Complications
Common in the early stage of refeeding, especially if misusing laxatives or purging prior to admission.
Significant edema during refeeding indicates a need for careful monitoring for signs and symptoms of refeeding syndrome.
Rule out heart failure as a possible etiology.
Recedes within 2 weeks without intervention, so reassurance should be provided.[92]
Due to rapid nutrition replacements, fluid shifts can occur, potentiated by electrolyte abnormalities.
The left ventricle is unable to handle the fluid increase, resulting in cardiac failure.
Referral to emergency medical care is recommended with continuous cardiac monitoring.
At start of enteral feeding, carbohydrate metabolism increases and phosphate reserves may deplete rapidly.
Additionally, feedings may contain inadequate phosphate amounts.
If severe, may result in cardiac and respiratory failure, delirium, and seizures.
Additional phosphorus supplements are necessary as refeeding therapy begins. Phosphorus supplementation is usually needed for no longer than 2 weeks during a refeeding program.[92]
The refeeding process may unmask electrolyte abnormalities, identified on laboratory testing.
Hypomagnesemia may be the underlying cause of refractory low potassium, low calcium, and low sodium.
Oral supplements may be used with caution as diarrhea may result, further offsetting fluid balance.
At the start of enteral feeding, individuals may endure severe deficiency due to prolonged starvation.
Oral thiamine supplementation is frequently used when deficiency is identified.[92]
May be the result of low iron, but may be artificially high due to dehydration or hemodilution early in treatment.
In severe malnutrition, iron utilization is blocked, so supplemented amounts cannot be utilized.
Once nutrition and metabolic disorders corrected through refeeding, anemia should correct.[92]
Menstruation stops for 3 or more months.
Cycle restores when normal weight returns.
There are some patients who continue to have menses even when their weight falls to low levels. The reason is not clear. One theory is the concept of "energy availability". This theory posits that in some patients consumption of calories equivalent to the calories expended decreases the likelihood of developing amenorrhea.[135]
Female patients may not be able to conceive due to amenorrhea.
Usually reversible on return of normal weight, regular menstrual cycle, and restoration of normal luteinizing hormone (LH) and follicle-stimulating hormone (FSH).
Increased risk if onset of AN is in mid-to-late teens, most commonly the peak of bone formation. Loss of bone mineral density occurs within 1 year of the onset of AN in most patients. There is both a decrease in the formation of bone and an increase in bone resorption. In a 2-year prospective study, the relative risk of fractures was 7.0.[136] The osteoporosis that occurs in these patients does not respond to oral hormone supplementation, but may respond to transdermal estrogen. Normal weight, high enough to be associated with resumption of menses, is needed for improved bone metabolism. Advise individuals with AN and osteoporosis or related bone disorders to avoid high-impact physical activities and activities that significantly increase the chance of falls or fractures.[65]
Malnutrition may affect levels of growth hormones, slowing normal growth.
Catch-up growth has been inconsistently reported in the literature; younger patients may have greater and more permanent effects on growth.[66]
May develop when the kidneys lose the ability to concentrate urine.
Management is via increasing the patient's calorie intake.
Complication reverses upon AN treatment.
People with eating disorders experience higher rates of dental erosion and caries; this occurs more frequently in those who self-induce emesis, but also occurs in those who do not.[66] Lip and mouth fissures may occur, due to riboflavin (vitamin B2) deficiency in severe disease. Glossitis and loss of taste may occur due to iron and zinc deficiencies. Bleeding gums may occur due to vitamin C deficiency. Encourage people with AN who are vomiting to have regular dental and medical reviews, avoid brushing teeth immediately after vomiting, rinse with nonacid mouthwash after vomiting and to avoid highly acidic foods and drinks. Offer cautious vitamin/mineral replacement as indicated in those with deficiency.[92]
Bradycardia and hypotension are the result of lowered calorie and fluid intake.
Heart function may decline with this subnormal activity, increasing the risk of heart failure.
Misuse of laxatives, enemas, diuretics, and emetics chronically increases the risk of heart failure.
Patient should stop misusing over-the-counter medication and resume normal weight.
With restricted diet and history of laxative misuse, delayed gastric emptying and slow intestinal transit time may occur, leading to symptoms of nausea, bloating, and postprandial fullness.[66] Constipation may also occur, and is multifactorial in etiology.[66]
Once weight is gained, bowel function usually returns to normal.
Management is via increasing the patient's calorie intake in order to achieve recommended weight restoration.
The initial treatment of slowed GI motility should be substitution of fluids for some of the solids. If needed, the patient can be treated with metoclopramide.[66] The risk of drug-induced parkinsonism, acute dystonia, and tardive dyskinesia needs to be carefully assessed in these patients.[66] They should be monitored at least every other month. Constipation may be treated with fiber laxatives, stool softeners, or osmotic agents.[66] Stimulant laxatives should be avoided.
Hypokalemic nephropathy occurs in 15% to 20% of patients with longstanding AN.[134]
Both acute and chronic kidney failure occur in AN and the most common cause is chronic hypokalemia and chronic volume depletion; vomiting and inappropriate laxative or diuretic use may be contributing factors.[66]
Glomerular filtration rate estimated from serum creatinine underestimates kidney damage; 24-hour creatinine clearance is a better measure but still underestimates damage.
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