Case records of the Massachusetts General Hospital. Case 29-2008. A 19-year-old man with weight loss and abdominal pain

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.

Reversible male hypogonadotropic hypogonadism due to energy deficit

CONTEXT

Calorie restriction and overtraining are increasingly seen in young men who suffer from increasing societal pressure to attain a perceived ideal male body image. The resulting energy deficit can lead to multiple endocrine consequences, including suppression of the male gonadal axis.

DESIGN

We reviewed the literature, including two unpublished cases.

RESULTS

We identified 23 cases, aged median (range) 20 years (16-33), with a body mass index of 15.9 kg/m² (12.5-20.5). Total testosterone was 3.0 nmol/L (0.6-21.3), and luteinizing hormone (LH) 1.2 mIU/L (<0.2-7.5), with 91% of cases demonstrating hypogonadotropic hypogonadism. Associated findings included evidence of growth hormone resistance (increased growth hormone in 57% and low insulin-like growth factor-1 in 71%), hypercortisolaemia (50%) and a nonthyroidal illness picture (67%). In cases with longitudinal measurements following weight regain, serum testosterone (n = 14) increased from median [interquartile range] 3.2 nmol/L [1.9-5.1] to 14.3 nmol/L [9.3-21.2] (P < 0.001), and LH (n = 8) from 1.2 IU/L [0.8-1.8] to 3.5 IU/L [3.3-4.3] (P = 0.008).

CONCLUSIONS

Hypogonadotropic hypogonadism can occur in the context of energy deprivation in young otherwise healthy men and may be underrecognized. The evidence suggests that gonadal axis suppression and associated hormonal abnormalities represent an adaptive response to increased physiological stress and total body energy deficit. The pathophysiology likely involves hypothalamic suppression due to dysregulation of leptin, ghrelin and pro-inflammatory cytokines. The gonadal axis suppression is functional, because it can be reversible with weight gain. Treatment should focus on reversing the existing energy deficit to achieve a healthy body weight, including psychiatric input where required.

Spontaneous Pneumomediastinum: An Unusual Pulmonary Complication in Anorexia Nervosa

Spontaneous pneumomediastinum (PM) is an uncommon condition in which free air enters the mediastinum. This usually occurs either through esophageal tears after vigorous vomiting, or after alveolar rupture subsequent to a rapid increase in intra-alveolar pressure. Spontaneous PM is a rare entity in anorexia nervosa (AN) and self-induced vomiting is often the cause of PM in patients with AN. We experienced a case of spontaneous PM in an anorexic adolescent, in whom vomiting was not the cause of PM.

Perioperative management of severe anorexia nervosa

As the prevalence of anorexia nervosa (AN) increased, surgery in severe AN patients also increased in the 2000s. We experienced a surgical case of a patient with severe AN, showing an extremely low BMI of 8.6 kg m(-2). We investigated the problems associated with this case and propose criteria to manage severe AN. We endeavour to report on the perioperative management of rare and severe symptoms and surgical indications of severely malnourished patients. All published reports were identified through comprehensive searches using PubMed, BioMedLib, and the Japan Medical Abstracts Society with the following terms and keywords: 'anorexia nervosa', 'eating disorder', 'hypoglycaemia', 'leucocytopaenia', 'gelatinous bone marrow', 'surgery', and 'operation'. In cases of AN with a BMI under 13 kg m(-2), marked hypoglycaemia, leucocytopaenia <3.0×10(9) litre(-1), or both, potentially fatal complications frequently occur. Accordingly, patients need strict nutritional support to avoid re-feeding syndrome until surgery. During the course of anaesthesia, careless loading of glucose or catecholamine may lead to disturbance of electrolytes or fatal arrhythmia. Intensive care and early feeding as soon as possible after surgery are important to prevent surgical site infection. Although not many perioperative cases of AN have been reported, clinicians must be aware of the danger and the causes of mortality in critical cases. Thus, the decision to undertake surgery must be taken carefully and close perioperative coordination among physicians, surgeons, psychiatrists, anaesthesiologists, and intensivists is essential.

Cognitive-behavioral therapy for weight management and eating disorders in children and adolescents

Eating disorders and obesity in children and adolescents involve harmful behavior and attitude patterns that infiltrate daily functioning. Cognitive-behavioral therapy (CBT) is well suited to treating these conditions, given the emphasis on breaking negative behavior cycles. This article reviews the current empirically supported treatments and the considerations for youth with weight control issues. New therapeutic modalities (ie, enhanced CBT and the socioecologic model) are discussed. Rationale is provided for extending therapy beyond the individual treatment milieu to include the family, peer network, and community domains to promote behavior change, minimize relapse, and support healthy long-term behavior maintenance.

The management of pneumothorax in patients with anorexia nervosa: A case report and review of the literature

Of the many body systems adversely affected by severe anorexia nervosa (AN), the pulmonary system is relatively spared. However, in the face of severe malnutrition of AN, the lung may undergo architectural changes that adversely affect its integrity and healing capacity. We report herein a case of a pneumothorax in a patient with severe AN, in which standard approaches to manage the pneumothorax were unsuccessful. Despite prolonged tube thoracostomy drainage, and subsequent thoracoscopic pleuredesis, the patient continued to have an air leak and non-resolution of her pneumothorax. We review the literature and discuss alternative approaches in this patient population.