Low Intestinal blood flow - standing/laying

Lolinda

weird OI: standing up stops my digestion
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I opened this thread for all discussions about low intestinal blood flow: measurement, causes, consequences, current research. Interesting questions such as:
  • which levels of low blood flow actually cause which problems
  • blood flow measurements are notoriously inexact. measuring hypoxia can help:
    • measurement of hypoxia-related cytokines: PGE2, IL-8, VEGF
    • manometry: measurement of ph in the gut. they do this in ICU patients to monitor hypoxia.
  • treatments
  • current research directions
  • connections to CFS

Regarding CFS, this connects in several ways:
  • low intestinal blood flow can cause low oxygen levels which facilitates growth of anaerobic bacteria in the small intestine. depending on the species involved this has been linked to cfs (see e.g. Meirleir).
  • It connects in some people to POTS: in healthy people, when standing up, blood flow in the superior mesenteric artery remains the same as when laying. this is thanks to a compensation mechanism. In illness it can diminish, creating hypoxia

I have quite some research papers on this, if you need some just ask!
 
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Lolinda

weird OI: standing up stops my digestion
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this discussion started on another thread:
http://forums.phoenixrising.me/inde...ith-low-stomach-acid.45191/page-2#post-746275

I feel it fits better here.


Are you saying excessive norepeniphrine causes you poor blood flow or is it something else?

Poor blood flow to the bowel is thought to be a major part of the reason why I have chronic GI dysfunction (Gastroparesis, Small bowel Pseudo-obstruction, Intestinal Ischemia, Hypomotility/hypermotility of the bowel). This has been diagnosed as Chronic Mesenteric Ischemic (in the form of Non-occlusive Mesenteric Ischemia) where blood flow to the bowel is not adequate for digestion through the mesentery artery microvascular network likely because of spasm in the small vessels due to low blood pressure.

The whole thing looks to be an issue of autonomic dysfunction also affecting the vasodilation/vasoconstriction response as the low blood pressure problem was considered to be part of the problem by my so called "GI experts" until autonomic function testing I had been pushing to get for a couple of years was finally agreed to and come back showing cardiovagal and sudomotor (abnormal sweat response, greatly reduced) dysfunction.

That is probably why nitrate vasodilator meds given for the pain of intestinal ischemia had an opposite effect with increasing my blood pressure too as well as improving the GI symptoms enough that I could stop tube feeding and return to an oral diet. Alas, that only lasted for a couple of years so I've been on a fruitless search thus far for an antibody cause as can be found with Autoimmune Gastrointestinal Dysmotility.
http://www.mayoclinic.org/medical-p...ces/autoimmune-gi-dysmotility-a-new-direction
The noradrenaline issue I will answer in a separate post.

First, my measurement results & observations:
- when I am lying, the blood flow in my SMA (superior nesenteric artery) is almost normal, it wont cause any problems at that level (the intestines are very effective at extracting oxygen, so a slightly diminished perfusion isnt a problem)
- when I am standing, blood flow is 50% diminished. In healthy people it stays the same. At 50% diminuation there is compromise of digestion. This is the problem.
- My resistance index (RI) in the SMA is surprisingly too low (if there is low blood flow it should be too high. is yours high or low? do you know how to compute the RI?). even more surprisingly, the standing/lying difference of the RI is normal. (When a healthy person stands up, the resistance index in the SMA diminishes, so that in spite of some blood dropping to the legs, the flow in the SMA remains just the same. This mechanism is perfectly healthy in me. it is a common problem in intestinal blood flow issues that the ability of the vessels to dilate when needed is diminished. for example after a meal or when standing up. was the main suspect in me, but is not the case.

Second, the interpretation & conclusions:
- all these things will not be the cause of my low stomach acid, because even laying all the time after eating, when blood flow is normal, stomach acid is low.
- now to the main issue: on the first glance all this seems totally contradictory: the low RI would normally imply an elevated flow. However, take the following:
- I also have a lowish blood pressure
- postprandially, I qualify for POTS when I try to stand up from bed (-> one of the reasons is blood dropping to the legs)
- and my skin is unusually warm, excessively perfused
Adding up all this: the problem is that my blood flows elsewhere. That is, technically speaking, the RI of the rest of my body is probably even lower than in the SMA (not yet measured).

