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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