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Medical Complications Of ED

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The medical complications encountered in the treatment of the eating disorder patient.

The medical complications encountered in the treatment of the eating disorder patient.

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Transcript

  • 1. EATING DISORDERS Medical Complications Nomi Fredrick MD Medical Director Pacific Shores Hospital Rader Programs
  • 2. Morbidity & Mortalityeating disorders have the highest mortality of anypsychiatric illnesses—higher than depression,schizophrenia, or bipolar disordercardiac complications are the most common cause ofdeath, with suicide being second in the younger populationlifetime mortality rates peak at 15–18%, approaching thedeath rates of certain cancersthe mortality rate for AN is more than 12 times higher thanthe general population of 15- to 24-year-old females
  • 3. Morbidity & MortalityBN has an overall lower mortality rate than restricting ANEDNOS is the most populated diagnostic group, and maycarry a higher mortality and complication rate than eitherAN or BNa substantial number of ED patients are dangerouslyoverlooked if clinicians only consider at risk those whofulfill strict diagnostic criteriaoverall death rates from ED approach 20%
  • 4. Signs & Symptoms Generalmarked weight loss, gain or fluctuationsweight loss, weight maintenance or failure to gain expectedweight in a child or adolescent who is still growingcold intoleranceweaknessfatigue or lethargydizziness and syncopehot flashes and sweating episodes
  • 5. Signs & Symptoms Oral & Dentaloral lacerations and ulcers from mechanicaltrauma, immunodeficiences and vitamindeficiencesdental erosion and dental cariesperimolysissalivary gland hypertrophy and impactation
  • 6. Signs & Symptomslanugo hair Dermatologicalhair lossyellowish discoloration of skinpoor skin turgor and healingimpaired capillary refillcalluses or scars on the dorsum of the handspellagra
  • 7. Signs & Symptoms Metabolichypokalemia from vomiting or diuretic or laxativeabuse leading to a metabolic alkalosis but somelaxatives can cause a metabolic acidosishypoglycemia may be severe and life threateningbecause glycogen stores in the liver are depleted instarvationhyperglycemia and diabetic ketoacidosis are commonin diabulimiahyponatremia, hypophosphatemia, hypomagnesemia,hypocalcemia
  • 8. Signs & Symptomschest pain and heart palpitations Cardiovasculardiminished peripheral circulation and acrocyanosisbradycardiaarrythmias and QT prolongation with increased risk ofsudden deathshortness of breathedema and ascitesorthostatic hypotension
  • 9. Signs & Symptoms Hematologicall components of the bone marrow are diminished theorder in which is wbcs > rbcs > platelets related to the totalbody fat mass lossanemia may be from several sources including chronicdisease, blood loss, vitamin and/or iron deficiencies -ferritin may be falsely elevated when there is hepaticbreakdown from starvation!the immune system is compromised with decrease in cd8 tcells and neutrophilsabsolute neutrophil count should be calculated and infectionprecautions institued if anc < 1000
  • 10. Signs & Symptoms Renalincreased incidence of chronic kidney disease because of dehydrationand chronic malnutritioncreatinine may be increased because of renal insufficiency or failureor decreased because of decreased muscle massnormal creatinine may be relatively elevated given the decreasedmuscle mass and may indicate impending renal insufficiency -creatinine clearance should always be done!hyperkalemia is an impending sign of renal problems becausenormally the potassium is low because of purgingdiabulimics have more of the secondary effects of diabetes with renalinsufficiency and failure because of poorly controlled blood sugarsand misuse of insulin
  • 11. Signs & Symptoms Gastrointestinalepigastric discomfortearly satiety, delayed gastric emptying, gastroparesisgastroesophageal reflux and ulcersesophageal strictures leading to dysphagiabarrett’s esophagitishematemesis and Mallory Weiss tearssuperior mesenteric artery syndrome
  • 12. Signs & Symptoms Gastrointestinalpancreatitisfatty infiltration of liver and elevatedtransaminasesconstipation, small bowel obstruction andimpactionhemorrhoids and rectal prolapsehematocheziaincreased incidence of IBS
  • 13. Signs & Symptoms Endocrinehypothalamic pitutitary gonadal axis is underactiveand levels are low of fsh and lh in females causinglow levels of estrogen and progesterone leading tosecondary ammenorhea and irregular mensesin males this causes low androgen levels andimpotenceloss of libidolow bone mineral density and increased risk ofosteopenia, osteoporosis and fractures
