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A deep dive into the tangled web of GI symptoms and how they connect to endometriosis, EDS, POTS, and Mast Cell Activation Syndrome. Dr. Zac Spiritos, a neuro-gastroenterologist, shares insights on differentiating between these conditions and finding effective treatment approaches.
• IBS is a “software not hardware problem” involving miscommunication between gut and brain nerves
• Endometriosis can sensitize nerves in the pelvis, leading to IBS-like symptoms even after excision
• POTS affects the autonomic nervous system, causing standing tachycardia and various GI symptoms
• Mast Cell Activation Syndrome manifests through skin issues and unusual GI symptoms like early-onset heartburn
• EDS affects connective tissue throughout the body, potentially causing problems in every part of the GI tract
• Salt intake helps POTS patients by increasing blood volume, though this approach isn’t sustainable for everyone
• Finding a doctor who remains curious about complex conditions is crucial for proper diagnosis and treatment
• Patient education is essential for informed decision-making and long-term management of chronic conditions
Follow Dr. Zac Spiritos on Instagram @drzacspiritos
Website endobattery.com
Is It Endo or Something Else?
Speaker 1
0:00
Is
it
your
gut
or
is
it
endo
?
Or
is
it
POTS
?
Or
maybe
it's
the
mast
cell
activation
throwing
a
party
that
you
didn't
invite
them
to
?
This
episode
dives
deep
into
the
tangled
webs
of
the
GI
system
and
how
it
connects
or
collides
with
endometriosis
,
eds
,
pots
and
mast
cell
activation
,
and
more
.
If
you've
ever
wondered
why
your
stomach
has
a
personality
all
its
own
,
this
one's
for
you
.
We're
sitting
down
with
Dr
Zach
Spears
,
host
,
just
to
learn
a
little
bit
more
about
this
.
Speaker 1
0:31
Stick
around
,
welcome
to
EndoBattery
,
where
I
share
my
journey
with
endometriosis
and
chronic
illness
,
while
learning
and
growing
along
the
way
.
This
podcast
is
not
a
substitute
for
medical
advice
,
but
a
supportive
space
to
provide
community
and
valuable
information
,
so
you
never
have
to
face
this
journey
alone
.
We
embrace
a
range
of
perspectives
that
may
not
always
align
with
our
own
,
believing
that
open
dialogue
helps
us
grow
and
gain
new
tools
.
Join
me
as
I
share
stories
of
strength
,
resilience
and
hope
,
from
personal
experiences
to
expert
insights
.
I'm
your
host
,
alana
.
This
is
EndoBattery
charging
our
lives
when
endometriosis
drains
us
.
Welcome
back
to
EndoBattery
.
Grab
your
cup
of
coffee
or
your
cup
of
tea
and
join
me
Meeting Dr. Zach Spiritos
Speaker 1
1:19
at
the
table
.
Speaker 1
1:19
Today
.
I'm
joined
by
my
guest
,
dr
Zachary
Spiritos
,
a
board-certified
neuro-gastroenterologist
with
a
passion
for
treating
irritable
bowel
syndrome
,
functional
abdominal
pain
and
mobility
disorders
.
A
Philadelphia
native
,
dr
Spiritos
graduated
from
Davidson
College
and
earned
his
MD
and
MPH
from
the
University
of
North
Carolina
at
Chapel
Hill
.
He
completed
his
internal
medicine
residency
at
Emory
and
went
on
to
complete
his
gastroenterology
fellowship
at
Duke
.
With
a
strong
background
in
teaching
,
research
and
patient-centered
care
,
he
brings
a
wealth
of
knowledge
and
compassion
to
the
table
.
Please
help
me
in
welcoming
Dr
Zach
Spiritos
to
the
table
.
Speaker 1
1:59
Thank
you
,
zach
.
So
much
for
sitting
down
with
me
today
.
I'm
really
excited
about
this
conversation
for
a
couple
reasons
.
So
much
for
sitting
down
with
me
today
.
I'm
really
excited
about
this
conversation
for
a
couple
reasons
.
First
reason
being
is
that
I've
never
had
a
GI
doctor
on
before
,
so
you're
the
first
that
has
raced
this
podcast
.
And
then
,
second
,
because
you
have
a
way
of
looking
at
not
only
the
whole
body
but
the
GI
system
and
how
it
all
correlates
,
and
this
is
something
that
many
of
us
face
,
so
I'm
excited
to
just
jump
in
.
Thank
you
for
taking
the
time
to
do
that
.
Speaker 2
2:32
This
is
some
big
shoes
to
fill
,
but
I
am
so
excited
to
get
into
this
.
I
certainly
have
a
lot
of
patients
with
comorbid
endometriosis
and
GI
conditions
.
Yeah
,
let's
mix
it
up
Understanding IBS & Neurogastroenterology
Speaker 2
2:47
and
GI
conditions
.
Speaker 1
2:47
Yeah
,
let's
mix
it
up
.
Yeah
,
I'm
excited
for
this
,
because
one
of
the
things
that
you
talk
about
a
lot
is
POTS
,
hypermobile
EDS
.
What
else
do
you
talk
about
?
Speaker 1
2:54
You
talk
about
a
lot
on
that
front
,
and
what
we
were
talking
about
a
little
bit
ago
is
that
there
is
a
correlation
between
those
and
endometriosis
.
For
some
reason
,
there's
a
lot
of
crossover
between
patients
who
have
endometriosis
and
have
all
of
these
other
things
that
they're
challenged
with
,
and
one
of
the
things
that
I
find
most
patients
struggle
with
is
their
GI
system
,
and
there's
a
lot
of
question
behind
why
.
Why
are
we
seeing
such
a
strong
correlation
between
all
of
these
symptoms
and
all
of
these
disorders
and
diseases
to
the
GI
system
?
Can
you
break
that
down
just
a
little
bit
for
us
in
what
you're
doing
and
how
we
can
look
at
our
GI
system
with
all
of
these
?
Speaker 2
3:40
That
is
a
loaded
question
,
goodness
,
okay
.
So
let's
start
with
irritable
bowel
syndrome
,
okay
,
because
I
see
it
a
lot
.
Comorbid
endometriosis
and
IBS
.
So
let's
talk
about
what
IBS
is
.
