Emergent Management of Anorexia Nervosa Clinical Presentation

  • Author: Ron D Waldrop, MD, MS, FAAP, FACEP, FACPE; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: Jun 17, 2011
 

History

Patients with anorexia nervosa may present to the emergency department (ED) with extreme weight loss, food refusal, dehydration, weakness, acute abdominal pain, or shock. They are frequent users of the emergency department, and, as a result, emergency physicians should be screening for both subclinical and overt clinical evidence of anorexia nervosa in adolescents. Many present at the urging of family members or friends and are in deep denial of their malnutrition and illness.

Patients should be questioned about their current weight, highest weight, lowest weight, exercise habits, and menstrual cycles. Further questioning should inquire with regard to eating habits, presence or absence of self-induced vomiting/binge eating, and use of laxatives.

Major depression and dysthymic disorder have been reported in up to 50% of patients with anorexia nervosa. Patients should be asked about early morning awakening, tearfulness, and thoughts of suicide or a plan for it.

Review of systems is often positive for constipation, early satiety, hypothermia, nausea, hair loss, and fatigue.

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Physical Examination

Patients with anorexia nervosa may present anywhere along the spectrum of weight loss. They may attempt to hide their weight loss by wearing bulky clothing or many layers.

Physical examination may reveal hypothermia, peripheral edema, thinning hair, and obvious emaciation.

Behaviorally, a patient may demonstrate a flat affect and display psychomotor retardation, especially in the later stages of the disease. Cases of acute psychosis in anorexia nervosa from Wernicke-Korsakoff syndrome due to severe thiamine deficiency have been reported.[23]

Vital sign abnormalities may include hypothermia, bradycardia, and hypotension.

Cardiac examination may reveal the mid-systolic click of mitral valve prolapse.

Patients with purging behavior may have parotid gland hypertrophy, dental enamel erosion and, in extreme cases, seizures from electrolyte disturbances.

Dermatologic examination reveals dry skin, lanugo (a fine, downy covering of hair on the extremities), and poor skin turgor.[24]

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Complications

Patients with anorexia nervosa are at risk for complications related to nutritional and electrolyte imbalances, as well as long-term social and interpersonal difficulties due to their disorder. Physiologic complications involve nearly every organ system.

Fluid and electrolyte imbalances include hypokalemia, hyponatremia, hypochloremia, metabolic alkalosis, elevated blood urea nitrogen (BUN), decreased glomerular filtration rate (GFR), and ketonuria. Cardiovascular complications range from bradycardia, orthostatic hypotension, prolonged QT interval, low voltage, and mitral valve prolapse, to frank congestive heart failure and life-threatening dysrhythmias.

Gastrointestinal effects include constipation, bloating, early satiety, parotid gland hypertrophy, delayed gastric emptying, Mallory-Weiss tears, esophageal or gastric perforation, fatty liver infiltration, gallstones, and pancreatitis. Hematologic findings include anemia, leukopenia, thrombocytopenia, and impaired immunity. Endocrine problems due to starvation involve growth retardation, delayed puberty, amenorrhea, depressed T3 levels, hypercortisolemia, and diabetes insipidus.

Dermatologic complications include acrocyanosis, hypercarotenemia, brittle hair and nails, hair loss, lanugo, and pitting edema.

Neurologically, patients may develop peripheral neuropathy, seizures, and cortical atrophy. Psychologically, patients are at risk for isolation, depression, and suicide in addition to their disordered thought patterns regarding food and weight.

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Contributor Information and Disclosures
Author

Ron D Waldrop, MD, MS, FAAP, FACEP, FACPE  Emergency Physician, Commonwealth Emergency Physicians; Director of Pediatric Quality Care Management, Inova Loudoun Hospital; Adjunct Clinical Professor, Georgetown University School of Medicine

Ron D Waldrop, MD, MS, FAAP, FACEP, FACPE is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Tracy A Cushing, MD, MPH, FACEP, FAWM  Assistant Professor, Department of Emergency Medicine, University of Colorado School of Medicine; Attending Physician, Denver Health Medical Center

Tracy A Cushing, MD, MPH, FACEP, FAWM is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert Harwood, MD, MPH, FACEP, FAAEM  Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine

Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of Siobhan O'Herron, MD,to the development and writing of the source article.

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