Case Report of the surgical management of small bowel and colonic ischaemia associated with Anorexia Nervosa binge/purge subtype.

INTRODUCTION: Anorexia Nervosa affects up to 1% of the population and can present with binge/purge episodes. A paucity of literature exists regarding small bowel and colonic ischaemia relating to this common condition. We report our own experience and management of a patient with anorexia nervosa binge/purge subtype with small bowel and colon ischaemia and review existing cases in the literature. PRESENTATION OF CASE: A 32year old female self-presented to the emergency department complaining of abdominal pain, abdominal distension and vomiting on a background history of binge/purge subtype eating disorder, following consumption of a large amount of carbohydrates. Computed tomography (CT) of the abdomen was performed urgently which revealed extensive pneumatosis involving the stomach and its draining veins with evidence of extensive portal venous gas. A right hemicolectomy followed by re-look laparotomy in 48h with resection of jejunum, jejunojejunal anastomosis and end-ileostomy was performed with a successful outcome. DISCUSSION: Anorexia nervosa can be a potentially life-threatening disease, with rates of death 10-12 times that of the normal population. Ischaemic bowel is a rare potential complication, with mortality rates of up to 80% having been reported prior to this case. Although the exact mechanism remains to be elucidated, gastric dilation, abnormal digestive motility, and faecal impaction appear to contribute, on a background of impaired blood supply.
CONCLUSION: Clinicians need to exhibit a high index of suspicion for patients with abdominal pain on the background of an eating disorder, particularly in the context of suspected recent refeeding/binge eating. Prompt involvement of appropriate radiology and surgery input are pivotal to outcome.

Introduction

Bulimia Nervosa and Anorexia Nervosa affect up to 1% of the female population and commonly present with a range of gastrointestinal complaints [1]. While the most common causes of death in this condition include severe malnutrition and suicide, there are significant gastrointestinal complications which may occur. These range from relatively common complaints affecting up to 90% of patients including postprandial fullness, abdominal distension, early satiety and nausea to rare surgical emergencies [2]. Significant binge eating episodes in this patient group have previously been reported to be associated with surgical emergencies such as acute gastric dilation which can lead to complications such as gastric necrosis and perforation [1], [3], [4], [5]. There are only five previously reported cases of binge eating episodes resulting in small bowel and colonic ischaemia, the majority resulting in mortality [6], [7], [8], [9], [10]. Here, we report our own experience and successful surgical management of an Anorexia Nerovsa patient exhibiting binge/purge subtype with small bowel and colon ischaemia and review the existing cases in the literature.

Case report

A 32 year old female was brought by ambulance to the emergency department complaining of abdominal pain, abdominal distension and vomiting on a background history of binge/purge subtype eating disorder. She described a binge of a large amount of carbohydrates (1 kg of porridge and approximately 20–30 potatoes, along with an unrecorded amount of split pea soup). On abdominal examination she had a distended and tender abdomen. Inflammatory markers were normal with a white cell count value of 5.4 and a c-reactive protein value of <1. Lactate on initial blood gas was 8.0, following fluid resuscitation this came down to 4.9, and she had a metabolic acidosis with a pH of 7.28. Computed tomography (CT) of the abdomen was performed urgently which revealed extensive pneumatosis involving the stomach and the draining veins of the stomach with evidence of extensive portal venous gas (Fig. 1).

Fig. 1

CT image revealing pneumatosis and portal venous gas.

Based on the clinical and radiological findings an emergency laparotomy was performed within approximately 6 h of presenting to the emergency department revealing small and large bowel diffusely dilated with contents from the binge episode. There was patchy ischaemia present throughout the small bowel and an ischaemic segment of terminal ileum and caecum, also noted was black thrombosed veins in small bowel and colonic mesentery intra-operatively. Decompression of the bowel was performed via an enterotomy and a right hemicolectomy was performed to resect the ischaemic segment of caecum and terminal ileum (Fig. 2).

Fig. 2

Ischaemic segment of caecum.

Due to the areas of patchy ischaemia throughout the small bowel including proximal jejunum, the stapled ends of terminal ileum and transverse colon were not anastomosed and a re-look laparotomy was performed following 48 h. At re-look laparotomy further areas of non-viable proximal jejunum were resected with jejunojejunal handsewn anastomosis and end ileostomy exteriorised in the right iliac fossa. The histology from the resected areas of bowel revealed ischaemic small and large bowel with variable mucosal to transmural necrosis and serositis. Focal small areas of thrombosis in small mesenteric veins were identified. Following several days of parenteral nutrition she returned to enteral diet and was discharged well with a plan for stoma reversal in the future and continued psychiatric input.

Discussion

Small bowel and colonic ischaemia following an episode of binge eating are exceptionally rare and are associated with a mortality rate of 80% according to previously reported cases [6], [7], [8], [9], [10] (Table 1).