Okay
,
perfect
.
So
this
is
more
of
a
software
than
a
hardware
problem
.
Speaker 2
4:02
So
anybody
who
struggled
with
IBS
like
I
can't
make
it
through
dinner
without
running
to
the
bathroom
,
or
,
goodness
,
I
have
to
wait
like
six
hours
in
the
morning
to
get
my
business
done
before
I
can
start
my
day
knows
how
frustrating
IBS
is
.
And
what's
even
more
frustrating
is
that
when
they
have
endoscopies
,
imaging
tests
,
blood
work
,
everything
is
completely
normal
.
And
the
doc's
like
,
hey
,
great
news
,
you
don't
have
Crohn's
disease
,
it's
completely
normal
.
And
the
doc's
like
,
hey
,
great
news
,
you
don't
have
Crohn's
disease
,
you
don't
have
cancer
.
Really
,
this
is
probably
just
IBS
,
like
just
IBS
.
What
are
you
nuts
Like
?
This
is
horrible
,
and
not
having
any
diagnostic
tests
to
substantiate
your
symptoms
is
really
frustrating
,
okay
.
So
,
again
,
it
is
a
software
problem
,
not
a
hardware
problem
.
Speaker 2
4:40
And
if
we
were
to
identify
one
specific
part
of
the
body
that
is
quote
,
unquote
off
an
IBS
,
it
is
the
nerves
.
Okay
,
so
the
nerves
that
are
delivering
signals
between
the
brain
and
the
gut
.
So
it's
where
?
So
in
this
kind
of
misfiring
crosstalk
.
The
gut
is
sending
pain
signals
to
the
brain
Because
IBS
one
of
the
cardinal
features
is
pain
and
that
causes
stress
and
anxiety
on
the
brain
.
And
if
we
were
to
kind
of
give
this
a
more
scientific
,
pathophysiologic
name
,
it'd
be
an
overactive
sympathetic
system
,
which
is
your
fight
or
flight
system
,
which
is
contrasted
by
the
parasympathetic
system
,
which
is
your
rest
and
digest
system
,
which
,
if
you
want
to
be
pooping
better
,
rest
and
digest
is
kind
of
where
we
want
to
live
.
And
IBS
folks
tend
to
live
in
the
sympathetic
overdrive
so
that
those
pain
signals
get
sent
to
the
brain
.
And
then
the
brain
,
believe
it
or
not
,
has
a
big
role
in
how
our
GI
system
moves
and
coordinates
.
And
when
the
brain
is
then
shifted
into
the
sympathetic
overdrive
it
can
lead
misspeaking
.
Just
be
like
that's
so
wrong
,
just
stop
right
there
.
Speaker 2
6:08
But
you
know
,
these
endo
implants
by
nature
cause
local
inflammation
in
the
pelvis
.
Okay
,
and
what
does
local
inflammation
do
?
It
causes
substantial
hypersensitivity
of
these
nerves
.
That
is
the
link
between
endometriosis
and
IBS
is
really
sensitizing
these
nerves
of
the
gut
and
the
pelvis
and
which
then
lead
to
more
stress
on
the
brain
,
a
highly
active
sympathetic
system
which
in
turn
can
lead
to
diarrhea
,
constipation
and
all
the
really
intrusive
,
challenging
symptoms
of
the
illness
.
I
think
that's
a
good
place
to
start
.
Speaker 2
6:44
But
that's
why
we
see
a
lot
of
IBS
in
folks
who
have
endometriosis
.
And
even
when
you
treat
the
end
of
disease
,
sometimes
they
have
persistent
IBS
afterwards
because
all
of
that
chronic
inflammation
really
leads
to
a
lot
of
pain
over
time
in
the
brain
.
We
know
that
if
someone
has
chronic
pain
from
a
certain
part
of
their
body
and
the
brain
continues
to
receive
these
signals
of
pain
,
eventually
that
pain
signal
starts
coming
from
the
brain
itself
as
opposed
to
the
organ
anymore
.
So
if
you
were
to
take
out
so
say
,
for
example
,
that
pain
is
coming
from
your
pelvis
,
right
From
endometriosis
,
and
then
you
take
those
implants
out
or
you
put
some
on
a
contraceptive
and
now
I'm
kind
of
speaking
out
of
because
I
do
not
know
how
to
treat
endometriosis
.
But
if
that
pain
fires
over
and
over
and
over
again
and
then
you
remove
the
inciting
issue
,
if
that
pain
happened
for
such
a
long
period
of
time
,
the
brain
will
start
creating
those
pain
signals
by
itself
.
Speaker 1
7:41
Right
.
Speaker 2
7:42
And
that's
where
it's
just
chronic
pain
,
nerve
sensitization
,
bowel
dysfunction
,
and
that's
how
it's
all
kind
of
linked
together
.
Speaker 1
7:51
The
POTS
EDS
conversation
is
different
altogether
and
we
can
certainly
jump
into
that
too
,
which
is
where
I
kind
of
want
to
jump
into
,
because
this
is
kind
of
where
you
have
identified
a
lot
of
chronic
pain
issues
with
the
GI
and
how
it's
all
connected
,
and
I
think
something
that
many
of
us
struggle
with
is
the
fact
that
we
don't
have
just
endometriosis
,
we
have
all
of
these
other
things
,
myself
included
,
that
we
find
a
challenge
with
sifting
through
the
symptoms
and
the
diagnosis
and
everything
else
and
how
they
all
correlate
and
how
they
correspond
together
.
How
is
it
for
you
Because
you
do
a
lot
of
the
POTS
and
EDS
and
stuff
like
that
Beyond
the
endometriosis
,
a
lot
of
us
have
good
excision
.
We
don't
have
the
pain
from
the
endometriosis
anymore
,
and
you
kind
of
alluded
to
the
fact
that
you
know
there's
still
some
of
that
inflammation
.
However
POTS, EDS & Mast Cell Activation
Speaker 1
8:43
,
I'm
going
to
caveat
this
by
saying
is
it
that
or
is
it
some
of
these
other
coinciding
conditions
,
and
how
do
you
differentiate
that
?
Speaker 2
8:51
That's
a
really
good
question
.
