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Monday, April 9, 2018

Gastroparesis and Eating Disorders Part Deux: What is the Difference?

I was watching a documentary about Amy Winehouse, and I had so much going on personally when she was going through her own troubles, that I did not give her a lot of thought. I was really sick, and knew there was something really wrong with me but the doctors who were testing me for different things could not find an answer, until 2012, when I was finally diagnosed with Gastroparesis. I had never heard of Gastroparesis before then and made it my mission to find out more about it, start my blog to keep track of research, and start Facebook pages and groups to help others who may have been diagnosed with the same.

I have been really sick the past week because of allergies to things growing, so I have a lot of mucus production, plus the nausea that comes with the mucus draining down my throat, and the throwing up of mucus and stomach acid because I have not been able to eat. I watch movies and listen to music to distract myself from the nausea, and I also use it to get me through the vomiting attacks. That sounds weird, I know, but it helps me to have something else to focus on. Because I have been sick for the past week, I've finally gotten to see Amy. I want to say that I have written about Gastroparesis vs Eating Disorders in the past, and you can read it here: http://www.emilysstomach.com/2015/04/gastroparesis-vs-eating-disorders.html.

I loved Amy Winehouse's music and her voice was a welcomed change at the time from the other voices already on the scene. She was not a part of a girl group, she did not look like a carbon copy of anyone, and she maintained her individuality. That is a feat that is hard to do in the entertainment industry when people are trying to market you, and are concerned with sales. I wanted to talk about her because something in her documentary bothered me more than anything else that was mentioned. She went to her mother and father, telling them about a diet she found where she could eat anything, and then vomit it all back up later. Her parents can be heard in the film saying they thought it would pass. However, it would not pass because it was bulimia.

According to National Eating Disorders (NEDA)

"Bulimia nervosa is a serious, potentially life-threatening eating disorder characterized by a cycle of bingeing and compensatory behaviors such as self-induced vomiting designed to undo or compensate for the effects of binge eating.



Image Source: http://www.geronguide.com/gallery/index.php/Bulimia-Nervosa/bulimia-06




DIAGNOSTIC CRITERIA

According to the DSM-5, the official diagnostic criteria for bulimia nervosa are:

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.

The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.
Self-evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of anorexia nervosa.




WARNING SIGNS & SYMPTOMS OF BULIMIA NERVOSA

Emotional and behavioral

In general, behaviors and attitudes indicate that weight loss, dieting, and control of food are becoming primary concerns

Evidence of binge eating, including disappearance of large amounts of food in short periods of time or lots of empty wrappers and containers indicating consumption of large amounts of food

Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or smells of vomiting, presence of wrappers or packages of laxatives or diuretics

Appears uncomfortable eating around others

Develops food rituals (e.g. eats only a particular food or food group [e.g. condiments], excessive chewing, doesn’t allow foods to touch)

Skips meals or takes small portions of food at regular meals

Disappears after eating, often to the bathroom

Any new practice with food or fad diets, including cutting out entire food groups (no sugar, no carbs, no dairy, vegetarianism/veganism)

Fear of eating in public or with others

Steals or hoards food in strange places

Drinks excessive amounts of water or non-caloric beverages

Uses excessive amounts of mouthwash, mints, and gum

Hides body with baggy clothes

Maintains excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury—due to the need to “burn off ” calories

Shows unusual swelling of the cheeks or jaw area

Has calluses on the back of the hands and knuckles from self- induced vomiting

Teeth are discolored, stained

Creates lifestyle schedules or rituals to make time for binge-and-purge sessions

Withdraws from usual friends and activities

Looks bloated from fluid retention

Frequently diets

Shows extreme concern with body weight and shape

Frequent checking in the mirror for perceived flaws in appearance

Has secret recurring episodes of binge eating (eating in a discrete period of time an amount of food that is much larger than most individuals would eat under similar circumstances); feels lack of control over ability to stop eating

