Tag Archives: anorexia nervosa

Brief Updates: COVID-19/Hydroxychloroquine, GALD, Anorexia Nervosa, and Esophaeal-gastric Dissociation Outcomes

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Recent reports indicate that hydroxychloroquine is not likely effective for COVID-19.  Submitted manuscript: Outcomes of hydroxychloroquine usage in United States veterans hospitalized with Covid-19 Commentary from Politco: More deaths, no benefit from malaria drug in VA virus study

An excerpt: A malaria drug widely touted by President Donald Trump for treating the new coronavirus showed no benefit in a large analysis of its use in U.S. veterans hospitals….The study was posted on an online site for researchers and has been submitted to the New England Journal of Medicine, but has not been reviewed by other scientists….About 28% who were given hydroxychloroquine plus usual care died, versus 11% of those getting routine care alone. About 22% of those getting the drug plus azithromycin died too, but the difference between that group and usual care was not considered large enough to rule out other factors that could have affected survival…The NIH and others have more rigorous tests underway.

HS Fischer et al. JPGN 2020; 70: 444-9. This study examined outcomes of 12 patients with gestational alloimmune liver disease over an 11 year period. Key findings:

  • Median age at diagnosis of neonatal acute liver failure (NALF): 2 days
  • All 12 received exchange transfusion ET).  Common signs: hypoglycemia, hyperferritinemia, cholestasis, and coagulopathy. Direct bilirubin typically increased after ET.
  • Outcomes: survival without transplantation occurred in 10 of 12.  Two patients died including one after liver transplantation.
  • “Most cases of NALF are due to GALD and should be timely treated with ET and IVIG.”  Current testing is lacking with regard to sensitivity and specificity, “early ET [and IVIG] before reaching a definitive diagnosis was associated with favorable outcomes.”

Related blog posts:

JE Mitchell, CB Peterson. Anorexia Nervosa (good review). NEJM 2020; 382: 1343-51.

Key points: 

  • Anorexia nervosa is a severe psychiatric disorder
  • Indications for hospitalization include profound hypotension or dehydration, severe electrolyte abnormalities, arrhythmias or severe bradycardia, suicide risk or BMI ≤15

Related blog posts:

S Battaglia et al. JPGN 2020; 70: 457-61. This retrospective study examined outcomes in 30 patients with severe neurologic impairment who underwent esophageal-gastric dissociation (E-GD) between 2000-18 and had a median follow-up of 3.5 years. E-GD was completed at a median age of 6.5 years. “Primary” E-GD was done in 23 and “Rescue” (after fundoplication) was done in 7 patients.

  • Hospitalizations and episodes of chest infections significantly decreased; weight improved
  • Vomiting and reflux resolved in all patients
  • 6 (20%) experienced early complications including 3 who needed surgery (1 obstruction, 1 volvulus, and 1 pyloric obstruction); 3 (10%) had late complications (adhesions/obstruction in 1, incisional hernia in 1, large para-esophageal hernia in 1)
  • There were no surgery-related deaths

The authors, in their discussion, compare primary E-GD with fundoplication.  Many of the referenced studies indicate that E-GD may have improved outcomes in the population of children with severe neurologic impairment, but also with a higher frequency of complications.  They conclude that E-GD “is a valid alternative to fundoplication…but is is just as effective and feasible when undertaken as a ‘Rescue’ procedure following failed surgical antireflux treatment.”

My take: The frequency of fundoplication operations have dropped markedly with increasing use of gastrojejunal tube placement.  In my view, I would usually recommend E-GD for ‘rescue’ after fundoplication failure.

A recent yard sign from my wife for neighborhood walkers during the pandemic

 

Afraid to Eat -Could be “Avoidant Restrictive Food Intake Disorder”

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A recent case report (JJ Thomas et al. NEJM 2017; 376: 2377-86) provides insight into something I’ve seen a lot but did not have a good label for previously: Avoidant Restrictive Food Intake Disorder (ARFID).

This report highlights an 11 year old who after a having a piece of meat briefly lodged into an orthodontic palate expander, stopped eating solid foods because she was “afraid I can’t chew it up enough to swallow it so I don’t choke.”  Even before this event, she had been a highly selective eater since infancy.  “Similar to many patients with ARFID, this patient had a long-term failure to gain weight appropriately and now had more acute weight loss.”  She did desired to gain weight and did not have any body distortion typical for anorexia nervosa.

This report provides a good list of etiologies which could trigger acute food refusal as well as conditions that could cause chronic poor weight gain.

