A 16-year-old male presents to the emergency department (ED) with his mother with the chief complaint of intermittent abdominal pain and constipation for several weeks. There are no red flag symptoms for an underlying surgical cause and review of systems is otherwise unremarkable. Vital signs include a heart rate of 50, blood pressure 85/40, temperature of 35.9 ˚C (96.6˚ F). Blood work is ordered, and it shows a mildly low potassium at 3.2 mEq/L, a mildly low hemoglobin at 11g/dl, and normal liver enzymes.

The patient is discharged from the ED with the diagnosis of low-risk  nonspecific abdominal pain with a recommendation to follow-up with their primary care physician and instructions to return for list of red flag symptoms. This case represents the miss of a potentially life-threatening diagnosis that emergency physicians have little knowledge of. In this ACEP Now column, I outline some of the salient features of eating disorders to improve our knowledge, recognition, and management of them in the ED.

Common, Deadly, Elusive

Eating disorders, which include anorexia nervosa, bulimia nervosa, binge eating disorder and avoidant/restrictive food intake disorder (ARFID), are common with increasing prevalence, increasing visits to EDs, and the highest mortality of any psychiatric illness.^1-3 The lifetime prevalence rates of anorexia nervosa are as high as four percent among females and is increasing among males.³ In young females, the mortality rate of eating disorders is estimated to be as high as 10 percent.⁴

In a recent study, after a five-year follow-up the mortality rate of anorexia nervosa

in admitted patients was found to be as high as 16 percent.⁵ Despite these disorders being common and deadly, eating disorders are often elusive diagnoses with only 27 percent of women with eating disorders receiving treatment, suggesting a significant portion remain undiagnosed or untreated.⁶ They are often missed in the ED for a variety of reasons including lack of physician education, vague presenting symptoms, patient factors such as lack of insight or denial, and atypical phenotype. In one study, only one out of 246 patients who screened positive for an eating disorder at ED triage had a chief complaint that specifically mentioned eating disorders.² Eating disorders affect all organ systems and present with a myriad of vague symptoms.

Identification

A range of medical conditions can mimic the symptoms of eating disorders—hence the description of “the great masquerader.” There is a lack of education on eating disorders in residency programs in the United States. A survey that looked at 637 residency programs including pediatric, family, and internal medicine in 2014 found that only 42 programs offered formal training in eating disorders.⁷ A more recent study surveyed emergency physicians’ knowledge and training and found that of 1.9 percent of 162 emergency physicians who completed a psychiatry rotation in residency, 93 percent were unfamiliar with the American Psychiatric Association practice guidelines on eating disorders.⁸