|
Introduction
Gastrointestinal Disorder
Anorexia Nervosa in Endocrine Disorders
Anorexia Nervosa in CNS Disorders
Anorexia Nervosa in Genetic Disorders
Anorexia Nervosa in Urinary Tract Disorders
Anorexia Nervosa with Cardiac Disorders and Sudden Death
Anorexia Nervosa with Nutritional Disorder
Anorexia Nervosa with Autophonia
Water Intoxication
Anorexia Nervosa in Hematologic Disorders
Introduction
Anorexia nervosa has been reported in association
with the following medical disorders: gastrointestinal
disorders, including esophageal achalasia (100), acute
gastric dilatation (101), dilatation with pancreatitis
(102), dilatation with perforation (103), Crohn's disease
(104), and necrotizing colitis (105), endocrine disorders,
including Cushing's disease (106), diabetes mellitus
(107,108,109,110,111,112), and hyperthyroidism (113),
central nervous system (CNS) disorders, including hypothalamic
tumor (83), Herpes Simplex (115), multiple sclerosis
(116), and spinal meningioma (117), genetic disorders
including Turner's syndrome (27,118,119), and Gaucher's
disease (120), urinary tract disorders including nephrolithiasis
(121) and urogenital malformations (122), cardiac disorders
such as bradycardia and EKG changes, including Q-T interval
prolongation (123), reduction of left ventricular muscle
mass (124), cardiac failure (125), sudden death (125),
and pericardial effusion (127), nutritional disorders
including thiamine deficiency (128,129), autophonia
(130), water intoxication (131), and hematologic disorders
(132).
In addition, pathophysiologic and clinical aspects
of medical, endocrine and nutritional abnormalities
in anorexia nervosa have been reported (133).
Gastrointestinal Disorder
Frequently, delayed gastric emptying is seen in anorexic
patients, improved with treatment by metoclopramide
(Regland) or domperidone, renutrition, and stabilization
of mood. This symptom may persist following weight gain
and present a significant resistence to clinical management
(135,136,137,138). Delayed gastric emptying has been
found in 28 percent of restrictive anorexic nervosa
and bulimia cases. Delayed gastric emptying of moderate
to severe degree (30-40 percent delay) was present.
Chronicity of illness in both anorexia nervosa and bulimia
was associated with more severe delay. In anorexia nervosa
there was increased delay in patients with depressive
disorder and a younger age of onset (137). Barrett et
al. (138) reported delayed gastric emptying in the "undereating"
malnourished phase of anorexia nervosa, resolving to
normal emptying rate with resumption of normal feeding
and weight gain. Moran (139) concurs with these findings,
noting that in low-weight bulimics there is a decreased
rate of gastric emptying, and that in anorectics delayed
gastric emptying improves as the body weight advances.
Crisp (134) has reviewed gastrointestinal disturbance
in anorexia nervosa, noting that anorectics frequently
complain of abdominal pain and distention. Chronic anorexia
nervosa can distort the gastrointestinal tract, producing
distention, then disuse atrophy followed by distention.
In some cases, cystic ovarian disease is the cause of
the abdominal discomfort.
In one patient, pseudoacute abdomen was manifested
by anorexia, with a 50 pound weight loss, intermittent
abdominal pain, and vomiting. A duodenal jejunostomy
was unsuccessful in diminishing weight loss and vomiting
(140). Anorexia nervosa should be considered in a patient
with weight loss, abdominal pain, and vomiting.
Anorexia nervosa has been reported in association
with disorders in the esophagus, stomach, and small
and large intestine.
Achalasia is produced by an atonic esophagus. Kenney
(100) reported a patient, age 14, with chief complaints
of nausea and a 63 pound weight loss. A barium swallow
revealed absent peristalsis, a dilated esophagus, and
almost complete distal obstruction. Endoscopic evaluation
confirmed an atonic esophagus with a minimally patent
lower-esophageal sphincter, subsequently treated by
pneumatic dilatation.
Gastric disturbances, including gastric dilatation
alone (101), gastric dilatation with pancreatitis (102),
and gastric dilatation with perforation, the latter
with a fatal outcome (103), have been reported.
Crohn's disease has been reported coexisting with
anorexia nervosa (104,141,142). Hershman and Hershman
(104) reported a 27-year-old anorexic female with diarrhea
and increasing lower abdominal pain who developed a
palpable cecal mass with inflamed appendix, and at surgery
a diagnosis of Crohn's disease was made. Diagnostic
confusion can arise between patients with Chrohn's disease,
atypical anorexia, and anorexia nervosa because of the
similar symptoms of nausea, anorexia, and abdominal
pain. In addition, these two disorders can coexist.
