Severe acute liver damage in anorexia nervosa: two case reports

OBJECTIVE: Two female patients (18 and 30 y old, body mass indexes 14.1 and 13.2 kg/m2) with severe, restrictive anorexia nervosa developed sudden severe liver damage. In addition to overt protein-energy malnutrition, they showed marked hypotension, bradycardia, dry skin, acrocyanosis, and hypothermia. Most common causes of liver failure, such as hepatotropic viruses, hepatotoxic drugs, alcohol, cannabis, and cocaine abuse, were excluded. METHODS: Therapeutic intervention consisted of immediate plasma volume support, progressive parenteral or oral nutritional rehabilitation, and parenteral potassium and phosphorus supplements to avoid the refeeding syndrome. RESULTS AND CONCLUSION: Improvement of initial clinical symptoms and rapid recovery of liver enzymes after this type of treatment suggest that severe liver damage in anorexia nervosa may be secondary to acute hypoperfusion.     

Nutrition et mucoviscidose : de la prise en charge préventive au support nutritionnel

Nutritional status has a strong association with respiratory function and survival. Implementation of the French nationwide newborn screening program since 2002 allows an early preventive nutritional approach and nutritional support if indicated, aiming at maintaining a nutritional status similar to healthy peers during the patient's life. This review relies on international recommendations and describes the dietetic approach, pancreatic enzymes and fat-soluble vitamins supplementation and also nutritional support in case of moderate or severe malnutrition.     

Successful management of gelatinous transformation of the bone marrow in anorexia nervosa with hematopoietic growth factors

Serous atrophy or gelatinous transformation of the bone marrow (GMT), often seen with severe nutritional deprivation in Anorexia Nervosa (AN), is characterized by hypocellularity and patchy or diffuse replacement of the bone marrow with hyaluronic acid‐like mucopolysaccharide material. Treatment with nutritional support alone is often temporary due to the relapsing nature of AN. We present the case of a patient with pancytopenia due to GMT who had multiple prior hospitalizations for infections and blood transfusions. Nutritional support was inadequate in restoring her bone marrow function. She was successfully treated with hematopoietic growth factors and achieved a sustained hematopoietic recovery. In addition, use of growth factors resulted in a 91% reduction in the cost of health care delivered to this patient. Int J Eat Disord 2010. © 2010 by Wiley Periodicals, Inc.     

不同营养方式对肝移植术后感染率的影响

目的 :对比不同营养方式下肝移植术后细菌、真菌感染率 ,与感染直接相关的病死率和感染部位分布等情况 ,寻找肝移植术后降低感染率方面更恰当的营养方式。　方法 :对 132例术前营养评估为中、重度营养不良的原位肝移植病人按时间段分为两组 ,第 1组 6 3例 ,术后实行全胃肠外营养 (TPN) 1周 ;第 2组 6 9例 ,术后第 2天起采取部分肠内营养 (EN)加肠外营养 (PN) ,再逐步向完全EN(TEN)过渡 ,比较两组病人细菌和真菌感染率、与感染直接相关的病死率和感染部位分布比例。　结果 :EN加PN组较TPN组病人肝移植术后真菌、细菌、肠道真菌和原发性血行细菌感染率均明显下降 (P <0 .0 5 ) ;EN加PN组与感染直接相关的病死率较TPN组有下降 ,但两组无显著差异(P >0 .0 5 )。　结论 :对于术前合并中、重度营养不良的病人 ,肝移植术后早期应用EN加PN ,再逐步向TEN过渡的方法在预防感染方面明显优于TPN。     

Pudendal nerve entrapment leading to avoidant/restrictive food intake disorder (ARFID): A case report

Avoidant/restrictive food intake disorder (ARFID) is a diagnosis in diagnostic and statistical manual of mental disorders‐5 (DSM‐5) manifested by persistent failure to meet nutritional and/or energy needs. Pudendal nerve entrapment (PNE) often causes pelvic discomfort in addition to constipation and painful bowel movements. Current literature on ARFID is sparse and focuses on the pediatric and adolescent population. No association between PNE and ARFID has been described. We present a case of ARFID in an adult male with PNE resulting from subsequent scarring from testicular cancer surgery. The patient's gastrointestinal symptoms due to PNE caused significant food avoidance and restriction subsequently leading to severe malnourishment. Clinicians should be aware that distressing gastrointestinal symptoms arising from a secondary disease process such as PNE might lead to dietary restriction and food aversion. More research is needed for proper screening, detection, and treatment of ARFID. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2017; 50:84–87)     

Does Aggressive Refeeding in Hospitalized Adolescents With Anorexia Nervosa Result in Increased Hypophosphatemia?

