Gastrointestinal Manifestations of Eating Disorders

Clinical characterization of Co-morbid autoimmune disease and eating disorders: a retrospective chart review

Research suggests a link between autoimmune illnesses (AI) and eating disorders (ED). We retrospectively reviewed charts of adolescent patients presenting for eating disorder treatment. We compared the presentation and treatment course for those with an ED and comorbid AI [with (GI-AI, N = 59) or without (non-GI, N = 21) gastrointestinal inflammation] with matched ED-only cases. The sample was overwhelmingly female, with an average age of 15.40. Weight gain trajectories differed across groups, with similar rates of weight gain between controls and non GI-AI cases and with a lower rate of weight gain for individuals with comorbid GI-AI. Over half (56%) of patients reported an AI diagnosis prior to ED; 38% reported an AI diagnosis following ED, and 6% reported ED and AI simultaneous diagnosis. On presentation, ED-only controls had higher rates of comorbid anxiety than cases in either AI group, while those with non-GI AI were more likely to report depression. Mean total GI symptoms, % goal weight at presentation, vital sign instability, and markers of refeeding syndrome did not differ across groups. Health care professionals treating patients with either condition should have a low threshold for asking additional questions to identify the presence of the other condition.

Gut-Brain Interaction Disorders and Anorexia Nervosa: Psychopathological Asset, Disgust, and Gastrointestinal Symptoms

BACKGROUND

Gastrointestinal (GI) symptoms are very common in subjects with eating disorders (EDs). This study aimed to (a) investigate the prevalence of gut-brain interaction disorders (DGBIs) in anorexia nervosa (AN) patients, according to ROME IV criteria; and (b) explore AN psychopathological assets and disgust that might impact GI symptoms.

METHODS

Thirty-eight female patients consecutively diagnosed with untreated AN (age 19.32 ± 5.59) in an outpatient clinic devoted to EDs underwent Eating Disorder Inventory-3 (EDI-3), Hospital Anxiety and Depression Scale (HADS), Social Phobia Anxiety Scale (SPAS), Body Uneasiness Test (BUT), and Disgust Scale (DS) questionnaires. The presence of DGBIs was evaluated and GI symptoms were assessed using a standardized intensity-frequency questionnaire.

RESULTS

A total of 94.7% of our sample met the diagnostic criteria for functional dyspepsia (FD), of which 88.8% presented the postprandial distress syndrome (PDS) subtype and 41.6% presented the epigastric pain syndrome (EPS) subtype. In addition, 52.6% of the sample met the diagnostic criteria for irritable bowel syndrome (IBS), while for functional constipation (FC), prevalence reached 7.9%. All participants presented a pathological score on the disgust scale. Significant correlations were found between several GI symptoms and psychopathological asset and disgust.

CONCLUSIONS

AN is a multifactorial disorder. It is necessary to implement studies with an integrated approach, taking into account DGBIs, as well as to monitor the emotional-cognitive structure that acts as a factor in maintaining the disorder.

Eating disorders and the role of the dental team

Although primarily classified as psychiatric disorders, eating disorders have a complex aetiology and presentation, with comorbidities spanning multiple disciplines, including dental complications. In some cases, general dental practitioners may be the first health professional to become aware that someone is struggling with an eating disorder. The dental team is in an ideal position to sensitively explore the presentation and signpost the patient to appropriate services while offering support and/or remedial management for dental complications of the eating disorder. Anyone from any background, gender or ethnicity may develop an eating disorder, of which the main diagnoses are anorexia nervosa, bulimia nervosa and binge eating disorder. Some of the frequently seen oral manifestations of these disorders include generalised dental erosion, caries, self-inflicted palatal or oropharyngeal trauma, atrophic mucosa, bilateral parotid gland enlargement, xerostomia and periodontal disease. The dentist's role is pivotal in recognising the possible implications of some of these findings, approaching the patient sensitively, and communicating empathetically to engage them in treatment, reducing the risk of further erosion and improving oral health and hygiene. The dental team may be able to signpost the patient to their general practitioner for onward referral or to a local eating disorder support network.

