Anorexia Nervosa Treatment Overview
We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.
Weight loss is a major problem in AIDS and directly influences survival. The causes of weight loss are complex and several factors may coexist in individual patients. Anorexia may occur secondary to drug therapy, opportunistic infection, taste disturbance, or oral discomfort, resulting in inadequate food intake. Malabsorption of fat, lactose, vitamin B12, and bile salts has been demonstrated.
Eating disorders occur along a spectrum. Besides AN and BN there are several variants of these disorders that may not meet full diagnostic criteria yet are associated with significant clinical impairment. Some of these may be sub-threshold cases of AN or BN, whereas others may represent atypical eating disorders. All are subsumed under the diagnosis Eating Disorder Not Otherwise Specified (EDNOS). Atypical eating disorders are ones in which overvalued concern with fear of fatness is absent yet the patient develops significant eating behavior pathology. Examples include globus hystericus (phobia of swallowing or choking resulting in food refusal), rumination, or psychogenic vomiting syndromes. Binge eating disorder (BED) is also considered an EDNOS. BED is characterized by frequent
The GI problems of most individuals with eating disorders result from starvation, from compensatory behaviors like vomiting, laxative or diuretic abuse, or from treatment (eg, the refeeding syndrome). That most of these problems are secondary to the behaviors is suggested by the fact that even in nonclinical college aged women, the severity and number ofGI complaints has been associated with the extent ofdieting behavior (Krahn et al, 1996). Most complaints have been found to reverse with normalization of eating behavior and do not require or respond to symptomatic treatment with typical pharmacological agents. It is important for gastroenterologists to be aware of common complaints in eating disordered patients so as not to miss a diagnosis and chance for early interven
Effective treatment depends on setting clear behavioral guidelines (eg, binging and vomiting decrement of 50 over 3 to 4 weeks, weight gain of 1 to 2 lbs week on a prescribed diet). The patient should be weighed at the beginning of each session and be instructed to maintain a daily food log and record of abnormal behaviors, such as vomiting or use of laxatives. Triggers for eating disordered behavior and situations that sustain it are discussed and alternate thoughts and behaviors are explored. The therapeutic approach is cognitive-behavioral and fairly directive, with the therapist playing an active role in helping the patient problem solve, develop healthier behaviors, and challenge irrational beliefs. Although the standard course of cognitive behavioral treatment for uncomplicated BN is brief, on the order of 16 to 20 weeks, persuading patients with AN to gain weight as outpatients is difficult, and outpatient psychotherapy for AN may be more protracted. In addition to individual...
The two most common eating disorders are anorexia nervosa and bulimia (Ruff et al, 1992). A variety of specialists, including gastroenterologists, psychiatrists, psychologists, dentists, internists, clinical social workers, nurses, and dietitians, must provide the treatment of eating disorders. There is a separate chapter on this topic (see Chapter 38, Anorexia Nervosa and Bulimia ). The cardinal oral manifestation of eating disorders is severe erosion of the enamel on the lingual surfaces of the maxillary teeth. Acids from chronic vomiting are the cause (Shaw, 1994 Tylenda et al, 1991). Examination of the patient's fingernails and volar surfaces of the fingers may disclose abnormalities related to using these fingers to initiate purging. Mandibular teeth are not usually affected to the same degree as the maxillary teeth. Parotid enlargement may develop as sequelae of starvation.
Bulimia dentomedical complications. Gen Dent 1992 40 22-5. Shaw BM. Orthodontic prosthetic treatment of enamel erosion resulting from bulimia a case report. J Am Dent Assoc 1994 125 188-90. Stege P, Visco-Dangler L, Rye L. Anorexia nervosa review including oral and dental manifestations. J Am Dent Assoc 1982 104 648-52. Tylenda CA, Roberts MW, Elin RJ, et al. Bulimia nervosa its effects on salivary chemistry. J Am Dent Assoc 1991 122 37-41.
Some diabetic patients present chiefly with weight loss, but even then the diagnosis is sometimes missed, and I have seen two teenagers referred for psychiatric management of anorexia nervosa before admission with ketoacidosis. Perhaps weakness, tiredness, and lethargy, which may be the dominant symptoms, are the most commonly misinterpreted tonics and iron are sometimes given as the symptoms worsen.
Anorexia nervosa (AN) and bulimia nervosa (BN) are serious behavioral disorders associated with a wide range of gastrointestinal (GI) complications (Chami et al, 1995). Because AN and BN are characterized by frequent denial and ambivalence towards treatment, individuals with these disorders may present first (or exclusively) to gastroenterolo-gists with secondary GI complaints (Winstead and Willard, 2001). Recognizing signs and symptoms of eating disorders, directing patients to appropriate psychiatric treatment, and assisting them in acknowledging their eating disorder is vital. For patients whose AN or BN is characterized by somatic complaints and denial of illness, a working alliance between an eating disorder specialist and a gastroenterologist is often a key factor in successful treatment. This chapter will cover definitions of AN, BN, and other eating disorders, GI complications of eating disorders and of refeeding, management recommendations, clinical screening questions,...
Of particular concern to the gastroenterologist is the high comorbidity between eating disorders and substance abuse, especially alcoholism. The overall rate of all substance use disorders among eating disordered patients was 37 in one study, and rates of alcoholism among bulimics were 40 (Braun et al, 1994). Patients abusing alcohol exhibit high rates of GI comorbidity, and women suffer adverse consequences, such as cirrhosis, from consumption of alcohol more quickly than do men. We recommend screening all eating disordered patients for alcohol abuse behaviors (Redgrave et al,2003). Mood disorders are highly comorbid with eating disorders between 40 to 80 of patients with eating disorders will have an affective disorder during their lifetime (Braun et al, 1994). The presence of major depressive disorder or bipolar disorder complicates the examination and management of the patient with AN or BN. Actively depressed patients may feel hopeless and be more likely to resist treatment. In...