Purges after a binge (e.g. self-induced vomiting, abuse of laxatives, diet pills and/or diuretics, excessive exercise, fasting)

Extreme mood swings

Physical

Noticeable fluctuations in weight, both up and down

Body weight is typically within the normal weight range; may be overweight

Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)

Difficulties concentrating

Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)

Dizziness

Fainting/syncope

Feeling cold all the time

Sleep problems

Cuts and calluses across the top of finger joints (a result of inducing vomiting)

Dental problems, such as enamel erosion, cavities, and tooth sensitivity

Dry skin

Dry and brittle nails

Swelling around area of salivary glands

Fine hair on body

Thinning of hair on head, dry and brittle hair (lanugo)

Cavities, or discoloration of teeth, from vomiting**

Muscle weakness

Yellow skin (in context of eating large amounts of carrots)

Cold, mottled hands and feet or swelling of feet

Menstrual irregularities — missing periods or only having a period while on hormonal contraceptives (this is not considered a 'true' period)

Poor wound healing


Impaired immune functioning





Image Source: https://anorexianervosaforpharmacists.weebly.com/eating-disorders.html





Many people with bulimia nervosa also struggle with co-occurring conditions, such as:

Self-injury (cutting and other forms of self-harm without suicidal intention)
Substance abuse
Impulsivity (risky sexual behaviors, shoplifting, etc.)
Diabulimia (intentional misuse of insulin for type 1 diabetes)
Learn more about co-occurring conditions





Image Source: https://www.fullcirclehealthcareinc.com/eating-disorders.html





HEALTH CONSEQUENCES OF BULIMIA NERVOSA

The recurrent binge-and-purge cycles of bulimia can affect the entire digestive system and can lead to electrolyte and chemical imbalances in the body that affect the heart and other major organ functions.

The body is generally resilient at coping with the stress of eating disordered behaviors, and laboratory tests can generally appear perfect even as someone is at high risk of death. Electrolyte imbalances can kill without warning; so can cardiac arrest. Therefore, it’s incredibly important to understand the many ways that eating disorders affect the body."
**You can get the same dental effects from Gastroparesis, see my article: http://www.emilysstomach.com/2017/12/gastroparesis-effects-on-dental-health.html





Image Source: https://it.123rf.com/photo_71030037_la-bulimia-%C3%A8-un-disturbo-alimentare-binge-eating-e-tentativi-di-sbarazzarsi-del-cibo-consumato-segni-e.html




Image Source: http://gi-north.com/are-you-at-risk-for-gastroparesis/


I found this article while I was doing research on eating disorders and Gastroparesis. I thought it would bring hope to those who have both, or maybe just have an eating disorder. According to Mirror Mirror, Eating Disorder Help,

"GI Symptoms in Eating Disorders

Gastrointestinal (GI) complications are commonly seen with anorexia, bulimia and binge eating disorder. Heartburn, gas, bloating, early fullness, nausea, abdominal distention, rectal pain, constipation or diarrhea might be considered simply 'irritable bowel syndrome' – potentially delaying rapid diagnosis and treatment of an underlying eating disorder. Often referred to as functional gut disorders, there is an impairment in the body’s normal 'functioning,' such as delayed movement of food through the digestive tract, hypersensitivity of intestinal nerve cells, and the way in which a person’s brain responds to these stimuli (1). Re-feeding and in turn, recovery, is difficult physically as well as emotionally.


Anorexia Nervosa, Restricting-Type

gastrointestinal symptoms eating disorders

Prolonged food restriction causes muscular atrophy of the entire digestive tract. This leads to slow stomach emptying (called Gastroparesis) and is a direct cause of the trapped gas, bloating and abdominal distention seen with anorexia. Post-meal pain, pressure and constipation can be quite severe.