PurposeConcerns about refeeding syndrome have led to relatively conservative nutritional rehabilitation in malnourished inpatients with anorexia nervosa (AN), which delays weight gain. Compared to other programs, we aggressively refed hospitalized adolescents. We sought to determine the incidence of hypophosphatemia (HP) in 12–18-year-old inpatients in order to inform nutritional guidelines in this group.MethodsA 1-year retrospective chart review was undertaken of 46 admissions (29 adolescents) with AN admitted to the adolescent ward of a tertiary children's hospital. Data collected over the initial 2 weeks included number of past admissions, nutritional intake, weight, height, body mass index, and weight change at 2 weeks. Serum phosphorus levels and oral phosphate supplementation was recorded.ResultsThe mean (SD) age was 15.7 years (1.4). The mean (SD) ideal body weight was 72.9% (9.1). Sixty-one percent of admissions were commenced on 1,900 kcal (8,000 kJ), and 28% on 2,200 kcal (9,300 kJ). Four patients were deemed at high risk of refeeding syndrome; of these patients, three were commenced on rehydration therapy and one on 1,400 kcal (6,000 kJ). All patients were graded up to 2,700 kcal (11,400 kJ) with further increments of 300 kcal (1,260 kJ) as required. Thirty-seven percent developed mild HP; no patient developed moderate or severe HP. Percent ideal body weight at admission was significantly associated with the subsequent development of HP (p = .007).ConclusionsThese data support more aggressive approaches to nutritional rehabilitation for hospitalized adolescents with AN compared to current recommendations and practice.     

Reversal of Parenteral Nutrition–Associated Liver Disease With a Fish Oil–Based Lipid Emulsion (Omegaven) in an Adult Dependent on Home Parenteral Nutrition

Patients with intestinal failure and short bowel syndrome usually require chronic parenteral nutrition (PN). PN is associated with risks, including infections, vascular thrombosis, and liver disease. PN‐associated liver disease (PNALD) can progress from steatosis to chronic hepatitis and ultimately to cirrhosis. The etiology of PNALD is not completely understood. Therapies for PNALD include carbohydrate or lipid calorie reduction, antibiotics, or the use of ursodeoxycholic acid. When these efforts fail, therapeutic options are limited and liver transplantation may be required. The transition from a soybean‐ to a fish oil–based lipid formulation, such as the ω‐3 parenteral lipid formulation (Omegaven), has shown a dramatic reversal of PNALD within the pediatric population. This is the first report of a PN‐dependent adult in the United States complicated by PNALD and hepatic failure who had improvement of liver disease with an ω‐3 fish oil–based parenteral formulation.     

To Improve the Initial Inpatient Management of Adolescents Admitted with Severe Anorexia Nervosa: A Narrative Review and a Convenient Protocol

Inadequate nutritional rehabilitation of severely malnourished adolescents with Anorexia Nervosa (AN) increases the risk of medical complications. There is no consensus on best practices for inpatient nutritional rehabilitation and medical stabilization for severe AN. This study aimed to elaborate an admission protocol for adolescents with severe AN based on a comprehensive narrative review of current evidence. A Pubmed search was conducted in July 2017 and updated in August 2020, using the keywords severe AN or eating disorders (ED), management guidelines and adolescent. Relevant references cited in these guidelines were retrieved. A secondary search was conducted using AN or ED and refeeding protocol, refeeding syndrome (RS), hypophosphatemia, hypoglycemia, cardiac monitoring or cardiac complications. Evidence obtained was used to develop the admission protocol. Selective blood tests were proposed during the first three days of nutritional rehabilitation. Higher initial caloric intake is supported by evidence. Continuous nasogastric tube feeding was proposed for patients with a BMI < 12 kg/m2. We monitor hypoglycemia for 72 h. Continuous cardiac monitoring for bradycardia <30 BPM and systematic phosphate supplementation should be considered. Developing protocols is necessary to improve standardization of care. We provide an example of an inpatient admission protocol for adolescents with severe AN.     