  • 14. Signs & Symptoms Endocrineabnormal responses of gut hormones: leptin, ghrelin, peptide yy,gastric inhibitory peptide, glucagon-like peptide 1, amylin,pancreastic polypeptide, cholecystokinin and insulinone year after losing weight appetite regulating hormones don’treturn to baselineanorexics have abnormal responses and levels of leptin and ghrelinwhich in over 50% of cases do not return to normal baseline oneyear after weight restorationincreased risk of diabetes II in bulimia and binge eatingwith diabulimia there is an increased risk of serious complicationsin diabetes i because of noncompliance with insulin to lose weight
  • 15. Signs & Symptoms Neuropsychiatricseizuresdeficits in memory tasks, flexibility and inhibitorytaskscerebral atrophy and the ventricular spaces andsulci increasegreater risk of Alzheimer’s in females because ofprolonged state of estrogen deficiencyabnormal responses to high calorie images withincreased activation in the amygdala and insula
  • 16. Signs & Symptoms Neuropsychiatricinsomniaself harmsuicidal ideation/ suicide attemptincreased risk of mood and anxiety disordersincreased risk of OCD, AN>>BNincreased risk of Borderline PD, BN>>ANincreased risk of substance abuse in BN and AN withpurging
  • 17. Signs & Symptoms Illnesses That Mimic EDschronic disease or infectiongastrointestinal disorders: celiac disease, ulcerativecolitis, chronic parasitic or bacterial infections,malabsorptionendocrine disorders: diabetes mellitus, addison’sdisease, hyperthyroidism, hypopituitarismcancerssuperior mesenteric artery syndrome (can also be aconsequence of an eating disorder)
  • 18. Signs & Symptoms Illnesses Associated With EDsdiabetes mellitusceliac diseasegastric bypassconditions that require increased attentiontoward or regulation of food intakeattention deficit hyperactivity disorder
  • 19. Laboratory Valuesglucose: ↓ poor nutrition,↑insulin omission Metabolicsodium: ↓ water loading or laxative abusepotassium: ↓ vomiting, laxatives, diuretics, refeedingchloride: ↓ vomiting, laxativesblood bicarbonate: ↑ vomiting, ↓ laxativesblood urea nitrogen: ↑dehydrationcreatinine: ↓ dehydration, renal dysfunction, poor muscle mass,normal may be “relatively elevated given low muscle masscalcium: slightly ↓ poor nutrition at the expense of bone
  • 20. Laboratory Values Metabolicphosphate: ↓ poor nutrition or refeedingblood bicarbonate: ↑ vomiting, ↓ laxativesmagnesium: ↓ poor nutrition, laxatives, refeedingtotal protein/albumin: ↑ early in malnutrition at the expenseof muscle mass, ↓ in later malnutritiontotal bilirubin: ↑ liver dysfunction, ↓ poor rbc masssgot, sgpt: ↑ liver dysfunctionamylase: ↑ vomiting, pancreatitislipase: ↑ pancreatitis
  • 21. Laboratory Values Complete Blood Countleukopenia, neutropenia, anemia or thrombocytopeniaanemia may be microcytic if iron deficiency is present,macrocytic if alcohol abuse or vitamin b12/folate deficiencypresent and/or anemia of chronic diseasebone marrow biopsy may be necessary if blood dyscrasias donot resolve with nutritional rehabilitationconsider IV iron if not responding or unable to tolerate posupplementation because of worsening constipationneutropenia may be present and an ANC should be calculatedhypercoagulable states may be present because of prolongedstates of immobility and dehydration and INR followed
  • 22. Laboratory Values Thyroid Functionslow to normal thyroid stimulating hormone andnormal or low thyroxine is typical of sickeuthyroid syndrome typical in both eatingdisorders and depressionif after compliance with nutritional rehabilitationthere isn’t an effective resolution of tfts, considerreplacement with levothyroxine or liiothyroninet3 levels are inversely correlated with the degreeof cerebral atrophy and nutritional deficits
  • 23. Laboratory Values Gonadotropins & Sex Steroidslow luteininzing hormone and folliclestimulating hormonelow estradiol in femaleslow testoterone and dhea in males
  • 24. Laboratory Values Lipid Panelvery often elevated in bulimia and binge eatingdisorder and may require treatmentparticularly in older patients, follow over timewith nutritional normalizationnot useful in anorexia since cholesterol may beelevated in early malnutrition and low inadvanced malnutrition
  • 25. Laboratory Values Imaging Studiespatients with anorexia and bulimia are at risk of low bonemineral density (bmd). there is no evidence that hormonereplacement (estrogen/progesterone in females ortestosterone in males) improves bmd, except for somerecent studies with the organophosphate, risedronate.older patients with binge eating frequently haveosteoarthritis severe for their relative agesnutritonal rehabilitation, normalization of weight andendogenous steroid production are the treatments of choicemeasure bone mineral density with dexa scan in patientswith ammenorhea for 6 months or longer