Assessment and management of disorders of gut-brain interaction in patients with eating disorders

Disorders of gut-brain interaction (DBGI), also known as functional gastrointestinal disorders, are common in individuals with eating disorders, and may precede or perpetuate disordered eating. Understanding the pathophysiology of common gastrointestinal symptoms in DGBI can be important for the care of many patients with eating disorders. In this review, we summarize the literature to date on the complex relationship between DBGI and eating disorders and provide guidance on the assessment and management of the most common symptoms of DBGI by anatomic region: esophageal symptoms (globus and functional dysphagia), gastroduodenal symptoms (functional dyspepsia and nausea), and bowel symptoms (abdominal pain, bloating and constipation).

"The role of L. reuteri DSM17938 in nutritional recovery and treatment of constipation in children and adolescents with anorexia nervosa - a randomized, double blind, placebo controlled study"

BACKGROUND

Anorexia nervosa (AN) carries the risk of potentially irreversible medical complications, especially in children and adolescents. Constipation is frequent and difficult to manage. Due to the symptoms it causes, constipation can further compromise nutritional rehabilitation.

OBJECTIVE

To investigate the role of probiotics (Lactobacillus reuteri DSM 17938) in children and adolescent with AN.

DESIGN, SETTING AND PARTICIPANTS

Randomized, double blind, placebo controlled study in 31 female pediatric AN patients with constipation, referred to nutritional therapy in Pediatric Gastroenterology Department, Sestre milosrdnice University Hospital Centre in Zagreb.

METHODS

At hospitalization, patients were randomly assigned into two groups; one taking L. reuteri, and other placebo for 3 months, along with the conventional nutritional rehabilitation. Patients were followed 3 months after stopping the treatment. The primary outcome was relief of constipation, assessed after 3 months, while secondary outcomes were normalization of body weight, stool frequency and consistency, relief of dyspepsia, weight gain and recovery of malnutrition regarding bone density and vitamin D3 levels.

RESULTS

The study showed statistically significant difference between the two groups considering the stool frequency (6.4 vs. 4.2 stools/week; p < 0.05) and normalization of body weight (93 vs. 63%; p = 0.04) after 6 months, but no significant effect on the rate of relief of constipation (87 vs. 64%; p = 0.22) at 3 months. In the L. reuteri group, the normalization of BMD was achieved in 8/15, whereas in the placebo group, in 3/16 patients. However, there was no statistically significant difference compared to the placebo group regarding the BMD recovery as well as the normalization of D3 levels (p = 0.056).

CONCLUSIONS

Probiotics may serve as simple and safe adjuvant therapy of constipation in childhood AN and contribute to faster nutritional recovery. Although a statistically significant difference between the two group in relief of constipation could not be shown after 3 months, a benefit from probiotics could be in increasing stool frequency and nutritional recovery in childhood AN after six months. Registered under ClinicalTrials.gov Identifier no. NCT02004288.

Eating Disorders in Children and Adolescents: A Practical Review and Update for Pediatric Gynecologists

Eating disorders (EDs) are common among female adolescents and young adults and can have serious and diverse health consequences. Pediatric gynecology providers have the opportunity to play a vital role in the recognition of EDs in this population. Early medical detection and referral for appropriate evidence-based treatment can lead to better health outcomes for youth. In this article we aim to increase the awareness of the pediatric gynecologist of typical and subtle presentations of EDs, provide guidance for screening, discuss common and serious medical complications, and review treatment considerations for gynecologic issues in patients with EDs.

Evaluating disorders of gut-brain interaction in eating disorders

OBJECTIVE

Eating disorders commonly co-occur with gastrointestinal problems. This case-control study aimed to (a) document the prevalence of disorders of gut-brain interaction (DGBI) in eating disorders, (b) examine the specific impact of disordered eating behaviors on the risk of DGBI, and (c) explore the impact of current eating disorder psychopathology on DGBI.

METHOD

We included 765 cases with eating disorders and 1,240 controls. DGBI were assessed via the ROME III questionnaire. Prevalences of DGBI were calculated across eating disorder diagnoses (anorexia nervosa, bulimia nervosa, and multiple eating disorders) and in controls. The association between disordered eating behaviors and DGBI was examined using logistic regression models. Lastly, we compared the total number of DGBI in individuals with high versus low current eating disorder symptoms.