Necrotizing colitis with a fatal outcome was reported
in a 17-year-old girl with colicky abdominaly pain,
nausea, vomiting, and constipation. At autopsy, "cement-like"
feces producing rectal impaction and portal vein obstruction
was found (105).
Anorexia Nervosa in Endocrine
Disorders
Anorexia nervosa has been associated with endocrine
disorders such as Cushing's Disease (106), Diabetes
Mellitus (111), and hyperthyroidism (113).
A woman, age 27, with a prior diagnosis of anorexia
nervosa and a 54 percent loss of body weight, subsequently
developed a pituitary corticotroph cell pituitary adenoma,
removed by trans-sphenoidal surgery. Within two years
of surgery, in the absence of hypercortisolism, anorexic
features reappeared (106).
Diabetes Mellitus coexisting with anorexia nervosa
and bulimia have been frequently reported (107-112,143-145).
The prevalence of anorexia nervosa with Diabetes Mellitus
ranged from zero percent (143) to 6.5 percent (111).
The presence of bulimia ranged from 6.5 percent (111)
to 35 percent (143). Rodin et al. (111) noted a sixfold
increase for anorexia nervosa and a twofold increase
for bulimia over the expected prevalence for nondiabetic
individuals.
Patients who failed to take their insulin developed
glucosoria and, thereby, an indirect chemical method
of "purging" (107).
The treatment of Diabetes Mellitus offers patients
numerous opportunities to pursue their morbid goal of
weight loss by dangerous maneuvers including surreptitious
vomiting after bulimic episodes, adjustment of the insulin
dose, failure to inject insulin, and failure to provide
urine samples (107-109). Fairburn and Steel (110) noted
that girls with anorexia nervosa could skillfully adjust
their insulin dosage to match their reduced carbohydrate
consumption. Diabetics with eating disorders have a
trump card in confronting the psychaitric team (110).
The most effective treatment combines behavior management
with psychotherapy and is a difficult therapeutic challenge
to both the psychiatrist and diabetologist (108). Hopelessness
and uncooperativeness occur frequently in treatment
(107).
Hyperthyroidism was noted in a very active 18-year-old
female whose atypical presentation included heat intolerance
and hyperactive deep-tendon reflexes. Surreptitious
thyroid ingestion was ruled out by an elevated I-131
uptake. If thyroid hormone were ingested, I-131 uptake
would be diminished or normal. Anorectic patients should
be evaluated for atypical presentations of hyperthyroidism.
Usually, low tri-iodotyronine (T3), elevated reverse
T3, normal thyroxine (T4), and normal thyroid stimulating
hormone (TSH) may be associated with clinical signs
of hypometabolism and undernutrition.
Anorexia Nervosa in CNS Disorders
There have been numerous reports of anorexia nervosa
associated with a hypothalamic tumor (114,146,83).
A 25-year-old female with a hypothalamic astrocytoma
developed anorexia (apparently precipitated by her father's
death) with sudden coma, increased 11-hydroxycortico
steroids, and fatal outcome (114).
Lesions of the lateral hypothalamus may produce anorexia
and weight loss, since the lateral hypothalamus initiates
feeding (148). Stricker and Andersen (149) felt that
a hypothalamic lesion which damages dopaminergic fibres
may disrupt voluntary behavior, including feeding.
An adolescent female with both anorexia nervosa and
a high thoracic spinal cord meningioma was reported
(117).
Central nervous system disorders have been reported
in anorexia nervosa. A 25-year-old female presenting
with complaints of poor memory, nausea, ataxia, diploplia,
and dysarthria was later diagnosed to have Wernicke's
encephalopathy. The anorexia, producing a thiamine deficiency,
may have caused this disorder. However, thiamine levels
were not performed because she presented six months
after resuming a normal diet. Anorexic patients developing
mental status changes with ataxia and nystagmus should
be screened for Wernicke's encephalopathy (82).
A 19-year-old female who presented with both acute,
severe depression and anorexia nervosa syndrome subsequently
developed petechial skin hemorrhages, suddenly collapsed,
and died. At post-mortem, disseminated herpes simplex
infection with massive intra-cerebral hemorrhage was
noted. The sudden onset of depression was due to the
herpes simplex infection. The patient's malnutrition
contributed to a lower immunological defense and to
her susceptibility to herpes simplex (115).
Symptoms of anorexia nervosa were reported in the
initial stage of multiple sclerosis (116).
Anorexia Nervosa in Genetic
Disorders
Anorexia nervosa has been reported in genetic diseases
such as Turner's Syndrome (27) and Gaucher's disease
(120).
There are 13 case reports of patients with the coexistence
of anorexia nervosa with Turner's Syndrome, a disorder
manifesting a 45-chromosome XO genotype webbed neck,
shield chest, and gonadal dysgensis (primitive ovary
or testes). Larocca (27) noted that many of these patients
(three of 13) were depressed, and he posited an association
between Turner's syndrome, anorexia nervosa, and affective
disturbance.