So
you
know
,
the
patient
narrative
obviously
informs
a
lot
of
this
.
What's
really
challenging
in
these
chronic
invisible
conditions
is
that
testing
just
doesn't
do
service
to
what's
going
on
.
And
so
you
know
,
if
someone
said
,
you
know
I've
been
dealing
with
endometriosis
,
you
know
since
forever
pelvic
pain
,
you
know
dysmenorrhea
,
you
know
dyspareunia
and
and
part
of
our
job
as
a
physician
is
to
take
a
complete
review
of
systems
like
head
to
toe
.
So
how
are
your
bowel
movements
?
Do
you
have
constipation
,
do
you
have
diarrhea
,
do
you
have
bloating
?
And
then
the
chronology
is
a
big
part
of
this
.
So
it's
like
what
started
first
?
And
then
you
can
start
building
the
narrative
Did
endometriosis
lead
to
IBS
,
or
perhaps
is
it
just
endometriosis
?
Speaker 2
9:43
So
I'm
kind
of
painting
this
with
a
broad
brush
.
But
if
someone
says
,
hey
,
my
IBS
symptoms
really
rev
up
during
my
cycle
,
then
I'm
like
perhaps
this
is
all
endometriosis
.
But
if
someone's
like
I
have
endometriosis
but
then
I
have
IBS
just
going
on
a
day-to-day
basis
,
then
perhaps
it's
endometriosis
leading
to
IBS
.
And
then
on
top
of
that
there's
like
the
anxiety
and
stress
component
of
things
which
make
everything
worse
.
And
no
,
anxiety
and
stress
are
do
not
cause
IBS
.
They
make
it
worse
,
certainly
,
but
one
can
imagine
like
who's
not
stressed
out
or
incredibly
anxious
if
they
can't
figure
out
,
like
they
can't
go
to
the
dinner
without
running
to
the
bathroom
or
identifying
you
know
where
all
the
restrooms
are
,
like
it's
incredibly
anxiety
provoking
and
so
it
behooves
us
to
kind
of
touch
on
that
as
well
.
So
I
guess
it's
a
long
way
of
saying
.
Speaker 2
10:33
You
kind
of
have
to
listen
to
the
story
and
see
what
started
first
,
Right
.
So
if
someone
said
I've
had
end
of
disease
for
a
while
and
then
all
of
a
sudden
,
goodness
,
like
my
heart
races
when
I
get
up
,
tell
me
more
about
that
,
right
.
But
unfortunately
,
you
know
,
in
today's
healthcare
we
kind
of
have
docs
,
have
like
a
finite
period
of
time
with
patients
.
Right
,
they
have
30
minutes
.
It's
very
important
to
shoot
.
Okay
,
if
diarrhea
boom
,
like
what
kind
of
diarrhea
?
Later
you
kind
of
put
you
on
,
kind
of
run
a
few
tests
,
but
,
truth
be
told
,
there's
crosstalk
between
your
GI
system
and
,
like
any
OBGYN
issues
going
on
,
your
on
any
psychiatric
kind
of
disease
in
the
background
,
insomnia
,
and
so
it's
all
kind
of
plays
off
each
other
.
And
so
what
I
do
is
I
kind
of
what's
the
biggest
symptom
that
bothers
you
today
and
let's
really
drill
into
it
and
get
to
when
it
started
,
how
it
started
and
what
are
precipitating
things
stress
,
anxiety
,
food
to
really
get
it
to
why
it's
there
to
begin
with
.
Speaker 1
11:24
Talk
to
us
a
little
bit
about
what
you
see
in
symptoms
with
your
hypermobile
EDS
people
and
your
POTS
people
,
and
are
you
seeing
like
the
MCAS
people
Because
that's
a
big
part
of
a
lot
of
our
history
as
well
,
amongst
a
slew
of
other
things
,
of
course
but
what
are
the
things
that
you
see
most
in
those
patients
?
Because
I
bet
you
,
if
we
could
sit
down
and
identify
,
okay
,
these
are
some
of
our
symptoms
too
.
Here's
maybe
some
ways
we
can
address
that
.
What
do
you
typically
see
in
those
three
subsets
of
patients
?
Speaker 2
12:00
Yeah
,
so
they
land
in
my
lap
.
So
I'm
a
neurogastroenterologist
,
so
I
stole
this
from
this
amazingly
smart
doctor
,
dr
Brandler
,
who's
a
neurogastroenterologist
up
in
Seattle
,
and
it's
,
we
are
electricians
,
not
plumbers
,
okay
.
And
so
when
patients
come
to
me
they
have
GI
symptoms
,
but
then
they
start
talking
about
other
things
that
don't
necessarily
fit
into
IBS
.
So
I
initially
,
when
I
first
graduated
and
I
was
in
practice
,
I
took
on
a
lot
of
IBS
patients
.
I
just
happened
to
love
taking
care
of
that
patient
.
Speaker 2
12:31
But
then
someone
would
say
you
don't
have
IBS
.
But
all
of
a
sudden
when
I
get
up
,
my
heart
just
races
.
Like
that's
not
IBS
.
I
think
an
antiquated
view
of
that
is
like
,
oh
,
you're
stressed
and
stress
causes
anxiety
and
stress
causes
palpitations
.
But
this
is
different
.
Speaker 2
12:46
So
in
POTS
the
hallmark
feature
is
standing
up
and
just
feeling
like
your
heart
is
racing
.
Okay
,
and
with
that
I
would
say
that
brain
fog
is
a
really
big
symptom
there
.
And
then
kind
of
secondarily
,
you
know
,
some
people
get
a
lot
of
blood
pooling
in
their
feet
,
like
their
feet
get
swollen
.
But
yeah
,
certainly
the
standing
tachycardia
,
or
the
heart
racing
from
going
or
sitting
to
a
standing
position
,
is
the
hallmark
features
of
postural
orthostatic
tachycardia
syndrome
.
But
they
also
may
have
a
lot
of
GI
symptoms
getting
full
,
early
,
tons
of
bloating
,
loose
stools
,
conversely
constipation
.
So
the
POTS
GI
system
doesn't
really
follow
any
specific
rulebook
.
Speaker 2
13:25
Yeah
,
okay
,
so
mast
cell
activation
syndrome
is
and
of
course
this
can
be
linked
with
POTS
too
.
