Rectal prolapse associated with bulimia nervosa: report of seven cases

The Most Common Functional Disorders and Factors Affecting Female Pelvic Floor

The pelvic floor (PF) is made of muscles, ligaments, and fascia, which ensure organ statics, maintain muscle tone, and are involved in contractions. This review describes the myofascial relationships of PF with other parts of the body that determine the proper functions of PF, and also provides insight into PF disorders and the factors contributing to them. PF plays an important role in continence, pelvic support, micturition, defecation, sexual function, childbirth, and locomotion, as well as in stabilizing body posture and breathing, and cooperates with the diaphragm and postural muscles. In addition, PF associates with distant parts of the body, such as the feet and neck, through myofascial connections. Due to tissue continuity, functional disorders of muscles, ligaments, and fascia, even in the areas that are distant from PF, will lead to PF disorders, including urinary incontinence, fecal incontinence, prolapse, sexual dysfunction, and pain. Dysfunctions of PF will also affect the rest of the body.

Assessing for Eating Disorders: A Primer for Gastroenterologists

Eating disorders involve irregularities in eating behavior that may cause gastrointestinal (GI) symptoms. Consequently, many patients with eating disorders seek gastroenterological healthcare at some point in their illness, with many seeking this care even before they seek treatment for and/or diagnosed with their eating disorder. As such, the gastroenterology provider is in a unique position to identify, manage, and facilitate treatment for an eating disorder early in the course of the illness. Although assessing eating disorders is already a difficult task, the identification of eating disorders in patients with GI disease represents an even greater challenge. In particular, common GI symptoms, such as nausea, vomiting, and bloating, may disguise an eating disorder because these symptoms are often viewed as a sufficient impetus for dietary restriction and subsequent weight loss. In addition, the focus on identifying an organic etiology for the GI symptoms can distract providers from considering an eating disorder. During this prolonged diagnostic evaluation, the eating disorder can progress in severity and become more difficult to treat. Unfortunately, a misconception that hinders eating disorder detection is the notion that the rate or method of weight loss is associated with an eating disorder. Regardless of whether weight loss is slow or rapid, purposeful or accidental, eating disorder behaviors and thought patterns may be present. Unidentified eating disorders are not only dangerous in their own right but also can interfere with effective management of GI disease and its symptoms. As such, it is imperative for the GI provider to remain well versed in the identification of these diseases.

Extreme Risk-Taking Behaviors in Patients With Eating Disorders

BACKGROUND

Patients with eating disorders (EDs) engage in different self-inflicted at-risk behaviors, including suicide, attempted suicide and non-suicidal self-injury. Our aim was to describe the occurrence and underlying motivations of non-suicidal extreme risk-taking behaviors in patients with EDs.

METHODS

Four cases from different treatment centers in Israel were analyzed.

RESULTS

All patients were females hospitalized in inpatient settings because of long lasting anorexia nervosa (AN) with either binge/purge or purging episodes (AN-B/P/AN-P), including in most cases both self-induced voting and laxative abuse. Case [1] was an adolescent also diagnosed with type 1 diabetes mellitus. She abused insulin, both omission and overdose, was highly suicidal, and suffered from comorbid oppositional behavior, depression and anxiety. Case [2] was a 24-years old woman, transitioning from restricting to AN with vomiting and laxative use during inpatient treatment. She was also diagnosed with attention deficit hyperactivity disorder, depression, anxiety, and suicidal thoughts. In hospital, she developed excessive water consumption, leading to very low urine concentrations and sodium levels, and one episode of loss of consciousness. Case [3] was in her late thirties, demonstrating particularly massive laxative abuse. She also suffered from alcohol addiction, sexual trauma, and one attempted suicide. During hospitalization she developed laxative-abuse-related rectal prolapse that was successfully operated. Nonetheless, after operation she resumed laxative abuse. Case [4] was a 23-year old pregnant women with highly active AN-B/P during pregnancy. She was hospitalized at 23 weeks of gestation following abdominal pressure. She only partly complied with inpatient treatment, discharged herself against medical advice after 5 weeks, and gave birth at week 34.