Inpatient treatment for BN is uncommon and is reserved for patients who have failed outpatient interventions, are medically unstable, or have serious comorbidity (eg, suicidal symptoms, alcohol dependence, or brittle diabetes). In AN, however, a significant proportion of patients require inpatient treatment for weight restoration. Dedicated eating disorder specialty units are multidisciplinary in nature, with important contributions made by various disciplines including nursing, nutritionists, occupational therapists, psychotherapists (social workers or psychologists), med ical consultants, and psychiatrists. Treatment is structured using a behavioral protocol aimed initially at blocking all eating disordered behaviors by using nursing observation and dietitian prescribed meals. Patients are gradually assisted in regaining appropriate responsibility over meal selection and preparation tasks. For the underweight patient, hospital stays can be long. Optimum weight gain is 3 to 4 lbs...
First, dramatic, unlikely or even impossible physical complaints may of course be symptomatic of primary psychiatric illness. somatic preoccupations are common in both schizophrenia and major depression, and may range from a chronic sense of unwellness to the fixed conviction of a dread disease (acquired immunodeficiency syndrome, cancer), to bizarre ideas of infestation, or to deliberate implantation of foreign bodies or devices. The true anorexia of depression, as well as the odd and rigid eating patterns seen in schizophrenia, obsessive compulsive disorder and eating disorders, may lead to weight loss and delayed transit times suggestive of primary medical illness. indeed, some
Anorexia and fatigue are consistently among the most common symptoms reported by patients with advanced cancer. Cachexia affects over 80 of such patients or patients with AIDS before death. It is particularly common in those with solid tumours of the upper gastrointestinal tract and lung. Those with cachexia have reduced survival, often experience anorexia and fatigue, have an altered body image, and have impaired physical activity and overall quality of life. Response to antineoplastic therapy is reduced and morbidity caused by treatment increased. Cachexia is usually progressive and is sometimes fatal.
A major complication of oral and esophageal diseases is decreased food intake. Dietary consultation with creative diet planning and choice may be quite beneficial in milder cases. Caloric supplementation with formula diets also may be helpful. In patients with local lesions that cannot be treated successfully or in refractory cases of anorexia, some form of nonvolitional feeding is required. Nutritional repletion has been reported in response to total parenteral nutrition (TPN) and to enteral feeding regimens. Nasoenteric tubes can be used, though there are problems with cooperation in long term use and there is the possibility of precipitating or exacerbating sinus disease. Percutaneous endoscopic gastrostomy feedings are efficacious and well tolerated by AIDS patients, and can be continued indefinitely.
The cachectic patient is like an accelerating car running out of petrol. Anorexia critically reduces fuel supply (by about 300-500 kcal (1254-2090 kJ) a day), while accelerated metabolic cycling (for example, glucose-lactate cycling) drives hypermetabolism (100-200 kcal a day). In addition, there are direct catabolic effects at the level of skeletal muscle (for example, activation of the ubiquitin-proteasome pathway) and adipose tissue. The mediators of these changes are complex and include proinflammatory cytokines, stress hormones, and tumour specific cachectic factors such as proteolysis inducing factor (PIF). The main energy (subcutaneous fat) and labile protein reserves (skeletal muscle) of the body are mobilised and the patient becomes prone to secondary effects such as insulin resistance and further muscle wasting due to immobility. These changes underlie a key paradox of cachexia in that while the metabolic rate may be increased, overall (or total) energy expenditure is...
IBD is frequently associated with malnutrition. These patients are often hypermetabolic and may have anorexia due to nausea and abdominal pain. Dietary therapy in IBD has always been considered important. However, no one specific diet can be recommended. Fat restriction may be important in patients with ileal disease or those who have undergone an ileal resection. The use of EN is an important component of IBD therapy for those patients who cannot eat. EN has not proven superior to TPN or drug therapy in inducing remissions in IBD (Lochs et al, 1990). It is, however, less costly and associated with fewer complications. The use of PN in IBD should be restricted to those who have not responded to conservative medical therapy (EN and medications) or in whom EN cannot be delivered.
PEG has been used for nutritional supplementation in patients with inflammatory bowel disease (IBD), short gut syndrome, and malabsorption syndrome. It has also been used in patients with normal swallowing, but inadequate oral intake, to improve their nutritional status. Examples include patients suffering from extensive burns, acquired immunodeficiency syndrome (AIDS) wasting syndrome, anorexia after bone marrow transplantation, and chronic illnesses, such as cystic fibrosis and congenital heart disease. However, the role of enteral feeding in AIDS wasting syndrome is controversial.
The clinical triad of chronic abdominal pain, weight loss, and an elevated eryth-rocyte sedimentation rate (ESR) in a patient with an abdominal aortic aneurysm is highly suggestive of an inflammatory aneurysm. Abdominal, flank, or back pain is present in up to 83 of patients with no ruptured IAAA compared to 14 of patients with noninflammatory aneurysms. Anorexia and weight loss occurs in 10-41 of patients with IAAA compared to 7-10 of those with AAA. The erythrocyte sedimentation rate is elevated in 40-88 of patients. The occurrence of fever and leukocytosis is quite variable (Table 16.1).
