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