70. Examining Abdominal Pain with Pradeep Chopra, MD

Episodes have been transcribed to improve the accessibility of this information. Our best attempts have been made to ensure accuracy,  however, if you discover a possible error please notify us at info@bendybodies.org

00:00
Dr. Pradeep Chopra
Vegetables and fruits and all that we may think that these are okay. I would suggest buying these vegetables and fruits from the farmers market. And this goes back to a theory that if you want to read about it's in the Walls protocol. Dr. Bluestein knows about that? 

00:19
Dr. Linda Bluestein
Yeah, I love the Walls protocol. 

00:20
Dr. Pradeep Chopra
Protocol where this is a neurologist. She treated her own Ms. And like from a wheelchair to no wheelchair. 

00:42
Jennifer Milner
Welcome back to the Bendy Bodies podcast, bringing you state of the art information to optimize your health. This is co host Jennifer Milner, a former professional ballet and Broadway dancer who struggled for years with hypermobility related problems. Now I train dancers to ensure the next generation of hypermobile artists are better equipped to work to their fullest potential. 

00:59
Dr. Linda Bluestein
I am Dr. Linda Bluestein, the hypermobility MD. I started Bendy Bodies to provide accessible information for everyone on the hypermobility spectrum. Combining my medical education and personal experiences enables me to treat and coach patients and clients to optimize their quality of life. This information is for educational purposes only and is not a substitute for medical advice. Today, we are so excited to chat with my mentor, Dr. Pradeep Chopra. Dr. Chopra is a Harvard trained anesthesiologist, double board certified in pain management, and anesthesiology director of the center for Complex Conditions and Assistant professor of the Brown Medical School with a special interest in complex chronic pain conditions and their associated coexisting conditions. He serves on the Medical Advisory Board for several chronic pain conditions and is the former chairman of the Eds International Pain Consortium. Dr. Chopra, hello and welcome to Bendy Bodies. 

01:49
Dr. Pradeep Chopra
Thank you. And thank you for inviting me to the Bendy Bodies Podcast. It's an honor and a pleasure. 

01:55
Dr. Linda Bluestein
Finally. We've been wanting to do this for so long. 

01:57
Jennifer Milner
That's what I was about to say. We are so glad that we finally have you all to ourselves. Your brain will be empty by the time we're done because we're going to pick it clean with all of our questions. I know. But before we get started, Dr. Chopra, can you tell our listeners a little bit about yourself? 

02:10
Dr. Pradeep Chopra
Sure. As Dr. Bluestein just explained, I did my training and my fellowship in pain medicine, and I have been in Rhode Island for about since 2000, so that's 23 years. And I have a special interest in complex conditions, so Eds being one of them. But I do have an interest in complex conditions as far as Eds is concerned. When I first came across this condition almost 20 years ago, I was shocked to find that there was really no information about it other than it being said, oh, it's a rare condition, and that's it. So part of my training has been in surgery, part of my training has been in Orthopedics. And then as anesthesiologist, I've been trained in a lot of the internal medicine and critical care subjects. And then on top of that, I have pain medicine. None of these times in my life did I learn about Eds. 

02:58
Dr. Pradeep Chopra
And so I took it on myself to better understand Eds and sort of bring in an understanding from all of these subjects the training that I had in the past to put them together and figure out what's going on with people with Eds. And one of the things I did discover that this is definitely not a rare condition. It is far more common than we thought. It's just rarely diagnosed. People miss it a lot. But in the last 1015 years, I have to say that this is more and more physicians are now beginning to, quote unquote, suspect Eds, which really helps a lot. My work in terms of treating Eds is kind of the primary care provider where when a patient comes to me with a suspected Eds, a typical appointment lasts about 5 hours. That's not counting the hour or 2 hours I've already spent the night before reviewing medical records and timelines and all that stuff. 

03:53
Dr. Pradeep Chopra
And so when a patient comes in, I go through everything, like from head toe. We go through everything, we come up with a plan. And that's one part of the conundrum of treating Eds. But the issue that I have, the problems that I face are that I can't find specialists who will understand what needs to be done. For example, just to pick up today's topic on abdomen, I really can't find a gastroenterologist who really understands the issues that come with Eds. I think I probably know two of them in the entire United States. And that's where the problem comes in. But again, it's a step. We start talking about it, we start the conversation rolling and then eventually people will learn and people will pick up on this and hopefully somebody will start some gastroenterologist somewhere, will listen to this podcast and say I am going to change my practice and I'm going to treat Eds the way they should be treated. 

04:50
Jennifer Milner
Well. And I think that your story is unfortunately a common one in that there is no training out there that I know of that is this is going to be a physician specialty on Eds and connective tissue disorders, right? So what we hear over and over again from some of the experts that we talk to is, well, I learned about this thing, and I just wanted to dig deeper into it. And I just put together sort of my own education, and maybe within another ten years that there will be more of a codified education for topics like this. But until then, we are extremely grateful that you decided to dive deep and figure it out and learn about it. And one of the issues that a lot of people with Eds have is that there are so many things that can go wrong and there are so many interconnected, so many comorbidities, it's really hard to parse it out and everybody's addressing one little piece of the elephant and nobody's seeing the whole elephant. 

05:42
Jennifer Milner
So we're really grateful that today we're talking about abdominal pain and not just looking at it from an allergist point of view or a GI specialist point of view as we dive into abdominal pain. Can you fill us in a little bit just on some basic abdominal anatomy so we know where we're going? 

05:55
Dr. Pradeep Chopra
Good, that's exactly what I wanted to talk about. Anatomy first, so people understand. So you've got to think of the abdomen like a bag, okay? And in this bag are intestines organs, blood vessels, nerves, all of that is stuffed into it. In fact, the intestines are about 20ft long. So you can imagine taking a bag and stuffing in a tube 20ft long, and then you put in the liver, the kidneys, the spleen, the uterus, the bladder and all that. So it's all in there. And then all of these organs have a nerve supply and actually two nerve supplies. And then there's a blood supply to these. So I'm going to start from the top of this long, 20ft long intestine. And it starts with the esophagus, which is the food pipe. It starts at your throat and then it gets into your crosses, the diaphragm, which is the muscle between the chest and the belly. 

06:54
Dr. Pradeep Chopra
It ends in a pouch called the stomach. And then from the pouch it curves into part of the small intestine known as the deodenum. Deodorant means ten fingers. So you put ten fingers together, and that's how wide the dudenum is, which is to make things easier. It's part of the small intestine. And then from there you get into the food, our path. Let's imagine that you're traveling down this intestine from the dudenum. We now enter into the small intestine, and then we wiggle through the intestine all the way till we reach the large intestine, which starts on the right lower pelvic region. And then that's where our journey climbs. Our roller coaster climbs up the right side and then travels across our abdomen and goes onto the left side. And then we go down this large tube known as a large intestine of the colon. 

07:49
Dr. Pradeep Chopra
And then it goes into an S shaped part of the colon called the sigmoid colon. And then it goes into the rectum and then into the anus. And then we're out. So this is the intestine. And just I'm going to recap it real quickly. Starts with the esophagus, which is known as the food pipe, goes into the pouch called the stomach, then the small intestine, then the large intestine, and then into the sigmoid colon, which is an S shaped part of the large colon, and then the rectum, and then it's out through the anus. So besides this, we also have our organs, the liver, which is on the right side, it hides under the rib cage. We have the spleen, which also hides under the rib cage. On the left side we have the two kidneys which are in the back, and then the uterus. 

08:36
Dr. Pradeep Chopra
Everybody knows where it is. If they don't know, then we have a problem. But it's in the pelvis. And then you have the two ovaries on each side, the bladder. And of course the bladder has an opening which goes out through the urethra. Now all of this has a very rich blood supply because when you eat food that nutrition is critical for the body. And so blood has to there's a tremendous amount of blood flow to all of these organs. So as the nutrition, so as the nutrients can be transported to the rest of the body to do that. There are two massive pipes in the back of our abdomen. Remember I told you the abdomen was like a bag? Back of the bag or the back of the abdomen. There are two large pipes. One that brings blood to the abdomen, that's called the AoTA, or to be more precise, abdominal AoTA. 