So
when
I'm
talking
to
one
of
these
patients
I'm
asking
all
these
questions
,
I'm
screening
for
every
one
of
these
things
to
see
if
we
can
kind
of
piece
this
together
.
But
the
hallmark
feature
of
mast
cell
activation
syndrome
is
probably
skin
manifestations
,
so
itching
,
rashes
,
secondarily
kind
of
ears
,
nose
and
throat
issues
,
rhinorrhea
,
eyes
watering
for
like
no
good
reason
.
And
then
GI
symptoms
are
kind
of
probably
coming
third
there
,
and
that's
bloating
,
diarrhea
,
lots
of
heartburn
and
someone
who
like
shouldn't
get
heartburn
.
You
know
,
heartburn
traditionally
affects
people
who
are
,
you
know
,
a
little
bit
,
a
little
bit
older
,
have
their
BMIs
,
are
probably
closer
to
30
.
Speaker 2
14:11
We
see
these
young
women
who
are
22
,
23
,
with
rip-roaring
heartburn
.
I'm
like
that
ain't
good
,
it
just
doesn't
make
any
sense
.
And
that's
MCAS
.
So
that's
where
.
So
just
one
of
the
,
without
getting
too
into
the
nittyitty
gritty
of
the
pathophysiology
of
MCAS
.
But
these
mast
cells
are
just
very
twitchy
.
They're
intended
to
be
selectively
defensive
against
certain
pathogens
that
our
body
doesn't
like
.
You
know
mold
if
anybody's
in
North
Carolina
like
me
.
Just
the
pollen
is
insane
,
so
mast
cells
are
supposed
to
be
acting
up
now
is
insane
,
so
muscles
are
supposed
to
be
acting
up
now
,
but
these
muscles
become
twitchy
and
react
to
virtually
everything
,
from
temperature
changes
to
emotional
changes
,
to
poor
sleep
,
to
medications
.
It's
really
wild
.
Speaker 2
14:52
And
one
of
the
chemicals
that
it
releases
and
it
releases
hundreds
of
chemicals-
is
histamine
,
and
histamine
plays
a
big
role
in
creating
acid
secretion
from
the
stomach
which
could
lead
to
heartburn
symptoms
.
But
for
all
intents
and
purposes
,
patients
don't
behave
like
traditional
gastroesophageal
reflux
patients
.
They
don't
respond
to
proton
pump
inhibitors
and
they
have
no
darn
reason
to
have
reflux
to
begin
with
,
right
,
they
don't
have
a
big
hiatal
hernia
,
which
is
a
traditional
risk
factor
for
heart
reflux
,
or
they're
not
overweight
,
and
so
that's
where
you
have
to
start
.
This
doesn't
quite
make
sense
,
okay
,
and
you
said
EDS
.
Speaker 1
15:27
EDS
,
this
is
a
big
one
for
us
,
okay
,
I
?
Speaker 2
15:29
have
a
lot
of
questions
for
this
one
.
So
again
,
I'm
a
GI
doctor
,
so
I
deal
with
a
lot
of
the
GI
manifestations
.
Speaker 1
15:36
Right
.
Speaker 2
15:36
But
they
certainly
screen
for
all
of
you
know
,
all
my
patients
who
I
you
know
,
who
have
MCAS
,
who
have
POTS
,
for
EDS-specific
symptoms
.
Speaker 2
15:44
And
the
Bait
and
Score
is
really
nice
,
testing
certain
joint
mobile
hyperflexibility
,
being
able
to
put
both
palms
on
the
floor
with
extended
knees
,
or
able
to
bend
your
pinky
back
beyond
a
certain
angle
.
You'd
be
able
to
bend
your
thumb
beyond
a
certain
angle
,
and
you
can
look
up
the
Bait
and
Score
and
kind
of
assess
for
yourself
.
But
did
you
have
kind
of
weird
random
joint
subluxations
as
a
kid
?
Did
your
knee
just
pop
out
of
joint
,
like
that's
not
supposed
to
happen
,
and
they're
like
oh
yeah
,
we
put
a
brace
on
it
and
kind
of
said
that
was
fine
.
I
was
like
that's
not
fine
,
reasonable
,
but
just
like
,
yeah
,
I
was
playing
kickball
and
my
knee
just
popped
out
of
place
,
like
that's
not
a
thing
,
right
.
So
,
in
a
nutshell
,
like
a
very
condensed
,
oversimplified
way
of
kind
of
,
I
think
,
compartmentalizing
those
conditions
.
So
it's
really
important
,
you
know
,
to
really
do
a
thorough
review
of
systems
and
ask
all
the
questions
so
you
can
really
understand
why
something
.
Speaker 1
16:44
And
so
and
I
yeah
,
and
it's
so
true
because
I
think
you
know
we
had
kind
of
talked
previously
to
this
about
providers
being
curious
,
right
,
like
we
.
We
need
to
be
able
to
seek
a
provider
who
is
curious
if
we
have
all
of
these
symptoms
,
because
I
feel
like
a
lot
of
us
,
especially
for
endometriosis
patients
,
we
go
in
primarily
with
IBS
.
We
get
diagnosed
with
that
time
and
time
again
.
It's
not
IBS
.
A
lot
of
times
it
tends
to
go
away
after
excision
surgery
or
it
lessens
at
least
where
we
can
eat
things
again
.
Speaker 1
17:21
Food
sensitivity
is
a
huge
thing
for
endometriosis
patients
and
histamine
response
to
all
of
these
things
.
Speaker 1
17:30
You
know
we're
seeing
such
a
correlation
between
all
of
this
stuff
,
and
a
lot
of
it
again
is
because
there
can
be
lesions
on
your
bowel
and
that's
something
that
happens
quite
often
.
Speaker 1
17:42
And
you
know
our
pelvis
is
you
think
about
it
and
we're
just
all
this
collective
little
unit
of
organs
right
,
and
they're
all
in
there
together
in
this
inflammatory
state
.
