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

-gastroenterology

• 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?

-complex

-multifactorial

-inheritabile

-substance abuse and eating disorders run in same family

-result in significant impairment

-physiology, functional mri’s

Risk Factors

-genetics

• 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)

Epidemiology

-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

-purging

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

-weakness

-fatique

Oral and fascial Symptons

-oral trauma

-dental erosion/caries

-dentists are in good position to dx

-parotid gland enlargement

-perimyolysis

-cheilosis

-sore throat

-conjunctival injection

-periorbital petechiae

Cardivascular Complications

presenting complaints

-chest pain

-palpitations

-dizziness or lightheadedness

-syncope

-edema

-Fatigue

Complete Blood count

 Electrolytes

EKG

Arythmias

-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

Hypotension

-volume depletion

-structural changes to heart (cardiac atrophy -muscle loss)

-autonomic dysfunction 

Orthostasis

-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

-bloating

-constipation

-early satiety

Evaluation - normal for any patient

Common causes

-GERD, esophagitis, eosophageal spasm

-malory -weiss tears

-Gastroparesis

----delayed gastric emptying

---suportive treatment

Borehave’s Syndrome

Cathartic colon syndrome

Acute gastric dilatation/gastric rupture

Acute hepatitis

Fulminant hepatic failure

Pancreatitis

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

-Hypokalemic

----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

Hypochloremia

hypocalcemia

Hypomagnesima

Hypophosphatemia

Metabolic alkalosis

Hypothermia

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

multifactorial

weight restoration best

Neurologic Complication

-cerebral atrophy and vetricular enlargement

-cognitive impairment

• decreased concentration, memory
• -peripheral neuropathy

Dermatologic and Hematologica Complications

-lanugo hair

-alopecia

-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

Comorbities

• 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

Sialdenosis

-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