Examining Abdominal Pain with Pradeep Chopra, MD

[00:54] Dr. Pradeep Chopra: Welcome back to 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.

[01:11] 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.
[01:30] 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.

[02:01] Dr. Pradeep Chopra: Thank you. And thank you for inviting me to the Bendy Bodies podcast. It's an honor and a pleasure.

[02:06] Dr. Linda Bluestein: Finally, we've been wanting to do this for so long.

[02:09] 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. But before we get started, Dr. Chopra, can you tell our listeners a little bit about yourself?

[02:22] 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 since 2000. So that's 23 years. And I have a special interest in complex conditions. EDS being one of them, but I do have an interest in complex conditions broadly.
[02:41] 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 an 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. 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.
[03:26] One of the things I did discover is 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 10, 15 years, more and more physicians are now beginning to, quote unquote, suspect EDS, which really helps a lot.
[03:44] My work in terms of treating EDS is kind of as 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. When a patient comes in, I go through everything from head to toe. 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 the abdomen, I really can't find a gastroenterologist who really understands the issues that come with EDS. I think I probably know 2 of them in the entire United States. And that's where the problem comes in.
[04:41] 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 some gastroenterologist somewhere will listen to this podcast and say, huh, I am going to change my practice and I'm going to treat EDS the way it should be treated.

[05:01] Jennifer Milner: Well, I think that your story is unfortunately a common one in that there is no training out there that I know of that is 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 my own education. And maybe within another 10 years 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.
[05:36] 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 comorbidities. It's really hard to parse it out. Everybody's addressing one little piece of the elephant and nobody's seeing the whole elephant. 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 give us a little bit just on some basic abdominal anatomy so we know where we're going?

[06:07] Dr. Pradeep Chopra: Good. That's exactly what I wanted to talk about first, the anatomy, so people understand. You've got to think of the abdomen like a bag. In this bag are intestines, organs, blood vessels, nerves. All of that is stuffed into it. In fact, the intestines are about 20 feet long. So you can imagine taking a bag and stuffing in a tube 20 feet long, and then you put in the liver, the kidneys, the spleen, the uterus, the bladder, and all that. And then all of these organs have a nerve supply — actually two nerve supplies. And then there is a blood supply to all of these.
[06:49] So I'm going to start from the top of this long, 20-foot intestine. It starts with the esophagus, which is the food pipe. It starts at your throat and then crosses the diaphragm, which is the muscle between the chest and the belly. It ends in a pouch called the stomach. And then from the pouch, it curves into part of the small intestine known as the duodenum. Duodenum means 10 fingers. So you put 10 fingers together and that's how wide the duodenum is — which is, to make things easier, part of the small intestine. And then from there, let's imagine that you're traveling down this intestine. From the duodenum, we enter into the small intestine and we wiggle through the intestine all the way until we reach the large intestine, which starts on the right lower pelvic region. Then our journey climbs up the right side, travels across our abdomen, and goes onto the left side. Then we go down this large tube known as the large intestine or the colon. Then it goes into an S-shaped part of the colon called the sigmoid colon. Then it goes into the rectum and then into the anus, and then we're out.
[08:11] So this is the intestine. Just to recap: starts with the esophagus, which is 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 goes out through the anus.
[08:33] Besides this, we also have our organs. The liver 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 — everybody knows where it is. It's in the pelvis. And then you have the 2 ovaries on each side, and the bladder. The bladder has an opening which goes out through the urethra.
[09:01] Now, all of this has a very rich blood supply, because when you eat food, that nutrition is critical for the body. There's a tremendous amount of blood flow to all of these organs so that 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. Out of the back of the abdomen, there are two large pipes: one that brings blood to the abdomen, called the aorta, or to be more precise, the abdominal aorta. And then the other pipe, which is more on the left side — they're both parallel to each other, but the aorta is on the right side. The inferior vena cava is on the left side and it 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 aorta is pretty large and carries a lot of blood. Same thing with the inferior vena cava.
[10:14] And then you have the nerve supply. You have the sympathetic nervous system, which pretty much goes to all the intestines and all the organs in the abdomen. The parasympathetic, which is predominantly the vagus nerve, actually follows the esophagus to the stomach, to the duodenum, through the small intestine, and then stops midway in the colon — actually in the middle of the transverse colon. The job of the sympathetic is to make the intestines move along. Imagine food in the intestine moving along like toothpaste: squeeze, squeeze, 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 that's 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.

[11:15] Jennifer Milner: Well, I appreciate that. And I also have to point out that as you talked through in a very basic 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 sympathetic nervous system. We touched on the urinary system. We touched on the cardiac system, the vascular system. So we've got a lot of things going on in what, as you said, was a very small bag. No wonder it's complicated. No wonder it's difficult.
[11:44] 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?

[11:55] Dr. Pradeep Chopra: True. There's a lot of activity going on in there, and 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 at what's inside the intestine, and that's a whole different ball game. 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.
[12:21] 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. And then you bring in the blood flow and then you bring in the foods or chemicals that you bring in. I'll give you a quick example. Color dyes are extremely harmful for us. Red dyes, blue dyes. And it's hard to get away from these dyes because medicines are colored. 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 colored dyes from Peeps. Hopefully once that happens, other manufacturers are going to learn something from it. In veterinary medicine, there was a class action lawsuit where colored 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 — something like a blue-colored drink can affect your entire body.

[13:35] Jennifer Milner: That's such a great point. And so much of it, as you said, is coming into the abdomen. I did not know that the most nerves you can find are in the abdomen after the brain. That's really interesting. So what are some of the causes of abdominal pain in people with symptomatic joint hypermobility?

[13:46] Dr. Pradeep Chopra: So I had the pleasure of listing them today, and I came up with approximately 22 causes.

[13:52] Jennifer Milner: Wow.

