Although eating disorders are on the psychiatric spectrum, they can have serious associated medical complications. Patients with eating disorders may present with complaints common to the emergency department such as abdominal pain, chest pain, syncope, or palpitations, often making management of these patients a challenge. This issue outlines the diagnostic criteria for eating disorders, reviews common physical examination findings associated with eating disorders, and discusses the treatment of acute medical complications of eating disorders, with a specific focus on the pathophysiology and management differences between a patient with an eating disorder and an otherwise healthy patient. You will learn:

Common chief complaints in patients with an eating disorder

How to use the SCOFF questionnaire as part of the history to help identify patients with an eating disorder

Diagnostic criteria for anorexia nervosa and bulimia nervosa

Key physical examination findings (eg, sialadenosis, dental erosion and enamel loss, Russell sign, lanugo) that will help make the diagnosis

Physiologic differences between a patient with an eating disorder and an otherwise healthy patient

Which laboratory studies should be ordered for all patients with an eating disorder, and when additional studies are warranted

General guidelines for management of pediatric patients with eating disorders, including how to manage physiologic instability, electrolyte disturbances (eg, refeeding syndrome), and surgical emergencies (eg, Boerhaave syndrome, pneumomediastiunum)

Indications for inpatient hospitalization of a patient with an eating disorder

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Weight/Growth Changes
      2. Head, Eyes, Ears, Nose, and Throat Findings
      3. Dermatologic Findings
      4. Cardiovascular Findings
         • Chest Pain
         • Dysrhythmias
         • Cardiac Complications From Ipecac Syrup Use
      5. Electrolyte Disturbances
      6. Endocrine Abnormalities
      7. Gastrointestinal Findings
      8. Pulmonary Findings
      9. Musculoskeletal Complications
      10. Psychiatric Disorders
9. Diagnostic Studies
10. Management
    1. Physiologic Instability
    2. Electrolyte Disturbances
       1. Refeeding Syndrome
    3. Surgical Emergencies
    4. Other Considerations
    5. Psychiatry Consultation
11. Special Populations
12. Disposition
13. Summary
14. Time- and Cost-Effective Strategies
15. Risk Management Pitfalls For Acute Complications of Eating Disorders in Pediatric Patients
16. Case Conclusions
17. Clinical Pathway For Management of Pediatric Patients With Potential Complications of Eating Disorders
18. Tables and Figures
    1. Table 1. Differential Diagnosis of Common Chief Complaints in Patients With an Eating Disorder
    2. Table 2. Prehospital Care of Acute Complications of Eating Disorders
    3. Table 3. The SCOFF Questionnaire
    4. Table 4. DSM-5 Diagnostic Criteria for Anorexia Nervosa and Bulimia Nervosa
    5. Table 5. Common Electrolyte Changes, by Purging Method
    6. Table 6. Diagnostic Studies for Evaluation of a Pediatric Patient With an Eating Disorder
    7. Table 7. General Guidelines for Management of Pediatric Patients With Eating Disorders
    8. Table 8. Indications for Inpatient Hospitalization of a Patient With an Eating Disorder
    9. Figure 1. Sialadenosis of the Parotid Glands
    10. Figure 2. Dental Abnormalities Associated With Eating Disorders
    11. Figure 3. Russell Sign
    12. Figure 4. Pathogenesis of Refeeding Syndrome
19. References

Abstract

Although eating disorders are on the psychiatric spectrum, they can have serious associated medical complications. Patients with eating disorders may present with complaints common to the emergency department such as abdominal pain, chest pain, syncope, or palpitations, but management of these conditions in eating disordered patients can pose a challenge. This issue provides a systems-based approach to the history, physical examination, evaluation, and treatment of acute complications of eating disorders, with a specific focus on the pathophysiology and management differences between an otherwise healthy patient and a patient with an eating disorder.