And
so
once
we
get
that
taken
care
of
,
a
lot
of
times
it
becomes
tricky
because
most
of
us
don't
realize
we're
living
with
these
other
signs
and
symptoms
of
these
other
conditions
until
we
get
proper
excision
and
we're
not
having
the
pain
from
endometriosis
anymore
,
and
so
to
me
hearing
you
talk
about
all
of
this
,
interestingly
enough
,
they
all
constipation
,
diarrhea
,
bloating
,
brain
fog
,
fatigue
,
similar
to
endometriosis
and
this
is
something
that
I
didn't
identify
until
after
my
excision
as
well
is
that
I
had
all
these
other
things
going
on
.
It
wasn't
just
one
or
the
other
,
but
something
that
a
lot
of
patients
have
learned
,
and
that
,
something
that
I'm
learning
,
is
that
within
the
EDS
space
,
the
laxity
in
tissues
creates
a
lot
of
issues
with
vascular
issues
and
otherwise
.
How
does
that
correlate
into
the
GI
field
?
Speaker 2
18:48
Yeah
,
that's
a
really
good
question
.
So
EDS
is
a
nuisance
Goodness
.
So
unfortunately
it
is
a
condition
sometimes
inherited
,
sometimes
not
that
affects
the
connective
tissue
and
connective
tissue
is
ubiquitous
,
it's
everywhere
,
it
affects
every
part
of
the
GI
tract
,
unfortunately
,
and
it
doesn't
play
by
any
specific
rule
.
So
somebody
may
have
upper
gi
symptoms
because
they
developed
a
hiatal
hernia
at
a
very
early
age
.
The
diaphragm
is
intended
to
hold
down
our
lower
esophageal
sphincter
to
prevent
gastric
contents
from
coming
up
into
our
esophagus
.
But
the
ligament
that
holds
the
diaphragm
to
lower
esophageal
sphincter
can
become
a
little
bit
loose
and
lax
in
the
context
of
an
eds
and
then
they
can
develop
a
little
hernia
there
which
leads
to
a
rip-roaring
gastroesophageal
reflex
disease
.
The
connective
tissue
in
our
esophagus
can
be
affected
,
leading
to
dysphagia
or
difficulty
swallowing
and
then
working
all
the
way
down
.
Perhaps
it
affects
your
small
bowel
.
To
where
your
small
bowel
doesn't
empty
very
well
,
you
develop
small
intestinal
bacterial
overgrowth
and
then
your
colon
right
you
can
develop
constipation
,
because
it's
just
your
constipation
isn't
as
moving
as
well
.
And
then
there
is
something
called
visceroptosis
which
is
challenging
.
But
our
organs
are
supposed
to
be
supported
by
connective
tissue
but
it's
not
working
.
It
sags
and
our
intestines
,
our
small
bowel
can
sag
into
our
pelvis
and
lead
to
obstructive
symptoms
in
our
colon
,
and
so
it
can
be
.
Speaker 2
20:16
You
just
have
to
keep
an
open
mind
to
someone
with
EDS
,
because
they
can
develop
everything
.
And
so
the
traditional
thinking
in
medicine
is
when
you
have
this
differential
diagnosis
of
what
you
think
may
be
going
on
,
based
on
a
patient's
presentation
.
But
,
quite
frankly
,
they
can
have
like
everything
.
You
just
have
to
keep
an
open
mind
and
you
try
one
thing
.
And
I
always
tell
patients
like
,
look
,
this
is
super
complex
,
this
is
not
like
a
pneumonia
.
I
give
you
amoxicillin
.
10
days
later
you're
able
to
,
like
you
know
,
walk
up
the
stairs
again
and
you'll
be
a
hundred
percent
better
.
Speaker 2
20:44
We're
looking
for
incremental
changes
because
these
are
really
tough
.
And
so
I
,
in
my
practice
,
we
will
try
something
.
Get
In
my
practice
,
we
will
try
something
,
get
some
diagnostic
information
and
I'll
say
,
look
,
I'm
looking
for
30%
improvement
by
next
year
.
And
if
we
misfire
,
then
I
looked
in
the
wrong
place
and
that's
on
me
and
I'm
sorry
,
but
this
is
tough
right
.
And
so
we
get
more
data
and
try
to
figure
it
out
.
But
you
just
have
to
keep
such
an
open
mind
and
understand
how
EDS
can
affect
people
.
And
,
quite
frankly
,
it
could
be
like
anything
and
then
forget
,
like
you
know
,
the
vascular
compression
symptoms
like
immediate
arcoteligament
syndrome
or
SMA
syndrome
,
which
are
incredibly
unique
in
the
general
population
.
But
if
you
have
EDS
and
this
is
why
you
have
to
screen
people
for
joint
laxity
in
clinic
,
because
it
expands
the
differential
to
all
this
weird
stuff
that
,
truth
be
told
,
you
never
see
unless
you
look
for
it
,
and
so
it
can
get
quite
challenging
.
Speaker 1
21:36
Yes
,
I
mean
this
is
a
lot
of
us
struggle
with
this
.
Now
we're
seeing
May-Thurner
and
Nutcracker
syndrome
being
all
in
correlation
with
it
.
It's
a
lot
,
right
,
indo
patients
.
We're
professional
patients
,
unfortunately
,
and
that's
it's
.
We're
professional
patients
,
unfortunately
,
and
that's
EDS Impact on the GI System
Speaker 1
21:57
that's
hard
for
a
lot
of
us
,
right
,
cause
we
give
so
much
to
our
care
and
trying
to
find
a
solution
to
a
problem
,
and
when
it's
not
a
an
easy
solution
,
it
gets
hard
and
and
so
I
love
that
you
have
you
don't
put
everything
on
the
patient
,
that
the
patient
.
We
are
all
research
projects
,
essentially
,
and
we
should
be
.
And
I
say
that
because
if
you
were
to
put
us
all
in
a
box
,
you
would
miss
a
lot
of
diagnoses
,
you
would
miss
half
of
our
care
if
you
put
everyone
in
the
same
box
,
right
.
So
I
love
that
you
don't
do
that
,
because
we
are
all
so
unique
in
our
symptoms
.
But
how
do
you
address
these
symptoms
?
How
do
you
address
the
EDS
patients
who
are
struggling
?
How
do
you
address
those
who
have
MCAS
or
POTS
when
it
comes
to
the
GI
stuff
?
