Laxative Abuse Research Articles

Atypical presentation of acute idiopathic megacolon in a 14-year-old patient

In clinical practice the term “megacolon” is used to indicate a marked dilatation of the cecum and the sigmoid colon (>12 and 6.5 cm, respectively) (1). From a clinical standpoint, a megacolon can be classified as chronic or acute depending on its clinical presentation. Chronic megacolon typically refers to a congenital disorder in which the enteric nervous system (ENS) supplying the colon does not develop properly, thereby leaving the distal segments of the viscus without myenteric and submucosal ganglia (i.e. Hirschsprung’s disease) (2). Other cases of non-aganglionic chronic megacolon can be secondary to variety of conditions such as Chagas’ disease and neurodegenerative diseases (e.g. Parkinson’s and Alzheimer’s diseases), leading to or associated with ENS abnormalities (3). The acute form of megacolon, also referred to as Ogilvie’s syndrome, is characterized by a predominant involvement of the cecum and right colon usually affecting elderly patients undergoing surgery (e.g. orthopedic procedures) or taking medications altering gut motility (e.g. opioids or antidepressants) (4). Some forms of acute megacolon, however, can be idiopathic in origin since no underlying etiology can be identified. Patients with acute idiopathic megacolon usually have a longstanding history of constipation, often accompanied by laxative abuse, and their clinical presentation is characterized by abdominal distension and severe pain with radiological evidence of stool impacted in the colon and rectum (1, 4). The case herein reported represents an unusual form of acute idiopathic megacolon characterized by massive descending and sigmoid colon distension complicated with a volvulus in a 14-year-old boy with no Hirschsprung’s disease. In addition, just to increase the peculiarity of this case report, the patient had an unremarkable clinical record, and never suffered from chronic constipation in the past.

Bulimia Nervosa in DSM-5

CME Educational Objectives 1. Outline the core clinical features of bulimia nervosa (BN). 2. Describe the concerns surrounding the DSM-IV criteria for BN. 3. Understand the rationale for changes in the diagnostic criteria for BN as recommended for DSM-5 . Bulimia nervosa, a disorder first introduced as “bulimia” in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition , 1 is characterized by recurrent binge eating episodes followed by inappropriate compensatory behaviors (such as, self-induced vomiting, laxative abuse, excessive exercising, and fasting) to prevent weight gain. The disorder is more common in females than in males, with onset typically in adolescence and young adulthood. 2

Laxative Abuse, Eating Disorders, and Kidney Stones: A Case Report and Review of the Literature

Kidney stones are listed among the complications of eating disorders; however, very few cases have been reported. We present an additional case of nephrolithiasis associated with laxative abuse, including detailed results of the patient's urine metabolic profiles, in a patient with idiopathic hypercalciuria. We review the literature and provide an explanation for the paucity of cases of nephrolithiasis associated with these disorders. Despite low urine volumes resulting from extracellular fluid volume depletion and hypocitraturia resulting from hypokalemia, both of which would tend to favor the formation of kidney stones, most patients with eating disorders are likely to be protected from stone formation by the hypocalciuric effect of extracellular fluid volume depletion and increased proximal tubular sodium reabsorption. However, patients with underlying idiopathic hypercalciuria who develop eating disorders may be at increased risk of stone formation in the setting of low urine volume and therefore high supersaturation of calcium oxalate and phosphate.

The clinical biochemistry of anorexia nervosa

In anorexia nervosa, under-nutrition and weight regulatory behaviours such as vomiting and laxative abuse can lead to a range of biochemical problems. Hypokalaemia is the most common electrolyte abnormality. Metabolic alkalosis occurs in patients who vomit or abuse diuretics and acidosis in those misusing laxatives. Hyponatraemia is often due to excessive water ingestion, but may also occur in chronic energy deprivation or diuretic misuse. Urea and creatinine are generally low and normal concentrations may mask dehydration or renal dysfunction. Abnormalities of liver enzymes are predominantly characterized by elevation of aminotransferases, which may occur before or during refeeding. The serum albumin is usually normal, even in severely malnourished patients. Amenorrhoea is due to hypogonadotrophic hypogonadism. Reduced concentrations of free T4 and free T3 are frequently reported and T4 is preferentially converted to reverse T3. Cortisol is elevated but the response to adrenocorticotrophic hormone is normal. Hypoglycaemia is common. Hypercholesterolaemia is a common finding but its significance for cardiovascular risk is uncertain. A number of micronutrient deficiencies can occur. Other abnormalities include hyperamylasaemia, hypercarotenaemia and elevated creatine kinase. There is an increased prevalence of eating disorders in type 1 diabetes and the intentional omission of insulin is associated with impaired metabolic control. Refeeding may produce electrolyte abnormalities, hyper- and hypoglycaemia, acute thiamin depletion and fluid balance disturbance; careful biochemical monitoring and thiamin replacement are therefore essential during refeeding. Future research should address the management of electrolyte problems, the role of leptin and micronutrients, and the possible use of biochemical markers in risk stratification.