DISCUSSION

All cases were females with long-standing B/P type AN, often with multiple purging behaviors, other impulsive and non-impulsive comorbidities, and many environmental vulnerabilities. Different motivations were found for these extreme behaviors in addition to ED-related factors, mostly not related to suicide. The severity of the medical and psychological condition required multimodal medical and psychological inpatient interventions. The patients mostly did not comply with their treatment, showing considerable indifference to their grave medical condition.

Which Symptoms, Complaints and Complications of the Gastrointestinal Tract Occur in Patients With Eating Disorders? A Systematic Review and Quantitative Analysis

BACKGROUND

Eating disorders (ED) such as anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) are often accompanied by a variety of psychological and physical comorbidities. Gastrointestinal (GI) symptoms are a classical feature in most patients with ED. The heterogeneity of studies on this topic is high, making it difficult to have a clear overview. The aim of this systematic review is therefore to provide an overview of subjectively and objectively measured differences and changes in the GI tract in patients with EDs, along with the occurrence of GI complications.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, and Google Scholar to find all relevant studies examining GI problems in AN, BN, and BED. Quantitative analyses were performed for objective GI physiology measures where applicable.

RESULTS

The review differentiated between ED types and also between studies that report GI outcomes of ED in (i) human studies with an ED diagnosis excluding case reports that provide an overview of GI problems in ED and (ii) case reports with an ED diagnosis describing rare GI complications in ED. GI symptoms and impaired gastric transit times were frequent features of EDs with specific differences found for the ED types. During the time course of treatment, GI symptoms changed and/or improved but not completely. GI complications extended the range of GI problems observed, including a variety of serious complications such as gastric dilatation.

CONCLUSIONS

Problems of the GI tract are frequent in patients with ED and it is likely that they complicate therapy, especially in patients with AN.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42019100585.

Eating Disorders and Gastrointestinal Diseases

Eating disorders (ED) are frequently associated with a wide range of psychiatric or somatic comorbidities. The most relevant ED are anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorders (BED). Patients with ED exhibit both upper and lower gastrointestinal (GI) symptoms. Evidence of alterations throughout the GI tract in ED will be analyzed given the role of the GI tract in food intake and its regulation. It remains a matter of debate whether GI disorders are inherent manifestations of ED or the results of malnutrition occurring from ED. Moreover, recent clinical studies have highlighted the growing role of intestinal microbiota in the pathogenesis of ED, making it possible to hypothesize a modulation of intestinal microbiota as a co-adjuvant to standard therapy. The aim of this review is to analyze the link between ED and GI diseases and to present, where known, the potential key factors underlying these conditions. Conclusions: The presence of GI disorders should be investigated in patients with ED. Screening for ED should also be encouraged in individuals seeking treatment for unexplained GI complaints to better address therapeutic issues that surround these difficult medical conditions.

Eating Disorders and Gastrointestinal Diseases

Eating disorders (ED) are frequently associated with a wide range of psychiatric or somatic comorbidities. The most relevant ED are anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorders (BED). Patients with ED exhibit both upper and lower gastrointestinal (GI) symptoms. Evidence of alterations throughout the GI tract in ED will be analyzed given the role of the GI tract in food intake and its regulation. It remains a matter of debate whether GI disorders are inherent manifestations of ED or the results of malnutrition occurring from ED. Moreover, recent clinical studies have highlighted the growing role of intestinal microbiota in the pathogenesis of ED, making it possible to hypothesize a modulation of intestinal microbiota as a co-adjuvant to standard therapy. The aim of this review is to analyze the link between ED and GI diseases and to present, where known, the potential key factors underlying these conditions. Conclusions: The presence of GI disorders should be investigated in patients with ED. Screening for ED should also be encouraged in individuals seeking treatment for unexplained GI complaints to better address therapeutic issues that surround these difficult medical conditions.