Disorders that suggest or predispose to volume depletion vomiting, diarrhea, pancreatitis, gastrointestinal bleeding, burns, heat stroke, fever, uncontrolled diabetes mellitus, diuretic use, orthostatic hypotension, nothing-by-mouth status, nasogastric suctioning Disorders that suggest or predispose to obstruction stream abnormalities, nocturia, anti-cholingeric medications, stones, urinary tract infections, bladder or prostate disease, intra-abnominal malignancy, suprapubic or flank pain, anuria, fluctuating urine volumes Symptoms of renal failure anorexia, vomiting, reversed sleep pattern, puritus
Presenting features of acute renal failure (ARF). ARF usually comes to clinical attention by the finding of either elevated (or rising) blood urea nitrogen (BUN) or serum creatinine concentration. Less commonly, decreased urine output ( less than 20 mL per hour) heralds the presence of ARF. It is important to acknowledge, however, that at least half of all cases of ARF are nonoliguric 2-6 . Thus, healthy urine output does not ensure normal renal function. Rarely, ARF comes to the attention of the clinician because of symptoms of uremia (eg, anorexia, nausea, vomiting, confusion, pruritus) or laboratory findings compatible with renal failure (metabolic acido-sis, hyperkalemia, hyperphosphatemia, hypocalcemia, hyper-uricemia, hypermagnesemia, anemia).
The etiologic diagnosis of disorders of food intake can be approached using a diagnostic algorithm (Figure 46-1). One should not conclude that anorexia is due to a medication until other possibilities are ruled out, or the patient responds positively to a supervised trial of medication withdrawal. In an AIDS patient with suspected esophageal candidiasis, it is advisable to treat empirically and only examine patients with persisting symptoms (Rabeneck and Laine, 1994). In contrast, all esophageal ulcerations should be investigated by direct examination and biopsy.
IPMNs were first recognized by Japanese gastroenterolo-gists in 1980 (Ohhashi et al, 1982). IPMNs are now much more widely recognized and currently account for 20 of all cystic neoplasms of the pancreas. As the name suggests, IPMNs are large, intraductal proliferations of usually papillary mucinous epithelium. These distinctive neoplasms occur with similar frequency in both men and women, and the average age at diagnosis is 65 years (range 25 to 94 years). Clinically, most patients present with abdominal pain, weight loss, anorexia, or pancreatitis. Remarkably, by the time a diagnosis can be established, most patients will report that these symptoms have been present for years. Abdominal imaging will often reveal dilatation of the main pancreatic duct, usually in the head of the gland. Mucin oozing from a patulous ampulla ofVater is an almost diagnostic finding on endoscopic retrograde pancreatography (ERCP). Clinical laboratory data are generally nonspecific.
The clinical presentation of intrahepatic cholangiocellular cancers is that of a liver mass. Patients may present with abdominal pain, an abdominal mass, anorexia, weight loss, night sweats, and malaise or may even be asymptomatic. The serum alkaline phosphatase activity is usually elevated, but patients are rarely jaundiced. Serum tumor markers, including carcinoembryonic antigen, cancer antigen (CA) 19-9, and CA 1255, may be elevated. The diagnosis of intrahep-
In a phase I study, GTI-2040 (18.5-222 mg m2 d) was administered by continuous iv infusion for 3 wk followed by 1 wk of rest between cycles to 27 patients with advanced cancer (84,86). Mild toxicities included anorexia, nausea, hypotension, chills, and fever. One patient experienced dose-limiting fatigue, and DLTs of diarrhea and hepatotoxicity were experienced at the highest dose of 222 mg m2 d. For phase II studies, 185 mg m2 d (5 mg kg d) was recommended. At this level, plasma concentrations of GTI-2040 of approx 1 g mL were deemed sufficient to achieve target suppression in clinical studies.
Infectious pancreatic necrosis virus causes mortality of fry and fingerling salmonids and is characterized by behavioural changes and gross external, internal and histopathological lesions. There are no specific pathognomonic signs of IPN disease. Behavioural changes (Wood et al., 1955) include anorexia and an agonal corkscrew swimming motion interspersed with ataxia. Nonspecific external signs include hyperpigmentation, exophthalmia and petechial haemorrhage on the ventral surfaces. Internal gross lesions are visceral petechia and an empty gut containing a yellow exudate. The disease may be manifested with only a few, or even none, of these signs. Microscopically, there is focal coagulative necrosis of the acinar and islet cells of the pancreas and of the haemopoietic cells of the kidney. There are typical icosohedral virus particles in the cytoplasm of pancreatic acinar cells (Lightner and Post, 1969 Hedrick et al., 1985). Viral titres in the tissues of infected fish are usually...
Treatment of acute GVHD begins with high dose steroids, followed by the addition of other immunosuppressive agents, such as mycophenolote mofetil (Cellcept) or pento-statin. Oral beclomethasone should be reserved for patients that have mild to moderate GVHD isolated to the GI tract and present primarily with nausea, vomiting, or anorexia (McDonald et al, 1998). For steroid refractory GVHD, response to a TNF-a monoclonal antibody (Infliximab) has been encouraging (Kobbe et al, 2001). Although no randomized controlled studies exist, control of the voluminous diarrhea associated with acute GVHD has reportedly been achieved by somatostatin (octreotide) given at 250 to 500 g 3 times daily subcutaneously (Ippoliti et al, 1997). Individuals with the most severe form of GVHD are at high risk of developing sepsis due to loss of the mucosal barrier and immunosuppression, so prophylactic antibiotic use is
Sulfasalazine may be started at 1 g daily with an increase in the dose by 1 g each day up to the target dose of 3 to 4 g d, if tolerated. The complete blood count should be checked after a week to look for toxicity, especially leukopenia. However, there are several drawbacks to using sulfasalazine instead of one of the newer 5-ASA preparations. Sulfasalazine should not be used in patients with a history of sulfa allergy. Besides allergic reactions, some patients develop headaches, nausea, anorexia, and other dose-related adverse effects. Sulfasalazine may cause reversible male infertility, which does not occur with the other oral 5-ASA medications.
