ANSWERS: EATING DISORDERS BOARD QUESTIONS
1. You are asked to evaluate a 17 year old girl who is binge eating and purging.
Of the following symptoms and signs, which is LEAST commonly associated with bulimia? A. Amenorrhea
B. Dental enamel erosion C. Electrolyte abnormalities D. Frequent weight fluctuations E. Parotid gland swelling
2-5. A 16 year-old girl has lost 30 lbs over the past 8 months. For the past 4 months she has had amenorrhea. On examination you notice that she is thin but alert and active. There is yellowish discoloration of her skin. You suspect anorexia nervosa.
2. Among the following elements of the patient’s medical history, the one LEAST consistent with the diagnosis of anorexia nervosa would be:
A. Laxative abuse
B. Concern about being too thin C. Ritualistic eating behaviors D. Preoccupation with food E. Dieting to lose weight
3. Among the following activities, the one LEAST commonly associated with this condition is: A. Ballet dancing
B. Field hockey C. Fashion modeling D. Gymnastics E. marathon running
4. Physical finding found with increasing frequency among patients with anorexia nervosa include each of the following EXCEPT:
A. Bradycardia B. Hypotension C. Lanugo D. Ankle edema E. Seborrhea
5. Of the following findings, the one LEAST suggestive of anorexia nervosa is: A. an elevated serum carotene level
B. an elevated ESR C. a low serum estradiol
D. reduced bone mineral density (osteopenia)
6. You are evaluating a previously healthy 15-year-old girl for secondary amenorrhea. She denies a history of nausea, vomiting, diarrhea, and headaches. She is in 10th grade, does well in school, and swims daily at the local health club. A 24-hour dietary recall appears adequate, although the patient states that she is considering eliminating red meat and fat from her diet. Her body mass index is 17. A urine pregnancy test is negative. Of the following, the most likely reason for this patient’s secondary amenorrhea is: A. Anorexia nervosa. B. Bulimia nervosa. C. Crohn disease. D. Depression. E. Hypothyroidism.
7. A 15-year-old girl is admitted to your facility with severe anorexia nervosa and amenorrhea. She weighs 35 kg and is 160 cm tall. She has bradycardia and orthostatic hypotension. You plan to stabilize her medically and begin re-feeding.
Of the following, the electrolyte abnormality that is MOST likely to occur during the first week of her treatment is A. hypercalcemia B. hyperphosphatemia C. hypocalcemia D. hyponatremia E. hypophosphatemia
8. You are evaluating a 17-year-old girl who has anorexia nervosa for possible hospital admission. She denies a recent history of vomiting, syncope, and hematemesis. Of the following physical findings, the most appropriate indication for hospitalization includes:
A. Hyperthermia.
B. Lower extremity edema. C. Orthostatic changes. D. Resting tachycardia. E. Tachypnea.
9. A 6-year old girl with a history of bulimia has weakness, dysphagia, tachycardia and hypotension. Her serum transaminase and CPK are elevated. The electrolyte levels are normal. The electrocardiogram shows ST segment depression and T wave inversion. The patient’s findings are MOST likely the result of chronic, excessive ingestion of:
A. Syrup of ipecac B. Furosemide C. Phenolphthalein D. Mineral oil
10. An otherwise asymptomatic 15-year old girl has primary amenorrhea. Thelarche occurred at age 14. She has been growing at the rate of 2 inches per year. Physical examination reveals: weight 3rd
percentile for age; BMI 50th percentile, breasts Tanner stage III, pubic hair Tanner stage II, and normal
findings on pelvic examination. Family history reveals the mother’s menarche occurs at age 16. The MOST likely cause of the girl’s amenorrhea is:
A. Anorexia nervosa B. Familial pubertal delay C. Gonadal dysgenesis D. Hypothyroidism
ANSWER SHEETS
QUESTION 1 CORRECT ANSWER ITEM: A Patients with bulimia do not have menstrual irregularities as often as do patients with anorexia nervosa. According to the criteria outlined in the Diagnostic and Statistical Manual of the American Psychiatric Association, Edition IV , amenorrhea of at least 3 month’ duration is one of the four criteria for diagnosis of anorexia nervosa. in contrast, the criteria for diagnosis of bulimia do not include menstrual
irregularities.
The major medical problems associated with bulimia are consequences of the purging behavior. The most frequent serious medical problems are electrolyte and acid-base disturbances including
hypokalemia, hypochloremia, hyponatremia, and alkalosis. Weight fluctuations and hypovolemia also may occur although hypovolemia is more likely to be present if the patient uses diuretic agent to control weight.