Amenorrhea, low estrogen levels, and pubertal delays
are common to both. In contrast, patients with Turner's
syndrome due to gonadal dysgenesis may have high levels
of gonadotrophins, whereas many anorexic patients have
prepubertal gonadotrophin levels (150).
In some cases of Turner's syndrome without a preexisting
eating disorder, estogren treatment immediately preceded
the onset of severe dieting. Estrogen replacement, elevating
both estrogen and testosterone levels, may promote the
onset of the sexual feelings of puberty and has been
associated with the onset of anorexia nervosa (118,119).
Gaucher's disease, an inherited metabolic disorder
characterized by a deficiency of the lysosomal enzyme
glucocerebrosidase, was reported in a 28-year-old male
with unexplained weight loss and weakness in his left
arm and leg. A vigorous medical workup of patients with
atypical presentations of anorexia is indicated (120).
Anorexia Nervosa in Urinary
Tract Disorders
Anorexia nervosa has been reported in association
with nephrolithiasis. A dehydrated female developed
acute abdominal pain and hematuria. By restricting fluids,
this patient may have contributed to her nephrolithiasis
(121).
Pines et al. (151) reported that a 28-year-old female
with laxative abuse developed hypopotassemia and metabolic
acidosis. The authors state that laxative abuse may
be associated with renal tubular acidification impairment.
Halmi and Regas (122) in a group of 29 anorectics
found six cases of urogenital malformations, including
patients with uterine absence of malformation (small
uterus, bifid uterus, nonpatent fallopian tubes, absence
of ovaries), malformed vagina (atresia and double vagina),
single malformed kidney (two patients), and one female
who has surgery for a sex change (female to male).
Anorexia Nervosa with Cardiac
Disorders and Sudden Death
Cardiovascular complications have been associated
with anorexia nervosa, including bradycardia and electrocardiographic
abnormalities (123).
Bradycardia with a heart rate from 28 to 60 occurs
with sinus origin, sinoatrial arrest, and ectopic atrial
rhythm. Electrocardiographic findings include ST-T changes
and Q-TU interval prolongation. Sudden deaths have been
reported in anorexic patients with documented QT interval
prolongation (0.46 to 0.61 seconds) and ventricular
tachyarythmias, including torsade de pointes.
All anorexic patients should be initially evaluated
with an EKG 24-hour Holter monitor, especially those
who wish to maintain a self-prescribed exercise program
(126). In addition, psychotropic drugs should be used
with caution in anorectics with electrocardiographic
abnormalities, since disorders of repolarization may
be worsened (123).
Dec et al (152) in contrast to the findings of Arik
et al. failed to observe serious arrythmias, abnormal
prolongation of QT interval, conduction abnormalities,
or depression in left ventricular function in 25 consecutively
hospitalized, serious ill, emaciated adolescents with
anorexia nervosa. Perhaps adolescent anorectics, in
contrast to many anorectics in their 20's, have not
had the illness long enough to develop serious cardiac
disturbance. The authors hypothesize that pure anorectics
who are older and who have had the illness for a longer
period of time have developed more severe cardiac abnormalities.
Furthermore, it is possible that some older anorectics
may have anorexia mixed with bulimia, with the use of
ipecac, which would further lead to cardiac problems.
Reduction in left ventricular muscle mass of less
than 100 grams, or essentially normal cardiac function
(normal is 90-360 grams), was noted (124). However,
cardiac failure in anorectics, especially during the
refeeding phase, may occur (123,125). Powers speculates
that increased metabolic demands occurring with refeeding
may predispose the patient to these complications. To
prevent or minimize these occurrences, physical exercise
during the recovery phase should be kept to a minimum,
and the patient should be under surveillance for signs
and symptoms of cardiac incompetence - including taking
the patient's pulse, blood pressure, and respiratory
rate, as well as checking for edema and gallops.
Inser et al. (126) described sudden death in three
anorectics, ages 27 through 37. QT interval prolongation
and ventricular tachyarrythemias were noted.
Pericardial effusion has been reported in four patients,
ages 15 through 23, diagnosed by echocardiogram. These
patients lost 38 to 53 percent body weight after the
onset of their illnesses (127).
Anorexia Nervosa with Nutritional
Disorder
Thiamine deficiency associated with hypothermia occurred
in a young woman with anorexia nervosa who consumed
a calorically restricted diet. Thiamine and sucrose
resulted in body temperature normalization (129).
Anorexia Nervosa with Autophonia
An interesting report associates anorexia nervosa
with autophonia, the perception of one's own voice and
breathing. Rapid weight loss seen in a variety of wasting
disorders including a
|
