Anorexia nervosa complicating inflammatory bowel disease

The intersect of gastrointestinal symptoms and malnutrition associated with anorexia nervosa and avoidant/restrictive food intake disorder: Functional or pathophysiologic?-A systematic review

OBJECTIVE

Although multiple pathophysiologic changes develop within the gastrointestinal (GI) system in the setting of malnutrition, the etiology of the reported multitude of symptoms in those with anorexia nervosa and avoidant restrictive intake disorder, as well as their contribution toward disordered eating, remain poorly understood. This systematic review seeks to better understand how these physiologic changes of malnutrition of the esophagus, stomach, intestines, and pancreas contribute toward the reported GI symptoms, as well as better understand how celiac disease, inflammatory bowel disease, pelvic floor dysfunction, and Ehlers-Danlos syndrome contribute toward disordered eating.

METHODS

Studies of any design exploring the pathogenesis of complications and treatment strategies were included. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to structure and complete the review.

RESULTS

A total of 146 articles were used for the review. The majority of studies were observational or case reports/case series.

DISCUSSION

Pathophysiologic changes of the esophagus, stomach, and intestines develop with malnutrition, although these changes do not consistently correlate with expressed GI symptoms in patients with restrictive eating disorders. Celiac disease and inflammatory bowel disease also contribute to disordered eating through the associated somatic GI complaints, while pelvic floor dysfunction and Ehlers-Danlos syndrome contribute through both somatic symptoms and functional symptoms. Indeed, functional GI symptoms remain problematic during the course of treatment, and further research is required to better understand the extent to which these symptoms are functional in nature and remit or remain as treatment ensues.

Anorexia Nervosa Complicating Pediatric Crohn Disease-Case Report and Literature Review

Crohn disease and anorexia nervosa share common symptoms of weight loss and reduced oral intake. The prevalence of both disorders has increased over time. Symptoms of Crohn disease and anorexia nervosa can mimic each other leading to a delayed diagnosis and requiring complex, multidisciplinary management. Here we present a case of a 15 year old girl with Crohn disease who subsequently developed anorexia nervosa, and review the published literature on the occurrence of both diagnoses.

Inflammatory Bowel Disease and Eating Disorders: A systematized review of comorbidity

OBJECTIVE

Research has shown that there is an association between Inflammatory Bowel Disease, anxiety and mood disorders, however little is known about their association with Eating Disorders. In this paper we will present a case of a young female with a comorbid diagnosis of Inflammatory Bowel Disease and Eating Disorder, and then discuss the results from a systematic review of the literature, describing published cases of patients with the same condition.

METHODS

A systematized review of the literature was conducted according to MOOSE guidelines. A computerized literature search of MEDLINE, PsycINFO and EMBASE, and a manual search through reference lists of selected original articles were performed to identify all published case-reports, case series and studies of Inflammatory Bowel Disease and Eating Disorders.

RESULTS

Fourteen articles were included, encompassing 219 cases, including ours. The vast majority were females ranging from 10 to 44years old. Anorexia Nervosa (n=156) and Crohn's Disease (n=129) was the most frequent combination (n=90) reported in the literature. These cases present a poor prognosis because of corticoid refusal, medication abandon and/or deliberate exacerbation of IBD symptoms, in the context of trying to lose weight.

CONCLUSION

Recent evidence suggests there is a possible association between Inflammatory Bowel Disease and Eating Disorders, although the mechanisms involved in its ethiopathogenesis are still unknown. To be aware of this association is important because a delayed diagnosis of this comorbidity may lead to worse prognosis. Further research and a multidisciplinary approach could facilitate earlier diagnosis and provide therapeutic interventions.

Gastrointestinal comorbidities which complicate the treatment of anorexia nervosa

Patients with anorexia nervosa often voice a multitude of symptoms in regards to their gastrointestinal tract. These complaints can complicate the treatment of their eating disorder as they distract attention from the important goal of weight restoration. Moreover, the restricting of certain food groups also makes the task of weight restoration substantially more difficult, or may result in binging. Therefore a working knowledge of common gastrointestinal comorbidities, such as celiac disease, irritable bowel syndrome, inflammatory bowel disease, and gastroparesis, is useful when treating a patient who has anorexia nervosa.