Hypothyroidism due to Hashimoto's thyroiditis masked by anorexia nervosa

Anorexia nervosa (AN) is typically associated with altered thyroid function tests, notably a low total and free T₃, and lower, but within normal range, free T₄ and TSH. A 16‐year‐old girl with a four‐year history of AN presented with elevated TSH that fluctuated with changes in weight. TSH was within normal limits (1.7–3.64 mIU/L) following periods of weight loss and elevated with weight gain (5.9–21.66 mIU/L). Antithyroperoxidase antibodies were markedly elevated, suggesting chronic Hashimoto's thyroiditis. Of note, the elevated TSH that would be expected in Hashimoto's thyroiditis was blunted by weight loss associated with AN. Physicians should be aware that AN may contribute to masking thyroid abnormalities in Hashimoto's thyroiditis. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2015; 48:932–935).     

Enteral nutritional support in acute alcoholic pancreatitis.

The experience to date with total enteral nutritional (TEN) support in acute alcoholic pancreatitis patients admitted to the University of Kentucky affiliated hospitals was reviewed.

Standard enteral formulas sufficient to meet patient's needs were administered into the small bowel via endoscopically placed nasoenteric feeding tubes in five patients. Feedings were administered for a mean of 28.4 days. Pancreatitis was mild to moderate in severity by Ranson's criteria in four patients, and severe in one.

Four patients developed complications of pancreatitis before initiation of TEN, representing the most common indication for nutritional support. Nutritional status was maintained by TEN with no significant complications from this nutritional support identified. Diarrhea that did not limit tube feeding developed in a single patient.

This experience further supports the safety of TEN in acute pancreatitis and suggests that adequate nutritional support can be delivered by this route.     

Evaluation of trained volunteer doula services for disadvantaged women in five areas in England: women's experiences

Disadvantaged childbearing women experience barriers to accessing health and social care services and face greater risk of adverse medical, social and emotional outcomes. Support from doulas (trained lay women) has been identified as a way to improve outcomes; however, in the UK doula support is usually paid‐for privately by the individual, limiting access among disadvantaged groups. As part of an independent multi‐site evaluation of a volunteer doula service, this study examined women's experiences of one‐to‐one support from a trained volunteer doula during pregnancy, labour and the post‐natal period among women living in five low‐income communities in England. A mixed methods multi‐site evaluation was conducted with women (total n = 137) who received the service before December 2012, using a combination of questionnaires (n = 136), and individual or group interviews (n = 12). Topics explored with women included the timing and nature of support, its impact, the relationship with the doula and negative experiences. Most women valued volunteer support, describing positive impacts for emotional health and well‐being, and their relationships with their partners. Such impacts did not depend upon the volunteer's presence during labour and birth. Indeed, only half (75/137; 54.7%) had a doula attend their birth. Many experienced volunteer support as a friendship, distinct from the relationships offered by healthcare professionals and family. This led to potential feelings of loss in these often isolated women when the relationship ended. Volunteer doula support that supplements routine maternity services is potentially beneficial for disadvantaged women in the UK even when it does not involve birth support. However, the distress experienced by some women at the conclusion of their relationship with their volunteer doula may compromise the service's impact. Greater consideration is needed for managing the ending of a one‐to‐one relationship with a volunteer, particularly given the likelihood of it coinciding with a period of heightened emotional vulnerability.     

Fear of food as a treatment target: exposure and response prevention for anorexia nervosa in an open series

Objective:

Anorexia nervosa (AN) is a severe mental illness with high rates of relapse and rehospitalization. New treatment approaches are needed. We aimed to evaluate the potential utility of addressing eating‐related fear in the treatment of AN using psychotherapy techniques known to be effective in the treatment of anxiety disorders and obsessive compulsive disorder, namely exposure therapy and response prevention.

Method:

We developed a brief treatment intervention for AN (AN‐EXRP) and evaluated its effects in an open series of nine individuals with AN towards the end of acute weight restoration. We focused on eating behavior as the primary outcome, as it is related both to anxiety and to longer term course.

Results:

Change in anxiety with AN‐EXRP was associated with greater caloric intake.