Consequences:
- I need to lay for hours after eating, which improves intestinal blood flow in me and avoids pain & cramps. I have a "siesta illness" :eek:

What I would be really interested to learn:
- do you have "only" pain or also crampiness in the belly? (low oxygen should cause muscle cramps)
- Do your symptoms get better or worse if you lay down / stand up after a meal?
- how was the sudomotor test done? (I had one too, pathological, but that was simply in the soles of the feet. it was done for a mild polyneuropathy
- how low is your BP?
- what is this spasm in the small vessels? l am curious to learn about this condition
 
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Lolinda

weird OI: standing up stops my digestion
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actually did they measure the flow in your SMA? what normal values did they use?
 
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PeterPositive

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@Llinda
Interesting. I have similar issues, with chronic low blood pressure and bad abdominal and peripheral blood flow.
I rarely get real cramps or spasms, it is more of a generalized abdominal tension which can result in mild pain and is usually worsend by standing up and resolved by laying down for a while.

Sometimes the tension is 2 inches below the belly button, and it feels like a tight belt around the waist. When that happens the blood flow towards the legs is also worse, as if there's an impediment for the circulation to come back up, I think.

I have done a bunch of functional GI tests but nothing that deals with blood flow or neuropathy. I have done the basic test where the doc touches your feet and ankles with the point of a pen to see if there's a loss in nerve function but I was able to feel even the slightest touch.

Similarly I have low HCL, but I suspect this is more of a consequence of all other issues than the cause of it.

You mentioned norepinephrine as a possible cause. How is that diagnosed and are there any known remedies?
 

Lolinda

weird OI: standing up stops my digestion
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chronic low blood pressure
yeah, thats me, too. how low is yours? I am asking cause I find it very interesting to see what parameters people with similar issues have. this way one can learn a lot, for example the commonalities are.
rarely get real cramps or spasms, it is more of a generalized abdominal tension which can result in mild pain and is usually worsend by standing up and resolved by laying down for a while.
literally the same in me. I could have written the same words, one by one. in fact, I almost never have real unpleasant crampiness - because I do not stand up after meals. For example, this post I am writing on my phone laying in bed. However, if I would stand up for a prolonged time, then I may sometimes get bad cramp and pain so that I cannot walk on, need to sit or lay down immediately. Hence, I learned to present my problem as abdominal cramp / pain and not as "need to lay in bed". this way the people (and doctos in particular) understand better.
do you also lay in bed for hours after eating? if so, how long?

If you stand up, you describe that tension. but if you do more, do you get also longer lasting issues? in me it is sthg like a flu-like feeling, a somewhat bloated belly, a loss of appetite, poor sleep.
Similarly I have low HCL, but I suspect this is more of a consequence of all other issues than the cause of it.
For that topic, I really recommend the other thread, there is a lot of interesting discussion going on, treatment suggestions, etc:
http://forums.phoenixrising.me/inde...ith-low-stomach-acid.45191/page-2#post-746275
I have done a bunch of functional GI tests but nothing that deals with blood flow or neuropathy.
Then how do you know its blood flow?
bad abdominal ... blood flow.
I have done a bunch of functional GI tests but nothing that deals with blood flow or neuropathy.
I am cürious what functional tests you did. I am a fan of functional medicine. But otherwise, I think you shoul get tested for abdominal blood flow. I see tons of people posting around here on PR who have all kind of assumptions but didnt do the tests. Unfortunately, some have no better options, being in countries where thats not possible. But if you can, I really encourage you cause its worth. I had a lot of ideas what itcould be, actually thought sometimes I had too much blood flow ("postprandial splanchnic hyperemia", ahat a beautiful mouthful of a monicer) and only when the results were there it became clear which of the many bad ghosts is my real enemy :D I can give you all the instructions, papers. While intestinal blood flow tests are commonplace, pre/post-prandial flow tests are uncommon, even at academic hospitals. you need to tell the doctors what to do and for that it needs scientific papers. Papers are like presenting them their own god they believe in. they will have to bow and pray :D :D

noradrenaline: I will open a thread on that, cause its a compliated topic on its own and will invite you.
 

PeterPositive

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yeah, thats me, too. how low is yours? I am asking cause I find it very interesting to see what parameters people with similar issues have. this way one can learn a lot, for example the commonalities are.
On a good day 110/70, on a bad one 100/65.

do you also lay in bed for hours after eating? if so, how long?
Usually on the couch is enough for me. 1 hour, sometimes a little more. There are times however when I need to collapse in bed, that's usually when I already feel very fatigued, even on an empty stomach.