Bulimia, binge-eating and their treatment J Hubert Lacey Bryony Bamford Amy Brown Bulimia, Binge-eating and their Treatment Sheldon Press 128pp £7.99 9781847090355 1847090354

THIS SHORT book is aimed at patients, but would be invaluable to clinicians who know little about eating disorders. It includes social and behavioural aspects, and explains the dangers of purging, bingeing, laxative abuse and other behaviours. There is also a self-assessment exercise.

Metabolic Alkalosis From Unsuspected Ingestion: Use of Urine pH and Anion Gap

Underlying causes of metabolic alkalosis may be evident from history, evaluation of effective circulatory volume, and measurement of urine chloride concentration. However, identification of causes may be difficult for certain conditions associated with clandestine behaviors, such as surreptitious vomiting, use of drugs or herbal supplements with mineralocorticoid activity, abuse of laxatives or diuretics, and long-term use of alkalis. In these circumstances, clinicians often are bewildered by unexplained metabolic alkalosis from an incomplete history or persistent deception by the patient, leading to misdiagnosis and poor outcome. We present a case of severe metabolic alkalosis and hypokalemia with a borderline urine chloride concentration in an alcoholic patient treated with a thiazide. The cause of the patient's metabolic alkalosis eventually was linked to surreptitious ingestion of baking soda. This case highlights the necessity of a high index of suspicion for the diverse clandestine behaviors that can cause metabolic alkalosis and the usefulness of urine pH and anion gap in its differential diagnosis.

Pseudo Bartter Syndrome from Surreptitious Purging Behaviour in Anorexia Nervosa

Pseudo Bartter syndrome is a rare disorder characterized by metabolic alkalosis, hypokalaemia, hyperaldosteronism, hyperreninism, normal blood pressure and hyperplasia of the juxtaglomerular apparatus. The most dangerous complication of Pseudo Bartter syndrome is hypokalemia. Hypokalemia caused by vomiting, diarrhea, prolonged fasting, abuse of potassium-depleting drugs, may be present in patients with binge /purging form of anorexia or bulimia nervosa. We report a case of a 19-year-old girl with anorexia nervosa (BMI 16.15 kg/m2) and severe prolonged hypokalemia (1.9 mEq/l), metabolic alkalosis and severe protracted secondary hyperaldosteronism (i.e. Pseudo Bartter’s syndrome) from surreptitious purging behaviour (vomit and laxative abuse). An intensive multidisciplinary day-hospital treatment including long-term potassium supplementation, a potassiumsparing diuretic was necessary to resolve the case and to allow the young girl to admit her previous purging behaviour and after three months to get at a normal kalemia without any potassium supplementation and BMI at a normal value (20 kg/m2). Given the dangers to the heart electrical and mechanical functions set by severe potassium deficiency, it is mandatory to find out the true cause so that a proper treatment can be started.

Chronisch entzündliche Darmerkrankung oder psychogene Essstörung – Fall 1/2012

A 33-year-old female patient with chronic anorexia nervosa was admitted for inpatient psychosomatic treatment after a recent severe weight loss. In addition, an inflammatory bowel disease had been suspected in the past 4 years. The patient was convinced that the weight loss had purely organic reasons. She reported frequent diarrhea after meals. Also laxative abuse was suspected because of melanosis coli. An MR Sellink showed no evidence for actual intestinal inflammation. No increased inflammation parameters were found in blood tests. Diarrhea could not be proved by investigation of excrements or a symptom diary. Treatment consisted of a multimodal approach with focus on cognitive behavioural therapy. Treatment revealed eating disorder specific cognitions, fears and behaviour. A partial acceptance of gastrointestinal symptoms and weight loss as eating disorder symptomatology could be achieved. Diagnostics and treatment of chronic anorexia nervosa are complicated by a coincidental (or suspected) organic intestinal disease. Gastrointestinal problems are common in eating disorders. Organic symptoms are often difficult to distinguish from psychosomatic symptoms. Somatic fixation complicates treatment of eating disorders.

