1. MARSIPAN MAnagement of Really SIck Patients with Anorexia Nervosa
Dr Matthew Cahill
Consultant Psychiatrist in Eating Disorders
CWP Eating Disorder Service

2. A Story……

3. SS 20 year old female Diagnosed with Ulcerative Colitis at age 8
Multiple hospital admissions and missed school
Developed Anxiety Disorder and disordered eating

4. SS – ‘Disordered Eating’
Overvaluation of bowel signals
Petrified of diarrhoea and flare-ups
Restricted eating
Probable eliciting of care through sick role
Overwhelming anxiety associated with eating and bowel habits
Misuse of laxatives

5. SS – Early Years
Multiple admissions to General and Mental Health Hospitals
Episodes of severe low weight - mixture of inflammatory bowel disease, laxative abuse, and psychological difficulties
Anxiety, OCD, panic attacks
Under Gastroenterology Team at DGH – poor engagement

6. SS - 2018 May 2018 - Referred to Adult Eating Disorder Service
Weight 35.4kg (BMI 11.9)
Scared of admission – affected engagement
June 2018 – Admitted to Oaktrees EDU

7. Admission 1 June – August 2018
Blood Glucose 1.9 – 3.3
WCC 2.2 Neutrophils 0.9
Abnormal LFTs
Attempts to regain weight unsuccessful
Engaging in behaviours to avoid weight gain
High levels of agitation and anxiety
Constant negotiation over plan
Constant requests for discharge

8. Admission 1 June – August 2018
Difficult decision between collaborative care versus coercive action
Agreed to discharge at BMI 12.2 to attempt community treatment

9. Admission 2 – September 2018 to February 2019
Admitted BMI 11.9
Denied anorexic cognitions
Health anxiety but declined therapy
Faecal incontinence (on supervised bathroom)
Similar presentation to before but physical health more compromised

10. Admission 2 – September 2018 to February 2019
WCC 1.9
Neutrophils 0.7
Bradycardia 41bpm
Hypothermic 35.2 degrees
NEWS 6
Deranged LFTs
Bone Scan – OSTEOPOROSIS

11. Admission 2 – September 2018 to February 2019
Only managed to get BMI to 13.5 by February 2019
Bloods generally stabilised
NEWS 1-2
Completing 1800 calories
Ongoing debates between voluntary versus coercive management
Requested discharge
Hands up…….

12. February 2019 – May 2019 Attempts to engage her in community EDS
BMI 14.4 May 2019
Reluctant to attend or engage in therapeutic work
Discharged from Community EDS May 2019 at her request

13. July 2019
Contact from Specialist Dietitian (DGH) who was seeing SS for Ulcerative Colitis and low weight.
Opening bowels 20x day
Weight loss down to BMI 13.3, further fall to BMI 12.6
Pulse 48, BP 99/65, Platelets 35

14. July 2019
Admitted to DGH
Unhappy about dietetic advice – self-discharged before Section 5(2) could be implemented
Despite reluctance to engage with services – would frequently call Oaktrees EDU for advice

15. August 2019 Admitted to DGH due to low phosphate level (0.6)
Placed under Section 2 of MHA as requested discharge
BMI 10.9, continued to fall
MARSIPAN Guidelines followed

16. August 2019 - DGH Unable to provide 1:1 nursing
SS continued to exercise
?Hiding food
?Purging
Severe diarrhoea
Prolonged QT interval – T-wave inversion V1 – V4

17. August DGH
Push to transfer to Oaktrees EDU, but SS becoming more unwell
Requiring iv Phosphate and Potassium
Weight dropping despite 1200 calorie plan
ALT 204
Phosphate remained low 0.55
Dilemma 1 – push nutrition versus manage refeeding syndrome versus both?