  • 26. Laboratory Values Imaging Studiesmri and ct and functional imaging studies, includingfmri, spect and pet, have been useful in elucidatingthe underlying abnormalities in neuroanatomy,neurophysiology and neurochemistrypathognomonic of anorexia and bulimia nervosathese studies have no useful purpose in the routineclinical workup of these patients unless there is astrong index of suspicion of dementia or theneurological exam is focal
  • 27. Laboratory Values Electrocardiogrambradycardialow voltageinverted T wavesU wavesvarious degrees of heart blockprolonged QT intervalincreased QT dispersion
  • 28. Laboratory Values ElectrocardiogramST segment depression, elevation, and non-specificchangesventricular premature complexesventricular tachycardiatorsades de pointes (an ominous form ofventricular tachycardia)ventricular fibrillationasystole (cardiac arrest)
  • 29. Laboratory Values Other Cardiac Findingsdecreased cardiac muscle massdiminished cardiac outputweak, thready pulsesacrocyanosisweak, medially displaced PMIdecreased heart sounds from decreased cardiac dynamicsincreased heart sounds from decreased chest wall thicknessincreased heart murmurs Friction rub (from pericardial effusion)myofibrillar degeneration
  • 30. Laboratory Values Other Cardiac Findingsdecreased ventricular volumedecreased cardiac outputautonomic dysregulationhypotensionincreased peripheral resistancemitral valve prolapsepericardial effusionsheart failureelevated cardiac enzymes (without coronary artery disease)
  • 31. Refeeding Syndrome Definitionrefeeding syndrome describes a potentially fatal shiftof fluid and electrolytes that can occur when refeeding(orally, enterally or parentally) a malnourished patientpatients with refeeding syndrome may have a non-specific presentation and so diagnosing this syndromemay be challengingthe serious consequences of refeeding syndromeinclude cardiac, hepatic, renal, respiratory failure,gastrointestinal problems, delirium and in some casesmulti-system organ failure and death
  • 32. Refeeding Syndrome Definitionthe serious consequences of refeedingsyndrome include cardiac, hepatic, renal and/or respiratory failure and in some casesrespiratory failure, gastrointestinal problems,delirium and in some cases multi-system organfailure and deathrefeeding syndrome is a potentially fatalsyndrome requiring specialized treatment on aninpatient unit
  • 33. Refeeding Syndrome Risk FactorsPATIENT HAS ONE OR MORE OF THEFOLLOWING:BMI less than 16 kg/m2unintentional weight loss greater than 15% withinthe last 3–6 monthslittle or no nutritional intake for more than 10 dayslow levels of potassium, phosphate or magnesiumprior to feeding
  • 34. Refeeding Syndrome Risk FactorsPATIENT HAS TWO OR MORE OF THEFOLLOWING:BMI less than 18.5 kg/m2unintentional weight loss greater than 10% withinthe last 3–6 monthslittle or no nutritional intake for more than 5 daysa history of alcohol abuse or drugs includinginsulin, chemotherapy, antacids or diuretics
  • 35. Refeeding Syndrome Management Of The High Risk Patientstarting nutrition support at a maximum of 10kcal/kg/day, increasing levels slowly to meet orexceed full needs by 4–7 daysusing only 5 kcal/kg/day in extreme cases (forexample, BMI less than 14 kg/m2 or negligibleintake for more than 15 days)monitoring cardiac rhythm continually in thesepeople and any others who already have ordevelop any cardiac arrhythmias
  • 36. Refeeding Syndrome Management Of The High Risk Patientrestoring circulatory volume and monitoringfluid balance and overall clinical status closelyproviding immediately before and during thefirst 10 days of feeding: oral thiamine 200–300mg daily, vitamin B complex 1 or 2 tablets, threetimes a day (or full dose daily intravenousvitamin B preparation, if necessary) and abalanced multivitamin/trace elementsupplement once daily
  • 37. Refeeding Syndrome Management Of The High Risk Patientproviding oral, enteral or intravenoussupplements of potassium (likely requirement2–4 mmol/kg/day), phosphate (likelyrequirement 0.3–0.6 mmol/kg/day) andmagnesium (likely requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) unlesspre-feeding plasma levels are highpre-feeding correction of low plasma levels isunnecessary
  • 38. Refeeding Syndrome Management Of The Low Risk Patient25–35 kcal/kg/day total energy (including thatderived from protein)0.8–1.5 g protein (0.13–0.24 gm nitrogen)/kg/day30–35 ml fluid/kg (with allowance for extralosses from drains and fistulae, for example,and extra input from other sources – forexample, intravenous drugs)
  • 39. Aim at heaven and you will get earth thrown in. Aim at earth and you get neither. C.S. LEWIS