09:32
Dr. Pradeep Chopra
And then the other pipe, which is more on the left side. They're both parallel to each other, but the AoTA is on the right side. The inferior vena cava is on the left side. And that brings blood back to the heart. So the basic principle of blood flow in the human body is what goes in has to come out. The same amount has to come out. So the AoTA is pretty large and it carries a lot of blood. Same thing with inferior vena CA. It has pretty large and carries a lot of blood. All of this is going to come into play later on. And then you have the nerve supply. You have the sympathetic nervous system. The sympathetic nervous system pretty much goes to the entire to all the intestines and all the organs in the abdomen. The parasympathetic, which is predominantly the vagus nerve, it follows esophagus to the stomach, to the deuteronom through the small intestine. 

10:26
Dr. Pradeep Chopra
And then it stops midway in the colon. It stops actually in the middle of the transverse colon. And that's the parasympathetic. The job of the sympathetic is to make the intestines move along. Just imagine food in the intestine moves along like a toothpaste. Squeeze, squeeze, squeeze, and it moves forward. That's the sympathetic nervous system doing that. And the parasympathetic nervous system keeps that under control. So this is Anatomy 101 in a very brief nutshell. The reason I wanted to do that was because as we talk about the different conditions, we will be referring to this anatomy again. 

11:04
Jennifer Milner
Well, I appreciate that, and I also have to point out that as you talked through in a very basic two minute summary, the contents of the abdominal cavity, we also touched on several different systems. We touched on the digestive system. We touched on the nervous system with the parasympathetic and the sympathetic nervous system. We touched on the urinary system. I can't remember what it's called now. And we touched on the cardiac system with blood supply, so vascular system. So we've got a lot of things going on in what, as you said, was a very small bag. So no wonder it's complicated and no wonder it's difficult. So is that part of the reason why abdominal pain is an issue with a lot of Eds people? Is it because there are so many different systems coming together in that small bag? 

11:44
Dr. Pradeep Chopra
True. I mean, there's a lot of activity going on in there and there's so many players in the abdomen. On top of that, I just talked to you about the outside of the intestine, we're not even looking and talk to you about what's inside the intestine. And then again, that's a whole different ballgame. And then on top of that, you're putting in food. And a lot depends on the quality of the food that we are eating and the nutrition that we get. There's a lot of controversy about the quality of food that we eat and how it affects our system. The nervous system, just a little FYI after the brain, the most nerves that you find are in the abdomen. So that's a lot of nerves over there. And then you bring in the blood flow and then you bring in the foods or chemicals that you bring in. 

12:32
Dr. Pradeep Chopra
I'll give you a quick example. Color dyes. Color dyes are extremely harmful for us. Red dyes, blue dyes, and it's hard to get away from these dyes because your medicines are colored. And I have no idea why you want to color your medicines, but red dyes and blue dyes are extremely harmful. There is actually a proposal in front of Congress right now where they want to remove color dyes from peeps. Hopefully, once that happens, other manufacturers are going to learn something from it. Veterinary medicine. There was a class action lawsuit where color dyes were removed. So all veterinary medicines do not have any color in them. But just as a quick pointer, I wanted to show you the intricacies of how little things can affect our entire body. Just like something like a blue colored drink can affect your entire body. 

13:24
Jennifer Milner
That's such a great point. And so much of it, as you said, is coming into the abdomen where I did not know that the most nerves you can find are in the abdomen after the brain. That's really interesting. What are some of the causes of abdominal pain in people with symptomatic joint hypermobility? 

13:40
Dr. Pradeep Chopra
So I had the pleasure of listing them today and I came up with approximately 22 causes. 

13:46
Jennifer Milner
Wow. 

13:47
Dr. Pradeep Chopra
So you guys are in for a long ride. 

13:49
Jennifer Milner
But no, let's hear it because I'm sure there are listeners who are going check as you go through your 22 items. So this will be great. They will feel validated, I'm sure. 

13:58
Dr. Pradeep Chopra
So the first thing I want to make clarify is that it's not anxiety disorder, okay? For somebody to be diagnosed with anxiety disorder, let's say somebody's having nausea and vomiting, and doctors are very prone to pointing out as anxiety disorder. And it's not. The only way you can call it anxiety disorder is unless you have proven conclusively, without a doubt that there is nothing else going on. And 99.9% of the times there is something going on, and it's not anxiety disorder. So with that, let's talk about the food pipe. The Esophagus, which is one of the commonest conditions that affect the Esophagus in Eds, isinophilic Esophagitis. So esinophils are allergy cells. They swarm into the esophagus and line it, and it causes an inflammation of Esophagus. So imagine your food pipe getting inflamed. Inflammation is defined as something that causes swelling, pain, redness. So it's a painful condition. 

15:04
Dr. Pradeep Chopra
So your Esophagus becomes hot and inflamed. So they have difficulty swallowing. Obviously. It also seems like your food is getting stuck in there. It's not moving along as well. One of the things to remember, and we'll get to this again and again, is if any part of the intestine gets inflamed, it stops functioning. That's the bottom line. It just stops moving till the inflammation is resolved. So the Esophagus is not pushing that food along, like I said, in terms of like a toothpaste. And so they also, because it's not moving along, they tend to vomit the food out. And of course, they have heartburn. In medicine, Isinophilic Esophagitis is classified as a separate condition. But when it was first classified into brought into medicine, we didn't know anything about mast Cell Activation Syndrome. Mast cell activation syndrome is a very young condition. It's only about 1012 years old. 

15:59
Dr. Pradeep Chopra
That's when he first heard about it. And I think that it is very closely related to mast Cell Activation Syndrome. In fact, it might be part of mast Cell Activation Syndrome. Essentially. Just to recap again, the food pipe gets inflamed, and when it gets inflamed, they have patients have difficulty swallowing. It looks like the food is getting stuck. They have vomiting and they have severe heartburn. And that's esophagitis, which might be a part of Mast cell activation syndrome. 

16:28
Jennifer Milner
That would make a lot of sense. If it is, I have a few different dancers with Eds who have been diagnosed with EOE, and that makes a huge amount of sense, right? 

16:37
Dr. Pradeep Chopra
So whenever I come across this diagnosis of Isinophilic Esophagitis, I start suspecting mast Cell Activation Syndrome, and then I start looking for other symptoms of mast cell. The second thing I want to talk to you about is very common is called Gerd or acid reflux. It's not particular to Eds. We all have it, and it's very particular to the foods that we eat. But gerd or acid reflux in Eds is closely related to mass cell activation syndrome. So one of the things that happens is that there are histamine receptors in the stomach and the stomach. Remember the pouch we talked about? In this pouch, this acid is produced normally, but in acid reflux is excessive amounts of acid produced it's so much so that it starts regurgitating itself back up the food pipe, the esophagus. Now, mass cells can stimulate histamine receptors. These are the H two or the histamine two receptors in the stomach, which then increases production of acid in the stomach. 

17:42
Dr. Pradeep Chopra
And the reason I brought this up was the most common drug prescribed for acid reflux of patients nowadays are pantaprazole, omiprazole, and all of these drugs are not safe for patients with Eds. In fact, they are not safe for anybody. And I'll explain that to you. Omiprazole or pantaprazole and all this class of what are called as PPIs, this class of drugs is only to be taken for 14 days. That's the black box warning on these drugs, not more than 14 days. And it's not surprising. Very often I'll see patients, and they've been on it for years. Why is it a problem? Number one, it decreases acid production, which is fine, but that decreases calcium absorption. You need that acid to absorb calcium. So these patients become prone to having early onset osteoporosis and osteopenia. The second problem is that if you kill all the acid, then it allows for the bad guys to grow, especially things like yeast, to start proliferating in the small intestine. 

18:47
Dr. Pradeep Chopra
And these are the two reasons? Well, these are the two reasons I don't like this group of drugs for short term use. It's fine, you can take it for and the official recommendation is not more than two weeks. 

18:59
Jennifer Milner
That makes a lot of sense. And I know sometimes we think we know better than what's on the box, or we think, oh, that feels good, maybe I should just keep taking it. And that's why it's important to have a doctor that follows along with your care and not just someone that you see once and get a prescription and then go on your merry way. And I also have to point out, this is a podcast so people can't see us. But Dr. Bluestein is like nodding vigorously. Oh, it's so much. 