[13:58] Dr. Pradeep Chopra: So you guys are in for a long ride, but—

[14:01] Jennifer Milner: No, no, let's hear it, because I'm sure there are listeners who are going check, check, check as you go through your 22 items. So this will be great. They will feel validated, I'm sure.

[14:07] Dr. Pradeep Chopra: So the first thing I want to clarify is that it's not an anxiety disorder. For somebody to be diagnosed with an anxiety disorder — let's say somebody's having nausea and vomiting, and doctors are very prone to pointing that out as an anxiety disorder — it's not. The only way you can call it an anxiety disorder is if you have proven conclusively without a doubt that there is nothing else going on. And 99.9% of the time, there is something going on and it's not an anxiety disorder.
[14:43] So with that, let's talk about the food pipe, the esophagus. One of the commonest conditions that affect the esophagus in EDS is eosinophilic esophagitis. Eosinophils are allergy cells. They swarm into the esophagus and line it, and it causes an inflammation of the esophagus. So imagine your food pipe getting inflamed. Inflammation causes swelling, pain, redness. So the esophagus becomes hot and inflamed. People have difficulty swallowing. It also seems like the 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. It just stops moving until the inflammation is resolved. So food gets stuck; the esophagus is not pushing it along. And because it's not moving along, they tend to vomit the food out. And of course they have heartburn.
[15:51] Now, in medicine, eosinophilic esophagitis is classified as a separate condition. But when it was first 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 10, 12 years old, that's when we first heard about it. And I think that eosinophilic esophagitis is very closely related to mast cell activation syndrome. In fact, it might be part of mast cell activation syndrome. Essentially, to recap again: the food pipe gets inflamed, and when it gets inflamed, patients have difficulty swallowing, it looks like the food is getting stuck, they have vomiting, and they have severe heartburn. And that's eosinophilic esophagitis, which might be a part of mast cell activation syndrome.

[16:40] 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.

[16:48] Dr. Pradeep Chopra: Right. So whenever I come across a diagnosis of eosinophilic esophagitis, I start suspecting mast cell activation syndrome, and I start looking for other symptoms of mast cell.
[16:59] The second thing I want to talk to you about is very common — it's 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 mast cell activation syndrome. One of the things that happens is that there are histamine receptors in the stomach. The stomach — remember the pouch we talked about — normally produces acid, but in acid reflux, excessive amounts of acid are produced. It's so much that it starts regurgitating back up the food pipe, the esophagus. Mast cells can stimulate histamine receptors — these are the H2, or histamine 2, receptors in the stomach — which then increases production of acid in the stomach.
[17:52] The reason I brought this up is that the most common drugs prescribed for acid reflux nowadays are pantoprazole, omeprazole, and all of those. These drugs are not safe for patients with EDS. In fact, they're not safe for anybody, and I'll explain that. Omeprazole, pantoprazole — this class of drugs, what are called PPIs — 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 who'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 early onset osteoporosis and osteopenia. The second problem is that if you kill all the acid, it allows the bad guys to grow, especially things like yeast, to start proliferating in the small intestine. Those are the two reasons I don't like this group of drugs. For short-term use, it's fine. The official recommendation is not more than two weeks.

[19:11] 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, 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 nodding vigorously.

[19:33] Dr. Linda Bluestein: It's not that people are doing it on their own — usually their doctors are continuing to prescribe it for years and years and years. So yeah, it is hard to get off sometimes. But that's one of the first things that I do: talk to somebody about, let's look at other options. And yes, if people are just listening and not watching the video, they don't see that.

[19:58] Jennifer Milner: We'll announce when you're nodding your head.

[20:03] Dr. Pradeep Chopra: So when I got into practice, I knew this group of drugs should not be taken 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'm mistaken. So I went back and looked it up, and sure enough, there is a black box warning: not to be taken for more than 14 days.
[20:23] So with this, we move on. We're now in the stomach, right? We're producing a lot of acid. I said one of the reasons we can be producing more acid is because of mast cell activation syndrome — mast cells can stimulate histamine 2 receptors, which increases acid production in the stomach. The other reason we produce excessive acid in the stomach is if you're eating something that you're intolerant to. For example, I'll give you my example: I'm intolerant to gluten, and if I eat something with gluten in it, I start having acid reflux. So acid reflux can be caused by foods, or it could be caused by mast cell activation syndrome.
[21:07] At some point, when we ever talk about mast cell activation syndrome treatments, one of the treatments is to use an H2 antagonist to block these H2 receptors. Right now, we only have two drugs on the market: one is called famotidine, sold as Pepcid, and the other is cimetidine, sold as Tagamet. These are H2 receptor blockers, which means that if you can block your histamine 2 receptors in the stomach, you can decrease acid production without having the harmful effects of the PPIs.
[21:42] So as we travel down from the stomach, we're now at the exit of the stomach and entering into the part of the small intestine called the duodenum. Here, there is a gate — a sphincter — called the pyloric sphincter. Very often, the pyloric sphincter goes into a spasm. When that happens, the gate shuts. When the gate shuts, food that's sitting in the stomach can't move along into the duodenum. The small intestine is empty and the stomach is bloated.
[22:00] The pyloric sphincter goes into a spasm for one reason: there is a separate nerve supply to it. There are separate sympathetic nerves that go to the pyloric sphincter, and also the parasympathetic vagus nerve. In patients with POTS, the sympathetic nervous system is hyperactive. So what happens is the pyloric sphincter shuts down because the sympathetic nervous system is overactive, and the vagus nerve by itself can't open it. So obviously treating the POTS makes sense here, but sometimes in extreme cases, gastroenterologists will go in and loosen up the pyloric sphincter muscle with Botox injections to allow food to pass easily. These patients are going to present with abdominal distension, nausea, and vomiting, because there's food sitting in the stomach.

[23:26] Jennifer Milner: That's so interesting because this is like our fourth or fifth issue that you've talked about. And we've moved from a mast cell dominance of the issues into a nervous system trigger for issues. So we're seeing the overlap of the different systems. Sorry, go ahead.

