CASE REPORT
Hyperbaric Oxygen for Anorexia Nervosa
Akinori Masuda, Tamotsu Nakano*, Hisato Uehara**, Katsuro Kuroki** and Chuwa Tei
Abstract
Hyperbaric oxygenwas given to a patient with anorexia
nervosa who had developed postoperative ileus, resulting
in not only improvement in ileus, hut also enhancement of
intestinal movement, inducing the feeling of hunger, and
thereby increasing food ingestion. Hyperbaric oxygen may
be effective as an initial treatment for anorectic patients
showing severe bloating and resistance to food ingestion.
(Internal Medicine 40: 635-637, 2001)
Key words: appendicitis, ileus, cognitive behavioral therapy,
gut motility
Introduction
Anorexia nervosa is an eating disorder characterized by fear
of fatness and compulsive dieting with resulting body weight
<85%of normal and with secondary amenorrhea in women
(1). About 90%of anorectic patients complain of constipation
and/or bloating (2). A study examined small bowel transit time
in anorectic patents and found it to be prolonged compared
with controls (3). Whole-gut transit time was significantly de-
layed in anorectic patients compared with controls (4). This
delayed transit could cause the patient to feel bloated, thereby
exacerbating fear of fatness.
Hyperbaric oxygen was given to an anorectic patients who
showed a strong bloating and gastric discomfort. Consequently,
intestinal movementwas improved, inducing feelings of hun-
ger, thereby allowing food ingestion. This is the first report
that suggests the potential for hyperbaric oxygen as a newtreat-
ment for anorexia nervosa.
Case Report
A 17-year-old female came to our hospital with anorexia
and malaise in April 1999. She refused to attend school. The
patient was 167 cm tall, and weighed 42 kg (body mass index
14.3); laboratory findings were normal. Based on amenorrhea
Fromthe First Department of Internal Medicine, *the Department of Psychosomatic Medicine, Kagoshima University, Kagoshima and **Kuroki Gastrointes-
tinal Surgical Hospital, Kagoshima
Received for publication July 3, 2000; Accepted for publication December 28, 2000
Reprint 890-8520
requests should be addressed to Dr. Akinori Masuda, the First Department of Internal Medicine, Kagoshima University, 8-35- 1 Sakuragaoka, Kagoshima
Internal Medicine Vol. 40, No. 7 (July 2001)
and fear of fatness, restricted-type anorexia nervosa was diag-
nosed (1). Anorexia and school refusal had continued since
she had encountered bullying one year earlier. Six months later,
her body weight decreased from 60 kg to 44 kg, and amenor-
rhea developed. Moreover, postprandial gastric discomfort,
nausea, and constipation werepresent, and general malaise was
aggravated. Noorganic abnormalities were revealed by gas-
troscopy and colonic examination.
Cognitive behavioral therapy was given (5). Food ingestion
was started from 800 kcal/day, but she could not eat because
the mere sight of food caused gastric discomfort. Drip infusion
of glucose solution (500 ml) was initiated, but her body weight
further decreased to 40 kg. Four weeks after admission, a slight
fever (37.8°C) and epigastric and periumblical pain appeared.
White blood count (WBC) was 7,600/mm3, but C-reactive pro-
tein (CRP) increased to 4.8 mg/dl, suggesting appendicitis.
Antibiotics were delivered via intravenous drip. On the fol-
lowing day, however, a high fever (39.5°C), aggravation of lower
abdominal pain, and muscular defense were appeared, and
WBCincreased to 10,200/mm3. Because perforation of the
vermiformappendix was suspected, emergencysurgery was
carried out, demonstrating perforation and abscess.
A fluid-based diet was initiated 2 days after operation, re-
placed by rice gruel 5 days later. Abdominal pain and disten-
sion appeared on the following day, and ileus was diagnosed
based on plain abdominal radiograph. Her body weight de-
creased to 38 kg. Total protein decreased to 5.2 g/dl, and edema
appeared in her lower limbs. Intravenous hyperalimentation and
hyperbaric oxygen (HBO, 2 atm for 60 min once a day) were
given. After the 2nd HBO,colonic peristaltic movementwith
flatus wasobserved. Peristaltic movementwasconfirmedby
auscultation, as well as by the patient's awareness of bowel
sounds. Solid stool was noted after the 4th HBO,bloating and
gastric discomfort was resolved after the 5th HBO.After the
8th HBO, ileus improved (Fig. 1) and the feelings of hunger
becamestronger, and she began to feel the urge to eat. There
were no side effects of hyperbaric oxygen. Afluid-based diet
was initiated, followed by stepwise recovery to a normal diet.
The amount of food was gradually increased at a rate of 200
kcal/day when the patient felt hungry and requested more food.
During this diet therapy, as improvement in the general physi-
635
 Masuda et al

cal condition was the top priority, no behavioral therapy or
psychotherapy that might excite the patient was performed.
However, counseling was given to reduce anxiety of the pa-
tient and her family. The patient was discharged from the hos-
pital because she wanted to return to school to avoid problems
in school attendance required for graduation. At discharge, the
patient could consume 2,000 kcal/day of food, and her body
Figure 1. Plain abdominal radiographs. Left: before hyperbaric
oxygen (HBO), Right: after HBO.
weight had increased to 43 kg (Fig. 2).
Discussion
Amongpatients with anorexia nervosa, resistance to eating
is strong due to fear of fatness, coupled with digestive prob-
lems such as constipation, bloating and postprandial gastric
discomfort. For treatment, cognitive behavioral therapy is per-
formed, and the dietary intake is gradually increased from a
low calorie level in order to correct the wrongcognition con-
cerning diet and body weight, and to transform the eating be-
havior (6). Difficulties are frequently encountered in treating
such patients because it is hard to transform cognition and be-
havior.
Here, hyperbaric oxygen was given to an anorectic patients
who had developed postoperative ileus, resulting in not only
improvement in ileus, but also enhancement of intestinal peri-
staltic movement, inducing feelings of hunger, thereby increas-
ing food ingestion. Her fear of gaining weight was reduced by
lessening the sensations of bloating. As a result, the amountof
food ingestion gradually increased, and the body weight in-
creased to 43 kg, accompanied by recovery of total protein levels
to 7.0 g/dl. Therefore, the patient was discharged from the hos-
pital. After returning to school, the amountof food ingestion

_ 46-

I«- ^
m 38- -^^ à""^"^
2,000

1,800
1? 1,600
^ i--
§ T1 1,400
0 Ileus j
-2 Appendicitis 1>2QQ
'Z I 1,000
1 800kcal/day | ,r I

' HBO
Operation
i i t i i I I I 1 1 1 1
1 2 3 4 5 6 7 8 9 10 ll 12

Time after admission (week)

Figure 2. Changes in dietary intake and body weight (kg). Food ingestion was started from 800 kcal/day, but she could
not eat. Hyperbaric oxygen (HBO) was given for ileus. After the 8th HBO, ileus improved and the feeling of hunger
became stronger. She began to eat, follwed by stepwise recovery to 2,000 kcal/day.
636 Internal Medicine Vol. 40, No. 7 (July 2001)
 HBOfor Anorexia Nervosa
was maintained, and the body weight further increased to 45
kg. But amenorrhea continues because her body weight is only References
75% of normal value. The patient graduated from high school
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Yasuyuki Koga for their excellent clinical support.

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