  • For acute food refusal, etiologies included acute oromotor dysfunction, foreign body ingestion, gastrointestinal ulceration, anorexia nervosa/other psychiatric reasons (including globus hystericus).
  • For chronic failure to gain weight: chronic oromotor dysfunction (numerous neurologic causes), achalasia, inflammatory bowel disease, celiac disease, endocrine etiologies (eg. Addison’s, hyperthyroidism, type 1 diabetes mellitus), infections (eg. tuberculosis, HIV), insufficient food/abuse & neglect, stimulant use, cancers, and other chronic diseases (pulmonary, cardiac, or renal)

Definition of ARFID:

  • “The presence of avoidant or restrictive eating that results in persistent failure to meet nutritional needs; evidence of ARFID includes low weight or failure to have expected gains or growth, nutritional deficiencies, reliance on nutritional supplements or enteral feeding, psychosocial impairment, or a combination of these features. Restrictive eating may be motivated by low appetite or lack of interest in eating, sensitivities to certain sensory aspects of foods, or fear of adverse consequences of eating, such as choking or vomiting.”
  • It is noted that coexisting psychiatric conditions “appear to be common among patients with ARFID. Concurrent anxiety disorders are the most prevalent; they occur in more than 70% of patients in some clinical samples.”

Treatment of ARFID:

There is little data to guide treatment.  Treatment of coexisting psychiatric conditions is recommended and behavioral interventions to improve eating.  In this patient with a choking phobia, the treatment included a gradual stepwise progression in food textures:

  • Liquids–>Purees (eg yogurt, applesauce)–>Textured purees (eg. oatmeal, mashed potatoes) –>Soft solids (eg. rice, mac & cheese, pasta, bread, potatoes, pizza) –>Crunchy solids (eg. chips, pretzels, crackers) –>Hard-to-chew solids (eg. meats)

My take: I think being able to use this relatively new term of Avoidant Restrictive Food Intake Disorder will improve disease classification and ultimately help promote better treatments.

I thought this candy store icon was funny due to the missing tooth

What Functional MRI Finds with Anorexia

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In yesterday’s post, functional MRI showed how rapidly anti-TNF agents can improve pain response in patients with Crohn’s disease.  A more complete description of this study is available from the AGA Blog: This is Your Brain on Anti-TNF Therapy. This link also includes access to a video abstract discussion with the author.

Another intriguing use of this technology provides insight into why Anorexia is difficult to treat.  The study was summarized in the NY Times:

Anorexia May Be Habit, Not Willpower  Here’s an excerpt:

The study’s findings may help explain why the eating disorder, which has the highest mortality rate of any mental illness, is so stubbornly difficult to treat. But they also add to increasing evidence that the brain circuits involved in habitual behavior play a role in disorders where people persist in making self-destructive choices no matter the consequences, like cocaine addiction or compulsive gambling…

The researchers used a brain scanning technique to look at brain activity in 21 women with anorexia and 21 healthy women while they made decisions about what foods to eat…

As expected, both the anorexic and the healthy women showed activation in an area known as the ventral striatum, part of the brain’s reward center. But the anorexic women showed more activity in the dorsal striatum, an area involved with habitual behavior, suggesting that rather than weighing the pros and cons of the foods in question, they were acting automatically based on past learning…

My take: This study shows an association between food selection and differences in brain activity between women with anorexia and in controls.  These changes do not prove a causal association but provide an important piece of information about what might be going wrong.

Atlanta Botanical Garden, Bruce Munro Exhibit

Atlanta Botanical Garden, Bruce Munro Exhibit

Reasons for refeeding syndrome

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Refeeding syndrome (RFS) is defined as the potentially fatal shifts in fluid and electrolytes that may occur in malnourished patients who are abruptly refed either enterally or parenterally.  The biochemical hallmark is hypophosphatemia.  Other changes can include hypokalemia, hypomagnesemia, and thiamin deficiency.  RFS can worsen the prognosis of children with celiac crisis as well (JPGN 2012; 54: 522-5).

A chart review from Lucknow, India from Jan-Dec 2010, identified 5 cases of RFS among 35 celiac patients.  All were severely malnourished.  All had anemia, hypoalbuminemia, hypophosphatemia, hypokalemia, and hypomagnesemia.  All improved with initial caloric restriction followed by gradual escalation of caloric intake along with electrolyte supplementation.

This article shows that a variety of causes of malnutrition can lead to refeeding syndrome. Considering refeeding syndrome in any severely malnourished child may help improve the prognosis by altering the nutritional management.

Additional references:

  • Nutr Clin Pract 2012; 27: 34-40. Reviewed refeeding syndrome publications since 2000.  Hypophosphatemia occurred in 96% of cases (26 of 27).
  • Crit Care Med 2010; 14: R172-R178.  Refeeding syndrome with anorexia.
  • Nutrition 2010; 26: 156-67. Review of refeeding syndrome treatment.
  • Nutr Clin Pract 2008; 23: 166-71.  Death due to refeeding syndrome.
  • JPEN 1990: 14.1; 90-97. Refeeding syndrome review.
  • Crit Care Med 1990; 18: 1030-1033. Review.