Psychopharmacological Interventions for Adolescents with Eating Disorders

The purpose of this article is to review evidence-based pharmacological treatments for eating disorders with a special focus on the adolescent population. Eating disorders commonly present in adolescence, yet little published data are available to guide the adolescent psychiatrist. The use of medications in the context of evidence-based psychotherapeutic interventions and co-morbid psychiatric conditions will be discussed. Defined will be the unique role of the adolescent psychiatrist in orchestrating treatment by a multidisciplinary team, determining the appropriate level of care, monitoring safety, and evaluating treatment response. Risks and benefits of the use of pharmacological interventions in individuals who are malnourished or engaging in eating disordered behaviors, such as purging or laxative abuse, will be delineated along with proposed monitoring. Each potentially affected organ system will be addressed. Sequentially described is the existing evidence for use of medications for anorexia nervosa, bulimia nervosa, and binge eating disorder in adults and, where available, adolescents. Atypical antipsychotics, particularly olanzapine, have shown promise for adults with anorexia nervosa. However, in a recent trial of adolescents, no benefit for olanzapine over placebo was found. Several antidepressants have been shown to be effective treatments for bulimia nervosa, and fluoxetine has the FDA approval for treatment of this disorder in adults. Although fluoxetine has been deemed safe and effective in an open trial of adolescent patients, controlled studies in this population are lacking. Special considerations for the use of these medications in adolescents are discussed.

Do Men with Eating Disorders Differ from Women in Clinics, Psychopathology and Personality?

To determine if male and female eating disorders differ in clinics, psychopathology and personality traits when compared with a healthy group. Sixty male and 60 female eating disorder individuals (16% anorexia nervosa, 42% bulimia nervosa and 42% eating disorder not otherwise specified), matched for age and diagnostic, were compared with 120 healthy-eating participants (60 male and 60 female participants). All were diagnosed according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Assessment measures included Eating Disorder Inventory--2, Symptom Checklist--Revised and Temperament and Character Inventory--Revised, as well as other clinical and psychopathological indices. Male eating disorder participants reported significant lower laxative abuse (p = 0.020) and significant higher vomiting episodes (p = 0.019) than female eating disorder participants. Differences on drive for thinness, body dissatisfaction and some Symptom Checklist--Revised scales were found across genders in eating disorder participants. Male eating disorder participants scored significantly lower than female participants with eating disorders on harm avoidance, reward dependence and cooperativeness. Although eating disorder clinical features were similar across genders, male eating disorder participants had less body image concern and general psychopathology than female eating disorder participants.

Concerns related to eating, weight, and shape: Typologies and transitions in men during the college years

How to best classify concerns related to eating, weight, and shape (CREWS) in men remains an open question. Research on men considering CREWS during different developmental periods could be particularly informative. Focusing on one potentially dynamic developmental period, this study charts the course of CREWS in men over the college years. Latent class/latent transition analysis identified typologies of weight- and shape-influenced self judgment, limiting attempts, fasting, overeating, binge eating, self-induced vomiting, and laxative or diuretic abuse for 1,025 men over the four traditional college years. Three classes emerged: (1) no obvious pathological eating-related concerns (61-65%); (2) a high likelihood of limiting attempts and a moderately high likelihood of overeating (31-34%); (3) pervasive bulimic-like concerns (4-6%). Class membership was highly stable across assessment occasions. The results contribute to the growing literature on empirically derived classifications of CREWS and indicate that for many men CREWS are a chronic presence during the college years.