[23:40] Dr. Pradeep Chopra: So the next one I want to talk to you about — we're now in the duodenum. We've traveled down the food pipe, the esophagus, come into the stomach pouch where we were flooded with acid, gone through the pyloric sphincter, and now we've entered the duodenum. Here we have a slightly different problem. We have what is called Superior Mesenteric Artery Syndrome, or SMAS.
[24:21] The duodenum is a pipe, and there's an artery that comes out from the aorta — remember, the aorta was the big pipe that supplies blood to the intestine — one of the pipes that comes out from it is called the superior mesenteric artery. This superior mesenteric artery snakes over the duodenum. In some cases, it's so tight that it causes an obstruction of the duodenum. So food that comes down the esophagus into the stomach, into the duodenum, can't go any further, because there's an artery outside it that's blocking it. This is called Superior Mesenteric Artery Syndrome.
[25:20] Think of a big pipe and there's a little pipe over it which is so tight that it obstructs the big pipe. Big pipe being the duodenum, the little pipe being the superior mesenteric artery. These patients present with the same symptoms of obstruction. They get full very quickly. They get nauseous because food has been sitting there and starting to ferment. They have vomiting, but they also have severe stabbing pain after eating, because the food is not moving forward and it's distending the duodenum. The stomach has room to distend, but the duodenum does not. So if you're trying to distend the duodenum, it's going to hurt a lot. They have belly bloating, lots of burping — that's gas being pushed back up. One of the things they may notice is that if they lie on their stomach, the pain gets better. That's just the mechanics of how it happens: you're moving the artery away from the duodenum, allowing it to open up. So that's Superior Mesenteric Artery Syndrome.

[26:37] Jennifer Milner: Well, I will say I encountered that probably 8 years ago with a dancer — it took about 2 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. Her mother had a history of some autoimmune and connective tissue problems. And they finally, after a severe, 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 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.

[27:22] Dr. Pradeep Chopra: It's true. But I'm not talking about something that's very, very rare. I'm talking about something that's actually very, very common in the EDS population. And the question is, why do people with EDS have it and non-EDS patients do not? And this is just my thought: the connective tissue that builds things up in people with EDS is soft. So when they are upright, the tissue is so soft that it descends just enough to cause obstruction in many, many different places. A small movement of the blood vessel downwards will cause obstruction of the duodenum.

[28:15] Jennifer Milner: That makes a lot of sense.

[28:17] 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 who's bloated, has severe nausea, vomiting, belly pain, and you're asking them to eat more. It never works, obviously.
[28:40] The treatment that does work very well is what's called a gastroduodenostomy. They take the stomach and they take the last part of the duodenum, which is loose, and they form a short circuit between the two. It's a simple, straightforward surgery. The food doesn't have to go through the pyloric sphincter into the duodenum — it goes straight from the stomach into the last part of the duodenum and into the small intestine. This is a surgery that has been done for decades for different conditions. It's not an unusual surgery. But that's the treatment for it, not eating more.
[29:14] I did come across some strange literature about something called derotation of the duodenum. I won't even elaborate on it. Just forget it. If someone offers you that surgery, don't even think about it. There's no good literature to support it.
[29:29] The next thing I want to talk to you about is how mast cell activation syndrome affects the abdomen. You have to think of mast cell activation syndrome as something that causes inflammation everywhere — from head to toe, every single muscle, ligament, all of the joints. These are all affected. The easiest way to figure out whether you have mast cell activation syndrome or not is that it feels like you have flu-like symptoms. Everything hurts, everything. You feel tired. You just want to stay in bed curled up, like you're coming down with the flu.
[31:07] Now, mast cells are like the National Guard. They're supposed to defend our body. They stay at the edge of where there is air or the environment and the body. In the intestine, for example, they line the inner lining of the intestine. They're on the throat. They accumulate around dry eyes, they accumulate in sinuses — anywhere there is a connection between the environment and the body. So mast cell activation syndrome 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.

[32:00] Jennifer Milner: That makes sense.

[32:02] Dr. Pradeep Chopra: That's where your gastroparesis can come in, a small intestine dysfunction can come from — because everything hurts. As a physician, when I examine these patients, I gently push on their stomach and they'll tell me it hurts. I even do what is called percussion, which is tapping on their abdomen, and that hurts because their intestines are so inflamed. That tells me that a large part of their bloating and pain in their abdomen is coming from mast cell activation syndrome.
[32:41] I don't know why I have interstitial cystitis as the next one, but we'll go with that. This is inflammation of the bladder. Mast cells tend to accumulate at the borders of the environment and the tissue. So, the lining of the bladder gets inflamed. Oftentimes these people will have bladder pain, commonly diagnosed as interstitial cystitis. I don't mind the term — you can say bladder pain, you can say interstitial cystitis — but the cause is oftentimes mast cell activation syndrome. It's easy to diagnose: you press on the bladder and it hurts.
[33:20] In the same sentence, you can talk about inflammation of the urethra. People with mast cell activation syndrome, if their bladder is inflamed and their urethra is inflamed, they'll urinate and it hurts — not because of an infection, but 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. Whenever I have a patient saying that in my office, I ask them, did your doctor actually look for an organism that's causing this so-called infection? And most times they'll say no, they just gave me antibiotics.

[34:03] Jennifer Milner: Right, right.

[34:04] Dr. Pradeep Chopra: The treatment lies in treating mast cell activation syndrome. That's the key here.

[34:08] Jennifer Milner: Well, 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?

[34:23] Dr. Pradeep Chopra: Yes. There is only one principle in pain medicine, actually: to figure out what's broken. 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 again and again and again? What's broken? That's the question we need to answer.
[34:52] Yes, you may have vomiting again and again, but giving Zofran is not the answer. That's the band-aid. That's a temporary treatment. What is the reason the person is vomiting is the key thing to find out. And just within the last 20 minutes, we must have talked about at least 7 reasons for a patient to have nausea, vomiting, and bloating.