Frequent vomiting can cause erosion of dental enamel and enlargement of the parotid and other salivary glands due to excessive reflex stimulation or reflux into the ducts. Hematemesis can occur if vomiting results in esophagitis or a tear in the gastric mucosa at or lightly below the esophagogastric junction (Mallory-Weiss syndrome).
References:
Comerci GD: Eating Disorders in Adolescents. Pediatric in Review 10:37-47, 1988.
Palla B, Litt IF. Medical complications of eating disorders in adolescents. Pediatrics 81:613-623, 1988.
American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders (4t edition, Text Revision). 4th edition ed. Washington D.C. APA Press, 2000.
QUESTION 2-5 CORRECT ANSWER ITEM 6: B CORRECT ANSWER ITEM 7: B CORRECT ANSWER ITEM 8: E CORRECT ANSWER ITEM 9: B Anorexia nervosa is a potentially fatal eating disorder that has its highest incidence in adolescent females. The mean age of onset is 14 years. Although most patients are Caucasian and from middle and upper middle class backgrounds, the syndrome is found in other ethnic and socioeconomic groups; approximately 10% of affected patients are male.
Anorexia nervosa is characterized by severe restriction of dietary intake, marked weight loss,
preoccupation with food, ritualistic eating behaviors, and an intense fear of being obese. Patients have a disturbance in body image and believe they are overweight even when they are emaciated. As many as one half of patients with anorexia nervosa will lose weight not only by starvation, but also by purging after eating (eg, vomiting) and /or the use of laxatives or diuretics.
No precise etiology for anorexia nervosa is known; it is believed to be the result of biologic, psychologic, and socio-cultural determinants. There is a strong genetic susceptibility. There is also an increased incidence of anorexia nervosa in persons who engage in activities and professions where thinness is considered an asset or necessity (eg, ballet dancing, fashion modeling, gymnastics, marathon running). The condition is associated less frequently with participation in team sports (eg, field hockey).
The diagnosis of anorexia nervosa is made clinically. The physical findings are similar to those of starvation from any cause and may include emaciation; bradycardia; hypotension; hypothermia; cold, bluish-purple hands and feet; lanugo hair; and peripheral edema. Seborrhea is not an associated finding. Laboratory findings are generally normal in patients with anorexia nervosa who do not purge. Any abnormal findings are similar to those found in other forms of starvation and include the low T3 syndrome and prepubertal levels of luteinizing hormone, follicle stimulating hormone, and estradiol with eventual osteoporosis. Patients usually are not anemic; and, although the white blood cell count may be low with a relative leukopenia, difficulty with infection is rare. About one half of patients will have an elevated serum carotene level (sometimes with an associated yellowish cast to the skin—carotenemia). The erythrocyte sedimentation rate is usually low in states of malnutrition.
References:
Fisher M. Treatment of Eating Disorders in Children, Adolescents, and Young Adults. Pediatr Rev. 2006 Jan;27(1):5-16.
Katzman DK, Golden NH. Anorexia Nervosa and Bulimia Nervosa. In Neinstein LS (ed). Adolescent Healthcare: A Practical Guide, 5e. Lippincott Williams & Wilkins, 2007.
QUESTION 6. CORRECT ANSWER: A The most likely reason for the patient’s amenorrhea is anorexia nervosa. While depression, Crohn’s disease and hypothyroidism can all cause secondary amenorrhea, there are no clinical features to suggest any of these diagnoses.
Despite the fact that the patient’s 24 hour intake appears adequate, her energy intake may be inadequate for her energy expenditure. She also may be using excessive exercise to control her weight. Her low fat diet and elimination of red meat further support the diagnosis of an eating disorder. Her BMI is 17, which is low.
The diagnostic criteria for anorexia nervosa include weight loss leading to a weight less than 85% of expected, preoccupation with body shape and weight, distortion in body image and amenorrhea (defined as lack of menses for at least 3 months). Amenorrhea usually accompanies weight loss, but in
approximately 20% of cases it may precede significant weight loss. Resumption of menses usually occurs within 6 months of achieving a weight at least 90% of median body weight for age and height. Patients who do not meet all the DSM IV criteria are classified as Eating Disorder Not Otherwise
Specified (EDNOS). Most adolescents referred for treatment do not meet strict criteria for either anorexia nervosa or bulimia nervosa and fall into the EDNOS category. Included in this group is the female athlete triad (disordered eating, amenorrhea and osteoporosis). In this situation energy intake is not sufficient for energy output. The energy deficit results in amenorrhea and increased fracture risk. Some patients with the female athlete triad do have an eating disorder, but many do not. The goals of treatment are to increase caloric intake and reduce intensity of training.