Hepatitis delta virus (HDV) A satellite virus, the only species in the genus Deltavirus. First recognized when a novel antigen (delta antigen) was observed in the nuclei of hepatocytes of some patients with chronic Hepatitis B virus (HBV) infection. Virions are spherical, about 34nm in diameter, with no surface projections. Transmission of HDV is dependent upon HBV, since it uses HBsAg as its own virion coat. The HDV genome is a small single-stranded circular RNA comprised of 1675 nucleotides with about 70 base-pairing so that the RNA forms a largely double-stranded, rod-shaped structure. A single conserved open reading frame in the negative sense encodes the Hepatitis delta antigen, which consists of two protein species one contains 195 amino acids (24kDa) and the other is identical except for an additional 19 amino acids at the C-terminus (27kDa). Most sera contain equal amounts of the two species of antigen, which appears to function during replication through its nuclear...
The diagnosis of AN or BN begins with a comprehensive history and physical examination. A certain amount of circumspection is helpful as some patients may be quite resistant to attempts to make an eating disorder diagnosis. The his- TABLE 38-1. Important Elements of the Eating Disorder History 13 Specific eating disordered behaviors tory should include careful questions about dieting and eating behavior, and screening for comorbid mood and substance abuse problems, because these often complicate the presentation of patients with eating disorders (see Table 381 for eating disorder-related questions we ask during an initial examination). Besides standard questions used to screen for eating disorder symptoms, we have found the following three questions to be sensitive in cases marked by denial of illness (1) How much would you like to weigh (desired weight) (2) Exactly what (and how much) did you eat yesterday and (3) in the case of excessive exercisers, If exercise did not burn calories...
Although approximately 50 of patients with AN and BN will recover in the long term, eating disorders, like substance use disorders, are best thought of as behavioral illnesses whose courses are relapsing and remitting. On the one hand, this means that clinicians treating these patients must be prepared for relapses, perhaps requiring rehospi-talization on the other hand, a certain therapeutic optimism is helpful when managing a relapse, helping the patient to dust themselves off and get back on the wagon.
Gastric emptying of solids, and possibly of liquids, is delayed in patients with AN (Dubois et al, 1979 Ricci and McCallum, 1988). This phenomenon presumably contributes to complaints of early satiety and fullness and may normalize more slowly than other markers of starvation, such as bradycardia and hypotension. Transaminase elevations are not uncommon in starved anorectic patients and often worsen transiently with refeeding. Compared with controls, patients are more likely to suffer from constipation and to demonstrate delayed whole gut and colonic transit times (Chun et al, 1997 Kamal et al, 1991).As with other eating disorder-related GI problems, slowed transit times resolve with weight restoration.
The cognitive model of depression has found support for descriptive aspects of its theory and for its treatment efficacy. Cognitive therapy has also been applied to a number of other psychological disorders, including anxiety, personality disorders, substance abuse, eating disorders, stress, and marital conflict. More recently, it has been applied to nonclinical problems, such as management problems in business and conflict resolution in schools.
Who are understandably drawn to simpler models that work with a limited range of concepts and techniques. However, the preliminary research that has been conducted on these novel forms of practice suggests that they are often more acceptable to clients than more regimented, prescriptive alternatives, that they can be effective for even quite discrete problems such as speech disfluencies, phobias, and social anxieties, and that they are adaptable to a range of formats including individual, group, and family therapy. With recent and ongoing efforts to examine their efficacy in the treatment of eating disorders, sexual abuse, and other serious clinical problems, we are optimistic that they will continue to contribute to the refinement of both psychotherapy research and practice.
Clinical signs of BP infections are non-specific gill and surface fouling, decreased growth and anorexia. Severe infections result in necrosis and loss of hepatopancreatic and midgut epithelia. Transmission occurs at all life stages, but patent infections (detectable occlusion bodies) may not develop in older shrimps. Pyramid-shaped occlusion bodies principally occur in the nuclei of the hepatopancreas and midgut epithelia (Fig. 20.5a) and are released in the faeces. Up to six occlusion bodies, measuring 0.5-20 mm across the base, can be found in a single nucleus and may contain rod-shaped virions, measuring 55-75 nm x 300 nm (Table 20.1 Fig. 20.5b) (Couch, 1974a). Penaeus monodon-type baculovirus is most pathogenic to P. monodon larvae, with lesser effects in P. merguiensis and P. semisulcatus larvae (Johnson and Lightner, 1988) however, intense infections may also occur in apparently healthy shrimp. Determination of MBV pathogenicity is further complicated by multiaetiology...
Anorexics and bulimics who vomit to compensate for real or perceived binges may develop perimolysis, a loss of the enamel and dentin on the lingual surface of the teeth caused by recurrent exposure of the teeth to gastric acids. Patients may complain of increased sensitivity to heat, cold, and acidic substances, as discussed in the chapter on oral medicine (see Chapter 7, Oral Considerations in Patients with Gastrointestinal Disorders ). The large amounts of carbohydrates consumed by bulimic patients during binges may further exacerbate the problem, contributing to an elevated frequency of caries. Parotid gland enlargement is a common manifestation of bulimia (Cuellar and Van Thiel, 1986 Jacobs and Schneider, 1985). No treatment is required, and the parotid enlargement usually subsides over time with cessation of vomiting. Some individuals abuse syrup of ipecac to induce vomiting, placing themselves at risk for cardiotoxicity resulting from accumulation of emetine in cardiac muscle....
