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Biolato M, Terranova R, Policola C, Pontecorvi A, Gasbarrini A, Grieco A. Starvation hepatitis and refeeding-induced hepatitis: mechanism, diagnosis, and treatment. Gastroenterol Rep (Oxf) 2024; 12:goae034. [PMID: 38708095 PMCID: PMC11069106 DOI: 10.1093/gastro/goae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/27/2024] [Accepted: 03/19/2024] [Indexed: 05/07/2024] Open
Abstract
Anorexia nervosa (AN) is one of the most common psychiatric disorders among young adults and is associated with a substantial risk of death from suicide and medical complications. Transaminase elevations are common in patients with AN at the time of hospital admission and have been associated with longer lengths of hospital stay. Multiple types of hepatitis may occur in these patients, including two types that occur only in patients with AN: starvation hepatitis and refeeding-induced hepatitis. Starvation hepatitis is characterized by severe transaminase elevation in patients in the advanced phase of protein-energy deprivation and is associated with complications of severe starvation, such as hypoglycaemia, hypothermia, and hypotension. Refeeding-induced hepatitis is characterized by a milder increase in transaminases that occurs in the early refeeding phase and is associated with hypophosphatemia, hypokalemia, and hypomagnesaemia. Among the most common forms of hepatitis, drug-induced liver injury is particularly relevant in this patient cohort, given the frequent use and abuse of methamphetamines, laxatives, antidepressants, and antipsychotics. In this review, we provided an overview of the different forms of anorexic-associated hepatitis, a diagnostic approach that can help the clinician to correctly frame the problem, and indications on their management and treatment.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Rosy Terranova
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Caterina Policola
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
- Unit of Endocrinology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alfredo Pontecorvi
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
- Unit of Endocrinology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
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2
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Schuster K, Staffeld A, Zimmermann A, Böge N, Lang S, Kuhla A, Frintrop L. Starvation in Mice Induces Liver Damage Associated with Autophagy. Nutrients 2024; 16:1191. [PMID: 38674881 PMCID: PMC11053507 DOI: 10.3390/nu16081191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/03/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Anorexia nervosa (AN) induces organ dysfunction caused by malnutrition, including liver damage leading to a rise in transaminases due to hepatocyte damage. The underlying pathophysiology of starvation-induced liver damage is poorly understood. We investigate the effect of a 25% body weight reduction on murine livers in a mouse model and examine possible underlying mechanisms of starvation-induced liver damage. Female mice received a restricted amount of food with access to running wheels until a 25% weight reduction was achieved. This weight reduction was maintained for two weeks to mimic chronic starvation. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were measured spectrophotometrically. Liver fat content was analyzed using an Oil Red O stain, and liver glycogen was determined using a Periodic acid-Schiff (PAS) stain. Immunohistochemical stains were used to investigate macrophages, proliferation, apoptosis, and autophagy. Starvation led to an elevation of AST and ALT values, a decreased amount of liver fat, and reduced glycogen deposits. The density of F4/80+ macrophage numbers as well as proliferating KI67+ cells were decreased by starvation, while apoptosis was not altered. This was paralleled by an increase in autophagy-related protein staining. Increased transaminase values suggest the presence of liver damage in the examined livers of starved mice. The observed starvation-induced liver damage may be attributed to increased autophagy. Whether other mechanisms play an additional role in starvation-induced liver damage remains to be investigated.
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Affiliation(s)
- Katharina Schuster
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
| | - Anna Staffeld
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
| | - Annelie Zimmermann
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
| | - Natalie Böge
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
| | - Stephan Lang
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
| | - Angela Kuhla
- Rudolf-Zenker-Institute for Experimental Surgery, Medical University Rostock, 18057 Rostock, Germany
| | - Linda Frintrop
- Institute of Anatomy, Rostock University Medical Center, 18057 Rostock, Germany; (K.S.); (A.Z.); (S.L.)