Consumption of sugar-free products and high fiber fruits and vegetables to blunt hunger can add to GI discomfort. Sorbitol — found in sugar-free gums and mints, and fructose –found in many fruits — can increase gas production. Psychological factors such as depression and/or anxiety, as well as pelvic floor dysfunction, can lead to heightened awareness of pain sensations in the gut, making the problem feel even worse (2,3).

A rare but documented cause of severe abdominal pain can be seen in extremely malnourished individuals. It is called Superior mesenteric artery (SMA) syndrome and is caused by compression of the artery by the first portion of the intestines called the duodenum (4). This is a medical emergency and therefore is imperative that individuals struggling with overcoming any type of eating disorder work with medical professionals to safely guide and monitor them.



Bulimia Nervosa

Purging can lead to a condition known as acute sialadenosis, in which the parotid glands become swollen and painful. This condition will cause an individual to have a characteristic “chipmunk-like” appearance. Treatment involves warm compresses, tart candies, and anti-inflammatory medication (5). Individuals struggling with bulimia also experience gas, bloating, indigestion and constipation as well as gastritis, an inflammation of the lining of the stomach causing upper abdominal pain.

Upper GI symptoms of acid reflux occur due to repeated bouts of self-induced vomiting. The valve (called a sphincter) that controls the connection between the stomach and esophagus becomes floppy, allowing stomach acids and partially digested foods to back up through the esophagus and into the throat. This is involuntary and may cause erosion of the mucosa of the esophagus, leading to a condition known as Barrett’s esophagus, a pre-cursor to esophageal cancer (3). Repeated bouts of self-induced vomiting can ultimately cause tears in the esophagus, referred to as a Mallory Weiss Tears. Vomiting blood is a very frightening experience and requires emergency medical care. Daily vomiting can put tremendous strain on the heart muscle resulting in arrhythmias, palpitations and death (4).

Bloodwork may show characteristic abnormalities more commonly seen when purging becomes frequent and habitual. The pancreas and liver enzymes may be elevated without other symptoms and electrolyte levels may be abnormal (5,6)

Difficulty swallowing is another problem commonly seen in anorexia and bulimia and may be related to the loss of muscle tone in the esophagus. It is important to see a physician when a patient complains of difficulty swallowing while increasing nutrition.




Image Source: http://www.eatingdisorderpro.com/2013/02/28/diabulimia/





Other purging disorders – Laxatives, Diuretics and Exercise

Laxative abuse has been reported in more than 1/3 of patients with eating disorders. Patients believe they are purging calories to stay thin, when in fact, most absorption of calories occurs in the small intestine. Most commonly (though not exclusively) seen in patients with bulimia, laxative abuse causes the bowel to become dependent on laxative stimulation to pass a bowel movement. Individuals who use laxatives, diuretics or both (to purge calories) become severely and chronically dehydrated. Kidney function can then suffer impairment from chronic depletion of blood flow due to dehydration. Stimulant laxatives work by irritating the nerves that stimulate the colon to cause frequent watery stools, while bulk-forming laxatives work by increasing stool mass to the point the bowels force it out.

This chronic overstimulation can cause complete bowel shutdown which is referred to as cathartic colon. Once a patient’s colon becomes incapable of transporting fecal material, they may require partial or complete colon resection, or even require a colostomy bag (7,8). Additionally, stopping these behaviors ‘cold turkey’ can cause extreme fluid shifts, renal shutdown and life threatening electrolyte imbalance. This is referred to as Pseudo-Bartters syndrome. (5,6) Medical practitioners need to carefully monitor patients as they wean off laxatives and diuretics for this reason. Over exercise is another form of purging behavior.



Rectal Prolapse

Rectal prolapse occurs when the rectum protrudes outside the opening of the anus. Although not a common feature, rectal prolapse has been seen in patients who binge and purge, and in patients suffering from severe constipation and/or laxative abuse.

