Bulimia nervosa

Background

• Pattern of binging then purging with self-induced vomiting or abuse of laxatives/diuretics abuse
• Most commonly late adolescent females
• Typically normal to high BMI
• More common than anorexia

Clinical Features

Diagnostic Criteria

• A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
  • 1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
  • 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
• B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
• C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
• D. Self-evaluation is unduly influenced by body shape and weight.
• E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Signs

• Dental enamel loss
• Scarring/erosions of dorsal fingers, hand from self-induced emesis
• Salivary gland hypertrophy (painless, bilateral)

Complications

• Arrhythmias secondary to hypokalemia, particularly with binge-purge subtype
• Metabolic alkalosis
• Dehydration, chronic contraction alkalosis
• Hypokalemia, hypochloremia
• GI complications
  • Odynophagia, dysphagia, hoarseness
  • Heartburn, GERD
  • Cathartic colon syndrome from chronic laxative abuse damaging intestinal nerve cells
• Must avoid use of bupropion as it may lead to seizures in patients with eating disorders

Differential Diagnosis

• Anorexia nervosa, binge eating/purging type
• Binge-eating disorder
• Klein-Levin syndrome
• Major depressive disorder, with atypical features
• Borderline personality disorder
• Organic causes of nausea/vomiting

Labs

• Dependent on type of purging
• Electrolytes

'	Na+	K+	Cl-	Bicarb	pH
Vomiting	Variable	↓	↓	↑	↑
Laxatives	Nl to ↑	↓	Variable	Variable	Variable
Diuretics	↓ to nl	↓	↓	↑	↑

Management

• IVF volume replacement
• Potassium oral replacement 40-80 mEq/day
• Referral to psych for CBT

Disposition

• Consider admission for:
  • Bradycardia <50 BPM
  • Syncope (potentially concerning for arrhythmia)
  • Severe electrolyte derangement
  • Suicidal ideation, concurrent psychiatric disorder

See Also

• Anorexia nervosa

References

https://pedemmorsels.com/eating-disorders/