[35:16] Jennifer Milner: Yeah.

[35:17] Dr. Pradeep Chopra: And that's the thing. There are so many reasons. And that's where we as physicians, gastroenterologists, and treating physicians have to tease out what's broken that we need to treat.

[35:29] Jennifer Milner: Well, if you listed 7 things, I think 6 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.

[35:39] 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 1,000 different types of bacteria that live there. These are friendly guys. They live there and they help us. The large intestine has 10,000 different types of bacteria. We know that material moves from the small intestine onto the large intestine and out. But if for any reason the intestines stop moving — whether it's mast cell activation syndrome or whatever reason they slow down — then these 10,000 bacteria in the large intestine creep over to the small intestine and overpopulate it. That's what's called small intestinal bacterial overgrowth.
[36:41] The test for SIBO is a breath test. They take samples of you breathing into tubes and look at methane and other gases. From that, they can predict if you have SIBO or not. And if you do have SIBO, the common treatment is to give you an antibiotic that does not get absorbed — like rifaximin or neomycin. It doesn't get absorbed. It just goes in there like Drano, kills all this overgrowth of bacteria, and is 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 giving people heavy-duty antibiotics to clean out the small intestine. Very often people will develop SIBO, get this Drano treatment, and then 3 months later they're back with SIBO again. Because we haven't treated the cause of the SIBO. SIBO itself is not the problem. People with SIBO generally present with bloating, they feel gassy, nauseous — the usual abdominal symptoms.
[37:58] Moving on to MALS — Median Arcuate Ligament Syndrome. Also commonly known as the Dunbar Syndrome, which I think is a better name. MALS or Dunbar Syndrome is an extremely painful condition. Essentially what happens is — remember the aorta we talked about, the large pipe that supplies blood to the intestine?

[38:27] Jennifer Milner: Yes.

[38:27] Dr. Pradeep Chopra: There is one little artery that comes out from it to provide blood to the stomach and the small intestine area. That artery is called the celiac artery. The celiac artery burrows under the diaphragm, which is the muscle that separates the abdomen from the chest. It burrows through it, forming a ligament around it called the median arcuate ligament. Then it comes out from the aorta and supplies blood to the intestine. There is also a bunch of nerves, part of the sympathetic nervous system, that travel along with the celiac artery and provide innervation to the small intestine and the stomach.
[39:13] We see MALS in patients with EDS quite often. And again, I haven't seen a MALS patient who was not an EDS patient. My theory is that people with EDS have soft connective tissue, and when they stand upright, the diaphragm and tissue kind of drops down and settles. When it settles, it compresses the celiac artery. So when they eat food, they feel this intense pain at the top of their belly — what's called the epigastric region or the solar plexus region — as soon as they eat.
[39:57] 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? When they lie down, the tissue goes back to where it's supposed to be. It gets worse when they're upright because the tissue is dropping down and choking the celiac artery. It also gets worse with exercise, because as you exercise you're upright, there's more blood flow demand, and because the celiac artery is being pinched, it can't supply enough blood.
[40:36] One of the other problems is that the celiac plexus — part of the sympathetic nervous system — travels along with the celiac artery and gets pinched also. So this is a pain caused by poor blood flow, or ischemia, and compression of the nerves. It's a very painful condition.
[41:00] For physicians, the clinical exam is not that difficult. You take the history, but on clinical exam, if you press on the solar plexus or the epigastric region, patients are going to wince. I'll say, look, I'm going to call this point number 1. I'm going to press on it — tell me how much that hurts. And they'll make a face and say, that's a really sharp stabbing pain. To make sure we're not confusing it, I'll take a random spot on the abdomen and press as hard and say, that's point number 2. Now, which one hurts more? And they'll always come back to point number 1. You can have them lie on their stomach and they feel relief right away.
[41:46] The treatment is, of course, to loosen up the ligament that's pinching the artery and the nerve. There are two schools of thought. Some vascular surgeons prefer to just loosen up the ligament and leave it at that. Another school of thought is to not just loosen up the ligament but also to remove the nerves. And it's the second group of surgeons who get the best results — that's my experience. Invariably, patients from the first group will come back and say the surgery didn't help. You ask them who did it, you look at the operative note, and they did not remove the nerve.
[42:38] Why is it important to remove the nerve? Because some of these nerves don't actually come through the arch of the ligament. They may make their own opening through the diaphragm. They don't always travel with the artery. 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.

[43:07] Jennifer Milner: That makes sense.

[43:08] Dr. Pradeep Chopra: So it's important to remove the nerve. Surgeons who do this surgery will actually do what is called a celiac plexus block first. They'll go in with a needle, numb up that celiac plexus, and in an ideal case, the patient will say they have very good results — they don't feel the pain. Then the pain comes back after a few hours when the numbing medicine wears off. So the caution here is to look for a surgeon who removes the nerve as well as loosening up the ligament.
[43:44] So that's Median Arcuate Ligament Syndrome, also known as Dunbar Syndrome. It's not as rare as people like to mention. It is quite common.
[43:56] The next one is called Nutcracker Syndrome. Nutcracker Syndrome is very difficult to diagnose, and I'm going to try to explain what happens. You have the left kidney and the right kidney. The left kidney is a little further away from the aorta — 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 left kidney is also longer than the right one. And remember the superior mesenteric artery we talked about?

Jennifer Milner: Yes.

