Pica patient,status post gastric bypass,improves with change in medication regimen

Abstract

The causes and origins of pica remain unknown and are the source of speculation and heated debate. Bariatric surgery patients are increasingly being observed in eating disorders treatment programs. Often associated with pregnancy, iron deficiency anemia, early development and mental retardation, pica has only recently been noted in post bariatric surgery patients, all of whom presented with pagophagia (eating of ice). Although there is literature detailing the presence of bezoars in gastric bypass patients, the association of pica, bezoars and abnormal eating behavior after bariatric surgery is still not understood completely. We present the case of a patient diagnosed with pica who underwent bariatric surgery due to a specific bezoar causing obstruction, followed by a treatment plan aimed at curbing the impulses. The patient was diagnosed to have a cardboard and paper bezoar causing gastric obstruction, which was removed endoscopically. After incomplete improvement of pica symptoms with treatment including ziprasidone, lorazepam and behavioral therapy, Saphris (asenapine) was introduced resulting in significant and complete resolution.

Introduction

Pica is defined as the eating of nonnutritive substances consistently for over 1 month which is not part of a culturally sanctioned practice [American Psychiatric Association, 2000]. As a syndrome, its causes and origins remain unknown, and are the source of speculation and heated debate. Bariatric surgery patients are increasingly being observed in eating disorders treatment programs. Often associated with pregnancy, iron deficiency anemia, early development and mental retardation, pica has only recently been noted in post bariatric surgery patients, all of whom presented with pagophagia (eating of ice). Previous studies have shown the association between pica and iron deficiency [Moizé et al. 2010]. Although there is literature detailing the presence of bezoars in gastric bypass patients, the association of pica, bezoars, and abnormal eating behavior after bariatric surgery is still not understood completely [Parsi et al. 2013; Patton and Gibbs, 2010; Powers and Miles, 2011; Rohde et al. 2013; Sarhan et al. 2010].

We present the case of a patient diagnosed with pica who underwent surgery due to a specific bezoar causing obstruction, followed by a treatment plan aimed at curbing the impulses. The patient was diagnosed to have a cardboard and paper bezoar causing gastric obstruction, which was removed endoscopically. After incomplete improvement of pica symptoms with treatment including ziprasidone, lorazepam and behavioral therapy, Saphris (asenapine) was introduced resulting in significant and complete resolution.

Case report

Emergency room

A.R. is a 53-year-old Costa Rican female with a past history of anxiety, depression, symptoms of severe personality disorders, cholecystectomy in teenage years, Roux-en-Y gastric bypass 7 years ago for morbid obesity [160 kg; body mass index (BMI) of 60.4 prior to surgery] and a hernia repair 6 years ago. A.R. presented 6 months ago to the emergency department, on her own accord, with a 3-day history of vomiting about 5 minutes after consuming both solids and liquids. These vomiting episodes had occurred 10 times and were associated with ‘fullness’ and an ‘aching’ sensation on a pain scale of 6 out of 10. The patient denied having bowel movements for 3 days. The patient’s last menstrual period was 8 days prior, and her medication regimen at the time was lorazepam 1 mg by moth (po) daily. Upon questioning, the patient denied shortness of breath, chest pain, allergies, smoking or alcohol abuse. Patient admitted to having uncontrollable cravings for paper products, specifically cardboard, which she described as ‘just so delicious’. This craving had led her to consume large amounts of cardboard and newspaper in the days prior to the onset of vomiting.

A.R. was admitted to the hospital in which we gathered serum chemistry, complete blood count (CBC), coagulation studies and a computerized topography (CT) of the abdomen and pelvis. Vital signs on admission were stable and physical exam was notable for mild abdominal distention with no guarding, tenderness, rigidity or masses. No rebound tenderness was elicited. The CT scan showed evidence of postsurgical changes involving the small bowel consistent with gastric bypass, a hiatal hernia, but no obstruction, focal inflammation, free fluids or gas. Laboratory values were within normal limits for amylase, lipase, liver function tests, coagulation studies, troponin, proteins and basic metabolic profile. The patient’s CBC was essentially within normal limits. While not anemic, she was iron deficient, as studies showed her ferritin and iron to be on the low end with ferritin of 10 ng/ml (normal 10–120 ng/ml), vitamin B12 of 299 pg/ml (normal 100–700 pg/ml) and iron of 25 μg/dl (normal 50–170 μg/dl).

