Esophageal cancer in a young woman with bulimia nervosa: a case report

Spatiotemporal Distribution, Time to Treatment Outcome Clustering and Determinants of Esophageal Cancer in Ethiopia, a Scoping Study

INTRODUCTION

Esophageal cancer was the eighth and sixth leading cause of morbidity of all cancers in the world, and the 15th and 12th in Ethiopia, respectively. There is a lack of comprehensive data regarding Ethiopia's esophageal cancer hotspot, treatment outcome clustering, and other factors.

OBJECTIVE

This scoping review was designed to understand the extent and type of existing evidence regarding spatiotemporal distribution, time to treatment outcome clustering, and determinants of esophageal cancer in Ethiopia up to March 28, 2023.

METHODS

Three-step search strategies were employed for the scoping review from March 15 to 28, 2023. Targeted databases included PubMed/Medline, PubMed Central (PMC), Google Scholar, Hinari, and Cochrane for published studies and different websites for unpublished studies for evidence synthesis. Data were extracted using the Joanna Briggs Institute (JBI) manual format.

RESULTS

Our final analysis comprised 17 (16 quantitative and 1 qualitative) studies. Three studies attempted to depict the country's temporal distribution, whereas 12 studies showed the spatial distribution of esophageal cancer by proportion. The regional state of Oromia recorded a high percentage of cases. Numerous risk factors linked to the tumor have been identified in 8 investigations. Similarly, 5 studies went into detail regarding the likelihood of survival and the factors that contribute to malignancy, while 2 studies covered the results of disease-related treatments.

CONCLUSIONS

The substantial body of data that underpins this finding supports the fact that esophageal cancer has several risk factors and that its prevalence varies greatly across the country and among regions. Surgery, radiotherapy, or chemotherapy helped the patient live longer. However, no research has investigated which treatment is best for boosting patient survival and survival clustering. Therefore, research with robust models for regional distribution, clustering of time to treatment outcomes, and drivers of esophageal cancer will be needed.

Barrett’s esophagus in a patient with bulimia nervosa: A case report

BACKGROUND

Barrett’s esophagus is a known complication of long-standing gastroesophageal reflux disease, and it is a potential risk factor of developing esophageal adenocarcinoma.

CASE SUMMARY

Here, we present a case of a 47-year-old male patient referred to the gastroenterology clinic for upper endoscopy because he has a long-standing history of heartburn and vomiting after meals. On examination, he had characteristic findings of self-induced vomiting as abrasions and callosities on the dorsum of the right hand and dental erosions. A detailed history revealed that he had 17 years of binge eating with self-induced vomiting. His upper endoscopy showed gastroesophageal reflux grade D with salmon-red mucosal projections, and the biopsy revealed intestinal mucosal metaplasia.

CONCLUSION

This case emphasized the importance of considering upper endoscopy screening for Barrett’s esophagus in patients with eating disorders, especially those with self-induced vomiting, as in bulimia nervosa.

Eating disorders and the risk of developing cancer: a systematic review

PURPOSE

Evidence concerning eating disorders as risk toward developing cancer is sparse. Energy restriction might be cancer protective, while malnutrition, vomiting, laxative and substance use might stimulate cancer development. We examined whether individuals with an eating disorder (not restricted to anorexia nervosa) had a different risk of developing cancer.

METHODS

A systematic search on Medline and Embase until 28th April 2020 identified relevant human original research publications, including all populations and all cancer types.

RESULTS

From 990 records, 6 case reports and 9 cohorts were included. Some cohorts found a decreased breast (3/5 studies) or cervical (1/2) cancer risk, while an increased esophageal (2/3), liver (1/1), brain (1/1 in men) and respiratory (2/4) cancer risk, but other cancer risks were non-significant, and an increased mortality overall (1/2), from breast (1/1), female genital (1/1) and skin (1/1) cancer in eating disorder patients. The case reports further described esophageal cancer and leukemia. No clear statistical differences in cancer risk were found depending on eating disorder type, perhaps due to the small sample size (n = 1783 for other than anorexia nervosa).