Speaker 2
22:50
Yeah
,
so
it
starts
with
certainly
an
interview
to
understand
what's
the
biggest
thing
that
bothers
you
.
Okay
,
so
if
it's
harper
and
they
are
happen
to
be
a
22
year
old
,
like
otherwise
healthy
person
,
I
would
no
reason
to
have
harper
.
I'm
like
,
all
right
,
well
,
let's
,
if
we
treat
the
mcas
,
the
harper
,
and
we'll
get
better
and
you
can
treat
them
with
like
Pepsid
,
over-the-counter
H1
blockers
.
But
it
sounds
like
I'm
really
bloated
like
all
the
time
.
Okay
,
well
,
and
you're
thinking
about
,
if
someone
has
endometriosis
or
EDS
and
POTS
,
then
you
got
to
start
thinking
about
is
this
gastroparesis
?
Is
this
small
intestinal
bacterial
overgrowth
?
So
,
truthfully
,
the
presenting
symptom
and
you
don't
want
to
discard
the
ancillary
symptoms
I
can't
sleep
the
brain
fog
but
the
presenting
symptoms
like
what
is
the
biggest
thing
that
bothers
you
today
Should
drive
the
discussion
and
where
you
go
.
So
is
it
I
get
full
right
after
eating
,
or
,
goodness
,
I
have
just
horrible
heartburn
that
keeps
me
up
all
night
,
or
I
haven't
pooped
in
like
13
days
,
or
,
conversely
,
I
can't
stay
off
the
toilet
.
So
that
informs
kind
of
where
we
start
the
investigation
.
Because
,
as
you
mentioned
,
so
in
POTS
,
right
,
the
underlying
issue
to
POTS
.
So
POTS
is
a
syndrome
.
Right
,
it's
just
a
constellation
of
symptoms
,
but
the
issue
underlying
it
is
dysautonomia
.
So
dysautonomia
is
the
nervous
system
that
does
everything
in
our
body
right
.
It
affects
our
cardiovascular
system
,
how
fast
our
heart
should
beat
or
shouldn't
beat
.
It
helps
with
vasoconstriction
to
kind
of
help
get
blood
back
to
our
brain
and
our
heart
Also
,
unfortunately
,
is
really
important
in
digestion
.
It
helps
things
move
and
coordinate
and
squeeze
,
but
it
doesn't
affect
the
same
.
Speaker 2
24:32
If
you
have
two
patients
with
POTS
,
it
can
be
so
completely
different
one
person
versus
the
other
,
and
so
as
a
provider
,
you
have
to
be
aware
of
all
the
sequelae
of
POTS
in
patients
from
a
GI
perspective
to
know
where
to
target
your
efforts
.
And
it's
really
important
to
be
informed
as
a
patient
too
,
and
hopefully
you
have
a
provider
that
will
listen
to
you
.
If
you
say
,
hey
,
you
know
I
have
POTS
,
goodness
,
and
I
know
that
in
POTS
patients
they
can
develop
these
GI
symptoms
and
I
have
bloating
,
like
could
it
be
one
of
these
?
And
if
you
don't
know
,
can
you
send
me
to
someone
who
does
?
And
if
you
say
it's
anxiety
in
my
head
,
I'm
going
to
give
you
a
horrible
Yelp
review
and
I'll
leave
here
immediately
.
Don't
do
that
.
Speaker 2
25:12
I
mean
,
I
do
think
,
generally
speaking
,
doctors
are
really
trying
to
do
.
I
give
doctors
the
benefit
of
the
doubt
and
I
know
people
have
had
horrible
experiences
.
I
can't
endorse
everything
people
have
said
or
done
,
because
there
have
been
some
things
out
there
that
are
certainly
uncalled
for
,
unreasonable
,
but
there
are
.
As
someone
who
is
in
the
system
right
now
,
you
don't
have
a
lot
of
time
with
patients
,
yeah
,
and
it's
someone
who's
medically
very
complex
.
You're
just
.
You
know
,
if
you
have
,
you've
been
treating
one
thing
the
same
way
your
whole
life
,
and
then
someone
comes
in
with
something
you
just
don't
know
how
to
address
.
You
don't
as
the
expert
.
You
don't
want
to
say
you
don't
know
.
Speaker 1
25:48
Right
,
Like
I
get
that
.
Speaker 2
25:49
Is
it
okay
to
say
it's
all
in
your
head
?
It
is
not
.
But
a
lot
of
doctors
have
a
tough
time
saying
I
don't
know
,
and
perhaps
let
me
do
some
research
to
figure
out
what
this
is
.
A
lot
of
people
are
kind
of
anchored
to
what
they've
always
known
and
always
believed
,
and
that's
where
the
disconnect
happens
.
And
so
,
as
we
talked
about
before
,
patients
are
incredibly
curious
,
but
doctors
need
to
be
incredibly
curious
.
Like
things
change
,
things
don't
fit
in
the
box
all
the
time
,
and
if
it
doesn't
fit
in
the
box
,
it's
not
okay
to
say
it's
in
someone's
head
.
It's
not
okay
to
dismiss
anybody
,
but
perhaps
try
to
do
some
research
.
Speaker 1
26:21
Right
With
pots
alone
.
They
always
say
high
intake
of
salt
is
what's
ideal
,
and
I
can
tell
you
,
as
someone
who
has
pots
salt
can
be
great
,
but
I
also
have
a
kidney
disorder
,
so
I
always
feel
like
this
catch-22
,
right
,
let's
just
pile
on
my
little
onion
,
you
know
.
And
so
is
that
a
long-term
solution
for
POTS
,
though
,
or
are
there
other
ways
to
manage
symptoms
from
,
specifically
,
probably
more
the
GI
for
what
you're
used
to
?
But
are
there
ways
to
manage
those
symptoms
other
than
atrocious
amount
of
salt
and
sodium
?
Speaker 2
26:56
Can
I
throw
something
back
at
you
?
Speaker 1
26:58
Please
do
.
Speaker 2
26:59
Why
were
you
told
to
eat
a
lot
of
salt
?
Speaker 1
27:02
That's
a
really
good
question
.
I
don't
know
.
Speaker 2
27:05
Right
,
and
so
this
is
why
,
when
I
talk
about
recommendations
to
patients
,
I'm
like
you're
going
to
do
this
.