Case Presentations

A 14-year-old girl with no known medical problems presents to the ED with worsening epigastric pain for 3 days. The girl says the pain worsens after eating. The patient denies associated symptoms including vomiting, diarrhea, constipation, dysuria, and fever. The patient also denies alcohol consumption, drug use, and sexual activity. Her vital signs are: heart rate, 55 beats/min; blood pressure, 90/50 mm Hg; respiratory rate, 18 breaths/min; and oxygen saturation, 100% on room air. On physical examination, you notice the patient has dry mucous membranes, discolored teeth, and a few scarred callouses on the dorsum of her right hand; the examination is otherwise normal. You are concerned about the patient’s vital signs, perplexed as to why she is not tachycardic despite her low blood pressure, and somewhat surprised that she is denying emesis or diarrhea, given her low blood pressure. You tell the patient’s parents that you will order fluids and some basic laboratory tests and then reassess. About 30 minutes later, the nurse calls you into the room because the patient's oxygen saturation has decreased to 85%, and she is in respiratory distress after completion of the fluid bolus. On auscultation, you hear diffuse crackles bilaterally. You place the patient on bilevel positive airway pressure and perform a bedside ultrasound that shows B-lines in bilateral lungs suggestive of pulmonary edema. A portable chest x-ray also shows evidence of pulmonary edema. Why did this patient rapidly develop pulmonary edema? Did the bolus worsen her condition? What diagnoses should be considered? Are there questions that you should ask the patient privately?

A previously healthy 17-year-old boy presents via ambulance after an episode of syncope during track practice. Per EMS, the patient was getting ready to start practice when he fell to the ground. His coach told them that the boy blacked out for a few seconds, but still had a pulse and did not stop breathing. The boy’s vital signs on arrival to the ED are: heart rate, 60 beats/min, but irregular; blood pressure, 90/50 mm Hg; respiratory rate, 18 breaths/min; temperature, 37°C (98.6°F); and oxygen saturation, 100% on room air. The review of systems is otherwise unremarkable. You are told that the boy’s parents are on their way to the hospital. The patient denies a prior history of syncopal episodes and reports that he remembered his heart was pounding, and the next thing he knew he was on the ground and his coach was standing over him. The boy reports intermittent episodes of palpitations recently, but he denies drug use. He admits he has been stressed about winning an upcoming track meet to secure a scholarship to college and believes the palpitations are secondary to stress. He also reports strict dieting and an increased workout regimen over the past few months. You are concerned about a possible underlying eating disorder, so you use the SCOFF questions as a screening tool. The patient answers “yes" to 2 of the 5 questions on the SCOFF questionnaire. How should the results of the questionnaire guide your diagnosis and the management of this patient? What studies should you order?

Introduction

The lifetime prevalence of eating disorders in adolescents is 2.7%.¹ Anorexia nervosa and bulimia nervosa, specifically, have a lifetime prevalence of 0.5% to 1% and 1% to 3%, respectively. Between 10% and 50% of female teenagers report occasional binge eating and purging behaviors.² Eating disorders are more common among females than males; anorexia nervosa and bulimia nervosa occur at a 10:1 female-to-male ratio.^3,4 Although eating disorders are not as common as other mental illnesses, they are associated with the highest mortality rates, when compared with other psychiatric disorders.⁵ In a 2009 study in the American Journal of Psychiatry, in which a longitudinal assessment of mortality was conducted, 2.8% of subjects with an eating disorder died of medical causes, followed by suicide (0.7%), substance use-related causes (0.5%), and traumatic causes (0.5%).⁶

Patients with undiagnosed eating disorders can present with complaints that are common to the emergency department (ED), such as abdominal pain, chest pain, syncope, and/or palpitations. This can make it difficult for the emergency clinician to recognize that these complaints arise from an underlying eating disorder. Likewise, many of the characteristic physical examination findings in patients with eating disorders are easily missed unless the clinician has a high index of suspicion. Failure to recognize an underlying eating disorder can lead to mismanagement and increased mortality if the cause of the complication is not determined and treated.

Managing a patient with a known diagnosis of an eating disorder can also be difficult for emergency clinicians. In a study that examined how comfortable residents from different specialties (including emergency medicine and pediatrics) felt when managing patients with a known eating disorder, participants reported comfort with assessment of these patients but not with management.⁷

This issue of Pediatric Emergency Medicine Practice outlines the diagnostic criteria for eating disorders, reviews the common—and sometimes subtle—physical examination findings associated with eating disorders, highlights physiologic differences between patients with eating disorders and healthy patients, and discusses the ED management of acute medical complications of eating disorders in pediatric patients.

Critical Appraisal of the Literature

A literature search was conducted using PubMed; the search terms included emergency care of eating disorders in pediatric patients, emergency care of anorexia and pediatric patients, emergency care of bulimia and pediatric patients, management of eating disorders in the emergency department of pediatric patients, medical complications of eating disorders in pediatric patients, and acute complications of eating disorders in pediatric patients. Abstracts and articles cited within the publications were also reviewed.