References:
American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders (4th edition, Text Revision). 4th edition ed. Washington D.C.: APA Press, 2000.
Golden NH, Shenker IR. Amenorrhea in anorexia nervosa - etiology and implications. In: Adolescent Medicine State of the Art Reviews. Adolescent Nutrition and Eating Disorders. Hanley & Belfus Inc, Philadelphia;1992:3:503-517.
Golden NH, Jacobson MS, Schebendach J, Solanto MV, Hertz, SM, Shenker IR. Resumption of menses in anorexia nervosa. Arch Pediatr Adolesc Med; 1997:151:16-21.
Golden NH. A Review of The Female Athlete Triad (Amenorrhea, Osteoporosis and Disordered Eating). Int J Adolesc Med Health;2002: 14: 9-17.
Golden NH, Katzman DK. Anorexia Nervosa and Bulimia Nervosa. In Neinstein LS (ed). Adolescent Healthcare: A Practical Guide, 5e. Lippincott Williams & Wilkins, in press, 2007
QUESTION 7. CORRECT ANSWER: E The girl described in the critique is severely malnourished and about to undergo intensive nutritional rehabilitation with enteral feeding. Although this therapy is lifesaving, it also may result in refeeding syndrome. In this syndrome, malnourished patients given oral, enteral, or intravenous nutrition develop fluid retention and electrolyte abnormalities. The most common electrolyte abnormality reported is hypophosphatemia, which can occur in approximately 25% of patients who have anorexia nervosa during refeeding. Other electrolyte and micronutrient abnormalities, including hyponatremia, hypocalcemia, hypokalemia, hyperglycemia, and thiamine deficiency, also may occur, but are less prevalent than hypophosphatemia. Hypercalcemia and hyperphosphatemia generally do not occur. With careful monitoring of electrolytes and slow refeeding, signs and symptoms of refeeding syndrome can be
avoided. However, the clinical manifestations include edema, muscle weakness, and cardiac arrhythmias. The precise mechanism by which phosphorus levels are lowered during refeeding has not yet been characterized fully. Malnourished patients are depleted in total body phosphorus, despite normal serum concentrations. The carbohydrate challenge during refeeding induces the release of insulin, which causes fluid and electrolyte shifts. In addition, malnourished patients being refed synthesize the phosphate-rich compounds creatine phosphokinase, 2,3 diphosphoglycerate, and adenosine triphosphate. Thus, total body stores of phosphorus may be depleted even further during energy synthesis.
To minimize the risk of refeeding syndrome, supplemental feedings should be introduced gradually to malnourished patients (beginning at 25% of recommended calories and advancing to full calories over 5 to 7 days). In addition, serum electrolytes, blood glucose, calcium, phosphorus, and magnesium should be measured at least daily for the first week of feeding. Some centers automatically prescribe a
phosphorus supplement (500 mg twice a day) to patients who have anorexia nervosa and are being refed.
References:
Frates SE. Eating disorders. In: Hendricks KM, Duggan C, eds. Manual of Pediatric Nutrition. 4th ed. Hamilton, Ontario, Canada: BC Decker; 2005:494-504
Kohn MR, Golden NH, Shenker IR. Cardiac arrest and delirium: presentations of the refeeding
syndrome in severely malnourished adolescents with anorexia nervosa. J Adolesc Health; 1988: 22:239-243.
Ornstein RM, Golden NH, Jacobson MS, Shenker IR. Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: implications for refeeding and monitoring. Journal of Adolescent Health; 2003: 32:83-88.
QUESTION 8. CORRECT ANSWER: C Most patients with anorexia nervosa can be treated as outpatients by a team of professionals including a pediatrician or adolescent medicine specialist, a therapist and a nutritionist.
The American Academy of Pediatrics, the Society for Adolescent Medicine and the American Psychiatric Association have all recently published guidelines as to which patients warrant hospitalization. There is general consensus that patients who are severely malnourished (<75% ideal body weight), have electrolyte disturbances, cardiac dysrrythmias, vital sign instability or are failing outpatient treatment, warrant admission to an inpatient unit. Other indications include syncope, hematemesis and suicidal ideation. In general the threshold for admission should be lower in adolescent than in adults.
Patients with anorexia nervosa may have hypothermia, bradycardia, orthostatic pulse and blood pressure changes. Tachypnea or resting tachycardia are not usual features of anorexia nervosa. Lower extremity edema can occur, usually during refeeding. However, it is not a reason for hospitalization.