19:22
Dr. Linda Bluestein
It's not that they're doing it on their own. Usually their doctors are continuing to prescribe it for years and years. So, yeah, it is hard to get off sometimes, but, yeah, that's one of the first things that I do, is talk to somebody about, let's look at other options. And, yes, you're right. If people are just listening and not watching the video later or something, they. 

19:42
Jennifer Milner
Don'T see the she's like cheering, we'll. 

19:47
Dr. Pradeep Chopra
Announce when you're nodding ahead. So when I got into practice and I was like, okay, I know this group of drugs should not be written for more than 14 days. And I had patients coming in who had been on it for years, and I was horrified. So I said, maybe I'mistaken So I went back and I looked it up, and sure enough, there is a black box warning not to be taken for more than 14 days. So with this, we move on to we're now in the stomach, right? So we're producing a lot of acid. And one of the reasons we can be producing more acid is because of Mast Cell Activation Syndrome. Mass cells, these annoying little fellows, can stimulate histamine two receptors, which increases acid production in the stomach. The other reason we produce acid, excessive acid in the stomach, is if you're eating something that you're intolerant to. 

20:38
Dr. Pradeep Chopra
Like, for example, I'll give you my example. I'm intolerant to gluten. And if I take something with gluten in it, I start having acid reflux. This acid reflux can be caused by foods or it can be caused by Mass Cell Activation Syndrome. And at some point, when we ever talk about Mass Cell Activation Syndrome treatments, one of the treatments for that is to use an H two antagonist to stop these h two receptors, block these H two receptors. And right now, we only have two drugs in the market. One is called phambotidine, sold as Pepsid. And the other one is Tagamet, also sold as well, cymatidine, sold as Tagamet. These are H two receptor blockers, which means that if you can block your histamine two receptors in the stomach, you can decrease acid production without having the harmful effects of the PPIs. So as we travel down the stomach, we're now at the exit of the stomach, and we're entering into the part of the small intestine called the deodinum. 

21:43
Dr. Pradeep Chopra
Over here, there is a gate. It's a gate, it's a sphincter. And this sphincter is called the Pyloric sphincter. And very often the Pyloric sphincter goes into a spasm. And the reason for that, which means that if it goes into a spasm, the gate shuts when the gate shuts. Now your food that's sitting in your pouch in the stomach can't move along into the deodorant is sitting there. So your small intestine is empty and your stomach is bloated. And the Pyloric sphincter goes into a spasm for one reason. And the reason is that there is a separate nerve supply to the Pyloric sphincter. So there are separate sympathetic nerves that go to the Pyloric sphincter. And also there is the parasympathetic, the vagus nerve, that goes to Pyloric sphincter. In patients with Pots, the sympathetic nervous system is hyperactive. And so what happens is that the Pyloric sphincter shuts down because the sympathetic nervous system is overactive and the vagus nerve by itself can't open it. 

22:46
Dr. Pradeep Chopra
So obviously, treating Pots makes sense over here. But sometimes we do need to in extreme cases, doctors or gastroenterologists will go in there and loosen up the muscle. The Spyloric sphincter with Botox injections to allow food to pass easily, these patients are going to present with abdominal distension, nausea, vomiting, because there's food sitting in the stomach forever. 

23:14
Jennifer Milner
That's so interesting because this is like our, what, 4th fifth issue that you've talked about. And we've moved from sort of a mast cell dominance of the issues into a nervous system trigger for issues. And so we're seeing the overlap of the different systems. Sorry, go ahead. 

23:33
Dr. Pradeep Chopra
So the next one I want to talk to you about was so we're now in the deodorant, right? We're traveling if we travel down the food pipe, the esophagus, we've come into the stomach pouch where were flooded with acid. Now we've gone through the pyloric sphincter, and now we've entered the deodinum. Here we have a slightly different problem. We have what is called superior mesentric artery syndrome. I'll repeat that superior mecentric artery syndrome, or SMAs. In superior mesentric artery, there's an artery that, so the is a pipe, right? And there's an artery that kind of comes out from the AoTA. Remember, the AoTA was a big pipe that supplies blood to the intestine. One of the pipes that come out from it to supply blood to the intestines is called the superior mesentric artery. And this superior mesentric artery snakes over the deodinum. And in some cases, what happens is the superior mezentric artery blocks it's so tight that it causes an obstruction of the deodorant. 

24:44
Dr. Pradeep Chopra
So now you have food that comes down the esophagus, stomach goes into the deodorum, and now it can't go any further because there's an artery outside it that's blocking it. And this is called superior mesentric artery syndrome. It's far more common than people think because we don't have the advantage of pictures. So I'm just going to give you a picture about it. Think of a big pipe, and there's a little pipe over it which is so tight that it obstructs the big pipe. The big pipe being the deodorant, the small pipe being the superior mesentric artery. This is called superior mesentric artery syndrome. These patients will again present with same symptoms of obstruction. They get full very quickly. They get nauseous because food has been sitting there and now it's starting to ferment and they have vomiting, but they also have severe stabbing pain after eating because this food is not moving forward and it's distending the deodorant. 

25:45
Dr. Pradeep Chopra
And the stomach has room to distend, but the deodorant does not have room to distend. And so if you're trying to distend the deodorant, it's going to hurt a lot. They do have belly bloating, lots of burping, that's gas being pushed back up through your windpipe. One of the things they may notice is that if they lie on their stomach, the pain gets better. Now, that's just the mechanics of how it happens. You're moving the artery away from the deodorant. You're moving the artery away. When you lie on your stomach, it hangs away from the deodorant and allows the deodorant to open up. So that's superior mecentric artery syndrome. 

26:25
Jennifer Milner
Well, and I will say I encountered that probably eight years ago with a dancer that it took about two years for her to get diagnosed with that as a dancer. She lost a lot of weight. People thought she had an eating disorder and her family really had to fight to say she does not have an eating disorder. She's not lying. There's something wrong with my child. And her mother had a history of some autoimmune and connective tissue problems. And they finally, after a severe loss of weight that put her into the emergency room, they finally found the SMAs and it was a game changer for her. So much of it is just not knowing what it is and how to treat it and how to deal with it for people. And so you feel like you're completely stuck in this weird world where you're trying to tell people what's going on and people are like, I don't know, but I don't think that's possible. 

27:10
Dr. Pradeep Chopra
No, it's true. But I'm not talking about something that's very rare. I'm talking about something that's very common, actually, in the Eds population. So the question is, why do people have SMA syndrome and all this? And then there are a bunch of things that we'll talk later on. Why do people with Eds have it? And people with non Eds patients do not have these things is because, and this is just my thought is that the tissue, the connective tissue that builds up people with Eds is soft. So when they are upright, the tissue is soft that it descends and it just has to descend a little bit and enough to cause obstruction in many different places. And we'll talk about that. A small movement of the blood vessel downwards will cause obstruction of the deodinum. 

28:04
Jennifer Milner
That makes a lot of sense. 

28:05
Dr. Pradeep Chopra
Now, over here, I have to talk a little bit about the treatment. If you look at the textbook, the treatment is to eat more, which to me is really funny. You have a person now who's, bloated, can't eat right, has severe nausea, vomiting, belly pain, and you're asking them to eat more. And it never works, obviously. But the treatment that does work very well is what's called a gastro deodinostomy. So they take the stomach and they take the last part of the deodorant, which is loose, and they form a short circuit between the two. It's a simple, straightforward surgery. Now, the food doesn't have to go through the pyloric sphincter into the deodorantum. It goes straight from the stomach into the last part of the deodorantum and into the small intestine. And this is a surgery that has been done for decades for different conditions. 

28:54
Dr. Pradeep Chopra
It's not an unusual surgery, it's not a weird surgery, but that's the treatment for it not eating more. I did come across some strange literature about called de rotation of the deodorantum. I won't even elaborate on it. Just forget it. Someone offers you that surgery, don't even think about it. There's no good. Literature to support it. The next thing I want to talk to you about was how Mast Cell Activation Syndrome affects the abdomen. And essentially you have to think of Masturbal Activation Syndrome as something that causes inflammation everywhere. Everywhere from head toe, every single muscle, ligament, not bone, but all of the joints, all of these are affected. And the easiest way to figure out whether you have Mass Cell Activation Syndrome or not is it feels like you have flulike symptoms. Everything hurts. Everything. You feel tired, you just want to stay in bed curled up like, as if you're coming down with flu like symptoms. 

