Send us a text with a question or thought on this episode ( We cannot replay from this link)
What if your “IBS” isn’t just a gut problem—but part of a larger endometriosis story that involves nerves, immune triggers, and the way your body processes pain? We sit down with a neurogastroenterologist, Dr. Zachary Spiritos and colorectal surgeon, Dr. Vincent Obias, to connect the dots between bowel endometriosis, mast cell activation, dysautonomia, and the stubborn symptoms that linger after surgery. No platitudes here—just clear explanations, candid timelines, and practical strategies that help you make sense of complex, overlapping conditions.
We explore how deep infiltrating endometriosis can change rectal compliance and bowel habits, why post-op bloating and urgency often follow colorectal procedures, and when those symptoms should improve. From the GI side, we challenge the “IBS” catch-all by listening for patterns—cyclical pain, flushing, migraines, brain fog, POTS—that point to mast cell activation or brain–gut dysregulation. You’ll hear how perioperative planning for MCAS (H1/H2 blockers, steroid rescue, anesthesia choices, fluids for POTS) reduces flares, and why excision by experienced teams beats ablation for long-term outcomes.
We also get real about the gray areas: normal tests with abnormal lives, “invisible” inflammation, and how hypermobility can complicate recovery. Expect concrete ideas—targeted imaging and ultrasound for bowel nodules, timelines for healing, SIBO and adhesions as culprits, pelvic floor retraining, sleep as a pain modulator, and GI-focused CBT or hypnosis to calm anticipatory anxiety. The big takeaway: better results come from better teams. When surgery, neuro-GI care, anesthesia planning, and pelvic rehab align, the gut, the nerves, and the person finally get on the same page.
If this conversation helped you see your symptoms in a new light, follow the show, share with a friend who needs answers, and leave a review with your top question for a future episode. Your story might guide our next deep dive.
Website endobattery.com
Endo Beyond the Pelvis
Alanna
0:00
What
happens
when
endometriosis
doesn't
just
affect
the
pelvis,
but
the
gut,
the
nerves,
and
the
very
way
the
body
communicates
with
itself?
Two Specialists, One Complex Problem
Alanna
0:08
Today's
episode
brings
together
two
specialties
who
don't
often
sit
at
the
same
table,
a
neurogastroenterologist
and
a
colorectal
surgeon
to
unravel
why
so
many
patients
fall
through
the
cracks,
from
bowel
endometriosis
to
mast
cell
activation,
from
lingering
post-op
symptoms
to
the
role
of
multidisciplinary
care.
This
conversation
Why Answers Aren’t Straightforward
Alanna
0:29
gets
real
about
the
complexity
of
endo
and
why
answers
aren't
always
straightforward.
If
When Surgery Doesn’t End Symptoms
Alanna
0:35
you've
ever
wondered
why
symptoms
persist
even
after
surgery,
or
why
your
GI
and
pelvic
pain
seem
inseparable,
you're
gonna
want
to
lean
in
for
this
one.
Welcome And Host’s Mission
Alanna
0:46
Let's
get
started.
Community, Not Medical Advice
Alanna
0:50
Welcome
to
Endo Battery,
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
Many Views, One Table
Alanna
1:05
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
Stories And Expert Insights
Alanna
1:13
me
as
I
share
stories
of
strength,
resilience,
and
hope,
from
personal
experiences
to
expert
insights.
Meet The Host And Show
Alanna
1:20
I'm
your
host,
Alana,
and
this
is
Indobattery,
charging
our
lives
when
Endometriosis
drains
us.
Coffee, Table, And Guests
Alanna
1:27
Welcome
back
to
Indobattery.
Grab
your
cup
of
coffee
or
your
cup
of
tea
and
join
me
at
the
table.
Introducing The Physicians
Alanna
1:33
Today
I'm
honored
to
welcome
two
incredible
physicians
to
the
table,
both
whom
bring
unique
expertise
and
deep
commitment
to
caring
for
patients
with
complex
conditions.
Dr. Spiritos’ Background
Alanna
1:43
First,
we
have
Dr.
Zach
Spiritos,
a
neurogastroenterologist
and
internist
whose
journey
took
him
from
Philadelphia
to
North
Carolina,
where
he's
now
rooted
with
his
family.
Dr.
Spiritos
trained
at
UNC
School
of
Medicine,
completed
his
residency
at
internal
medicine
at
Emory
University,
and
went
on
to
a
fellowship
in
gastroenterology
at
His Focus And Approach
Alanna
2:04
Duke.
He
specializes
in
a
wide
range
of
gastrointestinal
and
liver
disorders
with
particular
interest
in
irritable
bowel
syndrome,
functional
abdominal
pain,
motility
disorders,
and
dysautonomia,
including
conditions
like
POTS
and
mast
cell
activation
syndrome.
He
also
has
expertise
in
GI
complications
connected
to
hypermobility
syndromes
like
Eler
Stanlose.
Hypermobility And GI Links
Alanna
2:27
What
sets
Dr.
Spiritos
apart
is
his
holistic
approach
weaving
together
nutrition,
lifestyle,
and
gut
brain
therapies
to
empower
his
patients.
Also
joining
us
today
is
Dr.
Vincent
Obius,
a
professor
of
surgery
and
chief
of
the
Division
of
Colorectal
Surgery
for
the
National
Capital
Region.
Dr.
Obius
trained
at
the
Medical
Holistic Gut-Brain Care
Alanna
2:47
College
of
Virginia,
Eastern
Virginia
Medical
School,
and
Cleveland
Clinic
with
additional
advanced
training
and
laparoscopic
colorectal
Dr. Obias’ Surgical Profile
Alanna
2:55
surgery
at
University
Hospital's
Case
Medical
Center.
He
is
double
board
certified
in
general
and
colorectal
surgery,
and
his
specialties
include
robotic
minimally
invasive
techniques
as
well
as
surgery
for
deep
infiltrating
endometriosis.
Training And Specialties
Alanna
3:10
Beginning
October
2025,
Dr.
OBS
will
be
joining
Dr.
Melissa
McHale
and
Vicky
Vargas
as
a
partner
at
Washington
Endometriosis
and
Complex
Surgery
Group.
His
research
and
clinical
work
have
made
a
lasting
impact,
particularly
in
robotic
surgery
outcomes
and
complex
endometriosis
care.
Together,
these
two
Robotic And DIE Expertise
Alanna
3:30
doctors
bring
insights
from
both
the
gastrointestinal
and
surgical
perspectives,
making
today's
conversation
one
that
promises
to
be
both
informative
and
empowering
for
patients
and
providers
alike.
Please
help
me
in
welcoming
Dr.
Zach
Spiritos
and
Dr.
Vincent
Obius
to
the
table.
Thank
you
both
so
much
for
joining
me
today,
Upcoming Practice Move
Alanna
3:50
sitting
down
at
the
table
for
this
conversation
that's
a
little
nuanced
in
direction,
as
that
you
guys
don't
typically
work
hand
in
hand
together,
but
often
symptoms
go
hand
in
hand
somehow.
Indopatients
are
working
through
the
neurogastroenterology
as
well
as
colorectal
side,
trying
to
figure
out
the
different
pieces.
So
Why This Duo Matters
Alanna
4:08
thank
you
both
so
much
for
sitting
down
and
doing
this
with
me.
Dr. Zac Spiritos
4:10
Well,
yeah.
Thanks
for
having
us.
Thank
you
very
much.
Alanna
4:13
Can
you
give
us
each
a
background?
And
we'll
start
with
you,
Vince,
a
little
background
on
what
you
do
and
kind
of
what
you
specialize
in
so
that
we
have
a
good
place
to
start.
Dr. Vince Obias
4:22
Sure.
I'm
a
colorectal
surgeon,
board
certified,
about
20
years
of
practice.
Um,
I
take
care
of
deep
infiltrating
endometriosis,
colon
cancer,
rectal
cancer,
reticulitis,
inflammatory
bowel
disease.
I've
been
doing
um
endometriosis
Setting The Conversation
Dr. Vince Obias
4:36
surgery
with
my
minimally
invasive
gynecology
colleagues,
both
at
GW
and
Hopkins,
and
it's
uh
it's
a
passion
of
mine.
There's
a
lot
of
surgeons
who
take
care
of
cancer,
me
being
one
of
them,
but
there
are
Bowel Endo: Team Approach
Dr. Vince Obias
4:48
very
few
that
uh
take
care
of
endometriosis,
and
I'm
starting
to
specialize
in
it,
and
it's
incredible.