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3
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Staller K, Abber SR, Burton Murray H. The intersection between eating disorders and gastrointestinal disorders: a narrative review and practical guide. Lancet Gastroenterol Hepatol 2023; 8:565-578. [PMID: 36868254 DOI: 10.1016/s2468-1253(22)00351-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 03/04/2023]
Abstract
Eating disorders include a spectrum of disordered thinking patterns and behaviours around eating. There is increasing recognition of the bi-directional relationship between eating disorders and gastrointestinal disease. Gastrointestinal symptoms and structural issues might arise from eating disorders, and gastrointestinal disease might be a risk factor for eating disorder development. Cross-sectional research suggests that individuals with eating disorders are disproportionately represented among people seeking care for gastrointestinal symptoms, with avoidant-restrictive food intake disorder in particular garnering attention for high rates among individuals with functional gastrointestinal disorders. This Review aims to describe the research to date on the relationship between gastrointestinal disorders and eating disorders, highlight research gaps, and provide brief, practical guidance for the gastroenterology provider in detecting, potentially preventing, and treating gastrointestinal symptoms in eating disorders.
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Affiliation(s)
- Kyle Staller
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Sophie R Abber
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Helen Burton Murray
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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4
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Genetic investigation of the contribution of body composition to anorexia nervosa in an electronic health record setting. Transl Psychiatry 2022; 12:486. [PMID: 36402754 PMCID: PMC9675730 DOI: 10.1038/s41398-022-02251-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 10/31/2022] [Accepted: 11/04/2022] [Indexed: 11/21/2022] Open
Abstract
Anorexia nervosa (AN) is a psychiatric disorder defined by anthropometric symptoms, such as low body weight, and cognitive-behavioral symptoms, such as restricted eating, fear of weight gain, and distorted body image. Recent studies have identified a genetic association between AN and metabolic/anthropometric factors, including body mass index (BMI). Although the reported associations may be under pleiotropic genetic influences, they may represent independent risk factors for AN. Here we examined the independent contributions of genetic predisposition to low body weight and polygenic risk (PRS) for AN in a clinical population (Vanderbilt University Medical Center biobank, BioVU). We fitted logistic and linear regression models in a retrospective case-control design (123 AN patients, 615 age-matched controls). We replicated the genetic correlations between PRSBMI and AN (p = 1.12 × 10-3, OR = 0.96), but this correlation disappeared when controlling for lowest BMI (p = 0.84, OR = 1.00). Additionally, we performed a phenome-wide association analysis of the PRSAN and found that the associations with metabolic phenotypes were attenuated when controlling for PRSBMI. These findings suggest that the genetic association between BMI and AN may be a consequence of the weight-related diagnostic criteria for AN and that genetically regulated anthropometric traits (like BMI) may be independent of AN psychopathology. If so, individuals with cognitive-behavioral symptomatology suggestive of AN, but with a higher PRSBMI, may be under-diagnosed given current diagnostic criteria. Furthermore, PRSBMI may serve as an independent risk factor for weight loss and weight gain during recovery.
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Faragalla K, So J, Chan PC, Wang HL, Liu J. Value of liver biopsy in anorexia nervosa-related transaminitis: A case study and literature review. Hepatol Res 2022; 52:652-658. [PMID: 35583957 DOI: 10.1111/hepr.13792] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 03/31/2022] [Accepted: 04/14/2022] [Indexed: 02/08/2023]
Abstract
Anorexia nervosa (AN) is a complex eating disorder that affects multiple organs. 60% of patients have liver injury with transaminitis. The mechanism of liver injury in AN remains unclear. We present a case of a 19-year-old female with AN was admitted to our hospital with marked transaminitis but near normal liver histology on biopsy. Her transaminitis eventually improved as she regained weight. We also conducted a literature review of similar cases to delineate the clinicopathologic spectrum of liver injury in AN patients. English published cases of adult AN patients with elevated transaminases who underwent a liver biopsy or autopsy were selected. 32 cases (including ours). All except four patients were female, with median age of 26.5 years and median body mass index 11.9 kg/m2 . Presentations mainly included hypoglycemic coma and weight loss. 63% of patients had severe transaminitis (AST >15x ULN). Other lab findings included elevated international normalized ratio (72%) and hypoalbuminemia (47%). Microscopically, all cases showed intact hepatic architecture. Fibrosis was reported in 12 cases and necroinflamfmation in 8, but only half of each had severe transaminitis. AN patients display a wide spectrum of liver histopathology which often does not correlate with the degree of transaminitis. In severe persistent AN-related transaminitis, liver biopsy is useful to assess the degree of liver injury and to exclude other potential etiologies.