29:55
Dr. Pradeep Chopra
Now, mass cells are supposed to be, are like the National Guard. They are supposed to defend, they're supposed to defend our body. And what they do is they stay on the edge of where there is air or the environment and the body. So like in the intestine, for example, they're on the inner lining of the intestine, they are on the throat. You can see them in the throat because dry eyes, the muscles accumulate there. They accumulate in sinuses where there is a connection between the environment and their body. So it causes inflammation of the intestine everywhere. The small intestine is inflamed, the stomach is inflamed, the large intestine is inflamed. And like I told you before, when the intestine gets inflamed, it stops moving. 

30:47
Jennifer Milner
Well, that makes sense. 

30:49
Dr. Pradeep Chopra
That's where your gastroparesis can come in from, your small intestine dysfunction can come from because everything hurts. Obviously the diagnosis is to look into the symptoms of Mast Cell Activation Syndrome. But as a physician, when I examine these patients, I gently push on their stomach, very gently, and they'll tell you it hurts. I even do what is called a percussion, which is tap on their abdomen. And that hurts because their intestines are so inflamed. And that just tells me that a large part of their Bloating and pain in their abdomen is coming from Mast Cell Activation Syndrome. I don't know why I have interstitial cystitis as the next one, but we'll go on that. So this is inflammation of the bladder. So oftentimes, like I told you, mast cells tend to accumulate at the edges, the border of the environment and the tissue. So again, the lining of the bladder gets inflamed. 

31:49
Dr. Pradeep Chopra
And oftentimes these people will have bladder pain, commonly diagnosed as interstitial cystitis. Which is fine, I don't mind because you can say bladder pain, you can say interstitial cystitis, but the cause is oftentimes mast Cell Activation Syndrome. And it's easy to diagnose. You press on the bladder and it hurts. In the same sentence you can talk about inflammation of the urethra. And so people with Mast Cell Activation Syndrome, if their bladder is inflamed, their urethra is inflamed, they'll pee and it hurts. Not because of an infection, but it hurts because the urethra and the bladder are inflamed. They get a test done, they look for infection they can't find an organism and they repeatedly keep having this burning urine and burning bladder. They keep taking antibiotics empirically and they're not getting better. And so whenever I have a patient saying that to me in my office, I ask them, did your doctor actually look for an organism that's causing this so called infection? 

32:46
Dr. Pradeep Chopra
And most times they'll say, no, they just give me some antibiotics. 

32:51
Jennifer Milner
Right? 

32:51
Dr. Pradeep Chopra
But the treatment lies in treating Muscle Activation Syndrome. 

32:54
Jennifer Milner
That's the key here. Well, and it sounds like a fair amount of physicians may be treating the what? Like your stomach's not emptying, let's empty your stomach, your bladder hurts, let's assume it's infected rather than treating the why? Why does your bladder hurt? Why is this happening in your intestines? Is that fair to say? 

33:10
Dr. Pradeep Chopra
Yes. There's only one principle in medicine, in pain medicine, actually, is to figure out what's broken. So this is the only question I have in my head when I see a patient. What's wrong here? Why? What's the reason for this patient to vomit? What's the reason for this patient to have knee pain? What's the reason for this patient to have burning in their bladder and their urine again and again? So the question is what's broken? That's the question we need to answer. Yes, you may have vomiting again and again, but giving Zofran is not the answer. That's the Band Aid. Yes, that's a temporary treatment. But what is the reason the person is vomiting? Is the key one to find out. And just within the last 20 minutes, we must have talked about at least seven reasons for a patient to have nausea, vomiting, and Bloating. 

34:04
Dr. Pradeep Chopra
Yeah, and this is the thing. There are so many reasons. And that's where we as physicians and gastroenterologists and treating physicians, have to tease out what's broken here that we need to treat well. 

34:17
Jennifer Milner
And if you listed seven things, I think six of them came back to mast cells. And that's not where a lot of people start to look when they're trying to deal with abdominal pain. 

34:26
Dr. Pradeep Chopra
So the next one I want to talk about is SIBO S-I-B-O which stands for small intestinal bacterial overgrowth. What happens is the small intestine has 1000 different type of bacteria that live there. These are friendly guys. They live there, they help us. The large intestine has 10,000 different type of bacteria. And we know that the intestines move from the small intestine and onto the large intestine and out. We know that's the path that they follow. But if for any reason the intestines stop moving, for whatever reason this mast Cell Activation syndrome or whatever reason they stop moving or they slow down, then these 10,000 bacteria in the large intestine now creep over to the small intestine and they overpopulate it. And that's what's called small intestinal bacterial Overgrowth. The keyboard being here overgrowth. Now, most often people treat it as like oh, you've got lots of, you've got small the test for SIBO is a breath test. 

35:31
Dr. Pradeep Chopra
So they take these 1000 different samples of you breathing into tubes and then they look at methane and other gases that are in there. And from that they can predict if you have SIBO or not. And if they do have SIBO, the common treatment is to give you something, antibiotic that does not get absorbed. So antibiotic like refaxamine or neomycine or something like that, it doesn't get absorbed, it just goes in there like drano kills all this overgrowth of bacteria and then it's ejected out through the anus. But that's not the treatment. The treatment is why did this person get SIBO in the first place? Because the intestines are not moving well. And if they're not moving well, we need to fix that first before we give these people heavy duty antibiotics to clean out the small intestine. And very often people will develop SIBO, they get this draino treatment and then three months later they are back with SIBO again. 

36:30
Dr. Pradeep Chopra
And that's the reason, because we haven't treated the cause of the SIBO. SIBO itself is not the problem. The problem is to find out what the cause is. But people with SIBO generally present with Bloating. They feel gassy, nauseous, the usual abdominal symptoms. Moving on to Mal's median Arcwit ligament syndrome. Again, I'll repeat that, median Arquit ligament syndrome. It is commonly also known as the Dunbar syndrome, which I think is a better name, dunbar syndrome. But in any case, Mal's or the Dunbar syndrome is an extremely painful little trying. I'm going to try and explain it. But essentially what happens is remember the AoTA we had talked about the large pipe that supplies to the intestine. There is one little artery that comes out from it to provide blood to the stomach and the small intestine area. And that little artery is called celiac artery. 

37:24
Dr. Pradeep Chopra
And what happens is the celiac artery burrows under the diaphragm, which is the muscle that separates the abdomen from the stomach, that burrows through it, forming a ligament around it called the median Arquit ligament. And then it comes out from the AoTA and then it supplies blood to the intestine. Also there is a bunch of nerves, part of the sympathetic nervous system that travel along with the claic artery and they also come out through this and they provide innervation to the small intestine and the stomach. Remember I just mentioned that. So we see Mal's in patients with Eds quite often. And again, I haven't seen a Mal's patient in a non Eds patient. And the question is why? And this is again, my theory is that people with Eds have soft connective tissue. When they stand upright, the diaphragm and the tissue and everything kind of drops down, settles down, and when it settles down, it compresses the artery. 

38:24
Dr. Pradeep Chopra
Over here, the claic artery, the CLIC artery gets compressed in median Archid ligament syndrome. So when they eat food, as soon as they eat food, they feel this intense pain at the top of their belly, which is called epigastric region or the solar plexus region. They feel this intense pain there as soon as they eat. It gets better when they lie on their side, especially on their left side, or when they lie on their stomach. It gets worse when they're upright. Makes sense, right? If they lie down, it gets better because now your tissue is going back to where it's supposed to be. It gets worse when they're upright. Now your tissues is dropping down and choking the celic artery. It also gets worse as you exercise, because as you exercise, there's more blood flow, but you're upright. And as you're upright, you're exercising. And because the celiac artery is being pinched, it can't afford to supply enough blood, so you get this pain from it. 

39:23
Dr. Pradeep Chopra
One of the other problems with this is that there's a nervous system, the celiac plexus, it's called the celiac plexus. It's part of the sympathetic nervous system that travels along with the celiac artery and that gets pinched also. So this is a pain caused by poor blood flow or ischemic. Blood flow or ischemic ischemia and compression of the nerves. It's a very painful condition for physicians. The clinical exam is not that difficult. Of course, you got to take the history. But the clinical exam is if you press on the solar plexus or the epigastric region, patients are going to wince and they'll complain of a very different kind of a pain. It's a very sharp, stabbing pain. And I do that. I'll say, look, I'm going to call this point number one. I'm going to press on it and tell me how much that hurts. 