CONCLUSIONS

The literature on eating disorders and cancer risk is sparse with many gaps. Hormonal changes, sexual activity, nutritional status, vomiting and concomitant tobacco/alcohol abuse may explain increased/decreased cancer risk. Future large studies (now 1-366 cancer cases) that also include men (now 4.7%), bulimia nervosa (now 3.8%) and several cancer sites (now mainly breast cancer) are needed and should foresee longer follow-up time (now 5.4-15.2 years) and extensive confounder adjustment (now only age and sex).

LEVEL OF EVIDENCE

Level I, systematic review.

Common and Emergent Oral and Gastrointestinal Manifestations of Eating Disorders

Eating disorders (EDs) such as anorexia nervosa, bulimia nervosa, and avoidant/restrictive food intake disorder are associated with restricted diets and abnormal compensatory behaviors, frequently leading to malnutrition and oral and gastrointestinal manifestations. Dental and oral complications are generally caused by malnutrition, micro-nutrient deficiency, and chronic acid exposure; hence, treatment of the ED and frequent dental examinations are essential to reduce morbidity. Gastrointestinal manifestations are multifactorial in origin, and may be caused by disordered behaviors, malnutrition, anxiety, and/or may be a function of the ED itself. This article reviews the most common oral and gastrointestinal manifestations of EDs and describes emergent complications such as acute gastric dilation and superior mesenteric artery syndrome. It is important for providers to recognize complications associated with EDs to provide the best treatment possible.

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.

Pathology, Chemoprevention, and Preclinical Models for Target Validation in Barrett Esophagus

Despite esophageal adenocarcinoma (EAC) being the most widespread among gastrointestinal cancers, with an 11-fold increase in the risk of cancer for patients with Barrett esophagus (BE), its prognosis is still poor. There is a critical need to better perceive the biology of cancer progression and identification of specific targets that are the hallmark of BE's progression. This review explores the established animal models of BE, including genetic, surgical and nonsurgical approaches, potential chemoprevention targets, and the reasoning behind their applications to prevent Barrett-related EAC. The key methodological features in the design feasibility of relevant studies are also discussed. Cancer Res; 78(14); 3747-54. ©2018 AACR.

Gastrointestinal Manifestations of Eating Disorders

Individuals with eating disorders, including anorexia nervosa and bulimia nervosa, may present with a range of gastrointestinal (GI) manifestations. The oral cavity, salivary glands, GI tract, pancreas, and liver can be impacted by nutritional restrictive and binge/purging behaviors. Complications are often reversible with appropriate nutritional therapy. At times, however, the complications in these disorders may be severe, irreversible and even life threatening. Given the often covert nature of eating disorders, the practitioner must be attentive to subtle clues that may indicate their presence. Extensive diagnostic evaluations of the GI manifestations of eating disorders should be used only when nutritional rehabilitation does not remedy the problems.

Disparities by Sexual Orientation in Frequent Engagement in Cancer-Related Risk Behaviors: A 12-Year Follow-Up

OBJECTIVES

We examined sexual-orientation disparities in frequent engagement in cancer-related risk indicators of tobacco, alcohol, diet and physical activity, ultraviolet radiation, and sexually transmitted infections (STIs).

METHODS

We used longitudinal data from the national Growing Up Today Study (1999-2010). Of the analytic sample (n = 9958), 1.8% were lesbian or gay (LG), 1.6% bisexual (BI), 12.1% mostly heterosexual (MH), and 84.5% completely heterosexual (CH).

