Gastrointestinal complications and refeeding guidelines in patients with anorexia nervosa
TL;DR: The issues of gastrointestinal symptoms and complications in the course of Anorexia nervosa, and the rules of nutritional therapy are approached.
Abstract: Anorexia nervosa (AN) is the third most common disorder, after obesity and asthma, in the population of adolescents between 13-18 years of age. Food intake reduction is associated with whole body dysfunction, affecting its physical, psychological and social spheres. As a result of starvation, dysfunction develops in virtually all systems and organs. However, most frequently patients with AN complain of digestive symptoms, such as a feeling of fullness after meals, pain in the upper abdomen, dysphagia, nausea, bloating and constipation. They can have mild functional character, but may also reflect serious complications, including diseases requiring urgent surgical intervention. In addition, gastric complaints may hinder nutritional management of AN. Care of AN patients requires cooperation of many specialists in the field of psychiatry, psychology, paediatrics, internal medicine and nutrition. However, it is often difficult to organize such a team. Therefore, we decided to approach the issues of gastrointestinal symptoms and complications in the course of AN, and the rules of nutritional therapy.
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TL;DR: Clinicians are offered an overview of the evidence-based data in the literature concerning the medication (psychotropic drugs and medication for somatic and nutritional complications) in the field of anorexia nervosa since the 1960s to draw practical conclusions for everyday practise and future research.
Abstract: Drugs are widely prescribed for anorexia nervosa in the nutritional, somatic, and psychiatric fields. There is no systematic overview in the literature, which simultaneously covers all these types of medication. The main aims of this paper are (1) to offer clinicians an overview of the evidence-based data in the literature concerning the medication (psychotropic drugs and medication for somatic and nutritional complications) in the field of anorexia nervosa since the 1960s, (2) to draw practical conclusions for everyday practise and future research. Searches were performed on three online databases, namely MEDLINE, Epistemonikos and Web of Science. Papers published between September 2011 and January 2019 were considered. Evidence-based data were identified from meta-analyses, if there were none, from systematic reviews, and otherwise from trials (randomized or if not open-label studies). Evidence-based results are scarce. No psychotropic medication has proved efficacious in terms of weight gain, and there is only weak data suggesting it can alleviate certain psychiatric symptoms. Concerning nutritional and somatic conditions, while there is no specific, approved medication, it seems essential not to neglect the interest of innovative therapeutic strategies to treat multi-organic comorbidities. In the final section we discuss how to use these medications in the overall approach to the treatment of anorexia nervosa.
45 citations
TL;DR: For ED patients with a manic episode, olanzapine (plus fluoxetine) seems appropriate in AN and lamotrigine in BN and BED; whereas for bipolar depression, Olanz Zapine ( plus fluoxettine) seem appropriate in An and lorazepam in BNs.
44 citations
TL;DR: Using the alimentary tract as well as recent developments in interoceptive neuroscience and predictive processing as a guide, the current review summarizes evidence of gastrointestinal inter-ceptive dysfunction in eating disorders as discussed by the authors .
Abstract: Abnormal interoception has been consistently observed across eating disorders despite limited inclusion in diagnostic conceptualization. Using the alimentary tract as well as recent developments in interoceptive neuroscience and predictive processing as a guide, the current review summarizes evidence of gastrointestinal interoceptive dysfunction in eating disorders.Eating is a complex process that begins well before and ends well after food consumption. Abnormal prediction and prediction-error signals may occur at any stage, resulting in aberrant gastrointestinal interoception and dysregulated gut sensations in eating disorders. Several interoceptive technologies have recently become available that can be paired with computational modeling and clinical interventions to yield new insights into eating disorder pathophysiology. Illuminating the neurobiology of gastrointestinal interoception in eating disorders requires a new generation of studies combining experimental probes of gut physiology with computational modeling. The application of such techniques within clinical trials frameworks may yield new tools and treatments with transdiagnostic relevance.
19 citations
TL;DR: Current concepts regarding AN pathomechanisms that focus on the main biological aspects involving central and peripheral neurohormonal pathways, endocrine function, as well as the microbiome–gut–brain axis are reviewed.