May affect isolated nerves (45 of cases), overlapping nerves (40 ), or cause Clinical syndrome symmetric neuropathy (15 ). Patients typically present with a mixture of motor signs and sensory signs. Associated signs of systemic vasculitic disease include fever, weight loss, anorexia, rash, arthralgia, GI, lung, or renal disease. Usually the
Concentration of less than 20 mEq L indicates renal potassium conservation. In certain circumstances (eg, diuretics abuse), renal potassium losses may not be evident once the stimulus for renal potassium wasting is removed. In this circumstance, urinary potassium concentrations may be deceptively low despite renal potassium losses. Hypokalemia due to colonic villous adenoma or laxative abuse may be associated with metabolic acidosis, alkalosis, or no acid-base disturbance. Stool has a relatively high potassium content, and fecal potassium losses could exceed 100 mEq per day with severe diarrhea. Habitual ingestion of clay (pica), encountered in some parts of the rural southeastern United States, can result in potassium depletion by binding potassium in the gut, much as a cation exchange resin does. Inadequate dietary intake of potassium, like that associated ith anorexia or a tea and toast diet, can lead to hypokalemia, owing to delayed renal conservation of potassium however,...
For bloated stomach, anorexia, belching, and vomiting due to Stagnant Qi in the Spleen and Stomach, it is used with Radix Aucklandiae (Mu Xiang) and Fructus Aurantii (Zhi Qiao). For Stagnant Spleen and Stomach Qi with distension and a sensation of fullness in the epigastrium with belching, nausea, anorexia, and vomiting, it is used with Fructus Aurantii (Zhi Qiao) and Radix Aucklandiae (Mu Xiang) with lassitude and tiredness, it is used with Radix Codonopsis (Dang Shen), Rhizoma Atractylodis Macrocephalae (Bai Zhu), and Radix Glycyrrhizae Uralensis (Gan Cao) in The Marvelous Powder (Yi Gong San).
For Deficient Spleen with distension in the epigastrium and abdomen, anorexia, vomiting, diarrhea, and greasy coating on the tongue, it is used with Radix Codonopsis (Dang Shen), Rhizoma Atractylodis Macrocephalae (Bai Zhu), and Fructus Amomi (Sha Ren). For Stagnation of Spleen and Stomach Qi with anorexia, distension, and pain of the epigastrium and abdomen, borborygmus, and diarrhea, it is used with Fructus Aurantii (Zhi Qiao), Fructus Meliae Radicis (Chuan Lian Zi), and Rhizoma Corydalis Yanhusuo (Yan Hu Suo) for abdominal pain and diarrhea and dysentery due to Stagnation of Damp Heat of the Stomach and Intestines, it is used with Rhizoma Coptidis (Huang Lian) in The Aucklandiae and Coptidis Pill (Xiang Lian Wan) for diarrhea and dysentery with tenesmus due to stagnation of undigested food, it is used with Semen Arecae (Bing Lang), Fructus Aurantii (Zhi Qiao), Radix et Rhizoma Rhei (Da Huang), and Rhizoma Coptidis (Huang Lian) in The Pill of Aucklandiae and Are-cae (Mu Xiang Bing...
These patients are clearly suffering, and the compassionate physician is faced with the difficult task of setting limits on requests for tests and procedures without being overly paternalistic and persuading patients that they would benefit most from psychiatric behavioral treatment. Because of the morbidity and mortality associated with eating disorders, we feel it is justified to exert a certain amount of pressure on patients with eating disorders to accept appropriate (ie, psychiatric) treatment. If the patient persists in refusing to see an eating disorder specialist, the gastroenterologist may consider terminating treatment. Termination should be framed for the patient as a consequence of his or her decision not to engage in the recommended treatment. Thus, the gastroenterologist allies him or herself with the psychiatrist, rather than allowing the illness-driven manipulation to continue. Although patients may resist referral to an eating disorders specialist, it is our...
Equid herpesvirus 4 (EHV-4) A species in the genus Varicellovirus. A major cause of acute respiratory disease in horses worldwide, most horses being infected during the first 2 years of life. Shown in 1981 to be distinct from EHV-1 by restriction endonuclease studies on the virus genome. Horses may become latently infected, and reactivation with virus shedding may then occur to infect young foals and so maintain the virus indefinitely in a population of horses. Acute disease is associated with fever, anorexia and profuse nasal discharge. In extreme cases the disease may become a fatal bronchopneumonia. A combined EHV-4 EHV-1 inactivated vaccine is available, and alternative recombinant-derived vaccine candidates are under investigation. Synonyms equine herpesvirus 4 equine rhinopneumonitis virus respiratory infection virus.
Groans refer to the gastrointestinal manifestations of hypercalcemia, seen in 15 of primary hyper-parathyroidism. Patients can present with anorexia, constipation, weight loss, nausea and vomiting, and, peptic ulcer disease. Up to 10 of patients with parathyroid carcinoma can present with acute pancreatitis or recurrent severe pancreatitis. Unfortunately, the degree of anorexia, decreased fluid intake, and vomiting seen with untreated parathyroid carcinoma only aggravates the underlying intravascular depletion caused by hyperparathyroid-induced hypercalcemia.
Pleuronectid herpesvirus (PiHV-1) An unas-signed virus in the family Herpesviridae. First recognized in 1978 among young turbot, Scophthalmus maximus, in a fish farm in Scotland, but since then also recognized in Wales. The fish develop anorexia and lethargy and heavy mortality occurs. The only signs of infection are pathological changes in epithelial cells of the skin and gills where giant cells are seen containing herpesvirus-like particles. Virus isolation has not been reported. Synonyms herpesvirus scophthalmus turbot herpesvirus.