Increased intraabdominal pressure from vomiting, among other factors such as medication, poor diet and low fiber intake contribute to this condition. Surgical treatment is the definitive treatment for recurring prolapse but steps to prevent further constipation are essential. (5,6)




Binge Eating Disorder

Individuals who binge-eat tend to have erratic and irregular eating patterns around all meals, in turn causing a host of GI symptoms including constipation, gas, bloating and diarrhea.

Patients with anorexia who binge eat are at risk for acute gastric dilatation. This is due to slow gastric emptying and overeating large volumes in the face of weakened stomach musculature. The large quantity of food exceeds the stomach’s ability to empty which obstructs of blood flow to the stomach and intestines. The result is potential rupture of the stomach (4). Symptoms include vomiting, severe abdominal distention and pain.




Practical Suggestions to Reduce GI Discomfort While Recovering

It is advisable to see a physician to evaluate the many causes of gastrointestinal distress. Although many symptoms mentioned resolve with normal eating, it is important to rule out the potentially serious GI issues we see commonly with eating disorders.

The best long term relief for the discomfort accompanying normalized eating at the start of recovery is to schedule meals, snacks and fluids at regular intervals, and to sit calmly and mindfully while eating. Often referred to as “the rule of threes” (7,8) it is advisable to consume three meals and three snacks, at least three hours apart. Re-introducing foods as well as any type of nutritional supplementation should be done under the proper care and guidance of a physician and the dietitian to collaboratively treat these problems in a multidisciplinary approach.



GI Symptoms in Eating Disorders



Constipation Relief

For people with eating disorders, adequate fluids and fiber are the first line treatment for chronic constipation. It is advisable to increase fiber intake slowly to avoid additional gas and bloating. Examples of fiber-rich foods include whole grain breads and cereals, bran, nuts and seeds, lentils, beans and some fruits and vegetables.

Patients who are continuing to struggle with constipation should consult with their physicians for any potential medication needs. The fact remains that with continued good eating over time, many of these GI complains will resolve.



Gas, Bloating and Cramping

Physicians will recommend simethicone (Gas-X) to help with gas pain, and recent clinical guidelines by the American College of Gastroenterology suggest the use of metoclopramide (Reglan) to help with slow gastric emptying (9). Metoclopramide increases muscle contractions in the upper digestive tract and speeds up the rate at which the stomach empties into the intestines. This medication must be given with caution, however, as it can affect the heart rate of someone with anorexia.

One of the main goals in treating the GI symptoms of bulimia is to reduce and eliminate purging behavior. In cases where associated heartburn is frequent doctors will recommend a protein-pump inhibitor, a medication that protects the esophageal wall by reducing the stomach’s production of gastric acid.

In some cases, therapies to calm the gut including meditation or anti-anxiety meds, can be quite helpful. It is important to note that 'special' diets, or eliminating certain foods in an attempt to alleviate symptoms is not wise to try while in recovery. Dietitians need to individualize meal plans for the specific needs of each client.




Final Words

If you are in recovery or caring for someone in recovery, the abdominal discomfort with eating is very real. The body has gotten used to eating smaller amounts of food and the additional anxiety of increasing intake is truly distressing. As long as you’ve consulted a medical professional, the best treatment for GI upset is to continue following a plan of regular meals and snacks. Some patients have found heat pads or hot water bottles placed directly on the belly after meals to be helpful when pain is severe.





New Research Ahead – The Role of the Intestinal Microbiota

New research on the role of the intestinal microbiota in anorexia and other eating disorders is exciting. This research looks at the enteric nervous system, comprised of more than 100 million nerve cells lining your entire GI tract. This neural complex is thought to be equivalent to “a second brain” affecting digestion, weight regulation and even mood. Entirely new treatments are on the horizon as we begin to understand the interactive regulation that now clearly exists between the gut and the brain (10). Hopefully, we will continue to find new treatments for the gastric distress that eating disorder sufferers encounter as they work towards meaningful recovery.