Literature on the management of eating disorders in the ED is lacking, especially in the pediatric population. A total of 38 articles were reviewed: 16 review articles, 9 case reports, 5 case-control studies, 1 retrospective study, 1 cross-sectional study, 3 survey studies, 1 comparative study, 1 meta-analysis, and 1 longitudinal study. The greatest limitation of this literature is that the majority of evidence on the management of emergent complications of eating disorders is from case reports and expert clinical opinion.

Risk Management Pitfalls For Acute Complications of Eating Disorders in Pediatric Patients

1. “I thought he was dehydrated, so I gave him a fluid bolus, and he decompensated.”

Patients with eating disorders may present with hypotension and/or syncope due to an underlying cardiomyopathy rather than dehydration. A large fluid bolus, though indicated if the problem is dehydration, may cause the patient to develop flash pulmonary edema from decompensated heart failure.

3. “He said his palpitations were from anxiety, so I didn’t investigate further.”

Though eating disorders are on the psychiatric spectrum, they do have medical complications. Various arrhythmias, including long QT syndrome, are associated with eating disorders and can worsen with electrolyte shifts or certain medications.

6. “She denied having an eating disorder. How was I expected to diagnose it?”

Examination findings for anorexia nervosa and bulimia nervosa can be subtle and require a high level of suspicion and detailed examination. The mouth and hands should be examined carefully for signs of purging. Lanugo and dry skin can be an indicator of fasting.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

1. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980-989. (Cross-sectional study; 10,123 participants)
2. Kotler LA, Walsh BT. Eating disorders in children and adolescents: pharmacological therapies. Eur Child Adolesc Psychiatry. 2000;9 Suppl 1:I108-I116. (Review article)
3. Pinheiro AP, Root T, Bulik CM. The genetics of anorexia nervosa: current findings and future perspectives. Int J Child Adolesc Health. 2009;2(2):153-164. (Review article)
4. Keski-Rahkonen A, Hoek HW, Linna MS, et al. Incidence and outcomes of bulimia nervosa: a nationwide population-based study. Psychol Med. 2009;39(5):823-831. (Survey; 2881 participants)
5. Tintinalli JE. Eating disorders. In: Lewis GC, ed. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide 8th ed. McGraw-Hill Education: New York; 2016:1973-1976. (Texbook chapter)
6. Crow SJ, Peterson CB, Swanson SA, et al. Increased mortality in bulimia nervosa and other eating disorders. Am J Psychiatry. 2009;166(12):1342-1346. (Longitudinal study; 1885 patients)
7. Girz L, Robinson AL, Tessier C. Is the next generation of physicians adequately prepared to diagnose and treat eating disorders in children and adolescents? Eat Disord. 2014;22(5):375-385. (Survey; 880 participants)
8. Mazzeo SE, Bulik CM. Environmental and genetic risk factors for eating disorders: what the clinician needs to know. Child Adolesc Psychiatr Clin N Am. 2009;18(1):67-82. (Review article)
9. Bulik CM. Exploring the gene-environment nexus in eating disorders. J Psychiatry Neurosci. 2005;30(5):335-339. (Review article)
10. Strober M, Freeman R, Lampert C, et al. Controlled family study of anorexia nervosa and bulimia nervosa: evidence of shared liability and transmission of partial syndromes. Am J Psychiatry. 2000;157(3):393-401. (Survey; 1831 participants)
11. Rosen DS. Identification and management of eating disorders in children and adolescents. Pediatrics. 2010;126(6):1240-1253. (Review article)
12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association: Arlington, VA; 2013. (DSM-5)
13. Dooley-Hash S, Lipson SK, Walton MA, et al. Increased emergency department use by adolescents and young adults with eating disorders. Int J Eat Disord. 2013;46(4):308-315. (Retrospective chart review; 1920 participants)
14. Luck AJ, Morgan JF, Reid F, et al. The SCOFF questionnaire and clinical interview for eating disorders in general practice: comparative study. BMJ. 2002;325(7367):755-756. (Comparative study; 341 participants)
15. Trent SA, Moreira ME, Colwell CB, et al. ED management of patients with eating disorders. Am J Emerg Med. 2013;31(5):859-865. (Review article)
16. Campbell K, Peebles R. Eating disorders in children and adolescents: state of the art review. Pediatrics. 2014;134(3):582-592. (Review article)
17. Sachs K, Mehler PS. Medical complications of bulimia nervosa and their treatments. Eat Weight Disord. 2016;21(1):13-18. (Review article)
18. Mehler PS, Rylander M. Bulimia nervosa - medical complications. J Eat Disord. 2015;3:12. (Review article)
19. Strumia R. Skin signs in anorexia nervosa. Dermatoendocrinol. 2009;1(5):268-270. (Review article)
20. Mascolo M, Trent S, Colwell C, et al. What the emergency department needs to know when caring for your patients with eating disorders. Int J Eat Disord. 2012;45(8):977-981. (Review article)
21. Galetta F, Franzoni F, Prattichizzo F, et al. Heart rate variability and left ventricular diastolic function in anorexia nervosa. J Adolesc Health. 2003;32(6):416-421. (Case-control study; 50 participants)
22. Romano C, Chinali M, Pasanisi F, et al. Reduced hemodynamic load and cardiac hypotrophy in patients with anorexia nervosa. Am J Clin Nutr. 2003;77(2):308-312. (Case-control study; 153 patients)
23. Cooke RA, Chambers JB, Singh R, et al. QT interval in anorexia nervosa. Br Heart J. 1994;72(1):69-73. (Case-control study; 69 participants)
24. Isner JM, Roberts WC, Heymsfield SB, et al. Anorexia nervosa and sudden death. Ann Intern Med. 1985;102(1):49-52. (Case report; 3 patients)
25. Dresser LP, Massey EW, Johnson EE, et al. Ipecac myopathy and cardiomyopathy. J Neurol Neurosurg Psychiatry. 1993;56(5):560-562. (Case report; 2 patients)
26. Kamal N, Chami T, Andersen A, et al. Delayed gastrointestinal transit times in anorexia nervosa and bulimia nervosa. Gastroenterology. 1991;101(5):1320-1324. (Case-control study; 38 participants)
27. Zipfel S, Sammet I, Rapps N, et al. Gastrointestinal disturbances in eating disorders: clinical and neurobiological aspects. Auton Neurosci. 2006;129(1-2):99-106. (Review article)
28. Filosso PL, Garabello D, Lyberis P, et al. Spontaneous pneumomediastinum: a rare complication of anorexia nervosa. J Thorac Cardiovasc Surg. 2010;139(4):e79-e80. (Case report; 1 patient)
29. Hochlehnert A, Lowe B, Bludau HB, et al. Spontaneous pneumomediastinum in anorexia nervosa: a case report and review of the literature on pneumomediastinum and pneumothorax. Eur Eat Disord Rev. 2010;18(2):107-115. (Case report; 1 patient)
30. Sondike SB. Rhabdomyolysis in an adolescent with nonpurging bulimia nervosa. J Adolesc Health. 2011;48(4):421-423. (Case report; 1 patient)
31. Dooley-Hash S, Banker JD, Walton MA, et al. The prevalence and correlates of eating disorders among emergency department patients aged 14-20 years. Int J Eat Disord. 2012;45(7):883-890. (Cross-sectional survey; 942 participants)
32. De Caprio C, Alfano A, Senatore I, et al. Severe acute liver damage in anorexia nervosa: two case reports. Nutrition. 2006;22(5):572-575. (Case report; 2 patients)
33. Solomon SM, Kirby DF. The refeeding syndrome: a review. JPEN J Parenter Enteral Nutr. 1990;14(1):90-97. (Review article)
34. Marchili MR, Boccuzzi E, Vittucci AC, et al. Hypertransaminasemia and hypophosphoremia in an adolescent with anorexia nervosa: an event to watch for. Ital J Pediatr. 2016;42(1):49. (Case report; 1 patient)
35. Stanga Z, Brunner A, Leuenberger M, et al. Nutrition in clinical practice-the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr. 2008;62(6):687-694. (Case report; 7 patients)
36. Kimmel MC, Ferguson EH, Zerwas S, et al. Obstetric and gynecologic problems associated with eating disorders. Int J Eat Disord. 2016;49(3):260-275. (Review article)
37. Madsen IR, Horder K, Stoving RK. Remission of eating disorder during pregnancy: five cases and brief clinical review. J Psychosom Obstet Gynaecol. 2009;30(2):122-126. (Case study; 5 patients)
38. Golden NH, Katzman DK, Sawyer SM, et al. Update on the medical management of eating disorders in adolescents. J Adolesc Health. 2015;56(4):370-375. (Review article)
39. Arcelus J, Mitchell AJ, Wales J, et al. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry. 2011;68(7):724-731. (Meta-analysis; 36 studies, 17,272 patients)