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Master of disguise: Eating disorders in the emergency department
Children with eating disorders rarely present to the emergency department with a chief complaint of eating disorder symptoms. Much more frequently, children present with the co-morbid psychiatric illness or the medical sequelae of their eating disorder. This article will review the common eating disorders across three different age ranges. It will review the common co-morbid psychiatric presentations and the medical sequelae of starvation and medical symptoms specific to each eating disorder. Emergency department clinicians must include eating disorders in their differential for a variety of medical and psychiatric presentations to avoid missing an important and treatable illness of childhood. Clin Ped Emerg Med 5:181-186. © 2004 Elsevier Inc. All rights reserved.
Master of Disguise: Eating Disorders in the Emergency Department By Adelaide S. Robb, MD WASHINGTON, DC
E
From the Psychiatry and Behavioral Sciences, Children’s National Medical Center. Supported in part by a NARSAD Young Investigator Award. Address reprint requests to Adelaide S. Robb, MD, Children’s National Medical Center, 111 Michigan Ave. NW, Washington, DC 20010-2970. E-mail: [email protected]. 1522-8401/$—see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.cpem.2004.05.002
ATING DISORDERS ARE AN IMPORTANT diagnosis in all pediatric age groups as they have significant medical and psychiatric morbidity and mortality. Many eating disorders are difficult to diagnose, and patients and families may not seek treatment early in the course of the illness. Frequently, children with eating disorders may first seek treatment in an emergency department (ED) setting. Eating disorder patients may present to the ED because of a variety of reasons, including complaints not related to the underlying eating disorder. For many children suffering from an eating disorder, an astute diagnostician in the ED may facilitate an early diagnosis and referral for treatment of the eating disorder. In one study of a general medical population, less than 30% of patients let their primary care doctor know about the underlying eating disorder.1 This first section of this article will discuss the eating disorders that present most frequently in the toddler, school-age, and adolescent age groups. The second section of the article will discuss the major psychiatric and physical presentations of eating disorders in the ED.
Toddlers Toddlers can develop eating disorders with the transition to solid food and self-feeding. Infantile anorexia is the most common serious eating disorder in this age group. Children with infantile anorexia develop their illness because of difficulty with the transition to self-feeding. These children are much more interested in watching everything in their surroundings and the EA T ING D I SORD ERS I N T H E EMERG EN CY D EPA RTMEN T / A D ELA I D E S. ROB B
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environment than sitting quietly and eating their meals. As a consequence, these children tend to fall off the growth chart; they appear to have normal head circumference with low weight and height percentiles, regardless of parental growth parameters. Children with this disorder require care by a nutritionist and a child psychiatrist skilled in the treatment of infantile anorexia. The main goal of treatment is to remove the conflict and battle of wills from the mealtime. Meals are to be eaten in a specific setting and at a specific time without between meal snacks and chasing the toddler around the home begging her to eat. Other types of eating disorders that can present in toddlers are the post-traumatic feeding disorders. These children have a traumatic event during feeding such as choking on a piece of solid food or gagging on spoon-fed solids. After the choking incident, the child becomes afraid of the spoon or of specific solid food. If the incident was very frightening for the child, he may avoid or refuse all solid foods.2 It is the careful documentation of the history of onset of symptoms after a gagging or choking incident that will point toward this eating disorder. To the parent of the young toddler, the incident may seem minor such as the child gagging on a spoonful of cereal when fed. Treatment of this disorder would require hospitalization if the symptoms are severe and the child refuses all foods and beverages. If the child is only refusing solids, treatment can take place outside the hospital setting, employing a gradual reintroduction of solid foods. The emphasis is on maintaining caloric intake with formula or milk, and having the toddler start self-feeding with finger foods that were previously enjoyed. New and rougher textures are reintroduced gradually and utensils such as spoons are avoided in the beginning. This method allows the toddler to set the pace and feel more secure about solid foods.
School Aged Children Children prior to adolescence may present with signs and symptoms of anorexia nervosa. Since the diagnosis is much less common in pre-pubertal children, the clinician must remain aware of its presence in this age group in any child who presents with low weight. A second common eating complaint in this age group is the picky eater who only eats a select group of foods and refuses to try new foods. While this eating disorder is not lifethreatening, frustrated parents may present to the
ED asking for help. These children may be below family percentiles for linear growth and may have another relative with the same eating problem. Treatment includes meeting with a child psychiatrist and nutritionist to gradually expand food choices.