Image Source: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/psychiatry-psychology/eating-disorders/




About The Author:

Erica Leon, MS, RDN, CDN, CEDRD is the founder of Erica Leon Nutrition. She specializes in nutrition counseling for eating disorders and unhealthy eating patterns, as well as intuitive eating coaching.

Thank you so much to the following clinicians who kindly (and generously) reviewed this paper for accuracy of content:

Marcia Herrin, EdD, MPH, RDN, LD, FAED
Fellow, Academy of Eating Disorders
Author: The Parent’s Guide to Eating Disorders (Gurze Press, 2007) & Nutrition Counseling in the Treatment of Eating Disorders (Brunner-Routledge, 2013)

Patsy Catsos, MS, RDN, LD
Digestive Health Expert
Author: IBS—Free at Last! (2012)
Nutrition Works

References:

1) Janssen, P. Viewpoint, Can eating disorders cause functional gastrointestinal disorders? Neurogastroenterol Motil 2010; 22:1267-1269.

2) Wang, X, Luscombe, G, Boyd, C et al, Functional gastrointestinal disorders in eating disorder patients: Altered distribution and predictors using Rome III compared to Rome II criteria, World J Gastroenterol 2014; Nov 21; 20 (43): 16293 – 16299.

3) Sato, Y, and Fukudo, S, Gastrointestinal Symptoms and disorders in patients with eating disorders, Clin J Gastroenterol 2015; 8:255-263.

4) Norris, et al. Gastrointestinal Complications Associated with Anorexia Nervosa: A Systematic Review. Int J Eat Disord 2016; 49:3 216-237.

5) Mehler, S & Walsh, K, Electrolyte and Acid-Base Abnormalities Associated with Purging Behaviors. Int J Eat Disord 2016; 49:3 311-318.

6) Forney, J, Buchman-Schmitt, J et al, The Medical Complications Associated with Purging. Int J Eat Disord 2016; 49:3 249-259.

7) Herrin, M & Larkin, M, Nutrition Counseling in the Treatment of Eating Disorders, 2nd ed. Publ. Taylor & Francis, 2012.

8) Herrin, M & Matsumoto, N, The Parent’s Guide to Eating Disorders, 2nd Ed. Publ. Gurze Books, 2007.

9) Camilleri, M et al. Clinical Guideline: Management of Gastroparesis. Am J Gastroenterol, 2013; 108: 18-37.

10) Kleiman, S, Carroll, I, et al. Gut Feeling: A Role for the Intestinal Microbiota in Anorexia Nervosa? Int J Eat Disord 2015; 48 (5):449-451."


There is a wonderful documentary that looks into recovery of people who are facing an eating disorder. Even if you have Gastroparesis and no eating disorder, I would recommend this video highly. It brought me to tears. It's a really well done documentary:

https://youtu.be/mU6MT6Bzyw0



Eating disorders like Bulimia can lead to motility disorders like Gastroparesis. A lot of people have trouble understanding the difference between an eating disorder like Bulimia and a motility disorder like Gastroparesis, because both include vomiting and with Gastroparesis, there is the ability to get full easily because you retain food in your stomach because the stomach does not function normally.

People with Gastroparesis can gain weight instead of losing weight, but that does not mean they are not malnourished or vitamin deficient. A lot of people with Gastroparesis lose weight, and they do not want to lose the weight because they get down to scary levels of weight loss. Most people end up with a feeding tube at that point or TPN, because there is not much in the way of treatment for Gastroparesis. Bulimics can develop Gastroparesis and motility disorders because of the vomiting and weight loss. They can damage their vagus nerve, which controls so much in your body. if you do have an eating disorder and have been diagnosed with Gastroparesis, I do have a support group that you can join to talk to others and get support from others in the same position at: https://www.facebook.com/groups/GPandEDSupport/. You are NOT alone.