[44:31] Dr. Pradeep Chopra: The superior mesenteric artery is a troublemaker again here. It travels over the left renal vein. And when you stand up, the superior mesenteric artery drops down a little bit and pinches the left renal vein.
[44:52] In the human body, one of the rules is what goes in has to come out. You can't have 2 ounces of blood going to the left kidney and only 1 ounce coming out. So when the left renal vein gets compressed by the superior mesenteric artery, the problem is that you have a perfectly functional right kidney, but an iffy left kidney, and it's very difficult to diagnose.
[45:21] These patients may present with hematuria — blood in the urine. Sometimes it's not obvious; you're not going to see blood in the urine. It may be microscopic hematuria. The way to detect microscopic hematuria at home is to urinate on a white piece of paper or tissue, like Kleenex or toilet paper, and you can see redness remaining there — the red blood cells. There is left flank pain. In males, they'll have a varicocele. In both men and women, there's increased protein in their urine, and they also have anemia. These are very non-specific presentations, and that's why it's very difficult to diagnose.
[46:11] My piece of advice is that if you have a patient with Superior Mesenteric Artery Syndrome, check those patients for Nutcracker Syndrome also, because it's the same artery causing problems. SMA Syndrome is above and Nutcracker Syndrome is below. Same culprit. Best to check both at the same time.

[46:35] 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 — anemia and blood in the urine. I can't imagine trying to wade through all of the possibilities that it could be. I know people are taking notes copiously as you're speaking.

[46:52] Dr. Pradeep Chopra: You know, when I looked at these conditions, I thought, okay, you have SMA Syndrome caused by the superior mesenteric artery, and then you have Nutcracker Syndrome, which is again the superior mesenteric artery. Why is this happening? And it brings you back to the same theory: the tissue is loose, and when you stand upright, some of it descends. When I say descend, I don't mean by feet — just a small amount.

[47:15] Jennifer Milner: Just a bit.

[47:17] Dr. Pradeep Chopra: Yeah. And that's enough to compress arteries and veins everywhere.
[47:22] So the other one, which is not a big deal problem treatment-wise — and 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 the next one I want to talk to you about is ptosis, which is the liver descending down, or the kidney falling down, the spleen falling down, because of loose connective tissue.
[47:44] It's very difficult to diagnose, but what happens is, say the kidney falls down — it drops because the tissue is loose. When it drops, the blood flow to it may get compromised. It's extremely difficult to diagnose this condition because it doesn't really show up unless you're specifically looking for it. You might see it on an MRI or CT scan if you're looking for it. But clinically, it's very difficult to make out that your kidney, which should be living up in the back where your bra strap is, is now sitting down in your pelvis.

[48:33] Jennifer Milner: Well, I wonder — is it an issue if you're doing an MRI and, like you said, you're lying down, does the kidney sort of slide back enough that they don't really notice it in the MRI?

[48:44] Dr. Pradeep Chopra: Exactly. That is why MRIs and CT scans in EDS are not very helpful unless you do a dynamic study — take one when you're lying down and another when you're standing. Static MRIs and static pictures in EDS are not helpful.
[49:05] Pelvic vein congestion. In the pelvis, there is a ton of veins, especially in women. And again, when we stand, blood pools down our legs, and 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. I wanted to bring this up because patients will complain that the pain in the pelvis gets worse when they stand and gets better when they lie down. And obviously when you do a radiological study, you're lying down and it won't show up. So you've got to get it done lying down as well as upright.
[49:53] The second thing I wanted to bring up was POTS. We know that people with EDS have POTS for 3 different reasons, and that will hopefully be a different podcast. But taking the basic reason for POTS — where blood pools down the legs and your sympathetic nervous system is trying to pump this blood back up to your brain — 80% of the blood that pools down is in the pelvis, the buttocks, and the thighs. 80%. So wearing compression stockings on the lower legs is not very helpful. What we need is compression on the thighs, buttocks, and even the pelvis — some sort of compressive corset or tight swimsuit — something that will compress the pelvic veins, because 80% of the blood pools in that section. There's no point in compressing the lower 20%. That's not going to do anything.

[50:53] Jennifer Milner: Mm-hmm.

[50:56] Dr. Pradeep Chopra: 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. 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. Pelvic vein congestion will also get worse during periods. The only way you can diagnose endometriosis is to look in there — you do a diagnostic laparoscopy and you look in there and find endometriosis. If it's not much, they can remove it.
[51:44] But on the same subject, women with EDS should consider stopping their menstrual periods completely, whichever method they use. Because what happens is during the cycle, everything loosens up. Their POTS gets worse, their mast cell 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.

[52:15] Jennifer Milner: Interesting. I hadn't heard that.

[52:17] Dr. Pradeep Chopra: Pelvic floor spasm. Now, if you look at the pelvis, there is an opening on the top and there's a floor at the bottom. The floor is a muscle layer, called the pelvic floor. Oftentimes the pelvic floor goes into a spasm. One of the reasons — endometriosis can cause pelvic floor spasms, but another reason is sacroiliac joint dysfunction, or SI joint dysfunction.
[52:54] Think of the pelvis as a ring connected with 3 bones. Sometimes the pelvis kind of shifts a little bit. When it shifts, it pulls on the pelvic floor. Obstetricians and gynecologists may diagnose somebody with pelvic floor dysfunction, but they're not looking at the SI joint. The SI joint can go off for many reasons, starting from having loose ankles to loose knees to loose hips. It may sound funny, but a treatment for pelvic floor spasm may include stabilizing your ankles, because that stabilizes your knees, which then stabilizes your pelvis, which helps with the pelvic floor spasm.

[53:32] Jennifer Milner: That sounds funny, but it makes a lot of sense when you put it that way and you're looking all the way up and down the chain.