Adolescents The two most common eating disorders that present in adolescence are anorexia nervosa and bulimia nervosa. These disorders and their presentations in the emergency room will be discussed separately. Anorexia nervosa, according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), is a disorder of eating characterized by a weight of ⬍ 85% ideal body weight, fear of fatness, distortion of body image, and amenorrhea in females.3 This disorder has a male to female ratio of 1:9. Patients with anorexia nervosa may present to the ED with a chief complaint of “I have anorexia and need to be admitted to the hospital.” However, patients with anorexia may present to the ED with other physical or psychiatric symptoms. If the teenager is not questioned separately from the parent to verify the oral intake and ascertain concern about weight loss and excessive exercise, the diagnosis may be missed. Many adolescent boys who develop Anorexia begin their illness as overweight teenagers. They want to lose weight to be more fit and will start cutting out entire food groups (meat, fats) with no idea of the calorie content of foods. Such a drastic alteration in intake and exercise may lead to large weight losses in relatively short periods of time. Bulimia nervosa is an eating disorder characterized by recurrent eating binges 2⫻/week for three months, excessive preoccupation with weight and shape, and measures to reduce weight gain from the binges.3 Bulimia nervosa may arise de novo in an adolescent as the initial eating disorder. In other teens it may arise after a prior episode of anorexia nervosa. The prevalence of Bulimia in adult women may be as high as 2% to 3%.4 Rates in adolescent males are 0.1%-0.7%.5 Because patients with Bulimia may appear normal or can even be overweight, they are not visually obvious as eating disorder patients. This appearance makes them much less likely to be seen as eating disorder patients in the ED. Treatment of both anorexia and bulimia requires a team approach and may need inpatient, partial, or outpatient therapy settings.
EA T ING D I SORD ERS I N T H E EMERG EN CY D EPA RTMEN T / A D ELA I D E S. ROB B
Psychiatric Presentations Eating Disorder The most straightforward presentation of the eating disorder patient in the ED is the patient who presents for medical clearance before a psychiatric or medical admission for nutritional rehabilitation and psychiatric therapy. While these patients come with their eating disorder diagnosis known, they still require a thorough physical and psychiatric evaluation. Patients presenting with eating disorders need to be assessed for the common co-morbid medical and psychiatric illnesses. Without diagnosis and treatment of the co-morbid illnesses, the eating disorder treatment may fail. Much more frequently, eating disorder patients present with other psychiatric or physical symptoms as the chief complaint. Without a careful assessment especially for the cardinal symptoms, patients may be missed. In a study of 143 patients presenting to an adult psychiatric ED with non-eating disorder complaints, no patients had anorexia nervosa while 3.0% of women and 2.6% of men had bulimia nervosa that they had not revealed to their treating outpatient clinicians.6
Anxiety Disorder Anxiety disorders may occur in up to 60% of patients with eating disorders.7 The most common anxiety disorders seen in patients with eating disorders include obsessive-compulsive disorder, generalized anxiety disorder, panic disorder, and social phobia. When patients with eating disorders present for assessment, one needs to evaluate them for a co-morbid anxiety disorder. If the anxiety disorder is not treated or recognized, the eating disorder may remain refractory to treatment. Some eating disorder patients may present to the ED with a chief complaint of anxiety. If the clinician does not assess the patient with anxiety for eating symptoms, difficulty may arise in tailoring the patient’s treatment.
Mood Disorder and Suicide Attempts Mood disorder is one of the most common comorbid disorders with eating disorders. This includes both major depression and bipolar disorder. Major depression has a lifetime prevalence in eating disorders as high as 80%.8 Bipolar disorder occurs as well in patients with eating disorders. When patients present with either affective disorder, neu-
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rovegetative symptoms of change in weight or appetite are common. When patients present with an affective disorder and these appetite and weight changes, clinicians may stop their inquiry after diagnosing the mood disorder. If one does not also ask about distortion of body image, fear of fatness, bingeing episodes, restricted eating, and methods to eliminate calories after a binge, the clinician may miss a co-morbid eating disorder. With bulimia, affective disorder patients may be vomiting up their medications. They may present with low levels of mood stabilizers or “treatment resistant” mood disorder secondary to multiple lost doses of their antidepressant and mood stabilizers. The mortality rate from adolescent anorexia nervosa can be as high as 8.3% at 11 years with 50% of the mortality in anorexia coming from suicide.9 When patients present to the ED with a suicide attempt, affective disorders should always be the first diagnosis on the differential. However, eating disorders and their symptoms should also be assessed in patients who present with any suicide attempt.
Substance Abuse Disorder Patients with eating disorders may have co-morbid substance abuse disorders. Patients with anorexia nervosa who are trying to lose their appetite and restrict calories may use stimulants, cocaine, and amphetamines to limit their oral intake. Eating disorder patients with bulimia nervosa may use a variety of substances, including binge drinking of alcohol. Another substance that is also abused by bulimics is ipecac in an effort to promote emesis. Chronic ipecac use may lead to medical complications discussed below. Some patients with an underlying eating disorder will present to the ED with substance abuse complaints and/or intoxication. If the clinician does not inquire about other psychiatric symptoms including mood, anxiety, and eating symptoms, those diagnoses will not be made.