Miscellaneous Stone Types

Drug-induced calculi and other rare stone types, such as ammonium acid urate or protein matrix stones, represent only about 2% of all renal calculi. However, the chance to easily reverse stone formation risk by discontinuing the offending drug makes identification of these entities important for clinicians. Additionally, study of these rare stone types contributes to understanding the biochemistry of stone formation. Drug-induced calculi may be classified into two groups based on the mechanism of stone formation. The first group includes drugs that provoke calculi composed of principally the drug and its metabolites. These medications tend to be poorly soluble, highly excreted in urine, and required at high dosages for long durations of therapy. Historically, sulfonamides, triamterene, and the HIV protease inhibitor indinavir were leading causes of drug-induced calculi. Uses of novel agents within these drug classes or alternative therapies have reduced the incidence attributed to these drugs, although risk from newer, commonly used medications–notably ciprofloxacin, aminopenicillins, ceftriaxone, ephedrine, and guaifenesin– are increasingly being recognized. Microscopic analysis for crystalluria or infrared spectroscopy of collected stones aid in recognition of calculi composed primarily of a drug and its metabolites. Understanding of drug metabolism and pharmacokinetics, particularly related to effects of urine pH on drug solubility and excretion, provides a rational basis for both prevention and treatment recommendations. When possible, clinicians should avoid or exercise great caution when prescribing these medications to patients with a prior history of stones. The second group of drug-induced calculi includes drugs that cause stones due to their metabolic effects, primarily on calcium or purine metabolism. Because these calculi are identical in physical composition to the more common nephrolithiasis types, careful medication history and high clinical suspicion are required for diagnosis of these drug-induced “metabolic” calculi. Most drugs in this class are readily expected based on their effects on urinary calcium excretion such as calcium/Vitamin D supplements and loop diuretics. Carbonic anhydrase inhibitors, including the antiepileptics topiramate and zonisamide, are also included in this group. Ammonium acid urate stones are endemic in developing countries due to dietary limitations and recurrent diarrheal illness, but rarely occur in developed countries. Identification of these stones should raise clinical suspicion of epidemiologic risk factors including recurrent urinary tract infections with urea-splitting organisms, inflammatory bowel disease, and laxative abuse. Interestingly, these unusual clinical scenarios can recapitulate a common biochemical pathway to stone formation. Protein matrix stones are another unusual stone type associated with specific epidemiologic factors, namely recurrent urinary infections and proteinuric end-stage renal disease. Although distinctly rare, protein matrix stones provide opportunity to investigate basic biochemical mechanisms underlying stone formation.

Hypokalemic nephropathy in anorexia nervosa

A 25-year-old woman was admitted for weakness of two month’s duration. She had been diagnosed with anorexia nervosa (binge-eating/purging subtype) at the age of 21 years. She had a history of repeated admissions for hypokalemia caused by self-induced vomiting and abuse of laxatives. On examination

Influence of chronic bisacodyl treatment on the effect of acute bisacodyl on water and electrolyte transport in the rat colon.

Excessive or unnecessary taking of laxatives leads to a vicious circle with perpetuation of laxative abuse and increase of laxative dosage, accompanied by severe clinically evident disturbances. It was investigated in rats whether chronic administration of bisacodyl reduces the effects of acute bisacodyl administration on net water and electrolyte flux in the rat colon transport in-vivo. After chronic pretreatment with bisacodyl had been given for 21 days (3 mg and 10 mg kg-1 day-1), net water and sodium absorption was found to be decreased whereas potassium secretion was increased. After 21 days of pretreatment, the effect of acute bisacodyl (10 micrograms ml-1 intraluminal) on net water and sodium transport was reduced whereas the effect on potassium secretion remained unchanged. Serum and erythrocyte levels of sodium and potassium remained unchanged in chronically pretreated rats. Serum aldosterone levels were enhanced two fold. It is concluded that under the experimental conditions described, chronically administered bisacodyl leads to elevated serum aldosterone which counteracts the effect of bisacodyl on net water and sodium transport but acts synergistically with bisacodyl on the effect on potassium loss.

Transference and countertransference in anorexia nervosa care

Anorexia nervosa is an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight. Gastrointestinal symptoms that can manifest due to a decrease in food intake include constipation and complications due to laxative abuse. The focus of biofeedback therapy is to holistically assess the patient's symptoms, provide education and return bowel and muscle control to normality. In this article, Anna Swatton discusses the complexities of caring for a patient with anorexia nervosa in a gastrointestinal care setting, by reflecting on a case study. The dynamics and the importance of the therapeutic relationship and its importance of this in ensuring optimal patient care will be discussed.