References:
American Academy of Pediatrics Policy Statement. Identifying and treating eating disorders 2003;111:204-211.
Yager,J; Anderson,A; Devlin,M et al. American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders 2000: Suppl 157:1-39.
Golden NH, Kreipe RE, Katzman DK, Stevens SL, Rome ES, Nicolls D, Sawyer SM, Rees MS. Society for Adolescent Medicine Position Paper. Eating Disorders in Adolescents. Journal of Adolescent Health 2003; 33:496-503.
Shamim T, Golden NH, Arden MR, O’Reilly AM, Filiberto L, Shenker IR. Normalization of vital sign instability in the treatment of anorexia nervosa. Journal of Adolescent Health 2003; 32:73-77.
QUESTION 9
Syrup of ipecac has been used as a purgative by patients with eating disorders. Even though it has been taken off the market, it is readily available on the internet. The major pharmacologic effect of syrup of ipecac is the result of its alkaloid component, emetine, which persists in the body for long periods of time. When ingested chronically, emetine is extremely toxic, especially to cardiac, smooth, and skeletal
muscles. Manifestations of toxicity include dyspahgia, weakness, tachycardia, hypotenison, elevated serum transaminase and creatine kinase activities, and ST segment depression with T wave inversion on the electrocardiogram. Several deaths have been reported.
The chronic, excessive use of furosemide will result in electrolyte and fluid depletion and may lower calcium levels. Toxic manifestations include thirst, weakness, lethargy, muscle pains or cramps, hyptension, oliguria, tachycardia, arrhythmias, and gastrointesninal disturbances.
Phenolphthalein and mineral oil may produce rashes in some users. References:
Adler AG, Walinsky P, Krall RA, Cho SY: Death Resulting from Ipecac Syrup Poisoning. JAMA 243: 1927-1928, 1980
Friedman EJ: Death from Ipecad Intoxication in a Patient with Anorexia Nevosa. Am J Psychiatry 141: 702-703, 1984
Schiff RJ, Wurzel CL, Brunson SC, et al: Death due to Chronic Syrup of Ipecac use in a Patient with Bulimia. Pediatrics 78: 412-416, 1986.
QUESTION 10 CORRECT ANSWER ITEM 10: B The average age at menarche in the United States is 12.4 years. When menarche has not occurred by age 15 years, it is considered delayed. Assessment of a 15-year-old girl who has not yet menstruated is based on knowledge of the normal stages of pubertal development. For example, menarche usually occurs 2 to 3 years after the onset of sexual development, and the pubertal peak growth velocity usually occurs prior to menarche.
The patient in the vignette is still in the early stages of pubertal development and will most likely begin menstruating when she is 16 or 17 years old. Given that her mother’s menarche occurred at age 16, her amenorrhea is likely due to familial pubertal delay. Physical examination and assessment of growth should be repeated in 3 to 6 months to determine that pubertal development is progressing normally and to provide reassurance to the patient.
Anorexia nervosa can cause primary amenorrhea. This diagnosis, however, is unlikely in an adolescent who has BMI at the 50th percentile.
The teenager with amenorrhea due to gonadal dysgenesis usually has some feature of Turner syndrome, including short stature, webbed neck, wide-spaced nipples, low hairline, short fourth or fifth metacarpals, lymphedema, and multiple-pigmented nevi. Affected girls do not have normal secondary sex
characteristics and usually present with short status. If gonadal dysgenesis is suspected, karyotyping should be obtained. Approximately 50% of patients with gonadal dysgenesis will have an XO karyotype, and 50% will have mosaic karyotype. Girls with mosaic forms of gonadal dysgenesis have more subtle physical features of Turner syndrome and are more likely to develop some secondary sex characteristics. In addition, serum gonadotropin levels (which usually are elevated because of ovarian failure) should be measured.
Hypothyroidism can cause primary or secondary amenorrhea. This diagnosis is supported by physical examination findings consistent with decreased growth velocity and increased weight/height ration. Secondary sex characteristics may or may not be present depending on the time of onset of the hypothyroidism in the course of the patient’s pubertal development.
References:
Emans SJH, Goldstein DP: Delayed puberty and menstrual irregularities, in Pediatric and Adolescent Gynecology, ed 3. Boston, Little, Brown and Co, 1990, pp 149-221
American Academy of Pediatrics Committee of Adolescence. Menstruation in girls and adolescents: using the menstrual cycle as a vital sight. Pediatrics 2006; 118: 2245-2250.