Cognitive Disorder Patients with profound starvation and caloric restriction may complain of cognitive deficits. They may have difficulty with memory and concentration and complain of a gradual decline in academic performance. On examination in the ED, such patients may appear cognitively slowed as if the patient had a cognitive deficit or learning disability. Such patients may also appear very rigid or fixed in their thinking patterns.
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Medical Presentations General Patients with eating disorders may present to the ED with signs and symptoms of extreme weight loss and starvation. For young children with infantile anorexia, they may present as a failure-to-thrive child. Parents may note the child has refused to eat most solid foods and has fallen off the linear and weight growth curves while maintaining adequate head circumference. Parents of older children with underlying anorexia or bulimia nervosa may bring their child to the ED for unexplained weight loss. Parents may complain that their child eats normal amounts at home and has lost weight. Such a child may be suffering from anorexia nervosa and eating a normal 800 to 1000 kcal dinner with parents while consuming no calories for the rest of the day and exercising excessively to burn extra calories. Parents of a bulimic teenager may describe a child who eats lots of food including high calorie, high fat foods such as several slices of pizza and a whole carton of ice cream without gaining weight. What those parents do not realize is that after a binge of consuming, the teenager then purges all the calories or restricts the amount of subsequent food eaten and exercises excessively to eliminate the weight gain. Complaints of malaise and fatigue secondary to malnutrition and starvation are other general presentations in the ED.
Metabolic/Endocrine Patients with eating disorders may present with signs and symptoms of an underactive metabolism. They may complain of lanugo, hypothermia, and cyanotic extremities. Some patients with eating disorders may have hypothyroidism with low T3, low normal T4 and free T4, and normal to low thyroidstimulating hormone (TSH). This is the pseudohypothyroidism of starvation. In one study of adolescent girls with anorexia nervosa, the average T3 on admission to the hospital was 54.7 ng/dL.10 Patients with eating disorders may also present with marked abnormalities in their glucose metabolism. They may have hypoglycemia from starvation. They may present in ketoacidosis from starvation. They may also have elevated glucose from frequent bingeing and purging. In addition adolescent patients with diabetes mellitus may use noncompliance with their insulin regimen as a way
to eat all they want without the fear of weight gain. Hypercholesterolemia, hypertrigylceridemia, and hypercarotenemia may also be present in patients with eating disorders.
Renal/Electrolyte Patients with eating disorders may present with a variety of renal and electrolyte complications both from long-term starvation and from acute manipulations of fluid and electrolyte balance.11 One of the long-term complications of anorexia nervosa is renal impairment with increases in both blood urea nitrogen (BUN) and creatinine with renal failure as one of the more frequent physical causes of mortality in patients with anorexia nervosa. Patients with anorexia may fluid restrict as a way to decrease weight and can present with signs of dehydration such as elevated BUN and creatinine, hypernatremia, alkalosis, and hypokalemia. At times, patients with anorexia may water load to meet weight goals imposed by parents or physicians. These children could have severe hyponatremia and other symptoms of water intoxication. Anorexia nervosa patients may also have hypocalcemia, hypophosphatemia, and hypomagnesemia. Patients with bulimia nervosa who vomit will have signs and symptoms of persistent emesis including hypochloremic metabolic alkalosis. Other patients with bulimia nervosa may abuse diuretics and present with hypokalemia or abuse cathartics and present with a contraction alkalosis.
Cardiac Cardiac symptoms in eating disorders are very common. For patients with anorexia, two of the compensatory calorie-saving adaptations to starvation are bradycardia and hypotension. These adolescents may present to the ED with complaints of dizziness or syncope. Patients may have such severe bradycardia, with rates lower than 40, that an escape or junctional rhythm is present. They may also have first and second-degree heart block and abnormalities in QT intervals. After refeeding, patients may present with refeeding syndrome which includes large shifts between intra and extracellular electrolytes, especially hypophosphatemia and hypocalcemia. This may lead to compensatory fluid shifts and high output cardiac failure. While the body does attempt to spare muscle, especially myocardium, patients with prolonged starvation may have decrease in myocardium mass. Usually heart rates become normal with refeeding, but patients who present with a normal heart rate with extreme
EA T ING D I SORD ERS I N T H E EMERG EN CY D EPA RTMEN T / A D ELA I D E S. ROB B
starvation may be at increased risk for cardiac complications.12 For some bulimia nervosa patients prolonged vomiting or diarrhea with the accompanying electrolyte and pH shifts may lead to a variety of arrhythmias. Because some of the electrolyte disturbances are chronic, patients may have markedly abnormal electrocardiograms without any cardiac complaints at presentation. An electrocardiogram is advised in patients with bulimia nervosa, especially if electrolyte disturbances are noted on laboratory examination. Abuse of syrup of ipecac may also be present in some children with bulimia nervosa. Long-term use of this drug can lead to a cardiomyopathy.