If you stand up, you describe that tension. but if you do more, do you get also longer lasting issues? in me it is sthg like a flu-like feeling, a somewhat bloated belly, a loss of appetite, poor sleep.
I try not to push it. When I do it usually gets bad. I get shortness of breath, abdominal pain, fatigue, brain fog, the whole crappy lot... :rolleyes:

Then how do you know its blood flow?
For sure? I don't, but I have spoken with a couple of doctors and they suggested that as a possible issue, especially because I don't have a good peripheral circulation in my legs and feet and the two things seem to worsen or improve together.

One of the doc did an abdominal ultrasound that didn't show anything out of order.

I am cürious what functional tests you did. I am a fan of functional medicine. But otherwise, I think you shoul get tested for abdominal blood flow. I see tons of people posting around here on PR who have all kind of assumptions but didnt do the tests. Unfortunately, some have no better options, being in countries where thats not possible. But if you can, I really encourage you cause its worth. I had a lot of ideas what itcould be, actually thought sometimes I had too much blood flow ("postprandial splanchnic hyperemia", ahat a beautiful mouthful of a monicer) and only when the results were there it became clear which of the many bad ghosts is my real enemy :D I can give you all the instructions, papers. While intestinal blood flow tests are commonplace, pre/post-prandial flow tests are uncommon, even at academic hospitals. you need to tell the doctors what to do and for that it needs scientific papers. Papers are like presenting them their own god they believe in. they will have to bow and pray :D :D
After doing the tests were actually able to get some relief? Did they give you specific meds or therapies?

cheers
 

Lolinda

weird OI: standing up stops my digestion
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On a good day 110/70, on a bad one 100/65.
same here
try not to push it. When I do it usually gets bad. I get shortness of breath, abdominal pain, fatigue, brain fog, the whole crappy lot.
fits me. the shortness of breath I do not have any more since I am on very low carb paleo.
I believe that in me this did sthg have to do with low spo2. I still have low spoe, but did not have that measured at that time when I had the shortness of breadth

did you have an spoe done?
 
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Lolinda

weird OI: standing up stops my digestion
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One of the doc did an abdominal ultrasound that didn't show anything out of order
thts what they wanted to feed me with, too. and then they acted as if they had done it all, "we found nothing, there is no organic cause". bla. go back to medical school, sir... :eek: :D or start reading research...! :)

so one needs to do doppler tests for this issue. measure
- flow
- systolic flow speed
- diastolic flow speed
- all this before and after eating, each of these standing and lying.

After doing the tests were actually able to get some relief? Did they give you specific meds or therapies?
No. this is not so simple. it is not test->diagnosis->pill. :)
it is test->compare results with research->discuss->design new tests together to find causes->retest->...
it is a loong process. you will have to think if the effort is worth the utility.

so far the utility was:
- understanding the mechanism of whaats going on, I understood thaat there is no harm if I stand up for a very short time after meals. this gives me more freedom. in me its not only an hour, but more.
- understanding these blood flow issues prevented me from doing therapeutic trials for issues I do not have
- it enabled me to develop theories for the final cause which I am exploring right now. so I canread the right papers instead of reading 100 papers not knowing which applies to me
- will soon do a next round of tests for the possible final reasons. hope they will be treatable

in me the issue is more severe than in you, thats why I put in so much energy. laying 1h was enough a few years ago. it got more and more since. is your need to lay down also increasing? how fast?
 

Lolinda

weird OI: standing up stops my digestion
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mamma mia... thats low low low... :(

do you also have poor intestinal blood flow?
 

kangaSue

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I made a typo in the above highlighted passage, it was supposed to read "the low blood pressure problem was NOT considered to be part of the problem by my so called "GI experts" until autonomic testing....."

I posted more about my blood flow issue here http://forums.phoenixrising.me/index.php?threads/nicorandil-a-role-in-treating-cfs.29487/
First, my measurement results & observations:
- when I am lying, the blood flow in my SMA (superior nesenteric artery) is almost normal, it wont cause any problems at that level (the intestines are very effective at extracting oxygen, so a slightly diminished perfusion isnt a problem)
- when I am standing, blood flow is 50% diminished. In healthy people it stays the same. At 50% diminuation there is compromise of digestion. This is the problem.
- My resistance index (RI) in the SMA is surprisingly too low (if there is low blood flow it should be too high. is yours high or low? do you know how to compute the RI?). even more surprisingly, the standing/lying difference of the RI is normal. (When a healthy person stands up, the resistance index in the SMA diminishes, so that in spite of some blood dropping to the legs, the flow in the SMA remains just the same. This mechanism is perfectly healthy in me. it is a common problem in intestinal blood flow issues that the ability of the vessels to dilate when needed is diminished. for example after a meal or when standing up. was the main suspect in me, but is not the case.
I've not heard of a Resistance Index before so no, I don't know how to compute it or if there is a difference between laying and standing. The only measurements I've had done was mesentery artery flow velocities laying down by Duplex Doppler Ultrasound, only mid SMA was slightly elevated at 277 cm/second (>275 cm/second indicates 70% stenosis) but a subsequent CT Angiogram couldn't detect any occlusion to account for it despite also having an epigastric bruit, also indicative of an impaired blood flow.

