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Rapid Responses: Rapid Responses published:
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Recurrent regurgitation
- Joan McClusky (24 June 2006)
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Nutrition is a priority
- Clare E Shaw, HJN Andreyev, Consultant Physician and Gastroenterologist (24 June 2006)
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Unexplained persistent vomiting
- Stephen G Potts (25 June 2006)
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EDNOS ?
- Shyam Mohan Reddy Teegala (25 June 2006)
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Joan McClusky, medical writer New York, NY
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This patient has a combination of GERD and bulemia. If he eats massive amounts of food and spits it out, his weight will be maintained. He needs psychotherapy. Competing interests: None declared |
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Clare E Shaw, Consultant Dietitian The Royal Marsden NHS Foundation Trust, HJN Andreyev, Consultant Physician and Gastroenterologist
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We are puzzled why the authors have framed the questions in their current order. The most striking feature of this case is that this man has become severely malnournished as a result of his illness (BMI 14kg/m2). This degree of acute weight loss is life threatening as was demonstrated by the Irish hunger strikers in the 1980s. Weight loss of this degree can also affect mental health and it is known that such severe weight loss increases his overall morbidity and likelihood of prolonged hospital stay. By all published criteria he falls into the category of someone who is "severely malnourished". He requires immediate assessment and support from a nutrition support team which must include a registered dietitian, an experienced nutritional physician and a biochemist. He requires nutritional support probably initially with jejunal feeding. He is at high risk of refeeding syndrome and will require close monitoring. He probably needs supraphysiological doses of B vitamins to reduce the risk of Wernicke's encephalopathy developing. Competing interests: None declared |
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Stephen G Potts, Consultant in Liaison Psychiatry Royal Infirmary of Edinburgh EH16 4SA
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This sounds to me like a severe case of aerophagy or air-swallowing. I would present it to Mr Neville and his carers as an unusual form of irritable bowel syndrome affecting the oesophagus and stomach. It is not based in organic pathology, so further physical investigations are very unlikely to yield a different answer. I would explain it as an unconscious manifestation of anxiety upon gut motility, and would emphasise that it is definitely not consciously fabricated. There is no accusation that he is somehow "making it up" or "putting it on": the symptoms are in his stomach, not "all in the mind" and they are very real and obviously distressing. The psychiatric assessment identifies possibly relevant background factors, but I wonder also about other sources of anxiety, suggested by the observation that his symptoms worsened on his return to college. Mr. Neville is described as a student: What does he study? How is he doing? He's 22: is he in his final year? What exams does he face? What does he plan to do after University? I've seen other cases respond to anxiolytic medication such as an SSRI antidepressant, but I suspect Mr. Neville would not wish to pursue this course. Whether or not he does, the treatment is primarily psychological. If he is prepared to acknowledge that anxiety may make his symptoms worse, even if it doesn't explain them completely, then there is room to work with him, using a cognitive-behavioural therapy approach (CBT), and beginning with his anxieties about the symptoms themselves. As well as CBT,there is trial- based evidence for the benefit of relaxation, hypnotherapy and psychotherapy in IBS, and the choice between them should lie with Mr. Neville as far as possible. Their common aim is to identify a link between psychological factors and physical symptoms, and then to work on the psychological factors in an attempt to break the link. The most important part of any such treatment is the initial phase of engagement, which requires skilled handling and may take some time. Competing interests: None declared |
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Shyam Mohan Reddy Teegala, MD; MPH student in University of Texas, Houston University of Texas, Houston 77054
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Mr.Neville appears to have Eating Disorder Not Otherwise Specified as he does not completely meet the diagnostic criteria either for bulimia nervosa or anorexia nervosa. The most important finding is an underlying psychological illness causing the symptoms. The relationship between Mr.Neville and his mother and other immediate family members appear to be a likely cause. A formal evaluation by a psychiatrist is needed. The nutritional status of Mr.Neville is deteriorating. He needs adequate parenteral support as appropriate. The electrolyte levels especially the Potassium levels need to be monitored and maintained to avoid complications. Competing interests: None declared |
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