But
this
is
why
you
need
to
do
this
and
this
is
what
it's
going
to
work
for
,
because
if
it's
not
working
,
let's
counter
that
with
something
else
.
So
the
salt
intake
doesn't
necessarily
improve
a
whole
lot
of
GI
related
conditions
,
but
the
reason
why
?
So
not
all
pots
is
created
equal
.
But
generally
speaking
,
you
know
,
when
you
stand
up
,
there's
a
tremendous
shift
in
blood
.
So
when
you're
sitting
down
,
blood
pools
in
your
feet
.
Speaker 2
27:38
Okay
,
when
you
stand
up
,
there's
a
lot
of
things
that
have
to
work
perfectly
in
concert
to
get
that
blood
back
to
your
heart
and
back
to
your
brain
so
you
don't
hit
the
floor
and
so
your
heart
doesn't
race
because
it
receives
adequate
blood
volume
.
So
in
dysautonomia
and
POTS
,
blood
takes
quite
a
while
to
get
back
to
your
heart
.
So
your
heart's
like
Managing POTS & Achieving Long-term Relief
Speaker 2
27:50
,
oh
,
my
goodness
,
I'm
standing
up
.
I
got
to
make
sure
the
brain
is
okay
.
So
it
starts
really
,
really
beating
quite
a
bit
to
really
increase
that
stroke
volume
and
get
the
blood
to
your
brain
.
So
we
know
that
patients
with
POTS
have
a
difficult
time
shifting
that
blood
up
to
their
brain
,
but
we
also
know
that
patients
with
POTS
have
less
blood
volume
than
the
average
person
.
Their
kidneys
just
dump
volume
unnecessarily
,
and
that's
kind
of
a
different
conversation
in
and
of
itself
.
So
you're
playing
from
behind
from
two
perspectives
.
There's
a
discoordination
in
the
veins
and
the
arteries
veins
primarily
,
but
there's
also
a
massive
.
You
have
less
blood
circulating
,
and
so
what
salt
does
is
it
retains
blood
within
your
vasculature
.
Okay
,
and
so
by
increasing
your
blood
volume
,
you're
getting
more
blood
back
to
your
heart
.
So
you're
not
really
dealing
with
the
tachycardia
because
it's
seeing
more
volume
.
Speaker 2
28:38
So
,
yes
,
eating
six
to
eight
grams
of
salt
today
is
really
challenging
,
and
patients
like
this
sounds
impossible
like
this
.
This
is
ridiculous
.
I
can't
lick
a
salt
block
all
day
right
,
so
that's
not
working
.
You
know
,
and
I
always
work
on
the
lifestyle
pieces
first
.
So
compression
stockings
,
preferably
up
to
the
waist
,
if
you
can
tolerate
that
,
right
,
drinking
two
to
three
liters
of
water
a
day
and
a
lot
of
that
,
you
know
if
you
can
,
half
of
that
being
electrolyte
drinks
,
gatorade
Powerade
.
There's
a
quite
a
bit
of
sugar
content
in
there
,
and
there
are
great
recipes
online
for
making
your
own
kind
of
super
high
sodium
electrolyte
drink
that
are
laden
with
glucose
.
And
then
sometimes
,
if
we
need
to
,
we
use
medications
.
Speaker 2
29:17
Okay
so
there
are
medications
to
help
the
veins
squeeze
there's
something
called
Midodrine
,
and
there's
also
medications
to
increase
your
blood
volume
,
called
Florina
for
flugacortisone
.
Both
of
those
have
potential
side
effects
,
so
you're
always
weighing
the
risks
and
the
benefits
,
but
everybody's
case
is
completely
different
.
So
some
people
are
eating
a
bunch
of
salt
,
drinking
a
bunch
of
water
,
and
they
feel
fantastic
,
and
some
people
are
like
this
is
just
not
cutting
it
,
like
my
heart
is
beating
out
of
my
freaking
chest
.
This
is
brutal
,
and
you're
like
oh
well
,
maybe
it's
time
to
talk
about
medications
.
And
so
everybody's
approach
is
a
bit
different
.
Speaker 1
29:47
Yeah
,
I
just
feel
like
it's
like
is
this
sustainable
to
feel
like
you're
constantly
with
salt
?
I'm
like
this
can't
be
healthy
,
but
then
it's
a
catch-22
,
right
,
because
you
have
something
that
benefits
from
doing
it
,
but
you're
also
it
is
a
catch-22
,
I
think
,
for
a
lot
of
people
who
are
feeling
like
do
I
have
to
do
this
my
entire
life
?
Speaker 2
30:07
Right
,
right
,
but
I
think
if
you
know
why
you're
doing
it
no-transcript
of
counters
it
goes
back
to
just
good
communication
between
the
care
team
and
the
patient
.
Speaker 1
30:45
Yeah
,
well
,
and
I
think
too
.
I
mean
,
we've
talked
a
lot
about
the
care
and
the
patient
,
but
then
let's
also
say
patients
do
need
to
be
held
accountable
to
follow
practices
which
we're
not
always
good
at
.
I'm
an
ADHDer
over
here
.
I
can
do
things
for
about
0.2
seconds
before
I
get
a
little
bored
and
I
don't
want
to
do
it
anymore
.
So
we
have
to
.
How
do
we
accommodate
those
patients
a
little
bit
better
?
The
reality
is
,
is
that
if
we
are
living
with
these
conditions
long-term
our
whole
life
,
we
have
to
learn
how
to
live
with
it
.
Well
,
right
,
what
are
some
approaches
that
you
take
with
patients
to
help
that
maybe
psychosomatic
aspect
of
it
,
which
I
hate
that
word
psychosomatic
why
do
we
call
it
?
Speaker 2
31:32
It's
so
pejorative
,
so
pejorative
.
Yeah
,
I
emphasize
education
a
lot
,
so
I'm
always
I'm
recommending
books
to
patients
so
they
can
understand
why
POTS
happens
,
because
when
you're
doing
something
,
I
want
you
to
know
exactly
why
you're
doing
that
,
because
this
is
a
team
effort
.
This
ain't
on
me
,
this
ain't
on
you
,
this
is
us
working
together
to
figure
this
out
.