A gastroenterologist was consulted and a foreign body was removed endoscopically. The specimen was sent to pathology and was determined to be a gastric bezoar, yellowish green in color, measuring 2.5 cm × 1 cm × 0.8 cm. After removal, A.R. tolerated food and was discharged home on vitamin B12 1000 µg po daily, ferrous sulfate 325 mg 3 times per day, folate 1 mg po daily, calcium with vitamin D 500 mg po twice daily, and esomeprazole magnesium 40 mg po daily. A.R. was referred to the psychiatric outpatient clinic, where she received behavioral therapy and medication follow up.

Psychotherapy

A.R. admitted to having pica urges for most of her life, with uncontrollable exacerbation after her bariatric surgery. A.R. first became self-aware of her impulse control issues after she came across reading material that featured pica. A.R. said that she has had the problem intermittently throughout her life, but it increased in intensity since her gastric bypass surgery for obesity. She described intense periods of pica, which resulted in a bezoar removal. Patient describes her impulse disorder as ‘being attracted to certain smells’ and ‘feeling the urge to eat paper’. The patient claims she likes any kind of paper ‘as long as it is appealing’. Patient consumes other nonnutritive substances as well including cardboard, charcoal, soil, clay, paint and chalk. After A.R. indulges in her urge, she claims to feel relaxed and satisfied. Patient often ate nonnutritive substances at nighttime, claiming, ‘It helps me to go to sleep faster’. Patient’s past history is also notable for eating two or three pencil erasers per day after which she would feel an intense sense of relaxation. A.R. recalls her first urge to eat nonnutritive substances when she was pregnant for the first time at age 15.

A.R. recalls her mother also liked to eat charcoal and soil but does not recall any other substances that her mother may have eaten. After giving birth to her first child, A.R. said the urges and behavior never ceased. A.R. gave birth to two more children and recalls having the same attraction to nonnutritive substances in addition to leather while pregnant. Patient says, ‘I would salivate just thinking about leather’. When not pregnant, A.R. described having the same attraction toward certain smells, but did not feel the same need to indulge in eating nonfood items. Prior to the gastric bypass surgery, A.R. claims to have had better control over her pica urges after giving birth to her youngest child. For reasons unknown, the impulses and desire to consume nonnutritive substances returned after A.R. underwent gastric bypass. A.R. weighed 160 kg prior to surgery. She has lost 22.7 kg since surgery, currently weighing (137 kg) with a BMI of 51.8.

A.R. describes a troubled childhood including sexual abuse and neglect. She had previously been diagnosed with personality disorders not otherwise specified (NOS), noting symptoms of both schizotypal and paranoid personality disorders. Patient has continued to come to the mental health clinic for weekly behavioral therapy sessions with her psychologist. These sessions include having the patient record when she ate nonnutritive substances, what she was thinking about, feeling, and doing right before and after pica behavior.

Pharmacotherapy

Prior to bezoar removal and bariatric surgery, A.R. was taking Valium (diazepam) several years ago for anxiety and difficulty sleeping, but she stopped due to fear of potential addiction. Other medications A.R. had previously been taking include fluoxetine for depression, which she stopped due to fear of side effects, and Ativan (lorazepam) for anxiety. Status post bezoar removal, patient was started on a regimen of Geodon (ziprasidone) 80 mg twice daily with continuation of lorazepam. Monthly follow-up appointments were scheduled to monitor patient’s symptoms of pica. Since the patient was obese and atypical antipsychotics were reported to be useful in the management of pica, ziprasidone was chosen as the patient’s drug regimen [Lerner, 2008]. A.R. has continued supplementation with ferrous sulfate 325 mg three times daily.

