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What if your “IBS” isn’t just a gut problem—but part of a larger endometriosis story that involves nerves, immune triggers, and the way your body processes pain? We sit down with a neurogastroenterologist, Dr. Zachary Spiritos and colorectal surgeon, Dr. Vincent Obias, to connect the dots between bowel endometriosis, mast cell activation, dysautonomia, and the stubborn symptoms that linger after surgery. No platitudes here—just clear explanations, candid timelines, and practical strategies that help you make sense of complex, overlapping conditions.
We explore how deep infiltrating endometriosis can change rectal compliance and bowel habits, why post-op bloating and urgency often follow colorectal procedures, and when those symptoms should improve. From the GI side, we challenge the “IBS” catch-all by listening for patterns—cyclical pain, flushing, migraines, brain fog, POTS—that point to mast cell activation or brain–gut dysregulation. You’ll hear how perioperative planning for MCAS (H1/H2 blockers, steroid rescue, anesthesia choices, fluids for POTS) reduces flares, and why excision by experienced teams beats ablation for long-term outcomes.
We also get real about the gray areas: normal tests with abnormal lives, “invisible” inflammation, and how hypermobility can complicate recovery. Expect concrete ideas—targeted imaging and ultrasound for bowel nodules, timelines for healing, SIBO and adhesions as culprits, pelvic floor retraining, sleep as a pain modulator, and GI-focused CBT or hypnosis to calm anticipatory anxiety. The big takeaway: better results come from better teams. When surgery, neuro-GI care, anesthesia planning, and pelvic rehab align, the gut, the nerves, and the person finally get on the same page.
If this conversation helped you see your symptoms in a new light, follow the show, share with a friend who needs answers, and leave a review with your top question for a future episode. Your story might guide our next deep dive.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Alanna (00:00):
What happens when endometriosis doesn't just
affect the pelvis, but the gut,the nerves, and the very way the
body communicates with itself?
Today's episode brings togethertwo specialties who don't often
sit at the same table, aneurogastroenterologist and a
colorectal surgeon to unravelwhy so many patients fall
through the cracks, from bowelendometriosis to mast cell
(00:23):
activation, from lingeringpost-op symptoms to the role of
multidisciplinary care.
This conversation gets realabout the complexity of endo and
why answers aren't alwaysstraightforward.
If you've ever wondered whysymptoms persist even after
surgery, or why your GI andpelvic pain seem inseparable,
(00:43):
you're gonna want to lean in forthis one.
Let's get started.
Welcome to Endo Battery, whereI share my journey with
endometriosis and chronicillness while learning and
growing along the way.
This podcast is not asubstitute for medical advice,
but a supportive space toprovide community and valuable
information so you never have toface this journey alone.
(01:05):
We embrace a range ofperspectives that may not always
align with our own, believingthat open dialogue helps us grow
and gain new tools.
Join me as I share stories ofstrength, resilience, and hope,
from personal experiences toexpert insights.
I'm your host, Alana, and thisis Indobattery, charging our
lives when Endometriosis drainsus.
(01:26):
Welcome back to Indobattery.
Grab your cup of coffee or yourcup of tea and join me at the
table.
Today I'm honored to welcometwo incredible physicians to the
table, both whom bring uniqueexpertise and deep commitment to
caring for patients withcomplex conditions.
First, we have Dr.
Zach Spiritos, aneurogastroenterologist and
(01:48):
internist whose journey took himfrom Philadelphia to North
Carolina, where he's now rootedwith his family.
Dr.
Spiritos trained at UNC Schoolof Medicine, completed his
residency at internal medicineat Emory University, and went on
to a fellowship ingastroenterology at Duke.
He specializes in a wide rangeof gastrointestinal and liver
(02:08):
disorders with particularinterest in irritable bowel
syndrome, functional abdominalpain, motility disorders, and
dysautonomia, includingconditions like POTS and mast
cell activation syndrome.
He also has expertise in GIcomplications connected to
hypermobility syndromes likeEler Stanlose.
What sets Dr.
Spiritos apart is his holisticapproach weaving together
(02:31):
nutrition, lifestyle, and gutbrain therapies to empower his
patients.
Also joining us today is Dr.
Vincent Obius, a professor ofsurgery and chief of the
Division of Colorectal Surgeryfor the National Capital Region.
Dr.
Obius trained at the MedicalCollege of Virginia, Eastern
Virginia Medical School, andCleveland Clinic with additional
(02:52):
advanced training andlaparoscopic colorectal surgery
at University Hospital's CaseMedical Center.
He is double board certified ingeneral and colorectal surgery,
and his specialties includerobotic minimally invasive
techniques as well as surgeryfor deep infiltrating
endometriosis.
Beginning October 2025, Dr.
(03:12):
OBS will be joining Dr.
Melissa McHale and Vicky Vargasas a partner at Washington
Endometriosis and ComplexSurgery Group.
His research and clinical workhave made a lasting impact,
particularly in robotic surgeryoutcomes and complex
endometriosis care.
Together, these two doctorsbring insights from both the
gastrointestinal and surgicalperspectives, making today's
(03:36):
conversation one that promisesto be both informative and
empowering for patients andproviders alike.
Please help me in welcoming Dr.
Zach Spiritos and Dr.
Vincent Obius to the table.
Thank you both so much forjoining me today, sitting down
at the table for thisconversation that's a little
nuanced in direction, as thatyou guys don't typically work
(03:56):
hand in hand together, but oftensymptoms go hand in hand
somehow.
Indopatients are workingthrough the
neurogastroenterology as well ascolorectal side, trying to
figure out the different pieces.
So thank you both so much forsitting down and doing this with
me.
Dr. Zac Spiritos (04:10):
Well, yeah.
Thanks for having us.
Thank you very much.
Alanna (04:13):
Can you give us each a background?
And we'll start with you,Vince, a little background on
what you do and kind of what youspecialize in so that we have a
good place to start.
Dr. Vince Obias (04:22):
Sure.
I'm a colorectal surgeon, boardcertified, about 20 years of
practice.
Um, I take care of deepinfiltrating endometriosis,
colon cancer, rectal cancer,reticulitis, inflammatory bowel
disease.
I've been doing umendometriosis surgery with my
minimally invasive gynecologycolleagues, both at GW and
Hopkins, and it's uh it's apassion of mine.
(04:43):
There's a lot of surgeons whotake care of cancer, me being
one of them, but there are veryfew that uh take care of
endometriosis, and I'm startingto specialize in it, and it's
incredible.
Some of the most challengingcases are of women with
endometriosis, and certainly,you know, it's a population that
uh can really um you knowbenefit from someone who has a
lot of experience in pelvicsurgery.
(05:04):
So I'm very, very excited aboutit.
Alanna (05:06):
Yeah.
Zach, you we've had you onbefore, but you're back again.
Dr. Zac Spiritos (05:09):
I'm a neurogastroenterologist.
So I trained a Duke, and then Iwas at UNC and then branched
out to do my own practice.
I uh work with folks that notonly have issues with the tube
itself of the GI tract, uh thenamely the esophagus to the
rectum, but also the wiringbetween the tube and the central
nervous system, specificallyhow the tube is perceived and
(05:30):
felt, and also how it moves andpropagates kind of food, debris
towards our rectum.
Uh, and yeah, and try to helppeople work through this space
as well.
Alanna (05:38):
Yeah.
And I think I didn't put thesepieces together very well prior
to us kind of talking aboutthis, but there were so many
questions last time that Zachand I did a podcast together
that I felt like I couldn'tanswer these questions and they
were pretty prevalent.
Like a lot of people were wereasking these questions.
And so just jumping into this,I really want to get a better
(06:00):
idea of how it all functions inyour own specialties, if you
will.
Can you describe the role ofbowel endometriosis care?
Like when you see Vince, whenyou see bowel endometriosis,
what is the approach to thatpre-surgical approach of mapping
that out?
Dr. Vince Obias (06:17):
So I always do this with gynecology.
Um I don't feel thatendometriosis is purely a
colorectal issue.
Um, the gynecologists and mycolleagues, like Dr.
Var Vicky Vargas and MelissaMcHale, this is what they
specialize in.
So I usually get them involved.
Even when some patients come inwith pelvic pain and a CT
showing a mass as endo, I stillget them involved, a
(06:39):
gynecologist involved.
Generally, women present withpelvic pain, rectal bleeding at
times, and that leads to thatcan be a very broad area when
dealing with these symptoms.
And so the workup is verybroad.
You know, uh sometimes the painand bleeding that they're
having is not endometriosis.
So when I see them, we talkabout you know the workup for
(07:01):
this, which can be a variety ofthings, including laonoscopies,
erectile exams, of course, acomplete history and physical.
But what I see them and they'reinvolved, they're generally
about 30 to 40 percent of womenwith endometriosis, it will
involve the rectum or the bowelof some type.
So it's it's important to haveuh you know bowel surgeons like
myself involved at the start.
Alanna (07:21):
Yeah.
How does it affect the gutmechanically, though?
Dr. Vince Obias (07:27):
So um obviously if it gets large enough, you
can have obstructive typesymptoms.
You can also, if it's deepinfiltrating and eating through
the wall of full thickness, youcould see bleeding and you'll
see bleeding per rectum duringyour menses.
It can also, you know, the therectum is sort of uh it's a
capacity.
Its job is to sort of stretchand maintain stools.
(07:49):
So when you go to the bathroom,you can you can make it.
And if you have endo there thatkind of restricts it from
inflammation, these patientstend to have a bit more urgency.
Well, like they'll go to thebathroom and they don't see
much.
So they'll have someinteresting symptoms like that.
Some of these patients will be,because of what I've discussed,
will have chronic constipation.
And that workup, you know,which can be pretty advanced and
(08:12):
and broad.
But but endo, endo is it'salmost one of those disease
processes that we're taught inschool that it's almost like a
you do a full workup, and if youdon't find anything, then it
could be endometriosis.
And it it's it's terrible thatwe have much better ways of
finding these nodules now thanwe had in the past.
But that that's only been inthe last 10 years that I've
(08:34):
seen.
But yeah.
Alanna (08:35):
Zach, on your side of it, how does the gut
neurologically work typicallywith endometriosis patients that
you see and the differencebetween that, what Vince is
saying, and what you see?
Dr. Zac Spiritos (08:47):
I think it varies.
Uh, you know, it's definitelypain predominant.
And so, you know, thesepatients are labeled with IBS,
whatever that means, where theyhave a lot of pain and
alterations in their bowelhabits with a diagnostic workup
that is fairly unrevealing.
So that's what's reallyimportant to talk to these
people.
And, you know, because if youstay in your siloed world of GI
(09:08):
and you say, oh, you know,what's your Bristol stool scale?
Like how many times do you goin?
Do you have urgency?
Like, you're also like, do youhave your period?
Is it heavy?
Is it painful?
Do you have pelvic discomfort?
Right.
And if you expand theconversation to a true review of
systems, which sometimesbecause of the limited time that
you have in clinic or you'rejust kind of so focused on the
GI world that you sometimes missthat.
But endometriosis, you know,can certainly cause, you know, I
(09:31):
typically just think pain,pain, pain, pain.
Can it certainly causediarrhea?
Sure.
Or alterations in bowel uhmovements, as Vincent said, you
know, if you have this huge kindof endometrioma, you can have
obstructive symptoms.
I don't, I personally haven'tseen that a ton, but he
obviously in the surgical sidesees that a lot more than I do.
Alterations in bowel habits,pain, but so many things can do
that, right?
So many things can do that.
(09:51):
And so I think it just behoovesyou to just kind of talk to the
person and just make surethere's if there's any kind of
gynecologic symptoms as wellthat would kind of lead you
towards endometriosis.
And my teaching is, you know,if you have painful periods,
it's endometriosis until provenotherwise.
Like it's your job to provethat it's not that.
Alanna (10:07):
Yeah.
