Cathartic colitis

Critical gaps in the medical knowledge base of eating disorders

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.

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.

Gastrointestinal complaints in patients with eating disorders

BACKGROUND

Patients with eating disorders (EDs) typically have numerous somatic and gastrointestinal complaints. Early referral to treatment may result in improved outcomes. We sought to determine whether patients with EDs were presenting to gastroenterologists or primary care physicians with gastrointestinal complaints early in the disease course, when referral for specialized, comprehensive treatment would be most beneficial.

STUDY

Over a 1-year period, we administered a structured interview to a cohort of patients presenting for inpatient ED treatment. We also conducted the same interview on an age-matched cohort of medical students to determine baseline incidences of various gastrointestinal healthcare behaviors.

RESULTS

Patients with bulimia nervosa were significantly more likely to seek healthcare for a gastrointestinal complaint before seeking treatment for an ED than were controls. Patients with EDs were significantly more likely to be prescribed medication for the gastrointestinal tract than were controls.

CONCLUSION

Gastroenterologists and primary care physicians should employ available instruments to screen young women of low to normal weight with gastrointestinal complaints for possible EDs. Referral to specialized treatment programs should be made promptly when an ED is identified.

Incidence of laxative abuse in community and bulimic populations: a descriptive review

Estimates of the incidence of laxative abuse in bulimics and in the community-at-large vary widely for various population samples. This review identified 73 studies in which laxative abuse could be assessed in bulimics, nonbulimics, and the community-at-large. Relative risk values for laxative abuse among population subsamples were estimated by moment methods statistical procedure based on mixed model analysis. Results indicated that the lifetime occurrence for laxative abuse behavior in the community-at-large was 4.18%. Bulimic behavior increased the risk for laxative abuse 3.57-fold to 14.94%. Several methodologic and population parameter characteristics are examined for their select impact on laxative abuse. Review of medical nomenclature for classifying laxative substances, iatragenic effects of laxative abuse, and assessment recommendations are also included.

BULIMIA NERVOSA: Associated Physical Problems

1. Bulimia involves more serious problems than previously thought. Bulimia nervosa is a psychiatric disorder characterized by binge eating followed by some form of combination of purging, including laxative or diuretic use, strenuous exercise, and self-induced vomiting to eliminate unwanted calories. 2. Physical problems of bulimia include oral and neck problems, metabolic acid-base imbalances, volume depletion, hypochloremia, hypokalemia, hyponatremia, hypomagnesia, hypocalcemia, hyperuricemia, gastrointestinal problems, and edema. 3. The physical problems of bulimia are less well known than those of anorexia. Nurses must be alert for clues, act on suspicions, use a nonjudgmental approach, and be knowledgeable of all assessment factors, including psychological parameters.

Constipation. Mechanisms and management of a common clinical problem

Many persons, including physicians, regard a "normal" bowel habit as being at least one bowel movement per day. In truth, the spectrum of normal covers anywhere from three movements per day to three or even less per week. This article outlines aspects of the history that will be most helpful in determining if constipation is indeed present. It also provides very useful information on the mechanisms of laxative action.

Cathartic colon. Reversibility of roentgen changes

Cathartic colon is an infrequent and severe manifestation of chronic irritant laxative abuse. Little is known of its natural history after cathartics are stopped. Previous reported cases have shown residual roentgen abnormalities on follow-up examinations. A case is presented of cathartic colon caused by more than 70 years of laxative abuse that demonstrated complete reversal of the roentgen changes four months after stopping the medication. Some pathophysiologic correlates of this dramatic reversibility are discussed.