Some
of
the
most
challenging
cases
are
of
women
with
endometriosis,
and
certainly,
you
know,
it's
a
population
that
uh
can
really
um
you
know
benefit
from
someone
who
has
a
lot
of
experience
in
pelvic
surgery.
So
I'm
very,
very
excited
about
it.
Alanna
5:06
Yeah.
Zach,
you
we've
had
you
on
before,
but
you're
back
again.
Dr. Zac Spiritos
5:09
I'm
a
neurogastroenterologist.
So
I
trained
a
Duke,
and
then
I
was
at
UNC
and
then
branched
out
to
do
my
own
practice.
I
uh
work
Symptoms And Broad Workups
Dr. Zac Spiritos
5:17
with
folks
that
not
only
have
issues
with
the
tube
itself
of
the
GI
tract,
uh
the
namely
the
esophagus
to
the
rectum,
but
also
the
wiring
between
the
tube
and
the
central
nervous
system,
specifically
how
the
tube
is
perceived
and
felt,
and
also
how
it
moves
and
propagates
kind
of
food,
debris
towards
our
rectum.
Uh,
and
yeah,
and
try
to
help
people
work
through
this
space
as
well.
Alanna
5:38
Yeah.
And
I
think
I
didn't
put
these
pieces
together
very
well
prior
to
us
kind
of
talking
about
this,
but
there
were
so
many
questions
last
time
that
Zach
and
I
did
a
podcast
together
that
I
felt
like
I
couldn't
answer
these
questions
How Endo Alters Mechanics
Alanna
5:51
and
they
were
pretty
prevalent.
Like
a
lot
of
people
were
were
asking
these
questions.
And
so
just
jumping
into
this,
I
really
want
to
get
a
better
idea
of
how
it
all
functions
in
your
own
specialties,
if
you
will.
Can
you
describe
the
role
of
bowel
endometriosis
care?
Like
when
you
see
Vince,
when
you
see
bowel
endometriosis,
what
is
the
approach
to
that
pre-surgical
approach
of
mapping
that
out?
Dr. Vince Obias
6:17
So
I
always
do
this
with
gynecology.
Um
I
don't
feel
that
endometriosis
is
purely
a
colorectal
issue.
Um,
the
gynecologists
and
my
colleagues,
like
Dr.
IBS Labels And Missed Clues
Dr. Vince Obias
6:27
Var
Vicky
Vargas
and
Melissa
McHale,
this
is
what
they
specialize
in.
So
I
usually
get
them
involved.
Even
when
some
patients
come
in
with
pelvic
pain
and
a
CT
showing
a
mass
as
endo,
I
still
get
them
involved,
a
gynecologist
involved.
Generally,
women
present
with
pelvic
pain,
rectal
bleeding
at
times,
and
that
leads
to
that
can
be
a
very
broad
area
when
dealing
with
these
symptoms.
And
so
the
workup
is
very
broad.
You
know,
uh
sometimes
the
pain
and
bleeding
that
they're
having
is
not
endometriosis.
So
when
I
see
them,
we
talk
about
you
Pain, Periods, And Pattern
Dr. Vince Obias
7:00
know
the
workup
for
this,
which
can
be
a
variety
of
things,
including
laonoscopies,
erectile
exams,
of
course,
a
complete
history
and
physical.
But
what
I
see
them
and
they're
involved,
they're
generally
about
30
to
40
percent
of
women
with
endometriosis,
it
will
involve
the
rectum
or
the
bowel
of
some
type.
So
it's
it's
important
to
have
uh
you
know
bowel
surgeons
like
myself
involved
at
the
start.
Alanna
7:21
Yeah.
How
does
it
affect
the
gut
mechanically,
though?
Dr. Vince Obias
7:27
So
um
obviously
if
it
gets
large
enough,
you
can
have
obstructive
type
symptoms.
You
can
also,
if
it's
deep
infiltrating
and
eating
through
the
wall
of
Mast Cells, POTS, Hypermobility
Dr. Vince Obias
7:36
full
thickness,
you
could
see
bleeding
and
you'll
see
bleeding
per
rectum
during
your
menses.
It
can
also,
you
know,
the
the
rectum
is
sort
of
uh
it's
a
capacity.
Its
job
is
to
sort
of
stretch
and
maintain
stools.
So
when
you
go
to
the
bathroom,
you
can
you
can
make
it.
And
if
you
have
endo
there
that
kind
of
restricts
it
from
inflammation,
these
patients
tend
to
have
a
bit
more
urgency.
Well,
like
they'll
go
to
the
bathroom
and
they
don't
see
much.
So
they'll
have
some
interesting
symptoms
like
that.
Some
of
these
patients
will
be,
because
of
what
I've
discussed,
will
have
chronic
constipation.
And
that
workup,
you
know,
which
can
be
pretty
advanced
and
and
broad.
But
but
endo,
endo
is
Post-Op Symptoms Explained
Dr. Vince Obias
8:15
it's
almost
one
of
those
disease
processes
that
we're
taught
in
school
that
it's
almost
like
a
you
do
a
full
workup,
and
if
you
don't
find
anything,
then
it
could
be
endometriosis.
And
it
it's
it's
terrible
that
we
have
much
better
ways
of
finding
these
nodules
now
than
we
had
in
the
past.
But
that
that's
only
been
in
the
last
10
years
that
I've
seen.
But
yeah.
Alanna
8:35
Zach,
on
your
side
of
it,
how
does
the
gut
neurologically
work
typically
with
endometriosis
patients
that
you
see
and
the
difference
between
that,
what
Vince
is
saying,
and
what
you
see?
Dr. Zac Spiritos
8:47
I
think
it
varies.
Uh,
you
know,
it's
definitely
pain
predominant.
And
so,
Nerves, Adhesions, Expectations
Dr. Zac Spiritos
8:51
you
know,
these
patients
are
labeled
with
IBS,
whatever
that
means,
where
they
have
a
lot
of
pain
and
alterations
in
their
bowel
habits
with
a
diagnostic
workup
that
is
fairly
unrevealing.
So
that's
what's
really
important
to
talk
to
these
people.
And,
you
know,
because
if
you
stay
in
your
siloed
world
of
GI
and
you
say,
oh,
you
know,
what's
your
Bristol
stool
scale?
Like
how
many
times
do
you
go
in?
Do
you
have
urgency?
Like,
you're
also
like,
do
you
have
your
period?
Is
it
heavy?
Is
it
painful?
Do
you
have
pelvic
discomfort?
Right.
And
if
you
expand
the
conversation
to
a
true
review
of
systems,
which
sometimes
because
of
the
limited
time
that
you
have
in
clinic
or
you're
just
kind
of
so
focused
on
the
GI
world
that
you
sometimes
miss
that.
But
endometriosis,
you
know,
can
certainly
cause,
you
know,
I
typically
just
think
pain,
pain,
pain,
pain.
Can
it
certainly
cause
diarrhea?
Sure.
Or
alterations
in
bowel
uh
movements,
as
Vincent
said,
you
know,
if
Does The Story Fit The Surgery?
Dr. Zac Spiritos
9:39
you
have
this
huge
kind
of
endometrioma,
you
can
have
obstructive
symptoms.
I
don't,
I
personally
haven't
seen
that
a
ton,
but
he
obviously
in
the
surgical
side
sees
that
a
lot
more
than
I
do.
Alterations
in
bowel
habits,
pain,
but
so
many
things
can
do
that,
right?
So
many
things
can
do
that.
And
so
I
think
it
just
behooves
you
to
just
kind
of
talk
to
the
person
and
just
make
sure
there's
if
there's
any
kind
of
gynecologic
symptoms
as
well
that
would
kind
of
lead
you
towards
endometriosis.
And
my
teaching
is,
you
know,
if
you
have
painful
periods,
it's
endometriosis
until
proven
otherwise.
Like
it's
your
job
to
prove
that
it's
not
that.
Alanna
10:07
Yeah.
I
love
that
approach
because
I
think
that
should
be
taught
in
school
across
the
board
because
it
affects
so
many
different
systems
that
until
proven
otherwise,
especially
if
it's
cyclical,
should
be
thought
of
as
endometriosis.
Now,
I
think
what's
interesting,
Zach,
When It’s Not Endo—It’s MCAS
Alanna
10:23
you
talked
about
your
mass,
and
this
was
earlier,
your
mass
cell
activation
patients,
all
of
them
have
endometriosis.