I love that approach because Ithink that should be taught in
school across the board becauseit affects so many different
systems that until provenotherwise, especially if it's
cyclical, should be thought ofas endometriosis.
Now, I think what'sinteresting, Zach, you talked
about your mass, and this wasearlier, your mass cell
(10:27):
activation patients, all of themhave endometriosis.
Dr. Zac Spiritos (10:29):
All of them.
I mean, not all of them.
A lot of them do.
It's still just really highrate.
Yeah.
So I see a lot of patients whohave hypermobility and some have
POTS or dysautonomia, and theya lot of these times have mast
cell activation syndrome.
And so when we talk abouteverything that's going on, and
everybody, you know, when in atypical visit, and someone who
doesn't have mast cell, they goto their PCP and they're like,
(10:52):
is anything going on today?
And mast cell, it's like, whatare the five top things that
bother you today?
Right.
And because they have so muchgoing on.
They have endless amounts ofsymptoms, and that's why these
visits are required to bereally, really low.
And when you talk, when youstart kind of going down the
review of systems, like do youhave painful heavy periods, the
answer is often yes.
And so the you will often seeheavy periods, you know, mast
(11:12):
cells secrete a lot of differentchemical mediators.
Heparin is actually one ofthem.
You actually m see elevatedheparin levels in their blood.
And so they tend to haveheavier periods, and that's
fine.
You can live in you cancertainly ascribe a lot of
things to mast cell activationsyndrome, but the rate of which
we see endometriosis is so highthat I just have a low I have a
low threshold to to involvegynecology or, you know,
colorectal surgery to evaluatethese patients right off the
(11:35):
bat.
Alanna (11:36):
Yeah.
And part of the challenge theretoo for a lot of us is figuring
out okay, is it is itendometriosis or is it these
other things like mast cell or,you know, pots playing a part
into this?
One of the things that I thinka lot of people struggle with is
they have lingering symptomspost-operatively.
So they've had excision surgeryand they have lingering
(11:58):
symptoms, whether that'sconstipation, whether that's
food sensitivity, it might be,who knows?
Like there's just a lot ofbloating is another one of those
things.
Vince, when you're doingsurgery and the outcome of that,
and they're still having thisbloating, they're still having,
you know, all of those things,is it concern for you if there's
nerve involvement that iscausing this?
(12:19):
And this kind of plays hand inhand probably with what you do,
Zach, as far as like the nerveinvolvement as well.
Dr. Vince Obias (12:25):
Yeah.
So I will say that thosesymptoms are common after bowel
surgery.
So when you're when let's saywe someone has diverticulitis or
colon cancer or rectal cancer,whenever we cut the bowel and
put the two ends back together,bloating, discomfort,
constipation, diarrhea, thoseare common symptoms to have
after surgery for about two tothree months, up to six months.
(12:48):
Now, I will say after sixmonths after a collectomy, the
symptoms that you have are sortof your new pattern.
So I tell patients all thetime, I'm like, not sure you're
gonna have a bowel movement likeyou had in your 20s, but after
six months, you'll bepredictable.
And those conversations arereally important to have.
And since I'm a colorectalsurgeon to do bowel surgery, I
do have that for patients.
(13:08):
So their expectations are like,yeah, Doc, I'm bloated, or a
little bit of gas, or I haveurgency and nothing much is
coming out, or I have like fiveor six VMs a day, but they're
not upset because they knewabout it coming in.
Meanwhile, honestly, likegynecologists, they don't do a
lot of bowel surgery.
But if you're shaving or doinganything on the bowel or pelvic
surgery, you could still havethese same post-op symptoms.
(13:30):
So that kind of education isimportant to have up front so
that they understand that's partof the healing process.
Now, certainly, can endo comeback quickly?
Certainly.
I think you know that's one ofthe things we worry about.
But when we do excisional, theydon't usually come back that
quickly.
But you are dealing with thepost-surgical in terms of scar
tissue, in terms of inflammationfrom the surgery.
(13:52):
Like I said, that if you'redoing pelvic surgery and you're
mobilizing everything downthere, even if you don't cut the
rectum or bowel, the scartissue and inflammation will
change your bowel habitsafterwards.
And so when you go in withbloating and discomfort and you
leave with bloating, you'refeeling, oh, nothing was done.
But that's part of the process.
Give it time, three to sixmonths later.
(14:12):
That should be improved andcertainly more predictable.
In terms of nerves, so thenerves I deal with, especially
in cancer, which we don't reallyrun to when I we run into an
endometriosis, is sort of nearthe it's associated with like
sexual function, uh, and menerection, obviously, clip
clitoral erection, it can beassociated with, and bladder
(14:33):
function.
It but they're more posteriorto the rectum and maybe not
necessarily intrinsic to thebowel, but if that's normally
the nerves that we would dealwith, and that's more of a you
know, removing the rectum uh forcancer.
Alanna (14:46):
Yeah.
Zach, do you see aftersurgeries if people come to you,
they're still having issueswith GI, it could be related to
that mast cell activationpost-surgical that's ramped up
even more because of surgery,you think?
Dr. Zac Spiritos (14:59):
It depends.
Like Vince's end, like, youknow, you don't want to
pathologize everythingpostoperatively, right?
Like sometimes it's just ahealing process.
The question is like, does itmake sense, right?
Like, do they remove the TI,the terminal ileum, and acid mal
diarrhea?
Like that makes sense to me,right?
If you have a colectomy and youhave diarrhea, like, all right,
like you lost your rectum.
If there's rectal sparingsurgeries and whatnot, but does
the surgery and what happenedpair with what you're
(15:21):
experiencing, right?
You know, you can developcertainly like SIBO
postoperatively, right?
Is it adhesions?
Is it is it the narcotics totake post-operatively?
You know, is it um so there'sthings that exist certainly
outside of mast cell activationsyndrome.
So you take the person, thesurgical intervention, and what
their symptoms are, and you tryto combine all three.
I have had patients with mastcell whose symptoms were
attributed to endometriosis,they had endometriosis, surgery
(15:43):
was like was performed and theyfelt no better because it was
just mast cell, right?
But you have to do that.
You are required to look forthose things because
endometriosis can affect so manythings.
Fertility, right?
Like and so you want to do yourdue diligence when there's
something you can intervene andand fix.
Um and you can easily fall intoa trap where you blame
everything on mast cellactivation syndrome, which you
don't want to do.
You want to, you know,fortunately when people come to
(16:04):
me, they've had all the testing.
So I don't really have a lot ofrun left, but you still want to
keep a wide kind of lens, don'tbe myopic and keep everything
in perspective.
And so yeah, does it does thedoes do the symptoms fit what
happened?
And can you can you kind ofcreate a nice story with what's
happening if you can't, and youknow, there's like food
intolerances and brain fog aftersurgery, like that's not
(16:27):
related to the surgery, right?
That's something different.
And so you just have tounderstand the surgery,
understand what the symptomsare, and how to kind of connect
the dots.
Alanna (16:35):
Yeah.
And I can tell you, having agood surgery with a qualified
expert in this will make adifference in the outcomes.
I mean, if you're having ageneral G Y N, and I'm not
bashing on them, but if you havea general GYN doing your
surgery, chances are there'sdisease left behind.
And that because they're nottrained to excise the disease.
(16:57):
They're trained oftentimes todo ablation, which can cause
more scarring and stuff likethat.
Vince, have you experiencedthat you've done you've done
resections and you've been insurgeries where they've had
multiple surgeries, theycontinue having these symptoms.
Is it typically disease statethat you're seeing again, or is
it, you know, something that yousomething else completely?
Dr. Vince Obias (17:21):
Yeah, I I will say that um every time I'm in a
case, um, especially now workingwith Dr Vargas and Dr.
Mikhail, you know, theirsuccess rates in finding nodules
and of involvement of the bowelis like 100%.
So whenever and and like it wehad mentioned and discussed
earlier, sadly, most of thesurgeries I've involved, there's
been previous surgery, which isit's just sad to see.
(17:43):
So honestly, um, thegynecologist did the right
thing.
Rather than tackle this complexnodule on the rectum and have a
complication that's justterrible, don't do anything,
document it, get it to anexpert.
But yeah, I mean, when they'rehaving post-surgical and there's
usually because ofendometriosis that's been left
behind, sometimes inadvertentlyand regrown, or and sometimes
(18:04):
they knew it and are like, look,I'm not gonna not gonna risk
it.
And it's the smart thing to do,understanding that you know
they're a little bit out oftheir element.
The patient is not aware a bigsurgery can happen.
Um, and it's better to just,you know, get out, let them
recover quickly.
But it's very frustrating,honestly, for the patients who
are like, they came in, they'rehoping to have one procedure,
(18:25):
they're hoping to have thisdone, taken care of, and they've
been told not only that, youknow, we're we're we're doing
this, but there's gonna be, youknow, we couldn't do it all, but
there's also a worse situation,and you may need even more
advanced extensive stuff.
So um, so yes, I absolutelyhave seen that.
And the majority of the timeit's because of this end of
endometriosis getting there.
Alanna (18:45):
Okay.
Yeah.
I would I think that's probablypretty common with people that
I hear, in including my ownstory of that, of disease being
left.
But it, you know, that goes tosay that that's why this
education is so important,right?
We have to keep educating aboutthis.
Zach, is there a ideal pre andpost-operative routine or things
(19:07):
that we can do to help supportus pre and post-operatively when
it comes to GI-related things?
Dr. Zac Spiritos (19:14):
It's a really good question.
I would probably, you know, Idon't know if I'm the right
person to answer that questionnecessarily.
You know, I think you just wantto do your due diligence and
make sure that no otherpathologies at play.
But I don't know if there'sanything from a GI perspective
specifically that you would dialup to ensure better outcomes.
Like I think I'd probablyreserve, I'd leave that to the
(19:34):
surgeons and the gynecologist tomake sure the patient's like
the right candidate and a goodsurgical candidate, and that's
it's probably not my job todecide.
You know, certainly things wecan do to optimize people from a
mast cell perspective.
Alanna (19:46):
That's what, yeah, that from the mast cell part of it,
because I know a lot of people,including myself coming out of
it, things flare really bad.
How do we help alleviate alittle bit of that pre and
post-operatively?
Dr. Zac Spiritos (19:59):
Yes.
We want to make sure their mastcell is under as best control
as possible pre-operatively.
There's always, I tend to reachout to the surgeon to discuss
the case and just say, hey, thisis kind of this is how I would
think about this specificpatient, you know, whether
they're hypermobile and theyneed a neck brace during the
surgery because they have a lotof craniocervical instability.
(20:21):
Do they have HOTs and just needvery like do they really need
to be fluid resuscitated beforethe case and really just make
sure that they're adequatelyhydrated?
If they have mast cellactivation syndrome, there's
certain anesthetics that tend toflare mast cells and
postoperative narcotics likemorphine that tend to be more
aggravating for mast cells.
And there's also a dialoguelike what happens if they have a
(20:42):
huge flare and go onanaphylactic shock?
Like, we should probably havelike steroids and you know, H1
and H2 blockers ready to go incase that happens.
And so I have a protocol that,you know, I've I've written with
other, I haven't written, butI've adopted from other um mast
cell clinicians.
And I often will reach out tothe surgical team and say, this
is kind of what I would do uhand how I would approach this
(21:04):
patient kind of perioperativelyand intraoperatively just to get
the best outcomes.
Yeah.
Yeah.
Dr. Vince Obias (21:09):
Honestly, like the way Zach pointed out, it
it's important to emphasize thatwhen you're dealing with
something like endometriosisthat can affect so many
different areas colon, rectum,diaphragm, bowel, bladder, it's
multidisciplinary.
Just like when I deal withrectal cancer, we talk, we have
radio radi radiologists,oncologists, radiation
(21:30):
oncologists.
We we have a variety of peopleon the team to discuss it.
And so it endometriosis,especially complex stuff, is is
starting to lean that way whereyou have multidisciplinary teams
talking about it so that wedon't miss things.
Alanna (21:46):
Yeah, for sure.