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Affiliation(s)
- Kyrillos Faragalla
- Department of Internal Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jeffrey So
- Department of Internal Medicine, Halton Healthcare, Oakville, Ontario, Canada
| | - Pak C Chan
- Department of Lab Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, 27 King's College Cir, Toronto, ON, Canada
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Jimin Liu
- Department of Laboratory Medicine, Halton Healthcare, Oakville, Ontario, Canada.,Department of Pathology and Molecular Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Cuntz U, Voderholzer U. Liver Damage Is Related to the Degree of Being Underweight in Anorexia Nervosa and Improves Rapidly with Weight Gain. Nutrients 2022; 14:nu14122378. [PMID: 35745110 PMCID: PMC9230663 DOI: 10.3390/nu14122378] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 02/01/2023] Open
Abstract
Background: The present study investigates the relationship between hypertransaminasemia and malnutrition on the basis of a very large number of patients. We assume that the level of transaminases not only reflects the extent of underlying liver cell damage but also provides information about the metabolic situation under conditions of energy deficiency. Methods: We present an observational study in two different samples. The first sample consists of 3755 patients (mean age 22.7 years, Range 12−73 years; mean BMI 15.4 kg/m2, range 8.1−25.7) out of a total of 4212 patients with anorexia nervosa treated in the Roseneck Clinic within five years for whom a complete admission laboratory was available. The second sample was obtained from a special ward for medically at-risk patients with eating disorders. During the period in question, four hundred and ten patients with anorexia nervosa were treated. One hundred and forty-two female patients (mean age 26.4 years, Range 18−63 years; mean BMI 11.5 kg/m2, range 8.4−13) had a BMI of thirteen or less and a complete data set was obtained at admission and weekly in the following four weeks after admission. Results: The increase in liver transaminases shows a very high correlation with weight in sample one (N = 3755). The analysis of variance shows highly significant (<0.001) correlations with an F-value of 55 for GOT/AST and 63 for GPT/ALT. Nevertheless, the variance within the groups with the same BMI is quite high. With re-nutrition in sample two, GOT/AST decreased on average from 71 U/L to 26 U/L (MANOVA F 10.7, p < 0.001) and GPT/ALT from 88 to 41 U/L (F = 9.9, p < 0.001) within four weeks. Discussion: Below a BMI of about 13, the nutritional status of the patients becomes so critical that the energy supply of the patient is increasingly dependent on the autophagy of the liver, which can be seen in the very strong increase in transaminases here. Refeeding leads very quickly to the normalisation of the transaminases and, thus, a stabilisation of the metabolism leading also to a decrease in autophagy.
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Affiliation(s)
- Ulrich Cuntz
- Schoen Clinic Roseneck, Am Roseneck 6, 83209 Prien am Chiemsee, Germany;
- Forschungsprogramm für Psychotherapieevaluation im komplexen Therapiesetting, PMU Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
- Correspondence:
| | - Ulrich Voderholzer
- Schoen Clinic Roseneck, Am Roseneck 6, 83209 Prien am Chiemsee, Germany;
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-Universität München (LMU), 80336 Munich, Germany
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7
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Liver disease in obesity and underweight: the two sides of the coin. A narrative review. Eat Weight Disord 2021; 26:2097-2107. [PMID: 33150534 DOI: 10.1007/s40519-020-01060-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 10/16/2020] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Malnutrition, whether characterized by not enough or too much nutrient intake, is detrimental to the liver. We herein provide a narrative literature revision relative to hepatic disease occurrence in over or undernourished subjects, to shed light on the paradox where both sides of malnutrition lead to similar liver dysfunction and fat accumulation. METHODS Medline, EMBASE, and Cochrane Library were searched for publications up to July 2020. Articles discussing the association between both chronic and acute liver pathology and malnutrition were evaluated together with studies reporting the dietary intake in subjects affected by malnutrition. RESULTS The association between overnutrition and non-alcoholic fatty liver disease (NAFLD) is well recognized, as the beneficial effects of calorie restriction and very low carbohydrate diets. Conversely, the link between undernutrition and liver injury is more complex and less understood. In developing countries, early exposure to nutrient deficiency leads to marasmus and kwashiorkor, accompanied by fatty liver, whereas in developed countries anorexia nervosa is a more common form of undernutrition, associated with liver injury. Weight gain in undernutrition is associated with liver function improvement, whereas no study on the impact of macronutrient distribution is available. We hypothesized a role for very low carbohydrate diets in the management of undernutrition derived liver pathology, in addition to the established one in overnutrition-related NAFLD. CONCLUSIONS Further studies are warranted to update the knowledge regarding undernutrition-related liver disease, and a specific interest should be paid to macronutrient distribution both in the context of refeeding and relative to its role in the development of hepatic complications of anorexia nervosa. LEVEL OF EVIDENCE Narrative review, Level V.