Discussion:

These findings support the anxiety‐centered model of AN and suggest the potential utility of further developing this treatment approach. © 2011 by Wiley Periodicals, Inc. (Int J Eat Disord 2012)     

Beer is the cattle of women: Sorghum beer commercialization and dietary intake of agropastoral families in Karamoja,Uganda

Karimojong agropastoralists of Uganda have employed a dual subsistence strategy of cattle herding and sorghum cultivation to survive in an unpredictable environment, one afflicted by a severe humanitarian crisis. Armed raiding since the 1970s has led to devastating cattle losses, high male mortality, and increased sedentarization of women and children in densely populated homesteads, where infectious diseases and malnutrition rates are prevalent. Fieldwork in 1998–1999 confirmed the detrimental effects of armed raiding on child growth and development. During this period, however, women maintained largely traditional subsistence patterns. Follow-up fieldwork in 2004 revealed surprising subsistence changes: sorghum beer, an important food and ritual item, was being brewed for sale, which had not been noted in previous literature on the Karimojong. We outline the role of beer in the diet by analyzing the nutritional profile of Karimojong women and children, nutrients supplied by beer, and those supplied by foodstuffs purchased with sales profits. Commercial beer supplied from 3 to 6% of energy intake, and grains leftover from brewing (dregs) supplied from 3 to 12%. Selling beer was women's preferred form of casual labor, with differing patterns of participation in brewing between rural and peri-urban areas. Women who were paid in currency relied on profits to purchase nutrient-rich supplemental foodstuffs important in an otherwise marginal diet, as well as beer. The households of women who worked for other brewers or purchased beer wholesale and sold it retail relied heavily on dregs for daily subsistence. Nutrient intake was highest among women with cattle and sorghum who brewed and sold beer from their homesteads, and lowest among women who lacked sorghum and worked for commercial brewers in urban centers. Because nutritional status remains marginal in Karamoja, beer commercialization as a consequence of subsistence changes could have dramatic health consequences for women and children.     

Rapid recovery from anorexia nervosa after a life‐threatening episode with severe thrombocytopenia: Report of three cases

We report the cases of three patients with anorexia nervosa (AN) who each recovered rapidly after experiencing a life‐threatening episode with severe thrombocytopenia. All three cases were the typical restricting‐type of AN, occurring in adolescence. They refused to be admitted to a hospital until their general condition had been severely deteriorated. Their lowest platelet counts were 2.9, 4.6, and 2.3 × 10⁴/mm³, respectively. Apparent hemorrhagic tendencies, such as purpura, gingival and nasal bleeding, and gastrointestinal bleeding were observed. The bone marrow examination showed apparent hypoplasia in two patients. No evidence of disseminated intravascular coagulation or autoantibody to platelets was detected. The platelet counts recovered rapidly by water and nutritional supplementation. The recovery from the AN itself was excellent in all three patients without specific psycho‐ therapy. © 1999. John Wiley & Sons, Inc. Int J Eat Disord 25:113–118, 1999.     

ICP患者肝酶和新生儿预后的相关性分析

目的 探讨妊娠期肝内胆汁淤积症(ICP)患者的肝酶指标、胆汁酸水平与新生儿预后的相关性.方法 选取2014年1月至2015年12月在广东省东莞市妇幼保健院产检并分娩的ICP孕妇236例为ICP组,另选取同时期进行产检的正常孕妇120例为对照组,检测两组孕妇血清总胆汁酸、肝酶相关指标天冬氨酸氨基转移酶(AST)、丙氨酸氨基转移酶(ALT)及碱性磷酸酶(ALP)水平,对比两组孕妇分娩方式、分娩孕周、新生儿体重、Apgar评分及新生儿结局.结果 ICP组孕妇AST、ALT、ALP、总胆汁酸水平均显著高于对照组孕妇(t值分别为7.312、10.647、11.518、9.199,均P<0.05).ICP组孕妇剖宫产率显著高于对照组(χ2=12.331,P<0.05),分娩孕周显著低于对照组(t=4.159,P<0.05).三组新生儿体重、Apgar评分均有显著性差异(F值分别为8.913、10.532,均P<0.05),进一步每两组间比较发现,重度ICP组新生儿体重、Apgar评分均显著低于轻度ICP组和对照组(t值分别为2.769、2.963、2.543、2.447,均P<0.05),而轻度ICP组和对照组比较无显著性差异(t值分别为0.638、1.012,均P>0.05).三组胎儿宫内窘迫、早产、羊水污染、新生儿窒息发生率均有显著性差异(Z值分别为7.159、10.468、8.486、5.197,均P<0.05),以重度ICP组发生率均最高,对照组发生率均最低.结论 妊娠期肝内胆汁淤积症患者肝酶指标、胆汁酸水平明显升高,与新生儿预后存在密切的联系,应加强对肝酶指标及总胆汁酸的监测,以改善新生儿结局.     