Gastrointestinal Patients with eating disorders may present to the ED with a variety of gastrointestinal complaints. A lack of calories and oral intake causes chronic constipation, even obstipation in anorexia nervosa patients. These individuals may also present with complaints of lack of appetite or stomach pain. Patients with severe starvation who have started to eat again at home may present with severe abdominal pain. This presentation can indicate superior mesenteric artery syndrome with occlusion of the gastrointestinal blood vessels and infarction of the gut.13 Patients who have been starving for prolonged periods of time and then start eating large quantities of food again are also at risk for gastric rupture. Both of these rare complications of anorexia nervosa are potentially life threatening. Bulimia nervosa adolescents are more likely to complain of chronic vomiting and diarrhea. For individuals who vomit frequently, they may also have erosion of dental enamel, multiple caries, and parotitis. The knuckles of the dominant hand may also exhibit Russell’s sign, the classic callus from repetitive gagging and trauma to the knuckles. Patients with persistent vomiting may also present with hematemesis and are at risk for a Mallory Weiss tear, which can be life threatening. Patients with rapid weight loss from anorexia and bulimia are at risk for cholelithiasis and may present with biliary colic in the ED.
Neurologic Patients with eating disorders and accompanying electrolyte disturbance may present with seizures. Because of increased risks of seizures in these children, psychotropics that lower seizure threshold, such as Buproprion, are contraindicated. If a patient on Buproprion presents with a seizure, the
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clinician must check for both overdose and underlying eating disorder. Patients with long term starvation will also experience loss of both gray and white matter on computed tomography (CT) or magnetic resonance imaging (MRI) scans.14 In patients requiring a CT in the emergency department for head injury, such volume loss may be present in a thin patient without signs or symptoms of a neurologic illness associated with central nervous system (CNS) atrophy. When such a CT scan appears, parents and patient must be questioned about eating disorder symptoms. With volume loss in the CNS, eating disorder patients may be more vulnerable to shear injuries and may be more likely to have sequelae after closed head injury including hemorrhage.
Hematologic Starvation may lead to alterations in the hematologic system as well. Patients with starvation who fail to take a multivitamin with iron can present with an iron deficiency anemia. With more severe starvation they may also have lymphocytopenia, thrombocytopenia or even pancytopenia.15 Despite the lowered blood counts patients with eating disorders rarely present with infection secondary to a suppressed immune system. Patients may have increased bruising and prolonged bleeding times secondary to impaired platelet function.
Orthopedic Some patients with anorexia nervosa and bulimia nervosa suffer from osteoporosis and osteopenia.16 Because their bones are more fragile, they may have more fractures or fractures may be present after an injury that would not normally lead to a fracture. In addition since both groups are frequent abusers of exercise in an effort to lose weight, they may suffer from stress fractures, muscle and tendon damage, and shin splints.
