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Snapshot
  • A 16-year-old girl is brought to the pediatrician by her parents, who are concerned that their daughter has been refusing to eat dinner at home and has been appearing more "frail" than usual. The patient admits that she has been "terrified" of gaining more weight and feels that she is too fat. She is enrolled in several advanced classes at school and feels significant stress from her participation in the ballet club, as she is preparing to audition for a lead role. Upon further questioning, the patient reports that she has not had a menstrual period in 3 months.
Introduction
  • Overview
    • an eating disorder characterized by an extreme fear of weight gain, behavioral and dietary habits that prevent weight gain, and an altered perception of one's body weight
  • Epidemiology
    • prevalence
      • 0.3-1% overall in the US
        • as high as 4% among women
    • demographics
      • female:male ratio 10-20:1
      • most prevalent in pubertal and adolescent girls
        • majority have onset between ages 13-18 years
    • risk factors
      • female
      • family history of eating disorders
      • low self-esteem
  • Pathophysiology
    • result of a complex of psychosocial factors
  • Prognosis
    • mobidity 10-20%
    • about 50% of patients make a complete recovery
    • worse prognosis for patients who are older (> 18 years of age) at age of onset of the disorder as well as patients with an onset before 11 years of age
Presentation
  • Symptoms
    • anxiety
    • depression
    • negative self-image
    • amenorrhea
    • irritability
    • constipation
    • dry skin
    • hair loss
    • fainting or dizziness
    • lethargy
  • Physical exam
    • low BMI (< 18.5 kg/mm2)
    • hypotension
    • bradycardia
    • hypothermia
    • dry skin
    • lanugo
    • peripheral edema
    • loss of muscle mass
Studies
  • Serum labs
    • complete blood count 
      • may show leukopenia and thrombocytopenia
    • basic metabolic panel
      • may show electrolyte abnormalities in severe disease
  • EKG
    • may show evidence of sinus bradycardia
    • QT-interval prolongation indicates serious risk for cardiac arrhythmias
Differential
  • Hyperthyroidism
    • key distinguishing factor
      • abnormal thyroid hormone levels
  • Celiac disease
    • key distinguishing factor
      • intolerance to gluten-containing foods
Treatment
  • Lifestyle
    • psychological/behavioral therapy & nutritional rehabilitation
      • indications
        • BMI > 13 kg/mm2
        • mild electrolyte imbalances
      • technique
        • vitamin supplementation with calcium
        • monitor for refeeding syndrome, a possible complication that leads to electrolyte and fluid imbalances
          • labs: hypophosphatemia, hypokalemia, hypomagnesemia 
  • Medical
    • estrogen replacement (e.g. oral contraceptives)
      • indications
        • treatment of osteopenia associated with anorexia
    • hospital admission with inpatient treatment
      • indications
        • BMI < 13 kg/mm2
        • severe electrolyte imbalances
Complications
  • Malnutrition
  • Delayed puberty
  • Amenorrhea
  • Arrested growth
  • Osteoporosis
  • Electrolyte imbalances
  • Cardiovascular effects
    • cardiomyopathy
    • long QT sndrome
    • bradycardia

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