Friday, August 2, 2013

Eating Disorders, IDAA 2013 CME, Keystone, Colorado

How to recognise and manage eating disorders in any practice setting
  • Suzanne Dooley-Hash, MD
-emergency medical doctor

most of studies are from ER and samples are ER

Impact of Eating disorders

32x risk of suicide with anorexeia
only 28 x risk of suicide with major depression in comparison

Increased utilization of health care services
-mental health
-primary care
  • gynecology
  • emergency departments

“Any girl who shows to ER with hypokalemia is purging until proven otherwise”
Same holds true with metabolic alkalosis

Example 1
ED visits 3 weeks earlier for dizziness
  • admitted to history of anorexia
  • denied purging
  • potassium 2.8
  • Oral sumplemntation
  • Discharged with 2 day KCL

PCP visits 2 weeks 
  • worse k 2.6
  • encouraged outpatient treat
  • gave bid KCL

2 weeks later dead

Every time you encounter anorexia - it may be your last chance

What is eating disorder?
-substance abuse and eating disorders run in same family
-result in significant impairment
-physiology, functional mri’s

Risk Factors
  • body image dissatisfaction
  • -environmental and social pressure to be thin (models)
  • - Thin ideal internalization
  • Neuropsychological and personality traits
  • --perfectionism, high harm avoidance, impulsiviity
  • early puberty
  • co-morbidity
  • -trauma - including bullying and teasing
  • -High BMI
  • Dietting
(Don’t do dietting)

-age - onset in adolescences or young adults
-gender - females greaters than males (3-4:1 becoming closer)
-minorities = Caucasians - happen in everyone
  • High risk groups
  • ---atheletes - ballet, gymnastics, running, wrestling, body-building
  • Type I Diabetes Mellitus
  • Post-bariatric surgery patients

Anorexia Nervosa
-DSMV made important changes
-Body weight below 85% of expected weight for age and height
-intense fear of gaining weight
-distorted body image
minimizing seriousness of low body weight
-purely restrictive type or a binge/purge type
Bulimia Nervosa (AN)
At least once weekly episode of binge, loss of control, large quantity of food in 2 hour peri
-used of compensatory behaivours - laxatives, etc

Binge Eating Disorder (BED)
-recurrent binge without purge
-highly associated with obesity -40-70% of oese
-most common

Feeding and Eating Disorders not elsewhere classified

Recognition of Eating Disorders in Any Practice Setting
  • maintain high index of suspicion - less than 1/3 have been asked by health care worker, 90% say they would have responded if asked, but unlikely to offer

SCOFF Questionaire
5 questions 
2 of 5 is positive screen and indicateds need for more investigation

1.Do you make yourself sick because you feel uncomfortably full
  1. 345

Common presenting complaints
  • headache
  • young girl with sore throat - recurrent - consider purging
  • mood changes
  • dizzyness/syncope
  • palpitations
  • Fatigue/generalized weakness
  • sports related or overuse injuries
  • gastro complaints
  • amenorrhea
-marked weight loss
-failure to grow

Oral and fascial Symptons
-oral trauma
-dental erosion/caries
-dentists are in good position to dx
-parotid gland enlargement
-sore throat
-conjunctival injection
-periorbital petechiae

Cardivascular Complications
presenting complaints
-chest pain
-dizziness or lightheadedness

Complete Blood count

-sinus bradycardia - normal response to starving
-heart rate less than 60 beats per minute
-degree of bradycardia correlates with severity of disease

EKG changes are common
-low voltage changes
-right axis 
-conduction disturbances
-QT changes

-volume depletion
-structural changes to heart (cardiac atrophy -muscle loss)
-autonomic dysfunction 

-heart rate increases more than 15 when stand up 
-blood pressure decreases
  • reasons for admission
  • beware of overly aggressive fluid addition

Sudden Cardiac Death
-QT often blamed
-often multifactorial
-electrolyte abnormalities

Cardiovascular Complications
-Emetine cardiomyopathy
-syrup of ipecac
-Cardiotoxic alkalosis
-accumulates in muscle tissue
-irreversible dammage to the myocardium
-no antidote - as little as 40 dosages -40 days purging
-available over the counter

Edema - multiple causes

Mitral valve prolapse
  • atrophy of ventricular wall
  • -improves with weight gain
  • increased arrythmia
Pericardial Effusion

Pulmonary complications
  • aspiration
  • -rupture lung from forceful vomitting
  • -copd
  • -muscle failure in diaphragm

GAstrointestinal complications
-abd pain
-heart burn
-early satiety

Evaluation - normal for any patient

Common causes
-GERD, esophagitis, eosophageal spasm
-malory -weiss tears
----delayed gastric emptying
---suportive treatment

Borehave’s Syndrome
Cathartic colon syndrome
Acute gastric dilatation/gastric rupture
Acute hepatitis
Fulminant hepatic failure
Superior mesenteric artery syndrome
Biliary Colic or cholecysitis (complication of rapid weight loss or weight cycling)

SMA Syndrome
-functional duodenal obstruction
-loss of fat pad
-symptons similar to a SBO
  • acute treatment is bowel rest, IV Fluids, and gastric decompression
  • resolves wit htreatment

Metabolic and Electrolyte Abnormalities
----suspect purging
Mild -30 - 3.5
Consider if below 3
Takes alot of K to replace

Severe - less than 2.5 - must be admitted with cardiac monitoring
-must also correct magnesium as well

Hypnatremia - water loading

Metabolic alkalosis
Renal Dysfunction

Hypoglycemia  - poor prognosis sign 
Hyper glycemia - diabulimia- manipulate insulin 
recurrent diabetic Ketoacidosis
high increse of long term complications of diabetes
suicide by insulin overdose
treatment of DKA- iv fluids, electrolytes, insulin
-avoid aggressive fluid 

Patients abuse thyroid hormones
-thyroid abnormalities - euthyroid Sick syndrome
-high cortisol
-arrested linear growth
loss of libido

Decreased bone density
50-90% of anorexic patients of more than 1 year will have osteoporosis
Bone density scan if sick for more than a year
weight restoration best

Neurologic Complication
-cerebral atrophy and vetricular enlargement
-cognitive impairment
  • decreased concentration, memory
  • -peripheral neuropathy

Dermatologic and Hematologica Complications
-lanugo hair
-yellowing of skin from too many carrots
-britlle nails
-dry itchy skin
  • poor wound healing
  • -iron def anemia
  • -pancytopenia- decreased prducted
  • decreased ESR

Psychiatric Complications
  • irritability /mood changes
  • depression
  • anxiety
  • suicide

  • mood and anxiety disosrdes
  • self harm
  • substance abuse

Effects of Malnutrion
-conscientious objectors participated in experiment of starvation
1500 cal /day months. No psychiatric predisposition
-exercise routine
  • depression
  • apathy
  • fatigue
  • irritability
  • preoccupied with food
  • hyperactivity
  • insomnia
  • emotional numb or labile
  • sensitive to criticism
  • paranoia
  • one guy had full blown psychotic episode

All of this stuff comes from not being fed and improves with food

Guide to Eating Disorder Patient’s Medicine Cabinet
  • laxatives
  • diuretics
  • stimulants
  • ipecac
  • -alcohol
  • -illicit drugs
  • psychotropic medications

Complications of Recovery
-chronic hypertrophy of parotid glands
-appears 3-4 days after cessation of vomitting
-goes way

Pseud-Barter’s Syndrome
-crhonic hyperaldosteronism related to chronic dehydration
and purging

1 comment:

Anonymous said...

no matter how you treat it
it is not very pretty