[53:36] Dr. Pradeep Chopra: Yeah. That's called connecting the dots. You have to look at EDS as a jigsaw puzzle, and each piece of the puzzle has 4 sides, and all 4 sides have to match up. These 4 sides could be completely different. 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.
[53:58] The other one is a condition that gastroenterologists have come up with called rectal evacuatory dysfunction. For the life of me, I have not been able to find a clear definition of this. My conclusion is that it's a fancy way of saying you can't poop well. The reason I brought this up is that you remember we talked about the small intestine going into the large intestine and eventually going down the left side, becoming curvy, which is called the sigmoid colon? The sigmoid colon actually hangs off the back of the pelvis. It's just flapping around. In people with EDS, sometimes when the sigmoid colon becomes loaded — when it's full of stool — it sorts of drops to one side because it's become heavy. And then it becomes kinked. When it becomes kinked, they can feel the urge to pass stool, but they can't.
[55:07] And oftentimes when you ask kids — kids have this figured out. When you ask them, they'll tell you, do you have to shift positions when you poop? And they'll say, 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 figured out that you can shift the sigmoid colon to one side, flip it over, and then pass stool. And that's where the squatty potty came into being — it's the anatomically correct way of passing stool. You squat.
[55:45] The next one — by the way, we are on the 18th condition — is May-Thurner Syndrome. So May-Thurner Syndrome: let me start with the symptoms. These people have left leg pain. They tend to have deep vein 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 left iliac vein gets compressed by the right iliac artery. Because the vein is getting compressed, blood starts to pool down. And when blood stops moving, it forms clots. So these patients are at risk for developing deep vein thrombosis. These patients often have left leg pain, left leg swelling, and left leg deep vein thrombosis.
[57:03] But a lot of these patients are asymptomatic. And that's the scary part. Right now I have a 19-year-old girl who has a very clear May-Thurner Syndrome. But no surgeon wants to 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 vein thrombosis, and then you're in trouble.

[57:28] Jennifer Milner: Right.

[57:29] Dr. Pradeep Chopra: Because these conditions are not so well studied, we don't really have very good protocols in place. Surgeons don't want to fix something that's not squeaking. I see their point. But I also worry about what she may develop in the future.

[57:43] Dr. Linda Bluestein: I'm curious — if she's not having any symptoms, what made you suspect that in the first place?

[57:52] Dr. Pradeep Chopra: I knew you would ask me that question. She actually had pelvic vein congestion. She told me that anytime she stood up, she would feel this pain in her pelvis, and as soon as she lay down, it would feel better. So I was looking for pelvic vein congestion, not May-Thurner. And that's when May-Thurner Syndrome showed up. It was an incidental finding.

[58:12] Jennifer Milner: So is that why you include May-Thurner with abdominal pain issues, when the pain they would feel is in the left leg?

[58:21] Dr. Pradeep Chopra: Well, the left iliac vein is in the pelvis. It's not part of the leg, it's not part of the abdomen, but it's part of the pelvis. It kind of doesn't have a home.

[58:34] 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 — he operated in the pelvis before he retired. But I feel like GYN doctors and urologists who operate in that area don't necessarily always have a great understanding of all the complicated things that can happen in the pelvis. Super important information for a lot of people to have, right?

[59:00] Dr. Pradeep Chopra: And I don't blame them because there are so many players in the pelvis and the abdomen. The whole common concept of patients with EDS having loose joints is valid, but they also have to understand that tissue is loose, and when they stand up, it shifts. The GI and pelvic pain specialists don't always have that mindset. And that's why having these conversations will start people asking questions — patients are going to start asking questions — and eventually it will be much more commonly diagnosed.
[59:44] Now, the other one is tethered cord syndrome. Strangely enough, we know tethered cord syndrome causes bladder issues and leg pain. But it can also cause stool incontinence, and besides that, it can cause abdominal pain. We do not have a great explanation as to why. Yes, the spinal cord is getting yanked because of tethered cord syndrome. Is there a nerve going to the abdomen that's also getting pulled? We don't know enough about tethered cord syndrome yet. But we have seen patients improve their GI symptoms and abdominal pain after tethered cord surgery. Not everybody, but there are enough cases to say that there is some link between tethered cord syndrome and abdominal pain.
[1:00:35] 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 pain is from the bag itself, the abdominal wall. In the front of our abdomen, we have the six-pack muscle. At the edge of the six-pack muscle, there is a nerve that comes out from the spine and travels to the edge of the six-pack muscle through a tiny tunnel. What happens is that sometimes that tunnel narrows down and presses on the nerve — hence, Anterior Cutaneous Nerve Entrapment Syndrome.
[1:01:32] 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 the six-pack gets tight — and then I press on that edge of the six-pack and they'll complain of pain. We used to see this a lot in plumbers and HVAC workers, because they stick their tools against their stomach when they need both their hands free. We do also see it sometimes in patients who've had abdominal surgery, especially pelvic surgery.
The easiest diagnostic clue is that they'll say their belly hurts when they try to sit up — lying down and when they try to sit up, they feel this pain. That often brings up 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 the pain. The hard part is finding a surgeon and convincing them to go and release that nerve. Generally it's done by general surgeons.
[1:02:56] So that, ladies, is in a nutshell — wait, wait, I forgot there's more to it. Sorry. You've got to listen to me a little bit more.
[1:03:06] So hernias are common — hiatal hernia, ventral hernia. These are usually not painful. A large hiatal hernia can cause some issues. Ventral hernias happen around the belly button and are generally not painful.
[1:03:19] The other one to always keep in mind is intestinal rupture or an aneurysm rupture, especially in patients with vascular EDS. And the caution here is: just because somebody doesn't have vascular EDS doesn't mean they're not prone to having intestinal rupture or aneurysm rupture. We divide people with EDS into 13 subgroups, but it's not a clean division. A patient with hypermobile EDS can have an overlap with classical EDS symptoms, or with some symptoms of vascular EDS. We're not so clearly divided. So just because someone has hypermobile EDS, we can't sit back and say they can't have an intestinal rupture. It should always be in the back of everyone's mind.
[1:04:18] The next one is absorption of medicines. For some reason — and I think it's more from mast cell activation causing inflammation of the lining of the intestines — patients with EDS do not absorb medicines well. Very often we'll prescribe medicines and they'll come back and say, Doc, that didn't help me at all. You can give them beta blockers and they'll say their heart rate did not change at all. I would say a very high percentage of these patients do not absorb medications.
[1:04:51] The test for that is very simple. You give the patient Benadryl. We know that Benadryl makes you sleepy. And if they're not absorbing medicines, they're not absorbing that Benadryl, and they may not feel as sleepy. That gives you an idea that they're not absorbing meds well. If somebody has that issue, there are other routes. You can inhale it through the nose. You can nebulize the medicine — for example, Cromolyn can be nebulized. You can put it under your tongue, which bypasses the intestines and the stomach completely. You can have a compounding pharmacy make a skin lotion or a skin patch so it gets absorbed through the skin. And of course there's IV and intramuscular injections.
[1:05:36] The reason I brought this up is that even though it's not directly abdominal pain, it has a lot to do with mast cells affecting absorption of meds. And then there are food sensitivities to watch out for, and histamine-releasing foods like tomatoes and peppers and things like that. Most patients with EDS know that by now — they know that anytime they eat bread, they feel awful. But I just wanted to reinforce this.