18. August 2019 - DGH Dilemma 2 – Where to treat?
DGH with no 1:1 or ED treatment versus EDU with no iv access / medical input versus APH with no 1:1
NG feeding initiated due to presumed non-concordance with diet
Attempts to increase nursing observations

19. August / September 2019 Transferred to Oaktrees EDU end August
LFTs became more deranged
AST 243, ALT 306, GGT 70
BM 2.8
NEWS 9 (38bpm, 35.0 degrees, dehydration)
Transferred to APH, 1:1 nursing provided by Oaktrees staff

20. September 2019
BMI fell to 10.8
Attempts to refeed affected by low phosphate despite replacement
LFT deteriorating
(ALP 402, AST 2563, ALT 2567, GGT 218)
Platelets 40
Phosphate 0.45

21. September 2019 Tight communication between Oaktrees and APH staff
LFT deteriorated
ALP 537, AST 4717, ALT 4149, GGT 250
S continued to negotiate diet plan. Did not feel she needed increase to 900 calories (NG fed at this point)
Extensive diarrhoea when attempting to feed
No evidence of UC flare-up
Mobility impaired – more difficult to weigh
Platelet count dropping to 30
Phosphate 0.39

22. Mid-September 2019 Platelets reduced to 3
Haematemesis / PR bleeds / Nose Bleeds
Oedema +++
BMI 11.8
Discussion re OGD
Transferred to ITU as tachycardic 150
Diet plan increased

23. Mid-September 2019 OGD Report
In stomach there was some old blood, but no active fresh bleeding. Aspirating this away showed extensive areas of greater curve that were ulcerated / inflamed. Looked rather like ischaemic damage or corrosive damage, rather than typical peptic ulceration. NG tube in stomach and ends need antrum. Will have had some irritation from this, but looks much more extensive than that. Unable to bx as platelets still only 24 today. In antrum no ulceration, but haemorrhagic gastritis here and over incisura. D1 and D2 showed just minor inflammation and much more normal than the stomach. I did take extensive photos and then elected to spray haemospray throughout stomach. This means views then coming back up oesophagus very limited.

24. September 2019 Debate around continued NG feed v TPN
Some signs of improvement (transferred back to ward)
Liver settled (ALP 87, AST 86, ALT 134, GGT 47)
Increased anorexic drive and body image distortion
But – haematemesis increased, Hb 60
Transferred back to ITU
Blood transfusion

25. End September 2019 CT Scan revealed an ischaemic bowel
Decision to provide terminal care
SS died 27th September 2019 aged 20.

26. Anorexia Nervosa has the highest mortality rate of any psychiatric condition
Arcelus J, Mitchell AJ, Wales J. et al, "Mortality Rates in Patients with Anorexia Nervosa and Other Eating Disorders: A Meta Analysis of 36 Studies." Arch Gen Psychiatry 2011, 68: Sonnenville K, Micali N et al., "Common Eating Disorders Predictive of Adverse Outcomes are Missed by the DSM-IV and DSM-5 Classifications." Paediatrics 2012; 130:e289-95

27. MARSIPAN This case adhered to MARSIPAN Guidelines Outcome still tragic
Many success stories over last 10 years
Regional MARSIPAN group established
Still lots of work to be done to prevent further deaths
Lots can go wrong….

28. Who is at risk?
Criteria for determining people at high risk of developing re-feeding
problems (adapted from NICE 2006):
Patient has one or more of the following:
Little or no nutritional intake for more than 10 days
BMI < 16kg/m2
Weight loss >15% within last 3 – 6 months
Low levels of potassium, phosphate or magnesium prior to feeding
History of alcohol abuse or drugs including insulin, chemotherapy, antacids
or diuretics
The presence of purging behaviours
Or patient has two or more of the following:
Little or no oral intake for more than 5 days
BMI <18.5kg/m2
Weight loss > 10% within last 3 – 6 months

