We present two young people presenting with IBD and eating disorders and discuss how our management may evolve to prevent eating disorders and support patients with both diagnoses adequately.

Case 1: A 16-year-old girl attended clinic with 3-months weight loss, abdominal pain, loose and bloody stools ten times a day. We admitted her for intravenous fluids and ‘gut rest’. She has severe anxiety, and her mother reports that she has not been eating well for over a year. Meals are restricted to once a day. 48h after admission a nasogastric (NG) tube was inserted and she remains NG fed for anorexia 4 months later. She has an endoscopic diagnosis of ulcerative colitis treated with prednisolone then azathioprine. Blood inflammatory markers are normal but calprotectin remains elevated.

Case 2: A 13-year-old boy with autism was diagnosed with Crohn’s disease in 2021. Initial presentation was with nausea and spasmodic pain. At diagnosis he was noted to be tall for his age (190 cm) and slim with BMI 9th centile. He was treated with prednisolone and gained weight rapidly. He remained withdrawn with refusal to get out of bed. 6 months after steroids were weaned his parents noted that he was not eating and was walking compulsively. They had thought his reduced intake was due to pain; he lost 10kg in 3 weeks. His calprotectin and blood tests were normal. On direct questioning he disclosed he was walking 20000 steps a day and restricting intake to lose weight. He is cared for at home by the community eating disorders team and currently does not attend school.

Discussion These cases show that an eating disorder can make diagnosis and response to treatment in IBD challenging. Additionally, it is well recognized that IBD symptoms and recovery can contribute to developing an eating disorder¹ (crohnsandcolitisdietitians.com/disordered-eating-and-ibd). Case 1 would not have presented with anorexia had she not developed IBD, and it is now unclear whether her abdominal pain and loose stools are related to ongoing inflammation or to enteral feeds after starvation. Case 2 developed anorexia after regaining weight following treatment for Crohn’s disease.

During the COVID 19 lockdowns eating disorders and new diagnoses of inflammatory bowel disease both increased for complex reasons including changes in intestinal permeability with Covid infection and the decline in mental health of young people due to pandemic responses.^{2 3} It is clear from our cases (and others!) that eating disorders are more severe and complex than pre-Covid. It is widely recognized that IBD is a risk factor for disordered eating due to rapid weight loss, reconstitution of weight and often excessive weight gain with steroid treatment, as well as possible restricted foods in many cases may well predispose young people with IBD to developing eating disorders.

In the time following the Covid pandemic vigilance for eating disorders is needed to recognize these early and provide adequate support and resources for patients. We propose standard questions regarding eating and attitude to weight for all IBD patients attending outpatient clinic.

References

1. L Ilzarbe , M Fàbrega , R Quintero , A Bastidas , L Pintor J García-Campayo , F Gomollón , D Ilzarbe. Inflammatory bowel disease and eating disorders: a systematized review of comorbidity. Journal of Psychosomatic Research November 2017;102:47–53.

2. Cortes GM, Marcialis MA, Bardanzellu F, Corrias A, Fanos V, Mussap M. Inflammatory bowel disease and COVID-19: how microbiomics and metabolomics depict two sides of the same coin (frontiersin.org). Front Microbiol. 2022 Mar 21;13:856165. doi: 10.3389/fmicb.2022.856165. eCollection 2022

3. Juliette M. Kersten, Mirjam van Veen, Marlies A. van Houten, Jantien Wieringa, Jeroen G. Noordzij, Jolita Bekhof, Gerdien A. Tramper-Stranders, Héléne Visser-Trip, Nienke J. Vet, Matthijs D. Kruizinga. Adverse effect of lockdowns during the COVID-19 pandemic: increased incidence of pediatric crisis admissions due to eating disorders and adolescent intoxications. European Journal of Pediatrics https://doi.org/10.1007/s00431-022-04773-5