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Sarah Sheibani, MD
Recognizing Eating Disorders in the Patient ith G t i t ti l S twith Gastrointestinal Symptoms
Sarah Sheibani MDUniversity of Southern California
Keck School of Medicine
Eating Disorders (ED)
Anorexia Nervosa (AN)
• Excessive concern with weight/body• Fear of gaining weight • Amenorrhea
R t i ti d Bi /P i bt
Bulimia Nervosa (BN)
• Excessive concern with weight/body• Recurrent binge-eating• Weight-control behavior
• Restricting and Binge/Purging subtypes
• Underweight : BMI ≤17.5 kg/m2
• Lifetime prevalence in women: 0.9%
• Normal weight
• Lifetime prevalence in women: 1.5%
Fairburn and Harrison. Lancet 2003;361:407-416, Hudson et al. Biol Psychiatry 2007;61:348-358.
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Sarah Sheibani, MD
Clinical Features in Patients with EDSystem Affected Complications
Cardiovascular Arrhythmia, Bradycardia
Dermatologic Dry skin, Hair loss, Russell’s sign
Oral/Pharyngeal Dental erosions/carries
Endocrine/Metabolic Hyponatremia, Hypokalemia, Hypoglycemia, Hypomagnesemia, Euthyroid sick syndrome, Osteoporosis
Genitourinary/Reproductive Amenorrhea, Infertility
Neurologic Peripheral neuropathyNeurologic Peripheral neuropathy
Psychiatric Depression, Anxiety, Personality disorders
Gastrointestinal (GI) Abdominal bloating/pain, Constipation, Elevated amylase, Elevated liver tests, SMA syndrome, Gastric rupture
Fairburn and Harrison. Lancet 2003; 361: 407-416, Wolfe et al. Int J Eat Disord 2001; 30: 288-293, Zaider et al. J Clin Gastroenterol 2006; 40: 678-683, Sleisenger and Fordtran’s 2010, Ninth Edition.
Prevalence of GI Symptoms in ED
• 1,2Severe gastrointestinal symptoms are seen in 40-80% of inpatients with AN and BNof inpatients with AN and BN
• 3100 patients with ED completed Rome III questionnaire– 83% with at least one functional GI disorder
• 22% Functional heartburn, 41% IBS,15% Fecal Incontinence
• 4Compared to controls, patients with an ED are more likely to seek care for a GI complaint.
1Chami et al. Am J Gastroenterol 1995;90:88-92, 2Waldholtz et al. Gastroenterol 1990;98:1415-1419, 3Wang et al. World J Gastroenterol 2014;43:16293-16299, 4Winstead and Willard. J Clin Gastroenterol 2006;40:678-682.
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Sarah Sheibani, MD
Gastric Motility Impairments in ED
Author Patients Method Results Treatment Outcomes of Treatment
1Abell et al 8 AN Scintigraphy Delayed with Nutritional No change
Studies Evaluating Gastric Emptying in AN and BN
solids, not liquids
rehabilitation (16 weeks)
2Benini et al 23 AN(12 binge/purge, 11 restricting
Ultrasonographic Delayed Nutritional rehabilitation ( 4 and 22 weeks)
Improvement (Restricters)
3Inui et al 26 total (9 AN, 10 AN + BN, 7BN)
Scintigraphy Delayed with solids
-- --
4McCallum et al 16 AN Scintigraphy Delayed with Metoclopramide Improvement
1Abell et al. Gastroenterol 1987; 93: 958-65. 2Benini et al. Am J Gatroenterol 2004; 99: 1448-1454, 37: 35-41, 3Inui et al. Lancet 1995; 346, 1240, 4McCallum et al. Dig Dis Sci 1985; 30: 715-22. 5Stacher et al. Gut 1986; 27: 1120-1126. Chial et al. Am J Gastroenterol 2002; 97: 255-269.
4McCallum et al 16 AN Scintigraphy Delayed with solids, not liquids (13/16, 80%)
Metoclopramide Improvement
5Stacher et al 16 AN Scintigraphy Delayed with solids (13/16, 80%)
Domperidone Improvement
Constipation in ED
• 128 inpatients with ED, constipation seen in:– 100% of patients with AN, 67% with BN
Transit time decreased in both patients with AN and BN– Transit time decreased in both patients with AN and BN
• 2Pelvic floor dysfunction can also contribute to symptoms
• 3Impaired colonic transit can improve with refeeding and weight gain
• 4,5Rectal prolapse can be seen in constipated patients with AN and BN
1Kamal et al. Gastroenterol 1991; 101: 1320-1324, 2Chiarioni et al. Mayo Clin Proc 2000; 75: 1015-1019, 3Chun et al. Am J Gastroenterol 1997; 92: 1879-1883, 4Malik et al. Dis Colon Rectum 1997; 40: 1382-1385, 5Dreznik et al. Intl J Psychiatry Med 2001; 31: 347-352.
