Barrett’s esophagus in a patient with bulimia nervosa:A case report

lNTRODUCTlON

Barrett’s esophagus is the condition in which metaplastic columnar epithelial cells with gastric and intestinal features replace the stratified squamous epithelium that normally lines the distal esophagus.The condition develops due to chronic gastroesophageal reflux disease(GERD)and is a significant risk factor for adenocarcinoma of the esophagus[1].Bulimia nervosa is characterized by recurrent episodes of binge eating followed by inappropriate compensatory behavior to prevent weight gain,such as selfinduced vomiting,misuse of medications such as laxatives,diuretics,insulin,or thyroid hormone[2].

Binge eating disorder represents a real health problem.Low treatment rates highlight the importance of questioning patients about eating problems even when not mentioned in their presenting complaints[3].The complications that occur with bulimia nervosa can affect many organ systems and depend upon the method and frequency of purging(

self-induced vomiting or misuse of laxatives,diuretics,or enemas)[4].Gastrointestinal complications of bulimia nervosa can include GERD and Barrett’s esophagus[5].

CASE PRESENTATlON

Chief complaints

We present a case of a 47-year-old male patient referred for upper endoscopy for having heartburn and vomiting after meals.

History of present illness

The patient denied any history of eating or psychological disorders.

History of past illness

Upon intense history taking and after several attempts,the patient reported a 17-year history of having frequent heavy meals and drinking large amounts of carbonated drinks up to 10 cans every day,followed by self-induced vomiting using the index finger of the right hand.This condition confirms the diagnosis of bulimia nervosa.The patient also reported heavy smoking of Shisha.

Personal and family history

Gouda A performed the endoscopic procedure and collected the patient’s data;El-Kassas M wrote the first draft of the manuscript;Both authors reviewed and approved the final version of the manuscript.

Physical examination

Upon physical examination,abrasions and callosities were noticed on the dorsum of the right hand(Russell’s sign of self-induced vomiting,Figure 1A),and teeth erosions were observed(Figure 1B).

Laboratory examinations

Routine laboratory investigations were within the accepted ranges.

Imaging examinations

Long-term acid suppression was decided as a treatment for Barrett’s esophagus,in addition to the scheduling of an endoscopic surveillance program.

FlNAL DlAGNOSlS

The patient was diagnosed with bulimia nervosa and Barrett’s esophagus.

One day he said abruptly151 to his companion: O dear friend! I wish you would tell me what the rose did to the cypress, and what the sense of the riddle is

TREATMENT

Upper endoscopic examination showed incompetent dilated cardia with GERD grade D(Los Angeles classification).The lesions started 25 cm from the incisors.Salmon-red mucosal projections into the esophageal lumen and mucosal islands were observed.Multiple biopsies were taken,which later showed metaplastic columnar epithelium typical for Barrett’s esophagus without dysplasia(Figure 2).

OUTCOME AND FOLLOW-UP

Patient was referred for psychiatric consultation.

DlSCUSSlON

GERD symptoms in patients with eating disorders such as bulimia nervosa are usually linked to repeated,self-induced vomiting,but the relationship is still unclear[6].Acid exposure is not limited to purging patients;binge eating itself,which is commonly associated with various esophageal disorders,could be a risk factor for GERD[7].

In our case,there was a history of upper gastrointestinal problems,which was the chief presenting complaint.On the other hand,a more profound history revealed the riddle of the bulimia nervosa diagnosis that was beneath this presenting ailment.The patient had been suffering from bulimia nervosa for 17 years without a diagnosis because of his unwillingness to consult a therapist or because of the stigma possibly associated with the disease in his imagination.The patient had a history of binge eating episodes,including increased calorie intake and compensatory purging to eliminate the extra food intake.This led to the diagnosis of bulimia nervosa induced Barrett’s esophagus in our case,which is a rare occurrence.Many cohort studies reported that patients with Barrett’s esophagus who received maintenance therapy with proton pump inhibitors had a lower probability of developing neoplastic Barrett’s esophagus than those who did not receive maintenance therapy[12].Diagnosing Barrett’s esophagus in such cases should make a difference,considering the possibility of prescribing long-term proton pump inhibitors.

Repeated acid exposure can be associated with the development of Barrett’s esophagus,whereby the esophageal squamous epithelium is replaced by metaplastic columnar epithelium,being more susceptible to malignancy[8].Theoretically speaking,prolonged standing self-induced vomiting may be associated with the development of Barrett’s esophagus,but there is no definitive conclusion can be reached due to lack of data[9].Barrett’s esophagus is associated with a 30-fold increased risk of developing esophageal adenocarcinoma over the general population[10].Moreover,there are few case reports of patients with bulimia nervosa presenting with worsening epigastric pain and reflux who were finally diagnosed with esophageal adenocarcinoma[11].

CONCLUSlON

A thorough understanding of the risk factors for Barrett’s esophagus is required to combat the rising incidence of this precancerous lesion worldwide.The emerging risk factors for GERD and Barrett’s esophagus must be updated considering the rising incidence of psychological eating disorders in today’s world.Additionally,providers should consider endoscopic evaluation of patients with eating disorders who have persistent symptoms of dyspepsia or vomiting,given the potential risk of esophageal precancerous and cancerous disorders.

The Ant-King, with his thousands and thousands of followers31, had come during the night, and the grateful creatures had industriously32 gathered all the millet together and put it in the sacks

FOOTNOTES

His body mass index was maintained throughout this period,with no significant medical history.

The authors have read the CARE Checklist(2016),and the manuscript was prepared and revised according to the CARE Checklist(2016).

Then he started off in pursuit, making his way through bushes and briars, and never stopped all day; but in the evening the stag entirely disappeared, and when golden lad came to look about him he found himself just opposite a hut in which lived a witch

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.An informed consent was obtained from the participant included in the study.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: https://creativecommons.org/Licenses/by-nc/4.0/

Maris was traded to the St. Louis Cardinals10 on December 8, 1966-a dark day for me. That year, I went off to college at the University of Akron, in Ohio. My roommate had a picture of Raquel Welch on his wall, and I had a picture of Roger Maris.

“Thank you,” said little Gerda, and then she went to the other flowers, and looked into their little cups, and asked, “Do you know where little Kay is?” But each flower, as it stood in the sunshine, dreamed only of its own little fairy tale of history. Not one knew anything of Kay. Gerda heard many stories from the flowers, as she asked them one after another about him.

Nothing related to this work.

Egypt

Ahmed Gouda 0000-0001-5992-6113;Mohamed El-Kassas 0000-0002-3396-6894.

Long ago there lived a rich merchant who, besides possessing more treasures than any king in the world, had in his great hall three chairs, one of silver, one of gold, and one of diamonds

Fan JR

Filipodia

Well, you must take it to a goldsmith and get him to make it into a golden lion, with eyes of crystal9; and inside it must have something that will enable10 it to play tunes11

Fan JR

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