Summary Eating disorders are frequently seen in the ED at ever-younger ages. However, patients with eating disorders rarely present with their eating symptoms as the chief complaint. Much more frequently, these youngsters present with a co-morbid psychiatric illness or a medical complication as their chief complaint. It takes the skill of an astute diagnostician to accurately uncover the underlying eating pathology and refer the child for appropriate treatment.14
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References 1. Kaye WH, Frank GK, Strober M: Anorexia and bulimia nervosa. Ann Rev Med 51:299-313, 2000. 2. Szabo S: Food for thought. Ann Emerg Med 38: 184-185, 2001. 3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders Revised (ed 4). Washington, DC, American Psychiatric Press, 1994. 4. Fairburn CG, Beglin SJ: Studies of the epidemiology of bulimia nervosa. Amer J Psychiatr 147:401-408, 1990. 5. Ricciardelli L, Williams RJ, Kiernan MJ: Bulimic symptoms in adolescent girls and boys. Internat J Eating Disorders 26:217-221, 1999. 6. Johnson AS, Hillard JR: Prevalence of eating disorders in the psychiatric emergency room. Psychosomatics 31:337-341, 1990. 7. Bulick CM, Sullivan PF, Fear JL, Joyce PR: Eating disorders and antecedant anxiety disorders: A controlled study. Acta Psychiatr Scand 96:101-107, 1997. 8. Ivarsson T, Wentz E, Gilberg IC, et al: Depressive disorders in teenage-onset anorexia nervosa: A controlled longitudinal, partly community-based study. Comprehen Psychiatr 41:398-403, 2001. 9. Steinhausen H, Seidel R, Metzke C, et al: Evaluation of treatment and intermediate and long-term out-
come of adolescent eating disorder. Psychol Med 30: 1089-1098, 2000. 10. Robb AS, Ellis N, Orrell-Valente JK, et al: Supplemental nocturnal nasogastric refeeding may improve short-term outcome in inpatient adolescent females with anorexia nervosa. Am J Psychiatr 159: 1347-1353, 2002. 11. Mitchell JE, Pyle RL, Eckert ED, et al: Metabolic acidosis as a marker for laxative abuse in patient with bulimia. Internat J Eating Disorders 6:557-560, 1987. 12. Siegel JH, Hardoff D, Golden NH, et al: Medical complications in male adolescents with anorexia nervosa. J Adolesc Health 16:448-453, 1995. 13. Adson DE, Trenker SW: The superior mesenteric artery syndrome and acute gastric dilation in eating disorders: A report of two cases and a review of the literature. Internat J Eating Disorders 21:103-114, 1997. 14. Doraiswamy PM, Boyko OB, Husain MM, et al: Pituitary abnormalities in eating disorders: Further evidence from MRI studies. Biol Psychiatr 15:351-356, 1991. 15. Howard MR, Leggat HM, Chaudhry S: Hematological and immunological abnormalities in eating disorders. Brit J Hosp Med 48:234-239, 1992. 16. Salisbury JJ, Mitchell JE: Bone mineral density and anorexia nervosa in women. Am J Psychiatr 148:768774, 1991.
Master of Disguise: Eating Disorders in the Emergency Department By Adelaide S. Robb, MD WASHINGTON, DC
E
From the Psychiatry and Behavioral Sciences, Children’s National Medical Center. Supported in part by a NARSAD Young Investigator Award. Address reprint requests to Adelaide S. Robb, MD, Children’s National Medical Center, 111 Michigan Ave. NW, Washington, DC 20010-2970. E-mail: [email protected]. 1522-8401/$—see front matter © 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.cpem.2004.05.002
ATING DISORDERS ARE AN IMPORTANT diagnosis in all pediatric age groups as they have significant medical and psychiatric morbidity and mortality. Many eating disorders are difficult to diagnose, and patients and families may not seek treatment early in the course of the illness. Frequently, children with eating disorders may first seek treatment in an emergency department (ED) setting. Eating disorder patients may present to the ED because of a variety of reasons, including complaints not related to the underlying eating disorder. For many children suffering from an eating disorder, an astute diagnostician in the ED may facilitate an early diagnosis and referral for treatment of the eating disorder. In one study of a general medical population, less than 30% of patients let their primary care doctor know about the underlying eating disorder.1 This first section of this article will discuss the eating disorders that present most frequently in the toddler, school-age, and adolescent age groups. The second section of the article will discuss the major psychiatric and physical presentations of eating disorders in the ED.
Toddlers Toddlers can develop eating disorders with the transition to solid food and self-feeding. Infantile anorexia is the most common serious eating disorder in this age group. Children with infantile anorexia develop their illness because of difficulty with the transition to self-feeding. These children are much more interested in watching everything in their surroundings and the EA T ING D I SORD ERS I N T H E EMERG EN CY D EPA RTMEN T / A D ELA I D E S. ROB B
181
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environment than sitting quietly and eating their meals. As a consequence, these children tend to fall off the growth chart; they appear to have normal head circumference with low weight and height percentiles, regardless of parental growth parameters. Children with this disorder require care by a nutritionist and a child psychiatrist skilled in the treatment of infantile anorexia. The main goal of treatment is to remove the conflict and battle of wills from the mealtime. Meals are to be eaten in a specific setting and at a specific time without between meal snacks and chasing the toddler around the home begging her to eat. Other types of eating disorders that can present in toddlers are the post-traumatic feeding disorders. These children have a traumatic event during feeding such as choking on a piece of solid food or gagging on spoon-fed solids. After the choking incident, the child becomes afraid of the spoon or of specific solid food. If the incident was very frightening for the child, he may avoid or refuse all solid foods.2 It is the careful documentation of the history of onset of symptoms after a gagging or choking incident that will point toward this eating disorder. To the parent of the young toddler, the incident may seem minor such as the child gagging on a spoonful of cereal when fed. Treatment of this disorder would require hospitalization if the symptoms are severe and the child refuses all foods and beverages. If the child is only refusing solids, treatment can take place outside the hospital setting, employing a gradual reintroduction of solid foods. The emphasis is on maintaining caloric intake with formula or milk, and having the toddler start self-feeding with finger foods that were previously enjoyed. New and rougher textures are reintroduced gradually and utensils such as spoons are avoided in the beginning. This method allows the toddler to set the pace and feel more secure about solid foods.