RESULTS

A large majority (88.2-95.5%) of individuals with eating disorders reported at least one DGBI and 34.8-48.7% reported three or more DGBI. Of the DGBI categories, functional bowel disorders were the most commonly endorsed category, and of the individual DGBI, irritable bowel syndrome was the most frequently reported (43.9-58.8%). All investigated disordered eating behaviors showed a positive association with most DGBI categories. Finally, individuals reporting high current eating disorder symptoms reported higher mean number of DGBI (3.03-3.34) than those with low current symptoms (1.60-1.84).

DISCUSSION

The directionality and mechanisms underlying the nature of the relationship between gastrointestinal and eating disorder symptoms is worthy of further study and clinicians should adopt an integrated approach by attending to both gastrointestinal and eating disorder symptoms in their patients.

Gut microbiome dysbiosis in anorexia nervosa

Anorexia nervosa (AN) is described as an eating disorder, which is characterized by malnutrition, a fear of gaining body mass, and a disturbed self-body image. This disease is dependent on biological, psychological and socio-cultural factors. Among the various biological factors, the importance of intestinal microbiota has recently attracted much attention. Identification of the gut microbiota dysbiosis in patients with AN has opened new and promising research directions. Recent observations focus in particular on the association between intestinal microorganisms and the occurrence of functional gastrointestinal disorders associated with anorexia, anxiety and depression, as well as the regulation of eating habits. The composition of the gut microbiota differs between patients with AN and individuals with normal body mass. This is due to the incorrect diet of patients; on the other hand, there is growing interest in the role of intestinal microbiota in the pathogenesis of AN, its changes through re-nutrition practices, and in particular the modulation of intestinal microbiological composition by means of nutritional interventions or the use of preand probiotics as standard supplements therapy of eating disorders. There is a need for further research about the microbiome - intestine - brain axis. Furthermore, consequences of changes in dietary habits as part of AN treatment are also unknown. However, better knowledge about the relationship between the gut microbiome and the brain can help improve the treatment of this disorder. This review aims to present the current knowledge about the potential role of intestinal microbiota in the pathogenesis, course and treatment of AN.

Identification and Management of Eating Disorders in Children and Adolescents

Eating disorders are serious, potentially life-threatening illnesses afflicting individuals through the life span, with a particular impact on both the physical and psychological development of children and adolescents. Because care for children and adolescents with eating disorders can be complex and resources for the treatment of eating disorders are often limited, pediatricians may be called on to not only provide medical supervision for their patients with diagnosed eating disorders but also coordinate care and advocate for appropriate services. This clinical report includes a review of common eating disorders diagnosed in children and adolescents, outlines the medical evaluation of patients suspected of having an eating disorder, presents an overview of treatment strategies, and highlights opportunities for advocacy.

Characteristics of avoidant/restrictive food intake disorder in a general paediatric inpatient sample

OBJECTIVE

Although patients with avoidant/restrictive food intake disorder (ARFID) often consult general paediatric services initially, existing literature mostly concentrated on intensive eating disorder treatment settings. This cross-sectional study sought to describe symptoms of ARFID and their associations with eating disorder psychopathology, quality of life, anthropometry, and physical comorbidities in a general paediatric sample.

METHODS

In N = 111 patients (8-18 years) seeking treatment for physical diseases, prevalence of ARFID-related restrictive eating behaviours was estimated by self-report and compared to population-based data (N = 799). Using self-report and medical record data, further ARFID diagnostic criteria were evaluated. Patients with versus without symptoms of ARFID based on self-report and medical records were compared in diverse clinical variables.

RESULTS

The prevalence of self-reported symptoms of ARFID was not higher in the inpatient than population-based sample. Only picky eating and shape concern were more common in the inpatient than population-based sample. Although 68% of the inpatient sample reported any restrictive eating behaviours, only 7% of patients showed symptoms of ARFID based on medical records in addition to self-report, particularly those with underweight, without significant effects for age, sex, and medical diagnoses.

DISCUSSION

The study revealed the importance of considering ARFID within the treatment of children and adolescents with physical diseases, especially for those with underweight. Further research is needed to replicate the findings with interview-based measures and to investigate the direction of effects in ARFID and its physical correlates.

