Written by Clay Smith
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Anorexia nervosa (AN) is a common condition, with a high mortality rate. This will help you spot signs of severe illness, when to get labs and ECG, and when to admit.
Why does this matter?
A hallmark of this illness is the person is nonchalant about it. If you don’t know the danger signs, you may miss the severity on presentation, which could be a fatal error.
More dangerous than you think
AN is a common, severe psychiatric illness. It is often present with comorbid psychiatric illnesses. There is a high mortality rate, 5.6% per decade. It is notoriously difficult to treat with psychotherapy and pharmacotherapy. Most important for us in the ED is to recognize the danger signs and indications for immediate hospitalization.
History
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Ask about weight trends, eating habits, food restriction, purging, fear of weight gain, excessive exercise, menstrual history (often amenorrhea), and syncope.
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Ask others to corroborate focus on appearance, eating habits, fear of gaining weight, dissatisfaction with body shape, preoccupation with weight, and food intake.
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Ask about suicidal ideation or depression.
Exam
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Vitals: Take note of a BMI <16.5. Note the trajectory of weight loss as well. A rapid downward trend in weight is worrisome. A BMI ≤15 is often an indication for immediate admission. Look for orthostatic hypotension, bradycardia, and hypothermia. Note, patients will usually not become tachycardic, even if profoundly dehydrated.
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Look for signs of dehydration, hair loss, presence of lanugo, erosion of dental enamel or salivary gland hypertrophy to indicate purging, or evidence of self harm.
Workup
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If any concerns about severity, obtain labs and ECG.
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Look for hyponatremia, hypokalemia, hypochloremia, hypomagnesemia, hypophosphatemia, and hypoalbuminemia.
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On ECG, look for bradycardia, ectopy or other arrhythmias, and long QT interval.
Treatment
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Be careful. Severity of illness is easy to overlook in these patients. They downplay most symptoms and are often not forthcoming with the severity of their own calorie restriction.
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Some may need immediate hospitalization and refeeding. Indications may include: BMI ≤15, syncope, bradycardia, electrolyte abnormalities, concerning ECG findings, self harm, or suicidal ideation.
Source
Anorexia Nervosa. N Engl J Med. 2020 Apr 2;382(14):1343-1351. doi: 10.1056/NEJMcp1803175.
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