School Aged Children Children prior to adolescence may present with signs and symptoms of anorexia nervosa. Since the diagnosis is much less common in pre-pubertal children, the clinician must remain aware of its presence in this age group in any child who presents with low weight. A second common eating complaint in this age group is the picky eater who only eats a select group of foods and refuses to try new foods. While this eating disorder is not lifethreatening, frustrated parents may present to the
ED asking for help. These children may be below family percentiles for linear growth and may have another relative with the same eating problem. Treatment includes meeting with a child psychiatrist and nutritionist to gradually expand food choices.
Adolescents The two most common eating disorders that present in adolescence are anorexia nervosa and bulimia nervosa. These disorders and their presentations in the emergency room will be discussed separately. Anorexia nervosa, according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), is a disorder of eating characterized by a weight of ⬍ 85% ideal body weight, fear of fatness, distortion of body image, and amenorrhea in females.3 This disorder has a male to female ratio of 1:9. Patients with anorexia nervosa may present to the ED with a chief complaint of “I have anorexia and need to be admitted to the hospital.” However, patients with anorexia may present to the ED with other physical or psychiatric symptoms. If the teenager is not questioned separately from the parent to verify the oral intake and ascertain concern about weight loss and excessive exercise, the diagnosis may be missed. Many adolescent boys who develop Anorexia begin their illness as overweight teenagers. They want to lose weight to be more fit and will start cutting out entire food groups (meat, fats) with no idea of the calorie content of foods. Such a drastic alteration in intake and exercise may lead to large weight losses in relatively short periods of time. Bulimia nervosa is an eating disorder characterized by recurrent eating binges 2⫻/week for three months, excessive preoccupation with weight and shape, and measures to reduce weight gain from the binges.3 Bulimia nervosa may arise de novo in an adolescent as the initial eating disorder. In other teens it may arise after a prior episode of anorexia nervosa. The prevalence of Bulimia in adult women may be as high as 2% to 3%.4 Rates in adolescent males are 0.1%-0.7%.5 Because patients with Bulimia may appear normal or can even be overweight, they are not visually obvious as eating disorder patients. This appearance makes them much less likely to be seen as eating disorder patients in the ED. Treatment of both anorexia and bulimia requires a team approach and may need inpatient, partial, or outpatient therapy settings.
EA T ING D I SORD ERS I N T H E EMERG EN CY D EPA RTMEN T / A D ELA I D E S. ROB B
Psychiatric Presentations Eating Disorder The most straightforward presentation of the eating disorder patient in the ED is the patient who presents for medical clearance before a psychiatric or medical admission for nutritional rehabilitation and psychiatric therapy. While these patients come with their eating disorder diagnosis known, they still require a thorough physical and psychiatric evaluation. Patients presenting with eating disorders need to be assessed for the common co-morbid medical and psychiatric illnesses. Without diagnosis and treatment of the co-morbid illnesses, the eating disorder treatment may fail. Much more frequently, eating disorder patients present with other psychiatric or physical symptoms as the chief complaint. Without a careful assessment especially for the cardinal symptoms, patients may be missed. In a study of 143 patients presenting to an adult psychiatric ED with non-eating disorder complaints, no patients had anorexia nervosa while 3.0% of women and 2.6% of men had bulimia nervosa that they had not revealed to their treating outpatient clinicians.6
Anxiety Disorder Anxiety disorders may occur in up to 60% of patients with eating disorders.7 The most common anxiety disorders seen in patients with eating disorders include obsessive-compulsive disorder, generalized anxiety disorder, panic disorder, and social phobia. When patients with eating disorders present for assessment, one needs to evaluate them for a co-morbid anxiety disorder. If the anxiety disorder is not treated or recognized, the eating disorder may remain refractory to treatment. Some eating disorder patients may present to the ED with a chief complaint of anxiety. If the clinician does not assess the patient with anxiety for eating symptoms, difficulty may arise in tailoring the patient’s treatment.
