Feeding and eating disorders Flashcards
What are the risk factors for Anorexia Nervosa?
Perfectionism and poor self-esteem
Early menarche
Exposure to environment in which weight concerns and restrictive dieting prevails
Family history of members who are thin or underweight
What is a general description of What are the risk factors for Anorexia Nervosa?
Intense preoccupation with weight and body shape and a relentless pursuit of thinness.
What are the three key clinical features of What are the risk factors for Anorexia Nervosa?
Underweight for height and age
Intense fear of fatness and gaining weight, or behaviours to avoid weight gain
Overvalued ideas of body weight and shape on self-view, or denial of seriousness of low weight
What are common behavioural characteristics of people with What are the risk factors for Anorexia Nervosa?
Vomiting and laxative abuse Excessive exercise (sometimes covert) Both carried out obsessively with guilt present when not done.
What are the physical and biochemical findings associated with What are the risk factors for Anorexia Nervosa?
Decresed gonadotropins & sex hormones
Altered thyroid metabolism
Raised cortisol and GH
Severe electrolyte disturbances (Potassium, calcium, phosphates)
Cardiac arrhythmias
Renal failure
Osteopenia / osteoporosis
Rectal prolapse
In the emergency treatment of What are the risk factors for Anorexia Nervosa what are the 12 categories of changes that must be monitored and treated?
DR, I GET salty CHIPS, DER
Dental changes
Renal changes
Intercellular changes
Gastrointestinal changes
Endocrine changes
Temperature changes
Electrolyte changes
Cardiac changes Haematological changes Immune system changes Pregnancy changes Skin / bone changes
What is the main intercellular change in Anorexia nervosa and how is it monitored and managed acutely?
Change:
Increased protein catabolism
Monitoring:
Measure pulse and BP lying and standing
What are the main Endocrine changes in Anorexia nervosa and how are they monitored and managed acutely?
Changes:
Dehydration
Oedema
Low gonadotropin and sex steroids (amenorrhea)
Altered peripheral metabolism of thyroid hormone
Raise cortisol and GH
Hyperaldosteronism
Hypoglycaemia
Poor metabolic control in T1DM (needs specialist referral)
Monitoring:
TFT
Monitor hormone imbalances
Repeated BSL monitoring
Acute management:
Thiamine administration with refeeding for hypoglycaemia
What are the main Electrolyte changes in Anorexia nervosa and how are they monitored and managed acutely?
Changes: Hypokalaemia Hypochloraemia Metabolic alkalosis Hypomagnesaemia (**refractory hypokalaemia) Hypoglycaemia Hypophosphatemia Hyperphosphataemia (vomiting)
Monitoring:
Electrolytes
Blood gas
ECG
Acute management:
Careful K+ replacement (oral)
Correct alkalosis
What are the main Gastrointestinal changes in Anorexia nervosa and how are they monitored and managed acutely?
Changes: Acute pancreatitis Parotid and salivary gland hypertrophy Reduced gastric motility Oesophagitis / ulceration / strictures Mallory-weiss tears Gastric rupture Diarrhoea Raised liver enzymes Low albumin
Monitoring:
Physical exam (gastro)
LFT (AST &ALP) + Lipase
Acute management:
Surgical referral for complications
Bowel rest, NG suction, and fluid replacement for pancreatitis
What is the main Haematological change in Anorexia nervosa and how is it monitored and managed acutely?
Change:
Anaemia
Monitoring:
FBE +/- Iron studies
B12
Folate
Management:
Oral replacement therapies
What is the main Body Temperature change in Anorexia nervosa and how is it monitored and managed acutely?
Change:
Hypothermia
Monitoring:
Repeated temperature measurement
Observe for signs of infection as hypothermia can mask pyrexia
What are the main Immune function changes in Anorexia nervosa and how are they monitored and managed acutely?
Change:
Low white cell count
Susceptibility to bacterial infections
Monitor:
FBE
Monitor for signs of infection
What are the main Cardiovascular changes in Anorexia nervosa and how are they monitored and managed acutely?
Changes:
Bradycardia and hypotension
Arrhythmias
Cardiomyopathy (Ipecac (emetic) use)
Monitoring:
ECG (always)
CXR
Treatment:
Symptomatic oedema treatment
Treatment of arrhythmia
What are the main Renal changes in Anorexia nervosa and how are they monitored and managed acutely?
