Hypermobility and Gastrointestinal Dysmotility: Act II, We Are Going Number Two (Literally)

Food went in. Now what?

Welcome back to the Hypermobile House, where apparently the gastrointestinal tract has decided it is also community theater.

Opening night was glamorous, at least by digestive standards. There was chewing. There was swallowing. There was choreography. Food made its grand entrance, hit its marks, traveled down the esophagus, and disappeared behind the curtain.

Now we are backstage.

Act II is where the production gets considerably less elegant.

We are going number two.

Literally.

Because eventually, everything that entered through the stage door needs to find the back door.

Getting it there requires a surprisingly coordinated production inside our already complicated Hypermobile House. The gut has muscles moving scenery, nerves calling cues, blood vessels delivering supplies, immune cells working security, epithelial cells forming the walls, and trillions of microbes comprising a supporting cast whose names never appear above the marquee despite participating in nearly every performance.

When everybody hits their cues, nobody thinks much about the production.

When they don't, somebody is standing center stage holding a sandwich that should have left the building three days ago.

Once the stomach has mixed a meal with acid and digestive enzymes, what entered looking recognizably like dinner becomes something considerably less photogenic called chyme.

The stomach cannot simply dump all of this into the small intestine at once. It meters it out.

Think of the stomach as the loading dock in the Hypermobile House. Food arrives in bulk, gets processed, then smaller shipments are released through the pylorus into the duodenum.

The timing matters.

Too fast, and the small intestine receives more than it can comfortably handle. Too slow, and dinner hangs around backstage long after its scene was supposed to end.

Once chyme enters the small intestine, the next part of the production begins.

The pancreas sends digestive enzymes. The liver and gallbladder contribute bile. Carbohydrates, proteins, and fats continue being broken into components small enough to absorb. The intestinal surface is covered with folds, villi, and microscopic microvilli that dramatically increase the available surface area.

If the Hypermobile House had a pantry designed by someone obsessed with storage, this would be it.

Every available inch has another shelf.

Nutrients cross the intestinal epithelium. Water and electrolytes move. Digestive secretions are added and reclaimed. Microbes interact with whatever reaches them.

All the while, everything has to keep moving.

Hidden throughout the walls of the gastrointestinal tract is the enteric nervous system, an extensive network of neurons capable of coordinating much of this locally. The brain communicates with the gut, of course, but it is not personally micromanaging every intestinal contraction.

The enteric nervous system is the stage manager who actually lives in the theater.

The brain and autonomic nervous system can call with notes from corporate, sometimes very loudly, while the local crew handles the performance.

One of its major jobs is coordinating motility.

The intestine does not simply squeeze food forward like toothpaste through a tube. Different muscular patterns mix intestinal contents, expose them to digestive and absorptive surfaces, and propel them forward.

Sometimes the plumbing is open.

The choreography is simply off.

The scenery can move. Somebody keeps missing the cue.

The gastrointestinal tract even has a between-show cleaning cycle. During fasting, the stomach and small intestine generate a recurring pattern of electrical and muscular activity called the migrating motor complex, or MMC. It helps move residual material through the upper gastrointestinal tract between meals.

Think of it as the theater's cleaning crew.

The audience leaves. The lights come up. Somebody finds the abandoned programs, half a pretzel, and one mysterious shoe under Row G. The crew starts sweeping everything along so the theater is ready for the next performance.

Eating changes that pattern because now there is a new show to run.

Eventually, what remains reaches the large intestine.

By this point, much of what could be absorbed earlier has already been absorbed. The colon gets the leftovers: water, electrolytes, undigested carbohydrates and fibers, microbial products, sloughed intestinal cells, and material that the body has decided does not require an encore.

The colon reclaims water and electrolytes while transforming those contents into stool.

Meanwhile, our microbial supporting cast gets involved.

The gut microbiome often gets reduced to "good bacteria" and "bad bacteria," which is approximately as useful as describing Broadway as "good actors and bad actors."

It is an ecosystem.

Different organisms consume different substrates, compete and cooperate, and produce metabolites that can interact with epithelial cells, immune cells, nerves, and other microorganisms.

What reaches the colon helps determine what those organisms have available to eat. How quickly material travels through the colon matters too.