Treatment Results of Anorexia Nervosa and Bulimia Nervosa in a Residential Treatment Program

Data on the effectiveness of residential treatment for patients with anorexia nervosa (AN) and bulimia nervosa (BN) are limited. We analyzed patient survey results at admission and discharge from Monte Nido Residential Treatment Program. Of 287 consecutive admissions, 80% (231) “graduated” (completed ≥ 30 days of treatment), and of these (all of whom gave consent), only patients with AN (N = 120) or BN (N = 95) were included (215 of 231, 93%) in this study. Analyses included a comparison of admission vs. discharge variables (paired t-tests) for each diagnosis. At each assessment, graduates completed the Eating Disorders Inventory-2 (EDI-2), the Beck Depression Inventory (BDI), and a structured eating disorder assessment questionnaire. For patients with AN, there were statistically significant improvements in mean BMI. In addition, for both AN and BN patients, there were statistically significant improvements in BDI scores, all 11 EDI-2 subscales, and frequencies of bingeing, vomiting, laxative abuse, chewing and spitting, stimulant abuse, and restricting behavior. The great majority of patients completing treatment showed significant improvement at discharge from intensive residential treatment.

The Key to Unlocking the Virtual Body: Virtual Reality in the Treatment of Obesity and Eating Disorders

Obesity and eating disorders are usually considered unrelated problems with different causes. However, various studies identify unhealthful weight-control behaviors (fasting, vomiting, or laxative abuse), induced by a negative experience of the body, as the common antecedents of both obesity and eating disorders. But how might negative body image--common to most adolescents, not only to medical patients--be behind the development of obesity and eating disorders? In this paper, I review the "allocentric lock theory" of negative body image as the possible antecedent of both obesity and eating disorders. Evidence from psychology and neuroscience indicates that our bodily experience involves the integration of different sensory inputs within two different reference frames: egocentric (first-person experience) and allocentric (third-person experience). Even though functional relations between these two frames are usually limited, they influence each other during the interaction between long- and short-term memory processes in spatial cognition. If this process is impaired either through exogenous (e.g., stress) or endogenous causes, the egocentric sensory inputs are unable to update the contents of the stored allocentric representation of the body. In other words, these patients are locked in an allocentric (observer view) negative image of their body, which their sensory inputs are no longer able to update even after a demanding diet and a significant weight loss. This article discusses the possible role of virtual reality in addressing this problem within an integrated treatment approach based on the allocentric lock theory.

Combat laxative abuse by stopping stimulant laxatives and establishing healthy gastrointestinal function

Combat laxative abuse by stopping stimulant laxatives and establishing healthy gastrointestinal function

Anorexia Nervosa: Russell’s Sign with Concurrent Tetany

A 32-year-old female with a history of binge-purge type anorexia nervosa presented with abdominal pain and weight loss of 8 kg over the preceding 2 weeks. She denied prior diuretic or laxative abuse. Physical examination showed a thin female with a BMI of 14.2 kg/m2. The dorsal aspect of her hands revealed abrasions, callosities, and scarring (Fig. 1). Her hands were contracted in tetany, flexed at the metacarpophalangeal joints, with extension at the interphalangeal joints with the thumb flexed and adducted (Fig. 2). Laboratory studies revealed a serum calcium of 5.3 mg/dl, albumin of 3.0 g/dl, and normal serum 25-hydroxyvitamin D and parathyroid hormone levels. Figure 1 The dorsal aspect of the patient's hands revealed abrasions, callosities, and scarring. Figure 2 The patient's hands were contracted in tetany, flexed at the metacarpophalangeal joints, with extension at the interphalangeal joints with the thumb flexed and adducted. Figure 1 demonstrates Russell’s sign, with abrasions on the dorsum of the hand from contacting the incisors during self-induced vomiting1. This finding is reported in approximately 4% of patients with purging type anorexia nervosa2. Figure 2 shows an obstetrician or accoucheur’s hand, demonstrating the resemblance of tetany to the position one’s hand is held in while performing a vaginal delivery. Tetany of the patient's hands resolved with electrolyte repletion. On endoscopic evaluation, her abdominal pain was found to be secondary to esophagitis, likely from self-induced vomiting.

Antiobesity drugs-induced melanosis coli

Melanosis coli is described as a black or brown discoloration of the mucosa of the colon. It is a benign condition arising from laxative abuse and has no symptoms of its own. Representative autopsy appearances of melanosis coli are shown where the deceased took antiobesity drugs. Melanosis coli is most often detected during examinations for long-standing constipation, often in conjunction with a history of the chronic use of anthracene cathartics. This case report is intended to remind the clinicians that extensive melanosis coli may mimic ischemic colitis and thus must be considered as a differential diagnosis.