And I think too, it's importantthat we recognize that it takes
multiple people outside of justone specialty, meaning just
endometriosis.
It's like pelvic floor,acupuncture.
There's different ways that wecan support our bodies walking
through this.
And if we all talk together andhave that true team, outcomes
(22:06):
are so much better.
And it and that's proven.
Like that is a proven thingwhere if you have a good team,
solid team going into surgery,more prepared, outcomes tend to
be a little bit better for you.
So that was one of the things Ilearned the hard way as well.
Dr. Zac Spiritos (22:20):
Exactly.
Yeah.
Um how relaxed mostoperatively.
Alanna (22:24):
You what?
You relax?
Dr. Zac Spiritos (22:26):
Most operatively.
Gotta keep the bowels, gottakeep the bowels moving.
Alanna (22:30):
Yep.
Relax, yeah.
I love that stuff too.
Chewing gum?
Dr. Vince Obias (22:33):
Yeah, so so chewing gum is used for uh
return of bowel function rightafter surgery.
Yeah.
So you can chew gum, and so youend up swallowing a bunch of
air.
So there's been studies onthat.
But uh does it yeah, yeah.
But that's right after surgery.
I mean, I don't recommendchewing gum for the next six
months, but uh, if you want to,that's fine.
I'll make it bloated all right.
Dr. Zac Spiritos (22:50):
Do you have you randomized people to
different like bubble yum versuslike big chew?
Dr. Vince Obias (22:54):
Well, when I was a resident, I actually um I
put I gave everybody a pedometerand I had them walk around over
at Case Western, and I was ableto demonstrate the more steps
you did, the faster you hadphallatus and were at home.
So, you know, I I have lookedat some of that stuff, and steps
is one of them for sure.
That's very clear.
Alanna (23:12):
For sure.
Zach, is there a way to retainum bowel and brain communication
after a major bowel surgery?
I think this is something thatmany of us struggle with, is
that we get in patterns and thatit becomes this challenge of
like, this is what my body'salways done.
And now I'm still in thisbattle of is it really going on
(23:34):
still, or is this just the waymy body is trained?
That it's I hate the wordpsychosomatic, but a lot of
times that's what they refer toit.
As is there ways that we canretrain our brains and our
bowels to work better after.
Dr. Zac Spiritos (23:49):
It's a really good question.
You know, I think it's, youknow, you have to take
everything, it's such a bailoutanswer, but you gotta take
everything on a case-by-casebasis.
So if someone has been like,what are they experiencing
post-operatively?
Is it the same diarrhea they'vealways been that's kept them
locked up in the house?
And is that stress about havingdiarrhea making the diarrhea
(24:10):
worse to where you'reanticipating, like, oh my gosh,
like if I go out, I just knowI'm gonna have diarrhea as soon
as af after the appetizers?
And like that, you like speak,you think it into existence,
right?
And so you kind of have tountangle, like, okay, so like
what has your history been?
What are you currently worriedabout?
What is actually happening?
And what are kind of how can weintervene and help things out?
(24:30):
Like, are you are you raginglyconstipated?
Like, why are you constipated?
Is it a pelvic floor issue,right?
Is it because there's notenough fiber?
Is it because you're in fightor flight mode and you're really
stressed?
Is it because you have adisaanoma and you have pots and
it's because your colon doesn'tmove in?
And then it's like, okay, well,let's do what we can from a
dietary perspective and apharmacotherapy perspective to
maybe help alleviate the bowelsto some degree.
(24:53):
But there's always a chancethat the brain will override
everything we do and be like,mm-mm, like we're gonna back
things up or we're gonna getthings going, right?
And so how do we address thatas well?
So if we unentangle things andwe say, okay, well, there's a
really disruptive thoughtpattern that is making your
bowels really bad, right?
So that anticipatory anxiety,or man, if I don't poop like at
by 8 a.m.
this morning, the rest of myday is ruined.
(25:13):
Because I'm gonna get bloated,it's gonna be uncomfortable, and
everybody's gonna notice andit's gonna be terrible.
And that just makes thesymptoms that much worse.
And if we realize that thoughtpattern is happening, which in
turn will make the bowels worse,then maybe we talk about like,
what is maybe talking to atherapist, like a GI therapist,
like is a hypnosis somethingthat we can utilize?
Is cognitive behavioral therapysomething that we can use?
So it really is like take it ona case-by-case basis, but what
(25:35):
buttons can you press?
Medications, diet, exercise,sleep is a humongous one.
Lack of sleep definitelypredicts next day GI pain.
And so it's just you gotta justkind of look at everything and
see how they play off each otherand just listen to the patient,
right?
Just listen to them and seelike where can we where can we
meet in the middle here and findsolutions to what may be going
(25:55):
on.
Alanna (25:56):
Yeah.
I'm gonna do something that isa little probably a little
unorthodox.
And I'm I got so many messages,like I said before, which is
why we're coming together forthis.
So I want to read you guyssomething and I want to get both
of your perspectives on thisbecause I think this will help
clarify maybe some of thequestions that I got previously
and put it in in a way that ismaybe helpful.
(26:17):
And and this is not casespecific, it is not a medical
advice.
This is just insight into this.
So, sample message (26:24):
I'm a mom of a 21-year-old daughter who
has non-cyclical GI symptomssince she was 13.
Two years ago, she wasdiagnosed with endometriosis
after excision surgery withremoval.
She didn't have improvementafter surgery, and two years
later, she still struggles withongoing nausea and frequent
diarrhea each day.
(26:45):
She takes SSRI and was on oralcontraceptives, but isn't any
longer.
She has been treated for SIBO,received pelvic floor PT and
functional medicine protocol,tried low FODMAP and elimination
diets.
She had two unremarkablecolonoscopies and endoscopy.
Zach, you can fill that in.
(27:05):
Endoscopies.
And yet the GI symptoms arestill there.
She has also had a motilitystudy that was also within
normal limits.
Any ideas that you would havefor helping with symptoms or
overall treatment?
Dr. Zac Spiritos (27:20):
Just kidding.
GI doctoral psychic things.
Have you tried?
Um, I don't know.
That's really complex.
You know, so when I see apatient, right, I have 200 pages
of the records.
They've been everywhere.
They've had all the testing.
And I say, I don't care whattheir tests say.
Like, sure.
There are some tests that arehelpful.
I want to hear your story andhow you got here.
What makes it better?
What makes it worse?
(27:41):
What medications worse?
What make it what medicationshave helped so you can
understand like the mechanism ofaction of that?
Um and so, yeah, I mean,there's so many different like
what's does she have brain fog,fatigue, migraines, flushing,
allergies that would make youthink this is mast salt?
Does she have some form ofdysautonomia?
Does she have visceralhypersensitivity?
This is all this all happenafter like a huge GI bug.
(28:03):
So I think you just have tolisten to the person.
There's not a one size-fit-allapproach.
There's not a one medication.
Like, I don't have a box backhere of like, oh, I have this
golden pill that she's nevertried before.
Like maybe we we bust that out.
Like you just you really justhave to listen to someone and
see how they got here.
So I always tell everybody,tell me how you got here.
When's the last time you feltgreat?
And what's happened since then?
And what has worked and whathasn't worked.
(28:25):
And if there was like a uh, youknow, if there was a test that
was positive that showed whyeverything was wrong, like you
wouldn't be here, right?
And so you can run all thetests.
We have so many amazing tests,okay?
The thing is that we haveblunt-edged tools for these for
very elegant pathophysiology.
And so when you have like,okay, you have this motility,
your bowels.
Well, there's like three thingswe can do for that.
(28:46):
Like we don't have a lot ofmedications for that.
So you just have to kind oflisten to somebody, get a sense
of what's going on.
Is it stress-induced?
Is it more pain?
Is it nausea?
Nausea, we scope nausea all thetime.
It drives me nuts.
Nausea comes from the brain,okay?
Like if you have postpranbialnausea, but around the clock
nausea is a brain process, okay?
And so why is that there?
Is it stress?
Is it mast cell?
Is it a medication?
(29:07):
Is it an infection?
You just have to kind of gothrough everything, deconstruct
everything, and then build itback up to where you can
convince like a narrative has tofit, right?
You don't take any symptom in avacuum, be like, oh, nausea.
Like, why is that there?
But like, how do they getthere?
Did it happen post-operatively?
Did it happen after a breakup?
Like, what's happening here?
And so you can't take a symptomand be like, how do you treat
this?
It's like, well, it's in thecontext of who that person is.
(29:29):
You don't treat nausea, youtreat Bill's nausea or Susan's
nausea.
And there's a story there thatyou have to entangle.
And then once you get there,you can push the right buttons.
Right, right.
Alanna (29:37):
That's my I love it.
Vince, on you when you hearsomething like this, what is
your automatic response to that?
What are you hearing this thatyou would look at maybe from a
different lens?
Dr. Vince Obias (29:48):
Well, I mean, as a surgical side, I would
probably say surgery may not bethe answer.
I mean, this is such a broadsituation that it's not going to
be like a magic pill.
Zach mentioned, well, I don'thave a Magic blade to say, let
me just cut out this section ofthe bowel.
Let me cut a couple stitcheshere.
You can certainly try to ruleout endometriosis, you know,
MRIs of the pelvis are beingdone now.
(30:10):
Uh, you can do MRNography totake a look at her GI tract,
which we definitely useinflammatory bowel disease, but
we can certainly use for her ifshe has GI symptoms and you're
looking to see if there's anykind of inflammation of the
bowel or small bowels abnormal.
One of the newer techniquesthat uh Vicky Vargas and Melissa
McHale have sort of pioneeredis you know transvaginal
ultrasound to look at pelvicnodules and look at you know
(30:32):
nodules in the rectum to see ifthere's anything there.
But you know, the symptoms thatare being described is it's
very broad and non-specific.
And um, and you have to bereally careful before say, let's
get the surgeon involved,because I mean, sad to say, you
know, we we're like a hammer.
Our answer is gonna besometimes surgery, which I don't
think in her case it makes alot of sense.
(30:53):
You gotta sort of think outsidethe box as individualize the
situation, make sure that youknow what's being done for her
is gonna be something that willbe definitive rather than
something frustrated.
It may come down to somethinglike a laparoscopy to look
internally to make sure we'renot missing something.
But boy, I you I think you havethere's a lot of things that we
can done beforehand before itgot gets to that step.
Alanna (31:15):
Yeah.
How much pain, how much of thisis neuropathic and how much is
it inflammatory?
Because I think that also couldbe, I mean, maybe they go,
maybe they coincide.
I don't know, but I thinkthere's probably some play in
there for both of those.
Dr. Vince Obias (31:30):
Certainly, you can definitely get studies to
look for inflammation that wouldbe anatomically and
physiologically an issue, likesay like an MRI nonography or
MRIs or scans and whatnot.
And and certainly in someone inher age, you would definitely
lean towards MRIs to so it's youknow, the accumulative effects
of radiation and CT scans is notgreat.
But and you can find those.
And certainly there are bloodtests that we can do to look at
(31:52):
uh inflammatory factors.
But if there's subtleinflammation, sometimes you have
to do endoscopy andcolonoscopy, take a look at the
mucosa directly to see.
It it's a frustrating scenario,and it may be more as meant, as
Akin mentioned, it may be morenot associated necessarily with
something physical.
It could be something elseassociated with her symptoms
that that you know, a multimodalteam or a therapist or whatnot
(32:15):
or figure out if is if it'sstress-induced or environmental
in some way.
Um because I think you're gonnahave to think out of the box
because she's had so muchmedical stuff thrown at her
already and surgical stuff thatdoesn't seem to be addressing
it.
Dr. Zac Spiritos (32:28):
There's no test that's gonna pick up what's
going on.
Alanna (32:30):
Yeah.
Dr. Zac Spiritos (32:31):
I was waiting for you to say that's gonna pick
this up and to tease outneuropathic versus inflammatory
pain.
Are we sure not that's not oneand the same?
