Diseases information. Disorders. Treatment.

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.

From a GI standpoint; they get chipmunk cheeks. When you see adolescents who have anorexia nervosa, yet their cheeks look fairly broad - they look like they have mumps - it’s when you vomit a lot either through anorexia with purging or bulimia with purging, you get parotid hypertrophy. They are non-tender. And sometimes after purging, if they stop, their salivary glands are so used to producing they can get huge cheeks. They really do look like they have mumps. Their amylase is up. The loss of dental enamel; where do they have it? What part of their teeth? The lingual aspect. The inner aspect, because when you vomit the acid etches the inside of the teeth. Constipation; nothing going in, nothing going out. Bloody diarrhea is a complication of laxatives or cathartics, and constipation can also come from the use of laxatives and cathartics because they get a cathartic colon. They get intestinal atony. That also can come from hypokalemia or hypophosphatemia. Most patients with bulimia have delayed gastric emptying, as do patients with anorexia. So when they are re-fed they feel full all the time. And they really do feel full.

You can get esophagitis from acid going up, Mallory-Weiss tears from vomiting too often. You get streaks of blood. So a patient who all of a sudden has streaks of blood in their saliva from vomiting, think of bulimia. A perforation rupture of the stomach; almost unheard of, but that’s from eating too much. Fatty infiltration, focal necrosis of the liver. This can be really difficult because if you get really low weight your liver doesn’t work very well, it gets fat in it, your cholesterol goes up. You do a cholesterol on an anorectic and they see that the cholesterol is 210 but they haven’t looked at fat in a decade. It can be very disturbing. They even cut down more on fat. Acute pancreatitis but you should subdivide the amylase and do a lipase to make sure it’s not from the parotids. Superior mesenteric artery syndrome; what’s that? That’s when you are so thin when you lie down your superior mesenteric artery occludes your duodenum and you have vomiting. So every time they lie down they have vomiting. And gall stones.

Acrocyanosis just means cold hands and feet. Doesn’t necessarily mean warm heart. Yellow, dry skin. They look like a baby who is eating too many yellow vegetables. They don’t process carotene very well. So a thin patient who comes in, who is yellow but has normal liver function tests, think of anorexia. Brittle hair and nails, lanugo, just like a newborn baby, it’s to maintain temperature. Hair loss is often after they are gaining weight because they have antigen effluvium where they’ve shocked their head, and as they are gaining weight they lose hair and they are really pissed off at you because, “Hey you are making me gain weight and my hair is falling out.” Russell’s sign: Dr. Russell described it as calluses over the knuckles from sticking your finger down your throat. Pitting edema; once again, if your aldosterone system is turned on you take too much free water, it goes into the vessels and then into the periphery.

What you do is you take a weight for height chart, find the height, the patient we are talking about is somewhere between 170 and 175 cm. You go down to what the 50th percentile median weight for height is; that’s 55.5 I think, or is it 60? Okay, 60. Then you plot it. On this curve here you have a patient who is about … these are hard to see, whatever that percentile is. I think that’s 50th and this is at this height here. That’s the ideal body weight and that’s the ideal body weight there, and that’s the one that’s based on the height. Fiftieth percent for weight here.

Why don’t growth charts work? Well, what they did was, they took everyone at a certain age and did their height and everyone at a certain age and did their weight, but it’s not the same person who’s having the weight done. So you can have someone very tall and very large, very tall and very thin, very short and very thin, and very short and very … so it really mixes everything up so you can’t say, “Well, this patient is 50th percent for height therefore they should be 50th percent for weight. It works okay around 50th percentile, but you go here to 75th percentile, or 95th percentile probably up there, and you look at that and this is what you would say they would weigh. That’s an awful heavy person. This is what they really should be weighing. Look at the discrepancy. This is using the chart. Remember it was 60. So you should always use a height/weight chart once you get past puberty.

So bulimia; it’s recurrent episodes of binge eating. It’s not going out for your birthday to Cheesecake Factory. It’s more than any normal person would eat during a defined period of time. And a lack of control. That you just eat and eat and eat and can’t control it. Compensatory behavior; now that can be purging. Remember, with bulimia it’s the binge that’s important. How you compensate for it isn’t part of the diagnosis, other than whether you are a restrictor or non-restrictor. Recurrent inappropriate compensatory behavior to prevent weight gain; it could be self-induced vomiting, laxatives, diuretics or other medications. Fasting or even excessive exercise. Once again, if you ask someone with bulimia to draw themselves it’s very interesting to see how distorted the image is. This is just saying that this isn’t anorexia nervosa. How do you tell the difference? Anorexia nervosa are always thin. They may have purging but they don’t always have bingeing. Bulimia always has bingeing but they can be normal weight, below weight, or heavy.

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.

About half a percent of 15-19-year-olds have anorexia nervosa. Bulimia nervosa, it’s around 1-5%. But if you do surveys of self-induced vomiting in women, between 10 and 15% of women, depending on the sample, have had self-induced vomiting. Wrestlers, if you ask them - male wrestlers, not female wrestlers - you will find that a fair number of them will have self-induced vomiting to make weight. They’ve gotten around that by making the wrestlers weight mid-season and then right at competition. If there’s too much of a change in weight they won’t allow them to compete.

So anorexia. That’s refusal to maintain body weight over minimal weight for age and height; 15% below expected, or failure to make expected weight gain during a period of growth leading to body weight below 15%. But that’s complicated. I’ll show you in a minute. Intense fear of gaining weight. You’ve all dealt with anorexics. They are horrified of gaining weight, well most of us are too, but … the thing that you need to realize is that with young women in puberty and men in puberty, the two largest increasing groups of eating disorders are people of minority status and males. You see here, here’s the normal growth. Remember the familiar … you can see normal height up here, and this is what the expected weight increase should be. She goes up here and she maintains weight, so if you just went by maintaining stable weight you’d say she’s doing fine. But if you compare what her weight is to what it should be, she’s losing ground and at this point she becomes about 84% of ideal body weight. Body weight and shape are disturbed. You look in a mirror and your hips are too big. You can see your ileac crest and that’s considered to be fat because it’s something that pokes out. There is usually amenorrhea.

Two types of anorectics; those that restrict, which means that during anorexia nervosa they don’t binge or purge. One of the problems in looking at weight loss for teenagers is you are using the growth chart. You cannot use a growth chart. I’ve included in here the weight in kilograms for a 17-year-old.