I know my b.p. is worse when laying down. Whenever I'm in hospital, my b.p. has to be taken sitting up at night to prevent calling out the duty doctor because it usually falls below their safety threshold which I think is 80/50. Normal was around 90/60 mark until I found that nitrate vasodilator meds for the pain from intestinal ischemia actually raised my b.p. to 110/70 on good days. Either way, the response to standing is normal although on a tilt table test late last year, it dropped off to the lowest point of 69/40 at the 4 1/2 minute mark.
do you have "only" pain or also crampiness in the belly? (low oxygen should cause muscle cramps)
I developed a constant low grade background pain 7 years into having gastroparesis which was made considerably worse about half an hour after eating, that's Chronic Mesenteric Ischemia and the pain was generally well controlled for a couple of years with the nitrates but didn't stop the occasional acute flare every few months where I needed ER treatment for severe (10/10) pain, that's Acute Mesenteric Ischemia.
Do your symptoms get better or worse if you lay down / stand up after a meal?
Laying down after eating is something I've only tried in the last week as I am struggling again to control nausea and vomiting. It eases the discomfort from eating but as soon as I sit up, I regurgitate the majority of food the same as if I just sit still for an hour after eating. I need to have another CT Angiogram to see if this is from Superior Mesenteric Artery Syndrome as I have dropped below 40 kg.
how was the sudomotor test done?
It was done in a hospital laboratory setting, QSART, TST, Tilt Table, Valsalva Manouevre, Heart Rate Variability to Deep Breathing, several abnormal results concluded to be Restricted Autonomic Neuropathy. Had virtually no sweating at all after one hour at 40 deg C.
how low is your BP?
90/60 was a good day before starting nitrates. It still drops during an acute flare, 57/39 is the lowest I've recorded during one of these events and the pain can last for up to 3 days at a significant level.
what is this spasm in the small vessels? l am curious to learn about this condition
Small vessel disease is what the GI motility specialist calls it but it's the microvascular network fed by the mesentery arteries and veins. When blood volume or blood flow is insufficient, it can create spasm in these small vessels which is Non-occlusive Mesenyteric Ischemia (NOMI). I can't actually feel any spasm in the gut, it only translates as pain which is all located between the ribs (epigastric) as the bowel becomes increasingly hypoxic. The pain can be felt in different areas by others and can radiate to the back I believe. I only know I have NOMI because it is consistent with the type of mucosal damage seen at the transverse colon during a colonoscopy which is distinct from Ulcerative Colitis. Ischemic Colitis is somewhat similar I gather but that usually occurs with blood in the stool too, something which I do not get with NOMI.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2778114/

It's not known how extensive the ischemic damage is because the scope perforated the bowel
 

Lolinda

weird OI: standing up stops my digestion
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I've not heard of a Resistance Index before so no, I don't know how to compute it or if there is a difference between laying and standing.
thats a simple but very accurate way of finding out if autonomic function of intestinal blood flow regulation is working fine or not. I will post here soon the details and the research paper that is best for providing normal values. so you can get tested if you want. my results were surprising and useful for me. its damn late here (I am in Europe) and I am sooo sleepy :) :)
Thanks for all the details, I will answer soon the rest too. Thanks doubly for the information about Dr Diana Driscoll on the other thread, I aam working my waa through all the information.
 

kangaSue

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How do I find out about it?
Doppler Ultrasound of the mesentery arteries to measure the blood flow velocity is the usual screening test to start with. A referring doctor would likely need you to have symptoms of abdominal pain which worsens after eating as a minimum (sign of possible intestinal ischemia) and/or they can hear an epigastric bruit in with your bowel sounds, weight loss, possibly a fear of eating and preferably with other symptoms consistent with gastroparesis.