An update on gastrointestinal disturbances in eating disorders

Eating disorders, namely anorexia nervosa, bulimia nervosa and binge eating disorder are frequent diseases and often complicated by comorbidities, e.g. psychiatric or cardiovascular comorbidities. It is to note that also gastrointestinal symptoms/complications are frequently observed in patients with eating disorders. These diseases will be presented in the current review along with - where known - possible underlying mechanisms. Lastly, gaps in knowledge will be highlighted.

Medical complications of bulimia nervosa and their treatments

PURPOSE

The purpose of this article is to thoroughly review the medical complications associated with bulimia nervosa and their evidenced-based or typical treatments.

METHODS

A thorough review of medical literature to cull pertinent and best articles which guide the diagnosis and treatment of the medical complications of bulimia nervosa was performed.

RESULTS

There are many different medical complications of bulimia nervosa which are caused by the mode and frequency of purging. Some are fluid and electrolyte alterations from the utilized mode of purging and some are due to the local damaging effects of purging behaviors on those body sites.

CONCLUSION

Bulimia nervosa is a serious mental health disorder which has many medical complications associated with it. Most are reversible with treatment.

Medical Complications of Anorexia Nervosa and Bulimia

Anorexia nervosa and bulimia nervosa are serious psychiatric illnesses related to disordered eating and distorted body images. They both have significant medical complications associated with the weight loss and malnutrition of anorexia nervosa, as well as from the purging behaviors that characterize bulimia nervosa. No body system is spared from the adverse sequelae of these illnesses, especially as anorexia nervosa and bulimia nervosa become more severe and chronic. We review the medical complications that are associated with anorexia nervosa and bulimia nervosa, as well as the treatment for the complications. We also discuss the epidemiology and psychiatric comorbidities of these eating disorders.

Gastrointestinal symptoms and disorders in patients with eating disorders

The two most clinically serious eating disorders are anorexia nervosa and bulimia nervosa. A drive for thinness and fear of fatness lead patients with anorexia nervosa either to restrict their food intake or binge-eat then purge (through self-induced vomiting and/or laxative abuse) to reduce their body weight to much less than the normal range. A drive for thinness leads patients with bulimia nervosa to binge-eat then purge but fail to reduce their body weight. Patients with eating disorders present with various gastrointestinal disturbances such as postprandial fullness, abdominal distention, abdominal pain, gastric distension, and early satiety, with altered esophageal motility sometimes seen in patients with anorexia nervosa. Other common conditions noted in patients with eating disorders are postprandial distress syndrome, superior mesenteric artery syndrome, irritable bowel syndrome, and functional constipation. Binge eating may cause acute gastric dilatation and gastric perforation, while self-induced vomiting can lead to dental caries, salivary gland enlargement, gastroesophageal reflux disease, and electrolyte imbalance. Laxative abuse can cause dehydration and electrolyte imbalance. Vomiting and/or laxative abuse can cause hypokalemia, which carries a risk of fatal arrhythmia. Careful assessment and intensive treatment of patients with eating disorders is needed because gastrointestinal symptoms/disorders can progress to a critical condition.

Defecatory disorders in anorexia nervosa: a clinical study

BACKGROUND

Defecatory disorders in patients with eating disorders have been overlooked. We evaluated the prevalence and type of defecatory disorders in patients with anorexia nervosa.

METHODS

The aim of our questionnaire-based study was to determine the prevalence of constipation and faecal incontinence (FI) in patients with anorexia nervosa attending our dedicated eating disorders outpatient clinics and whether length of illness and low body mass index (BMI) exacerbate both constipation and FI. The Wexner constipation score (WCS), Altomare's obstructed defecation score (OD score) and the faecal incontinence severity index (FISI) were used to evaluate constipation and incontinence. A WCS ≥5, OD score ≥10 and a FISI ≥10 were considered clinically relevant.