Dr. Zac Spiritos
10:29
All
of
them.
I
mean,
not
all
of
them.
A
lot
of
them
do.
It's
still
just
really
high
rate.
Yeah.
So
I
see
a
lot
of
patients
who
have
hypermobility
and
some
have
POTS
or
dysautonomia,
and
they
a
lot
of
these
times
have
mast
cell
activation
syndrome.
And
so
when
we
talk
about
everything
that's
going
on,
and
everybody,
you
know,
when
in
a
typical
visit,
and
someone
who
doesn't
have
mast
cell,
they
go
to
their
PCP
and
they're
like,
is
anything
going
on
today?
And
mast
cell,
it's
like,
what
are
the
five
top
things
that
bother
you
today?
Right.
And
because
they
have
so
much
going
on.
They
have
endless
amounts
of
symptoms,
Surgeon Skill And Residual Disease
Dr. Zac Spiritos
11:00
and
that's
why
these
visits
are
required
to
be
really,
really
low.
And
when
you
talk,
when
you
start
kind
of
going
down
the
review
of
systems,
like
do
you
have
painful
heavy
periods,
the
answer
is
often
yes.
And
so
the
you
will
often
see
heavy
periods,
you
know,
mast
cells
secrete
a
lot
of
different
chemical
mediators.
Heparin
is
actually
one
of
them.
You
actually
m
see
elevated
heparin
levels
in
their
blood.
And
so
they
tend
to
have
heavier
periods,
and
that's
fine.
You
can
live
in
you
can
certainly
ascribe
a
lot
of
things
to
mast
cell
activation
syndrome,
but
the
rate
of
which
we
see
endometriosis
is
so
high
that
I
just
have
a
low
I
have
a
low
threshold
to
to
involve
gynecology
or,
you
know,
colorectal
surgery
to
evaluate
these
patients
right
off
the
bat.
Alanna
11:36
Yeah.
And
part
of
the
challenge
there
too
for
a
lot
of
us
is
figuring
out
okay,
is
it
is
it
endometriosis
or
is
it
these
Pre/Post-Op MCAS Protocols
Alanna
11:44
other
things
like
mast
cell
or,
you
know,
pots
playing
a
part
into
this?
One
of
the
things
that
I
think
a
lot
of
people
struggle
with
is
they
have
lingering
symptoms
post-operatively.
So
they've
had
excision
surgery
and
they
have
lingering
symptoms,
whether
that's
constipation,
whether
that's
food
sensitivity,
it
might
be,
who
knows?
Like
there's
just
a
lot
of
bloating
is
another
one
of
those
things.
Vince,
when
you're
doing
surgery
and
the
outcome
of
that,
and
they're
still
having
this
bloating,
they're
still
having,
you
know,
all
of
those
things,
Anesthesia, Narcotics, Flares
Alanna
12:15
is
it
concern
for
you
if
there's
nerve
involvement
that
is
causing
this?
And
this
kind
of
plays
hand
in
hand
probably
with
what
you
do,
Zach,
as
far
as
like
the
nerve
involvement
as
well.
Dr. Vince Obias
12:25
Yeah.
So
I
will
say
that
those
symptoms
are
common
after
bowel
surgery.
So
when
you're
when
let's
say
we
someone
has
diverticulitis
or
colon
cancer
or
rectal
cancer,
whenever
Multidisciplinary Care Wins
Dr. Vince Obias
12:36
we
cut
the
bowel
and
put
the
two
ends
back
together,
bloating,
discomfort,
constipation,
diarrhea,
those
are
common
symptoms
to
have
after
surgery
for
about
two
to
three
months,
up
to
six
months.
Now,
I
will
say
after
six
months
after
a
collectomy,
the
symptoms
that
you
have
are
sort
of
your
new
pattern.
So
I
tell
patients
all
the
time,
I'm
like,
not
sure
you're
gonna
have
a
bowel
movement
like
you
had
in
your
20s,
but
after
six
months,
you'll
be
predictable.
And
those
conversations
are
really
important
to
have.
And
since
I'm
a
colorectal
Early Mobility, Simple Hacks
Dr. Vince Obias
13:06
surgeon
to
do
bowel
surgery,
I
do
have
that
for
patients.
So
their
expectations
are
like,
yeah,
Doc,
I'm
bloated,
or
a
little
bit
of
gas,
or
I
have
urgency
and
nothing
much
is
coming
out,
or
I
have
like
five
or
six
VMs
a
day,
but
they're
not
upset
because
they
knew
about
it
coming
in.
Meanwhile,
honestly,
like
gynecologists,
they
don't
do
a
lot
of
bowel
surgery.
But
if
you're
shaving
or
doing
anything
on
the
bowel
or
pelvic
surgery,
you
could
still
have
these
same
post-op
symptoms.
So
that
kind
of
education
is
important
to
Rewiring The Brain-Gut Loop
Dr. Vince Obias
13:34
have
up
front
so
that
they
understand
that's
part
of
the
healing
process.
Now,
certainly,
can
endo
come
back
quickly?
Certainly.
I
think
you
know
that's
one
of
the
things
we
worry
about.
But
when
we
do
excisional,
they
don't
usually
come
back
that
quickly.
But
you
are
dealing
with
the
post-surgical
in
terms
of
scar
tissue,
in
terms
of
inflammation
from
the
surgery.
Like
I
said,
that
if
you're
doing
pelvic
surgery
and
you're
mobilizing
everything
down
there,
even
if
you
don't
cut
the
rectum
or
bowel,
the
scar
tissue
and
inflammation
will
change
your
bowel
habits
afterwards.
And
so
when
you
go
in
with
bloating
and
discomfort
and
you
leave
with
bloating,
you're
feeling,
oh,
nothing
was
done.
But
that's
part
of
the
process.
Give
it
time,
three
to
six
months
later.
That
should
be
improved
and
certainly
more
predictable.
In
terms
of
nerves,
so
the
nerves
I
deal
with,
especially
in
cancer,
which
we
don't
really
run
to
when
I
we
run
into
an
Therapy, Sleep, And Habits
Dr. Vince Obias
14:23
endometriosis,
is
sort
of
near
the
it's
associated
with
like
sexual
function,
uh,
and
men
erection,
obviously,
clip
clitoral
erection,
it
can
be
associated
with,
and
bladder
function.
It
but
they're
more
posterior
to
the
rectum
and
maybe
not
necessarily
intrinsic
to
the
bowel,
but
if
that's
normally
the
nerves
that
we
would
deal
with,
and
that's
more
of
a
you
know,
removing
the
rectum
uh
for
cancer.
Alanna
14:46
Yeah.
Zach,
do
you
see
after
surgeries
if
people
come
to
you,
they're
still
having
issues
with
GI,
it
could
be
related
to
that
mast
cell
activation
post-surgical
that's
ramped
up
even
more
because
of
surgery,
you
think?
Dr. Zac Spiritos
14:59
It
depends.
Like
Vince's
end,
like,
you
know,
you
don't
want
to
pathologize
everything
postoperatively,
right?
Like
The 21-Year-Old Case Puzzle
Dr. Zac Spiritos
15:04
sometimes
it's
just
a
healing
process.
The
question
is
like,
does
it
make
sense,
right?
Like,
do
they
remove
the
TI,
the
terminal
ileum,
and
acid
mal
diarrhea?
Like
that
makes
sense
to
me,
right?
If
you
have
a
colectomy
and
you
have
diarrhea,
like,
all
right,
like
you
lost
your
rectum.
If
there's
rectal
sparing
surgeries
and
whatnot,
but
does
the
surgery
and
what
happened
pair
with
what
you're
experiencing,
right?
You
know,
you
can
develop
certainly
like
SIBO
postoperatively,
right?
Is
it
adhesions?
Is
it
is
it
the
narcotics
to
take
post-operatively?
You
know,
is
it
um
so
there's
things
that
exist
certainly
outside
of
mast
cell
activation
syndrome.
So
you
take
the
person,
the
surgical
intervention,
and
Narrative Over Normal Tests
Dr. Zac Spiritos
15:35
what
their
symptoms
are,
and
you
try
to
combine
all
three.
I
have
had
patients
with
mast
cell
whose
symptoms
were
attributed
to
endometriosis,
they
had
endometriosis,
surgery
was
like
was
performed
and
they
felt
no
better
because
it
was
just
mast
cell,
right?
But
you
have
to
do
that.
