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

Another reason we miss these diagnoses is that patients often do not fit the stereotypical phenotype of an eating disorder as eating disorders are seen in all genders, racial/ethnic identities, and socioeconomic backgrounds. Additionally, many patients with eating disorders have a normal body mass index (BMI) and may not appear underweight, especially male patients who may appear muscular due to excessive weightlifting (a common manifestation of anorexia nervosa in males). Finally, many patients with eating disorders have a lack of insight and/or denial, similar to patients with schizophrenia and dementia, and may deny feeling sick when they present to the ED with their parents.

It is important that we identify eating disorders in the ED, as the earlier treatment is started, the better the long-term outcomes (similar to schizophrenia), the lower the mortality rate, and the less likely they are to develop serious medical complications.⁴ With eating disorders missed often in the ED, and the importance of early recognition and treatment, there is an argument for universal screening at emergency triage with a quick screening tool such as the SCOFF questionnaire.⁹

The hallmark of anorexia nervosa is an inability or refusal to maintain a body weight at or above 85 percent of the expected weight based on age-appropriate BMI charts. Individuals with anorexia often engage in severe caloric restriction or excessive exercise as a means to cope with emotional distress or psychological pain, accompanied by an intense fear of gaining weight or becoming overweight. Bulimia is defined by episodes of uncontrollable binge eating, often followed by compensatory  purging behaviors such as self-induced vomiting or the misuse of laxatives. Individuals with the binge-eating/purging subtype of anorexia may also engage in similar binge and purge cycles. Those with bulimia can present at a normal weight, but they may also be underweight or overweight.

It is imperative that when assessing youth with vague physical symptoms or any psychiatric symptoms in the ED, physicians ask the patient and their parent(s) a few simple questions to screen for eating disorders: What is your highest ever weight and what is your weight currently? Do you make yourself sick because you feel uncomfortably full? Do you believe yourself to be fat when others say you are too thin? Tell me what you eat in a day. When was your last menstrual period?

If there is any suspicion for a possible eating disorder based on these questions, risk factors should be explored, investigations to screen for medical complications should be ordered, and specialist consultation or referral should be arranged. Risk factors for eating disorders include family history (as twin studies suggest that they are 60 percent to 70 percent heritable), personality type of high achieving perfectionism with a pronounced fear of failure, impulsive personality, participation in sports that rely on a lean and/or muscular body type, chronic medical conditions such as diabetes, and transgender youth.^10,11 It is a misconception that parents are the cause of eating disorders. Parental blame is counter-therapeutic and should be avoided.

A Medical and Psychiatric Disorder

Common ED presentations of eating disorders include vague gastrointestinal complaints, palpitations, dizziness and syncope. Complications of eating disorders include life-threatening conditions in all body systems. Cardiac complications include severe bradycardia, Torsades de Pointes, and heart failure. Metabolic complications include hypokalemia, hypophosphatemia, and hypoglycemia. Gastrointestinal complications include gastric perforation because of acute gastric dilatation impeding venous return leading to necrosis, esophageal rupture, pancreatitis, and superior mesenteric artery syndrome. Pulmonary complications include pneumothorax and pneumomediastinum. Musculoskeletal complications include osteopenia with increased risk for long bone fractures. Finally, hematologic and neurologic complications include pancytopenia and intracranial hemorrhage related to severe thrombocytopenia.¹²

Physical exam may provide important clues to the presence of an eating disorders. Bradycardia is very common and may be erroneously dismissed in athletic patients.¹³  Although a resting heart rate of 48 may be normal in an adult elite athlete, bradycardia is almost never normal in an adolescent and needs to be investigated. Normal triage vitals should not be reassuring as patients with eating disorders who are bradycardic at baseline may be especially anxious when presenting to the ED. For this reason, vital signs should be repeated after 10 minutes of rest with the patient supine and should include orthostatic vitals. A “blind” weight should be obtained post-void with the patient in a hospital gown only (to prevent hidden weights), and the patient’s back to the weight display.

The skin may provide clues to the presence of an eating disorder. Skin findings may include dryness, loss of subcutaneous fat, the presence of lanugo (fine body hair), and hypercarotenemia, characterized by an orange discoloration of the palms and soles because of excessive carrot consumption. Patients who engage in self-induced vomiting may exhibit calluses on the dorsum of the dominant hand and erosion of dental enamel.¹⁴ Enlargement of the salivary glands is another notable indicator of purging behaviors.¹² Expose the patient’s back. Bruising or erythema over the spinous processes suggests excessive sit-ups or crunches. However, many patients may have a completely normal physical examination, particularly in the early stages of the disorder.