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Sarah Sheibani, MD
Serious Complications of ED: Superior Mesenteric Artery (SMA) Syndrome
• Obstruction of the 3rd portion of the duodenum due to narrowing of the angle 13°g gbetween aorta and SMA
– Aorto-mesenteric angle ≤ 25°• Due to loss of mesenteric fat pad
• Bilious emesis, abdominal pain with distension
• Conservative treatment: TPN jejunal tube• Conservative treatment: TPN, jejunal tube feeds
• Surgery: Intestinal bypass LAC/USC
Agrawal and Patel. Surgery 2013; 153: 601-602, Adson et al. Intl J of Eating Disorders 1997; 21: 103-114, Mearelli et al. Am J Medicine 2014; 127: 393-394.
Serious Complications of ED: Gastric Necrosis
Gastric Dilation(SMA syndrome, Impaired Motility)
• Abdominal pain/distension, Inability to vomit
Gastric Necrosis(Intragastric pressure >Gastric venous pressure)
• Worsening abdominal pain, peritoneal signs, sepsis
• Air in gastric wall
Gastric Rupture
Mishima et al. Surg Today 2012; 42: 997-1000, Abdu et al. Arch Surg 1987; 122: 830-832, Arie et al. J Gastrointest Surg 2008; 12: 985-987.
• High mortality• Surgical emergency
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Sarah Sheibani, MD
Serious Complications of ED: Pneumomediastinum
• Free air within the mediastinum
– Spontaneous
– Disruption of the GI tract (secondary)Disruption of the GI tract (secondary)
• Can present with diffuse soft tissue emphysema, pneumoperitoneum, pneumothorax
• Symptoms: chest pain, dyspnea, hoarsenesshoarseness
• Treatment:– Spontaneous: Conservative management
– Secondary: Surgical intervention
Van Veelen et al. Eur J Pediatr, 2008; 167: 171-174, Hunt et al. NEJM 2012; 367: 157-167, Lin et al Int J Eat Disord 2005; 38: 277-280, Corless et al. Int J Eat Disord 2001; 30: 110-112.
Hunt et al. NEJM
Abnormal Laboratory Tests in ED
• 1,2,3Elevated amylase – Seen in 25-60% of patient with BN
Positive correlation between serum amylase and parotid gland size– Positive correlation between serum amylase and parotid gland size
– Secondary to binge-eating and purging
– *Reports of acute pancreatitis in AN and BN
• 4,5,6Elevated Liver Tests Mild ele ations seen in 4 15% of o tpatients and 43% of inpatients– Mild elevations seen in 4-15% of outpatients and 43% of inpatients with AN
– Seen more often in patients with lower BMI (<12)
– Improvement with refeeding
1Levine et al. Int J Eat Disord 1991; 12: 431-439, 2Wolfe et al. Physiology & Behavior 2011; 104: 684-686, 3Morris et al. J Pancreas 2004; 5: 231-234, 4 Montagnese et al. Int J Eat Disord 2007; 40: 746-750,5 Mickley et al. Int J Eat Disord 1996; 325-329, 6Hanachi et al. Clinical Nutrition 2013; 32: 391-395.
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Sarah Sheibani, MD
Hepatocellular Injury in AN
Author Age (yrs)/Sex
BMI(kg/m2)
AST/ALT (U/l)
Total Bili/Direct
(mg/dl)
PT (sec) Albumin (g/dl)
Liver Biopsy
Case reports of patients with AN presenting with severe hepatocellular injury
(mg/dl)
1Yamada et al 22/F 12.6 347/799 0.8 11.4 - _
2Furata et al 20/F 11 5000/3980 2.0 19 4 _
3Di Pascoli et al 26/F 10.8 9980/3930 1.4 17.5 4.3 _
4Di Caprio et al 18/F 14 1219/1696 3
1Yamada et al. Int Med 2006; 35: 560-563, 2Furata et al. Int Med 1999; 38: 575-579, 3Di Pascoli et al. Int J Eat Disord 2003; 36: 114-117, 4Di Caprio et al. Nutrition 2006; 22: 572-575, 5Hunt et al. NEJM 2012; 367: 157-167.