Nutrition Issues in Pediatric Crohn's Disease

Twenty-five percent of inflammatory bowel disease (IBD) diagnoses present in childhood, with Crohn's disease (CD) being the most common type. Many children have poor nutrition status at presentation of the disease, which may worsen during the clinical course, with a significant number of children having impaired linear growth. The cause of this poor nutrition status is complex, and contributing factors include inadequate intake, malabsorption, altered energy demands, and losses through stool, particularly in colitis. The principal aim of medical management is to induce disease remission, with minimal side effects, thereby enabling normal growth and development. This must include active consideration of the nutrition needs of such children and how they may be best met. However, our understanding of the manner in which the disease process affects the energy demands of children with CD or how poor nutrition, in turn, may affect the disease course is limited. This may constrain the efficacy and effectiveness of standard therapeutic approaches to care. This review explores the many factors of relevance in the delivery of nutrition support to children with inflammatory bowel disease, and explores the role of exclusive enteral nutrition as a corticosteroid-sparing strategy to induce remission in children with active Crohn's disease.

Rare medical manifestations of severe restricting and purging: "Zebras," missed diagnoses, and best practices

OBJECTIVE

Medical problems that arise due to severe restricting and/or purging may be misdiagnosed or suboptimally treated, from outpatient clinics to top medical hospitals. A symptom may be presumed to be a psychological manifestation of the eating disorder and inappropriately dismissed for further medical evaluation. Alternatively, a detailed medical workup may be performed, overlooking a classic relationship between starvation and a physical finding, which delays referral to eating disorder care. This review article focuses on rare medical issues (also called "zebras" in medical training), diagnoses that may be missed in patients with eating disorders, and best practices for management, organized by organ system.

METHOD

A PubMed search was performed, using search terms "eating disorder," "anorexia nervosa," and "bulimia nervosa" in combination with different words for each organ system and known medical manifestations of severe eating disorders, with high quality and relevant studies from the past 20 years cited.

DISCUSSION

Adults with eating disorders may present with extreme organ dysfunction and atypical signs and symptoms of typical medical problems. Timely diagnosis, risk awareness, appropriate treatment, and avoidance of harm are all vital. With judicious management and nutritional rehabilitation, most of these complications will significantly improve or resolve. ©

Disordered eating practices in gastrointestinal disorders

PURPOSE

To systematically review evidence concerning disordered eating practices in dietary-controlled gastrointestinal conditions. Three key questions were examined: a) are disordered eating practices a feature of GI disorders?; b) what abnormal eating practices are present in those with GI disorders?; and c) what factors are associated with the presence of disordered eating in those with GI disorders? By exploring these questions, we aim to develop a conceptual model of disordered eating development in GI disease.

METHODS

Five key databases, Web of Science with Conference Proceedings (1900-2014) and MEDLINE (1950-2014), PubMed, PsycINFO (1967-2014) and Google Scholar, were searched for papers relating to disordered eating practices in those with GI disorders. All papers were quality assessed before being included in the review.

RESULTS

Nine papers were included in the review. The majority of papers reported that the prevalence of disordered eating behaviours is greater in populations with GI disorders than in populations of healthy controls. Disordered eating patterns in dietary-controlled GI disorders may be associated with both anxiety and GI symptoms. Evidence concerning the correlates of disordered eating was limited.

CONCLUSIONS

The presence of disordered eating behaviours is greater in populations with GI disorders than in populations of healthy controls, but the direction of the relationship is not clear. Implications for further research are discussed.

A case of anorexia nervosa with comorbid Crohn's disease: beneficial effects of anti-TNF-α therapy?

This case report describes a 26-year-old woman affected by long-lasting anorexia nervosa (AN) and Crohn's disease. Worsening of the bowel illness led to the prescription of immunosuppressive therapy (biologic infliximab for 4 months, followed by adalimumab for 6 months) and referral to our Eating Disorders Unit. Although she initially demonstrated denial of her eating disorder, in a few months she gradually improved her weight and psychopathology. Crohn's disease can worsen AN by modifying hunger and energy expenditure through the effects of TNF-α and IL-6, pro-inflammatory cytokines which moderate leptin and melanocortin signaling. Previous studies have observed the antidepressant effects of TNF antagonist in patients with treatment-resistant depression with high baseline inflammatory biomarkers. Our case report suggests that future studies are needed to clarify the existence, patterns, and extent of increased inflammatory markers in patients with AN, and whether they determine clinical features or identify subgroups of patients. Potential therapeutic significance of above issues remains to be determined.

