Transcript Welcome Applicants!! - LSU School of Medicine

Welcome Applicants!!
Morning Report: Friday, November 18th
Eating Disorders
A Little History Lesson…
Behaviors
simulating those seen in
current eating disorders go back to:
• Binging and purging seen in ancient Rome
• Fasting and exercise reported among ascetics
in the Middle Ages
A Little History Lesson…
The Island of Fiji had no people
with eating disorders for 2 centuries
until the appearance of American
television programs!

Demographics
0.5%
of adolescent and young adult
women have anorexia nervosa
• Begins in adolescence
1-3%
have bulimia nervosa
• Begins young adulthood
Much
more common in women
(10-20:1)
• Recent increase seen in men
Demographics
Seen
more commonly in Caucasian
and Asian youth
• Less in African American and Latino youth
More
common in developed than in
developing countries
Pathogenesis
Multifactorial
• Cultural factors
• Individual and family factors
• Genetic/ biochemical factors
Cultural Factors
Individual and Family Factors
Individual
Factors
• Anorexia nervosa

Lack of control and self-confidence found in otherwise
successful, although somewhat restricted, young women
• Bulimia nervosa

Impulsivity

Ongoing substance abuse

?Past sexual abuse
Individual and Family Factors
Family
Factors
• Over-involvement
• Enmeshment
Genetic/ Biological Factors
Cultural,
psychological and family
factors likely not sufficient to cause the
onset of an eating disorder
Psychiatric conditions more common
in individuals/ families with eating
disorders
• Depression
• OCD
• Addictions
Genetic/ Biologic Factors
Several
alterations are being
considered
• Hormonal

Ghrelin

Leptin

Melanocortin
• Genetic

Serotonin receptor genes
Pathogenesis, Presentation and
Prevention…
*Diagnosis
Diagnosis
Eating
Disorder, NOS
• Those who have not missed 3 menstrual
cycles or are not quite 15% below IBW
• Those who vomit or use laxatives regularly but
do not binge
• Children 8-12 whose eating disorder behaviors
are not driven by a fear of gaining weight
Evaluation
Nutrition
History
• Weight
• Diet
• Eating disorder behaviors

Excessive exercise?

Use of diet pills, laxatives, diuretics, ipecac
• **Have parents confirm history**
Evaluation
 Medical
symptoms
• Malnutrition

Constipation

Feeling cold/faint
• Vomiting

Chest pain

Hematemesis
• Other medical causes of wt loss

HA

Polyuria/ polydipsia

Persistent Diarrhea
Evaluation
Psychosocial
History
• What is the individual thinking?
• How is he/she functioning?
• Body image?
• Reason for wt loss?
• Symptoms of depression or other psych
diagnoses?

Suicidality??
*Differential Diagnosis
*Complications
Medical
complications
• Malnutrition of anorexia nervosa
• Bulimic behaviors
• Refeeding syndrome
*Complications
Metabolic
abnormalities
• Electrolyte disturbances

Anorexia: hyper/hyponatremia

Bulimia (vomiting/ laxative use): hypochloremic,
hypokalemic metabolic alkalosis
• CAN RESULT IN SUDDEN DEATH!!!

Rapid refeeding: hypophosphotemia
*Complications
 Cardiac
Abnormalities
• Anorexia

Bradycardia

Hypotension

Orthostasis

Prolonged QT interval

Pericardial effusion
• Bulimia

Sudden cardiac death due to hypokalemia

Irreversible cardiomyopathy
• Refeeding

Cardiac failure
*Complications
Gastrointestinal
abnormalities
• Anorexia

Abdominal pain

Constipation

Delayed gastric emptying with prolonged peristalsis
• Bulimia

Esophageal irritation
• Chest pain
• (GER symptoms)
*Complications
Endocrine
abnormalities
• Decreased LH/FSH

Amenorrhea osteopenia osteoporosis
• Decreased thyroid function

Low temperature, pulse, BMR, ECG voltage

T4/TSH in low-normal range; T3 may be low (“euthyroid
sick syndrome”)
• Decreased vasopressin

Polyuria
*Complications
Neurologic
abnormalities
• Seizures
• Peripheral neuropathy
• Brain atrophy
Hematological
abnormalities
• Mild anemia (?low WBC and plts)
*Management
Laboratory
evaluation
• CBC
• BMP
• UA
• TFTs

?Other hormonal values
• EKG
*When to Admit?
Mild
cases
• Outpatient management

Pediatrician

Nutritionist
More
severe cases
• Outpatient management

Eating disorder team
• Inpatient management
*Treatment
Watch
for and intervene with
complications
• Electrolyte abnormalities
• Cardiac abnormalities
• Refeeding syndrome
• Amenorrhea
• Osteopenia
*Treatment
Nutritional
therapy
• Anorexia

Weight GAIN!
• Diets in the range of 1000-2000 kcal range used initially with
slow increases by 200-400 kcal to a goal of 2000-4000 kcal
• Goal 1-1.25 lbs/wk or 4-5 lbs/mo
• Daily food diary
• Exercise restriction (if needed)
• Bulimia

Nutritional stabilization
*Treatment
 Psychological
Therapy
• Counseling

Individual (mainstay)

Family

Group (?)
• Medications

SSRIs
• Affect amount of binging and purging in bulimia
• Do not affect weight gain in anorexic patients (?decrease relapse)

Atypical anti-psychotics
*Prognosis
ALL
outcomes (short and long-term)
are VARIABLE
• No indicator provides a specific prognosis for any
individual case

??Hospital discharge wt in pts with anorexia
Long-term
outcome
• 50% of patients do well, 30% do reasonably well
but have symptoms, 20% do poorly
• Mortality 5-10%

Highest mortality rates of all psychiatric illnesses
*Prognosis
Long-term
outcome (con’t)
• Prognosis in adolescents better??

Good motivation to maintain a high level of suspicion
and have a low threshold to intervene!
Thanks for your attention!
Noon Conference: Dr. Simon, Sinusitis