Why Do Some GI Problems Hide from Every Test? with Dr. Zachary Spiritos (Ep 153)

Dr. Zachary Spiritos explains why common GI tests (endoscopy, CT, routine labs, many stool panels) can look “normal” despite significant symptoms—especially in patients with POTS/dysautonomia, EDS, and MCAS. He highlights mechanisms that often evade standard testing: disordered motility (delayed/rapid gastric emptying, slow transit, dyssynergic defecation), visceral hypersensitivity, autonomic dysfunction affecting gut perfusion and motility, connective‑tissue laxity altering gut mechanics, and intermittent mast‑cell mediator release that may be missed outside of flares. He reviews the limits and best uses of specialized tests (gastric emptying studies, wireless motility capsule, breath tests for SIBO with attention to false positives/negatives, anorectal manometry, pelvic floor evaluation) and the value of a symptom‑pattern history over “test chasing.” Management focuses on layered, low‑risk strategies: nutrition adjustments (small frequent meals, low‑fat/low‑fiber during flares, selective fiber types, cautious low‑FODMAP trials), hydration/salt and posture strategies for POTS‑related GI symptoms, bowel regimen individualization (osmotic laxatives, magnesium, stimulant rescue), prokinetics or antispasmodics when appropriate, MCAS‑directed trials (H1/H2 blockers, cromolyn) for suspected mediator‑related flares, neuromodulators for hypersensitivity, pelvic floor physical therapy, and brain‑gut therapies. He emphasizes avoiding unnecessary repeat testing, screening for comorbidities (iron/B12 deficiency, celiac, thyroid), and referring to motility centers when red flags or refractory dysmotility are present.