The medical complications of bulimia nervosa are listed in . Several treatment issues are unique to patients who binge and purge.
Medical Complications of Bulimia Nervosa
Gastrointestinal complications can occur at any part of the gastrointestinal tract from the mouth to the colon. Dental erosion from gastric acid may occur and may be irreversible.58,59
Brushing the teeth after a binge can worsen the problem, but rinsing with baking soda after vomiting seems to alleviate some of the acid-related complications. Parotid gland swelling can occur from repeated vomiting.60–62
Other gastroesophageal complications include reflux due to chronic relaxation of the sphincter and esophageal rupture from vomiting.63
Acute gastric dilitation and rupture is rare but is associated with a mortality rate of 80% when it occurs.64–66
Other gastrointestinal complications include postbinge pancreatitis and constipation due to laxative abuse.67
Cathartic colon with toxic degeneration of Auerbach's plexus due to overuse of stimulant laxatives can render the colon unable to perform normal peristalsis without large doses of laxatives.68,69
Pulmonary and mediastinal complications include aspiration pneumonitis and pneumomediastinum.70,71
Cardiac complications include arrhythmias due to electrolyte imbalances, palpitations and hypertension due to diet pills, and mitral valve prolapse. Emitene (ipecac syrup), which is designed for one-time use, has been associated with cardiomyopathy and death when used repeatedly to induce vomiting.72–74
Endocrine and metabolic complications include hypoglycemia and electrolyte imbalances, particularly hypokalemia. Dehydration leads to aldosterone-induced renal potassium losses, and sodium loss in the stool causes activation of renin-angiotensin resulting in sodium retention and loss of potassium. Finally, in a chronic low potassium environment, a kaliopenic nephropathy occurs when tubular dysfunction leads to decreased urine-concentrating ability. Vomiting leads to loss of hydrochloric acid and a metabolic alkalosis, whereas laxative abuse leads to a loss of bicarbonate and a metabolic acidosis.75–77
Bulimics also may have hypothalamic hypogonadism, even at normal weights. If a progesterone challenge does not lead to withdrawal bleeding, hypoestrogenism is present and is associated with low bone mineral density. Use of estrogen replacement is probably indicated until the binge-purge pattern is eliminated.
Goal setting is important in bulimia and is focused on elimination of binge/purge behaviors, normalization of eating patterns, and resumption of normal menses. Contract setting between the patient and all members of the treatment team includes agreement on monitoring interval; agreement to keep food, exercise, and binge/purge diaries; and agreement on what parameters will be followed and how frequently they will be followed. Although most bulimics can be managed as outpatients, advance discussion about what would mandate more intensive treatment (e.g., severe electrolyte imbalances, need for withdrawal from laxatives or diuretics) is appropriate and should be clearly specified in a written contract shared by the patient and all members of the team. Chronicity of symptoms is not rare. Relapse is more frequent in those who are more symptomatic at onset.
Criteria for inpatient hospitalization in bulimia include severe depression and suicidality; marked fluid and electrolyte imbalances; the need for withdrawal from laxatives, diuretics, emetics, or diet pills; and significant substance abuse.4