You
are
required
to
look
for
those
things
because
endometriosis
can
affect
so
many
things.
Fertility,
right?
Like
and
so
you
want
to
do
your
due
diligence
when
there's
something
you
can
intervene
and
and
fix.
Um
and
you
can
easily
fall
into
a
trap
where
you
blame
everything
on
mast
cell
activation
syndrome,
which
you
don't
want
to
do.
You
want
to,
you
know,
fortunately
when
people
come
to
me,
they've
had
all
the
testing.
So
I
don't
really
have
a
lot
of
run
left,
but
you
still
want
to
keep
a
wide
Surgery Isn’t A Magic Blade
Dr. Zac Spiritos
16:10
kind
of
lens,
don't
be
myopic
and
keep
everything
in
perspective.
And
so
yeah,
does
it
does
the
does
do
the
symptoms
fit
what
happened?
And
can
you
can
you
kind
of
create
a
nice
story
with
what's
happening
if
you
can't,
and
you
know,
there's
like
food
intolerances
and
brain
fog
after
surgery,
like
that's
not
related
to
the
surgery,
right?
That's
something
different.
And
so
you
just
have
to
understand
the
surgery,
understand
what
the
symptoms
are,
and
how
to
kind
of
connect
the
dots.
Alanna
16:35
Yeah.
And
I
Imaging And Limits Of Scopes
Alanna
16:36
can
tell
you,
having
a
good
surgery
with
a
qualified
expert
in
this
will
make
a
difference
in
the
outcomes.
I
mean,
if
you're
having
a
general
G
Y
N,
and
I'm
not
bashing
on
them,
but
if
you
have
a
general
GYN
doing
your
surgery,
chances
are
there's
disease
left
behind.
And
that
because
they're
not
trained
to
excise
the
disease.
They're
trained
oftentimes
to
do
ablation,
which
can
cause
more
scarring
and
stuff
like
that.
Vince,
have
you
experienced
that
you've
done
you've
done
resections
and
you've
been
in
surgeries
where
they've
had
multiple
surgeries,
Inflammation Or Nerve—Or Both?
Alanna
17:10
they
continue
having
these
symptoms.
Is
it
typically
disease
state
that
you're
seeing
again,
or
is
it,
you
know,
something
that
you
something
else
completely?
Dr. Vince Obias
17:21
Yeah,
I
I
will
say
that
um
every
time
I'm
in
a
case,
um,
especially
now
working
with
Dr
Vargas
and
Dr.
Mikhail,
you
know,
their
success
rates
in
finding
nodules
and
of
involvement
of
the
bowel
is
like
100%.
So
whenever
and
and
like
it
we
had
mentioned
and
discussed
earlier,
sadly,
most
of
the
surgeries
I've
involved,
The MCAS Knowledge Gap
Dr. Vince Obias
17:40
there's
been
previous
surgery,
which
is
it's
just
sad
to
see.
So
honestly,
um,
the
gynecologist
did
the
right
thing.
Rather
than
tackle
this
complex
nodule
on
the
rectum
and
have
a
complication
that's
just
terrible,
don't
do
anything,
document
it,
get
it
to
an
expert.
But
yeah,
I
mean,
when
they're
having
post-surgical
and
there's
usually
because
of
endometriosis
that's
been
left
behind,
sometimes
inadvertently
and
regrown,
or
and
sometimes
they
knew
it
and
are
like,
look,
I'm
not
gonna
not
gonna
risk
it.
And
it's
the
smart
thing
to
do,
understanding
that
you
know
they're
a
little
bit
out
of
their
element.
The
patient
is
not
aware
a
big
surgery
can
happen.
Hypermobility And Vascular Overlap
Dr. Vince Obias
18:15
Um,
and
it's
better
to
just,
you
know,
get
out,
let
them
recover
quickly.
But
it's
very
frustrating,
honestly,
for
the
patients
who
are
like,
they
came
in,
they're
hoping
to
have
one
procedure,
they're
hoping
to
have
this
done,
taken
care
of,
and
they've
been
told
not
only
that,
you
know,
we're
we're
we're
doing
this,
but
there's
gonna
be,
you
know,
we
couldn't
do
it
all,
but
there's
also
a
worse
situation,
and
you
may
need
even
more
advanced
extensive
stuff.
So
um,
so
yes,
I
absolutely
have
seen
that.
And
the
majority
of
the
time
it's
because
Environment, Food, And Triggers
Dr. Vince Obias
18:43
of
this
end
of
endometriosis
getting
there.
Alanna
18:45
Okay.
Yeah.
I
would
I
think
that's
probably
pretty
common
with
people
that
I
hear,
in
including
my
own
story
of
that,
of
disease
being
left.
But
it,
you
know,
that
goes
to
say
that
that's
why
this
education
is
so
important,
right?
We
have
to
keep
educating
about
this.
Zach,
is
there
a
ideal
pre
and
post-operative
routine
or
things
that
we
can
do
to
help
support
us
pre
and
post-operatively
when
it
comes
to
GI-related
things?
Dr. Zac Spiritos
19:14
It's
a
really
good
question.
I
would
probably,
you
know,
I
don't
know
if
I'm
the
right
person
to
answer
that
question
necessarily.
You
know,
I
think
you
just
want
to
do
your
due
Old Theories, New Evidence
Dr. Zac Spiritos
19:22
diligence
and
make
sure
that
no
other
pathologies
at
play.
But
I
don't
know
if
there's
anything
from
a
GI
perspective
specifically
that
you
would
dial
up
to
ensure
better
outcomes.
Like
I
think
I'd
probably
reserve,
I'd
leave
that
to
the
surgeons
and
the
gynecologist
to
make
sure
the
patient's
like
the
right
candidate
and
a
good
surgical
candidate,
and
that's
it's
probably
not
my
job
to
decide.
You
know,
certainly
things
we
can
do
to
optimize
people
from
a
mast
cell
perspective.
Alanna
19:46
That's
what,
yeah,
that
from
the
mast
cell
part
of
it,
because
I
know
a
lot
of
people,
including
myself
coming
out
of
it,
things
flare
really
bad.
How
do
we
help
alleviate
a
little
bit
of
that
pre
and
post-operatively?
Dr. Zac Spiritos
19:59
Yes.
We
Many Diagnoses, One Patient
Dr. Zac Spiritos
20:00
want
to
make
sure
their
mast
cell
is
under
as
best
control
as
possible
pre-operatively.
There's
always,
I
tend
to
reach
out
to
the
surgeon
to
discuss
the
case
and
just
say,
hey,
this
is
kind
of
this
is
how
I
would
think
about
this
specific
patient,
you
know,
whether
they're
hypermobile
and
they
need
a
neck
brace
during
the
surgery
because
they
have
a
lot
of
craniocervical
instability.
Do
they
have
HOTs
and
just
need
very
like
do
they
really
need
to
be
fluid
resuscitated
before
the
case
and
really
just
make
sure
that
they're
adequately
hydrated?
Where To Find The Guests
Dr. Zac Spiritos
20:30
If
they
have
mast
cell
activation
syndrome,
there's
certain
anesthetics
that
tend
to
flare
mast
cells
and
postoperative
narcotics
like
morphine
that
tend
to
be
more
aggravating
for
mast
cells.
And
there's
also
a
dialogue
like
what
happens
if
they
have
a
huge
flare
and
go
on
anaphylactic
shock?
Like,
we
should
probably
have
like
steroids
and
you
know,
H1
and
H2
blockers
ready
to
go
in
case
that
happens.
And
so
I
have
a
protocol
that,
you
know,
I've
I've
written
with
other,
I
haven't
written,
but
I've
adopted
from
other
um
mast
cell
clinicians.
And
I
often
will
reach
out
to
the
surgical
team
and
say,
this
is
kind
of
what
I
would
do
uh
and
how
I
would
approach
this
patient
kind
of
perioperatively
and
intraoperatively
Closing And Advocacy
Dr. Zac Spiritos
21:07
just
to
get
the
best
outcomes.
Yeah.
Yeah.
Dr. Vince Obias
21:09
Honestly,
like
the
way
Zach
pointed
out,
it
it's
important
to
emphasize
that
when
you're
dealing
with
something
like
endometriosis
that
can
affect
so
many
different
areas
colon,
rectum,
diaphragm,
bowel,
bladder,
it's
multidisciplinary.
Just
like
when
I
deal
with
rectal
cancer,
we
talk,
we
have
radio
radi
radiologists,
oncologists,
radiation
oncologists.
