, we can see you while you're there. 

Dr. Linda Bluestein: I see, I see. So, so they have to be sitting in that state when they have the, uh, tele appointment with you.

Dr. Zachary Spiritos: Exactly. 

Dr. Linda Bluestein: Okay. Okay. Very good. Well, thank you so much again for taking time out of your very busy schedule to chat with me and share some really great clinical pearls that, uh, people can, can walk away with. So thank you. 

Dr. Zachary Spiritos: My pleasure.

Dr. Linda Bluestein: So I'm [01:18:00] so grateful to Dr. Spiritos for coming on the show today and talking about gastrointestinal concerns that people have with EDS dysautonomia and mast cell activation. We know that this is so common and I know so many of you are suffering from these symptoms. Um, I'm excited that he's opened his clinic and I know that he doesn't currently accept insurance, but he's hoping to in the future.

So just wanted to give you a heads up about that. And I just wanna thank you 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.

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