Eating Disorders 5

Endocrine problems; growth retardation or short stature, delayed puberty. Of course amenorrhea. Low T-3 syndrome just means that what happens is T-3, if you measure it, is low but reverse T-3 is reversed. They really don’t have … they kind of look functionally hypothyroid but their TSH is normal. They develop a partial diabetes insipidus, as I said before. They lack the diurnal variation in ADH. Cortisol levels are really high. Growth hormone levels are really high. It’s stress. Your body is saying, “I want to do better.” Skeletal; you have osteopenia and fractures. One of the problems is, how do you deal with this? There is no evidence that birth control pills help in a really low weight anorectic. We often do it, but you should, in a really thin anorectic with amenorrhea, you should get a bone density to look for osteopenia. If they are exercising a lot they can get fractures, and exercise alone doesn’t compensate. It can help but it doesn’t completely compensate.

If you do a smear, there is mild marrow suppression, mild anemia. They can have leukopenia, thrombocytopenia. Sed rate is always low, so you can’t use that as an indicator of inflammation. It’s usually 1 or 2. They have impaired cell mediated immunity in the lab, but if you do studies of patients with anorexia they don’t have more colds or sore throats than the average patient.

From a neurologic standpoint, you have seizures from an electrolyte instability, myopathy from ipecac and just weight loss. You can have peripheral neuropathy, particularly from a B6 deficiency. Cortical atrophy. Now in the past we thought this was regained. A new study that just came out from Toronto sick kids shows that an MRI shows cortical atrophy that does not go back to normal with weight gain. Now this is short-term. Perhaps with long-term weight gain – but it’s kind of scary if you lose actual brain tissue with your weight loss. When you put patients in the hospital, it depends upon what kind of insurance they have. Really, this is from the Society for Adolescent Medicine, indications for hospitalizations; I have found this useful, as other people have, if you use this and say, “This is what the Society for Adolescent Medicine says …” insurance companies will back down because they don’t want to be sued. So if you send them a critical pathway or a guideline, they will often say okay. But you have to do it. Sometimes they won’t.

Severe malnutrition; weight less than 75th percentile of ideal body weight using weight-for-height charts not growth chart, dehydration, electrolyte disturbances, dysrhythmia and significant physiological instability. If you are not growing, you can actually prematurely close your epiphysis. Failure of outpatient treatment. If they are not eating at all, that’s a good reason to put them in the hospital. And uncontrolled bingeing and purging. Often patients with bulimia, unless you arrest the cycle, you can’t stop the process. So putting them in a day treatment program, they’ll just vomit all night, so they often need to go in the hospital.

Medical complications; seizures, syncope and such. Acute psychiatric emergency such as suicide ideation or psychosis, and comorbid diagnosis, particularly if they can’t live with their family. They can’t live with their family. Now what is the one thing that pediatricians miss, and that may show up on a Board question, and that’s hypophosphatemia. There have been several cases of death in anorectics if you re-feed them too fast. If you re-feed a TPN patient with short gut too fast you have hypophosphatemia. So you really must follow electrolytes as you are re-feeding. And the NPI in their eating disorder unit they’ll often start with 600 calories a day and slowly re-feed. What can happen? You can screw up your heart. You have altered RBC morphology, you can have liver dysfunction. Paralysis; patients don’t like that very much. Confusion, coma, cranial nerve palsy, sensory loss, Guillain-Barre syndrome. Ventilatory failure – you stop breathing – that’s also not a good thing to do.

So how do you avoid it? Know that it could happen. Re-feeding anybody who is emaciated. This is like the concentration camp survivors. Some died when they were re-fed too quickly. A Big Mac is not the best thing after being starved. Recognize who is at risk. Test and correct electrolyte abnormalities before initiating nutrition, restore circulatory volume, monitor pulse rate, increase calories slowly. Vitamins; monitor particularly phosphorus, potassium, magnesium. Glucose isn’t usually a problem, and I don’t do urinary electrolytes. The authors here say a little nutritional support is good, too much is lethal.

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