The cast affects the theater.

The theater affects the cast.

Everyone is apparently improvising together.

There is one more member of this production we need to acknowledge.

The walls.

We have previously touched on the possibility that epithelial dysfunction may matter in hypermobility. Dr. Anne Maitland has proposed looking beyond hEDS as exclusively a primary connective tissue disorder and considering a broader neuroimmune epithelial dysfunction.

That is a fascinating hypothesis.

It is also getting its own Floppy File because there is absolutely no way we are unpacking that entire suitcase while somebody is waiting to poop.

For now, we only need to remember that the intestinal epithelium is not passive wallpaper.

In many places, a single layer of epithelial cells separates the contents of the intestine from the tissues underneath. That barrier helps regulate what crosses, communicates with the immune system, responds to microbial signals, and participates in maintaining the environment in which those microbes live.

Back in the Hypermobile House, these are not ordinary walls. They have doors, sensors, security systems, maintenance crews, and direct lines to the electrical panel and neighborhood watch.

Exactly where epithelial dysfunction fits into hEDS, whether upstream, downstream, or somewhere inside a much larger feedback loop, remains an open question.

We will come back to the walls.

Right now, we have a colon to deal with.

Remember corporate?

The autonomic nervous system has opinions.

Sympathetic and parasympathetic signaling can influence gastrointestinal motility, secretion, blood flow, and immune activity. That becomes particularly interesting when autonomic dysfunction and gastrointestinal symptoms are living in the same Hypermobile House.

The sympathetic nervous system does not have to personally massacre the microbiome to change its neighborhood.

Imagine repeatedly changing a neighborhood's water pressure, thermostat, food deliveries, traffic patterns, and trash collection.

Nobody attacked the residents.

The residents are still going to notice.

Change transit time and you change how long intestinal contents remain in particular environments. Change secretion and you change those environments again. Change motility and different nutrients become available to microbes in different places for different amounts of time.

The nervous system can change the theater.

The theater can change the cast.

The cast produces chemical signals that can influence the theater.

Our supposedly simple journey from sandwich to poop has acquired several subplots.

Colonic motility has its own choreography. Some contractions mix contents and facilitate absorption. Others propel material farther along. Periodically, stronger coordinated contractions can move stool substantial distances toward the rectum.

One familiar trigger for increased colonic activity is eating, through what we call the gastrocolic reflex.

Food enters upstairs and activity increases downstairs.

Someone rang the front doorbell in the Hypermobile House, and the people in the basement immediately started taking out the trash.

This is one reason some people suddenly need to poop after breakfast. Coffee may receive all the credit, but breakfast itself can be part of the cue.

Eventually, stool reaches the rectum.

Places, everyone.

The rectum fills. Stretch receptors notice. Signals travel. The internal and external anal sphincters have different jobs. The pelvic floor has to coordinate. Abdominal pressure may contribute. The rectum needs to generate appropriate propulsive force.

Most importantly, muscles that need to relax must actually relax.

This sounds obvious.

Apparently nobody told the human pelvis.

If the pelvic floor contracts or fails to relax appropriately during attempted defecation, someone can be pushing against a door their own body is simultaneously trying to hold shut.

The colon delivered the package. The rectum knows it is there. The person desperately wants it gone.

The stage door remains locked.

In hypermobility, gastrointestinal dysmotility and constipation can have multiple contributors, which makes understanding what is actually happening backstage especially important.

This is why constipation is not one physiological problem.

Slow colonic transit is not the same thing as an evacuation disorder. Hard stool is not the same thing as impaired muscular coordination. Dysmotility is not the same thing as a mechanical obstruction.

Several can coexist, because the Hypermobile House has never respected departmental boundaries.

Treating "I can't poop" without asking why is a little like responding to "the show isn't starting" by selling more tickets.

We should probably figure out what is happening backstage.

When rectal sensation, muscular coordination, stool consistency, pressure, sphincter relaxation, and pelvic floor mechanics finally cooperate, the last scene occurs.

The curtain falls.

The audience applauds.

Poop exits through the back door.

No encore necessary.

Which gives us the point of this entire ridiculous production.

Pooping is not an isolated event at the end of digestion. It is the final result of everything that happened before it.