We
we
have
a
variety
of
people
on
the
team
to
discuss
it.
And
so
it
endometriosis,
especially
complex
stuff,
is
is
starting
to
lean
that
way
where
you
have
multidisciplinary
teams
talking
about
it
so
that
we
don't
miss
things.
Alanna
21:46
Yeah,
for
sure.
And
I
think
too,
it's
important
that
we
recognize
that
it
takes
multiple
people
outside
of
just
one
specialty,
meaning
just
endometriosis.
It's
like
pelvic
floor,
acupuncture.
There's
different
ways
that
we
can
support
our
bodies
walking
through
this.
And
if
we
all
talk
together
and
have
that
true
team,
outcomes
are
so
much
better.
And
it
and
that's
proven.
Like
that
is
a
proven
thing
where
if
you
have
a
good
team,
solid
team
going
into
surgery,
more
prepared,
outcomes
tend
to
be
a
little
bit
better
for
you.
So
that
was
one
of
the
things
I
learned
the
hard
way
as
well.
Dr. Zac Spiritos
22:20
Exactly.
Yeah.
Um
how
relaxed
most
operatively.
Alanna
22:24
You
what?
You
relax?
Dr. Zac Spiritos
22:26
Most
operatively.
Gotta
keep
the
bowels,
gotta
keep
the
bowels
moving.
Alanna
22:30
Yep.
Relax,
yeah.
I
love
that
stuff
too.
Chewing
gum?
Dr. Vince Obias
22:33
Yeah,
so
so
chewing
gum
is
used
for
uh
return
of
bowel
function
right
after
surgery.
Yeah.
So
you
can
chew
gum,
and
so
you
end
up
swallowing
a
bunch
of
air.
So
there's
been
studies
on
that.
But
uh
does
it
yeah,
yeah.
But
that's
right
after
surgery.
I
mean,
I
don't
recommend
chewing
gum
for
the
next
six
months,
but
uh,
if
you
want
to,
that's
fine.
I'll
make
it
bloated
all
right.
Dr. Zac Spiritos
22:50
Do
you
have
you
randomized
people
to
different
like
bubble
yum
versus
like
big
chew?
Dr. Vince Obias
22:54
Well,
when
I
was
a
resident,
I
actually
um
I
put
I
gave
everybody
a
pedometer
and
I
had
them
walk
around
over
at
Case
Western,
and
I
was
able
to
demonstrate
the
more
steps
you
did,
the
faster
you
had
phallatus
and
were
at
home.
So,
you
know,
I
I
have
looked
at
some
of
that
stuff,
and
steps
is
one
of
them
for
sure.
That's
very
clear.
Alanna
23:12
For
sure.
Zach,
is
there
a
way
to
retain
um
bowel
and
brain
communication
after
a
major
bowel
surgery?
I
think
this
is
something
that
many
of
us
struggle
with,
is
that
we
get
in
patterns
and
that
it
becomes
this
challenge
of
like,
this
is
what
my
body's
always
done.
And
now
I'm
still
in
this
battle
of
is
it
really
going
on
still,
or
is
this
just
the
way
my
body
is
trained?
That
it's
I
hate
the
word
psychosomatic,
but
a
lot
of
times
that's
what
they
refer
to
it.
As
is
there
ways
that
we
can
retrain
our
brains
and
our
bowels
to
work
better
after.
Dr. Zac Spiritos
23:49
It's
a
really
good
question.
You
know,
I
think
it's,
you
know,
you
have
to
take
everything,
it's
such
a
bailout
answer,
but
you
gotta
take
everything
on
a
case-by-case
basis.
So
if
someone
has
been
like,
what
are
they
experiencing
post-operatively?
Is
it
the
same
diarrhea
they've
always
been
that's
kept
them
locked
up
in
the
house?
And
is
that
stress
about
having
diarrhea
making
the
diarrhea
worse
to
where
you're
anticipating,
like,
oh
my
gosh,
like
if
I
go
out,
I
just
know
I'm
gonna
have
diarrhea
as
soon
as
af
after
the
appetizers?
And
like
that,
you
like
speak,
you
think
it
into
existence,
right?
And
so
you
kind
of
have
to
untangle,
like,
okay,
so
like
what
has
your
history
been?
What
are
you
currently
worried
about?
What
is
actually
happening?
And
what
are
kind
of
how
can
we
intervene
and
help
things
out?
Like,
are
you
are
you
ragingly
constipated?
Like,
why
are
you
constipated?
Is
it
a
pelvic
floor
issue,
right?
Is
it
because
there's
not
enough
fiber?
Is
it
because
you're
in
fight
or
flight
mode
and
you're
really
stressed?
Is
it
because
you
have
a
disaanoma
and
you
have
pots
and
it's
because
your
colon
doesn't
move
in?
And
then
it's
like,
okay,
well,
let's
do
what
we
can
from
a
dietary
perspective
and
a
pharmacotherapy
perspective
to
maybe
help
alleviate
the
bowels
to
some
degree.
But
there's
always
a
chance
that
the
brain
will
override
everything
we
do
and
be
like,
mm-mm,
like
we're
gonna
back
things
up
or
we're
gonna
get
things
going,
right?
And
so
how
do
we
address
that
as
well?
So
if
we
unentangle
things
and
we
say,
okay,
well,
there's
a
really
disruptive
thought
pattern
that
is
making
your
bowels
really
bad,
right?
So
that
anticipatory
anxiety,
or
man,
if
I
don't
poop
like
at
by
8
a.m.
this
morning,
the
rest
of
my
day
is
ruined.
Because
I'm
gonna
get
bloated,
it's
gonna
be
uncomfortable,
and
everybody's
gonna
notice
and
it's
gonna
be
terrible.
And
that
just
makes
the
symptoms
that
much
worse.
And
if
we
realize
that
thought
pattern
is
happening,
which
in
turn
will
make
the
bowels
worse,
then
maybe
we
talk
about
like,
what
is
maybe
talking
to
a
therapist,
like
a
GI
therapist,
like
is
a
hypnosis
something
that
we
can
utilize?
Is
cognitive
behavioral
therapy
something
that
we
can
use?
So
it
really
is
like
take
it
on
a
case-by-case
basis,
but
what
buttons
can
you
press?
Medications,
diet,
exercise,
sleep
is
a
humongous
one.
Lack
of
sleep
definitely
predicts
next
day
GI
pain.
And
so
it's
just
you
gotta
just
kind
of
look
at
everything
and
see
how
they
play
off
each
other
and
just
listen
to
the
patient,
right?
Just
listen
to
them
and
see
like
where
can
we
where
can
we
meet
in
the
middle
here
and
find
solutions
to
what
may
be
going
on.
Alanna
25:56
Yeah.
I'm
gonna
do
something
that
is
a
little
probably
a
little
unorthodox.
And
I'm
I
got
so
many
messages,
like
I
said
before,
which
is
why
we're
coming
together
for
this.
So
I
want
to
read
you
guys
something
and
I
want
to
get
both
of
your
perspectives
on
this
because
I
think
this
will
help
clarify
maybe
some
of
the
questions
that
I
got
previously
and
put
it
in
in
a
way
that
is
maybe
helpful.
And
and
this
is
not
case
specific,
it
is
not
a
medical
advice.
This
is
just
insight
into
this.
So,
sample
message:
I'm
a
mom
of
a
21-year-old
daughter
who
has
non-cyclical
GI
symptoms
since
she
was
13.
Two
years
ago,
she
was
diagnosed
with
endometriosis
after
excision
surgery
with
removal.
She
didn't
have
improvement
after
surgery,
and
two
years
later,
she
still
struggles
with
ongoing
nausea
and
frequent
diarrhea
each
day.
She
takes
SSRI
and
was
on
oral
contraceptives,
but
isn't
any
longer.
She
has
been
treated
for
SIBO,
received
pelvic
floor
PT
and
functional
medicine
protocol,
tried
low
FODMAP
and
elimination
diets.
She
had
two
unremarkable
colonoscopies
and
endoscopy.
Zach,
you
can
fill
that
in.
Endoscopies.
And
yet
the
GI
symptoms
are
still
there.
She
has
also
had
a
motility
study
that
was
also
within
normal
limits.
Any
ideas
that
you
would
have
for
helping
with
symptoms
or
overall
treatment?
Dr. Zac Spiritos
27:20
Just
kidding.
GI
doctoral
psychic
things.
Have
you
tried?