[1:06:09] Jennifer Milner: Yeah, that's great. Thank you.

[1:06:13] Dr. Pradeep Chopra: So, in a nutshell, those are the GI and abdominal issues in patients with EDS.

[1:06:19] Dr. Linda Bluestein: I feel like when I was in medical school taking embryology and thinking, wow, how does any baby ever come out relatively healthy? Listening to this list and thinking of various different patients that I've had — 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 parenteral nutrition — being fed through the blood vessels because her gut doesn't work — 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.

Dr. Pradeep Chopra: Yes.

[1:06:52] Dr. Linda Bluestein: And 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 listening to this to go and stop their medications.
That's a perfect lead into my next question, which is: I'm sure a lot of people 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 the root cause of my pain, with or without the help of someone on my medical team? Obviously you can't just go into a hospital and request to order some of these tests on your own. 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 if they have abdominal pain and they're trying to sort out what might be going on?

[1:07:46] Dr. Pradeep Chopra: Yes, I have a little hack for finding out what's going on. One of the commonest issues is gastroparesis, or poor movement of the intestines. They don't move well. And depending on the day, it varies from day to day. Someone may go for that radioactive test and it comes back normal, but then the next day they still have bloating and all those issues.
[1:08:15] So you can do this at home: take beet. When you eat beet, check your stool for the next 2 days. After 2 days, it should not be red in color anymore. If it's still red 6 days later, 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 who had an official GI test with a radioactive egg and were told it's normal — which some days it is normal. It all depends on the day you go. I've had one patient who went 5 times before they found out it was gastroparesis.
[1:08:54] The hack is: take beet. Somebody suggested taking corn — that's another way to do it — but I think color stands out better than looking for corn. After 48 hours, you should not have any more beet in your stool.

[1:09:10] Dr. Linda Bluestein: That's great. And I tell people all the time that any test you do is a snapshot in time. And like you said, if it's supine or upright, things that are worse when you're upright aren't going to really show up with a supine test. That's a great hack for people to try on their own. How much beet should they eat? Is there a specific amount?

[1:09:38] Dr. Pradeep Chopra: No, go to town. Have as much as you like.

[1:09:40] Dr. Linda Bluestein: Okay.

[1:09:41] Dr. Pradeep Chopra: It doesn't matter. 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 stool 6 days later, then you probably have gastroparesis.

[1:09:57] Dr. Linda Bluestein: That is a great hack. People are going to love that — people love getting little tidbits like that.

[1:10:05] Dr. Pradeep Chopra: Well, the other one I came across was corn. Instead of chewing the corn, you just swallow it whole and look for it. Which is a hard one to do because you have to sift through your stool, which is not—

[1:10:17] Jennifer Milner: Yes, which is not as fun. The sales of beets are going to skyrocket for the week after this.

[1:10:24] Dr. Linda Bluestein: And a lot of people are probably corn sensitive too.

[1:10:27] Dr. Pradeep Chopra: Right, right. One of the things that is a huge problem, and I don't have a full answer, is the manufactured food that we eat. Try to stay away from manufactured food, obviously, because manufacturers are putting a lot of stuff in there — chemicals that I can't even pronounce. I'll give you an example. I have to be very careful about what I eat — I am gluten sensitive and all of these things. But every few days I feel a bit queasy, and maybe I ate something. When I go to Europe — and I was there about 2 weeks ago, I gave a talk on EDS in Germany — they don't really believe in this stuff. They don't have much mast cell activation syndrome. They were like, what, you guys are food sensitive? They didn't really understand the concept of mast cell activation syndrome because they're not getting exposed to these chemicals. And I could eat anything. I went to town on bread just to test it, and nothing happened. I felt great. And then as soon as I came back, it was the same thing.
[1:11:43] So eating processed foods is a problem. The other thing is vegetables and fruits. We may think that these are always okay. I would suggest buying vegetables and fruits from the farmer's market. This goes back to a theory — if you want to read about it, it's in the Wahls Protocol. Dr. Bluestein knows about that.

[1:12:09] Dr. Linda Bluestein: Yeah, I love the Wahls Protocol.

[1:12:10] Dr. Pradeep Chopra: The Wahls Protocol — this is a neurologist. She treated her own MS, going from a wheelchair to no wheelchair. The only thing she did was she changed her food, her diet. The theory is that our microbiome — the bacteria and all the organisms that live in our intestines — is used to the local environment. 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 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 — I don't fully understand all the theory behind it — eating foods from faraway lands affects our microbiome significantly.
So Dr. Wahls's theory was to eat foods that are locally grown: the chicken that's free-roaming and eating grain or bugs in your area. That's one of the things you can try and change. Even with fruits — not even talking about processed food, but natural foods like vegetables and fruits — buy the local ones as much as possible. And chickens and meats locally too, because the chickens are going to eat bugs from the ground in your environment. And this affects the microbiome significantly. This has been studied. There was a really great study done where they looked at the microbiome in Pygmies in Africa and were able to figure out the difference — why these people can survive so well and stay healthy on their local foods. But if you disrupt that microbiome, they become unhealthy. That's why I suggest getting local foods. Obviously, grow it if you can. Your next best option is the farmer's market.

