Case Presentation
A 26-year-old Caucasian woman who had been grappling with a severe and enduring battle against anorexia nervosa had a history marked by her relentless struggle with the disease. Doctors initially diagnosed her with anorexia nervosa of the restrictive subtype when she was just 16, even though the first signs of the disorder emerged at the tender age of 13. Her journey through treatment began at age 18 when she checked into her first residential treatment facility. Over the next eight years, she experienced multiple admissions, totaling six, with stays from the ages of 18 to 26. In addition, she had to be hospitalized seven times for acute medical stabilization, starting at the age of 15.
This young lady, with a height of 5 feet, 5.5 inches, saw her weight fluctuate dramatically over the years. At the age of 13, her highest recorded weight was 127 pounds, yielding a Body Mass Index (BMI) of 20.8. However, her lowest point came at age 19 when she weighed merely 82 pounds with a BMI of 13.4. Her turbulent journey led her back to residential treatment at 26, where she stayed for two months. Alarmingly, soon after her discharge, she lost 17 pounds in just two months, plummeting from 116 pounds (with a BMI of 19) to 99 pounds (with a BMI of 16.2).
Multiple Presentations
She found herself in the emergency department, with “unintentional weight loss and nausea with a history of anorexia nervosa” as her chief complaint. However, her routine laboratory tests returned “normal” results. Thus, doctors sent her home with the diagnosis of “non-intractable vomiting with nausea, unspecified vomiting type.” She made a second visit to the same emergency department three weeks later. This time with complaints of “nausea, vomiting, diarrhoea, unintentional weight loss (followed by a dietician), worsening pain, and decreased intake.” Yet again, doctors discharged her with the same diagnosis, as her labs showed no concerning abnormalities.
It wasn’t until her third visit to the emergency department, six days later, that she was hospitalized. This was due to severe malnutrition and persistent symptoms of nausea, vomiting, inability to eat, early satiety, and constant “fullness.” It’s important to note that her physical examination yielded no irregularities except for her noticeably thin body build. Her lab results remained “normal.” During the two months leading up to this hospitalization, she had lost a staggering 15.5% of her total body weight. Her BMI fell from 19 to 16.2.
Final Diagnosis
As medical professionals attempted to place a DobHoff tube for enteral feedings, they encountered difficulty during fluoroscopic-guided placement. Suspecting superior mesenteric artery (SMA) syndrome, further examination with ultrasound confirmed the diagnosis, revealing an “acute aorto-mesenteric angle that can be seen with SMA syndrome.” The treatment plan that followed involved nutritional rehabilitation, lasting for three weeks. Her symptoms, consistent with SMA syndrome, gradually improved alongside weight gain. Remarkably, despite still being underweight, her SMA syndrome resolved completely with consistent weight gain, leading to the disappearance of her abdominal pain and early satiety.
Discussion
Anorexia nervosa (AN) is marked by self-imposed starvation, malnutrition, and significant weight loss in individuals or inadequate weight gain in growing children due to an intense fear of gaining weight or a distorted body image. To receive a diagnosis of anorexia nervosa according to the DSM-5, individuals must meet three specific criteria:
They must restrict their calorie intake significantly, resulting in a body weight that is significantly below the expected range for their age, sex, development, and overall physical health (less than minimally expected). The individual must possess an intense fear of gaining weight or exhibit persistent behaviours that hinder weight gain. They must experience disturbances related to their body weight or shape. Moreover, it has a profound impact on self-worth based on body weight or shape
Despite its origins in psychiatric conditions, it is a multifaceted medical disorder with implications for neurobiology and metabolism. The DSM-5 distinguishes between two subtypes—the restricting type and the binge-eating/purging type. The restricting type refers to individuals who achieve weight loss through methods such as dieting, fasting, and excessive exercise without engaging in binge eating or purging behaviours over the past three months. In contrast, the binge-eating/purging type pertains to patients who have experienced recurrent episodes of binge-eating or purging within the same three-month period. This may include self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
While AN predominantly affects adolescent girls and young women, around 10% of patients are male. Notably, anorexia nervosa is the sole psychiatric condition linked to multiple, often life-threatening medical complications that impact virtually every organ system, intensifying as the disease progresses. Consequently, AN has the highest mortality rate among all eating disorders.
Anorexia with SMA Syndrome
Although research on SMA syndrome in AN is limited, there is a call for a more balanced approach to diagnosing and acknowledging medical conditions in parallel with psychiatric illnesses. This case report underscores the distinctive aspect of anorexia as the only psychiatric disorder intertwined with numerous, potentially life-threatening medical complications. Ordinarily, the mesenteric fat pad secures the superior mesenteric artery, preventing its displacement. SMA syndrome, however, stems from reduced mesenteric fat pad around the artery. It causes the compression of a portion of the duodenum as it passes between the abdominal aorta and the superior mesenteric artery. As mentioned earlier, many symptoms of SMA syndrome can overlap with those of anorexia nervosa. Consequently, physicians need to maintain a high level of suspicion when evaluating patients with significant weight loss, early satiety, and persistent abdominal pain in the context of an anorexia nervosa diagnosis.