RESULTS

More sexual minorities (LGs, BIs, and MHs) than CHs frequently engaged in multiple cancer-related risk behaviors (33%, 29%, 28%, and 19%, respectively). Sexual-minority young women, especially BI and MH, more frequently engaged over time in substance use and diet and physical activity risk than CH women. More young gay than CH men frequently engaged over time in vomiting for weight control (odds ratio [OR] = 3.2; 95% confidence interval [CI] = 1.1, 9.4), being physically inactive (OR = 1.7; 95% CI = 1.2, 2.4), and using tanning booths (OR = 4.7; 95% CI = 3.0, 7.4), and had a higher prevalence of ever having an STI (OR = 3.5; 95% CI = 2.0, 6.4). Individual analyses were generally comparable to the group-level analyses.

CONCLUSIONS

Young sexual minorities are at risk for cancer through frequent exposure to cancer-related risk behaviors over time. Long-term, longitudinal studies and surveillance data are essential and warranted to track frequent engagement in the risk behaviors and cancer-related morbidity and mortality.

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.

Risk of oesophageal cancer among patients previously hospitalised with eating disorder

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There are case reports of oesophageal cancer in patients with eating disorders.

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We followed up a cohort of patients hospitalised previously with eating disorders.

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These patients were at significantly increased risk of oesophageal cancer.

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All cancers were squamous cell carcinomas in females with prior anorexia nervosa.

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Indirect evidence suggests confounding by established risk factors.

Background

It has been suggested that the risk of oesophageal adenocarcinoma might be increased in patients with a history of eating disorders due to acidic damage to oesophageal mucosa caused by self-induced vomiting practiced as a method of weight control. Eating disorders have also been associated with risk factors for squamous cell carcinoma of the oesophagus, including alcohol use disorders, as well as smoking and nutritional deficiencies, which have been associated with both main sub-types of oesophageal cancer. There have been several case reports of oesophageal cancer (both main sub-types) arising in patients with a history of eating disorders.

Methods

We used linked records of hospitalisation, cancer registration and mortality in Scotland spanning 1981–2012 to investigate the risk of oesophageal cancer among patients with a prior history of hospitalisation with eating disorder. The cohort was restricted to patients aged ≥10 years and <60 years at the date of first admission with eating disorder. Disregarding the first year of follow-up, we calculated indirectly standardised incidence ratios using the general population as the reference group to generate expected numbers of cases (based on age-, sex-, socio-economic deprivation category-, and calendar period-specific rates of disease).

Results

After exclusions, the cohort consisted of 3617 individuals contributing 52,455 person-years at risk. The median duration of follow-up was 13.9 years. Seven oesophageal cancers were identified, as compared with 1.14 expected, yielding a standardised incidence ratio of 6.1 (95% confidence interval: 2.5–12.6). All were squamous cell carcinomas arising in females with a prior history of anorexia nervosa.

Conclusions

Patients hospitalised previously with eating disorders are at increased risk of developing oesophageal cancer. Confounding by established risk factors (alcohol, smoking, and nutritional deficiency) seems a more likely explanation than acidic damage through self-induced vomiting because none of the incident cases of oesophageal cancer were adenocarcinomas, and because the study cohort had higher than background rates of hospitalisation with alcohol-related conditions and chronic obstructive pulmonary disease.

Somatic involvement assessed through a cumulative score of clinical severity in patients with eating disorders

PURPOSE

To evaluate the overall somatic involvement in patients with eating disorders (EDs).

METHODS

The medical records of 206 patients (age 15-56 years, 96.1% females) with diagnosis of anorexia nervosa (AN, n = 63, 30.6%), bulimia nervosa (BN, n = 78, 37.9%), or eating disorder not otherwise specified (EDNOS, n = 65, 31.6 %) were analyzed. A cumulative score of clinical severity (SCS) was computed according to the presence of physical, instrumental, and laboratory abnormalities, as well as to their prognostic impact. Based on the tertile distribution of SCS, three levels of severity were defined: low, medium, and high.

RESULTS

A medium/high level of severity was found in 63% of the whole sample, 89% of AN, 49% of BN, and 55% of EDNOS. In the whole sample, the risk of medium/high SCS was significantly and inversely related to the body mass index (BMI) and to the lifetime minimum BMI. The severity level was significantly and positively associated with diagnosis of AN, duration of amenorrhea C1 year, and presence of ED-related symptoms. EDNOS patients showed a higher risk for increased SCS than BN patients, although not significantly.

