• Symptoms of hyperthyroidism, diabetes, malignancy, infection, inflammatory bowel disease?
Possible Findings on Physical Examination in Children and Adolescents With Eating Disorders
Orthostatic by pulse or blood pressure
Orthostatic by pulse or blood pressure
Cardiac murmur (one third with mitral valve prolapse)
Cardiac murmur (mitral valve prolapse)
Dull, thinning scalp hair
Hair without shine
Sunken cheeks, sallow skin
Atrophic breasts (postpubertal)
Russell’s sign (callous on knuckles from self-induced emesis)
Atrophic vaginitis (postpubertal)
Pitting edema of extremities
Emaciated, may wear oversized clothes
Dental enamel erosions
May look entirely normal
Cold extremities, acrocyanosis
Other cardiac arrhythmias
Diagnosis of Anorexia Nervosa, Bulimia Nervosa, and Eating Disorders Not Otherwise Specified, From DSM-IV25
1. Intense fear of becoming fat or gaining weight, even though underweight.
2. Refusal to maintain body weight at or above a minimally normal weight for age and height (ie, weight loss leading to maintenance of body weight <85% of that expected, or failure to make expected weight gain during period of growth, leading to body weight <85% of that expected).
3. Disturbed body image, undue influence of shape or weight on self-evaluation, or denial of the seriousness of the current low body weight.
4. Amenorrhea or absence of at least 3 consecutive menstrual cycles (those with periods only inducible after estrogen therapy are considered amenorrheic).
Restricting—no regular bingeing or purging (self-induced vomiting or use of laxatives and diuretics).
Binge eating/purging—regular bingeing and purging in a patient who also meets the above criteria for anorexia nervosa.
1. Recurrent episodes of binge eating, characterized by:
a. Eating a substantially larger amount of food in a discrete period of time (ie, in 2 h) than would be eaten by most people in similar circumstances during that same time period.
b. A sense of lack of control over eating during the binge.
2. Recurrent inappropriate compensatory behavior to prevent weight gain; ie, self-induced vomiting, use of laxatives, diuretics, fasting, or hyperexercising.
3. Binges or inappropriate compensatory behaviors occuring, on average, at least twice weekly for at least 3 mo.
4. Self-evaluation unduly influenced by body shape or weight.
5. The disturbance does not occur exclusively during episodes of anorexia nervosa
Purging—regularly engages in self-induced vomiting or use of laxatives or diuretics.
Nonpurging—uses other inappropriate compensatory behaviors; ie, fasting or hyperexercising, without regular use of vomiting or medications to purge.
Eating Disorder Not Otherwise Specified (those who do not meet criteria for anorexia nervosa or bulimia nervosa, per DSM-IV
1. All criteria for anorexia nervosa, except has regular menses.
2. All criteria for anorexia nervosa, except weight still in normal range.
3. All criteria for bulimia nervosa, except binges <twice a wk or <3 times a mo.
4. A patient with normal body weight who regularly engages in inappropriate compensatory behavior after eating small amounts of food (ie, self-induced vomiting after eating 2 cookies).
5. A patient who repeatedly chews and spits out large amounts of food without swallowing.
6. Binge eating disorder: recurrent binges but does not engage in the inappropriate compensatory behaviors of bulimia nervosa.
Medical Complications Resulting From Eating Disorders
Medical Complications Resulting From Purging
1. Fluid and electrolyte imbalance; hypokalemia; hyponatremia; hypochloremic alkalosis.
2. Use of ipecac: irreversible myocardial damage and a diffuse myositis.
4. Use of laxatives: depletion of potassium bicarbonate, causing metabolic acidosis; increased blood urea nitrogen concentration and predisposition to renal stones from dehydration; hyperuricemia; hypocalcemia; hypomagnesemia; chronic dehydration. With laxative withdrawal, may get fluid retention (may gain up to 10 lb in 24 h).
5. Amenorrhea (can be seen in normal or overweight individuals with bulimia nervosa), menstrual irregularities, osteopenia.
Medical Complications From Caloric Restriction
1. Cardiovascular Electrocardiographic abnormalities: low voltage; sinus bradycardia (from malnutrition); T wave inversions; ST segment depression (from electrolyte imbalances). Prolonged corrected QT interval is uncommon but may predispose patient to sudden death. Dysrhythmias include supraventricular beats and ventricular tachycardia, with or without exercise. Pericardial effusions can occur in those severely malnourished. All cardiac abnormalities except those secondary to emetine (ipecac) toxicity are completely reversible with weight gain.
2. Gastrointestinal system: delayed gastric emptying; slowed gastrointestinal motility; constipation; bloating; fullness; hypercholesterolemia (from abnormal lipoprotein metabolism); abnormal liver function test results (probably from fatty infiltration of the liver). All reversible with weight gain.
3. Renal: increased blood urea nitrogen concentration (from dehydration, decreased glomerular filtration rate) with increased risk of renal stones; polyuria (from abnormal vasopressin secretion, rare partial diabetes insipidus). Total body sodium and potassium depletion caused by starvation; with refeeding, 25% can get peripheral edema attributable to increased renal sensitivity to aldosterone and increased insulin secretion (affects renal tubules).
4. Hematologic: leukopenia; anemia; iron deficiency; thrombocytopenia.