Table 1

Previous case reports and time to presentation, imaging and surgery.

References	Country of Origin	BMI	Time from Refeeding to Presentation	Time to Imaging	Time to Surgery
Diamanti et al. [7]	Italy	N/a*	4 days	N/a	Conservative Management
Yamada et al. [9]	Japan	12	N/a	2 days	3 days
Kaye et al. [8]	UK	N/a	2 months	2 days	N/a
Neychev et al. [6]	USA	11	N/a	N/a	3 h
Sakka et al. [10]	UK	N/a	2 days	Immediate	Following imaging/resuscitation

N/a: Not available.

The DSM-V describes two subtypes of Anorexia nervosa, namely the restricting subtype and the binge eating and purging subtype [11]. The patient in our case report appeared to display the latter subtype with a history of bulimia also. Ischaemic bowel is fortunately an exceptionally rare complication of anorexia nervosa. It does however, result in a high mortality rate with 80% mortality reported in the existing literature in this patient subgroup.

A constellation of gastrointestinal symptoms are common in patients with eating disorders with a previous series reporting up to 96% suffer with postprandial fullness, 90% experience abdominal distension and more than 50% complain of abdominal pain and nausea [12]. However this case along with the pre-existing literature stress the need for clinicians to exhibit a high index of suspicion for ischaemic bowel in patients with eating disorders who present with abdominal pain; especially if preceded by suspected binge eating/recent re-feeding. Survival is only reported in one of five of the case reports previously described, and in that case the patient was already in an intensive care setting when the condition was recognised and was successfully managed non-operatively. All other cases managed operatively have resulted in mortality, likely due to the length of time between binge eating and presentation (Table 2). Our case differed in that there was survival post-operatively. The patient had similar bowel histology to those described in the existing case reports. Contributing factors to survival could have been the small interval between presentation and surgery, and the fact that the patient had a normal BMI and a binge-purge subtype of eating disorder rather than purely restrictive.

Table 2

Bowel affected, management, pathology and outcome.

First Author	Segment of bowel affected	Management	Pathology	Outcome
Diamanti et al.	N/a	Conservative: antibiotics	N/a	Discharged after 4 months
Yamada et al.	Ileum	Surgery – removal of ileum and caecuma	Transmural infarction, haemorrhagic necrosis	Death – 3 days post-op
Kaye et al.	Pancolic and distal ileum	Laparotomy – subtotal colectomy	Rectum impacted with ‘cement like' faeces	Death – 8 h post op
Neychev et al.	Entire small bowel and right hemicolon	Exploratory laparotomy	N/a	Death – soon post-op
Sakka et al.	Colon from ileo-caecal junction to splenic flexure	Extended right hemicolectomyb	Necrotizing colitis with +ve tissue gram stain	Death – 12 days post initial procedure

N/a: not available.

Initially tried to manage patient conservatively, when this failed proceeded to surgery.

Patient went for repeat laparotomy 11 days post-op due to clinical deterioration but found to have non-viable GIT.

The mechanism behind this condition remains poorly understood. Proposed mechanisms include a reduction in blood supply secondary to malnutrition, exacerbated by faecal impaction and paralytic ileus which are common in patients with eating disorders [8], [9]. Diamanti et al. suggested a similarity to necrotizing colitis in the new-born with starvation leading to reduced mucosal integrity, intestinal ischaemia and impairment of digestive motility [7]. The presence of gas producing bacteria was evident in three of the case reports [7], [8], [10]. The association of clostridium and anorexia nervosa has not been fully elucidated or established. Although Clostridium was not noted in our case reports, other aspects of these case reports were similar including gastric dilatation and stasis, and faecal impaction; as well as the presence of binge eating/re-feeding. Sakka et al. described a similarity between this condition and enteritis necroticans observed in prisoners of war following re-feeding of comparatively small amounts [10]; with haemorrhagic, inflammatory or ischaemic necrosis of the jejunum being characteristic [13].

Conclusion

Ischaemic bowel following re-feeding or binge eating in the setting of an eating disorder is a rare but often fatal condition. Clinicians should have a high index of suspicion when patients with eating disorders present with abdominal pain especially in suspicion of recent re-feeding/binge eating; emphasis should be placed on prompt imaging and involvement of an appropriate surgical team as delay to operative treatment could prove fatal.

Conflicts of interest

None.

Funding

None.

Ethical approval

None.

Consent

None.

Contribution of authors

Ann T. Foran – writing of manuscript, acquisition of data.

Cillian Clancy – writing of manuscript, acquisition of data

Shiva Sharma – acquisition of data, writing of manuscript

Tom F. Gorey – concept

Jurgen Mulsow – concept.

Guarantor

Ann T. Foran.

Cillian Clancy.