Gastroparesis, according to the Mayo Clinic, is a condition that affects the normal spontaneous movement of the muscles (motility) in your stomach. Ordinarily, strong muscular contractions propel food through your digestive tract. But if you have gastroparesis, your stomach's motility is slowed down or doesn't work at all, preventing your stomach from emptying properly. Gastroparesis can interfere with normal digestion, cause nausea and vomiting, and cause problems with blood sugar levels and nutrition. The cause of gastroparesis is usually unknown. Sometimes it's a complication of diabetes, and some people develop gastroparesis after surgery. There is no cure for Gastroparesis.

The Medscape Journal of Medicine has a really detailed, in depth look into Gastroparesis and what causes it. You can read the article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2258461/, but I will post an excerpt here,

"Gastroparesis presents with symptoms of gastric retention and nongastrointestinal manifestations, with objective evidence of delayed gastric emptying in the absence of mechanical obstruction. Diabetic, idiopathic, and postsurgical gastroparesis are the most common forms, although many other conditions are associated with symptomatic delayed gastric emptying (Table 1). Gastroparesis is estimated to affect up to 4% of the US population[1] and may produce either mild, intermittent symptoms of nausea, early satiety, and postprandial fullness with little impairment of daily function, or relentless vomiting with total disability and frequent hospitalizations. A recent report estimated that inpatient costs for patients with severe gastroparesis approach $7000/month.[2]

Gastroparesis presents with a constellation of symptoms. In one study, nausea was reported by 93% of patients whereas early satiety and vomiting were noted by 86% and 68%, respectively.[3] In another series, nausea, vomiting, bloating, and early satiety were reported by 92%, 84%, 75%, and 60% of patients, respectively.[4] Many patients in both case series (89% and 46%) also reported abdominal pain (Table 2). Others experience heartburn from acid reflux into the esophagus that is facilitated by fundic distention which increases the rate of transient lower esophageal sphincter relaxations.[5] Although some gastroparetics with frequent vomiting lose weight and develop malnutrition, most patients were overweight or obese in one series, indicating that the disorder does not necessarily restrict food intake.[6] Phytobezoars are organized concretions of indigestible food residue that are retained within the stomach. These may increase gastroparesis symptoms or produce a palpable epigastric mass, gastric ulceration, small intestinal obstruction, or gastric perforation.[7] Bezoars are eliminated by endoscopic disruption and lavage, enzymatic digestion (papain, cellulose, or N-acetylcysteine), and dietary exclusion of high-residue foods. Variably delayed gastric emptying may cause unpredictable food delivery in diabetics with gastroparesis, affecting glycemic control and increasing risks of both severe hypo- and hyperglycemia.[8]

Gastroparesis has many causes. In a case series of 146 gastroparesis patients seen at a large US tertiary medical center, 29% had underlying diabetes, 13% developed symptoms after gastric surgery, and 36% were idiopathic.[4] The mean age of onset for gastroparesis is 34 years. Eighty-two percent of cases occur in women.[4]"



Image Source: http://studylib.net/doc/7356614/super-cereal-recipes



If you do have an eating disorder, and you want to get help - there are several ways you can do so. You can make an appointment with your primary doctor, who can refer you to a doctor who can help you. There are several numbers you can call for help and links below (click on the bold words):

Shoreline Eating Disorders.

Eating Disorder Hope.

National Eating Disorders.

Help Guide - Helping Someone with an Eating Disorder.

Selah House.

Magnolia Creek - Bulimia Help for Women.

National Eating Disorders Collaboration.

Bulimia.com - for 24/7 hour advisors to help you, call 1-866-578-1604.






Image Source: https://www.eatingrecoverycenter.com/blog/2016/04/30/eating-recovery-day-why-we-celebrate





I am not a doctor, I am a researcher. Please call your doctor if you have any questions or concerns so that they may decide the best care for you. Everyone is different. Everyone with Gastroparesis is different. I just wanted to distinguish between eating disorders and Gastroparesis, and to make sure people know that eating disorders can lead to Gastroparesis as well. Like I said before, if you have any questions or concerns, please consult your doctor.

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