Some people are asymptomatic however as there is usually abundant collateral blood flow and abnormalities in the mesentery arteries are often found when investigating a separate condition. It was no easy task trying to convince even a GI motility specialist that I could have this condition so expect resistance from doctors on the subject.
 

ahimsa

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Hi, I hope this is not a digression, but thought I'd answer this question:
No one else stuck at 90/60 for years like me??? :ill::rolleyes:
Back when I was young (and very healthy) my resting blood pressure was often 90/60. My systolic pressure was usually between 85-95, very occasionally up to 100. And how did I know my own blood pressure back then? I had a few measurements by the doctor (rare) but mostly I remember the numbers from when I used to donate blood regularly.

The blood donation folks always measured BP before anyone was allowed to donate. They had a guideline that the pulse pressure -- systolic (top number) minus diastolic (bottom number) -- had to be greater than 25.

So between ages 18 - 29, when I was donating blood, my blood pressure was pretty much always in this range.

I'm only commenting here because it seems to me that just having low blood pressure alone is not necessarily a problem. At least, low BP was not a problem for me. In addition to working full time I also did a lot of exercise - hiking, weight lifting, running, etc. I managed to climb to the summit of Mt. Hood twice. I had no problem with exertion at all.

It was only after I caught some sort of weird "flu" (viral infection / whatever) at age 29 that I ever started having problems with Orthostatic Intolerance (NMH and POTS).

Just my two cents. I don't claim to know about anyone else's situation! So take this all with a grain of salt (pun intended). Low BP may signal a problem in many cases but it was not a problem for me back when I was healthy.

And sorry if this is a digression from the discussion on intestinal blood flow, which is a separate issue. I do seem to get some splanchnic pooling which is why I have learned to always recline for an hour or so after eating. I probably won't bother with any measurements but reading about this topic is interesting. (but mostly over my head!)
 

PeterPositive

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No. this is not so simple. it is not test->diagnosis->pill. :)
it is test->compare results with research->discuss->design new tests together to find causes->retest->...
it is a loong process. you will have to think if the effort is worth the utility.
Hmm, ok but what are the possible solutions? Are there known methods / therapies that can be used to improve abdominal blood flow? For example if the suspected cause is dysautonomia (disregulation of autonomic n.s.) what could be the options, if any?
 

kangaSue

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Interesting. I have similar issues, with chronic low blood pressure and bad abdominal and peripheral blood flow.
I rarely get real cramps or spasms, it is more of a generalized abdominal tension which can result in mild pain and is usually worsend by standing up and resolved by laying down for a while.
literally the same in me. I could have written the same words, one by one. in fact, I almost never have real unpleasant crampiness - because I do not stand up after meals.
I had gastroparesis for 7 years before I had any real pain with it. The beginning of this epigastric pain that morphed into the chronic intestinal ischemia aspect of it started out as you guys mention here, a dull background ache that was a little worse for a bit after eating which would be helped by laying down. It was about 3 1/2 after the onset this discomfort that the pain after eating was severe enough every few months that I had to seek out treatment at my local hospital ER where i.v fluid and fentanyl (the only opiate-like thing I tolerate) would settle the pain.

ER trips were greatly reduced after starting nitrate vasodilators but episodes of pain started to get severe again about 2 years later which I still don't have a cure for another 3 years down the track.
 
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I've wondered if transient ischemia could be responsible for ulcerative colitis, this gives me some info to look into. Thank you.
 

kangaSue

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Hmm, ok but what are the possible solutions? Are there known methods / therapies that can be used to improve abdominal blood flow? For example if the suspected cause is dysautonomia (disregulation of autonomic n.s.) what could be the options, if any?
There are a few threads on PR about symptom improvement with using nitric oxide (NO) boosting supplements or meds, the same things increase blood flow to the bowel too and it's only prescription nitrates that have given me significant symptom improvement in chronic GI dysfunction.

It's also a dysregulation of autonomic function thing for me too as nitrate vasodilators paradoxically raise my low blood pressure, same as has been reported for some with ME/CFS.
I've wondered if transient ischemia could be responsible for ulcerative colitis, this gives me some info to look into. Thank you.
Not a lot of research has been done into a connection between UC and the splanchnic microcirculation but I saw this paper recently http://www.ncbi.nlm.nih.gov/pubmed/19685450 suggesting that the same form of chronic mesenteric ischemia that I have, Non-occlusive Mesenteric Ischemia (intestinal microvascular ischemia), could be a causative of UC.

I was speaking to an IBD specialist recently seeking a second opinion about my whole GI dysfunction as I thought he would know about intestinal ischemia issues too but he was unaware that a link between microvascular ischemia and IBD even on the drawing board.