Eating disorders in adolescents and young women with spina bifida

This is the first report of the association of spina bifida and eating disorders. Five patients were diagnosed rather late in the course of their illness. They all had been overweight premorbidly and had been urged to lose weight for years in order to improve their mobility. As they dieted, they experienced their weight loss as a source of power that could somehow compensate for their losses and neurologic limitations. They responded to a multidisciplinary intervention. Clinicians taking care of patients with spina bifida need to be cognizant that they may be at risk of developing an eating disorder. Such awareness should influence the quality of nutritional counseling (prevention aspect) and the clinical assessment of sudden weight loss (early intervention).

Lessons learned about adolescent nutrition from the Minnesota Adolescent Health Survey

In 1986-1987, more than 30,000 adolescents completed the Minnesota Adolescent Health Survey, a comprehensive assessment of adolescent health status, health behaviors, and psychosocial factors. Although the survey included relatively few items on nutrition-related issues, a wealth of knowledge about adolescent nutrition was gained. Lessons learned from a decade of subsequent analyses of data collected in the survey and implications for working with youth are summarized in this article. Major concerns identified included high prevalence rates of inadequate intake of fruits, vegetables, and dairy products; unhealthful weight-control practices; and overweight status. For example, inadequate fruit intake was reported by 28% of the adolescents and inadequate vegetable intake was reported by 36%. Among female adolescents, 12% reported chronic dieting, 30% reported binge eating, 12% reported self-induced vomiting, and 2% reported using diuretics or laxatives. Some of the risk factors for inadequate food intake patterns or unhealthful weight-control practices included low socioeconomic status, minority status, chronic illness, poor school achievement, low family connectedness, weight dissatisfaction, overweight, homosexual orientation among male adolescents, and use of health-compromising behaviors. To improve adolescent eating behaviors, the results suggest a need for innovative outreach strategies that include educational and environmental approaches. Dietitians play a key role in developing interventions and promoting research in the field of adolescent nutrition.

Disordered eating among adolescents with chronic illness and disability: the role of family and other social factors

OBJECTIVES

To compare prevalence rates of weight-control behaviors among adolescents with and without chronic illness and to explore the role of familial and other social factors on associations between disordered eating and chronic illness.

DESIGN AND SETTING

Survey conducted in public schools in Connecticut.

PARTICIPANTS

A representative statewide population-based sample of 9343 7th-, 9th-, and 11th-grade public school students, of whom 1021 reported a chronic illness.

MAIN OUTCOME MEASURES

Disordered eating (vomiting, diet pills, and laxatives), dieting, and exercise for weight control; chronic illness status; family structure, family communication, parental caring, parental monitoring, parental expectations, peer support, and sexual and physical abuse.

RESULTS

Adolescents with chronic illness were at greater risk for disordered eating than youth without chronic illness, after controlling for sociodemographic variables (girls: odds ratio, 1.59 [95% confidence interval, 1.19-2.14]; boys: odds ratio, 2.22 [95% confidence interval, 1.49-3.32]). Adolescents with chronic illness were less likely to come from 2-parent families; reported lower levels of family communication, parental caring, and parental expectations; and reported more sexual and physical abuse than youth without chronic illness. Male adolescents with chronic illness were more likely to report low peer support and low parental monitoring. Most of these familial-social factors were also associated with an increased prevalence of disordered eating. After familial-social factors were controlled for, however, associations between disordered eating and chronic illness remained statistically significant.

CONCLUSIONS

Adolescents with chronic illness are at greater risk for disordered eating behaviors than youth without chronic illness. Factors other than the familial-social factors assessed in this study may be contributing to this increased risk. In the clinical setting, youth with chronic illness need to be screened for disordered eating and familial and other social concerns.

Crohn's disease: nutrition and nutritional therapy

Disordered nutrition is common in Crohn's disease and is multifactorial. Regular and systematic monitoring of at least a minimum set of nutrition data is an essential component of care of children and adults with Crohn's disease. However, even in children, monitoring of growth and development may be deficient. Multiple macro- and micronutrient deficiencies are common in Crohn's disease, especially in those with extensive small bowel deficiencies or after multiple surgical resections. Body composition analysis may show differences from simple starvation, and metabolic effects of inflammation are increasingly being recognized. Nutritional support is part of the management of all patients with Crohn's disease, but nutritional intervention with defined formula liquid diet is an effective specific anti-inflammatory therapy. Although meta-analysis of published trials suggest that steroids are more effective than defined formula liquid diets, objective evidence from whole gut lavage fluid analysis and from faecal excretion of radiolabelled leukocytes shows unequivocal benefit of elemental diet based on measuring parameters of tissue damage. Enteral feeding with liquid diets should be considered in patients with incomplete small bowel obstruction, severe painful perianal disease, failure of corticosteroids in active Crohn's disease, borderline intestinal failure and in children with active Crohn's disease or with growth failure.

