eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Eating Disorder: Anorexia: Differential Diagnoses & Workup

Author: Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House, Consultant to Child Guidance Resource Centers, Early Elementary Education Program
Contributor Information and Disclosures

Updated: Mar 31, 2008

Differential Diagnoses

Achalasia
Esophageal Stricture
Celiac Sprue
Hyperthyroidism
Chronic Mesenteric Ischemia
Hypothyroidism
Clostridial Cholecystitis
Irritable Bowel Syndrome
Clostridium Difficile Colitis
Malabsorption
Constipation
Panhypopituitarism
Crohn Disease
Protein-Losing Enteropathy
Cytomegalovirus Colitis
Ulcerative Colitis
Cytomegalovirus Esophagitis
Esophageal Motility Disorders
Esophageal Spasm

Other Problems to Be Considered

Inflammatory bowel disease
Cancer
Chronic undiagnosed organic disease (infectious, congenital, or metabolic)
Osteoporosis
Osteopenia
Myeloma
Cardiac valvular disease
Pellagra
Occult infection (if heart rate is normal or elevated)
Sheehan syndrome
Cataracts
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS)18
Rash (due to low zinc)19

Workup

Laboratory Studies

Because an eating disorder is a clinical diagnosis, no specific diagnostic tests are available. However, perform the following laboratory tests to evaluate the patient:

  • Obtain a CBC count with erythrocyte sedimentation rate (ESR).
  • Perform urinalysis.
  • Obtain blood chemistries analysis.
  • Hyponatremia reflects excess water intake or the inappropriate secretion of antidiuretic hormone (ADH).
  • Hypoglycemia is observed secondary to lack of glucose precursors in the diet or low glycogen stores.
  • Renal function is generally normal except in the case of dehydration when the BUN level may be elevated.
  • A hypokalemic hypochloremic metabolic alkalosis is observed with vomiting, and acidosis is observed in cases of laxative abuse.
  • Protein and albumin are surprisingly normal because, although the amount of food intake is restricted, it usually contains high-quality proteins.
  • Liver function test results are minimally elevated, but levels encountered in patients with active hepatitis are not observed.
  • Dramatic elevations in cholesterol are observed in cases of starvation. This elevation may be secondary to (1) decrease in triiodothyronine (T3) levels, (2) low cholesterol binding globulin, and (3) leakage of intrahepatic cholesterol.
  • Leukopenia, secondary to increased margination, and thrombocytopenia are observed. The leukopenia is not a sign that the patient is at an increased risk for infection.
  • Hemoglobin levels are typically normal, although elevations are observed in states of dehydration. If anemia is observed, it is not due to menstrual blood loss because these patients are usually amenorrheic. In such cases, further investigation is warranted.
  • The ESR is normal. Elevations should prompt a search for an organic etiology as noted above.

Other Tests

  • Cardiovascular complications account for most of the morbidity and mortality associated with this condition.
  • An ECG is helpful in evaluating for a prolonged QT interval. ECG findings may include low voltage, prolonged QTc, and nonspecific T-wave changes.13 In patients taking drugs with a prolonged QT, potential harmful dysrhythmias are possible.

Staging

Anorexia nervosa can be divided into an early or mild stage and an established stage.17,20

  • Early or mild stage is defined by the following:
    • Mildly distorted body image
    • Weight 90% or less of average weight for height
    • No symptoms or signs of excessive weight loss
    • Use of potentially harmful weight-control methods or a strong drive to lose weight
  • Established or moderate stage features include the following:
    • Definitely distorted body image that has not diminished with weight loss
    • Weight goal less than 85% of average weight for height associated with a refusal to gain weight
    • Symptoms or signs of excessive weight loss associated with a denial that any problems is present
    • Unhealthy means to lose weight, such as eating fewer than 1000 calories per day, purging, or excessive exercise

More on Eating Disorder: Anorexia

Overview: Eating Disorder: Anorexia
Differential Diagnoses & Workup: Eating Disorder: Anorexia
Treatment & Medication: Eating Disorder: Anorexia
Follow-up: Eating Disorder: Anorexia
References
Further Reading
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Further Reading

The SCOFF questionnaire is a screening tool for eating disorders. One point is awarded for every positive reply. A score greater than 2 indicates likely anorexia nervosa or bulimia. The questionnaire is as follows: 45

  • Do you make yourself Sick because you feel uncomfortably full?
  • Do you worry you have lost Control over how much you eat?
  • Have you lost more than One stone in a 3-month period?
  • Do you believe yourself to be Fat when others say you are too thin?
  • Would you say that Food dominates your life?

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Keywords

anorexia, anorexia nervosa, eating disorders, excessive weight loss, anorexiant, anorexic, anorectic, diminished appetite, aversion to food, psychiatric disorder, fear of weight gain, dieting, amenorrhea, constipation, hypotension, bradycardia, hypothermia, dry skin, hypercarotenemia, lanugo body hair, acrocyanosis, breast atrophy, mitral valve prolapse, hypokalemic hypochloremic metabolic alkalosis, acidosis, leukopenia, thrombocytopenia, dehydration, distorted body image, congestive heart failure, CHF, edema, psychosis

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Contributor Information and Disclosures

Author

Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House, Consultant to Child Guidance Resource Centers, Early Elementary Education Program
Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association
Disclosure: Nothing to disclose.

Medical Editor

Angelo P Giardino, MD, PhD, Clinical Associate Professor, Department of Pediatrics, Baylor College of Medicine; Medical Director, Texas Children's Health Plan, Inc
Angelo P Giardino, MD, PhD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and American Professional Society on the Abuse of Children
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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