After several years in which A.R. had incomplete resolution of pica symptoms, a new drug regimen was started. Ziprasidone was discontinued and Saphris (asenapine) was started. Patient is currently prescribed Saphris, lorazepam and ferrous sulfate. Currently, A.R. is responding well to medication and therapy, reporting a decrease in the urge to eat cardboard, as well as eating any other nonnutritive substances. Prior to the start of Saphris, patient did experience a decrease in pica symptoms, but it was a relative lessoning; instead of indulging multiple times per day, patient would eat nonnutritive substances once daily. After 6 months of Saphris administration, A.R. reports no urge to eat nonnutritive substances. A.R. is confident in wanting to continue her current treatment regimen, which she feels is working successfully and completely to allow her to resist any and all pica impulses.

Discussion

According to the Diagnostic and Statistical Manual of Mental Disorders [American Psychiatric Association, 2000], the diagnostic criteria for pica include persistent eating of nonnutritive substances for at least 1 month that are inappropriate for the specific level of a person’s development, and not an acceptable part of one’s culture. If this occurs with other mental disorders, it must be severe enough to warrant further clinical assessment to receive a separate diagnosis of pica. As in our patient, it is seen at times in pregnant females, but is most commonly found in young children. It is frequently associated with other mental disorders like pervasive developmental disorder and mental retardation. Occasional vitamin and mineral deficiencies, such as iron or zinc, have been reported, but usually no abnormalities are found. Medical treatment usually begins with onset of complications, iron deficiency anemia, or as in this case, mechanical bowel obstruction due to a bezoar.

Several theories have been proposed about the origins of pica. The nutritional theory is popular due to pica’s frequent association with mineral deficiencies, such as iron deficiency anemia, but controversy exists as to whether it is the cause or the result (i.e. anemia due to eating clay instead of iron-containing substances). Another popular theory is that pica is normal in early development; it may be a manifestation of delayed development or mental retardation. The cultural theory is supported by observation of pregnant women eating starch or clay, and the incidence of pica is relatively high in pregnant African American women living in rural areas [Newcomb, 2008]. In the Roux-en-Y procedure, bypass of the duodenum and proximal jejunum can significantly decrease iron uptake in the patient, leading to iron deficiency anemia, and therefore potentially triggering pica in a susceptible patient, such as ours and the ones previously reported [Kushner et al. 2004; Kushner and Shanta-Tetelny, 2005].

While rare, this is not the first reported case of pica associated with bariatric surgery. In 2004, Kushner and colleagues reported the first cases of re-emergent pica following bariatric surgery in two patients with pagophagia (eating of ice) associated with concomitant iron deficiency anemia [Kushner et al. 2004]. Pagophagia is one of the most common forms of pica associated with iron deficiency anemia. The first patient, a 41-year-old white female, presented with uncontrollable ice eating, as well as a previous history of childhood consumption of dirt, chalk and clay. The second patient, a 34-year-old African American woman, suffered from a lifelong desire to eat dirt, which she was able to resist, but succumbed to pagophagia in pregnancy and later developed iron deficiency anemia with a hemoglobin of 5.52 mmol/l. A second series of cases were reported, again by Kushner’s group, one involving a 35-year-old female with iron deficiency anemia and hemoglobin of 5.83 mmol/l and pagophagia presenting two years after Roux-en-Y. Her history was significant for having eaten clay as a child, but this new pagophagia was so intense that she purchased two snow cone machines, one for home and one for work, in an attempt to satisfy her urges. Another patient, a 45-year-old African American female, had an irresistible craving for Tums, eating 40–50 a day, as well as several big gulps of ice. Her hemoglobin at the time was 3.16 mmol/l [Kushner and Shanta Retelny, 2005]. A third case was reported in 2008 and described a 33-year-old woman with iron deficiency anemia presenting with nocturnal pagophagia following Roux-en-Y anastomosis. This woman’s hemoglobin was 3.6 g/dl, and she reported repeatedly waking up in the night and heading downstairs to eat the frost off the icemaker [Marinella, 2008].