Oral cavity and eating disorders: An insight to holistic health

Oral health is vital to the general well being and is a time-tested indicator of the systemic health of an individual. Oral cavity may be the primary site affected in endocrine disorders, renal disorders, gastrointestinal, cardiovascular, hematological, autoimmune cutaneous disorders, and psychosomatic disorders. Eating disorders (primarily Anorexia nervosa and bulimia) are psychosomatic disorders having multifaceted etiology, and characterized by abnormal eating patterns. In many cases, the oral cavity may be the only site of the manifestations of eating disorders. An oral physician may often unveil the mystery of this underlying systemic pathology by a vigilant and meticulous examination of the oral cavity. This not only helps in nabbing the disease in its early course but also prevents the patients from the appalling consequences due to the disease. This article aims to highlight the etiopathogenesis and various oral features in eating disorders. The oral physician should be familiar with the bizarre oral features of eating disorders and should work in close connection with other healthcare physicians to prevent the psychosomatic and systemic consequences.

Incontinence and constipation in adolescent patients with anorexia nervosa-Results of a multicenter study from a German web-based registry for children and adolescents with anorexia nervosa

OBJECTIVE

Nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI) are common disorders in childhood and are frequently accompanied by comorbid psychiatric disorders. Despite a high association between urinary and fecal incontinence with psychiatric and neurodevelopmental disorders, research on comorbidity between incontinence and anorexia nervosa (AN) remains scarce. Yet, it is well known that somatic consequences of AN include metabolic and gastrointestinal disorders. The study sought to assess the prevalence of incontinence and constipation in children and adolescents with AN and to examine associations of these two symptoms with body weight at admission and with BMI changes during inpatient treatment.

METHODS

Data collected between 2015 and 2017 by a multicenter German web-based registry for AN were analyzed. Three hundred and forty-eight patients with AN (96.3% female, mean age = 15.1 ± 1.8 years) were assessed regarding AN subtype, psychiatric comorbidity, body weight, incontinence, and constipation.

RESULTS

Overall, 27.6% of patients had constipation, 1.8% had NE and 1.8% DUI. Prevalence of constipation did not significantly differ between AN subtypes. Constipation did not lead to any significant differences in weight/BMI changes during inpatient treatment.

DISCUSSION

This is the largest study of incontinence and constipation in patients with AN, so far. Our results indicate that constipation is highly prevalent in adolescent patients with AN and reflects a clinically relevant condition. Despite, patients with AN do not have an increased prevalence of incontinence compared with the general population. Future studies should include medical examinations like ultrasound and physical examination of the lower abdomen to evaluate the severity of constipation.

Breath test using 13C methacetin does not seem to be useful in the assessment of liver function in girls with anorexia nervosa: a case control study

BACKGROUND

Anorexia nervosa (AN) concerns approximately up to 1.8% of the pediatric female population. One of the complications that can occur in the course of this disease is acute liver failure. This study's objective was to assess the usefulness of the 13C labeled Methacetin Breath Test (MBT) in the diagnostics of the liver function in girls with eating disorders.

METHODS

For the study 81 girls aged 12 to 17 years were recruited, including 41 patients with confirmed diagnosis of AN (mean age 14.7 ± 1.48 years) and 40 age-matched controls. The diagnosis was based on the present Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Weight and height were measured in all study participants and the Body Mass Index (BMI) was calculated. In the study and control group laboratory tests assessing the liver function and the MBT were performed.

RESULTS

In all controls the anthropometric as well as laboratory liver function parameters were normal. In the study group 25 patients (61%) had BMI below the lower limit for age. The total percentage of 13CO2 recovery in the 120th minute of the test did not exceed the lower limit in patients and controls. A result of the 13CO2 cumulative recovery above the upper normal range was found in 18 girls with AN (44% of the study group) and 2 controls (5%). Patients with AN were characterized by significantly higher 13CO2 cumulative dose recovery after ingestion of the substrate in comparison to the control group in all time points of the test.

CONCLUSIONS

The obtained results confirm a significant stimulation of the liver metabolism of 13C labeled methacetin in female patients with AN. The increased cumulative dose recovery of the substrate in girls with AN impacts the credibility of this measurement and implies a risk of false negative results.