Chewing mattered. Swallowing mattered. Gastric emptying mattered. Small-intestinal motility mattered. Absorption mattered. Microbial metabolism mattered. Colonic transit mattered. Stool consistency mattered. Rectal sensation mattered. Pelvic floor coordination mattered.

The entire cast had to get food from stage door to back door.

Maybe this is why we should stop treating gastrointestinal problems like inconvenient side quests in hypermobility.

Reflux, nausea, early fullness, bloating, constipation, diarrhea, incomplete evacuation, difficulty swallowing, and food intolerance can get scattered across different rooms of the Hypermobile House as though nobody has noticed they share plumbing.

Perhaps some are consequences of connective tissue differences. Perhaps autonomic dysfunction contributes. Perhaps altered motility changes the microbial environment.

Perhaps epithelial and immune signaling are another piece of the puzzle.

Probably, for many people, several things are happening at once.

None of that means "fix your gut and fix your hEDS."

We do not know that.

The question can be much smaller.

What if we simply help the production run better?

What if swallowing problems are evaluated? What if reflux is managed? What if abnormal gastric emptying is identified? What if intestinal or colonic dysmotility is investigated? What if constipation is treated according to what is actually causing it? What if pelvic floor dysfunction is recognized instead of telling someone to consume increasingly heroic quantities of fiber?

What if somebody can eat more comfortably, move food more effectively, absorb what they need, and reliably get rid of what they don't?

Could improving gastrointestinal function also change the environment inside the gut? Could that influence microbial activity, epithelial signaling, or inflammation? Could any of those changes matter elsewhere in the Hypermobile House?

Maybe.

We honestly don't know yet.

That is where the next acts of science need to take us.

Here is the part I do know.

If getting appropriate help moving food from stage door to back door makes life 5 percent better for someone living in a hypermobile body, I am taking the 5 percent.

Five percent is still less pain.

Five percent is still more food.

Five percent is still fewer hours negotiating with your own colon.

Five percent is still getting out of the bathroom and back into your life.

One day, perhaps we will discover that some of the walls inside the Hypermobile House have been doing far more than holding up the scenery.

They are getting their own Floppy File.

For now, our cast has successfully completed Act II.

Food went in.

Nutrients came out.

Water got reclaimed.

Microbes had opinions.

The nervous system sent notes from corporate.

The pelvic floor received several conflicting copies of the script.

Eventually, hopefully, poop made it out the back door.

Curtain.

Want to go down the rabbit hole?

1. Thwaites, P. A., Gibson, P. R., & Burgell, R. E. (2022). Hypermobile Ehlers-Danlos syndrome and disorders of the gastrointestinal tract: What the gastroenterologist needs to know. Journal of Gastroenterology and Hepatology, 37(9), 1693–1709.https://doi.org/10.1111/jgh.15927

2. Alomari, M., Hitawala, A., Chadalavada, P., et al. (2020). Prevalence and predictors of gastrointestinal dysmotility in patients with hypermobile Ehlers-Danlos syndrome: A tertiary care center experience. Cureus, 12(4), e7881.https://doi.org/10.7759/cureus.7881

3. Aziz, Q., Harris, L. A., Goodman, B. P., Simrén, M., & Shin, A. (2025). AGA Clinical Practice Update on GI manifestations and autonomic or immune dysfunction in hypermobile Ehlers-Danlos syndrome: Expert review. Clinical Gastroenterology and Hepatology, 23(8), 1291–1302.https://doi.org/10.1016/j.cgh.2025.02.015

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About the Author

Allyson Barnes, PT, DPT is the founder of BAR Therapies and BAR Institute. She is a physical therapist specializing in the evaluation and treatment of symptomatic hypermobility and related connective tissue disorders. Through The Floppy Files, Allyson translates complex research into practical, evidence-informed education that helps patients, families, and healthcare professionals better understand hypermobility and participate more fully in everyday life.

Learn more about Allyson, explore more articles in The Floppy Files, or browse continuing education courses through BAR Institute.

Disclaimer

This content is intended for educational purposes only and is not medical advice. It is not a substitute for individualized evaluation, diagnosis, or treatment. Always consult your qualified healthcare provider regarding your specific health concerns.