40:10
Dr. Pradeep Chopra
And they'll make a face and they'll say, that's a really sharp stabbing pain. To make sure that we're not confusing it, I'll take a random spot on the abdomen and press as hard and I'll say that's point number two. Now, which one do you think hurts more? And they'll always come back to point number one. You can have them lie on their stomach and they feel the relief right away. You can have them lie on their left side mostly, or even the right side. They'll get relief from the pain. So the treatment here is, of course, you loosen up the ligament that's pinching the artery and the nerve. And there are two schools of thought over here. There are some surgeons, these are vascular surgeons prefer to just loosen up the ligament and let it be there. There's another school of thought, is to not just loosen up the ligament, but also to remove the nerves. 

41:01
Dr. Pradeep Chopra
And it's the second group of surgeons who get the best results. That's my experience. They get better, much better results than the first group. And I've had patients from both groups and invariably the first group, you'll always find that they had this mal surgery and they'll come back and say it didn't help. You ask them, like, who did it? And then you find out, you look at the operative note and, yeah, they did not remove the nerve. So why is it important to remove the nerve? We know it's getting pinched. So you've released a ligament. And so why is it important to remove the nerve is because some of these nerves don't. They actually come through the diaphragm. They make their own opening through the diaphragm. They don't always come through the arch of the ligament. They don't always travel with artery. They find their own path through the diaphragm. 

41:48
Dr. Pradeep Chopra
So even if you loosen up the ligament, the nerve that is passing through the diaphragm is going to get pinched every time they stand up. 

41:54
Jennifer Milner
That makes sense. 

41:56
Dr. Pradeep Chopra
So it's important to remove and surgeons who do this surgery will actually do what is called a celebrate plexus block. So they'll go in there with a needle, numb up that celiac plexus, and the patient will in an ideal case, the patient will respond, will say that they have very good results. They don't feel the pain. And then the pain comes back after a few hours when the numbing medicine wears off. So the caution here is, besides being diagnosed and all, the caution here is to look for a surgeon that removes the nerve as well as loosening up the ligament. That's the important part. So that's Median arcuate Ligament Syndrome, or also known as a Dunbar syndrome, it's not as rare as people like to mention it. It's pretty common, very common. The next one is called the Nutcracker syndrome. 

42:47
Jennifer Milner
Okay? 

42:48
Dr. Pradeep Chopra
The Nutcracker syndrome is very difficult to diagnose, and I'm going to try and explain what happens. So you have the left kidney and you have the right kidney. The left kidney is a little further away from the AoTA. Remember I told you the abdominal aorta was on the right side? So the blood flow to the left kidney, the renal artery that goes to the left kidney is a little longer than the right one. Similarly, the vein that comes from the kidney is also longer than the right one. And you remember the superior mesenteric artery we had talked about? The superior mesenteric artery is a troublemaker. Again, over here, it travels over the left renal vein. And again, when you stand up, the superior mesenteric artery kind of drops down a little bit and it pinches the left renal vein. Now, okay, in the human body, one of the rules is what goes in has to come out. 

43:44
Dr. Pradeep Chopra
The amount of blood that goes to an organ, that's the amount of blood that has to come out. You can't have 2oz of blood going to the left kidney and only 1oz coming out. That you cannot have that happen. And so what happens is the left renal vein gets compressed by the superior mesentric artery. The problem here is that they have a wonderful right kidney, but they have an iffy left kidney, and it's very difficult to diagnose it. These patients may present with hematuria, that is, blood in the urine. Now, sometimes it's not very obvious. Like, you're not going to obviously see blood in the urine. It may be microscopic hematuria. The way to diagnose microscopic hematuria at home is you pee on a Kleenex, on a white piece of Kleenex or toilet paper, and you can see redness remaining there. The red blood cells. 

44:34
Dr. Pradeep Chopra
That's microscopic hematuria. There is left flank pain in males. They'll be a varicoseal. Their urine has in both men and women. There's increased protein in their urine, and they also have anemia. These are very nonspecific presentations, and that's why it's very difficult to diagnose this. My piece of advice is that if you have a patient with superior mesenteric artery syndrome, just check these patients for Nutcracker also because it's the same artery that's causing problems down the line. Superior mesenteric artery syndrome is above, and the Nutcracker syndrome is below. So it's the same culprit so it's best to check both at the same time. 

45:22
Jennifer Milner
Well, it makes sense now that you've told me that, but I think so many people out there just wouldn't connect the dots of the things that you've said, like anemia and blood in the urine. I can't imagine trying to wade through all of the possibilities that it could be. So. I know people are taking notes. Copiously as you're speaking here. 

45:40
Dr. Pradeep Chopra
When I looked at these conditions, I'm like, okay, you have the SMA syndrome caused by the superior mesenteric artery, and then you have the Nutcracker syndrome, which is, again, the superior mesenteric artery. Why is this happening? And it brings you back to the same theory that, yes, the tissue is loose, and when you stand upright, some of this descends. Now, when I say descent, obviously I don't mean by descends by feet. Just a small just a bit. Yeah. And that's enough to compress arteries and veins everywhere. So the other one, which is not a big deal problem, by the way, the treatment for Nutcracker syndrome is taking the left kidney and transplanting it to the right side. That's the best treatment. But anyway, the next one I want to talk to you about is Proptosis, which is the liver descending down or the kidney falling down, the spleen falling down because it's loose, connective tissue. 

46:34
Dr. Pradeep Chopra
It's very difficult to diagnose it. But what happens is that let's say the kidney falls down. It drops down because the tissue is loose, it drops down. When it drops down, then the blood flow to it may get compromised. And that's the problem with proptosis. It's extremely difficult to diagnose this condition because it doesn't really show up in any unless you're specifically looking for it. If you do an MRI or Cat scan or something, it might show up, but otherwise, clinically, it's very difficult to diagnose it when your kidney should be living up in the back where your bra strap is, and now your kidney is sitting down in your pelvis. It's very difficult to make that out clinically well. 

47:21
Jennifer Milner
And I wonder, is it an issue, like you said, if you're doing an MRI or something, since you're lying down, does the kidney sort of slide back enough that they don't really notice it in the MRI? 

47:31
Dr. Pradeep Chopra
Exactly. That is why MRIs and Cat scans in Ads are not very helpful unless you do a dynamic Cat scan. So you take one when you're lying down and you take another one when you're standing or something like that. Static MRIs and static pictures in Eds are not helpful. Yes, that is a very good point. Pelvic vein congestion. So in the pelvis you have a ton of veins. Especially with women, there's lots of veins. And again, as you recall, when we stand, blood pools down our legs. And when blood pools down our legs, especially in people with Eds, their feet turn dark and red on the same principle. When they stand, the veins in the pelvis get congested. This is a point I wanted to bring, was because patients will complain that when the pain in the pelvis gets worse when they stand, gets better when they lie down. 

48:29
Dr. Pradeep Chopra
And obviously when you do any kind of a study, a radiological study, you're lying down and it won't show up. So you got to get it done lying down as well as upright. That's the thing. The second thing I wanted to bring was Pots. So we know Pots is people with Eds have Pots for three different reasons, and that hopefully will be a different podcast. But Pots, just to take the basic reason for Pots, where blood pulls down the legs and your sympathetic nervous system is trying to pump this blood back up to your brain, 80% of the blood that pulls down is in the pelvis, the buttocks and the thighs, 80%. So wearing stockings, compression stockings, is not helpful at all. What we need is compression into in our thighs, in our buttocks, and even the pelvis, like some sort of a compressive corset or something like that, or a tight swimsuit, something like that will compress the pelvic veins. 

49:29
Dr. Pradeep Chopra
Because 80% of the blood pools in that section, the lower section, like the buttocks, the thighs and the pelvis, there's no point in compressing 20%. That's not going to do anything. Endometriosis. I won't dwell on this too much, because endometriosis is something that's seen in women. We don't know if it's more common in Eds or not. We have no idea. But I just wanted to bring it up because it's something to think about when you have pain in the pelvic region, oftentimes the pain in the pelvis gets worse during periods and it gets better. May not go away when you don't have your periods. But again, pelvic vein congestion will get worse when you have your periods also. So that's one of the things. The only way you can diagnose endometriosis is to peek in there and have a look. So you do a diagnostic laparoscopy and you look in there and you find endometriosis. 