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8
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Hypoxic hepatitis with marked elevation of serum ferritin probably due to activation of intrahepatic macrophages: another form of hypoxic hepatitis hitherto not reported? Acta Gastroenterol Belg 2021; 84:317-320. [PMID: 34217182 DOI: 10.51821/84.2.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND STUDY AIMS Hypoxic hepatitis (HH) is an acute liver injury that develops in patients with underlying diseases, such as heart failure, respiratory failure, septic/toxic shock. However, some patients do not have underlying diseases or episodes which are known to result in HH. Here, we analyzed the clinical characteristics of this particular patient group (called 'unknown HH' hereafter) to understand its pathogenesis. PATIENTS AND METHODS Between October 2010 and January 2016, 157 consecutive patients with acute liver injury were admitted to our hospital. Among these patients, 15 patients were categorized as unknown HH. Medical histories and blood test results of unknown HH were analyzed. RESULTS Among 15 patients of unknown HH, 11 were habitual drinkers and all experienced one of digestive symptoms which might result in mild hypovolemia such as vomiting, diarrhea, appetite loss, and epigastralgia. All patients of unknown HH presented marked elevation of serum ferritin concentration paralleled with aspartate transaminase (AST), alanine transaminase (ALT), and lactate dehydrogenase (LDH) concentrations. The serum levels of ferritin, ALT, LDH, and prothrombin time-international normalized ratio (PT-INR) were rapidly decreased during hospitalization and all 15 patients of unknown HH recovered without any complication. CONCLUSIONS We found the particular group of HH with marked elevation of serum ferritin probably due to intrahepatic macrophage activation. Anti-inflammatory treatments might be effective for this group of hypoxic hepatitis.
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Gibson D, Drabkin A, Krantz MJ, Mascolo M, Rosen E, Sachs K, Welles C, Mehler PS. Critical gaps in the medical knowledge base of eating disorders. Eat Weight Disord 2018; 23:419-430. [PMID: 29681012 DOI: 10.1007/s40519-018-0503-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022] Open
Abstract
Eating disorders are unique in that they inherently have much medical comorbidity both as a part of restricting-type eating disorders and those characterized by purging behaviors. Over the last three decades, remarkable progress has been made in the understanding and treatment of the medical complications of eating disorders. Yet, unfortunately, there is much research that is sorely needed to bridge the gap between current medical knowledge and more effective and evidence-based medical treatment knowledge. These gaps exist in many different clinical areas including cardiology, electrolytes, gastrointestinal and bone disease. In this paper, we discuss some of the knowledge gap areas, which if bridged would help develop more effective medical intervention for this population of patients.
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Affiliation(s)
- Dennis Gibson
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Anne Drabkin
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Mori J Krantz
- Division of Cardiology, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | | | - Elissa Rosen
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Katherine Sachs
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Christine Welles
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA
| | - Philip S Mehler
- ACUTE, at Denver Health, 777 Bannock Street, Denver, CO, 80204, USA.
- Eating Recovery Center, Denver, 7351E Lowry Blvd, Denver, CO, 80230, USA.
- , Denver, USA.
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10
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Li XX, Liu J, Chen YL, Chen GJ, Wang ZY, Zhu JJ, Guo YW, Wei XQ. Atypical Presentation of Adrenocortical Insufficiency with Anorexia and Jaundice. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:705-709. [PMID: 29910458 PMCID: PMC6042472 DOI: 10.12659/ajcr.909190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Patient: Female, 65 Final Diagnosis: Adrenocortical insufficiency Symptoms: Anorexia and jaundice Medication: Glucocorticoid replacement Clinical Procedure: — Specialty: Gastroenterology and Hepatology
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Affiliation(s)
- Xiang-Xing Li
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Jie Liu
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - You-Lian Chen
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Guang-Jian Chen
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Zhen-Yu Wang
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Jun-Jun Zhu
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland)
| | - Yun-Wei Guo
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Xiu-Qing Wei
- Department of Gastroenterology, Yuedong Hospital of the Third Affiliated Hospital of Sun Yat-sen University, Meizhou, Guangdong, China (mainland).,Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
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11
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Norris ML, Harrison ME, Isserlin L, Robinson A, Feder S, Sampson M. Gastrointestinal complications associated with anorexia nervosa: A systematic review. Int J Eat Disord 2016; 49:216-37. [PMID: 26407541 DOI: 10.1002/eat.22462] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE A systematic review identifying gastrointestinal (GI) complications attributable to anorexia nervosa (AN) was completed. METHOD Studies of any design exploring the pathogenesis of complications and treatment strategies were included. The review was completed in accordance with PRISMA standards. RESULTS A total of 123 articles were retained, including one randomized control trial. The majority of included studies were case reports and case series. Controlled studies demonstrated that patients with AN were more likely to have delays in gastric motility, gastric emptying and intestinal transit than comparator groups although results were not uniform across all studies. Published reports suggest that complications can occur at any segment of the GI tract. These issues may derive as a consequence of severe malnourishment, from eating disorder related symptoms such as self-induced purging or from the refeeding process itself. Multiple studies noted that patients with AN report high rates of GI symptoms although in the few cases where medical testing was undertaken, correlations between self-reported symptoms and measurable pathology were not demonstrated. DISCUSSION GI complications may occur throughout the entire GI tract in patients with AN. It is recommended that clinicians use careful judgment when pursuing targeted investigation or introducing symptom specific treatments in response to GI complaints. Evidence suggests that most GI complications resolve with refeeding and cessation of ED symptoms.