Alanna (32:38):
Right.
Dr. Zac Spiritos (32:39):
Right?
Like I mean, the the immunesystem and the neurologic system
and the hormonal system areintimately linked, right?
So I don't think you can teaseone out and be like, oh, it's
neuropathic, put it on gabapan.
Like that's not gonna work.
Right.
Yeah.
I think you have to understandwhy, why this is like why isn't
the test picking up on it?
Like, why is this a lit like,you know, we have very elegant
tests.
Is it a brain gut communicationissue?
(33:00):
Is it a central process?
Or is it something climaticlike mast cell activation
syndrome where it's just thereare very pervasive symptoms, but
we just there's shortcomings inthe testing that we can use to
pick it up.
Alanna (33:09):
Yeah.
Well, and I think that not verymany people are gonna think
mast cell activation.
In fact, I've had doctors rolltheir eyes at me for people
don't think it exists, for sure.
Dr. Zac Spiritos (33:18):
Yeah, yeah.
I will say that I have hundredsof people in clinic that all
have mast cell activation thatwould disagree.
And we didn't learn anythingabout it.
Like I was at Duke not too longago.
I didn't hear a darn thingabout it until a couple years
ago.
And I had about 40 people in myclinic that I had no idea what
to do with.
They had all these bowelsymptoms, but they also had
migraines and endometriosis andallergies and flushing and
(33:38):
tachycardia.
And they were 24 and had sevensubspecialists, and they're
being treated for migraines,inappropriate sinus tachycardia,
endometriosis, IBS.
And you're like, there's gottabe something here, right, guys?
Like, what's the statisticallikelihood that they have
independently all of thesesymptoms?
It's not.
They have mast cell activation.
And you did a little digging,and it's like, and they actually
you put them on.
I remember my first patientthat they thought had Crohn's
(34:00):
disease.
They put her empirically on uhsky Rizzy for small bowel
Crohn's disease because theythought they saw a wisp of some
inflammation on a video capsulestudy.
And she had bloating andfatigue and migraines and heavy
painful periods, and we put heron pepsid and zertec and almost
all of her symptoms went away.
It doesn't always go like that.
It doesn't for the most part,but you put someone on some
histamine blockers and they feelphenomenal.
(34:22):
And I would say that nine outof ten of my patients don't
respond that way to that.
But I remember seeing that Iwas like, oh, there's a lot
about this world of medicinethat I don't get.
And I spent a ton of time inthe hospital and reading, and
there's just the more I I readand learn more, the more I I
don't understand.
I think there's just there's,you know, we reduce people's
symptoms down to MRIs and CTscans and x-rays and blood work.
(34:43):
Like, look, there's a worldbeyond us that we don't
understand to properlycategorize pain and inflammation
and brain gut communication andmast cell activation.
And we're, you know, I justit's it's really tough.
And these patients getminimized and gaslit a lot
because we didn't we didn'tlearn about any of this stuff.
Alanna (35:01):
Right.
Well, and there's also thatlink too with Mae Thurner
Nutcracker syndrome.
Like these all play a part inthat as well.
And that's a whole nother topicwith someone like Dr.
Brooke Spencer.
But it is there's similarsymptoms for a lot of these
people as well.
Dr. Zac Spiritos (35:15):
So that's what there's downloads is the
connectivity.
So you know, mast cellactivation primarily happens to
bendy people.
And they also, their collagendoesn't work, their connective
tissue doesn't work very well,everything sags, they get pelvic
venous congestion, and they getmedian arguably ligament
syndrome, which I thought never,ever, ever happened.
I see it once a week now.
Okay, I see SMA syndrome everytwo weeks.
(35:36):
I see nutcracker and pelvicvenous congestion on a weekly
basis.
That's because I only see, Ireally see a ton of people with
hypermobility.
And these this patientpopulation doesn't play by any
rules that we have.
You can write a whole differentmedical textbook on these
people.
And you just, when they go tothe traditional uh hospitals and
clinics, they just don't knowwhat to do with them because
they don't fit in any box.
(35:57):
So they say maybe it's anxiety,maybe it's stress, and it's
really frustrating.
And when I get on the phone andcall the inpatient hospital
team, like, hey, this is what'sgoing on, I get looked at like
I'm a nut.
And I was like, well, tell mewhat's going on then.
Like, do you have anotherexplanation of what's happening?
And so it's just, I do thinkthat mast cell is on the rise in
prevalence.
And I think COVID is unleashinga lot of this.
(36:18):
Like, we haven't had anythingnew in medicine since HIV,
right?
And mastell is just this newthing.
The thing is, mast cell isinvisible.
Like HIV and AIDS, you canfollow CD4 counts, like
something real was happening.
There is like this boom ofthese patients.
They're everywhere.
And if you just it's like theone in medical practice, Vince,
if you saw like, oh, that personis allergic to 35 medications,
they must be off the rocker.
(36:39):
It's like, no.
Their mast cells hate everymedication.
They're exquisitely sensitiveto all these medications.
And we see them all the time,we just don't know what to do
with them.
And I really think that COVIDreally increased the prevalence
of mast cell.
And it's, I think in 10 years,we're really gonna we're gonna
start to appreciate andunderstand this a lot more than
we do now.
Because we have a very kind ofvery faulty understanding of
what's going on.
Alanna (36:59):
Well, and if you want to know my theory on this too, and
you guys can sound off beforebefore we wrap up, but one of my
theories is because when youhave a hypermobile person and
that connective tissue is somuch looser, you I don't know
about you, but for me, mythought process is like if
that's looser, you're giving wayfor a lot more things to happen
within that tissue as itstands.
(37:20):
Like there's with theendometriosis specifically, with
you know, cells implanting,when you have a connective
tissue that's already loose,it's giving room for that to
implant more.
I don't know.
I'm not the scientist.
Dr. Zac Spiritos (37:31):
I have like seven different theories, right?
So mast cells live in yourcellular space.
So they're meant to look forthreats.
Like evolutionarily, that'swhat mast cells are meant to do.
So when things are overlybendy, are they like, wow, this
is a really messed upenvironment.
Like it's it shouldn't bendthis way, and they get
constitutively activated, or isit there's a leak, there's an
increased intestinalpermeability because the
collagen isn't that isn't thatthe t it just is not that the
(37:53):
tight junctions are loose,right?
So you get a lot more gutpermeability and leaky gut and
uh more kind of immuneactivation, and that's how
mastell happens.
There's this have you heard oftilt before?
Toxin-induced loss oftolerance.
Yeah.
So it's it's sort of dates backto like the industrial times
where we started a coal mine,and women that lived close to
coal mines used to develop allthese wacky symptoms.
And of course, like older whiteguys like me would say, Oh,
(38:17):
it's hysteria, right?
And they would and the thethought is like maybe they were
just living next to the coalmines and there's all these
toxins that were pissing offtheir mast cells, that the mast
cells are now recognizing thesethings that shouldn't really be
around and causing them to beoverly active.
And you know, is mast cell aproduct of our environment?
That all these, you know,people with mast cell tend to
smell chemicals and they getmigraines and headaches.
(38:38):
They just really sensitivesmells.
Like so they walk by like theHollister store at the mall and
they almost have a seizure.
And so, like, is it that thisenvironment that we've bred that
is very synthetic and full ofchemicals and pesticides?
People with mast cell feel somuch better in Europe when they
eat the food.
And I mean the regular theregulation around food here, the
pesticide use is crazy.
And so I've had patients moveto France because their mast
(39:01):
cell is too bad here, right?
And so there's something aboutthe environment in conjunction
with someone being bendy andhypermobile that makes this
happen.
I can't figure it out.
But you're onto something aswell.
Like this is it's all theory,but they coexist all like at the
same time.
Alanna (39:14):
Yeah, which I also think because of the laxicity, maybe
even in the bowel and like therectum and things like that,
that you see a lot more.
In fact, you'll see moreendometriosis, typically
peritoneum, but bowel, rectum,bladder, things like that, even
more than your ovaries, uterus,things like like the
reproductive organs are notnearly as involved as those
(39:38):
other structures that they'rethose other organs are.
And so I think that'sinteresting to think about as
well how much uh it plays a rolein endometriosis is yeah, it's
insight.
Dr. Vince Obias (39:49):
It's so digital there.
It's really fascinating.
Uh, as he's acting, we have notheard about mast cell
activation, obviously in medschool and residency, and
there's so much stuff comingout.
I mean, you touched upon avariety of things that are that
are associated with, you know,we just kind of throw up our
hands and say, oh, well, we'renot sure.
Let's do some more tests.
So, you know, any kind of likeresearch or view or different
(40:12):
thoughts on these is isimportant because we still don't
have an answer of like, well,inflammatory bowel disease.
What's the cause of Crohn's?
What's the oscillophyllitis?
We we know what we see and wecan treat it with
anti-inflammatories, but we'renot 100% like I know how colon
cancer starts, I know how rectalcancer starts, you know.
We think we know howendometriosis starts, but some
of these things like you hitupon, absolutely true.
(40:33):
There's something environmentalwe're running into.
Dr. Zac Spiritos (40:36):
The reverse isn't the endometriosis, and
like I am way outside my boundshere, but like isn't the
endometriosis theory like thereverse menstruation?
Alanna (40:43):
That's old and it has not been proven.
Dr. Zac Spiritos (40:46):
Okay.
And I don't I don't I don'tknow.
And is it a mass up?
I don't just for everybody.
Alanna (40:57):
Dr.
David Redwine did a wholepresentation, which you can find
on the YouTube channel that Ihave, and it was prior to his
passing, it was right before hispassing, actually, where he
goes through the um genomicaspect of endometriosis and how
he sees endometriosis and hasbeen proven to some extent,
evolving in the body.
It's very fascinating, and Iencourage everyone to go back
(41:20):
and listen to it because I thinkit'll spark a conversation.
Why ACOG, why all these otherassociations aren't looking at
what's being proven.
Like if it were retrogrademenstruation by now, I would
think that they would probablyhave cameras, enough cameras to
be able to prove it, but theycannot prove it.
There's no actual evidence ofit.
But they have seen it infetuses, which don't menstruate
(41:42):
yet.
They see it, they've seen it invery minute population of men.
Men don't menstruate.
So I think that we have to, Ithink that all of these kind of
go hand in hand.
And one Wendy Bingham out ofextrapelvic not rare touched on
the gestational yolk sack.
And again, I'm out of my scopeon this as well.
But essentially, they did thisstudy where they noticed that
(42:05):
when they broke off, like therole of the yolk sac in
gestation, when that broke off,what they were seeing is that a
lot of these cells for thesediseases were all together in
this.
I'm breaking, I, you know,whatever it is.
I'm not doing this justice.
I'm just saying that right now.
But essentially, like theyactually saw it in in very young
cellular phase of life.
(42:26):
So I think it's it's aninteresting thing to talk about.
It's an interesting thing toconsider, especially for those
that have, for some reason,multiple diagnoses, right?
Like it's not one.
I don't know an endometriosispatient with one diagnosis.
Or I just don't.
I have never met one person whocan have excision surgery and
(42:47):
be done.
There's usually other thingsthat they're dealing with.
So I think there's something toit.
Dr. Zac Spiritos (42:53):
Right.
There's so much to learn.
Alanna (42:54):
So much to where can people find you guys to learn
more?
I know you're doing a lot ofwork, Zach, who has you have
amazing content out on Instagramspecifically.
Where can people find you tolearn more about mast cell,
hypermobility, all the thingsthat we've talked about today?
Dr. Zac Spiritos (43:11):
Thank you.
That's that's very kind.
So my Instagram is Dr.
Zach Spiritos, and we I have aclinic called Ever Better
Medicine where we focus oncomplex GI conditions, POS, mast
cell activation.
We see a lot of hypermobilefolks as well.
Um we are hiring more peopleand we're expanding our staff
because um unfortunately wedon't have any um clinic
openings anytime soon.