CONCLUSION

The non-negligible frequency of a relevant somatic involvement in patients with EDNOS suggests that a transdiagnostic scoring system might be helpful to identify ED cases at risk of medical complications.

Sexual orientation disparities in cancer-related risk behaviors of tobacco, alcohol, sexual behaviors, and diet and physical activity: pooled Youth Risk Behavior Surveys

OBJECTIVES

We examined sexual orientation disparities in cancer-related risk behaviors among adolescents.

METHODS

We pooled data from the 2005 and 2007 Youth Risk Behavior Surveys. We classified youths with any same-sex orientation as sexual minority and the remainder as heterosexual. We compared the groups on risk behaviors and stratified by gender, age (< 15 years and > 14 years), and race/ethnicity.

RESULTS

Sexual minorities (7.6% of the sample) reported more risk behaviors than heterosexuals for all 12 behaviors (mean = 5.3 vs 3.8; P < .001) and for each risk behavior: odds ratios (ORs) ranged from 1.3 (95% confidence interval [CI] = 1.2, 1.4) to 4.0 (95% CI = 3.6, 4.7), except for a diet low in fruit and vegetables (OR = 0.7; 95% CI = 0.5, 0.8). We found sexual orientation disparities in analyses by gender, followed by age, and then race/ethnicity; they persisted in analyses by gender, age, and race/ethnicity, although findings were nuanced.

CONCLUSIONS

Data on cancer risk, morbidity, and mortality by sexual orientation are needed to track the potential but unknown burden of cancer among sexual minorities.

Radiology of eating disorders: a pictorial review

Eating disorders are a major challenge for health professionals, with many patients receiving ineffective care due to underdiagnosis or poor compliance with treatment. The incidence of eating disorders is increasing worldwide, producing an increasing burden on healthcare systems, and they most often affect young patients, with significant long-term complications. The effects of long-term malnutrition manifest in almost every organ system, and many can be detected radiologically, even without overt clinical findings. Musculoskeletal complications including osteoporosis result in a high incidence of insufficiency fractures, with long-term implications for bone health and growth, while respiratory complications are often recognized late due to disordered physiologic responses to infection. Gastrointestinal complications are numerous and in extreme cases may result in fatal outcomes after acute gastric dilatation and rupture subsequent to binge eating. In patients with severely disordered eating, in particular anorexia nervosa, marked derangement of electrolyte levels may result in refeeding syndrome, which requires emergent management. Recognition of such complications is critical to effective patient care and requires radiologists to be aware of the spectrum of imaging abnormalities that may be seen. Since many patients are reluctant to disclose their underlying condition, radiologists also play a critical role in identifying previously undiagnosed eating disorders.

Esophageal cancer in young people: a case series of 109 cases and review of the literature

Certain geographically distinct areas of the world have very high rates of esophageal cancer (EC). Previous studies have identified western Kenya as a high risk area for EC with an unusual percentage of cases in subjects 30 years of age or younger. To better understand EC in these young patients, we abstracted available data on all 109 young patients diagnosed with EC at Tenwek Hospital, Bomet District, Kenya from January 1996 through June 2009, including age at diagnosis, sex, ethnicity, tumor histology, residence location, and medical interventions. We also attempted to contact all patients or a family member and obtained information on ethnicity, tobacco and alcohol use, family history of cancer, and survival. Sixty (55%) representatives of the 109 young patients were successfully interviewed. The median survival time of these 60 patients was 6.4 months, the most common tumor histology was esophageal squamous cell carcinoma (ESCC) (98%), the M:F ratio was 1.4∶1, and only a few subjects used tobacco (15%) or alcohol (15%). Seventy-nine percent reported a family history of cancer and 43% reported having a family history of EC. In summary, this case series describes the largest number of young EC patients reported to date, and it highlights the uniqueness of the EC experience in western Kenya.