RESULTS

Eighty-five patients (83 females; mean age 28 years ± 13) with anorexia nervosa (study group) and mean BMI of 16 ± 2 kg/m(2) (range 14-19 kg/m(2)) were studied. This group was compared to 57 healthy volunteers (control group) with mean BMI of 22 ± 3 kg/m(2) (range 20-27 kg/m(2)). In the study group, 79/85 (93%) patients suffered from defecatory disorders defined as at least one abnormal score, either WCS, OD score or FISI, compared to 7/57 (12%) controls (p < 0.001). Constipation (defined as WCS ≥5) was present in 70/85 (83%) patients with anorexia and in 7/57 (12%) controls (p = 0.001), while obstructed defecation syndrome (defined as OD score ≥10) was present in 71/85 (84%) patients with anorexia and 7/57 (12%) controls (p < 0.001). In patients with anorexia, the mean WCS score was 10 ± 5 standard deviation (SD) (3 ± 2 SD in controls; p < 0.001), and the mean OD score was 12 ± 4 SD (3 ± 4 SD in controls; p < 0.001). Overall, 62/85 (73%) patients with anorexia had FI defined as FISI score ≥10, and the mean FISI score in anorexia patients was 12 ± 9 SD. A combination of constipation and FI (either both WCS and FISI abnormal or both OD score and FISI abnormal) was present in 55/85 (64%) and 8/85 (9%) presented with FI alone. Moreover, all results are influenced by the severity of the disease measured by BMI and duration. The percentage of defecatory disorders rises from 75 to 100% when BMI is <18 kg/m(2) and from 60 to 75% when the duration of illness is ≥5 years (p < 0.001 and p = 0.021, respectively).

CONCLUSIONS

Defecatory disorders are associated with anorexia nervosa and increased with the duration and severity of the illness.

Imaging findings in eating disorders

OBJECTIVE

Eating disorders, such as anorexia nervosa and bulimia nervosa, are often undiagnosed but potentially treatable illnesses that, if not identified, can lead to morbidity and death. Often, because of embarrassment or social stigma, patients do not readily admit to these disorders when interviewed by caregivers. Imaging findings can suggest the presence of an eating disorder; understanding these findings allows the radiologist to contribute to the diagnosis of these insidious conditions and alert the referring caregiver. Current concepts in eating disorders and their multimodality imaging findings in several organ systems will be reviewed.

CONCLUSION

After reviewing this article, the radiologist will understand the imaging findings in eating disorders. This knowledge will empower the radiologist to raise the question of a patient's eating disorder, a condition that may be unsuspected by the referring caregiver and could otherwise remain undiagnosed.

Rectal prolapse associated with anorexia nervosa: a case report and review of the literature

Anorexia nervosa is one of a few mental health diagnoses that affects every organ system. Patients with AN often present with multiple secondary effects of starvation at the time of first assessment, including gastrointestinal (GI) complaints. In extreme cases, severe GI complications such as rectal prolapse may be encountered as a consequence of the illness although formal studies investigating the frequency of such occurrences are lacking. We present the case of a 16 year old female previously diagnosed with anorexia nervosa that developed a rectal prolapse as a consequence of her disease as well as a detailed literature review investigating the frequency and prevalence of such occurrences in this population.

Bulimia nervosa presenting as rectal purging and rectal prolapse: case report and literature review

Rectal prolapse, but not rectal purging (excessive finger evacuation to induce defecation), has been formally associated with eating disorders in the medical literature. We describe a young woman with bulimia nervosa and irritable bowel syndrome who used rectal purging as a method of counteracting the effects of her binge eating and who underwent two corrective surgeries for rectal prolapse in a 15-month interval. Further research into the relationship between eating disorders, rectal purging, and gastrointestinal dysfunction is called for.

Medical complications of bulimia nervosa and their treatments

OBJECTIVE

To present a cogent and practical review of the medical complications and their treatment in patients with bulimia nervosa.

METHOD

Thorough review of the medical literature from 1990 to current in regards to the medical complications of bulimia nervosa and the therapeutic intervention that are effective to treat them.

