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Feb 5, 2018

Vicky Vella is an emergency physician practicing in the United Kingdom with a special interest and expertise in eating disorders. In December of last year, Vicky had a guest post on the St Emlyn’s blog about the MARSIPAN Guidelines. Never heard of them? Neither had pretty much anybody. MARSIPAN is an acronym for Management of Really Sick Patients with Anorexia Nervosa.

Anorexia is often viewed as a chronic condition that doesn't really warrant emergency care, but that's not the case. Mortality with anorexia nervosa is high (on the order of 10-20%) and patients can present, as MARSIPAN suggests, really sick.

 

Consider an eating disorder/anorexia in patients presenting with

  • Self Harm. Up to 70% of patients with anorexia will self harm
  • Diabetic Ketoacidosis.  In the UK around half of 15-25 year olds with type 1 diabetes will withhold insulin to try and lose weight. Not all of them will have an eating disorder, but many will
  • Vasovagal syncope. We often ask if a patient had breakfast or enough to drink today, but there may be an underlying eating disorder

 

What question(s) to ask

  • Vicky starts with, "What's your relationship with food?" "Do you eat regular meals?"
  • The patient may not disclose that there's a problem. Information may come from a family member

 

Who has anorexia nervosa

  • Highest risk is 13-17 yo age group, both male and female
  • Can actually affect all ages, races, genders

 

What's the difference between anorexia nervosa and someone who just doesn't eat much?

  • Anorexia is a mental illness. Sometjing the person doesn't have much control over
  • Less of a desire to be thin than a fear of being obese
  • Guilt associated with eating
  • May restrict intake, exercise to burn off consumed calories
  • Often mood swings, social isolation, can become aggressive toward family

DSM 5 Criteria

  1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
  2. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
  3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

 

Red Flags in the Anorexia Workup (from the MARSIPAN Guidelines)

BMI

  • low risk 15–17.5
  • medium risk 13–15
  • high risk <13

Physical examination

  • low pulse (<40bpm)
  • blood pressure (especially if associated with postural symptoms)
  • core temperature (<35C)
  • muscle power reduced
  • Sit up–Squat–Stand (SUSS) test (scores of 2 or less, especially if scores falling)

Blood tests

  • low sodium: suspect water loading (<130 mmol/L high risk) or occult chest infection with associated SIADH
  • low potassium: vomiting or laxative abuse (<3.0mmol/L high risk) (note: low sodium and potassium can occur in malnutrition with or without water loading or purging)
  • raised transaminases
  • hypoglycaemia: blood glucose <3mmol/L (if present, suspect occult infection, especially with low albumin or raised C-reactive protein)
  • raised urea or creatinine: the presence of any degree of renal impairment vastly increases the risks of electrolyte disturbances during re-feeding and rehydration (although both are difficult to interpret when protein intake is negligible and muscle mass low)

ECG

  • bradycardia
  • raised QTc (>450ms)
  • non-specific T-wave changes
  • hypokalaemic changes

 

Bibliography

MARSIPAN Guidelines PDF Link

Junior MARSIPAN Guidelines PDF Link

Arcelus, Jon, et al. "Mortality rates in patients with anorexia nervosa and other eating disorders: a meta-analysis of 36 studies." Archives of general psychiatry 68.7 (2011): 724-731. Full Text  PMID: 21727255

What psychiatric disorder has the highest mortality? Article Link