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ANOREXIA NERVOSA IN ASSOCIATION WITH MEDICAL DISORDERS

 

 

   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

 

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