So we're excited to kind ofexpand our breadth um and see
(43:35):
people who uh who hopefully orwho need some help.
Alanna (43:38):
Yeah, I love it.
Vince, where can we find you?
Dr. Vince Obias (43:41):
Just uh look up Vincent Obius in Washington, DC
area and endometriosis, and mywebsite will pop up.
Alanna (43:47):
Thank you both so much for doing this kind of odd
little black swan podcastinterview where we don't
normally get together.
I appreciate you taking thetime.
I know you're both incrediblybusy, but I just feel like this
is gonna help so many peoplemaybe understand these little
nuances of endometriosis, mastcell, stomach, all the things.
(44:08):
So thank you both so much forsitting down with me.
Dr. Vince Obias (44:11):
Yeah, thanks for having me.
I appreciate it.
Thank you very much.
Alanna (44:14):
Yeah, thank you.
Until next time, everyone,continue advocating for you and
for others.
What happens when endometriosis doesn't just
affect the pelvis, but the gut,the nerves, and the very way the
body communicates with itself?
Today's episode brings togethertwo specialties who don't often
sit at the same table, aneurogastroenterologist and a
colorectal surgeon to unravelwhy so many patients fall
through the cracks, from bowelendometriosis to mast cell
(00:23):
activation, from lingeringpost-op symptoms to the role of
multidisciplinary care.
This conversation gets realabout the complexity of endo and
why answers aren't alwaysstraightforward.
If you've ever wondered whysymptoms persist even after
surgery, or why your GI andpelvic pain seem inseparable,
(00:43):
you're gonna want to lean in forthis one.
Let's get started.
Welcome to Endo Battery, whereI share my journey with
endometriosis and chronicillness while learning and
growing along the way.
This podcast is not asubstitute for medical advice,
but a supportive space toprovide community and valuable
information so you never have toface this journey alone.
(01:05):
We embrace a range ofperspectives that may not always
align with our own, believingthat open dialogue helps us grow
and gain new tools.
Join me as I share stories ofstrength, resilience, and hope,
from personal experiences toexpert insights.
I'm your host, Alana, and thisis Indobattery, charging our
lives when Endometriosis drainsus.
(01:26):
Welcome back to Indobattery.
Grab your cup of coffee or yourcup of tea and join me at the
table.
Today I'm honored to welcometwo incredible physicians to the
table, both whom bring uniqueexpertise and deep commitment to
caring for patients withcomplex conditions.
First, we have Dr.
Zach Spiritos, aneurogastroenterologist and
(01:48):
internist whose journey took himfrom Philadelphia to North
Carolina, where he's now rootedwith his family.
Dr.
Spiritos trained at UNC Schoolof Medicine, completed his
residency at internal medicineat Emory University, and went on
to a fellowship ingastroenterology at Duke.
He specializes in a wide rangeof gastrointestinal and liver
(02:08):
disorders with particularinterest in irritable bowel
syndrome, functional abdominalpain, motility disorders, and
dysautonomia, includingconditions like POTS and mast
cell activation syndrome.
He also has expertise in GIcomplications connected to
hypermobility syndromes likeEler Stanlose.
What sets Dr.
Spiritos apart is his holisticapproach weaving together
(02:31):
nutrition, lifestyle, and gutbrain therapies to empower his
patients.
Also joining us today is Dr.
Vincent Obius, a professor ofsurgery and chief of the
Division of Colorectal Surgeryfor the National Capital Region.
Dr.
Obius trained at the MedicalCollege of Virginia, Eastern
Virginia Medical School, andCleveland Clinic with additional
(02:52):
advanced training andlaparoscopic colorectal surgery
at University Hospital's CaseMedical Center.
He is double board certified ingeneral and colorectal surgery,
and his specialties includerobotic minimally invasive
techniques as well as surgeryfor deep infiltrating
endometriosis.
Beginning October 2025, Dr.
(03:12):
OBS will be joining Dr.
Melissa McHale and Vicky Vargasas a partner at Washington
Endometriosis and ComplexSurgery Group.
His research and clinical workhave made a lasting impact,
particularly in robotic surgeryoutcomes and complex
endometriosis care.
Together, these two doctorsbring insights from both the
gastrointestinal and surgicalperspectives, making today's
(03:36):
conversation one that promisesto be both informative and
empowering for patients andproviders alike.
Please help me in welcoming Dr.
Zach Spiritos and Dr.
Vincent Obius to the table.
Thank you both so much forjoining me today, sitting down
at the table for thisconversation that's a little
nuanced in direction, as thatyou guys don't typically work
(03:56):
hand in hand together, but oftensymptoms go hand in hand
somehow.
Indopatients are workingthrough the
neurogastroenterology as well ascolorectal side, trying to
figure out the different pieces.
So thank you both so much forsitting down and doing this with
me.
Dr. Zac Spiritos (04:10):
Well, yeah.
Thanks for having us.
Thank you very much.
Alanna (04:13):
Can you give us each a background?
And we'll start with you,Vince, a little background on
what you do and kind of what youspecialize in so that we have a
good place to start.
Dr. Vince Obias (04:22):
Sure.
I'm a colorectal surgeon, boardcertified, about 20 years of
practice.
Um, I take care of deepinfiltrating endometriosis,
colon cancer, rectal cancer,reticulitis, inflammatory bowel
disease.
I've been doing umendometriosis surgery with my
minimally invasive gynecologycolleagues, both at GW and
Hopkins, and it's uh it's apassion of mine.
(04:43):
There's a lot of surgeons whotake care of cancer, me being
one of them, but there are veryfew that uh take care of
endometriosis, and I'm startingto specialize in it, and it's
incredible.
Some of the most challengingcases are of women with
endometriosis, and certainly,you know, it's a population that
uh can really um you knowbenefit from someone who has a
lot of experience in pelvicsurgery.
(05:04):
So I'm very, very excited aboutit.
Alanna (05:06):
Yeah.
Zach, you we've had you onbefore, but you're back again.
Dr. Zac Spiritos (05:09):
I'm a neurogastroenterologist.
So I trained a Duke, and then Iwas at UNC and then branched
out to do my own practice.
I uh work with folks that notonly have issues with the tube
itself of the GI tract, uh thenamely the esophagus to the
rectum, but also the wiringbetween the tube and the central
nervous system, specificallyhow the tube is perceived and
(05:30):
felt, and also how it moves andpropagates kind of food, debris
towards our rectum.
Uh, and yeah, and try to helppeople work through this space
as well.
Alanna (05:38):
Yeah.
And I think I didn't put thesepieces together very well prior
to us kind of talking aboutthis, but there were so many
questions last time that Zachand I did a podcast together
that I felt like I couldn'tanswer these questions and they
were pretty prevalent.
Like a lot of people were wereasking these questions.
And so just jumping into this,I really want to get a better
(06:00):
idea of how it all functions inyour own specialties, if you
will.
Can you describe the role ofbowel endometriosis care?
Like when you see Vince, whenyou see bowel endometriosis,
what is the approach to thatpre-surgical approach of mapping
that out?
Dr. Vince Obias (06:17):
So I always do this with gynecology.
Um I don't feel thatendometriosis is purely a
colorectal issue.
Um, the gynecologists and mycolleagues, like Dr.
Var Vicky Vargas and MelissaMcHale, this is what they
specialize in.
So I usually get them involved.
Even when some patients come inwith pelvic pain and a CT
showing a mass as endo, I stillget them involved, a
(06:39):
gynecologist involved.
Generally, women present withpelvic pain, rectal bleeding at
times, and that leads to thatcan be a very broad area when
dealing with these symptoms.
And so the workup is verybroad.
You know, uh sometimes the painand bleeding that they're
having is not endometriosis.
So when I see them, we talkabout you know the workup for
(07:01):
this, which can be a variety ofthings, including laonoscopies,
erectile exams, of course, acomplete history and physical.
But what I see them and they'reinvolved, they're generally
about 30 to 40 percent of womenwith endometriosis, it will
involve the rectum or the bowelof some type.
So it's it's important to haveuh you know bowel surgeons like
myself involved at the start.
Alanna (07:21):
Yeah.
How does it affect the gutmechanically, though?
Dr. Vince Obias (07:27):
So um obviously if it gets large enough, you
can have obstructive typesymptoms.
You can also, if it's deepinfiltrating and eating through
the wall of full thickness, youcould see bleeding and you'll
see bleeding per rectum duringyour menses.
It can also, you know, the therectum is sort of uh it's a
capacity.
Its job is to sort of stretchand maintain stools.
(07:49):
So when you go to the bathroom,you can you can make it.
And if you have endo there thatkind of restricts it from
inflammation, these patientstend to have a bit more urgency.
Well, like they'll go to thebathroom and they don't see
much.
So they'll have someinteresting symptoms like that.
Some of these patients will be,because of what I've discussed,
will have chronic constipation.
And that workup, you know,which can be pretty advanced and
(08:12):
and broad.
But but endo, endo is it'salmost one of those disease
processes that we're taught inschool that it's almost like a
you do a full workup, and if youdon't find anything, then it
could be endometriosis.
And it it's it's terrible thatwe have much better ways of
finding these nodules now thanwe had in the past.
But that that's only been inthe last 10 years that I've
(08:34):
seen.
But yeah.
Alanna (08:35):
Zach, on your side of it, how does the gut
neurologically work typicallywith endometriosis patients that
you see and the differencebetween that, what Vince is
saying, and what you see?
Dr. Zac Spiritos (08:47):
I think it varies.
Uh, you know, it's definitelypain predominant.
And so, you know, thesepatients are labeled with IBS,
whatever that means, where theyhave a lot of pain and
alterations in their bowelhabits with a diagnostic workup
that is fairly unrevealing.
So that's what's reallyimportant to talk to these
people.
And, you know, because if youstay in your siloed world of GI
(09:08):
and you say, oh, you know,what's your Bristol stool scale?
Like how many times do you goin?
Do you have urgency?
Like, you're also like, do youhave your period?
Is it heavy?
Is it painful?
Do you have pelvic discomfort?
Right.
And if you expand theconversation to a true review of
systems, which sometimesbecause of the limited time that
you have in clinic or you'rejust kind of so focused on the
GI world that you sometimes missthat.
But endometriosis, you know,can certainly cause, you know, I
(09:31):
typically just think pain,pain, pain, pain.
Can it certainly causediarrhea?
Sure.
Or alterations in bowel uhmovements, as Vincent said, you
know, if you have this huge kindof endometrioma, you can have
obstructive symptoms.
I don't, I personally haven'tseen that a ton, but he
obviously in the surgical sidesees that a lot more than I do.
Alterations in bowel habits,pain, but so many things can do
that, right?
So many things can do that.
(09:51):
And so I think it just behoovesyou to just kind of talk to the
person and just make surethere's if there's any kind of
gynecologic symptoms as wellthat would kind of lead you
towards endometriosis.
And my teaching is, you know,if you have painful periods,
it's endometriosis until provenotherwise.
Like it's your job to provethat it's not that.
Alanna (10:07):
Yeah.
I love that approach because Ithink that should be taught in
school across the board becauseit affects so many different
systems that until provenotherwise, especially if it's
cyclical, should be thought ofas endometriosis.
Now, I think what'sinteresting, Zach, you talked
about your mass, and this wasearlier, your mass cell
(10:27):
activation patients, all of themhave endometriosis.
Dr. Zac Spiritos (10:29):
All of them.
I mean, not all of them.
A lot of them do.
It's still just really highrate.
Yeah.
So I see a lot of patients whohave hypermobility and some have
POTS or dysautonomia, and theya lot of these times have mast
cell activation syndrome.
And so when we talk abouteverything that's going on, and
everybody, you know, when in atypical visit, and someone who
doesn't have mast cell, they goto their PCP and they're like,
(10:52):
is anything going on today?
And mast cell, it's like, whatare the five top things that
bother you today?
Right.
And because they have so muchgoing on.
They have endless amounts ofsymptoms, and that's why these
visits are required to bereally, really low.