50:27
Dr. Pradeep Chopra
If it's not much, they can remove it and take it out. But on the same vein, women with Eds should stop their menstrual periods completely, whichever way method they use. Because what happens is during the cycle, everything loosens up. Their pots gets worse, their mcas gets worse, their Eds gets worse, their ligaments loosen up. And then when the cycle is over, everything starts to tighten up again. But by the time it does that, the second round has come on. So it's best to completely stop the periods and people do well with that. 

51:03
Jennifer Milner
Interesting, I hadn't heard that. 

51:04
Dr. Pradeep Chopra
Pelvic floor spasm. So now, if you look at the pelvic pelvis, there is an opening on the top and there's an opening in the bottom. The opening on the top is where all your intestines and everything drop into the pelvis. But at the bottom, there is a floor, there is a muscle layer and that is called the pelvic floor. And oftentimes the pelvic floor goes into a spasm. And one of the reasons there are other reasons. So like endometriosis can cause pelvic floor spasms, but another reason is sacralic joint dysfunction, si joint dysfunction. So think of the pelvis as a ring, which is a ring that is connected with three bones. And sometimes the pelvis kind of shifts a little bit. When it shifts, it pulls on the pelvic floor. Now, Obstetricians and Gynecologists may diagnose somebody with pelvic floor, but they are not looking at the si joint. 

52:00
Dr. Pradeep Chopra
The si joint can go off for many reasons, starting from having loose ankles to loose knees to loose hips. It may sound funny that a treatment for pelvic floor spasm may include stabilizing your ankles, because then that stabilizes your knees, which then stabilizes your pelvis, which helps with the pelvic floor spasm. 

52:19
Jennifer Milner
It sounds funny, but it makes a lot of sense when you put it that way. And you're looking all the way up. 

52:23
Dr. Pradeep Chopra
And down the chain and that's called connecting the dots. So Eds, you have to look at Eds as a jigsaw puzzle. And each piece of the puzzle has four sides and all four sides have to match up. And these four sides could be completely different. So we're talking about back pain and pelvic floor spasms and we're talking about ankle instability in the same sentence. This is how far these things are connected. The other one is so there's a condition that the gastroenterologists have come up with called rectal evacuatory dysfunction. And for the life of me, I have not been able to find out the definition. What do you mean by rectal evacuatory dysfunction? And my conclusion is that it means it's a fancy word that you can't poop. Well, I couldn't come up of a reason, but the reason I brought this up is that you remember we talked about the small intestine then becoming going into the large intestine, and then eventually going on the left side descending down, and then it kind of becomes curvy, which is called the sigmoid colon. 

53:27
Dr. Pradeep Chopra
The sigmoid colon actually hangs off the back of the pelvis. It's flapping around. And in people with Eds, sometimes what happens is when the sigmoid colon becomes loaded, when it's full of poop, it sort of drops to one side because it's become heavy, and then it becomes kinked. And when it becomes kinked, they can feel the urge to pass stool, but they can't. And oftentimes when you ask kids have this figured out. When you ask kids, they'll tell you, do you have to shift positions when you do poop? And they'll tell you yes. What I do is I sit on my right side, and then I sit on my left side, and I can do it. I can pass my stool. That's because they're shifting. They figured out that you can shift the sigmoid colon to one side, flip it over, and then pass stool. 

54:19
Dr. Pradeep Chopra
And that's where the squatty 40 came into being. Was that it sort of anatomically is correct way of passing stool. You sort of have a bowel movement while squatting. The next one, by the way, we are on the 18th condition is the May-Thurner syndrome. Okay? So the May-Thurner syndrome is let me start with the symptoms. It's left leg pain, okay? These people have left leg pain. They tend to have deep pain thrombosis on the left leg, and they can have pain in their pelvis also. But it's mostly the left leg that is affected. In May-Thurner syndrome, the vein that goes down the leg, called the iliac vein, the left iliac vein gets compressed by the right iliac artery. It took me a while to remember who's compressing who, but I now have it ingrained into my brain. Dr. Bluestein is probably wondering, what did you say? 

55:17
Dr. Pradeep Chopra
Just say left iliac vein gets compressed by the right iliac artery but affects the left leg. So that's how it is. Because the vein is getting compressed, blood starts to pool down, and you don't want blood to be at a standstill anywhere in the body. When blood stops to move, it forms clots. And so these patients are at risk for developing deep vein thrombosis. So these patients often have left leg pain, left leg swelling, and left leg deep brain thrombosis. But a lot of these patients are asymptomatic, and that's the scary part. They have no symptoms. Actually, right now, I have a 19 year old girl, and she has a very clear May-Thurner syndrome, but no surgeon wants touch it because their argument is that there's no problem going on here. Why should we fix it? But my worry is that one day she might develop a deep brain thrombosis and then you're in trouble. 

56:15
Dr. Pradeep Chopra
Right. So because these conditions are not so well studied, we don't really have very good protocols in place, and surgeons don't want to fix something that's not squeaking. I see their point, but I also worry about what in the future, she may develop a deep brain thrombosis. 

56:31
Dr. Linda Bluestein
And I'm curious to ask your patient that you were just describing if she's not having any symptoms. What made you suspect that in the first place? 

56:40
Dr. Pradeep Chopra
I knew you would ask me that question. She actually had pelvic vein congestion, and so she told me that anytime she stood up, she would feel this pain in her pelvis and it would hurt, and as soon as she lay down, it would feel better. I was looking for pelvic vein congestion, not May-Thurner. And that's when the May-Thurner syndrome showed up. So it was an incidental finding. 

57:01
Jennifer Milner
So is that why you include May-Thurner with abdominal pain issues when the pain that they would feel is in the left leg? 

57:08
Dr. Pradeep Chopra
Well, the lefty leg vein is in the pelvis. Okay? It's not part of the leg. It's not part of the abdomen, but it's part of the pelvis. It doesn't have a home. 

57:21
Dr. Linda Bluestein
Actually, I think this is such a great conversation because I feel like the pelvis is kind of the black box anyway. My husband who's a urologist, I mean, he operates in the pelvis, or he did before he retired, but I feel like GYN doctors and urologists who operate in that area don't necessarily have a great understanding sometimes of all the complicated things that can happen in the pelvis. Super important information for a lot of people to have. 

57:47
Dr. Pradeep Chopra
Right. And I don't blame them because there are so many players in the pelvis itself and the abdomen and the whole concept of that. Patients with Eds have loose joints. That's the common concept. But they also have to understand that tissue is loose and when they stand up, it shifts. That's what the GI and the pelvic pain people have to sort of their mindset is not on that part. And that's why having these conversations will start a conversation. Like people are going to start asking questions. Patients are going to start asking questions, and eventually it will be a much more understood, much more commonly diagnosed, I should say. Now, the other one is tethered Cord syndrome. Strangely enough, tethered Cord syndrome, we know, causes bladder issues and leg pain and all that, but it can also cause stool incontinence. It can cause that, but besides that, it can cause abdominal pain, and we do not have a great explanation as to why. 

58:55
Dr. Pradeep Chopra
I mean, yes, the spinal cord is getting yanked because of tethered Cord syndrome, and is there a nerve that's going to the abdomen that's also getting pulled? We don't know enough about tethered Cord syndrome, but we have seen patients improve their GI system, their abdominal pain improve after. Tethered cord syndrome. Not everybody, but there are enough cases to say that there is some link between tethered cord syndrome and abdominal pain. The last one is called acnes, anterior cutaneous nerve entrapment syndrome. This is not particular to Eds, but you do see it in a lot of cases. This is outside the abdomen. Remember I told you about the abdomen, all the organs being in a bag? This pain is from the bag itself. So in the front of our abdomen, we have the six pack muscle and the six pack muscle. At the edge of the six pack muscle, there is a nerve that comes out from the spine and it travels to the edge of the six pack muscle and it's a tiny tunnel and it goes under the tunnel and into the muscle. 

