Choledocholithiasis leading to diagnoses of severe malnutrition and atypical anorexia nervosa in an adolescent

An adolescent female presented with acute cholecystitis associated with obstructive choledocholithiasis. As she was being prepared to undergo urgent endoscopic retrograde cholangiopancreatography and cholecystectomy, it was noted that she was profoundly bradycardic with resting heart rate as low as 33 beats per minute. Though her body mass index was within normal limits at presentation, her bradycardia prompted review of her growth curve which showed almost 100 pounds of weight loss in the previous year. History revealed severe disordered eating behaviours and led to a diagnosis of atypical anorexia nervosa. Rapid weight loss likely caused her acute biliary presentation, cardiac compromise and a high risk of refeeding syndrome that needed to be addressed before she could safely undergo surgery. This case highlights the severity of medical complications of malnutrition and eating disorders in youth presenting with normal or high weight, and the importance of early recognition for good prognosis.