Um,
I
don't
know.
That's
really
complex.
You
know,
so
when
I
see
a
patient,
right,
I
have
200
pages
of
the
records.
They've
been
everywhere.
They've
had
all
the
testing.
And
I
say,
I
don't
care
what
their
tests
say.
Like,
sure.
There
are
some
tests
that
are
helpful.
I
want
to
hear
your
story
and
how
you
got
here.
What
makes
it
better?
What
makes
it
worse?
What
medications
worse?
What
make
it
what
medications
have
helped
so
you
can
understand
like
the
mechanism
of
action
of
that?
Um
and
so,
yeah,
I
mean,
there's
so
many
different
like
what's
does
she
have
brain
fog,
fatigue,
migraines,
flushing,
allergies
that
would
make
you
think
this
is
mast
salt?
Does
she
have
some
form
of
dysautonomia?
Does
she
have
visceral
hypersensitivity?
This
is
all
this
all
happen
after
like
a
huge
GI
bug.
So
I
think
you
just
have
to
listen
to
the
person.
There's
not
a
one
size-fit-all
approach.
There's
not
a
one
medication.
Like,
I
don't
have
a
box
back
here
of
like,
oh,
I
have
this
golden
pill
that
she's
never
tried
before.
Like
maybe
we
we
bust
that
out.
Like
you
just
you
really
just
have
to
listen
to
someone
and
see
how
they
got
here.
So
I
always
tell
everybody,
tell
me
how
you
got
here.
When's
the
last
time
you
felt
great?
And
what's
happened
since
then?
And
what
has
worked
and
what
hasn't
worked.
And
if
there
was
like
a
uh,
you
know,
if
there
was
a
test
that
was
positive
that
showed
why
everything
was
wrong,
like
you
wouldn't
be
here,
right?
And
so
you
can
run
all
the
tests.
We
have
so
many
amazing
tests,
okay?
The
thing
is
that
we
have
blunt-edged
tools
for
these
for
very
elegant
pathophysiology.
And
so
when
you
have
like,
okay,
you
have
this
motility,
your
bowels.
Well,
there's
like
three
things
we
can
do
for
that.
Like
we
don't
have
a
lot
of
medications
for
that.
So
you
just
have
to
kind
of
listen
to
somebody,
get
a
sense
of
what's
going
on.
Is
it
stress-induced?
Is
it
more
pain?
Is
it
nausea?
Nausea,
we
scope
nausea
all
the
time.
It
drives
me
nuts.
Nausea
comes
from
the
brain,
okay?
Like
if
you
have
postpranbial
nausea,
but
around
the
clock
nausea
is
a
brain
process,
okay?
And
so
why
is
that
there?
Is
it
stress?
Is
it
mast
cell?
Is
it
a
medication?
Is
it
an
infection?
You
just
have
to
kind
of
go
through
everything,
deconstruct
everything,
and
then
build
it
back
up
to
where
you
can
convince
like
a
narrative
has
to
fit,
right?
You
don't
take
any
symptom
in
a
vacuum,
be
like,
oh,
nausea.
Like,
why
is
that
there?
But
like,
how
do
they
get
there?
Did
it
happen
post-operatively?
Did
it
happen
after
a
breakup?
Like,
what's
happening
here?
And
so
you
can't
take
a
symptom
and
be
like,
how
do
you
treat
this?
It's
like,
well,
it's
in
the
context
of
who
that
person
is.
You
don't
treat
nausea,
you
treat
Bill's
nausea
or
Susan's
nausea.
And
there's
a
story
there
that
you
have
to
entangle.
And
then
once
you
get
there,
you
can
push
the
right
buttons.
Right,
right.
Alanna
29:37
That's
my
I
love
it.
Vince,
on
you
when
you
hear
something
like
this,
what
is
your
automatic
response
to
that?
What
are
you
hearing
this
that
you
would
look
at
maybe
from
a
different
lens?
Dr. Vince Obias
29:48
Well,
I
mean,
as
a
surgical
side,
I
would
probably
say
surgery
may
not
be
the
answer.
I
mean,
this
is
such
a
broad
situation
that
it's
not
going
to
be
like
a
magic
pill.
Zach
mentioned,
well,
I
don't
have
a
Magic
blade
to
say,
let
me
just
cut
out
this
section
of
the
bowel.
Let
me
cut
a
couple
stitches
here.
You
can
certainly
try
to
rule
out
endometriosis,
you
know,
MRIs
of
the
pelvis
are
being
done
now.
Uh,
you
can
do
MRNography
to
take
a
look
at
her
GI
tract,
which
we
definitely
use
inflammatory
bowel
disease,
but
we
can
certainly
use
for
her
if
she
has
GI
symptoms
and
you're
looking
to
see
if
there's
any
kind
of
inflammation
of
the
bowel
or
small
bowels
abnormal.
One
of
the
newer
techniques
that
uh
Vicky
Vargas
and
Melissa
McHale
have
sort
of
pioneered
is
you
know
transvaginal
ultrasound
to
look
at
pelvic
nodules
and
look
at
you
know
nodules
in
the
rectum
to
see
if
there's
anything
there.
But
you
know,
the
symptoms
that
are
being
described
is
it's
very
broad
and
non-specific.
And
um,
and
you
have
to
be
really
careful
before
say,
let's
get
the
surgeon
involved,
because
I
mean,
sad
to
say,
you
know,
we
we're
like
a
hammer.
Our
answer
is
gonna
be
sometimes
surgery,
which
I
don't
think
in
her
case
it
makes
a
lot
of
sense.
You
gotta
sort
of
think
outside
the
box
as
individualize
the
situation,
make
sure
that
you
know
what's
being
done
for
her
is
gonna
be
something
that
will
be
definitive
rather
than
something
frustrated.
It
may
come
down
to
something
like
a
laparoscopy
to
look
internally
to
make
sure
we're
not
missing
something.
But
boy,
I
you
I
think
you
have
there's
a
lot
of
things
that
we
can
done
beforehand
before
it
got
gets
to
that
step.
Alanna
31:15
Yeah.
How
much
pain,
how
much
of
this
is
neuropathic
and
how
much
is
it
inflammatory?
Because
I
think
that
also
could
be,
I
mean,
maybe
they
go,
maybe
they
coincide.
I
don't
know,
but
I
think
there's
probably
some
play
in
there
for
both
of
those.
Dr. Vince Obias
31:30
Certainly,
you
can
definitely
get
studies
to
look
for
inflammation
that
would
be
anatomically
and
physiologically
an
issue,
like
say
like
an
MRI
nonography
or
MRIs
or
scans
and
whatnot.
And
and
certainly
in
someone
in
her
age,
you
would
definitely
lean
towards
MRIs
to
so
it's
you
know,
the
accumulative
effects
of
radiation
and
CT
scans
is
not
great.
But
and
you
can
find
those.
And
certainly
there
are
blood
tests
that
we
can
do
to
look
at
uh
inflammatory
factors.
But
if
there's
subtle
inflammation,
sometimes
you
have
to
do
endoscopy
and
colonoscopy,
take
a
look
at
the
mucosa
directly
to
see.
It
it's
a
frustrating
scenario,
and
it
may
be
more
as
meant,
as
Akin
mentioned,
it
may
be
more
not
associated
necessarily
with
something
physical.
It
could
be
something
else
associated
with
her
symptoms
that
that
you
know,
a
multimodal
team
or
a
therapist
or
whatnot
or
figure
out
if
is
if
it's
stress-induced
or
environmental
in
some
way.
Um
because
I
think
you're
gonna
have
to
think
out
of
the
box
because
she's
had
so
much
medical
stuff
thrown
at
her
already
and
surgical
stuff
that
doesn't
seem
to
be
addressing
it.
Dr. Zac Spiritos
32:28
There's
no
test
that's
gonna
pick
up
what's
going
on.
Alanna
32:30
Yeah.
Dr. Zac Spiritos
32:31
I
was
waiting
for
you
to
say
that's
gonna
pick
this
up
and
to
tease
out
neuropathic
versus
inflammatory
pain.
Are
we
sure
not
that's
not
one
and
the
same?
Alanna
32:38
Right.
Dr. Zac Spiritos
32:39
Right?
Like
I
mean,
the
the
immune
system
and
the
neurologic
system
and
the
hormonal
system
are
intimately
linked,
right?
So
I
don't
think
you
can
tease
one
out
and
be
like,
oh,
it's
neuropathic,
put
it
on
gabapan.