A natural infection of felids (domestic cats, lions and tigers), but in zoos usually the smaller species (raccoons, mink and foxes) are susceptible. Chiefly seen as a severe febrile illness, with vomiting and sometimes blood-stained diarrhea in young cats, although older cats may be attacked when virus is first introduced to a previously virus-free group. Subclinical and mild cases probably occur and give immunity. Infected animals may excrete virus for a year, and virus contaminating the environment may remain infectious for months. Kittens infected before 9 days of age may suffer damage to the developing cerebellum and at 3-4 weeks show ataxia and tremors. Cats, mink and newborn ferrets can be infected experimentally. After an initial leukocytosis there is a progressive fall in circulating lymphocytes and polymorphs, with lethargy and anorexia. Virus replicates in kitten kidney cell cultures. CPE may be transient. Virus
Frank mesenteric ischemia may present as abdominal pain out of proportion to findings on physical examination, progressing to bloody diarrhea, acidosis, and hypotension. However, in its early stages the presentation of mesenteric ischemia may be more subtler, with symptoms of postprandial abdominal pain ( abdominal angina ) or perhaps just nausea or anorexia. Because bowel infarction may occur before the symptoms and signs of mesenteric ischemia are fully manifest, it is essential that all care providers be aware of and vigilant for the earliest warning symptoms so that intervention can be performed in a timely fashion6. Renal ischemia or infarction may present with flank pain (renal infarction) but more often is manifest only by acute renal insufficiency and a drop in urine output. Lower extremity arterial compromise may result in a cold, pulseless, and or painful limb. Therefore, patients with acute aortic dissection should be monitored for renal function and urine output and should...
Premenstrual Dysphoric Disorder (PMDD), formerly Late Luteal Phase Dysphoric Disorder (LLPDD) Terms that refer to that small percentage of women who have premenstrual syndrome with primarily emotional symptoms severe enough to affect their ability to function at home or in the workplace. Premenstrual Exacerbation Aggravation of such chronic conditions such as asthma, depression, anxiety, eating disorders, substance abuse, headaches, allergies, seizures, or herpes during the premenstrual phase.
In general, broad cultural factors also have a strong influence on health. An obvious example in Western society comes from the huge emphasis on slimness equating with beauty and fashionability throughout the previous two or three decades. No doubt this has not been the only influence on the development of eating disorders in women, with all the attendant health risks, but it has surely been an important factor. Similarly, although, in another sense, by contrast, the large-scale advertising of fast foods has surely added to the potential to be overweight and thus at a greater health risk. There are numerous examples of such influences, such as the influence on tooth decay in children or the advertising of sugar-based products.
Asymptomatic elevations in liver tests may be the only abnormality, but the majority of severe cases present with malaise, fatigue, anorexia, headache, nausea, and vomiting (see Table 120-2). Right upper quadrant or epigastric pain may mimic acute cholecystitis or reflux esophagitis. Within 1 to 2 weeks of onset of symptoms, and within days following clinical jaundice, the disease may rapidly worsen, leading to acute liver failure, with hepatic encephalopathy, ascites, edema, and renal insufficiency. Hallmarks of preeclampsia (hypertension, proteinuria) are seen in over 50 of cases.
Although many of the enzymes that are of value in feed applications can be found in nature, the levels produced by wild-type organisms are relatively low, making the economics unsuitable for most commercial applications. An added issue is the fact that many microorganisms produce a mixture of enzymes. While these mixtures may show a benefit in the application, only one or two of the enzymes present may actually be responsible. Also, while certain enzymes produced by a microorganism may be of benefit, others may exert a negative effect in the application. An example is an enzyme mixture containing both an endo-type xylanase, which is useful in reducing the viscosity of xylan, and a xylosidase, which catalyses the hydrolysis of short xylooligosaccharides to xylose. Given that xylose is known to cause cataracts, diarrhoea and anorexia in some animals, this side activity is not desirable (Schutte, 1990 Schutte etal., 1990, 1991). Therefore, before designing a production organism or host,...
Excuse women give for not wanting to quit), and evidence of yo-yo dieting and disorders such as binge eating (consuming inordinately large amounts of food within a specified period 3 times a week or more in private for over 1 year with loss of control and negative emotional sequelae) or bulimia nervosa (binging plus purging, either by vomiting, use of diuretics, or excessive exercise). When an eating disorder is suspected, referral to a center experienced in the treatment of these problems is recommended. There is a separate chapter on anorexia and bulimia (see Chapter 38, Anorexia Nervosa and Bulimia ).
Eating disorders In the extreme, when eating goes wrong, the disorders of anorexia nervosa and bulimia can develop. There are many reasons for this, some of them stemming from patterns that are laid down in early childhood, from family background, from personality, and so on. These disorders can be extreme and life-threatening and those who suffer from them need a great deal of help to control or overcome them. It is not, as some people think, a matter of simply starting to eat or starting to eat sensibly, in other words, of 'pulling their socks up'. It is far more complex than this.
Combination therapy within the context of integrated care pathways promises better management of cachexia. At present, clinical trials are hampered by heterogeneity of patients, difficulty with defining end points, mild to moderate activity of combination regimens, loss of patients, and cost. Greater understanding of the complex pathophysiology of both cachexia and anorexia will hopefully provide new targets for drugs, which, in combination with better trial design, should lead to future progress.
Cachexia, anorexia, and fatigue are an overlapping and often neglected group of symptoms that at some stage affect most patients with cancer. Similar symptoms may be seen in other conditions, including advanced cardiac failure, COPD, renal failure, and AIDS and in patients who have been in intensive care units. The term cachexia is derived from the Greek words kakos and hexis meaning poor condition. Cachexia is a broad heterogeneous syndrome. The key feature is wasting that cannot be easily or completely reversed by an increase in food intake alone. Anorexia or reduced appetite often accompanies cachexia. Some patients with anorexia, however, do not have cachexia. Equally some cachectic patients become wasted but apparently do not have anorexia. Fatigue is a common element but again this can occur in isolation. Cachexia is complex and multifactorial. A patient's evident chronic negative energy and protein balance is most commonly driven by a combination of reduced food intake and...