Mood Disorder and Suicide Attempts Mood disorder is one of the most common comorbid disorders with eating disorders. This includes both major depression and bipolar disorder. Major depression has a lifetime prevalence in eating disorders as high as 80%.8 Bipolar disorder occurs as well in patients with eating disorders. When patients present with either affective disorder, neu-
183
rovegetative symptoms of change in weight or appetite are common. When patients present with an affective disorder and these appetite and weight changes, clinicians may stop their inquiry after diagnosing the mood disorder. If one does not also ask about distortion of body image, fear of fatness, bingeing episodes, restricted eating, and methods to eliminate calories after a binge, the clinician may miss a co-morbid eating disorder. With bulimia, affective disorder patients may be vomiting up their medications. They may present with low levels of mood stabilizers or “treatment resistant” mood disorder secondary to multiple lost doses of their antidepressant and mood stabilizers. The mortality rate from adolescent anorexia nervosa can be as high as 8.3% at 11 years with 50% of the mortality in anorexia coming from suicide.9 When patients present to the ED with a suicide attempt, affective disorders should always be the first diagnosis on the differential. However, eating disorders and their symptoms should also be assessed in patients who present with any suicide attempt.
Substance Abuse Disorder Patients with eating disorders may have co-morbid substance abuse disorders. Patients with anorexia nervosa who are trying to lose their appetite and restrict calories may use stimulants, cocaine, and amphetamines to limit their oral intake. Eating disorder patients with bulimia nervosa may use a variety of substances, including binge drinking of alcohol. Another substance that is also abused by bulimics is ipecac in an effort to promote emesis. Chronic ipecac use may lead to medical complications discussed below. Some patients with an underlying eating disorder will present to the ED with substance abuse complaints and/or intoxication. If the clinician does not inquire about other psychiatric symptoms including mood, anxiety, and eating symptoms, those diagnoses will not be made.
Cognitive Disorder Patients with profound starvation and caloric restriction may complain of cognitive deficits. They may have difficulty with memory and concentration and complain of a gradual decline in academic performance. On examination in the ED, such patients may appear cognitively slowed as if the patient had a cognitive deficit or learning disability. Such patients may also appear very rigid or fixed in their thinking patterns.
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Medical Presentations General Patients with eating disorders may present to the ED with signs and symptoms of extreme weight loss and starvation. For young children with infantile anorexia, they may present as a failure-to-thrive child. Parents may note the child has refused to eat most solid foods and has fallen off the linear and weight growth curves while maintaining adequate head circumference. Parents of older children with underlying anorexia or bulimia nervosa may bring their child to the ED for unexplained weight loss. Parents may complain that their child eats normal amounts at home and has lost weight. Such a child may be suffering from anorexia nervosa and eating a normal 800 to 1000 kcal dinner with parents while consuming no calories for the rest of the day and exercising excessively to burn extra calories. Parents of a bulimic teenager may describe a child who eats lots of food including high calorie, high fat foods such as several slices of pizza and a whole carton of ice cream without gaining weight. What those parents do not realize is that after a binge of consuming, the teenager then purges all the calories or restricts the amount of subsequent food eaten and exercises excessively to eliminate the weight gain. Complaints of malaise and fatigue secondary to malnutrition and starvation are other general presentations in the ED.
Metabolic/Endocrine Patients with eating disorders may present with signs and symptoms of an underactive metabolism. They may complain of lanugo, hypothermia, and cyanotic extremities. Some patients with eating disorders may have hypothyroidism with low T3, low normal T4 and free T4, and normal to low thyroidstimulating hormone (TSH). This is the pseudohypothyroidism of starvation. In one study of adolescent girls with anorexia nervosa, the average T3 on admission to the hospital was 54.7 ng/dL.10 Patients with eating disorders may also present with marked abnormalities in their glucose metabolism. They may have hypoglycemia from starvation. They may present in ketoacidosis from starvation. They may also have elevated glucose from frequent bingeing and purging. In addition adolescent patients with diabetes mellitus may use noncompliance with their insulin regimen as a way
to eat all they want without the fear of weight gain. Hypercholesterolemia, hypertrigylceridemia, and hypercarotenemia may also be present in patients with eating disorders.
Renal/Electrolyte Patients with eating disorders may present with a variety of renal and electrolyte complications both from long-term starvation and from acute manipulations of fluid and electrolyte balance.11 One of the long-term complications of anorexia nervosa is renal impairment with increases in both blood urea nitrogen (BUN) and creatinine with renal failure as one of the more frequent physical causes of mortality in patients with anorexia nervosa. Patients with anorexia may fluid restrict as a way to decrease weight and can present with signs of dehydration such as elevated BUN and creatinine, hypernatremia, alkalosis, and hypokalemia. At times, patients with anorexia may water load to meet weight goals imposed by parents or physicians. These children could have severe hyponatremia and other symptoms of water intoxication. Anorexia nervosa patients may also have hypocalcemia, hypophosphatemia, and hypomagnesemia. Patients with bulimia nervosa who vomit will have signs and symptoms of persistent emesis including hypochloremic metabolic alkalosis. Other patients with bulimia nervosa may abuse diuretics and present with hypokalemia or abuse cathartics and present with a contraction alkalosis.