[1:14:23] 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 who has not talked about nutrition and diet as one of those things that will help you. And it's something we just take for granted — yeah, yeah, I'm supposed to eat better. But what a concrete reason to look at that: not just eat healthier fruits and vegetables, but fruits and vegetables from your local farmer's market. Very concrete reason for that. And I love that.
[1:14:53] 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 common elements. We can look at this big long list of issues and say, oh, too much acid, pinched artery, bacterial overgrowth, pinched nerve. Or we can look at this big long list of issues and say, oh, mast cell problem, nervous system dysregulation, loose connective tissue. 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 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. Come at it from there, rather than: what's the diagnosis, let's fix that.
[1:15:43] I feel like I've just sat through a masterclass, and I am going to be listening to my own podcast again several times just to have a chance to absorb everything. We are so grateful for you coming on to share your wealth of knowledge with us. Where can people find you? Is there a way for them to find you and learn more about what you do?

[1:16:01] Dr. Pradeep Chopra: Oh, doctors can't hide anywhere.

Jennifer Milner: True.

[1:16:01] Dr. Pradeep Chopra: You can't hide anywhere. I'm in Rhode Island, obviously. And my website is PainRI — Pain Rhode Island — painri.com. Pretty much everywhere.
[1:16:23] One more hack that just came up on the nausea and vomiting part. Any cold medicine is a very good anti-nausea medicine.

[1:16:33] Jennifer Milner: That's a great hack because that's easy to find.

[1:16:35] Dr. Pradeep Chopra: In fact, before Zofran was invented, we were giving patients Benadryl for nausea and vomiting.

[1:16:43] Jennifer Milner: Vistaril.

[1:16:44] Dr. Pradeep Chopra: Dr. Bluestein will remember that. Vistaril.

[1:16:46] Jennifer Milner: Oh yeah.

[1:16:46] Dr. Pradeep Chopra: We used to always give — with a narcotic like morphine or meperidine, you would add Vistaril, which is an antihistamine. So if you don't have Zofran handy or your doctor didn't give it to you, take a pill of Benadryl and that's an anti-nausea medicine.

[1:17:03] Dr. Linda Bluestein: Well, I think that's actually a great suggestion too, because I think a lot of people don't realize that Zofran can actually contribute to constipation and headaches. It has some side effects that I feel like a lot of people prescribe it like it's nothing. I have lots of patients who take it very, very regularly. So it's great to have other alternatives for people to try.

[1:17:18] Jennifer Milner: And I was thinking when you said Benadryl for nausea — the Benadryl may help address at least short-term some of the mast cell issues, which will help the nausea in that way. So it's also a great little diagnostic tool.

[1:17:33] Dr. Pradeep Chopra: Well, I'll give you another tip on that. We're not just talking about Benadryl — we're talking about antihistamines: Benadryl, Zyrtec, Claritin, and all of those. Benadryl being the king, but there's hydroxyzine also. All of these have vagal stimulating effects. They're not very strong vagal stimulating effects, but you want vagal stimulation, because your sympathetic nervous system is so revved up. So Benadryl or any of these, besides helping with nausea, can also help with some of the movement of the intestines — make it much easier.

[1:18:09] Jennifer Milner: Mm-hmm. That's really cool. It all just kind of links back in on itself. It's so interesting.
[1:18:18] 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, 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.

[1:18:34] Dr. Pradeep Chopra: Thank you so much for inviting me. Happy to be here.

[1:18:39] Dr. Linda Bluestein: Yay. We finally got to talk to you and we look forward to more conversations for sure.

[1:18:43] Dr. Pradeep Chopra: Hacks, hacks. I love hacks.

[1:18:45] Dr. Linda Bluestein: Yes, we love hacks too.

[1:18:46] Jennifer Milner: We love hacks. We're going to do a whole series on hacks now just because you started it.

[1:18:51] Dr. Linda Bluestein: We're going to pin you down and take all your EDS hacks. High-probability hacks.

[1:18:56] Dr. Pradeep Chopra: We need to have a — no, the reason, as you can see, is because when you first asked me, I said there's no way you can cover everything in one shot. I mean, it's almost 4 PM and 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 that compiles all of this together. The hard part is gastroenterologists just like to do a scope from the top and from the bottom and look inside the intestine. But everything we talked about today was all outside the intestine. There are so many problems just outside it, and they don't want to touch that. And this was the reason why I wanted to bring it up: patients should be aware of these things so they can bring them up with their doctors.

[1:19:54] Jennifer Milner: Well, we are grateful that you did. This is such an interesting way to look at it. Thank you again.

[1:19:59] Dr. Pradeep Chopra: You're welcome. Guys, take care. Have a wonderful weekend.

[1:20:03] Dr. Linda Bluestein: Thank you. You too. We really appreciate all the great information and we know a lot of people will find this really valuable.

[1:20:10] Dr. Pradeep Chopra: Thank you.

[1:20:11] Dr. Linda Bluestein: If you found this helpful, follow the Bendy Bodies podcast to avoid missing future episodes. Please leave a review and share the podcast so more people know about Bendy Bodies and joint hypermobility. Screenshot this episode, tagging us in your story so we can connect. Our website is www.bendybodies.org, and follow us on Instagram at bendy_bodies. We love seeing your posts and stories, so please tag us using #BendyBuddy. This information is not intended to diagnose, treat, cure, or prevent any disease. The information shared is for educational purposes only and is not a substitute for medical advice, diagnosis, or treatment. Please refer to your local qualified health practitioner for any medical concerns. We'll catch you next time on the Bendy Bodies Podcast.