Abstract: Anorexia nervosa (AN) represents a disorder with the highest mortality rate among all psychiatric diseases, yet our understanding of its pathophysiological components continues to be fragmentary. This article reviews the current concepts regarding AN pathomechanisms that focus on the main biological aspects involving central and peripheral neurohormonal pathways, endocrine function, as well as the microbiome–gut–brain axis. It emerged from the unique complexity of constantly accumulating new discoveries, which hamper the ability to look at the disease in a more comprehensive way. The emphasis is placed on the mechanisms underlying the main symptoms and potential new directions that require further investigation in clinical settings.
16 citations
Saarland University1, University of Marburg2, RWTH Aachen University3, Humboldt University of Berlin4, Hofstra University5, Dresden University of Technology6, University Medical Center Freiburg7, University of Duisburg-Essen8, Witten/Herdecke University9, University of Mainz10, University Hospital Heidelberg11, University of Bern12, Ruhr University Bochum13, University of Ulm14
TL;DR: The results indicate that constipation is highly prevalent in adolescent patients with anorexia nervosa and reflects a clinically relevant condition, despite, patients with AN do not have an increased prevalence of incontinence compared with the general population.
Abstract: OBJECTIVE:
Nocturnal enuresis (NE), daytime urinary incontinence (DUI), and fecal incontinence (FI) are common disorders in childhood and are frequently accompanied by comorbid psychiatric disorders. Despite a high association between urinary and fecal incontinence with psychiatric and neurodevelopmental disorders, research on comorbidity between incontinence and anorexia nervosa (AN) remains scarce. Yet, it is well known that somatic consequences of AN include metabolic and gastrointestinal disorders. The study sought to assess the prevalence of incontinence and constipation in children and adolescents with AN and to examine associations of these two symptoms with body weight at admission and with BMI changes during inpatient treatment.
METHODS:
Data collected between 2015 and 2017 by a multicenter German web-based registry for AN were analyzed. Three hundred and forty-eight patients with AN (96.3% female, mean age = 15.1 ± 1.8 years) were assessed regarding AN subtype, psychiatric comorbidity, body weight, incontinence, and constipation.
RESULTS:
Overall, 27.6% of patients had constipation, 1.8% had NE and 1.8% DUI. Prevalence of constipation did not significantly differ between AN subtypes. Constipation did not lead to any significant differences in weight/BMI changes during inpatient treatment.
DISCUSSION:
This is the largest study of incontinence and constipation in patients with AN, so far. Our results indicate that constipation is highly prevalent in adolescent patients with AN and reflects a clinically relevant condition. Despite, patients with AN do not have an increased prevalence of incontinence compared with the general population. Future studies should include medical examinations like ultrasound and physical examination of the lower abdomen to evaluate the severity of constipation.
12 citations
References
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TL;DR: Patients with anorexia nervosa present multiple gastrointestinal abnormalities involving control mechanisms as well as target organs, and differences between patient and control groups were statistically significant.
211 citations
"Gastrointestinal complications and ..." refers background in this paper
...According to some authors, the stomach emptying delay occurs only after solid food intake [13], whereas other researchers have shown that it concerns both solid and liquid foods [12]....
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TL;DR: During fasting, fractional emptying rates and hydrogen ion output were decreased twofold in PAN, as compared with healthy controls, and fluid output was slightly but not significantly decreased; but fluid output were not significantly modified following weight gain.
144 citations
"Gastrointestinal complications and ..." refers background in this paper
...According to Dubois [14], the abnormalities persist even after gaining proper weight....
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TL;DR: In anorexia nervosa patients who are symptomatic and seeking medical care, gastric emptying of solids is significantly delayed when compared with female subjects of similar age and normal body weight and with patients of less than 90% ideal body weight but without psychiatric disorder.