肝移植术后营养支持

目的 探讨肝移植术后的营养支持方法。方法 对２例肝移植病人术后的营养方法和营养状况进行了回顾性分析,在术后２～３天内采用全肠外营养（ＴＰＮ）,并辅以人血白蛋白以维持血浆白蛋白水平,在术后第３－４天开始肠内营养（ＥＮ）结合肠外营养（ＰＮ）,并逐渐过渡为完全经口饮食,结果 ２例病人现生活质量均良好,结论 术后应视移植肝功能恢复的程度,适当控制营养供给量,并循序渐进,一旦病人胃肠功能恢复,宜尽早开始ＥＮ     

Are doctors nutritionists? What is the role of doctors in providing nutrition advice?

Diet and nutritional status impact on health outcomes. The global rise of diet‐related non‐communicable diseases plus the double burden of obesity and malnutrition means that it is imperative more than ever that all healthcare professionals are able to provide at least basic evidence‐based nutrition advice. Improving an individual's diet requires more than just information provision, it requires consistent and long‐term support to change and maintain new behaviours. Doctors acknowledge that nutrition plays a crucial role in health and agree that providing nutrition advice is part of their role. However, providing sufficiently detailed nutrition advice that is relevant to a patient's health goals, useful for the patient, and that results in measurable changes, is not common in practice settings. Numerous challenges and barriers have been identified for why doctors do not provide nutrition recommendations to their patients. A lack of nutrition education and training, time constraints during appointments, and patients who have access to an ever‐growing body of nutrition and health information via the Internet and social media, together may explain why doctors tend not to include nutrition advice in their care plans. This paper outlines both short‐ and long‐term strategies for improving doctors' engagement with nutrition interventions and collaborative working with dietitians in the context of collaborative care. Having doctors support and advocate for evidenced‐based nutrition practice is a crucial element of the World Health Organization's Decade of Action on Nutrition achieving measurable success.     

Nutrition in pediatric patients before liver transplantation

Malnutrition leading to growth failure is one of the main problems in maintainig children with chronic liver diseases. The pathogenesis of malnutrition is complex and includes reduced calorie intake, fat malabsorption, impaired protein metabolism and increased energy expenditure. The nutritional status is an important risk factor for survival post liver transplantation. Aggressive nutritional support with careful monitoring is essential, particularly where liver transplantation is considered. When the oral nutrition is inadequate, the enteral feeding with nocturnal intragastric tube should be started. In case of gastrointestinal intolerance, severe malnutrition and gastrointestinal bleeding, parenteral nutrition should be considered.     

Enteral nutrition and liver function test abnormalities

There have been reports of liver enzyme abnormalities among enterally fed patients. The aim of this study was to determine the pattern of liver function tests (LFTs) in patients on enteral nutrition support receiving a minimum of 1500 kcal/day for at least two weeks. In addition, factors which might be responsible for such changes were defined. Patients with normal LFTs at the start of the study period had liver function tests repeated weekly during nutritional support. Body weight, arm muscle circumference, triceps skinfold and serum albumin were measured on entry to the study.
Nineteen patients fulfilled the study entry criteria. Eleven patients (Group 1) developed abnormal LFTs; in the remaining eight patients LFTs remained normal (Group 2). There was no significant difference between the two groups at the start of enteral feeding with respect to anthropometric measurements or serum albumin. Six of the 11 patients in Group 1 developed septic complications. No patient in Group 2 had clinical or bacterial evidence of infection during nutritional support.
Abnormalities in LFTs are more likely to be due to associated clinical complications than the enteral nutritional support alone.