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Affiliation(s)
- Mark L Norris
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Megan E Harrison
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Leanna Isserlin
- Department of Psychiatry, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Amy Robinson
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Stephen Feder
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Margaret Sampson
- Library and Media Services, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
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12
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Frølich J, Palm CVB, Støving RK. To the limit of extreme malnutrition. Nutrition 2015; 32:146-8. [PMID: 26520917 DOI: 10.1016/j.nut.2015.08.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/13/2015] [Accepted: 08/27/2015] [Indexed: 11/27/2022]
Abstract
Extreme malnutrition with body mass index (BMI) as low as 10 kg/m(2) is not uncommon in anorexia nervosa, with survival enabled through complex metabolic adaptations. In contrast, outcomes from hunger strikes and famines are usually fatal after weight loss to about 40% below expected body weight, corresponding to BMI 12 to 13 kg/m(2) in adults. Thus, many years of adaptation in adolescent-onset anorexia nervosa, supported by supplements of vitamins and treatment of intercurrent diseases, may allow survival at a much lower BMI. However, in the literature only a few cases of survival in patients with BMI <9 kg/m(2) have been described. We report on the case of a 29-y-old woman who was successfully treated in a specialized unit. She had a BMI of 7.8 kg/m(2). To our knowledge, this level of extreme malnutrition has not previously been reported. The present case emphasizes the importance of adherence to guidelines to decrease refeeding complications.
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Affiliation(s)
- Jacob Frølich
- Centre for Eating Disorders, Department of Endocrinology, Odense University Hospital, Odense, Denmark.
| | | | - Rene K Støving
- Centre for Eating Disorders, Department of Endocrinology, Odense University Hospital, Odense, Denmark
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13
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Liver autophagy in anorexia nervosa and acute liver injury. BIOMED RESEARCH INTERNATIONAL 2014; 2014:701064. [PMID: 25250330 PMCID: PMC4163421 DOI: 10.1155/2014/701064] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 08/04/2014] [Indexed: 02/07/2023]
Abstract
Autophagy, a lysosomal catabolic pathway for long-lived proteins and damaged organelles, is crucial for cell homeostasis, and survival under stressful conditions. During starvation, autophagy is induced in numerous organisms ranging from yeast to mammals, and promotes survival by supplying nutrients and energy. In the early neonatal period, when transplacental nutrients supply is interrupted, starvation-induced autophagy is crucial for neonates' survival. In adult animals, autophagy provides amino acids and participates in glucose metabolism following starvation. In patients with anorexia nervosa, autophagy appears initially protective, allowing cells to copes with nutrient deprivation. However, when starvation is critically prolonged and when body mass index reaches 13 kg/m(2) or lower, acute liver insufficiency occurs with features of autophagic cell death, which can be observed by electron microscopy analysis of liver biopsy samples. In acetaminophen overdose, a classic cause of severe liver injury, autophagy is induced as a protective mechanism. Pharmacological enhancement of autophagy protects against acetaminophen-induced necrosis. Autophagy is also activated as a rescue mechanism in response to Efavirenz-induced mitochondrial dysfunction. However, Efavirenz overdose blocks autophagy leading to liver cell death. In conclusion, in acute liver injury, autophagy appears as a protective mechanism that can be however blocked or overwhelmed.
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