Doctor123.org

Eating Disorder, Emergency Medicine

Basics

Description

- Recurrent inappropriate compensatory behaviors used to prevent weight gain: - Self-induced vomiting - Misuse of laxatives or enemas - Diuretics - Diet pills - Fasting - Excessive exercise

- Binge eating episodes associated with 3 or more of the following: - Eating much more rapidly than normal - Eating until feeling uncomfortably full - Eating large amounts of food when not feeling physically hungry - Eating alone because of embarrassment about how much one is eating - Feeling disgusted with oneself, depressed, or very guilty after overeating

- Psychiatric conditions - Borderline personality disorder - Mood disorders - Obsessive-compulsive disorder - Substance abuse

- Psychiatric risk: - Severe depression, psychosis, or other comorbid psychiatric diagnosis - Suicidality - Lack of motivation or cooperation with treatment - Failure of outpatient treatment - Severe impairment in functioning - Toxic family environment

- Outpatient treatment requires a team approach composed of a: - Psychiatrist and/or psychologist - Nutritionist, preferably one who specializes in eating disorders - Pediatrician or internist - Family therapist - Group therapist - Dentist

- Prognosis: - AN and BN: - 20% chronic course - 30% improve - 50% recover

- Mortality rate 5.6% per decade for AN - Outcomes improved with early diagnosis and treatment

Anorexia Nervosa (AN)

  • Restriction of intake, leading to markedly low body weight for age, height, and/or developmental trajectory
  • Intense fear of gaining weight or becoming fat, or behavior that prevents weight gain
  • Severe body image disturbance, undue influence of body weight and shape on self-evaluation, or denial of seriousness of low body weight
  • Lifetime prevalence: 0.5% of females in US
  • Typical age of onset for AN is bimodal at 13-14 yr and 17-18 yr

Bulimia Nervosa (BN)

  • Recurrent episodes of binge eating characterized by:Eating an unusually large amount of food in a discrete period of timeA sense of loss of control over eating during the episode
  • Recurrent inappropriate compensatory behaviors used to prevent weight gain:Self-induced vomitingMisuse of laxatives or enemasDiureticsDiet pillsFastingExcessive exercise
  • Bingeing and compensation occur on average at least once a week for 3 mo
  • Self-evaluation that is excessively influenced by weight or body shape
  • Lifetime prevalence: 2% of females in US
  • Commonly onset in late adolescence or early adulthood.

Binge Eating Disorder (BED)

  • Recurrent episodes of binge eating characterized by:Eating a larger than usual amount of food in a discrete period of timeA sense of loss of control over eating during the episode
  • Binge eating episodes associated with 3 or more of the following:Eating much more rapidly than normalEating until feeling uncomfortably fullEating large amounts of food when not feeling physically hungryEating alone because of embarrassment about how much one is eatingFeeling disgusted with oneself, depressed, or very guilty after overeating
  • Marked distress over binge eating
  • Occurs on average at least once a week for 3 mo
  • No compensatory behavior
  • Lifetime prevalence: 3.5% of females and 2% males in US
  • Onset in late adolescence or early adulthood.

Etiology

  • Twin studies have supported a strong genetic component.
  • Cultural emphasis on thinness as a valued attribute has been implicated
  • Temperament or personality attributes of perfectionism, anxiety, and behavioral rigidity have been described
  • Family conflict or stress is a frequent element
  • Neurochemical (serotonin) and neuroendocrinologic (leptin, HPA axis) abnormalities have been reported
  • Dieting is a frequent immediate precipitant

Diagnosis

Signs and Symptoms

History

  • Rapid or sustained weight loss
  • Typical detailed days eating pattern shows restricting and/or bingeing behavior
  • Purging (vomiting, laxatives, diuretics, enemas)
  • Excessive exercise
  • Dizziness, syncope
  • Bloating (gastroparesis), constipation, abdominal pain
  • Fatigue, lethargy
  • Palpitations
  • Cold intolerance
  • Amenorrhea, loss of libido
  • Family history of eating disorders and obesity
  • Comorbid psychiatric disorder (e.g., mood disorder, substance abuse, personality disorder)