So
I
don't
put
it's
not
my
job
to
fix
you
.
I'm
your
guide
,
it's
kind
of
your
job
,
but
I'm
here
to
like
,
I'm
here
to
help
,
but
you
can't
do
your
job
in
getting
better
,
like
you
shouldn't
rely
on
doctors
.
You
shouldn't
,
because
this
is
your
life
Like
,
and
doctors
are
just
people
Like
we
just
read
a
bunch
,
bunch
,
that's
all
we
did
and
took
some
tests
,
that's
it
.
And
so
I
really
try
to
educate
people
a
ton
so
they
know
exactly
why
they're
doing
this
.
And
I
recommend
books
for
patients
with
IBS
,
for
POTS
patients
.
Speaker 2
32:21
I
have
a
different
set
of
books
For
EDS
,
different
set
of
books
,
mcas
different
set
of
books
so
you
can
understand
not
only
the
pathophysiology
of
what's
going
on
.
I'm
like
,
look
,
you
don't
need
to
read
,
you
know
Grey's
Anatomy
or
something
like
wildly
boring
.
Patient
experience
books
are
pretty
awesome
because
they
can
tell
you
what
they
did
.
Maybe
,
again
,
they
didn't
.
What
they
did
isn't
going
to
work
for
you
,
but
there
are
stories
of
hope
that
someone
who
came
from
really
they
came
from
behind
and
really
have
figured
this
thing
out
and
their
,
their
journey
is
not
going
to
be
the
same
as
yours
,
but
it
gives
you
a
basis
for
understanding
why
the
disease
processes
,
how
other
people
got
better
.
The
fact
that
you
can
get
better
is
a
reality
.
That
is
out
there
.
Yeah
,
I
think
it's
a
long
way
to
say
it's
like
.
I
really
try
to
educate
people
and
I
give
them
a
lot
of
materials
to
go
home
and
some
people
throw
it
in
the
trash
.
I
get
that
.
I
get
it
and
I
don't
give
people
quizzes
when
they
come
back
in
.
Speaker 2
33:09
Although
maybe
they
should
you
failed
,
see
you
later
.
No
,
I
mean
,
it's
a
team
effort
,
man
.
It's
a
team
effort
and
we
work
on
it
together
,
and
that's
my
.
I've
always
thought
of
it
as
that
way
.
It's
a
partnership
about
informed
consent
.
Speaker 1
33:32
You
can't
make
an
informed
decision
if
you
don't
have
all
the
education
behind
it
,
and
that
is
something
that
I
think
a
lot
of
us
lack
in
our
decision
making
is
that
informed
consent
.
The
provider
shouldn't
be
making
that
decision
,
but
they
can
give
you
the
information
to
make
the
best
decision
for
your
care
.
And
so
I
think
there's
that
aspect
of
taking
responsibility
for
those
decisions
too
and
owning
them
and
doing
your
education
,
of
taking
responsibility
for
those
decisions
too
and
owning
them
and
doing
your
education
.
Even
when
you're
exhausted
Like
I
get
that
100%
.
When
you
have
brain
fog
,
fatigue
,
you
don't
feel
good
,
you're
barely
getting
out
of
bed
in
the
morning
.
I
get
that
aspect
of
it
for
sure
.
But
you
can't
Education as Part of Patient Care
Speaker 1
34:06
make
an
informed
decision
if
you
don't
learn
the
education
and
put
the
work
in
,
and
that's
hard
,
it's
very
hard
to
do
as
a
patient
,
especially
when
it
comes
to
owls
,
because
no
one
really
wants
to
talk
about
that
other
than
you
.
Clearly
you
want
to
talk
about
that
.
Speaker 2
34:23
If
you
show
me
a
picture
of
poop
,
I
will
look
at
it
.
Speaker 1
34:25
Yeah
,
and
I'm
not
going
to
be
bummed
out
by
it
.
Speaker 2
34:27
It's
not
weird
,
it's
just
pulling
a
job
,
it's
,
it's
education
.
Speaker 1
34:29
It's
dinner
conversation
at
this
point
.
My
son
is
five
.
Speaker 2
34:35
I
told
him
the
other
day
and
I
probably
shouldn't
have
told
him
this
,
but
I
was
like
you
know
what
your
dad
does
for
a
living
?
He
goes
.
What
I
said
I
look
at
butts
all
day
,
he
goes
.
Excuse
me
,
it's
the
same
thing
as
telling
a
five-year-old
boy
that
I'm
Michael
Jordan
.
My
wife
was
like
why
did
you
say
it
like
that
?
That's
not
a
good
idea
.
But
yeah
,
so
poop
,
you
know
it
is
.
I
mean
,
we
all
poop
.
It's
really
important
and
when
we
don't
poop
,
well
,
it
causes
a
lot
of
stress
and
anxiety
.
So
it's
important
to
hash
that
out
.
Can
I
ask
you
,
as
someone
with
endometriosis
,
what
are
some
of
the
common
bowel
issues
that
people
like
I
see
people
in
clinic
but
what
is
like
,
what
are
some
of
the
day-to-day
concerns
that
have
come
up
in
your
life
that
you'd
,
you
know
,
that
think
you
think
people
would
really
want
to
hear
about
in
terms
of
just
making
sense
,
heads
and
tails
of
why
things
are
the
way
they
are
?
Speaker 1
35:22
That's
a
wrap
of
part
one
of
our
two
part
series
,
and
if
this
episode
had
you
nodding
along
,
taking
notes
or
just
feeling
seen
,
you're
not
going
to
want
to
miss
the
next
one
.
In
part
two
,
we're
diving
into
some
seriously
important
and
often
overlooked
territory
like
painful
bowel
movements
,
the
gut
microbiome
and
how
all
of
that
ties
into
chronic
illness
.
Dr
Zach
even
flips
the
script
a
bit
,
asking
his
own
questions
,
so
you
get
to
learn
right
alongside
him
.
It's
real
,
it's
raw
and
it's
packed
with
insight
.
So
make
sure
you're
following
and
share
this
episode
with
someone
who
needs
it
,
and
get
ready
because
part
two
is
coming
in
hot
.
Until
next
time
,
continue
advocating
for
you
and
for
others
.