Endgames Case report

Refeeding syndrome in a patient with anorexia nervosa

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c56 (Published 11 February 2010) Cite this as: BMJ 2010;340:c56
  1. Tharaka Gunarathne, specialist trainee in psychiatry,
  2. Rebecca McKay, staff grade gastroenterologist,
  3. Lesley Pillans, speciality doctor, psychiatry,
  4. Alastair Mckinlay, consultant gastroenterologist,
  5. Philip Crockett, consultant psychiatrist in psychotherapy and eating disorders
  1. 1Eden Unit, North of Scotland Inpatient Eating Disorder Unit, Royal Cornhill Hospital, Aberdeen AB25 2ZH
  1. Correspondence to: P Crockett philipcrockett{at}nhs.net

    A 22 year old woman with a one year history of anorexia nervosa was admitted as an emergency after she collapsed. She was hypoglycaemic, with a blood glucose concentration of 1.5 mmol/l. Her hypoglycaemia was corrected, and, after discussion with her and her eating disorder specialist, she was transferred to the gastroenterology unit to start nasogastric refeeding. Her body mass index was 12.9.

    During the next 10 days her liver function tests became deranged—alanine transaminase was 546 U/l, and γ glutamyltransferase was 47 U/l. She was subsequently transferred to a specialist eating disorder unit as an inpatient for psychiatric and psychotherapeutic management alongside the continued refeeding programme.

    Questions

    • 1 What classic biochemical and physical complications may occur in refeeding syndrome?

    • 2 What is the most likely cause of the deranged liver function tests?

    • 3 How can refeeding syndrome be prevented?

    • 4 What other important physical risks exist in severe anorexia nervosa?

    • 5 What are the most important elements of the psychiatric management of this disease?

    Answers

    1 What classic biochemical and physical complications may occur in refeeding syndrome?

    Short answer

    Hypophosphataemia, hypomagnesaemia, gastric dilation, congestive cardiac failure, severe oedema, confusion, coma, and death.

    Long answer

    Refeeding syndrome is chiefly defined as the potentially fatal shifts in fluids and electrolytes that can occur in malnourished patients receiving artificial feeding.1 It can however encompass a mixture of biochemical, electrolyte, fluid balance, and metabolic changes. These changes can include—or lead to—hypophosphataemia, hypomagnesaemia, hypokalaemia, gastric dilation, congestive cardiac failure, severe oedema, confusion, coma, and death.

    2 What is the most likely cause of the deranged liver function tests?

    Short answer

    Hepatic fatty change associated with refeeding.

    Long answer

    Refeeding—whether by artificial means or by gradual increases in oral intake—can result in a wide range of less predictable biochemical and metabolic changes, one example of which is fatty hepatic change.

    3 How can refeeding syndrome be prevented?

    Short answer

    Very gradual refeeding, either orally or enterally can help prevent refeeding syndrome. In general, if nutrition is given enterally, patients should be given 21-42 kJ/kg/day (5-10 kcal/kg/day) initially, and this should be gradually increased. Assume that the patient has thiamine deficiency and treat it. Monitor daily, with treatment as needed, for hypophosphataemia, hypomagnesaemia, hypokalaemia, and other electrolyte disturbances. Patients are likely to have other important micronutrient and vitamin deficiencies. You may need to consider using the Mental Health Act if refeeding is refused.

    Long answer

    The best way to avoid this syndrome is very gradual refeeding, either orally or by enteral means. In general, if nutrition is given enterally, patients should be given 21-42 kJ/kg/day initially, and this should be gradually increased. You should assume that the patient has thiamine deficiency and treat it. Rehydrate carefully. Monitor daily, with treatment as needed, for hypophosphataemia, hypomagnesaemia, hypokalaemia, and disturbances in other electrolytes, such as calcium and potassium. Deficiencies in multiple vitamins, minerals, and micronutrients probably result from severe malnutrition as well as behaviours such as purging and misuse of laxatives. Foods with high concentrations of refined sugar are more likely to provoke refeeding syndrome. Dietetic advice is invaluable if not essential. Refeeding must be tailored to the patient, and those with a body mass index below 14 or those who have had negligible nutrition for 10 days or more should start at lower rates of refeeding.2

    Refeeding via artificial means is covered by provisions of the Mental Health Act in both England and Scotland. Not all patients with very severe anorexia nervosa will accept refeeding voluntarily. This is a complex matter that requires understanding of the act in question, the nature of the eating disorder, and capacity issues; all of these will require assessment by a psychiatrist.

    4 What other important physical risks are seen in severe anorexia nervosa?

    Short answer

    Hypoglycaemia, hypothermia, osteoporosis, renal failure, arrhythmias, pancreatitis, neutropenia, immunosuppression, and anaemia.

    Long answer

    The wide variety of physical complications that exist vary greatly in frequency and likelihood. They vary from acute disturbances to those associated with more chronic illness. The first category includes hypoglycaemia, hypothermia, arrhythmias, neutropenia, immunosuppression, and anaemia. The second category includes osteoporosis, renal failure, congestive cardiac failure, and pancreatitis. Mortality is relatively high for a psychiatric disorder, and causes of death include suicide. As well as treating the acute disturbances, effective treatment usually involves some degree of refeeding.3

    5 What are the most important elements of the psychiatric management of this disease?

    Short answer

    Forming a good therapeutic alliance; working on motivational factors; providing information on the effects of the illness and its treatments, both physical and psychological; working with families and carers; and if appropriate, treating comorbidities such as depression, anxiety, and obsessive compulsive disorder.

    Long answer

    Refeeding is an essential component of the physical treatment of anorexia nervosa, but psychological treatment is also necessary because the patient’s anxiety will increase as refeeding progresses. It is therefore essential to form a good therapeutic alliance, which once established will enable you to work on motivational factors and provide a thorough psychoeducation—information on the effects of the illness and its treatments, both physical and psychological. Working with families and carers may be useful, and in younger patients it may even be essential. Where appropriate, treat comorbidities such as depression, anxiety, and obsessive compulsive disorder, which can be barriers to effective treatment.

    In the longer term, refeeding can help treat the anxiety and depression often seen in anorexia nervosa partly as a result of malnutrition and also improve the typical cognitive distortions, such as those pertaining to body image.3 4

    Patient outcome

    Our patient was treated in hospital for three months. She progressed well with attention to both psychological and physical treatment. Family concerns were dealt with, and she gradually returned home. She continues to receive outpatient management including dietetic advice, psychotherapy, and occasional psychiatric review. Her body mass index is now 18, and she is physically and psychologically well six months after admission.

    Notes

    Cite this as: BMJ 2010;340:c56

    Footnotes

    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; externally peer reviewed.

    • Patient consent obtained.

    References