Laboratory investigations should be ordered in the ED for all patients with any suspicion of an eating disorder after clinical assessment is completed, as they may reveal clues to a diagnosis, potentially life-threatening metabolic conditions and help to guide disposition. I recommend an order set that includes ECG, glucose, creatinine, liver enzymes, lipase, amylase, electrolytes including calcium, magnesium, and phosphate ketones, and urinalysis. Some laboratory findings suggestive of an eating disorder and/or that can be clues to a specify eating disorder features include urine pH greater than eight suggesting active catabolism, a low urine specific gravity, which is suspicious for water loading, urine ketones suggestive of starvation, hypoglycemia, and hypokalemia, which suggests repetitive vomiting or diuretic use.¹⁶ An elevated amylase suggests repetitive vomiting as well. Serum phosphate should be obtained in all patients with eating disorders as hypophosphatemia is suggestive of refeeding syndrome, which can be fatal.¹⁶ Refeeding syndrome occurs when feeding is started after a period of prolonged deprivation. The sudden influx of carbohydrates stimulates insulin release, causing a rapid intracellular shift of phosphate, potassium, and magnesium. This metabolic disturbance can result in life-threatening complications, including cardiac arrhythmias, respiratory failure, and multiorgan dysfunction. A common cause of unexplained weight loss and vague gastrointestinal symptoms in young people is inflammatory bowel disease. Consider obtaining erythrocyte sedimentation rate and C-reactive protein to screen for this diagnosis. These tests are almost always normal in patients with eating disorders.¹⁷

Treatment

When it comes to ED treatment of patients with eating disorders, besides addressing immediate life-threatening complications, there should be no specific treatment initiated. It may be tempting to administer crystalloid boluses to patients with eating disorders who appear to be dehydrated in the ED; however, this should be avoided because a common cardiac complication is heart failure. It also might be tempting to administer dextrose in the ED; however, this should also be avoided as it increases the risk for refeeding syndrome.

The American Academy of Pediatrics admission criteria for adolescents with an eating disorder include: less than 75 percent median BMI for age and sex, dehydration, electrolyte disturbance (hypokalemia, hyponatremia, hypophosphatemia), ECG abnormalities (severe bradycardia or prolonged QTc), heart rate less than 50 beats per minute daytime or less than 45 beats per minute at night, blood pressure less than 90/45, temperature less than 96, orthostatic pulse increase greater than 20 beats per minute or decrease in blood pressure greater than 20 systolic or greater than 10 diastolic, arrested growth and development, failure of outpatient treatment, acute food refusal, uncontrollable binge eating and purging, acute medical complications of malnutrition (syncope, seizures, heart failure, pancreatitis, etc.), and comorbid condition that prohibits or limits appropriate outpatient treatment (severe depression, suicidal ideation, obsessive compulsive disorder, Type 1 diabetes).¹⁸

A common pitfall is reassuring a patient with an eating disorder that they have a normal physical exam and investigations. Both physical exam and lab findings may be normal in patients with severe eating disorders. This false reassurance reinforces the common perception by the patient that they do not have an eating disorder and is counterproductive to initiation and maintenance of treatment. Do not minimize the illness.

Have a low threshold to consult pediatrics, internal medicine, or psychiatry, and/or refer to the local outpatient eating disorder program for a multidisciplinary assessment. Timely follow-up in a clinic with experience managing patients with eating disorders is essential. Generally, primary care physicians are not equipped to manage eating disorders alone and should not be the sole follow-up care provided.

Next time you are faced with a young person who presents to the ED with vague symptoms, it is imperative to consider eating disorders. Ask a few simple screening questions. Obtain repeat resting vital signs including orthostatic vitals. Perform a focused physical exam looking for clues of eating disorders. Order appropriate investigations, and have a low threshold for consultation or timely referral to a clinic familiar with eating disorders management. With these principles in mind you are more likely to pick up these often elusive diagnoses, get them on the road to early initiation of treatment, prevent chronic relapsing disease, and, potentially, save another life!

A special thanks to Dr. Samantha Martin and Dr. Jennifer Tomlin for their expertise in the EM Cases podcast that inspired this column.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of the Emergency Medicine Cases podcast and website.

References

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