And when you talk, when youstart kind of going down the
review of systems, like do youhave painful heavy periods, the
answer is often yes.
And so the you will often seeheavy periods, you know, mast
(11:12):
cells secrete a lot of differentchemical mediators.
Heparin is actually one ofthem.
You actually m see elevatedheparin levels in their blood.
And so they tend to haveheavier periods, and that's
fine.
You can live in you cancertainly ascribe a lot of
things to mast cell activationsyndrome, but the rate of which
we see endometriosis is so highthat I just have a low I have a
low threshold to to involvegynecology or, you know,
colorectal surgery to evaluatethese patients right off the
(11:35):
bat.
Alanna (11:36):
Yeah.
And part of the challenge theretoo for a lot of us is figuring
out okay, is it is itendometriosis or is it these
other things like mast cell or,you know, pots playing a part
into this?
One of the things that I thinka lot of people struggle with is
they have lingering symptomspost-operatively.
So they've had excision surgeryand they have lingering
(11:58):
symptoms, whether that'sconstipation, whether that's
food sensitivity, it might be,who knows?
Like there's just a lot ofbloating is another one of those
things.
Vince, when you're doingsurgery and the outcome of that,
and they're still having thisbloating, they're still having,
you know, all of those things,is it concern for you if there's
nerve involvement that iscausing this?
(12:19):
And this kind of plays hand inhand probably with what you do,
Zach, as far as like the nerveinvolvement as well.
Dr. Vince Obias (12:25):
Yeah.
So I will say that thosesymptoms are common after bowel
surgery.
So when you're when let's saywe someone has diverticulitis or
colon cancer or rectal cancer,whenever we cut the bowel and
put the two ends back together,bloating, discomfort,
constipation, diarrhea, thoseare common symptoms to have
after surgery for about two tothree months, up to six months.
(12:48):
Now, I will say after sixmonths after a collectomy, the
symptoms that you have are sortof your new pattern.
So I tell patients all thetime, I'm like, not sure you're
gonna have a bowel movement likeyou had in your 20s, but after
six months, you'll bepredictable.
And those conversations arereally important to have.
And since I'm a colorectalsurgeon to do bowel surgery, I
do have that for patients.
(13:08):
So their expectations are like,yeah, Doc, I'm bloated, or a
little bit of gas, or I haveurgency and nothing much is
coming out, or I have like fiveor six VMs a day, but they're
not upset because they knewabout it coming in.
Meanwhile, honestly, likegynecologists, they don't do a
lot of bowel surgery.
But if you're shaving or doinganything on the bowel or pelvic
surgery, you could still havethese same post-op symptoms.
(13:30):
So that kind of education isimportant to have up front so
that they understand that's partof the healing process.
Now, certainly, can endo comeback quickly?
Certainly.
I think you know that's one ofthe things we worry about.
But when we do excisional, theydon't usually come back that
quickly.
But you are dealing with thepost-surgical in terms of scar
tissue, in terms of inflammationfrom the surgery.
(13:52):
Like I said, that if you'redoing pelvic surgery and you're
mobilizing everything downthere, even if you don't cut the
rectum or bowel, the scartissue and inflammation will
change your bowel habitsafterwards.
And so when you go in withbloating and discomfort and you
leave with bloating, you'refeeling, oh, nothing was done.
But that's part of the process.
Give it time, three to sixmonths later.
(14:12):
That should be improved andcertainly more predictable.
In terms of nerves, so thenerves I deal with, especially
in cancer, which we don't reallyrun to when I we run into an
endometriosis, is sort of nearthe it's associated with like
sexual function, uh, and menerection, obviously, clip
clitoral erection, it can beassociated with, and bladder
(14:33):
function.
It but they're more posteriorto the rectum and maybe not
necessarily intrinsic to thebowel, but if that's normally
the nerves that we would dealwith, and that's more of a you
know, removing the rectum uh forcancer.
Alanna (14:46):
Yeah.
Zach, do you see aftersurgeries if people come to you,
they're still having issueswith GI, it could be related to
that mast cell activationpost-surgical that's ramped up
even more because of surgery,you think?
Dr. Zac Spiritos (14:59):
It depends.
Like Vince's end, like, youknow, you don't want to
pathologize everythingpostoperatively, right?
Like sometimes it's just ahealing process.
The question is like, does itmake sense, right?
Like, do they remove the TI,the terminal ileum, and acid mal
diarrhea?
Like that makes sense to me,right?
If you have a colectomy and youhave diarrhea, like, all right,
like you lost your rectum.
If there's rectal sparingsurgeries and whatnot, but does
the surgery and what happenedpair with what you're
(15:21):
experiencing, right?
You know, you can developcertainly like SIBO
postoperatively, right?
Is it adhesions?
Is it is it the narcotics totake post-operatively?
You know, is it um so there'sthings that exist certainly
outside of mast cell activationsyndrome.
So you take the person, thesurgical intervention, and what
their symptoms are, and you tryto combine all three.
I have had patients with mastcell whose symptoms were
attributed to endometriosis,they had endometriosis, surgery
(15:43):
was like was performed and theyfelt no better because it was
just mast cell, right?
But you have to do that.
You are required to look forthose things because
endometriosis can affect so manythings.
Fertility, right?
Like and so you want to do yourdue diligence when there's
something you can intervene andand fix.
Um and you can easily fall intoa trap where you blame
everything on mast cellactivation syndrome, which you
don't want to do.
You want to, you know,fortunately when people come to
(16:04):
me, they've had all the testing.
So I don't really have a lot ofrun left, but you still want to
keep a wide kind of lens, don'tbe myopic and keep everything
in perspective.
And so yeah, does it does thedoes do the symptoms fit what
happened?
And can you can you kind ofcreate a nice story with what's
happening if you can't, and youknow, there's like food
intolerances and brain fog aftersurgery, like that's not
(16:27):
related to the surgery, right?
That's something different.
And so you just have tounderstand the surgery,
understand what the symptomsare, and how to kind of connect
the dots.
Alanna (16:35):
Yeah.
And I can tell you, having agood surgery with a qualified
expert in this will make adifference in the outcomes.
I mean, if you're having ageneral G Y N, and I'm not
bashing on them, but if you havea general GYN doing your
surgery, chances are there'sdisease left behind.
And that because they're nottrained to excise the disease.
(16:57):
They're trained oftentimes todo ablation, which can cause
more scarring and stuff likethat.
Vince, have you experiencedthat you've done you've done
resections and you've been insurgeries where they've had
multiple surgeries, theycontinue having these symptoms.
Is it typically disease statethat you're seeing again, or is
it, you know, something that yousomething else completely?
Dr. Vince Obias (17:21):
Yeah, I I will say that um every time I'm in a
case, um, especially now workingwith Dr Vargas and Dr.
Mikhail, you know, theirsuccess rates in finding nodules
and of involvement of the bowelis like 100%.
So whenever and and like it wehad mentioned and discussed
earlier, sadly, most of thesurgeries I've involved, there's
been previous surgery, which isit's just sad to see.
(17:43):
So honestly, um, thegynecologist did the right
thing.
Rather than tackle this complexnodule on the rectum and have a
complication that's justterrible, don't do anything,
document it, get it to anexpert.
But yeah, I mean, when they'rehaving post-surgical and there's
usually because ofendometriosis that's been left
behind, sometimes inadvertentlyand regrown, or and sometimes
(18:04):
they knew it and are like, look,I'm not gonna not gonna risk
it.
And it's the smart thing to do,understanding that you know
they're a little bit out oftheir element.
The patient is not aware a bigsurgery can happen.
Um, and it's better to just,you know, get out, let them
recover quickly.
But it's very frustrating,honestly, for the patients who
are like, they came in, they'rehoping to have one procedure,
(18:25):
they're hoping to have thisdone, taken care of, and they've
been told not only that, youknow, we're we're we're doing
this, but there's gonna be, youknow, we couldn't do it all, but
there's also a worse situation,and you may need even more
advanced extensive stuff.
So um, so yes, I absolutelyhave seen that.
And the majority of the timeit's because of this end of
endometriosis getting there.
Alanna (18:45):
Okay.
Yeah.
I would I think that's probablypretty common with people that
I hear, in including my ownstory of that, of disease being
left.
But it, you know, that goes tosay that that's why this
education is so important,right?
We have to keep educating aboutthis.
Zach, is there a ideal pre andpost-operative routine or things
(19:07):
that we can do to help supportus pre and post-operatively when
it comes to GI-related things?
Dr. Zac Spiritos (19:14):
It's a really good question.
I would probably, you know, Idon't know if I'm the right
person to answer that questionnecessarily.
You know, I think you just wantto do your due diligence and
make sure that no otherpathologies at play.
But I don't know if there'sanything from a GI perspective
specifically that you would dialup to ensure better outcomes.
Like I think I'd probablyreserve, I'd leave that to the
(19:34):
surgeons and the gynecologist tomake sure the patient's like
the right candidate and a goodsurgical candidate, and that's
it's probably not my job todecide.
You know, certainly things wecan do to optimize people from a
mast cell perspective.
Alanna (19:46):
That's what, yeah, that from the mast cell part of it,
because I know a lot of people,including myself coming out of
it, things flare really bad.
How do we help alleviate alittle bit of that pre and
post-operatively?
Dr. Zac Spiritos (19:59):
Yes.
We want to make sure their mastcell is under as best control
as possible pre-operatively.
There's always, I tend to reachout to the surgeon to discuss
the case and just say, hey, thisis kind of this is how I would
think about this specificpatient, you know, whether
they're hypermobile and theyneed a neck brace during the
surgery because they have a lotof craniocervical instability.
(20:21):
Do they have HOTs and just needvery like do they really need
to be fluid resuscitated beforethe case and really just make
sure that they're adequatelyhydrated?
If they have mast cellactivation syndrome, there's
certain anesthetics that tend toflare mast cells and
postoperative narcotics likemorphine that tend to be more
aggravating for mast cells.
And there's also a dialoguelike what happens if they have a
(20:42):
huge flare and go onanaphylactic shock?
Like, we should probably havelike steroids and you know, H1
and H2 blockers ready to go incase that happens.
And so I have a protocol that,you know, I've I've written with
other, I haven't written, butI've adopted from other um mast
cell clinicians.
And I often will reach out tothe surgical team and say, this
is kind of what I would do uhand how I would approach this
(21:04):
patient kind of perioperativelyand intraoperatively just to get
the best outcomes.
Yeah.
Yeah.
Dr. Vince Obias (21:09):
Honestly, like the way Zach pointed out, it
it's important to emphasize thatwhen you're dealing with
something like endometriosisthat can affect so many
different areas colon, rectum,diaphragm, bowel, bladder, it's
multidisciplinary.
Just like when I deal withrectal cancer, we talk, we have
radio radi radiologists,oncologists, radiation
(21:30):
oncologists.
We we have a variety of peopleon the team to discuss it.
And so it endometriosis,especially complex stuff, is is
starting to lean that way whereyou have multidisciplinary teams
talking about it so that wedon't miss things.
Alanna (21:46):
Yeah, for sure.
And I think too, it's importantthat we recognize that it takes
multiple people outside of justone specialty, meaning just
endometriosis.
It's like pelvic floor,acupuncture.
There's different ways that wecan support our bodies walking
through this.
And if we all talk together andhave that true team, outcomes
(22:06):
are so much better.
And it and that's proven.
Like that is a proven thingwhere if you have a good team,
solid team going into surgery,more prepared, outcomes tend to
be a little bit better for you.
So that was one of the things Ilearned the hard way as well.
Dr. Zac Spiritos (22:20):
Exactly.
Yeah.
Um how relaxed mostoperatively.
Alanna (22:24):
You what?
You relax?
Dr. Zac Spiritos (22:26):
Most operatively.
Gotta keep the bowels, gottakeep the bowels moving.
Alanna (22:30):
Yep.
Relax, yeah.
I love that stuff too.
Chewing gum?
