EDs in the ED - Recognition and Managemeng of Eating Disorders

Eating disorders have the highest mortality rate of any psychiatric illness and are frequently missed in the Emergency Department. Patients rarely present with complaints that suggest an eating disorder, and normal BMI, labs, or vitals do not exclude severe pathology. Early recognition and appropriate intervention can save lives.

Why Are Eating Disorders Missed in the ED?

Despite their severity, eating disorders (EDs) are often under-recognized in emergency settings. Here’s why:

1. Lack of Training

• Only 42 of 637 U.S. residency programs offer formal ED training.

• Just 1.9% of EM physicians report receiving eating disorder education during residency.

2. Misconceptions & Bias

• Most patients do not appear emaciated—many have normal BMI or appear athletic (especially males).

• EDs affect all genders, ethnicities, and socioeconomic backgrounds.

• Weight stigma and diet culture contribute to under-recognition.

3. Patient Factors

• Denial, shame, and poor insight are common—parallels with schizophrenia or dementia.

• Patients rarely disclose eating disorder behaviors. Common ED presentations: vague GI symptoms, syncope, dizziness, fatigue, chest pain.

Clinical Pitfall: Dismissing vague symptoms (e.g., dizziness or abdominal pain) as benign without considering an underlying eating disorder.

Medical Complications: Every Organ System is at Risk

System	Complication Examples
Cardiac	Bradycardia, QT prolongation, heart failure, sudden cardiac death
Hematologic	Pancytopenia, bleeding risk
Neurological	Seizures, Wernicke’s encephalopathy, suicide risk
Endocrine	Hypoglycemia, osteoporosis, refeeding syndrome
Pulmonary	Aspiration pneumonia, spontaneous pneumothorax
GI	SMA syndrome, esophageal rupture, pancreatitis

Pitfall: A normal BMI, normal vitals, or normal labs do not rule out life-threatening complications.

Screening: Use the SCOFF Questionnaire

Ask the following validated screening questions:

• Do you make yourself Sick because you feel uncomfortably full?

• Do you worry you have lost Control over how much you eat?

• Have you recently lost more than One stone (14 lbs / 6.35 kg) in 3 months?

• Do you believe yourself to be Fat when others say you are too thin?

• Would you say Food dominates your life?

2 or more “yes” answers = high suspicion for an eating disorder.

Key Physical Exam Findings

• Bradycardia: HR <50 bpm (day) or <45 bpm (night) — common admission criterion.

• Orthostatic changes: SBP drop >20 mmHg or HR rise >30 bpm.

• Weight assessment:

  
  

  • Post-void, in hospital gown, patient blinded to weight.

  • Admission criteria:

    
    

    • BMI <15 kg/m² in adults.

    • <75% expected body weight in adolescents.

    • Weight loss >10% over 1–3 months.

  
  

• Skin & Oral Clues:

  
  

  • Lanugo, dry skin, hypercarotenemia (orange palms).

  • Russell’s sign (knuckle calluses), dental erosion from purging.

Clinical Pitfall: Do not attribute bradycardia to “athleticism” in a teen—always assess for an eating disorder.

Laboratory Workup

Ensure your ED has a standardized Eating Disorder order set. If not, advocate for one.

Test	Why It Matters
ECG	Bradycardia, QT prolongation
Electrolytes	Look for hypokalemia, hypophosphatemia, hypoglycemia
CBC	Pancytopenia
LFTs, Amylase, Lipase	Amylase ↑ from purging; lipase screens for pancreatitis
Urinalysis	pH >8 (catabolism), ketones (starvation)
ESR/CRP	Rule out IBD mimics

Pitfall: Normal results do not mean the patient is safe for discharge - clinical judgment trumps the numbers.

Refeeding Syndrome: Know It, Prevent It

A life-threatening complication when reintroducing nutrition:

Key Features:

• Severe hypophosphatemia (hallmark)

• Hypokalemia, hypomagnesemia

• Fluid overload, arrhythmias, respiratory failure

Management:

• Replace phosphate aggressively if <0.32 mmol/L

• Monitor closely for arrhythmias and fluid shifts

Admission Criteria

Criteria vary, but common indications include:

• HR <50 bpm (day) or <45 bpm (night)

• Orthostatic instability (SBP drop >20 mmHg or HR rise >30 bpm)

• Electrolyte derangements (especially hypophosphatemia, hypokalemia)

• BMI <15, acute food refusal, syncope, or suicidal ideation

If discharging, arrange urgent outpatient eating disorder follow-up within 1-2 weeks.

Communication Tips

• Validate distress:

  • “I understand this is hard. We’re here to help.”

• Externalize the illness:

  • “This isn’t you - it’s the eating disorder talking.”

• Involve caregivers: Especially crucial for adolescents.

• Avoid minimization:

  • False reassurance delays recovery.

• Reframe food:

  • “Food is medicine - essential to healing.”

Key Take-Home Points

• EDs are common, dangerous, and frequently missed.

• Patients may appear well - do not rely on BMI or labs alone.

• Use SCOFF, weight history, and thorough vital/exam assessment.

• Look for red flags: bradycardia, orthostasis, rapid weight loss, purging signs.

• Be cautious with IV fluids in malnourished patients.

• Refeeding syndrome = emergency—think “hypophos!”

• Have a low threshold for admission and early specialist involvement.

Early detection can prevent life-threatening complications and save lives.

Stay vigilant. Screen. Act.

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