Changes: Elevated UEC (increased muscle catabolism) Hypokalaemic nephropathy Reduced serum creatinine High ketones Polyuria
Monitoring:
UEC
Treatment:
If needed, specialist referral
What are the main Skin / Bone changes in Anorexia nervosa and how are they monitored and managed acutely?
Changes: Osteopenia / stress fractures Brittle hair and hair loss Lanugo hair Vomiting, dorsal hand abrasions, facial purpura, and conjunctival haemorrhage (from initiating vomiting)
Monitoring:
Dexa scan
Treatment:
Calcium and vitamin D supplementation
DO NOT GIVE PHOSPHATE
What is the main Dental change in Anorexia nervosa and how is it monitored and managed acutely?
Change:
Erosions and perimyolysis
Monitoring and treatment:
Dental referral
What are the pregnancy complications in patients with Anorexia Nervosa?
Spontaneous abortion Perinatal mortality Prematurity Low birth weight Congenital malformations
What is the general exam findings in a patient with suspected Anorexia Nervosa?
Vital signs (Mitral prolapse, and irregular pulse) Oedema Stress fractures Acrocyanosis Lanugo hair Enlarged thyroid Low weight Abrasions on the dorsum of the hand Dental erosions Perimyolysis
What are some key points to cover when discussing treatment with someone with Anorexia Nervosa?
Resuming normal eating will diminish preoccupation with food, relieve tiredness and depression, and facilitate improved relationships.
They will not be confined to a bed
They will not be force fed
They will not be isolated from friends and family
They will not become obese
Compromise cannot be made on food intake (you can’t be a little anorexic)
What is refeeding syndrome?
When metabolism is stimulated by refeeding and demand for substances like potassium and phosphates increases.
Since reserves are depleted this causes a rapid drop in serum concentrations.
What are the significant signs of refeeding syndrome?
SOB Oedema Weakness Seizures Delirium Coma
What is Bulimia Nervosa?
A cyclic pattern of behaviour typified by episodes of binges and uncontrolled overeating, associated with shame.
Can be restricting (over exercise) or purging (vomiting, emetics, laxatives) types
What are the four primary clinical features of Bulimia Nervosa?
Recurrent binge eating or uncontrolled overeating
Use of extreme measures to control weight (purging and non-purging)
Overvalued ideas of body weight and shape on self view
Normal weight or overweight
What are the most significant electrolyte changes observed in patients with Bulimia Nervosa?
Decreased serum potassium
Metabolic acidosis
What ECG changes are associated with hypokalaemia?
Increased amplitude and width of P wave Prolonged PR interval T wave flattening and inversion ST depression Prominent U waves (on precordial leads)
**long QT (really fusion of T and U waves)
Which drugs has been shown to attenuate binge eating independent on its effects on other psychological / psychiatric disturbances?
SSRIs
What is Binge eating disorder?
A disorder characterised by recurrent episodes of binge eating without the need for compensation
What are the 4 key clinical features of Binge eating disorder?
Recurrent and distressing binge eating
No regular use of extreme measures to control weight
Overvalued ideals of body weight and shape on self-view not required
Normal weight or overweight
What are the two goals in treatment for Anorexia Nervosa?
- The restoration of normal weight for height and age
2. Identification and management of any contributing family and personal problems
What is the indicated pharmacological treatment in Anorexia Nervosa?
Drugs are of no proven benefit for primary Anorexia Nervosa.
Antidepressants can be prescribed IF the patient has a persistently depressed mood, neurovegetative symptoms, and depressive ideation.
TCAs and MAOIs should be used only as a last resort and with comprehensive monitoring for cardiotoxicity.
Treatment is in line with depression guidelines, but all dosages are halved.
**Olanzapine may be used if the patient is extremely agitated
What is the pharmacological treatment used in Bulimia Nervosa?
First line:
Fluoxetine (20-60mg)
Second line:
Citalopram (10-40mg)
Fluvoxamine (50-300mg)
Sertraline (50-200mg)
What is the preferred non-pharmacological treatment for eating disorders in general?
CBT
Psychoeducation
Nutritional advice / planning