Cardiac Cardiac symptoms in eating disorders are very common. For patients with anorexia, two of the compensatory calorie-saving adaptations to starvation are bradycardia and hypotension. These adolescents may present to the ED with complaints of dizziness or syncope. Patients may have such severe bradycardia, with rates lower than 40, that an escape or junctional rhythm is present. They may also have first and second-degree heart block and abnormalities in QT intervals. After refeeding, patients may present with refeeding syndrome which includes large shifts between intra and extracellular electrolytes, especially hypophosphatemia and hypocalcemia. This may lead to compensatory fluid shifts and high output cardiac failure. While the body does attempt to spare muscle, especially myocardium, patients with prolonged starvation may have decrease in myocardium mass. Usually heart rates become normal with refeeding, but patients who present with a normal heart rate with extreme
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starvation may be at increased risk for cardiac complications.12 For some bulimia nervosa patients prolonged vomiting or diarrhea with the accompanying electrolyte and pH shifts may lead to a variety of arrhythmias. Because some of the electrolyte disturbances are chronic, patients may have markedly abnormal electrocardiograms without any cardiac complaints at presentation. An electrocardiogram is advised in patients with bulimia nervosa, especially if electrolyte disturbances are noted on laboratory examination. Abuse of syrup of ipecac may also be present in some children with bulimia nervosa. Long-term use of this drug can lead to a cardiomyopathy.
Gastrointestinal Patients with eating disorders may present to the ED with a variety of gastrointestinal complaints. A lack of calories and oral intake causes chronic constipation, even obstipation in anorexia nervosa patients. These individuals may also present with complaints of lack of appetite or stomach pain. Patients with severe starvation who have started to eat again at home may present with severe abdominal pain. This presentation can indicate superior mesenteric artery syndrome with occlusion of the gastrointestinal blood vessels and infarction of the gut.13 Patients who have been starving for prolonged periods of time and then start eating large quantities of food again are also at risk for gastric rupture. Both of these rare complications of anorexia nervosa are potentially life threatening. Bulimia nervosa adolescents are more likely to complain of chronic vomiting and diarrhea. For individuals who vomit frequently, they may also have erosion of dental enamel, multiple caries, and parotitis. The knuckles of the dominant hand may also exhibit Russell’s sign, the classic callus from repetitive gagging and trauma to the knuckles. Patients with persistent vomiting may also present with hematemesis and are at risk for a Mallory Weiss tear, which can be life threatening. Patients with rapid weight loss from anorexia and bulimia are at risk for cholelithiasis and may present with biliary colic in the ED.
Neurologic Patients with eating disorders and accompanying electrolyte disturbance may present with seizures. Because of increased risks of seizures in these children, psychotropics that lower seizure threshold, such as Buproprion, are contraindicated. If a patient on Buproprion presents with a seizure, the
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clinician must check for both overdose and underlying eating disorder. Patients with long term starvation will also experience loss of both gray and white matter on computed tomography (CT) or magnetic resonance imaging (MRI) scans.14 In patients requiring a CT in the emergency department for head injury, such volume loss may be present in a thin patient without signs or symptoms of a neurologic illness associated with central nervous system (CNS) atrophy. When such a CT scan appears, parents and patient must be questioned about eating disorder symptoms. With volume loss in the CNS, eating disorder patients may be more vulnerable to shear injuries and may be more likely to have sequelae after closed head injury including hemorrhage.
Hematologic Starvation may lead to alterations in the hematologic system as well. Patients with starvation who fail to take a multivitamin with iron can present with an iron deficiency anemia. With more severe starvation they may also have lymphocytopenia, thrombocytopenia or even pancytopenia.15 Despite the lowered blood counts patients with eating disorders rarely present with infection secondary to a suppressed immune system. Patients may have increased bruising and prolonged bleeding times secondary to impaired platelet function.
Orthopedic Some patients with anorexia nervosa and bulimia nervosa suffer from osteoporosis and osteopenia.16 Because their bones are more fragile, they may have more fractures or fractures may be present after an injury that would not normally lead to a fracture. In addition since both groups are frequent abusers of exercise in an effort to lose weight, they may suffer from stress fractures, muscle and tendon damage, and shin splints.
Summary Eating disorders are frequently seen in the ED at ever-younger ages. However, patients with eating disorders rarely present with their eating symptoms as the chief complaint. Much more frequently, these youngsters present with a co-morbid psychiatric illness or a medical complication as their chief complaint. It takes the skill of an astute diagnostician to accurately uncover the underlying eating pathology and refer the child for appropriate treatment.14
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