Dr. Vince Obias (22:33):
Yeah, so so chewing gum is used for uh
return of bowel function rightafter surgery.
Yeah.
So you can chew gum, and so youend up swallowing a bunch of
air.
So there's been studies onthat.
But uh does it yeah, yeah.
But that's right after surgery.
I mean, I don't recommendchewing gum for the next six
months, but uh, if you want to,that's fine.
I'll make it bloated all right.
Dr. Zac Spiritos (22:50):
Do you have you randomized people to
different like bubble yum versuslike big chew?
Dr. Vince Obias (22:54):
Well, when I was a resident, I actually um I
put I gave everybody a pedometerand I had them walk around over
at Case Western, and I was ableto demonstrate the more steps
you did, the faster you hadphallatus and were at home.
So, you know, I I have lookedat some of that stuff, and steps
is one of them for sure.
That's very clear.
Alanna (23:12):
For sure.
Zach, is there a way to retainum bowel and brain communication
after a major bowel surgery?
I think this is something thatmany of us struggle with, is
that we get in patterns and thatit becomes this challenge of
like, this is what my body'salways done.
And now I'm still in thisbattle of is it really going on
(23:34):
still, or is this just the waymy body is trained?
That it's I hate the wordpsychosomatic, but a lot of
times that's what they refer toit.
As is there ways that we canretrain our brains and our
bowels to work better after.
Dr. Zac Spiritos (23:49):
It's a really good question.
You know, I think it's, youknow, you have to take
everything, it's such a bailoutanswer, but you gotta take
everything on a case-by-casebasis.
So if someone has been like,what are they experiencing
post-operatively?
Is it the same diarrhea they'vealways been that's kept them
locked up in the house?
And is that stress about havingdiarrhea making the diarrhea
(24:10):
worse to where you'reanticipating, like, oh my gosh,
like if I go out, I just knowI'm gonna have diarrhea as soon
as af after the appetizers?
And like that, you like speak,you think it into existence,
right?
And so you kind of have tountangle, like, okay, so like
what has your history been?
What are you currently worriedabout?
What is actually happening?
And what are kind of how can weintervene and help things out?
(24:30):
Like, are you are you raginglyconstipated?
Like, why are you constipated?
Is it a pelvic floor issue,right?
Is it because there's notenough fiber?
Is it because you're in fightor flight mode and you're really
stressed?
Is it because you have adisaanoma and you have pots and
it's because your colon doesn'tmove in?
And then it's like, okay, well,let's do what we can from a
dietary perspective and apharmacotherapy perspective to
maybe help alleviate the bowelsto some degree.
(24:53):
But there's always a chancethat the brain will override
everything we do and be like,mm-mm, like we're gonna back
things up or we're gonna getthings going, right?
And so how do we address thatas well?
So if we unentangle things andwe say, okay, well, there's a
really disruptive thoughtpattern that is making your
bowels really bad, right?
So that anticipatory anxiety,or man, if I don't poop like at
by 8 a.m.
this morning, the rest of myday is ruined.
(25:13):
Because I'm gonna get bloated,it's gonna be uncomfortable, and
everybody's gonna notice andit's gonna be terrible.
And that just makes thesymptoms that much worse.
And if we realize that thoughtpattern is happening, which in
turn will make the bowels worse,then maybe we talk about like,
what is maybe talking to atherapist, like a GI therapist,
like is a hypnosis somethingthat we can utilize?
Is cognitive behavioral therapysomething that we can use?
So it really is like take it ona case-by-case basis, but what
(25:35):
buttons can you press?
Medications, diet, exercise,sleep is a humongous one.
Lack of sleep definitelypredicts next day GI pain.
And so it's just you gotta justkind of look at everything and
see how they play off each otherand just listen to the patient,
right?
Just listen to them and seelike where can we where can we
meet in the middle here and findsolutions to what may be going
(25:55):
on.
Alanna (25:56):
Yeah.
I'm gonna do something that isa little probably a little
unorthodox.
And I'm I got so many messages,like I said before, which is
why we're coming together forthis.
So I want to read you guyssomething and I want to get both
of your perspectives on thisbecause I think this will help
clarify maybe some of thequestions that I got previously
and put it in in a way that ismaybe helpful.
(26:17):
And and this is not casespecific, it is not a medical
advice.
This is just insight into this.
So, sample message (26:24):
I'm a mom of a 21-year-old daughter who
has non-cyclical GI symptomssince she was 13.
Two years ago, she wasdiagnosed with endometriosis
after excision surgery withremoval.
She didn't have improvementafter surgery, and two years
later, she still struggles withongoing nausea and frequent
diarrhea each day.
(26:45):
She takes SSRI and was on oralcontraceptives, but isn't any
longer.
She has been treated for SIBO,received pelvic floor PT and
functional medicine protocol,tried low FODMAP and elimination
diets.
She had two unremarkablecolonoscopies and endoscopy.
Zach, you can fill that in.
(27:05):
Endoscopies.
And yet the GI symptoms arestill there.
She has also had a motilitystudy that was also within
normal limits.
Any ideas that you would havefor helping with symptoms or
overall treatment?
Dr. Zac Spiritos (27:20):
Just kidding.
GI doctoral psychic things.
Have you tried?
Um, I don't know.
That's really complex.
You know, so when I see apatient, right, I have 200 pages
of the records.
They've been everywhere.
They've had all the testing.
And I say, I don't care whattheir tests say.
Like, sure.
There are some tests that arehelpful.
I want to hear your story andhow you got here.
What makes it better?
What makes it worse?
(27:41):
What medications worse?
What make it what medicationshave helped so you can
understand like the mechanism ofaction of that?
Um and so, yeah, I mean,there's so many different like
what's does she have brain fog,fatigue, migraines, flushing,
allergies that would make youthink this is mast salt?
Does she have some form ofdysautonomia?
Does she have visceralhypersensitivity?
This is all this all happenafter like a huge GI bug.
(28:03):
So I think you just have tolisten to the person.
There's not a one size-fit-allapproach.
There's not a one medication.
Like, I don't have a box backhere of like, oh, I have this
golden pill that she's nevertried before.
Like maybe we we bust that out.
Like you just you really justhave to listen to someone and
see how they got here.
So I always tell everybody,tell me how you got here.
When's the last time you feltgreat?
And what's happened since then?
And what has worked and whathasn't worked.
(28:25):
And if there was like a uh, youknow, if there was a test that
was positive that showed whyeverything was wrong, like you
wouldn't be here, right?
And so you can run all thetests.
We have so many amazing tests,okay?
The thing is that we haveblunt-edged tools for these for
very elegant pathophysiology.
And so when you have like,okay, you have this motility,
your bowels.
Well, there's like three thingswe can do for that.
(28:46):
Like we don't have a lot ofmedications for that.
So you just have to kind oflisten to somebody, get a sense
of what's going on.
Is it stress-induced?
Is it more pain?
Is it nausea?
Nausea, we scope nausea all thetime.
It drives me nuts.
Nausea comes from the brain,okay?
Like if you have postpranbialnausea, but around the clock
nausea is a brain process, okay?
And so why is that there?
Is it stress?
Is it mast cell?
Is it a medication?
(29:07):
Is it an infection?
You just have to kind of gothrough everything, deconstruct
everything, and then build itback up to where you can
convince like a narrative has tofit, right?
You don't take any symptom in avacuum, be like, oh, nausea.
Like, why is that there?
But like, how do they getthere?
Did it happen post-operatively?
Did it happen after a breakup?
Like, what's happening here?
And so you can't take a symptomand be like, how do you treat
this?
It's like, well, it's in thecontext of who that person is.
(29:29):
You don't treat nausea, youtreat Bill's nausea or Susan's
nausea.
And there's a story there thatyou have to entangle.
And then once you get there,you can push the right buttons.
Right, right.
Alanna (29:37):
That's my I love it.
Vince, on you when you hearsomething like this, what is
your automatic response to that?
What are you hearing this thatyou would look at maybe from a
different lens?
Dr. Vince Obias (29:48):
Well, I mean, as a surgical side, I would
probably say surgery may not bethe answer.
I mean, this is such a broadsituation that it's not going to
be like a magic pill.
Zach mentioned, well, I don'thave a Magic blade to say, let
me just cut out this section ofthe bowel.
Let me cut a couple stitcheshere.
You can certainly try to ruleout endometriosis, you know,
MRIs of the pelvis are beingdone now.
(30:10):
Uh, you can do MRNography totake a look at her GI tract,
which we definitely useinflammatory bowel disease, but
we can certainly use for her ifshe has GI symptoms and you're
looking to see if there's anykind of inflammation of the
bowel or small bowels abnormal.
One of the newer techniquesthat uh Vicky Vargas and Melissa
McHale have sort of pioneeredis you know transvaginal
ultrasound to look at pelvicnodules and look at you know
(30:32):
nodules in the rectum to see ifthere's anything there.
But you know, the symptoms thatare being described is it's
very broad and non-specific.
And um, and you have to bereally careful before say, let's
get the surgeon involved,because I mean, sad to say, you
know, we we're like a hammer.
Our answer is gonna besometimes surgery, which I don't
think in her case it makes alot of sense.
(30:53):
You gotta sort of think outsidethe box as individualize the
situation, make sure that youknow what's being done for her
is gonna be something that willbe definitive rather than
something frustrated.
It may come down to somethinglike a laparoscopy to look
internally to make sure we'renot missing something.
But boy, I you I think you havethere's a lot of things that we
can done beforehand before itgot gets to that step.
Alanna (31:15):
Yeah.
How much pain, how much of thisis neuropathic and how much is
it inflammatory?
Because I think that also couldbe, I mean, maybe they go,
maybe they coincide.
I don't know, but I thinkthere's probably some play in
there for both of those.
Dr. Vince Obias (31:30):
Certainly, you can definitely get studies to
look for inflammation that wouldbe anatomically and
physiologically an issue, likesay like an MRI nonography or
MRIs or scans and whatnot.
And and certainly in someone inher age, you would definitely
lean towards MRIs to so it's youknow, the accumulative effects
of radiation and CT scans is notgreat.
But and you can find those.
And certainly there are bloodtests that we can do to look at
(31:52):
uh inflammatory factors.
But if there's subtleinflammation, sometimes you have
to do endoscopy andcolonoscopy, take a look at the
mucosa directly to see.
It it's a frustrating scenario,and it may be more as meant, as
Akin mentioned, it may be morenot associated necessarily with
something physical.
It could be something elseassociated with her symptoms
that that you know, a multimodalteam or a therapist or whatnot
(32:15):
or figure out if is if it'sstress-induced or environmental
in some way.
Um because I think you're gonnahave to think out of the box
because she's had so muchmedical stuff thrown at her
already and surgical stuff thatdoesn't seem to be addressing
it.
Dr. Zac Spiritos (32:28):
There's no test that's gonna pick up what's
going on.
Alanna (32:30):
Yeah.
Dr. Zac Spiritos (32:31):
I was waiting for you to say that's gonna pick
this up and to tease outneuropathic versus inflammatory
pain.
Are we sure not that's not oneand the same?
Alanna (32:38):
Right.
Dr. Zac Spiritos (32:39):
Right?
Like I mean, the the immunesystem and the neurologic system
and the hormonal system areintimately linked, right?
So I don't think you can teaseone out and be like, oh, it's
neuropathic, put it on gabapan.
Like that's not gonna work.
Right.
Yeah.
I think you have to understandwhy, why this is like why isn't
the test picking up on it?
Like, why is this a lit like,you know, we have very elegant
tests.
Is it a brain gut communicationissue?
(33:00):
Is it a central process?
Or is it something climaticlike mast cell activation
syndrome where it's just thereare very pervasive symptoms, but
we just there's shortcomings inthe testing that we can use to
pick it up.
Alanna (33:09):
Yeah.
Well, and I think that not verymany people are gonna think
mast cell activation.
In fact, I've had doctors rolltheir eyes at me for people
don't think it exists, for sure.
