See also [[Paediatric consent#special situations| paeds anorexia consent]] See: [EM Cases - eating disorders](https://emergencymedicinecases.com/eating-disorders/) for a good overview # Diagnostic criteria - body weight >15% below epected or BMI <17.5 - fear of gaining weight or becoming fat usually present - body image distortion - one or more of: - self-induced vomiting - self-induced purging - excessive exercise - use of appetite suppressants or diuretics - associated endocrine disorder # findings - hypoalbuminaemia - low plasma creatine - ↑ may be indicative of low muscle bulk - hypophosphatemia concerning for *refeeding syndrome* - bradycardia - hypothermia - dental - enamal erosion ## long-term complications - osteoporosis - short stature - stress fractures - renal calculi - miscarriage # Ix - [[hypokalemia|hypo-k]] - [[Hypocalcemia|hypo-Ca]] - hypoalbuminaemia - increase urea - [[Anaemia]] - Fe-deficiency - thrombocytopaenia - low WCC - ECG changes - T inversion - ST dep - [[Long QT]] - atrial ectopics - VT # ED management - rehydration - nutrition support - tx complications # Refeeding syndrome *Refeeding Syndrome* is the adverse metabolic effects and clinical complications when a starved or seriously malnourished individual commences feeding via oral enteral or parenteral routes. - most likely in first week of re-feeding - results from rapid shifts in electrolytes and **rapid thiamine depletion** **effects:** - *hypophosphatemia* - hallmark feature (see [[hypophosphataemia|hypo-PO4]]) - body in fasting/starvation state becomes catabolic (breaking down muscle mass) → phosphate lost from muscle → then lost from body in urine - even if serum levels are normal, total body stores are depleted - severe hypo-PO4 can be precipitated by increased glycolysis → ATP generated and utilises PO4 during refeeding with carbohydrates when carbohydrates replace body fat as main source of energy - [[hypokalemia|hypo-k]] and [[Hypomagnesemia|hypo-mg]] - on re-feeding, pt begins to use glucose as primary source of energy → results in **increased insulin release** → as glucose taken into cell, K and Kg come in as well - acute thiamine deficiency - any available thiamine used as co-enzyme for increased carbohydrate metabolism → glycolysis-induced thiamine depleiton can lead to Wernicke's encephalopathy - this is why we give alcoholics thiamine before giving any glucose > **PO4** > normal: 0.8-1.5 mmol/L > mild ↓ PO4: 0.6-0.75 mmol/L (2-2.5 mg/dL) > mod: 0.3-0.6 mmol/L (1-2 mg/dL) > **severe** ≤ 0.3 mmol/L (1mg/dL) ## risks for refeeding syndrome high risk if ≥ 2 of the following: - BMI < 18.5 - frail elderly pt - limited or no nutritional intake for 5 days - behaviours that deplete electrolyte/thiamine stores eg EtOH, vomiting, laxative abuse - weight loss >10% within past 3-6 months very high risk if *any*: - BMI <16 - low K, PO4, or Mg prior to feeing - normal levels do not mean the person is not at risk - weight loss > 15% over past 3-6 months - little or no nutritional intake for > 10 days ## clinical features - severe ↓ PO4 - neuromuscular disturbances - myopathy to paralysis - confusion or [[Seizures]] - cardioresp disturbances - resp muscle failure - heart failure - haematological disturbances - haemolysis - impaired leukocyte funciton - thrombocytopaenia - [[rhabdomyolysis]] - [[Hypomagnesemia|hypo-mg]] - arrhythmias - seizures - [[hypokalemia|hypo-k]] - arrhythmia - muscle weakenss - Thiamine def - wernicke's enecphalopathy ## management - close lab monitoring - dietician involvement - judicious IVF - calories: slow 30-50% or estimated requ gradually over week - multivitamin and zinc/Fe/selenium/folate/B12/B6 - Thiamine 100mg BD 30 min before feeding # Indication for hospitalisation **medical** - HR < 45 - BP < 90/60 - symptomatic hypoglycaemia - K <3 - T <36 - dehydration - sodium <130 - phosphate < 0.5 mmol/L - prolonged QT - BMI < 14 - postural BP drop >20 - symptomatic **weight related** - weight <75% expected - weight loss of >1kg/week - unable to eat independenty - requires NG feeding **psychological** - failure of outpatient tx - severe co-existing psychiatric disease anorexia nervosa eating disorder refeeding syndrome ![[Pasted image 20240929163805.png]] # Related Questions ## anorexia - 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[ ] 13Q: [Anorexia Nervosa](x-devonthink-item://A077BF03-A063-4A6D-9330-67795A4B931D?page=15) -- [Answer](x-devonthink-item://C6B02ACE-5059-45D1-81CD-F99A8A13A863?page=13) - [ ] 14Q: [Anorexia Nervosa](x-devonthink-item://F0CF1E99-6E8D-4E3C-9C45-046E93F30DBA?page=6) -- [Answer](x-devonthink-item://E437B768-E942-4349-941C-A97410E4E28F?page=4) ## refeeding syndrome - [x] DUPLICATE Q: [Anorexia Nervosa](x-devonthink-item://D466AD93-18B7-467C-BB6E-192EEBE26935?page=17) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=7) - [x] DUPLICATE Q: [Anorexia Nervosa](x-devonthink-item://F0CF1E99-6E8D-4E3C-9C45-046E93F30DBA?page=6) -- [Answer](x-devonthink-item://E437B768-E942-4349-941C-A97410E4E28F?page=4)