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
- 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
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