RESULTS

Extensive and detailed review of the medical complications of bulimia nervosa.

Laxative abuse: epidemiology, diagnosis and management

Laxatives have been used for health purposes for over 2000 years, and for much of that time abuse or misuse of laxatives has occurred. Individuals who abuse laxatives can generally be categorized as falling into one of four groups. By far the largest group is made up of individuals suffering from an eating disorder such as anorexia or bulimia nervosa. The prevalence of laxative abuse has been reported to range from approximately 10% to 60% of individuals in this group. The second group consists of individuals who are generally middle aged or older who begin using laxatives when constipated but continue to overuse them. This pattern may be promulgated on certain beliefs that daily bowel movements are necessary for good health. The third group includes individuals engaged in certain types of athletic training, including sports with set weight limits. The fourth group contains surreptitious laxative abusers who use the drugs to cause factitious diarrhoea and may have a factitious disorder. Normal bowel function consists of the absorption of nutrients, electrolytes and water from the gut. Most nutrients are absorbed in the small intestine, while the large bowel absorbs primarily water. There are several types of laxatives available, including stimulant agents, saline and osmotic products, bulking agents and surfactants. The most frequently abused group of laxatives are of the stimulant class. This may be related to the quick action of stimulants, particularly in individuals with eating disorders as they may erroneously believe that they can avoid the absorption of calories via the resulting diarrhoea. Medical problems associated with laxative abuse include electrolyte and acid/base changes that can involve the renal and cardiovascular systems and may become life threatening. The renin-aldosterone system becomes activated due to the loss of fluid, which leads to oedema and acute weight gain when the laxative is discontinued. This can result in reinforcing further laxative abuse when a patient feels bloated and has gained weight. Treatment begins with a high level of suspicion, particularly when a patient presents with alternating diarrhoea and constipation as well as other gastrointestinal complaints. Checking serum electrolytes and the acid/base status can identify individuals who may need medical stabilization and confirm the severity of the abuse. The first step in treating laxative misuse once it is identified is to determine what may be promoting the behaviour, such as an eating disorder or use based on misinformation regarding what constitutes a healthy bowel habit. The first intervention would be to stop the stimulant laxatives and replace them with fibre/osmotic supplements utilized to establish normal bowel movements. Education and further treatment may be required to maintain a healthy bowel programme. In the case of an eating disorder, referral for psychiatric treatment is essential to lessen the reliance on laxatives as a method to alter weight and shape.

The eating disorders medicine cabinet revisited: a clinician's guide to ipecac and laxatives

OBJECTIVE

To describe the frequency of alternative medication use in bulimia nervosa (BN), and to review available nonprescription emetic (ipecac) and laxative products and their potential toxicities.

METHOD

Survey data were collected from 39 consecutive treatment-seeking patients with BN or subthreshold BN. Survey data of the available nonprescription and herbal products from local retail stores were also collected. Toxicology information was reviewed on these agents from MEDLINE and herbal textbooks.

RESULTS

Ipecac use occurred in 18% of the 39 patients. Laxatives had been used at some point to control weight or "get rid of food" by 67% of the patients. Of these, 31% had abused laxatives during the month prior to evaluation. In the product survey, 248 laxative-containing products were identified.

CONCLUSION

There are numerous laxative products readily available to patients, and many of them have significant associated toxicities. Patients with BN tend to endorse high rates of laxative use. While ipecac is used infrequently, it can have deleterious consequences. Patients with BN should be screened for use of both ipecac and laxatives and should be educated about the potential consequences associated with the misuse of these agents.

Rectal prolapse

INTRODUCTION

Rectal prolapse, or procidentia, is defined as a protrusion of the rectum beyond the anus. It commonly occurs at the extremes of age. Rectal prolapse frequently coexists with other pelvic floor disorders, and patients have symptoms associated with combined rectal and genital prolapse. Few patients, a lack of randomized trials and difficulties in the interpretation of studies of anorectal physiology have made the understanding of this disorder difficult.