29. Who Is at Risk? (My World)
BMI less that 13kg/m2
Losing 1kg/week or more
Abnormal Blood film, Low WCC and Neutrophils
Raised LFTs
Reduced Pulse (<50bpm) and BP (<90/50)
Abnormal ECG
Poor insight / lack of capacity
Actively engaging in activities to promote weight loss

30. Awareness 18 year old Anorexia Nervosa for 5 years
Admitted with low weight after deteriorating in a general psychiatric ward
Medical team re-fed but failed to diagnose refeeding syndrome
Died of multiple organ failure
Lessons
Non-specialist services should work closely with specialist services and hand over care when appropriate
Medical services need to be educated about MARSPIAN
England

31. Diagnosis Age 37 Anorexia Nervosa for 20 years BMI 8.9
Admitted to SEDU
“Lack of regular physical observations or appropriate blood tests”
Died after 4 weeks
Lesson – Patients in high risk range must have regular physical observations
Pulse and BP
Daily ECG
Daily Blood Tests – Electrolytes, LFTs, Calcium, Magnesium and Phosphate
England

32. Urgency
Isabelle Caro
“We want to do some tests but so as not to bother you we will let you have some sleep first”
Died 48 hours later from severe dehydation
Lesson – Make your risk assessment without delay
France

33. Underfeeding Syndrome
21 year old
6 year history of AN
Admitted to A+E with chest pain
No cause found but admitted due to abnormal LFTs
Not fed during admission through fear of refeedign syndrome
Died after 7 days on 0 calories
Lessons – Get patient to SEDU unless medical bed is essential
Avoid refeeding syndrome by refeeding slowly but reassess every 12 hours and increase feed
England

34. Specialist Treatment Age 20 Anorexia Nervosa for 9 years
Admitted to General Psychiatry Ward as no SEDU beds
Died at 32kg
Lesson – Admit to SEDU as soon as possible
Australia

35. NG Tube? 24 years old 6 year history of AN General Medical Ward
Consultant refused to pass an NG tube against patient’s will
Patient overexercised – developed fatal hypoglycemia
Lesson – You may need to treat against patient’s will and/or use NG tube
England

38. MARSIPAN

40. Google MARSIPAN and anorexia
The MARSIPAN Reports
Google MARSIPAN and anorexia

41. Food and Hydration are treatments under the Mental Health Act (1983)

42. Start Vitamins and Minerals
Sanatogen A-Z or Forceval (2 daily)
Calcichew D3 Forte (2 daily)
Thiamine 100mg bd
Vitamin B Co Strong (2 tds)

43. Anorexia Nervosa Re-feeding Syndrome
The first 7-10 days of feeding a seriously ill patient with anorexia nervosa poses a significant risk of developing re-feeding syndrome and its related complications
Essential to re-feed slowly and gradually

44. How to Prevent and Treat Refeeding Syndrome
Recommend that an initial starting intake of 15-20Kcals/Kg of body weight (MARSIPAN Guidelines) is used. Where severity indicators are present, a lower starting intake may be required e.g. 10 Kcals/Kg body weight
Monitor electrolytes by taking daily bloods (no need or point in giving electrolytes prior to commencing feeding even if blood levels low, as until CHO is present to stimulate insulin production which activates membrane pumps, any given prior to this will be excreted.)
Vitamin and trace element supplementation

45. What Should You Do? Access / familiarise MARSIPAN Guidelines Prepare!
Does your hospital have a MARSIPAN pathway?
Is there an identified lead?
Are staff adequately trained / knowledgeable in this area?
Are you aware of local eating disorders provision?

46. What Should You Do? Act Use the Mental Health Act if appropriate
Be mindful / suspicious of compensatory behaviours if not continually observed by nursing staff
Keep a close eye of physical health and weight
Weigh DAILY
Get specialist eating disorder psychiatry help
Keep communication tight
Careful balance between underfeeding and overfeeding
Be understanding towards Mental Health Eating Disorder services – we know our trade, and can assess/predict physical risk

47. Questions…