01:00:03
Dr. Pradeep Chopra
What happens is that sometimes that tunnel, for whatever reason, narrows down and it presses on the nerve, hence anterior, which is front cutaneous, which is subcutaneous tissue nerve entrapment syndrome. These patients often have a very specific pain on their abdomen. You can reproduce it by pressing on it. What I do is I have them do a little sit up. That's when their six pack gets tight. And then I press on that edge of the six pack and they complain of pain. We used to see this a lot in plumbers and HVAC people. People who do HVAC work because they stick their tools to their stomach, because if they have to use both their hands, they put a pipe or a rod against their belly to push against it and eventually develop this syndrome, acnes. We do see it sometimes in patients who've had abdominal surgery, especially pelvic surgery. 

01:01:03
Dr. Pradeep Chopra
We do see that the easiest diagnosis to make is that they'll say that my belly hurts when I try to sit up. I'm lying down. And when they try to sit up, they feel this pain. It hurts. And that often brings in a suspicion for acnes. To confirm the diagnosis, a doctor can inject a tiny bit of numbing medicine at that spot and it should relieve their pain. That's the easy part. The hard part is finding a surgeon and convincing him to go and release that nerve. Generally it's done by general surgeons, but I have a hard time finding somebody to do that. But these are some of the solutions. So that, ladies, is in a nutshell. Wait, I forgot there's more to it. Sorry, got to listen to me a little bit more. So hernias are common hiatal hernia, ventral hernia. These are usually not painful. 

01:01:58
Dr. Pradeep Chopra
And hiatle hernia can cause some amount of hyatt. If it's a big one, then it can cause some issues. But ventral hernias are hernias that happen around the belly button or something like that, and they're not painful. The other one to watch out for, and that is always on the top of my head, is intestinal rupture, aneurysm rupture, especially in patients with vascular Eds. Now, this is a caution here. Just because somebody doesn't have vascular Eds doesn't mean that they are not prone to having intestinal rupture or aneurysm rupture. We divide people with Eds into 13 subgroups, but it's not a clear subgroup division. So a patient with hypermobile Eds can have an overlap with classical Eds symptoms, or a hypermobile patient can have some symptoms of vascular eds. We're not so clearly divided. And so just because someone doesn't have vascular Eds and just has hypermobile eds, we can't sit back and say, this patient can't have an intestinal rupture because they don't have vascular eds. 

01:03:04
Dr. Pradeep Chopra
It should always be on the top of their mind. The next one is absorption of medicines. For some reason, and I'm not quite sure I think it's more from the mast cell activation causing inflammation of the lining of the intestines, that patients with Eds do not absorb medicines. And very often we'll write medicines, and they'll come back and say, doc, that didn't help me at all. I mean, you can give them beta blockers, and they'll say their heart rate did not change at all, and you're left wondering what's going on. And I would say a very high percentage of these patients do not absorb meds. And the test for that is very simple. You give the patient some benadryl. We know that benadryl makes you sleepy. And if they're not absorbing medicines, they're not absorbing their benadryl, and they may not feel as sleepy. And that kind of gives you an idea that they're not absorbing their meds. 

01:03:52
Dr. Pradeep Chopra
Well, now, if somebody has that issue, let's say they're not absorbing meds, there are other paths that you can do. You can take it by nose inhale it. You can nebulize the medicine. For example, chromalin. You can nebulize it. You can put it under your tongue. That bypasses the intestines in the stomach completely. You can have the compounding pharmacy make a skin lotion or a skin patch. So the skin gets absorbed. It gets absorbed through the skin. So these are some of the other and of course, there's IV and im injections. That's the other one. So the reason I brought this up was because even though it's not abdominal pain, but it has a lot to do with muscle affecting our absorption of meds. And then there are food sensitivities that one has to watch out for Bloating, and then they have to watch out for histamine releasing foods like tomatoes and peppers and things like that. 

01:04:48
Dr. Pradeep Chopra
Most patients with Eds know that by now. They know that anytime they eat bread, they feel awful. But I just wanted to kind of reinforce this. 

01:04:59
Jennifer Milner
Yeah, that's great. 

01:04:59
Dr. Pradeep Chopra
Thank you. So these are, in a nutshell, GI or abdominal issues in patients with Eds. 

01:05:06
Dr. Linda Bluestein
I feel like when I was in medical school and taking embryology and thinking, wow, how does any baby ever come out, like, relatively healthy? Listening to this list and thinking, of various different patients that I've had. And it's interesting what you were saying about the malabsorption. I had a patient who was on TPN, and she said when she was in the process of going on total parental nutrition or being fed through the blood vessels because her gut doesn't work, and she's had a lot of these procedures that you've mentioned, a lot of problems. But she said at one point she had to stop 17 different medications that she was taking, and she noticed nothing different at all. 

01:05:42
Dr. Pradeep Chopra
Yes. 

01:05:42
Dr. Linda Bluestein
And so she said, I don't think I was absorbing anything because I stopped all 17 all of a sudden. And a lot of them were medications that you were not supposed to stop all of a sudden. And obviously we don't want anyone to listen to this conversation right. And stop their medication, which is a perfect lead into my next question, which. 

01:05:58
Dr. Pradeep Chopra
Is, I'm sure a lot of people. 

01:06:00
Dr. Linda Bluestein
Are listening to this and going, oh my gosh, I have abdominal pain. I've gone to the doctor. I've complied with the instructions. They're not willing to look into deeper causes. How do I begin to figure out what might be at the root cause of my pain with or without the help of someone on my medical team? And obviously, you can't just go into a hospital and request to order some of these tests on your own. So for a lot of these things, you do need some support from your medical team. But what do you suggest that people do as some steps that maybe they could do if they have abdominal pain and they're trying to sort out what. 

01:06:32
Dr. Pradeep Chopra
Might be going on? Yes, I have a little hack for finding out what's going on. Okay. One of the commonest issues is gastroparesis or movement of the intestines not being good. They don't move well, and depending on the day, it varies from day to day. And they may go for that radioactive test, and that comes back normal, but then the next day, they still have bloating and all those issues. So you can do this at home is to take beet. When you take beet, you should not and check your poop for the next two days. And after two days, it should not be red in color anymore. Now, if it is still red, like six days later and your poop is still red, that means your intestines or your stomach isn't moving. Well, that's a little home hack to get your diagnosis a little more confirmed, because we've had patients that have had an official GI test with a radioactive egg, and they've been told it's normal, which some days it is normal. 

01:07:36
Dr. Pradeep Chopra
It all depends on the day you go. I've had one patient who went five times before they found out that it was gastroparesis. The hack is you can take beet. Somebody suggested taking corn. That's another way to do it. But I think color stands out better than looking for corn. But after 48 hours, you should not have any more beet in your stool. That's a small, tiny hack you can look at. 

01:07:59
Dr. Linda Bluestein
That's great. And I tell people that all the time that any test that you do is a snapshot in time. It's just showing you what's going. And like you said, if it's supine or upright, these things that are worse when you're upright aren't going to really show up with a supine test. So that's a great hack for people to try on their own. How much beet should they eat? Is there like an amount per cups per kilo or anything like that? 

01:08:25
Dr. Pradeep Chopra
No. Go town, have as much as you like. Okay, it doesn't matter. But approximately in 48 hours, it should be gone. After 48 hours, if you see a little bit, it's okay. But if you're still having red colored poop six days later yes. Then you probably have gastroparesis. 

01:08:44
Dr. Linda Bluestein
Okay, that is a great hack. Any other I love that. People are going to love that. People love getting little tidbits like that. 

01:08:52
Dr. Pradeep Chopra
Well, the one other one I came across was corn. Instead of chewing the corn, you just swallow the corn and you look for corn, which is kind of a hard one to do because you have to sift through your poop, which is not. 

01:09:05
Jennifer Milner
Yes, which is not as fun. The sales of beets are going to Skyrocket for the week after, and a. 

01:09:11
Dr. Linda Bluestein
Lot of people are probably corn sensitive too. 

01:09:13
Jennifer Milner
I feel like. 

01:09:17
Dr. Pradeep Chopra
One of the things is, which is a huge problem and I don't have answer, is the food that we eat, the manufactured food, try to stay away from manufactured food, obviously, because manufacturers are putting a lot of stuff in their chemicals that I can't even pronounce. And I'll just give you an example. I have a lot of these food. I have to eat what I eat. I have to be very careful because I am gluten sensitive and all of these things. But there will be every few days I feel yucky and queasy and maybe I ate something. But if I go to Europe and I was there about two weeks ago, I gave a talk on Eds actually, in Germany, and they don't believe in this stuff. They don't have mast cell activation syndrome. They're like what? You guys are food sensitive. And they didn't really understand the concept of mast cell activation syndrome because they're not getting exposed to these chemicals. 