Di Caprio et al 18/F30/F
1413.2
1219/16963701/1634
_ _ 33.5
_
5Hunt et al 27/M 14 3969/2576 2.8/2.1 20 3.5 Lipofuscin, Iron
deposition
Acute Liver Injury in AN: Role of Autophagy
• 12 patients with acute liver injury (INR >1.7)
• Median BMI of 11.3
• Liver biopsy in all patients: – No evidence of hypoxic hepatitis or
chronic liver disease
– Decreased glycogen in all cases
– Electron Microscopy in 4 patients:py p
• Autophagosomes present
• Autophagy may be involved in liver cell death during AN
Pierre-Emmanuel et al. Gastroenterology 2008; 135: 840-848.
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Sarah Sheibani, MD
Evaluation of a Patient with a Suspected ED• Clinical History
– Evaluate for weight fluctuations
– Purging: vomiting, laxative abuseg g g,
– Menstrual history
– Psychiatric illness
• Physical Examination – Low BMI (≤ 17.5kg/m2)
– Bradycardia, Hypothermia
Lanugo like body hair
Russell’s sign (Struma et al)
– Lanugo-like body hair
– Dry skin, Russell’s sign
– Dental erosions
– Swelling of parotid and/or submandibular glands
– Dependent edema
Sleisenger and Fordtran’s 2010, Ninth Edition, Struma. Am J Clin Dermatol 2005; 6: 165-173.
Evaluation of a Patient with a Suspected ED
• Laboratory/Tests – Serum creatinine and electrolytes
S l– Serum glucose
– Complete blood count
– Liver tests
– EKG
• Exclude other medical disorders: – Hyperthyroidism yp y
– Malabsorption
– Malignancy
– Causes of secondary amenorrhea
Sleisenger and Fordtran’s 2010, Ninth Edition, Wolfe et al. Int J Eat Disord 2000; 30: 288-293.
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Sarah Sheibani, MD
Management of Patients with ED
Mental Health Clinicians Nutritionists Primary Care/ M di l S i lt
Outpatient Inpatient (Severe Symptoms)
• Weight <70% of ideal weight
• Medical Instability• Poor motivation
PsychotherapyPharmacotherapy
Medical Specialty Care
Sleisenger and Fordtran’s 2010, Ninth Edition, Hofner et al. Nutrition 2014; 30: 524-530.
Nutrition/Weight Management
• Cognitive Behavioral Therapy• Medications: SSRI
Pathophysiology of Refeeding SyndromeMalnutrition/Starvation
Insulin, Glucagon g(Gluconeogenesis)
Refeeding
I li T ll l Shift Thi iInsulin
Sodium
Hypervolemic State: Edema, CHF
Transcellular Shifts
K Mg
Arrhythmias, Spasm
P
ATP
Muscle weakness, Rhabdomyolysis
Anemia
Boateng et al. Nutrition 2010; 26: 156-167.
Thiamine
Wernicke-Korsakoff, Beriberi
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Sarah Sheibani, MD
Management: Nutrition • Goal: steady rate of weight gain
• Outpatient– 800-1200kcal/day, increase by 200-250kcal/week
– Goal weight gain: 0.5-1kg/week
• Inpatient (Severely malnourished, Risk of refeeding syndrome)– Days 1-3: 10 kcal/kg
– Days 4-10: 15-20 kcal/kg
– Check and replete:Check and replete:• Electrolytes: Phosphorus, Magnesium, Potassium
• Vitamins: Thiamine, Folate, Pyridoxine, Cobalamin
• Micronutrients: Selenium, Zinc, Iron
– Fluid/Sodium balance
– Monitoring: vitals signs, electrolytes, glucose, weight, EKG
Hofner et al. Nutrition 2014; 30: 524-530, Boateng et al. Nutrition 2010; 26: 156-167.
Summary• Clinical features and complications of ED can involve various organ
systems
• GI symptoms are common and non-specific
• Severe complications are and include:
– SMA syndrome
– Gastric necrosis/rupture
– Pneumoperitoneum
• Clinical history and laboratory analysis can assist in establishing a diagnosis
• Management requires a multidisciplinary approach– Consider refeeding syndrome in severely malnourished patients
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