From the Guidelines
When evaluating gastrointestinal symptoms in eating disorder patients during refeeding, focus on severity, persistence, and specific warning signs, and investigate further if symptoms are severe, persistent beyond 2-3 weeks of consistent nutrition, or accompanied by warning signs, as recommended by the American Psychiatric Association practice guideline for the treatment of patients with eating disorders 1. The initial evaluation should include a comprehensive review of systems, assessment of vital signs, and laboratory assessment, including a complete blood count and a comprehensive metabolic panel, as recommended by the American Psychiatric Association practice guideline for the treatment of patients with eating disorders 1. Key considerations include:
- Red flags warranting immediate workup, such as severe abdominal pain, significant distension, persistent vomiting not self-induced, blood in stool, fever, or signs of electrolyte disturbances
- The potential for refeeding syndrome, which can cause GI symptoms due to rapid shifts in fluids and electrolytes, particularly phosphate, potassium, and magnesium, as noted in the ESPEN practical guideline: clinical nutrition in cancer 1
- The importance of gradual refeeding with close monitoring of electrolytes to minimize symptoms, as recommended in the ESPEN guidelines on nutrition in cancer patients 1
- The possibility of comorbid functional GI disorders, such as IBS or delayed gastric emptying, which may require specific management alongside refeeding, as suggested by the ESPEN guideline on clinical nutrition in inflammatory bowel disease 1 A multidisciplinary approach involving gastroenterology consultation can be valuable for complex cases where symptoms persist despite appropriate refeeding protocols, as recommended by the American Psychiatric Association practice guideline for the treatment of patients with eating disorders 1. The initial workup should include a comprehensive physical exam, basic metabolic panel, complete blood count, liver function tests, amylase/lipase, and possibly abdominal imaging if indicated, as suggested by the guidelines for enteral feeding in adult hospital patients 1. Additionally, consider the importance of supplying vitamin B1 in daily doses of 200-300 mg as well as a balanced micronutrient mixture, and monitoring and substituting electrolytes, such as potassium, phosphate, and magnesium, as necessary, as recommended in the ESPEN guidelines on nutrition in cancer patients 1.
From the Research
Identifying Refeeding Syndrome in Eating Disorder Patients
To determine when to work up GI symptoms in eating disorder patients during refeeding, it is essential to understand the signs and symptoms of refeeding syndrome. Refeeding syndrome is a potentially fatal condition that can occur in patients receiving parenteral, enteral, or oral feedings after a period of sustained malnutrition or starvation 2. The syndrome is characterized by hypophosphatemia, hypokalemia, and hypomagnesemia.
Clinical Manifestations and Diagnosis
The clinical manifestations of refeeding syndrome include hypophosphatemia, hypomagnesemia, hypokalemia, and thiamine deficiency, which can lead to Wernicke's encephalopathy/Korsakoff psychosis and sodium/water retention 3. However, the diagnosis of refeeding syndrome is not facilitated by a universal agreement on its definition, and the presence of hypophosphatemia alone does not necessarily mean that refeeding syndrome is present 4.
Key Considerations for Refeeding
When refeeding eating disorder patients, it is crucial to:
- Monitor patients closely for signs and symptoms of refeeding syndrome, such as hypophosphatemia, hypomagnesemia, and hypokalemia 3
- Provide generous vitamin and electrolyte supplementation while increasing calorie intake reasonably rapidly from 10 to 20 kcal/kg/24 hours 3
- Be aware that patients may not be hungry initially, but the restoration of their appetite over a few days can indicate that the risks of refeeding have been managed 3
- Consider using a higher-calorie refeeding protocol, which may be safe and associated with a lower incidence of hypoglycemia 5
Distinguishing Refeeding Syndrome from Other GI Symptoms
To distinguish refeeding syndrome from other GI symptoms, clinicians should:
- Look for a consistent pattern of abnormally low phosphorus and magnesium levels, as hypophosphatemia is a consistent finding in refeeding syndrome 6
- Be aware that other laboratory abnormalities, such as hypokalemia, hypomagnesemia, and hypocalcemia, may not be consistently present 6
- Monitor patients closely for clinical signs and symptoms, such as edema, hypoglycemia, and electrolyte disturbances, which can indicate refeeding syndrome 5