Eating Disorders 3

Purging type is they do something to get rid of it. Non-purging type; they either fast or exercise. You can get this over the counter, Diurex. They may take 60 or 80 of them a day, 60 or 80 laxatives. I mean, it’s like your pants have to be so tight that during your period you have to use Diurex so you can fit into them.

Now what can happen? I’m going to mix together both anorexia and bulimia and look at general medical complications of eating disorders, largely because they happen together. Very few patients are pure restrictors or pure bulimics. So you should be looking for this in any patient with an eating disorder. Hypokalemia; what does hypokalemia hypochloremic alkalosis make you think of? Pyloric stenosis, exactly the same. If you have a thickened pylorus or you have bulimia and are vomiting, it’s the same thing. Hypochloremic hypokalemic metabolic alkalosis. You treat it the same too, except you don’t fix the pylorus. You can get hyponatremic from water loading or using diuretics, elevated BUN because they are chronically dehydrated. They have abnormal vasopressin secretion so they are unable to concentrate urine, often don’t drink a lot so their GFR can be down, and ketonuria because you are breaking down your own protein. One of the things that happens with the elevated BUN and being chronically in a dehydrated state is all your sodium retention hormones are revved up, and we’ll talk about that in a minute. Bradycardia; it’s like going into hibernation. Your body shuts down. It’s almost like being excessively hypothyroid. Orthostatic hypotension. If you have a Board question about a patient that stands up and has a significant blood pressure change, they need to be in the hospital because their compensatory mechanisms don’t work very well in general with their low weight, so if they do have a significant orthostatic hypotension, that’s an ominous sign. Also if they feel weak.

They can have dysrhythmias from electrolyte abnormalities and also from thinned heart muscle. Ipecac; I haven’t seen much of this lately, but when ipecac was given out on almost every well-child visit, a lot of teenagers had access to it. They would take it so they could throw up, so they didn’t have to stick their finger or toothbrush down their throat, but it takes more and more and more to induce vomiting. Ipecac is a neurotoxin, a myotoxin, so they end up having cardiomyopathy, and a peripheral myopathy. You can get MVP just because you lose heart muscle and you stretch the cords to the valve and you’ll have someone who has prolapse. When they gain weight again, the prolapse goes away.

Congestive cardiac failure. This is when your aldosterone and your angiotensin system are really revved up. You get too much free water. It goes into your lungs and backs up into your heart. You get kind of a cor pulmonale, you get pericardial effusion. You get low voltage because there’s not much heart to conduct. A prolonged QT syndrome is particularly ominous. Any newly diagnosed anorectic should have a 12 lead EKG with a long rhythm strip. If they are hypokalemic they have low T-waves, if they are hyperkalemic they have tented T-waves. QT can be quite prolonged, in which case you need to monitor them very closely.

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