Physical Exam

  • Weight <85% IBW or BMI <17.5 for AN
  • Hypothermia
  • Hypotension, orthostasis
  • Bradycardia, arrhythmia
  • Skin: Dry skin, lanugo (soft downy body hair on chest and arms), carotenoderma
  • Breast atrophy
  • Parotid swelling, submandibular swelling
  • Abnormal dentition
  • Abrasions of dorsum of hand
  • Skin breakdown, poor wound healing
  • Peripheral edema
  • Muscle weakness

Essential Workup

  • History
  • Physical exam
  • Lab testing
  • Nutritional assessment
  • Psychiatric interview:Concurrent psychiatric illnessSuicide risk assessmentExplore psychosocial context
  • Family evaluation when patient lives with his or her family

Diagnosis Tests & Interpretation

Lab

  • CBC (anemia, leukopenia, thrombocytopenia)
  • Electrolytes, BUN, creatinine, glucose (hyponatremia, hypokalemia, hypoglycemia, dehydration, metabolic alkalosis)
  • Calcium, magnesium, phosphorus, albumin (hypocalcemia, hypomagnesemia, hypophosphatemia, hypoalbuminemia)
  • LFTs (hepatic dysfunction)
  • UA including specific gravity
  • Toxic screen
  • β-hCG
  • Amylase (salivary hyperamylasemia if vomiting, pancreatitis)
  • Lipase (more accurate than amylase in predicting pancreatitis)
  • Consider checking thyroid-stimulating hormone.

Imaging

Specific tests may be useful in making differential diagnoses, e.g., MRI (rule out brain tumor), abdominal CT (rule out obstruction) á

Diagnostic Procedures/Surgery

  • ECG (QTc prolongation, arrhythmia)
  • Consider cardiac echo if substantial weight loss (cardiomyopathy from AN or ipecac)
  • Bone mineral density (osteoporosis)

Differential Diagnosis

  • Medical conditions:GI disease (e.g., Crohns Disease, IBD, celiac disease)Endocrine disorder (e.g., DM, thyroid disorder, adrenal insufficiency)Cancer
  • Psychiatric conditionsBorderline personality disorderMood disordersObsessive-compulsive disorderSubstance abuse

Treatment

Initial Stabilization/Therapy

  • ABCs
  • Careful fluid resuscitation for dehydration to avoid precipitating peripheral or pulmonary edema
  • Replete phosphate and thiamine since both may drop with refeeding
  • Correct hypokalemia, hypomagnesemia, hypocalcemia
  • Correct hypoglycemia
  • Warming blankets for severe hypothermia

Ed Treatment/Procedures

  • Initial workup
  • Medical stabilization
  • Psychiatric consultation (including assessment of suicide risk and psychiatric comorbidities)

Medication

First Line

  • No medication has been demonstrated to be of benefit for AN per seSmall trials have suggested possible benefit from atypical antipsychotics, particularly olanzapine 2.5-10 mg PO QDIt may be helpful to treat psychiatric comorbidities
  • Only fluoxetine 20-60 mg PO QD has FDA indication for the treatment of BN, though other SSRIs are frequently used. There is also evidence for tricyclic antidepressants as well as topiramate
  • There is evidence for imipramine, sertaline, citalopram/escitalopram, and topiramate for BED

Follow-Up

Disposition

Admission Criteria

  • Medical risk:Extremely low weight (<75% IBW)Rapid weight lossSerum electrolyte imbalance (K <3, glucose <60)Bradycardia <40BP <90/60Orthostasis (>20 bpm or >20 mm Hg/10 mm Hg)Hypothermia <97 ░FArrhythmia or heart failureHepatic or renal dysfunction
  • Psychiatric risk:Severe depression, psychosis, or other comorbid psychiatric diagnosisSuicidalityLack of motivation or cooperation with treatmentFailure of outpatient treatmentSevere impairment in functioningToxic family environment