Symptoms of chronic sinusitis vary considerably. Fever may be absent or be of low grade. Frequently symptoms are protracted and include malaise, easy fatigability, difficulty in mental concentration, anorexia, irregular nasal or postnasal discharge, frequent headaches, and pain or tenderness to palpation over the affected sinus.
The gastrointestinal tract should be used whenever possible because enteral nutrients may help to maintain gastrointestinal function and the mucosal barrier and thus prevent translocation of bacteria and systemic infection 61 . Even small amounts of enteral diets exert a protective effect on the intestinal mucosa. Recent animal experiments suggest that enteral feeds may exert additional advantages in acute renal failure (ARF) patients 63 in glycerol-induced ARF in rats enteral feeding improved renal perfusion, A, and preserved renal function, B. For patients with ARF who are unable to eat because of cerebral impairment, anorexia, or nausea, enteral nutrition should be provided through small, soft feeding tubes with the tip positioned in the stomach or jejunum 61 . Feeding solutions can be administered by pump intermittently or continuously. If given continuously, the stomach should be aspirated every 2 to 4 hours until adequate gastric emptying and...
Nal fibrosis, sclerosing cholangitis, Riedel's thyroiditis, and fibrous pseudotumor of the orbit. In the clinical setting, patients with idio-pathic retroperitoneal fibrosis exhibit systemic symptoms such as malaise, anorexia and weight loss, and abdominal or flank pain. Renal insufficiency is often seen and is caused by bilateral ureteral obstruction. Laboratory test results usually demonstrate anemia and an elevated sedimentation rate. The treatment is directed to the release of the ureteral obstruction, which initially can be achieved by placement of ureteral stents. Administration of corticosteroids is helpful to control the systemic manifestations of the disease and
Hypercalcaemia usually presents as long-standing anorexia, malaise, weight loss, failure to thrive and vomiting. Causes include hyperparathyroidism, hypervitaminosis D or A, idiopathic hypercalcaemia of infancy, malignancy, thiazide diuretic abuse and skeletal disorders. Initial treatment is with volume expansion with normal saline. Following this, investigation and specific treatment are indicated.
Nausea and vomiting in the SCT recipient is so common that it may be attributed to the preparative regimen or other immunosuppressive agents or antibiotics administered. However, nausea with or without vomiting may be the only manifestation of acute GVHD. Upper endoscopy with gastric and duodenal biopsies will confirm the diagnosis. Therapy for acute GVHD was discussed above. In addition, oral beclomethasone 8 mg d allows the more rapid tapering of high dose prednisone used in the treatment of mild to moderate acute GVHD that presents primarily with nausea, vomiting, early satiety, and anorexia (McDonald et al, 1998).
Six tapeworms, three large and three small, commonly infect humans. The large tapeworms include Taenia sagi-nata (beef tapeworm, up to 25 m in length), Taenia solium (pork tapeworm, up to 7 m), and Diphyllobothrium latum (fish tapeworm, up to 10 m). Infection with the large tapeworms occurs by eating raw or undercooked beef, pork, or brackish or freshwater fish, respectively. Infection with these tapeworms is generally asymptomatic or occasionally vague GI symptoms or systemic symptoms occur. The small tapeworms are Hymenolepis nana (dwarf tapeworm, 25 to 40 mm), Hymenolepis dimunata (rodent tapeworm, 20 to 60 cm), and Dipylidium caninum (dog tapeworm, 10 to 70 cm). A light burden of these small tapeworms is generally asymptomatic, whereas a heavy burden may cause diarrhea, abdominal pain, anorexia, weight loss, vomiting, and malaise. Diagnosis is made by stool examination for worm segments or eggs.
The current system envisions abnormal psychiatric conditions as affecting encapsulated individuals. While cultural differences in the incidence of unwanted conduct are well known, and some patterns of behavior are culturally specific, as anorexia is to modern industrially advanced cultures, the goals of treatment, as well as the interpretation of the problem, rarely extend beyond the distressed individual. Although the stresses of poverty, for example, may increase the incidence of many abnormal conditions, current practice assumes that abnormal behavior happens to individuals independent of social contexts. To take more seriously conditions such as poverty, and to make them medically relevant, one can of course add a note to the diagnostic statement, codified as the marginally salient Axis IV in DSM-IV. An impartial examination of demographic data of persons diagnosed as psycho-pathological would suggest that the mental health professions should advocate as therapeutically relevant...
Indications for starting dialysis for chronic renal failure are empiric and vary among physicians. Some begin dialysis when residual glomerular filtration rate (GFR) falls below 10 mL min 1.73 m2 body surface area (15 mL min 1.73 m2 in diabetics.) Others institute treatment when the patient loses the stamina to sustain normal daily work and activity. Most agree that, in the face of symptoms (nausea, vomiting, anorexia, fatigability, diminished sensorium) and signs (pericardial friction rub, refractory pulmonary edema, metabolic acidosis, foot or wrist drop, asterixis) of uremia, dialysis treatments are urgently indicated.
Tacrolimus is a more potent calcineurin inhibitor than cyclosporine, which allows children treated with it to be less steroid dependent. Like cyclosporine, tacrolimus is primarily metabolized in the liver and appears to use similar degradative pathways mediated by the cytochrome P-450 system. Blood levels should be monitored with a goal range of 10 to 12 ng mL in the immediate posttransplantation period. Some of the side effects are anorexia, chronic GI symptoms, hypertension, tremors, hyperglycemia, chronic renal tubular damage, and the predisposition to posttransplantation lymphoproliferative disease (PTLD).
For disturbance of the Spleen and Stomach due to the accumulation of Dampness, with epigastric distension, anorexia, nausea, and vomiting, it is used with Rhizoma Atractylodis (Cang Zhu), Cortex Magnoliae Officinalis (Hou Po), and Rhizoma Pinelliae (Ban Xia) in The Priceless Health Restoring Powder (Bu Huan Jin Zhen Qi San).
