Medical Complications in Patients with Eating Disorders: An ER Perspective

A healthy-looking young woman comes into the emergency room complaining of lightheadedness, dizziness, tiredness, dehydration and constipation. She tells you she doesn’t know what’s wrong, but what she is not telling you is that she has an eating disorder. How do you find out? More importantly, how do you avoid complications that may arise from using conventional treatments for patients without eating disorders?

I often come across questions posted on websites and forums asking if others have experienced a particular symptom, what could be causing it and whether going to the hospital is necessary. I am not a physician, not training to be a physician and not doing research in anything directly relevant to medicine or health. Moreover, I always use caution when answering questions online – the best advice is to go see a doctor (but of course, that’s not always possible, unfortunately).

My goal with this post is to do a brief overview of some common health complications faced by eating disorder sufferers, their underlying causes and some advice on proper treatment/management.

This information is coming from a paper by Mascolo and colleagues which was written for ER physicians who may be unfamiliar with eating disorders. Nonetheless, I think will be useful for patients and caregivers (particularly if (or when?) you meet clinicians who may not know much about eating disorders).

The authors organize the content based on complications common in anorexia nervosa and bulimia nervosa. Most patients, however, fall somewhere between AN and BN, and so the complications listed below are not exclusive to one disorder.

Patients with eating disorders commonly complain about dizziness, fatigue, dehydration, palpitations (irregular heartbeat), syncope (fainting), seizures and muscle spasms. The notes below explain some of the possible causes for these symptoms.

ANOREXIA NERVOSA in the ER

physical exam findings

• malnutrition leads to a decrease in muscle mass, including the heart muscle, this in turn leads to a  decreased ability of the heart to contract and pump blood, resulting in:
  • decreased blood pressure, or hypotension  (often less than 90/50 mm Hg)
  • decreased heart rate, or bradycardia (< 60 beats/min)
• symptoms resulting from hypotension and bradycardia should be monitored
• authors warn that rapid amounts of intravenous fluids (IVF) should not be administered as it can lead to heart failure in patients with reduced heart muscle mass

cardiac dysrhythmias (irregular heartbeat)

• a risk for patients with <70% of ideal body weight, can lead to sudden death
• an electrocardiogram (EKG) should be done if patient complains of weakness, fainting, or palpitations

chest pain

• could be due to mitral valve prolapse (seen in 30-50% of patients with severe anorexia)
• authors note that this is usually benign (unless accompanies by dysrhytmias)
• an electrocardiogram should be done to exclude acute coronary syndrome (though unlikely in young patients)

muscoskeletal complaints

• osteoporosis is a common and often irreversible complication in anorexia nervosa
• 6 month duration of the illness is often enough to detect significant bone density loss
• peak bone mass is reached by around 20 years of age, patients with AN in adolescence do not reach the peak bone mass
• bone density scan is recommended, particularly if there are complains about hip/lower back pain

refeeding syndrome

• can occur in starved individuals when refeeding is accomplished too quickly as a result of rapid changes in fluid and electrolyte levels, can lead to heart failure
• risk factors: <70% of IBW (ideal body weight), little to no caloric intake for 10 days, and abnormal electrolytes (potassium, phosphorus or magnesium)
• (more on refeeding syndrome) [note: I am planning a more in-depth post on refeeding syndrome at a future point]

liver function

• hypoglycemia (low blood sugar), which can lead to seizures, can be a sign of liver dysfunction
• liver failure can also occur and cn be detected by elevations in liver function tests
• importantly, liver dysfunction can negatively affect metabolism of medications

When it comes to complications occurring in bulimia nervosa, the authors focus on two main ones: “complications associated with the usage of IVF to correct dehydration and electrolyte disorders” and “gastrointestinal, associated with self-induced vomiting and the abuse of laxatives.”

Of course, individuals with binge-purge type of anorexia nervosa are also at risk of suffering from the complications listed under “bulimia.”

BULIMIA NERVOSA in the ER

pseudo-bartter’s syndrome

• self-induced vomiting and diuretic abuse leads to dehydration, this activates the kidney’s renin–angiotensin–aldosterone system (regulates blood pressure and fluid balance), resulting in an INCREASE of sodium and bicarbonate absorption and a DECREASE in potassium and hydrogen absorption, which further results in hypokalemia and metabolic alkalosis (called pseudo-Bartter’s syndrome)

Patients with non-bulimia nervosa who present to the ED with hypokalemia, metabolic alkalosis, and hypovolemia are often treated with large amounts of intravenous normal saline in order to restore volume. However, given the state of sodium avidity present with the upregulation of aldosterone, patients with bulimia nervosa retain salt and water leading to rapid accumulation of marked edema. It is not usual for patients with bulimia nervosa to accumulate 10 pounds of edema in 1 or 2 days with abrupt cessation of purging behaviors even in the absence of IVF administration. Reverting to the typical rate of IVF administration in a patient with bulimia will cause rapid weight gain, which is uncomfortable and emotionally distressing for patients with bulimia who have intense fears of gaining weight and body image issues. This distress has unfortunately led many patients with binge-purge anorexia and with bulimia not to seek emergent treatment for fear of edema development based on previous ED visits.

gastointestinal (GI) complaints

• persistent self-induced vomiting can lead to: dysphagia, heartburn,hematomesis, hoarseness
  • dysphagia, heartburn and hoarseness are often due to gastric acid reflux
  • hematemesis is often due to Mallory-Weiss syndrome (self-healing if one stays away from vomiting)
• laxative abuse can lead to: diarrhea, abdominal cramping and constipation
  • detoxing from laxative abuse can be very hard, the authors suggest using a nonstimulant laxative (“to combat constipation and bloating”) and keep hydrated

The authors caution ER physicians to be aware that “many patients with eating disorders are hesitant to present to an ED precisely because of prior mismanagement and bad experiences.” And so recognizing an eating disorder as the underlying cause of these symptoms is imperative.

When possible, it is important for the mental health providers of these patients to proactively alert the [ER physician] of the potential medical caveats in caring for such a population.

My advice is: don’t hesitate to tell clinicians about your eating disorder.

Yes, there is a chance they might know nothing about EDs and/or be completely dismissive – but if you don’t tell them, they wont even think about the possibility that your symptoms are related to an underlying eating disorder. Conversely, if you do tell them, they might seek advice or help from other physicians or educate themselves on the precautionary measures that need to take when treating patients with EDs. The best alternative, of course, is that they know exactly what to do, and by telling them, you are preventing the deadly consequences that can result from “treatment as usual” (i.e., for patients without eating disorders).

References

Mascolo, M., Trent, S., Colwell, C., & Mehler, P.S. (2012). What the emergency department needs to know when caring for your patients with eating disorders. The International Journal of Eating Disorders PMID: 22707235