Like
that's
not
gonna
work.
Right.
Yeah.
I
think
you
have
to
understand
why,
why
this
is
like
why
isn't
the
test
picking
up
on
it?
Like,
why
is
this
a
lit
like,
you
know,
we
have
very
elegant
tests.
Is
it
a
brain
gut
communication
issue?
Is
it
a
central
process?
Or
is
it
something
climatic
like
mast
cell
activation
syndrome
where
it's
just
there
are
very
pervasive
symptoms,
but
we
just
there's
shortcomings
in
the
testing
that
we
can
use
to
pick
it
up.
Alanna
33:09
Yeah.
Well,
and
I
think
that
not
very
many
people
are
gonna
think
mast
cell
activation.
In
fact,
I've
had
doctors
roll
their
eyes
at
me
for
people
don't
think
it
exists,
for
sure.
Dr. Zac Spiritos
33:18
Yeah,
yeah.
I
will
say
that
I
have
hundreds
of
people
in
clinic
that
all
have
mast
cell
activation
that
would
disagree.
And
we
didn't
learn
anything
about
it.
Like
I
was
at
Duke
not
too
long
ago.
I
didn't
hear
a
darn
thing
about
it
until
a
couple
years
ago.
And
I
had
about
40
people
in
my
clinic
that
I
had
no
idea
what
to
do
with.
They
had
all
these
bowel
symptoms,
but
they
also
had
migraines
and
endometriosis
and
allergies
and
flushing
and
tachycardia.
And
they
were
24
and
had
seven
subspecialists,
and
they're
being
treated
for
migraines,
inappropriate
sinus
tachycardia,
endometriosis,
IBS.
And
you're
like,
there's
gotta
be
something
here,
right,
guys?
Like,
what's
the
statistical
likelihood
that
they
have
independently
all
of
these
symptoms?
It's
not.
They
have
mast
cell
activation.
And
you
did
a
little
digging,
and
it's
like,
and
they
actually
you
put
them
on.
I
remember
my
first
patient
that
they
thought
had
Crohn's
disease.
They
put
her
empirically
on
uh
sky
Rizzy
for
small
bowel
Crohn's
disease
because
they
thought
they
saw
a
wisp
of
some
inflammation
on
a
video
capsule
study.
And
she
had
bloating
and
fatigue
and
migraines
and
heavy
painful
periods,
and
we
put
her
on
pepsid
and
zertec
and
almost
all
of
her
symptoms
went
away.
It
doesn't
always
go
like
that.
It
doesn't
for
the
most
part,
but
you
put
someone
on
some
histamine
blockers
and
they
feel
phenomenal.
And
I
would
say
that
nine
out
of
ten
of
my
patients
don't
respond
that
way
to
that.
But
I
remember
seeing
that
I
was
like,
oh,
there's
a
lot
about
this
world
of
medicine
that
I
don't
get.
And
I
spent
a
ton
of
time
in
the
hospital
and
reading,
and
there's
just
the
more
I
I
read
and
learn
more,
the
more
I
I
don't
understand.
I
think
there's
just
there's,
you
know,
we
reduce
people's
symptoms
down
to
MRIs
and
CT
scans
and
x-rays
and
blood
work.
Like,
look,
there's
a
world
beyond
us
that
we
don't
understand
to
properly
categorize
pain
and
inflammation
and
brain
gut
communication
and
mast
cell
activation.
And
we're,
you
know,
I
just
it's
it's
really
tough.
And
these
patients
get
minimized
and
gaslit
a
lot
because
we
didn't
we
didn't
learn
about
any
of
this
stuff.
Alanna
35:01
Right.
Well,
and
there's
also
that
link
too
with
Mae
Thurner
Nutcracker
syndrome.
Like
these
all
play
a
part
in
that
as
well.
And
that's
a
whole
nother
topic
with
someone
like
Dr.
Brooke
Spencer.
But
it
is
there's
similar
symptoms
for
a
lot
of
these
people
as
well.
Dr. Zac Spiritos
35:15
So
that's
what
there's
downloads
is
the
connectivity.
So
you
know,
mast
cell
activation
primarily
happens
to
bendy
people.
And
they
also,
their
collagen
doesn't
work,
their
connective
tissue
doesn't
work
very
well,
everything
sags,
they
get
pelvic
venous
congestion,
and
they
get
median
arguably
ligament
syndrome,
which
I
thought
never,
ever,
ever
happened.
I
see
it
once
a
week
now.
Okay,
I
see
SMA
syndrome
every
two
weeks.
I
see
nutcracker
and
pelvic
venous
congestion
on
a
weekly
basis.
That's
because
I
only
see,
I
really
see
a
ton
of
people
with
hypermobility.
And
these
this
patient
population
doesn't
play
by
any
rules
that
we
have.
You
can
write
a
whole
different
medical
textbook
on
these
people.
And
you
just,
when
they
go
to
the
traditional
uh
hospitals
and
clinics,
they
just
don't
know
what
to
do
with
them
because
they
don't
fit
in
any
box.
So
they
say
maybe
it's
anxiety,
maybe
it's
stress,
and
it's
really
frustrating.
And
when
I
get
on
the
phone
and
call
the
inpatient
hospital
team,
like,
hey,
this
is
what's
going
on,
I
get
looked
at
like
I'm
a
nut.
And
I
was
like,
well,
tell
me
what's
going
on
then.
Like,
do
you
have
another
explanation
of
what's
happening?
And
so
it's
just,
I
do
think
that
mast
cell
is
on
the
rise
in
prevalence.
And
I
think
COVID
is
unleashing
a
lot
of
this.
Like,
we
haven't
had
anything
new
in
medicine
since
HIV,
right?
And
mastell
is
just
this
new
thing.
The
thing
is,
mast
cell
is
invisible.
Like
HIV
and
AIDS,
you
can
follow
CD4
counts,
like
something
real
was
happening.
There
is
like
this
boom
of
these
patients.
They're
everywhere.
And
if
you
just
it's
like
the
one
in
medical
practice,
Vince,
if
you
saw
like,
oh,
that
person
is
allergic
to
35
medications,
they
must
be
off
the
rocker.
It's
like,
no.
Their
mast
cells
hate
every
medication.
They're
exquisitely
sensitive
to
all
these
medications.
And
we
see
them
all
the
time,
we
just
don't
know
what
to
do
with
them.
And
I
really
think
that
COVID
really
increased
the
prevalence
of
mast
cell.
And
it's,
I
think
in
10
years,
we're
really
gonna
we're
gonna
start
to
appreciate
and
understand
this
a
lot
more
than
we
do
now.
Because
we
have
a
very
kind
of
very
faulty
understanding
of
what's
going
on.
Alanna
36:59
Well,
and
if
you
want
to
know
my
theory
on
this
too,
and
you
guys
can
sound
off
before
before
we
wrap
up,
but
one
of
my
theories
is
because
when
you
have
a
hypermobile
person
and
that
connective
tissue
is
so
much
looser,
you
I
don't
know
about
you,
but
for
me,
my
thought
process
is
like
if
that's
looser,
you're
giving
way
for
a
lot
more
things
to
happen
within
that
tissue
as
it
stands.
Like
there's
with
the
endometriosis
specifically,
with
you
know,
cells
implanting,
when
you
have
a
connective
tissue
that's
already
loose,
it's
giving
room
for
that
to
implant
more.
I
don't
know.
I'm
not
the
scientist.
Dr. Zac Spiritos
37:31
I
have
like
seven
different
theories,
right?
So
mast
cells
live
in
your
cellular
space.
So
they're
meant
to
look
for
threats.
Like
evolutionarily,
that's
what
mast
cells
are
meant
to
do.
So
when
things
are
overly
bendy,
are
they
like,
wow,
this
is
a
really
messed
up
environment.
Like
it's
it
shouldn't
bend
this
way,
and
they
get
constitutively
activated,
or
is
it
there's
a
leak,
there's
an
increased
intestinal
permeability
because
the
collagen
isn't
that
isn't
that
the
t
it
just
is
not
that
the
tight
junctions
are
loose,
right?
So
you
get
a
lot
more
gut
permeability
and
leaky
gut
and
uh
more
kind
of
immune
activation,
and
that's
how
mastell
happens.
There's
this
have
you
heard
of
tilt
before?
Toxin-induced
loss
of
tolerance.
Yeah.