Dr. Zac Spiritos (33:18):
Yeah, yeah.
I will say that I have hundredsof people in clinic that all
have mast cell activation thatwould disagree.
And we didn't learn anythingabout it.
Like I was at Duke not too longago.
I didn't hear a darn thingabout it until a couple years
ago.
And I had about 40 people in myclinic that I had no idea what
to do with.
They had all these bowelsymptoms, but they also had
migraines and endometriosis andallergies and flushing and
(33:38):
tachycardia.
And they were 24 and had sevensubspecialists, and they're
being treated for migraines,inappropriate sinus tachycardia,
endometriosis, IBS.
And you're like, there's gottabe something here, right, guys?
Like, what's the statisticallikelihood that they have
independently all of thesesymptoms?
It's not.
They have mast cell activation.
And you did a little digging,and it's like, and they actually
you put them on.
I remember my first patientthat they thought had Crohn's
(34:00):
disease.
They put her empirically on uhsky Rizzy for small bowel
Crohn's disease because theythought they saw a wisp of some
inflammation on a video capsulestudy.
And she had bloating andfatigue and migraines and heavy
painful periods, and we put heron pepsid and zertec and almost
all of her symptoms went away.
It doesn't always go like that.
It doesn't for the most part,but you put someone on some
histamine blockers and they feelphenomenal.
(34:22):
And I would say that nine outof ten of my patients don't
respond that way to that.
But I remember seeing that Iwas like, oh, there's a lot
about this world of medicinethat I don't get.
And I spent a ton of time inthe hospital and reading, and
there's just the more I I readand learn more, the more I I
don't understand.
I think there's just there's,you know, we reduce people's
symptoms down to MRIs and CTscans and x-rays and blood work.
(34:43):
Like, look, there's a worldbeyond us that we don't
understand to properlycategorize pain and inflammation
and brain gut communication andmast cell activation.
And we're, you know, I justit's it's really tough.
And these patients getminimized and gaslit a lot
because we didn't we didn'tlearn about any of this stuff.
Alanna (35:01):
Right.
Well, and there's also thatlink too with Mae Thurner
Nutcracker syndrome.
Like these all play a part inthat as well.
And that's a whole nother topicwith someone like Dr.
Brooke Spencer.
But it is there's similarsymptoms for a lot of these
people as well.
Dr. Zac Spiritos (35:15):
So that's what there's downloads is the
connectivity.
So you know, mast cellactivation primarily happens to
bendy people.
And they also, their collagendoesn't work, their connective
tissue doesn't work very well,everything sags, they get pelvic
venous congestion, and they getmedian arguably ligament
syndrome, which I thought never,ever, ever happened.
I see it once a week now.
Okay, I see SMA syndrome everytwo weeks.
(35:36):
I see nutcracker and pelvicvenous congestion on a weekly
basis.
That's because I only see, Ireally see a ton of people with
hypermobility.
And these this patientpopulation doesn't play by any
rules that we have.
You can write a whole differentmedical textbook on these
people.
And you just, when they go tothe traditional uh hospitals and
clinics, they just don't knowwhat to do with them because
they don't fit in any box.
(35:57):
So they say maybe it's anxiety,maybe it's stress, and it's
really frustrating.
And when I get on the phone andcall the inpatient hospital
team, like, hey, this is what'sgoing on, I get looked at like
I'm a nut.
And I was like, well, tell mewhat's going on then.
Like, do you have anotherexplanation of what's happening?
And so it's just, I do thinkthat mast cell is on the rise in
prevalence.
And I think COVID is unleashinga lot of this.
(36:18):
Like, we haven't had anythingnew in medicine since HIV,
right?
And mastell is just this newthing.
The thing is, mast cell isinvisible.
Like HIV and AIDS, you canfollow CD4 counts, like
something real was happening.
There is like this boom ofthese patients.
They're everywhere.
And if you just it's like theone in medical practice, Vince,
if you saw like, oh, that personis allergic to 35 medications,
they must be off the rocker.
(36:39):
It's like, no.
Their mast cells hate everymedication.
They're exquisitely sensitiveto all these medications.
And we see them all the time,we just don't know what to do
with them.
And I really think that COVIDreally increased the prevalence
of mast cell.
And it's, I think in 10 years,we're really gonna we're gonna
start to appreciate andunderstand this a lot more than
we do now.
Because we have a very kind ofvery faulty understanding of
what's going on.
Alanna (36:59):
Well, and if you want to know my theory on this too, and
you guys can sound off beforebefore we wrap up, but one of my
theories is because when youhave a hypermobile person and
that connective tissue is somuch looser, you I don't know
about you, but for me, mythought process is like if
that's looser, you're giving wayfor a lot more things to happen
within that tissue as itstands.
(37:20):
Like there's with theendometriosis specifically, with
you know, cells implanting,when you have a connective
tissue that's already loose,it's giving room for that to
implant more.
I don't know.
I'm not the scientist.
Dr. Zac Spiritos (37:31):
I have like seven different theories, right?
So mast cells live in yourcellular space.
So they're meant to look forthreats.
Like evolutionarily, that'swhat mast cells are meant to do.
So when things are overlybendy, are they like, wow, this
is a really messed upenvironment.
Like it's it shouldn't bendthis way, and they get
constitutively activated, or isit there's a leak, there's an
increased intestinalpermeability because the
collagen isn't that isn't thatthe t it just is not that the
(37:53):
tight junctions are loose,right?
So you get a lot more gutpermeability and leaky gut and
uh more kind of immuneactivation, and that's how
mastell happens.
There's this have you heard oftilt before?
Toxin-induced loss oftolerance.
Yeah.
So it's it's sort of dates backto like the industrial times
where we started a coal mine,and women that lived close to
coal mines used to develop allthese wacky symptoms.
And of course, like older whiteguys like me would say, Oh,
(38:17):
it's hysteria, right?
And they would and the thethought is like maybe they were
just living next to the coalmines and there's all these
toxins that were pissing offtheir mast cells, that the mast
cells are now recognizing thesethings that shouldn't really be
around and causing them to beoverly active.
And you know, is mast cell aproduct of our environment?
That all these, you know,people with mast cell tend to
smell chemicals and they getmigraines and headaches.
(38:38):
They just really sensitivesmells.
Like so they walk by like theHollister store at the mall and
they almost have a seizure.
And so, like, is it that thisenvironment that we've bred that
is very synthetic and full ofchemicals and pesticides?
People with mast cell feel somuch better in Europe when they
eat the food.
And I mean the regular theregulation around food here, the
pesticide use is crazy.
And so I've had patients moveto France because their mast
(39:01):
cell is too bad here, right?
And so there's something aboutthe environment in conjunction
with someone being bendy andhypermobile that makes this
happen.
I can't figure it out.
But you're onto something aswell.
Like this is it's all theory,but they coexist all like at the
same time.
Alanna (39:14):
Yeah, which I also think because of the laxicity, maybe
even in the bowel and like therectum and things like that,
that you see a lot more.
In fact, you'll see moreendometriosis, typically
peritoneum, but bowel, rectum,bladder, things like that, even
more than your ovaries, uterus,things like like the
reproductive organs are notnearly as involved as those
(39:38):
other structures that they'rethose other organs are.
And so I think that'sinteresting to think about as
well how much uh it plays a rolein endometriosis is yeah, it's
insight.
Dr. Vince Obias (39:49):
It's so digital there.
It's really fascinating.
Uh, as he's acting, we have notheard about mast cell
activation, obviously in medschool and residency, and
there's so much stuff comingout.
I mean, you touched upon avariety of things that are that
are associated with, you know,we just kind of throw up our
hands and say, oh, well, we'renot sure.
Let's do some more tests.
So, you know, any kind of likeresearch or view or different
(40:12):
thoughts on these is isimportant because we still don't
have an answer of like, well,inflammatory bowel disease.
What's the cause of Crohn's?
What's the oscillophyllitis?
We we know what we see and wecan treat it with
anti-inflammatories, but we'renot 100% like I know how colon
cancer starts, I know how rectalcancer starts, you know.
We think we know howendometriosis starts, but some
of these things like you hitupon, absolutely true.
(40:33):
There's something environmentalwe're running into.
Dr. Zac Spiritos (40:36):
The reverse isn't the endometriosis, and
like I am way outside my boundshere, but like isn't the
endometriosis theory like thereverse menstruation?
Alanna (40:43):
That's old and it has not been proven.
Dr. Zac Spiritos (40:46):
Okay.
And I don't I don't I don'tknow.
And is it a mass up?
I don't just for everybody.
Alanna (40:57):
Dr.
David Redwine did a wholepresentation, which you can find
on the YouTube channel that Ihave, and it was prior to his
passing, it was right before hispassing, actually, where he
goes through the um genomicaspect of endometriosis and how
he sees endometriosis and hasbeen proven to some extent,
evolving in the body.
It's very fascinating, and Iencourage everyone to go back
(41:20):
and listen to it because I thinkit'll spark a conversation.
Why ACOG, why all these otherassociations aren't looking at
what's being proven.
Like if it were retrogrademenstruation by now, I would
think that they would probablyhave cameras, enough cameras to
be able to prove it, but theycannot prove it.
There's no actual evidence ofit.
But they have seen it infetuses, which don't menstruate
(41:42):
yet.
They see it, they've seen it invery minute population of men.
Men don't menstruate.
So I think that we have to, Ithink that all of these kind of
go hand in hand.
And one Wendy Bingham out ofextrapelvic not rare touched on
the gestational yolk sack.
And again, I'm out of my scopeon this as well.
But essentially, they did thisstudy where they noticed that
(42:05):
when they broke off, like therole of the yolk sac in
gestation, when that broke off,what they were seeing is that a
lot of these cells for thesediseases were all together in
this.
I'm breaking, I, you know,whatever it is.
I'm not doing this justice.
I'm just saying that right now.
But essentially, like theyactually saw it in in very young
cellular phase of life.
(42:26):
So I think it's it's aninteresting thing to talk about.
It's an interesting thing toconsider, especially for those
that have, for some reason,multiple diagnoses, right?
Like it's not one.
I don't know an endometriosispatient with one diagnosis.
Or I just don't.
I have never met one person whocan have excision surgery and
(42:47):
be done.
There's usually other thingsthat they're dealing with.
So I think there's something toit.
Dr. Zac Spiritos (42:53):
Right.
There's so much to learn.
Alanna (42:54):
So much to where can people find you guys to learn
more?
I know you're doing a lot ofwork, Zach, who has you have
amazing content out on Instagramspecifically.
Where can people find you tolearn more about mast cell,
hypermobility, all the thingsthat we've talked about today?
Dr. Zac Spiritos (43:11):
Thank you.
That's that's very kind.
So my Instagram is Dr.
Zach Spiritos, and we I have aclinic called Ever Better
Medicine where we focus oncomplex GI conditions, POS, mast
cell activation.
We see a lot of hypermobilefolks as well.
Um we are hiring more peopleand we're expanding our staff
because um unfortunately wedon't have any um clinic
openings anytime soon.
So we're excited to kind ofexpand our breadth um and see
(43:35):
people who uh who hopefully orwho need some help.
Alanna (43:38):
Yeah, I love it.
Vince, where can we find you?
Dr. Vince Obias (43:41):
Just uh look up Vincent Obius in Washington, DC
area and endometriosis, and mywebsite will pop up.
Alanna (43:47):
Thank you both so much for doing this kind of odd
little black swan podcastinterview where we don't
normally get together.
I appreciate you taking thetime.
I know you're both incrediblybusy, but I just feel like this
is gonna help so many peoplemaybe understand these little
nuances of endometriosis, mastcell, stomach, all the things.
(44:08):
So thank you both so much forsitting down with me.
Dr. Vince Obias (44:11):
Yeah, thanks for having me.
I appreciate it.
Thank you very much.
Alanna (44:14):
Yeah, thank you.
Until next time, everyone,continue advocating for you and
for others.
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