HBeAg, hepatitis B surface antigen (HbsAg), and HBV DNA should be monitored at the beginning of therapy, at the end of 16 weeks of therapy, as well as at 3 and 6 months after cessation of therapy, because some patients may become virologic responders after discontinuation of therapy. Patients who respond to therapy often develop a flare (transient increase in ALT 2 times baseline value) 8 to 12 weeks after initiation of therapy (59 of responders versus 35 of nonresponders). IFN can be continued during the flare unless signs of liver failure ensue patients should be monitored clinically and biochemically every 2 weeks during a flare. Adverse effects include flu-like symptoms, anxiety, depression, anorexia, weight loss, hair loss, bone marrow suppression, thyroid disorders, and auto-antibody induction.
After the safety of ISIS 5132 was demonstrated in these phase I trials, several phase II trials were initiated. There was no evidence of single agent activity of ISIS 5132 in pretreated patients with recurrent ovarian cancer (33). In this study, 22 patients were treated at a dose of 4 mg kg d by 21-d continuous intravenous infusion every 4 wk. ISIS 5132 was well tolerated with no grade 3 or 4 hematological or biochemical toxicity. There were six documented episodes of grade 3 nonhematological toxicity (two cases of lethargy, one of anorexia, two of pain, and one of shortness of breath). No objective clinical response was seen. Three patients had stable disease for a median of 3.8 mo, and the remaining evaluable patients had documented progressive disease. No patient had a decrease in CA-125 of 50 or more.
For treatment of constipation, we advocate the use of bulking agents, stool softeners, and nonstimulant laxatives. Avoid prescription of stimulant laxatives because of their abuse liability in patients with eating disorders. A lactulose taper can be used to wean severe laxative abusers off cathartic agents. We do not advocate NG refeeding or the placement ofper-cutaneous endoscopic gastrostomy (PEG) tubes, for several reasons. First, there is morbidity associated with the use of NG and PEG tubes. Second, eating disordered patients with NG tubes and PEG tubes have a tendency to medicalize their disorders as a means of avoiding responsibility for recovery. Third, the extinction of the drive to starve oneself is best accomplished by exposure and desensitization (ie, eating a diverse range of foods). There is no evidence that placing NG tubes improves outcomes, shortens lengths of stay, or reduces morbidity independent of refeeding itself. Enteral and parenteral feeding for weight...
(effective approximately 50 of the time), while the latter usually requires reoperation. Stomal ulceration may cause unrelenting pain and, if unresponsive to acid suppression, may require operative intervention. Stomal bleeding is usually from external band erosion or, in patients after RYGB, from acid exposure to the gastrojejunostomy. The latter may occur from staple line breakdown and reflux of acid from the distal bypassed stomach into the proximal pouch or from too big a proximal pouch that thus secretes acid. In both situations, the unprotected jejunal mucosa of the Roux limb, which no longer has alkaline pancreatobiliary secretions flowing through it, is at high risk for stomal ulceration if gastric acid bathes the gastro-jejunostomy. Stomal perforation is extremely rare and has a similar pathogenesis to stomal ulceration. Finally, the so-called maladaptive eating disorder is related to a functional obstruction to the emptying of solid ingested foods from the proximal pouch....
Imagine a psychotherapist working in the public health system who is conducting an initial interview with a patient. The patient has been referred to the therapist because of an eating disorder. She is clearly anorexic and has become so dangerously underweight that she is somewhat at risk both of extreme physical collapse and possibly of harming herself in other ways.
The refeeding syndrome is characterized by fluid and electrolyte shifts (especially hypokalemia, hypophosphatemia, and hypomagnesemia), hypoglycemia, low levels of thiamine, and potentially serious consequences, including severe edema, congestive heart failure, transaminitis, cardiac arrhythmias, Wernicke's encephalopathy, seizures, delirium, and death. This syndrome is encountered most frequently in patients of very low body weight (eg, 60 of ideal body weight) who are being aggressively re-fed, and has been described in victims of famine and prisoners of war, as well as in underweight patients with eating disorders. NG and IV feeding are associated with higher risk of such complications than oral refeeding (Crook et al, 2001 Faintuch et al,2001).
Nervous system involvement is preceded by a flu-like set of symptoms, including fever, headache, muscle aches, pharyngitis, anorexia, nausea, and vomiting. Neurological signs and symptoms include restlessness, irritability, and signs of meningitis (back neck stiffness, Brudzinski and Kernig signs). This situation may then proceed to paralytic poliomyelitis.
Does not occur consistently throughout the day and is often worst at night or early in the morning. There may be no specific food intolerances, as diarrhea is worsened by any significant food intake. However, stool volumes are decreased by fasting. The infections producing malabsorption usually are not associated with fever or anorexia, though food intake may be decreased voluntarily to avoid diarrhea. A notable exception to this rule is Mycobacterium avium complex (MAC), a disorder in which spiking fevers may be seen. Weight loss typically is slow and progressive. In contrast, enterocolitic diseases produce numerous, small volume bowel movements that occur at regular intervals throughout the day and night. Cramping and tenesmus may occur but usually are not severe. The clinical course often is associated with fever, anorexia, rapid and progressive weight loss, and extreme debilitation.
Axis I disorders disorders of infancy, childhood or adolescence cognitive disorders such as dementia and amnesia substance-related disorders psychotic disorders such as schizophrenia mood disorders anxiety disorders somatoform disorders (that is, disorders about the body) factitious disorders (in which symptoms are feigned or consciously produced) dissociative disorders (temporary alterations to consciousness) sexual disorders eating disorders sleep disorders impulse control disorders (such as compulsive stealing or lying) adjustment disorders.