Eating Disorder Evaluation
What might you ask on H&P to help with evaluation of an eating disorder?
Obtain history with and without family present
When did problematic eating behaviors begin?
Perception
Diet:
Other Behaviors
SSHADESS Exam
What labs might you get in evaluating someone with an eating disorder?
Thiamine
Name at least 2 teams to consult for a patient with an eating disorder.
1. Nutritionist
2. Psychology/Therapy
3. Adolescent Medicine (if primary team not comfortable managing)
What are signs of heavy menstrual bleeding?
- changing pad/tampon every 1-2 hours
- “Flooding” or “accidents”
- 8 days or longer
- Symptoms: hemodynamic instability, lethargy, fatigue, lightheadedness, syncope, cold intolerance; PICA, CP, SOB
- Hb <7 or <10 with active heavy bleeding
What is the difference between Atypical Anorexia Nervosa and Anorexia Nervosa? Which one is more common?
Atypical Anorexia Nervosa: Meets criteria for Anorexia Nervosa without the low body weight
Atypical AN is much more common! It has same issues with cognitive dysfunction, loss of menses, BMD.
If someone has callus over their knuckles or parotitis, what disordered eating behavior do you think of?
Purging
List some examples (at least 1) of good practices to measure weight in a patient with an eating disorder.
- Blind (patients turn around, number is not revealed to them, whited out, not discussed)
- Post-Void in AM (lightest weight)
- In a gown (to not hide weights)
We ask families to throw away scales
For a patient with an eating disorder, if you had to choose one therapy with the most evidence behind it, which one is best to start - SSRI, Antipsychotic, or Psychotherapy?
Therapy
(Eating Disorder specific Family Based Therapy is gold standard)
What are some DDX for Heavy Menstrual Bleeding? (list 2 for points)
- HPO axis immaturity
- Hypo or hyperthyroidism
- Testosterone disorder - like congenital adrenal hyperplasia, testosterone secreting tumor
- Prolactinoma: galactorrhea, headache, visual field defects
- Bleeding disorder (like VWD): HX excessive bleeding with surgical or dental procedures, easy bruising, frequent nose bleeds
- Acquired: Gonorrhea/chlamydia, pregnancy
What is the difference between Anorexia Nervosa and Bulimia Nervosa?
Essentially, which behavior is more prevalent restricting (even if has binge-eating/purging) vs binge-eating (even if it has compensatory restricting)
Common organ dysfunction in a patient with an eating disorder
- Gastroparesis, GERD, constipation
- Orthostatic hypotension, POTS, cool extremities
- Menses irregularity/amenorrhea
What labs do you order to monitor for refeeding syndrome?
Phos, Mag, K
(LFTs can also be elevated)
List 1 common medicine given to help with emotional distress related to eating.
Olanzapine or Fluoxetine (SSRI)
Most common cause of abnormal uterine bleeding in adolescents (particularly in the first 1-2 years of menstruation).
Hypothalamic-Pituitary-Ovarian (HPO) axis immaturity
Avoidant/Restrictive Food Intake Disorder
An eating or feeding disturbance, usually presents as
As manifested by persistent failure to meet appropriate nutritional and/or energy needs with one (or more) of the following
Not attributable to a concurrent medical condition, mental disorder, lack of available food, culturally sanctioned practice
List some criteria for inpatient hospitalization:
- <75% median BMI
- Dehydration
- Electrolyte disturbances
- EKG abnormalities (prolonged QTc, severe bradycardia)
- Vital sign instability (HR <50 daytime, <45 nighttime; hypotension <90/45, temp <96, orthostatic +)
- Arrested growth
- Failure of outpatient treatment, acute food refusal, uncontrollable bingeing/purging
- Syncope, seizures, cardiac failure, pancreatitis...
- Comorbid psychiatric or medical condition limits outpatient treatment (severe depression, SI, T1DM)
Cardiovascular Compromise: Tachycardia, Heart Failure, Hypotension, Hypertension
Respiratory Failure:
Neurological: Tremors, paresthesias, delirium, seizures
Muscular: Impaired contractility, weakness, myalgia, and tetany
Elevated LFTs
How much weight gain would you like your patient with an eating disorder to gain?
100-200g/day (1-2 lbs/week)
First line treatment for Abnormal Uterine Bleeding if there are no contraindications.
Estrogen (IV conjugated estrogen or combined estrogen-progesterone pill up to q6h until bleeding stops)
A patient with an eating disorder has early satiety, epigastric abdominal pain soon after starting a meal, nausea, vomiting. What might you consider as part of the DDX.
SMA Syndrome: The superior mesenteric artery is normally covered with fatty tissue; weight loss reduces the fat pad and narrows the angle between the two vessels (SMA + aorta), entrapping the duodenum and causing a small bowel obstruction
Imaging (CTA)
- Duodenal obstruction with an abrupt cutoff in the third portion and active peristalsis.
- An aortomesenteric artery angle of ≤25° is the most sensitive measure of diagnosis, particularly if the aortomesenteric distance is ≤8 mm.
- High fixation of the duodenum by the ligament of Treitz, abnormally low origin of the superior mesenteric artery, or anomalies of the superior mesenteric artery.
Weight gain in as little as 5-10 lbs can improve symptoms
If someone has not had a period in 6 months or more, what might you get to evaluate this person's health?
How do you treat refeeding syndrome?
ABCs + Aggressively replace electrolytes +
DO NOT ADVANCE DIET (may even decrease calorie to previously tolerated calorie)
A patient needs eating-disorder specific therapy. What level of care would the patient get the most therapy?
Residential
Other options:
- Partial hospitalization: Daily, 4-8 hours/day
- Intensive outpatient: 2-3 days a week
- Outpatient: Weekly to monthly
List some contraindications to estrogen usage (list at least 2)
- History of VTE, vascular disease, ischemic heart disease
- Migraine with aura
- Breast cancer
- Decompensated cirrhosis, liver cancer
- Lupus; FHX of autoimmune diseases