Abstract: Upper gastrointestinal symptoms may be prominent in anorexia nervosa. This study is an investigation of the gastric emptying of solid and liquid meal components in 16 female patients (mean age 20.0 years, range 14–40 years) who met accepted psychiatric diagnostic criteria for anorexia nervosa. The results were compared with those of gastric emptying studies in 10 normal females of ideal body weight (mean age 25.4 years, range 20–35), 13 normal persons (12 males), and six patients (mean age 12 years, range 9–14 years) with weight loss (<90 percent ideal body weight) secondary to Crohn's disease with no psychiatric symptoms. A dual-isotope technique using chicken liver intracellularly labeled with technetium-99m (99mTc) bound to sulfur colloid as the solid-phase marker, and indium-111 (111In)-labeled water as the liquid-phase marker was used. Gastric emptying was monitored for 2 hr by gamma camera. In 13 of the 16 anorexia nervosa patients (80%), gastric emptying of solids was slower than the range in the two groups of normal subjects, and mean gastric emptying was significantly slower (P<0.05) than in the weight-loss patients. Liquid emptying (water) in anorexia nervosa was normal and similar to the control groups studied. In 11 of the anorexia nervosa patients with delayed gastric emptying, intramuscular metoclopramide, 10 mg, significantly (P<0.05) accelerated the mean gastric emptying from 60 through 120 min after the meal. We conclude that in anorexia nervosa patients who are symptomatic and seeking medical care: (1) gastric emptying of solids is significantly delayed when compared with female subjects of similar age and normal body weight and with patients of less than 90% ideal body weight but without psychiatric disorder; (2) these data are consistent with an antral motility disturbance, either primary or secondary; and (3) metoclopramide, a gastric prokinetic agent, accelerates (delayed) gastric emptying.
125 citations
TL;DR: Daily monitoring of serum phosphorus with supplementation as needed during the first week of hospitalization, especially in those who are severely malnourished, is recommended.
122 citations
"Gastrointestinal complications and ..." refers background in this paper
..., the occurrence of RS is associated only with hypophosphatemia, especially when diagnosed before the start of refeeding [48]....
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TL;DR: Clinical evaluation of patients with presumed primary anorexia nervosa should rule out the possibility that disordered oesophageal motor activity underlies the symptoms of disordered upper gastrointestinal motor activity, and delayed gastric emptying is a frequent feature in primary anoresis nervosa and might be returned to normal with domperidone.
Abstract: Gastrointestinal motor function in patients with primary anorexia nervosa has rarely been investigated. We studied oesophageal motor activity in 30 consecutive patients meeting standard diagnostic criteria for primary anorexia nervosa (Feighner et al; DSM III). Seven were found to suffer from achalasia instead of primary anorexia nervosa, one from diffuse oesophageal spasm and one from severe gastro-oesophageal reflux and upper oesophageal sphincter hypertonicity, while partly non-propulsive and repetitive high amplitude, long duration contractions prevailed in the lower oesophagus of another six. In four patients with oesophageal dysmotility not responding to therapy and in 12 of 15 patients with normal oesophageal manometry, gastric emptying of a semisolid meal was studied. Emptying was normal in only three but markedly delayed in 13 cases (half emptying times 97-330 min, median: 147 min, as compared with 21-119 min, median: 47 min, in 24 healthy controls). In eight patients, the effects of domperidone 10 mg iv and placebo were compared under random double blind conditions. Half emptying times were shortened significantly (p less than 0.01) by domperidone. Conclusions: symptoms of disordered upper gastrointestinal motor activity may be mistaken as indicating primary anorexia nervosa; clinical evaluation of patients with presumed primary anorexia nervosa should rule out the possibility that disordered oesophageal motor activity underlies the symptoms; delayed gastric emptying is a frequent feature in primary anorexia nervosa and might be returned to normal with domperidone.
122 citations
"Gastrointestinal complications and ..." refers background in this paper
...[8] examined 30 female patients aged 14–43 years, finding esophageal motility disorder in half of them....
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...They found achalasia in 7 patients, distal dysphagia in 6 patients, gastroesophageal reflux in 1 patient, and diffuse esophageal spasm also in 1 patient [8]....
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