01:10:21
Dr. Pradeep Chopra
And I could eat anything. I went town on bread just to test it and nothing happened. I felt great. I felt fine. And again, as I came back, it was the same thing. So eating processed foods is very dangerous. I shouldn't say dangerous, but it is a problem. The other thing is vegetables and fruits and all that. We may think that these are okay. I would suggest buying these vegetables and fruits from the farmers market. And this goes back to a theory that if you want to read about it's in the Walls protocol. Dr. Bluestein knows about that. Yeah, I love the Walls Protocols protocol where this is a neurologist. She treated her own Ms and like, from a wheelchair to no wheelchair. And the only thing she did was she changed her food, her diet. And what happened is theory is that our microbiome, the guys who live in our intestines, the bacteria and all that, the microbiome is used to the local environment. 

01:11:25
Dr. Pradeep Chopra
So I'm in New England. My microbiome is used to the New England environment. But if I eat an orange that comes from Florida or I eat a tomato that comes from Mexico that is growing in soil that is very different from the soil in New England. And for some reason, and I don't understand the whole theory behind it is but for some reason, eating foods from faraway lands affects our microbiome significantly. And so Dr. Wall's theory was to, okay, you've got to eat the foods that are locally grown, the chicken that's going around and eating grain or bugs that are free roaming in New England or in my area. And that's one of the things I can think of that you can try and change. Even with the fruit, not even talking about the processed food. I'm talking about the natural foods, like vegetables and fruits. 

01:12:19
Dr. Pradeep Chopra
As far as possible, buy the local ones. Again, chickens and meats, also locally, because the chickens are going to eat bugs and stuff from the ground that's in your area, in your environment. And that affects the microbiome significantly. And this study has been done. In fact, there was a really great study done where they looked at the microbiome in Pygmies in Africa, and they looked at their microbiome and they were able to figure out the difference why these people can survive so well. And they are healthy on their local foods. But if you disrupt that microbiome, then they become unhealthy. And this is the reason why I would suggest is getting local foods. Obviously, we can grow it. Your next best option is to go to the farmers market. 

01:13:11
Jennifer Milner
That makes so much sense. And I feel like we have not had a single expert on to talk about any issues related to hypermobility that have not talked about your nutrition and your diet as one of those magic silver bullets that will help you. And it's something that we just take for granted. Yeah, I'm supposed to eat better, but what a concrete reason to look at that, to say, hey, not just eat healthier, like you said, fruits and vegetables, but fruits and vegetables from your local farmers market. Very concrete reason for that. And I love that. That's reminding me to get back to the farmers market. So we have just skimmed the surface of so many issues, but in doing so, we have done a really deep dive into abdominal pain and actually uncovered a very few sort of common elements. So in one way, we can look at this big long list of issues and say, oh, too much acid, pinched artery, a bacterial overgrowth or a pinched nerve. 

01:14:01
Jennifer Milner
Or we can look at this big long list of issues and say, oh, mast, cell problem, nervous system sort of dysregulation, loose connective tissue. Like there are these few things that come up again and again even though we have so many different diagnoses in the other column. And it's really helpful to look at it that way and see it that way as a recurring theme and to once again remind ourselves to ask the question, Why? Or as you said, what's broken? 

01:14:23
Dr. Pradeep Chopra
Right? 

01:14:23
Jennifer Milner
And try to come at it from there rather than what's the diagnosis? Let's fix that. Let's fix what's broken that's causing the diagnosis. I feel like I've just sat through a master class and I am going to be listening to my own podcast again several times just to have a chance to absorb everything in this. We are so grateful for you coming on to share your wealth of knowledge with us all. Where can people find you? Is there a way for them to find you and find out more about you and what you can? 

01:14:49
Dr. Pradeep Chopra
Doctors can't hide anywhere. You can hide. I well, I'm in Rhode Island, obviously, and my website is painri, pain, rhode island, painria.com and pretty much everywhere. One more hack that just came up on the nausea vomiting part. Any cold medicine is a very good anti nausea medicine. 

01:15:20
Jennifer Milner
That's a great hack because that's easy to find. 

01:15:22
Dr. Pradeep Chopra
In fact, before Zofrin was invented I'm that old. Before Zofrin was invented, were giving patients Benadryl for nausea and vomiting. Visceral. Dr. Bluestein will remember that. Visceral. We used to always give a narcotic like Morphine or meparidine, you would add Visceral, which is antihistamine. So if you don't have Zofrin handy or your doctor didn't give it to you or something like that, take a tablespoon of or a pill of Benadryl, and that's anti nausea medicine. 

01:15:50
Dr. Linda Bluestein
Well, I think that's actually a great suggestion, though, too, because I think a lot of people don't think Zofran can actually contribute to constipation, right. And headaches, it has some side effects that I feel like a lot of people just prescribe it like it's nothing. And I have lots of patients, they take it very regularly. And so it's great to have other alternatives of things for people to try. 

01:16:10
Jennifer Milner
And I was thinking when you said Benadryl for the nausea, the Benadryl may help address, at least short term, some of the mass cell issues which will help the nausea in that way. So it's also a great little diagnostic tool. 

01:16:21
Dr. Pradeep Chopra
Well, I'll also give you another tip on that. We're not just talking about Benadryl, we're talking about antihistamines Benadryl, zertech, claritin, and all of those benadryl being the king. But there's hydroxyzine also. All of these have vagal stimulating effects. The only thing is that they're not very strong vagal stimulating effects. But you want vagal stimulation because your sympathetic nervous system is so revved up that you want to have vagal stimulation. And so Benadryl or any of these besides the nausea, can also help with some of the movement of the intestines, make it much easier. 

01:17:00
Jennifer Milner
That's really cool. It all just kind of links back in on itself. It's so interesting. Well, you have been listening to the Bendy Bodies with the Hypermobility MD podcast. I'm your co host Jennifer Milner here with Dr. Linda Bluestein, the founder of Bendy Bodies. Dr. Chopra, we are so grateful for you coming on and chatting with us today and sharing your knowledge. I know that this podcast episode is going to really help a lot of people. Thank you so much for joining us. 

01:17:23
Dr. Pradeep Chopra
Thank you so much for inviting me. Happy to be here. 

01:17:26
Dr. Linda Bluestein
Yay, we finally got to talk to you and we look forward to more conversations for sure. 

01:17:31
Dr. Pradeep Chopra
Hacks. Hacks. I love hacks. 

01:17:33
Dr. Linda Bluestein
Yes, we love hacks too. 

01:17:35
Jennifer Milner
We love hacks. We're going to do a whole series on hacks now just because you started it. We're going to down and we're going to take all your Eds. 

01:17:41
Dr. Pradeep Chopra
Hacks. 

01:17:42
Jennifer Milner
Hacks. 

01:17:42
Dr. Linda Bluestein
High probability hacks. We need to have a no. 

01:17:45
Dr. Pradeep Chopra
The reason, as you can see why, because when you first asked me, I said there's no way that you can cover everything in one shot. I mean, it's almost 04:00 p.m.. We haven't really gone into tons of details. We've just sort of skimmed through things. But I wanted to bring this up because there's no place where you find all of this in one place. There's no literature or nothing like that you can find this in one place. The hard part is gastroenterologists. Just like to do a scope from the top and from the bottom and then they look inside the intestine. But all of that we talked today was all outside the intestine. There's so many problems just outside it and they don't want touch that. And so this was the reason why I wanted to bring it up was because patients to be aware of these things and they can then bring them up with their doctors. 

01:18:41
Jennifer Milner
Well, we are grateful that you did. 

01:18:43
Dr. Pradeep Chopra
Yes. 

01:18:43
Jennifer Milner
And this is such an interesting way to look at it. So thank you again. 

01:18:47
Dr. Pradeep Chopra
You're welcome guys. Take care. Have a wonderful weekend. 

01:18:51
Jennifer Milner
Thank you. 

01:18:51
Dr. Linda Bluestein
You too. We really appreciate all the great information and we know a lot of people will find this really valuable. 

01:18:57
Dr. Pradeep Chopra
Thank you. 

01:18:58
Dr. Linda Bluestein
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