Eating attitudes and the irritable bowel syndrome

A series of 48 new patients with irritable bowel syndrome (IBS) were asked to complete an Eating Attitudes Test. The same test was given to a series of 32 patients attending an Eating Disorder clinic, a series of 31 patients attending a gastroenterology outpatient clinic with a diagnosis of inflammatory bowel disease (IBD), and to a group of 28 'normal' controls. The results showed that there was no significant difference between the IBD group and control groups for EAT score. The EAT score for the group with eating disorders was significantly higher than for all other groups. The EAT score for the IBS group was greater than those for the IBD and control group (p = 0.05) when all four groups were compared using analysis of variance and the Least Significant Difference test.

Hypercarotenemia and transaminitis in female adolescents with eating disorders: a prospective, controlled study

PURPOSE

Hypercarotenemia and transaminitis are reported as laboratory features of anorexia nervosa. However, the specificity and sensitivity of an elevation in serum carotene and transaminase are not known. Therefore, a prospective study was undertaken to determine the clinical utility of these serum markers.

METHODS

Serum carotene was measured in 46 female adolescents between 13 years and 18 years of age (21 anorexia nervosa, 17 bulimia nervosa, 8 unclassified eating disorders). Findings were compared to levels of carotene in serum samples obtained from similarly aged females with either chronic inflammatory bowel disease (22 Crohn disease, 11 ulcerative colitis) or acute medical symptoms not associated with undernutrition or intestinal inflammation (N = 26), and 21 children of either sex with dyspeptic symptoms.

RESULTS

Serum carotene was elevated in 6/46 (13.0%) females with eating disorders compared with only 2/80 (2.5%) children in the three comparison groups (p < 0.01). Hypercarotenemia was present in 4/21 girls with anorexia nervosa compared with 0/17 females with bulimia nervosa (p = 0.11). Transaminitis was present in 38.5% (AST) and 7.7% (ALT) of eating disorder patients. Liver enzyme abnormalities, however, did not correlate with hypercarotenemia. Transaminitis was also not specific for eating disorders since transaminitis was observed with comparable frequency in the three comparison groups.

CONCLUSIONS

These findings confirm that hypercarotenemia is a laboratory feature in some subjects with eating disorders, in particular, anorexia nervosa. The low sensitivity (13.0%) does not provide justification for its use as a screening test. However, in complicated diagnostic settings a serum carotene determination could prove useful because the specificity (97.5%), positive predictive value (75.0%), and negative predictive value (66.1%) of an elevated carotene were high. These data also show that elevated carotene levels are not associated with hepatic abnormalities. Although transaminitis is reported as a laboratory feature of eating disorders, the prevalence of such abnormalities in this study was not higher than in age-matched comparison groups.

Medical management of chronic inflammatory bowel disease

In the absence of a definitive cure for Crohn's disease and ulcerative colitis, the aim of therapy must be to induce and maintain clinical remission at acceptable cost to the patient in terms of adverse effects. Despite the differences in their pathogenesis, the first-line treatments for Crohn's disease and ulcerative colitis are still based upon combinations of amino-salicylic acid derivatives and corticosteroids, although the use of enteral nutrition regimes is becoming increasingly widespread in Crohn's disease. In this chapter we attempt to provide reasonably didactic guidance for the management of most cases of chronic inflammatory bowel disease. However, we have tried to go beyond this brief, motivated by the recent explosion in knowledge of inflammatory mechanisms, to suggest a rational approach to the choice of newer and less well tested therapeutic approaches in the affected child who is not responding effectively. The relative failure of cyclosporine therapy in Crohn's disease has been particularly disappointing in view of its ideal theoretical suitability. However, the encouraging early reports of treatment with anti-CD4 and anti-TNF alpha monoclonals suggest that the shift from broad spectrum immunomodulation to the targeting of critical components of the inflammatory cascade may yet field important dividends.