METHODS OF TREATMENT

Surgical management is aimed at restoring physiology by correcting the prolapse and improving continence and constipation, whereas in patients with concurrent genital and rectal prolapse, an interdisciplinary surgical approach is required. Operation should be reserved for those patients in whom medical treatment has failed, and it may be expected to relieve symptoms. Numerous surgical procedures have been suggested to treat rectal prolapse. They are generally classified as abdominal or perineal according to the route of access. However, the controversy as to which operation is appropriate cannot be answered definitively, as the extent of a standardized diagnostic assessment and the types of surgical procedures have not been identified in published series.

LITERATURE REVIEW

This review encompasses rectal prolapse, including aetiology, symptoms and treatment. The English-language literature about rectal prolapse was identified using Medline, and additional cited works not detected in the initial search were obtained. Articles reporting on prospective and retrospective comparisons and case reports were included.

Case report of abuse of Orlistat

A case report of abuse of the anti-obesity drug, Orlistat, is reported in a normal-weight woman with an eating disorder and stimulant dependence. The case is discussed with reference to the availability of prescription drugs on the Internet, abuse of nonamphetamines and the side effect profile of Orlistat versus laxatives.

Bulimia Nervosa: A Primary Care Review

Bulimia nervosa is a psychiatric condition that affects many adolescent and young adult women. The disorder is characterized by bingeing and purging behavior and can lead to medical complications. Thus, patients with bulimia nervosa commonly present in the primary care setting. Physical and laboratory examinations reveal markers of bulimia nervosa that are useful in making the diagnosis. Treatment is beneficial, and outcomes of early intervention are good. This article discusses the history, presentation, and tools needed for recognizing and treating bulimia nervosa in primary care.

Rectal prolapse: a possibly underrecognized complication of anorexia nervosa amenable to surgical correction

OBJECTIVE

Rectal prolapse is a complication of anorexia nervosa (AN) that may be more common than previously recorded experience would suggest.

METHOD

In this report we document, for the first time, the association of (AN) and rectal prolapse in a series of three patients seen in the past three years. An extensive review of the literature using Medline over the period from 1966 to Jan 2000 failed to reveal any previous example of this association.

RESULTS AND CONCLUSION

The finding could have significant health care implications if confirmed. It would suggest that patients with either the psychiatric or surgical problem may not be receiving the appropriate complementary referrals: psychiatrist to surgeon and vice versa. The importance of recognition of this association in anorectic patients is the availability of effective surgical therapy.

Rectal prolapse in women with other defects of pelvic floor support

OBJECTIVES

We describe a series of patients with rectal prolapse who had other pelvic floor defects.

STUDY DESIGN

Patients with rectal prolapse that we examined between 1990 and 2000 were reviewed.

RESULTS

During this time frame 55 patients with rectal prolapse were seen by one of us. Fifty-two of these patients had other defects of pelvic floor support and are the subject of this report. The diagnosis was established in all patients with video defecography. Thirty-nine of the patients had internal (occult) prolapse that simulated either a rectocele or an enterocele. The mean number of surgical procedures for pelvic floor support before the diagnosis of rectal prolapse was 1.5. Thirty-one patients underwent a sigmoid resection with rectopexy, 12 underwent a rectopexy alone, 3 underwent a Ripstein procedure, 2 elderly patients had physical therapy alone, and the other 4 patients had surgical correction of the rectal prolapse before being referred for repair of vaginal vault prolapse. Other procedures performed simultaneously included sacral colpopexy, sacrospinous suspension, rectopubic urethropexy, and abdominal fixation of the vagina to the uterosacral ligaments.

CONCLUSIONS

Rectal prolapse frequently coexists with other pelvic floor defects. Internal rectal prolapse may simulate a rectocele or enterocele and requires defecography to establish the diagnosis. Rectopexy (with or without sigmoid resection) is a satisfactory technique for correction and may be combined with other reconstructive procedures on the pelvic floor.