The common risk factors appear to be female gender, Roux-en-Y procedure, iron deficiency anemia and pagophagia. It is interesting to note that our patient did not have pagophagia, despite having low iron and a history of Roux-en-Y gastric resection. Several studies have shown that pagophagia, and indeed pica, in iron deficient states and iron deficiency anemia can be rapidly curbed with iron supplements [Kushner and Shanta Retelny, 2005]. Our patient, found to be low in iron, is currently on iron supplementation, yet continues to experience pica cravings, albeit less so than before. It is possible that her pica has confounding psychiatric factors, including history of sexual abuse and family’s reported continual dependence on her.

Treatment of pica is unclear, with each patient likely needing individualized and customized care. Children need proper supervision to watch for ingestion of lead-containing substances such as paint chips. Iron supplements are recommended for iron deficiency anemia, and as prophylaxis for iron deficiency anemia in Roux-en-Y patients [Kushner et al. 2004; Newcomb, 2008]. Pica in pregnant patients needs close monitoring to maintain adequate nutrition and to prevent accidental poisonings [Bernstein and Weinstein, 2007]. A report on three young children with pica noted successful treatment of one with automatic reinforcement, and the other two with a combination of social and automatic reinforcement [Piazza et al. 1998]. A 2008 review of pica in The Psychiatric Times lists the treatment modalities under behavioral options to be differential reinforcement of other behaviors such as chewing gum and response prevention. Under pharmacologic treatments, positive effects have been noted with selective serotonin reuptake inhibitors, bupropion, atypical antipsychotics, buprenorphine and clomipramine. Regardless, all patients are in need of counseling [Blinder and Salama, 2008]. Olanzapine has also been tried as a treatment for pica in isolated cases [Lerner, 2008].

Current literature is very limited regarding the use of Saphris (asenapine) for the treatment of pica. Saphris is a psychotropic agent that is available for sublingual administration. Saphris belongs to the class dibenzo-oxepino pyrroles and comes in tablets containing 5 or 10 mg. To ensure optimal absorption, patients are instructed to place the tablet under the tongue and allow it to dissolve completely. Saphris is rapidly absorbed with peak plasma concentrations occurring within 0.5–1.5 hours. The absolute bioavailability of sublingual Saphris at 5 mg is 35%. Increasing the dose from 5 to 10 mg twice daily results in less than linear (1.7 times) increases in both the extent of exposure and maximum concentration. The absolute bioavailability of Saphris when swallowed is low (<2% with an oral tablet formulation). Saphris is rapidly distributed and has a large volume of distribution (approximately 20–25 l/kg), indicating extensive extravascular distribution [Merck Sharp & Dohme, 2013]. It is important to note both the absorption and distribution properties of a medication when considering prescription in a patient status post bariatric surgery.

Conclusion

Pica remains a mysterious condition with a number of apparent causes and treatments. Patients being considered for bariatric surgery should be evaluated regarding past history of pica, and be monitored for recurrence of this behavior, particularly in iron deficient individuals. In patients whose pica is refractory to treatment with iron supplements, psychiatric intervention may be of help.

Treatment with Saphris (asenapine) has shown to be a novel approach in a patient status post bariatric surgery. It is likely that medications taken orally in a patient with reduced stomach surface area may show decreased affectivity of the drug being prescribed. Since Saphris is absorbed sublingually, it bypasses the gastric system, thus increasing its total bioavailability when distributed. Other nutritional derangements due to deficiencies of micronutrients like iron, vitamin B12, fat-soluble vitamins, thiamine and folate are especially common after malabsorptive bariatric procedures. In our patient with pica and a history of bariatric surgery, Saphris has shown to be a very effective treatment in not only reducing symptoms, but also complete resolution of impulse urges for the past 6 months. Continued psychotherapy and pharmacotherapy will proceed with A.R. to ensure further progress and to limit the possibility of pica recurrence.