So
it's
it's
sort
of
dates
back
to
like
the
industrial
times
where
we
started
a
coal
mine,
and
women
that
lived
close
to
coal
mines
used
to
develop
all
these
wacky
symptoms.
And
of
course,
like
older
white
guys
like
me
would
say,
Oh,
it's
hysteria,
right?
And
they
would
and
the
the
thought
is
like
maybe
they
were
just
living
next
to
the
coal
mines
and
there's
all
these
toxins
that
were
pissing
off
their
mast
cells,
that
the
mast
cells
are
now
recognizing
these
things
that
shouldn't
really
be
around
and
causing
them
to
be
overly
active.
And
you
know,
is
mast
cell
a
product
of
our
environment?
That
all
these,
you
know,
people
with
mast
cell
tend
to
smell
chemicals
and
they
get
migraines
and
headaches.
They
just
really
sensitive
smells.
Like
so
they
walk
by
like
the
Hollister
store
at
the
mall
and
they
almost
have
a
seizure.
And
so,
like,
is
it
that
this
environment
that
we've
bred
that
is
very
synthetic
and
full
of
chemicals
and
pesticides?
People
with
mast
cell
feel
so
much
better
in
Europe
when
they
eat
the
food.
And
I
mean
the
regular
the
regulation
around
food
here,
the
pesticide
use
is
crazy.
And
so
I've
had
patients
move
to
France
because
their
mast
cell
is
too
bad
here,
right?
And
so
there's
something
about
the
environment
in
conjunction
with
someone
being
bendy
and
hypermobile
that
makes
this
happen.
I
can't
figure
it
out.
But
you're
onto
something
as
well.
Like
this
is
it's
all
theory,
but
they
coexist
all
like
at
the
same
time.
Alanna
39:14
Yeah,
which
I
also
think
because
of
the
laxicity,
maybe
even
in
the
bowel
and
like
the
rectum
and
things
like
that,
that
you
see
a
lot
more.
In
fact,
you'll
see
more
endometriosis,
typically
peritoneum,
but
bowel,
rectum,
bladder,
things
like
that,
even
more
than
your
ovaries,
uterus,
things
like
like
the
reproductive
organs
are
not
nearly
as
involved
as
those
other
structures
that
they're
those
other
organs
are.
And
so
I
think
that's
interesting
to
think
about
as
well
how
much
uh
it
plays
a
role
in
endometriosis
is
yeah,
it's
insight.
Dr. Vince Obias
39:49
It's
so
digital
there.
It's
really
fascinating.
Uh,
as
he's
acting,
we
have
not
heard
about
mast
cell
activation,
obviously
in
med
school
and
residency,
and
there's
so
much
stuff
coming
out.
I
mean,
you
touched
upon
a
variety
of
things
that
are
that
are
associated
with,
you
know,
we
just
kind
of
throw
up
our
hands
and
say,
oh,
well,
we're
not
sure.
Let's
do
some
more
tests.
So,
you
know,
any
kind
of
like
research
or
view
or
different
thoughts
on
these
is
is
important
because
we
still
don't
have
an
answer
of
like,
well,
inflammatory
bowel
disease.
What's
the
cause
of
Crohn's?
What's
the
oscillophyllitis?
We
we
know
what
we
see
and
we
can
treat
it
with
anti-inflammatories,
but
we're
not
100%
like
I
know
how
colon
cancer
starts,
I
know
how
rectal
cancer
starts,
you
know.
We
think
we
know
how
endometriosis
starts,
but
some
of
these
things
like
you
hit
upon,
absolutely
true.
There's
something
environmental
we're
running
into.
Dr. Zac Spiritos
40:36
The
reverse
isn't
the
endometriosis,
and
like
I
am
way
outside
my
bounds
here,
but
like
isn't
the
endometriosis
theory
like
the
reverse
menstruation?
Alanna
40:43
That's
old
and
it
has
not
been
proven.
Dr. Zac Spiritos
40:46
Okay.
And
I
don't
I
don't
I
don't
know.
And
is
it
a
mass
up?
I
don't
just
for
everybody.
Alanna
40:57
Dr.
David
Redwine
did
a
whole
presentation,
which
you
can
find
on
the
YouTube
channel
that
I
have,
and
it
was
prior
to
his
passing,
it
was
right
before
his
passing,
actually,
where
he
goes
through
the
um
genomic
aspect
of
endometriosis
and
how
he
sees
endometriosis
and
has
been
proven
to
some
extent,
evolving
in
the
body.
It's
very
fascinating,
and
I
encourage
everyone
to
go
back
and
listen
to
it
because
I
think
it'll
spark
a
conversation.
Why
ACOG,
why
all
these
other
associations
aren't
looking
at
what's
being
proven.
Like
if
it
were
retrograde
menstruation
by
now,
I
would
think
that
they
would
probably
have
cameras,
enough
cameras
to
be
able
to
prove
it,
but
they
cannot
prove
it.
There's
no
actual
evidence
of
it.
But
they
have
seen
it
in
fetuses,
which
don't
menstruate
yet.
They
see
it,
they've
seen
it
in
very
minute
population
of
men.
Men
don't
menstruate.
So
I
think
that
we
have
to,
I
think
that
all
of
these
kind
of
go
hand
in
hand.
And
one
Wendy
Bingham
out
of
extrapelvic
not
rare
touched
on
the
gestational
yolk
sack.
And
again,
I'm
out
of
my
scope
on
this
as
well.
But
essentially,
they
did
this
study
where
they
noticed
that
when
they
broke
off,
like
the
role
of
the
yolk
sac
in
gestation,
when
that
broke
off,
what
they
were
seeing
is
that
a
lot
of
these
cells
for
these
diseases
were
all
together
in
this.
I'm
breaking,
I,
you
know,
whatever
it
is.
I'm
not
doing
this
justice.
I'm
just
saying
that
right
now.
But
essentially,
like
they
actually
saw
it
in
in
very
young
cellular
phase
of
life.
So
I
think
it's
it's
an
interesting
thing
to
talk
about.
It's
an
interesting
thing
to
consider,
especially
for
those
that
have,
for
some
reason,
multiple
diagnoses,
right?
Like
it's
not
one.
I
don't
know
an
endometriosis
patient
with
one
diagnosis.
Or
I
just
don't.
I
have
never
met
one
person
who
can
have
excision
surgery
and
be
done.
There's
usually
other
things
that
they're
dealing
with.
So
I
think
there's
something
to
it.
Dr. Zac Spiritos
42:53
Right.
There's
so
much
to
learn.
Alanna
42:54
So
much
to
where
can
people
find
you
guys
to
learn
more?
I
know
you're
doing
a
lot
of
work,
Zach,
who
has
you
have
amazing
content
out
on
specifically.
Where
can
people
find
you
to
learn
more
about
mast
cell,
hypermobility,
all
the
things
that
we've
talked
about
today?
Dr. Zac Spiritos
43:11
Thank
you.
That's
that's
very
kind.
So
my
is
Dr.
Zach
Spiritos,
and
we
I
have
a
clinic
called
Ever
Better
Medicine
where
we
focus
on
complex
GI
conditions,
POS,
mast
cell
activation.
We
see
a
lot
of
hypermobile
folks
as
well.
Um
we
are
hiring
more
people
and
we're
expanding
our
staff
because
um
unfortunately
we
don't
have
any
um
clinic
openings
anytime
soon.
So
we're
excited
to
kind
of
expand
our
breadth
um
and
see
people
who
uh
who
hopefully
or
who
need
some
help.
Alanna
43:38
Yeah,
I
love
it.
Vince,
where
can
we
find
you?
Dr. Vince Obias
43:41
Just
uh
look
up
Vincent
Obius
in
Washington,
DC
area
and
endometriosis,
and
my
website
will
pop
up.
Alanna
43:47
Thank
you
both
so
much
for
doing
this
kind
of
odd
little
black
swan
podcast
interview
where
we
don't
normally
get
together.
I
appreciate
you
taking
the
time.
I
know
you're
both
incredibly
busy,
but
I
just
feel
like
this
is
gonna
help
so
many
people
maybe
understand
these
little
nuances
of
endometriosis,
mast
cell,
stomach,
all
the
things.
So
thank
you
both
so
much
for
sitting
down
with
me.
Dr. Vince Obias
44:11
Yeah,
thanks
for
having
me.
I
appreciate
it.
Thank
you
very
much.
Alanna
44:14
Yeah,
thank
you.
Until
next
time,
everyone,
continue
advocating
for
you
and
for
others.