Current view: Anorexia Nervosa A blog post cannot fully do justice to Anorexia Nervosa as it is a multisystem and multi-domain psychosomatic condition. However this an area of ignorance for many clinicians both in terms of diagnosis and management. My experience of eating disorders is from my work in the UK as a Consultant Psychiatrist in the NHS and in Private Tier 4 Eating Disorders Units. When you see a very thin patient in your clinic do you ask the following: - Do you fear putting on weight? - Do you think you are fat and ugly? - Do you have menstrual periods? - Have you lost weight recently? Have anyone thought of doing an ovarian ultrasound scan to check the reproductive maturity? A bone density (dexa) scan for early features of osteoporosis? To cut the details short I would outline some important aspects in practical management of anorexia nervosa Anorexia is a psychiatric condition with severe medical consequences. Severe low BMI and electrolyte fluctuations could cause arrhythmia and sudden death. Low pulse (as low as 30/min can be seen), Low BP and low body temperature are common. The triad of hypoglycaemia, hypothermia and bradycardia can be lethal. Body Mass Index needs to be calculated for every patient, adolescents weight for height for age should be calculated and charted. Pulse, BP and temperature should be charted at every contact. Initial stages of treatment should be in the hospital. There should be psychological or psychiatric support at discharge What blood tests? Full blood count (TC/DC, Hb) (often blood count is low, predisposing the patient to severe infections) Renal Function Tests (dehydration is common). Electrolyte monitoring will be life saving : Na, K, Mg, Ca, PO4 and the minimum to be done. Nutritional deficiencies like Zn are also monitored in the UK. Hypokalemia is common in vomiting (purging type anorexia). Calcium is often low due to poor nutrition. PO4 need to be monitored during initial refeeding. Hypophosphatemia is called refeeding syndrome and can be lethal. LFT and Thyroid Function Tests should be done to rule out consequences or other physical causes. Ovarian maturity: Anorexia nervosa is often a condition seen in women. Ovaries need a healthy BMI (body fat) to achieve maturity. Two consequences of ovarian immaturity are Osteoporosis and Infertility. An USG Pelvis will get you an idea. Ovarian maturity can be assessed by checking the number and size of ovarian follicles and it’s comparison with the rest of the reproductive system. Bone Scan: I have used bone density (dexa) scans for anorexic patients and was often shocked to see the degree of osteoporosis. The scan looks for the average bone density for age. The lumbar spine and hips are the most vulnerable predisposing the patient to fractures. Refeeding:Current dietetic input should be assessed. Often it is less than 600KCals per day, in an anorexic. You could involve the hospital dietician for the calculations. Diet has to be increased slowly by 200-300KCals per day every 2-3 days with electrolyte monitoring (daily). The aim is to achieve 0.5-1kg weight gain per day. NG feeding may be required in severe resistant cases. When do you maintain weight: Although a BMI of 18 is healthy, it is good to get to a BMI of 20/21. In severe anorexia this is not practical. Hence any weight which achieves the ovarian functions should be the minimum healthy weight. It varies with the patient Nutritional supplements & Exercise: Calcium, Multivitamins and treat nutritional deficiencies. Physiotherapy and mild exercise programme can be useful for wasted muscles and joints. Discharge and psychological management: If you have a good community psychiatry team and psychologist, patients can be managed in the community if their BMI is 16 or above. Individual Therapy (CBT, Motivational Therapy) and Family Interventions and important to relax the patient about weight gain and maintain a healthy weight Anorexia Nervosa is an interesting area for young doctors who wish to specialise in Eating Disorders. For others it is important to prevent morbidity and mortality associated with the condition. Anorexia nervosa is a secretive condition and it is often not diagnosed due to the same reason. I know, I have only scratched the surface. If this is interesting for readers we could have more discussions. Dr S Krishnan DFM MRCPsych (Consultant Psychiatrist, NHS, UK) Note: The authors of the G2M blog will not be responsible for your patient management. The information given here is for the purpose of learning and not for direct clinical application.
Posted on: Thu, 10 Jul 2014 12:05:33 +0000
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