Discharge Criteria

  • Medically and psychologically safe enough to be managed on an outpatient basis
  • Multimodal, multidisciplinary team in place to manage medical, nutritional, and psychological issues

Issues for Referral

  • Outpatient treatment requires a team approach composed of a:Psychiatrist and/or psychologistNutritionist, preferably one who specializes in eating disordersPediatrician or internistFamily therapistGroup therapistDentist
  • Prognosis:AN and BN:20% chronic course30% improve50% recoverMortality rate 5.6% per decade for ANOutcomes improved with early diagnosis and treatment

Follow-Up Recommendations

  • For outpatient treatment the team must establish modest goals and clear parameters, including expected weight gain for anorexic patients and compliance with follow-up appointments.
  • Internist/pediatrician: Monitor vital signs, weight, BMI, electrolytes, and ECG.
  • Nutritionist: Monitor diet, calorie intake, and exercise.
  • Psychotherapy:Cognitive behavioral therapy and interpersonal psychotherapy are the most effective forms of psychotherapy for BN.Cognitive behavioral therapy, family therapy, and psychodynamic therapies are all useful for AN.Family-based treatment is the preferred therapy for teenagers with AN, and it is promising for teenagers with BN as well.
  • Pharmacotherapy:Only indicated within the context of psychotherapy, especially with comorbid psychopathology.No accepted pharmacologic treatment of AN.Case studies suggest that 2nd-generation antipsychotics may be helpful in AN.There is no clear evidence for specific treatment of osteoporosis in AN apart from weight restoration and nutritional calcium supplementation.Antidepressant medications are shown to significantly reduce bingeing and purging behaviors:Fluoxetine is the best studied

Pearls and Pitfalls

  • Eating disorders are associated with high medical risk and risk of suicide; prioritize safety assessment
  • Rapid restoration of nutrition, volume resuscitation, and/or failure to replete vitamins and electrolytes can result in potentially fatal refeeding syndrome
  • Avoid trying to "out-obsess"Ł the obsessional patient
  • Coordinate care with PCP and other members of a multidisciplinary team

Additional Reading

  • Aigner áM, Treasure áJ, Kaye áW, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of eating disorders. World J Biol Psychiatry. 2011;12:400-443.
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  • American Psychiatric Association (APA). Practice Guidelines for the Treatment of Patients with Eating Disorders. 3rd ed. Washington, DC: 2006, and Guideline Watch (update) August 2012.
  • Mascolo áM, Trent áS, Colwell áC, et al. What the emergency department needs to know when caring for your patients with eating disorders. Int J Eat Disord. 2012;45:977-981.
  • Mitchell áJE, Crow áS. Medical complications of anorexia nervosa and bulimia nervosa. Curr Opin Psychiatry. 2006;19(4):438-443.
  • Rosen áDS, American Academy of Pediatrics Committee on Adolescence. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126:1240-1253.

Codes

ICD9

  • 307.1 Anorexia nervosa
  • 307.50 Eating disorder, unspecified
  • 307.51 Bulimia nervosa
  • 307.59 Other disorders of eating

ICD10

  • F50.00 Anorexia nervosa, unspecified
  • F50.2 Bulimia nervosa
  • F50.9 Eating disorder, unspecified
  • F50.02 Anorexia nervosa, binge eating/purging type
  • F50.01 Anorexia nervosa, restricting type
  • F50.0 Anorexia nervosa
  • F50.8 Other eating disorders
  • F50 Eating disorders

SNOMED

  • 72366004 Eating disorder (disorder)
  • 56882008 Anorexia nervosa (disorder)
  • 78004001 Bulimia nervosa (disorder)
  • 439960005 binge eating disorder (disorder)
  • 16985007 fasting (finding)
  • 34923007 self-induced vomiting (disorder)