Feb 26, 2020
Patricia Westmoreland, MD, returns to the Psychcast to conduct a
Masterclass on treating bulimia.
Dr. Westmoreland, an attending psychiatrist at the Eating
Recovery Center in Denver,
previously discussed eating disorders. She is an adjunct
assistant professor in the department of psychiatry at the
University of Colorado at Denver, Aurora, and has a private
forensic psychiatry practice in Denver.
- Anorexia nervosa and bulimia nervosa can have life-threatening
- All medical complications can resolve with consistent nutrition
and full weight restoration.
- Eating disorders must be treated and associated behaviors
stopped to prevent complications from returning.
- Anorexia-related medical complications usually are attributable
to weight loss and malnutrition.
- Bulimia-related medical complications can occur at any weight,
and are related to the mode and frequency of purging. Complications
include metabolic abnormalities, such as electrolyte and acid-base
disturbances, volume depletion, and damage to the colon.
- Patients with bulimia have a lower mortality rate than do those
with anorexia. However, the mortality of patients with bulimia is
two times higher than that of age-matched healthy controls because
of acid-base disturbances and severe electrolyte abnormalities.
- The weight of the patients with bulimia does not matter.
Acid-based disturbances and severe electrolyte abnormalities can
kill patients at any time without warning and at any weight.
- About 90% of purging behaviors consists of self-induced
vomiting and/or laxative abuse.
- Self-induced vomiting can cause local complications such as
gastric reflux, which can lead to dysphagia and dyspepsia;
hematemesis from Mallory-Weiss
tears in the esophagus; nosebleeds and subconjunctival
hemorrhages; and parotid gland enlargement, known as
sialadenosis, which is a chronic, noninflammatory cause of
swelling of the major salivary glands.
- Systemic complications of self-induced vomiting include
metabolic derangements, such as hypokalemia, metabolic alkalosis,
and volume depletion, which can lead to pseudo-Bartter
syndrome from chronic aldosterone secretion as the body
attempts to maintain blood pressure; the syndrome is characterized
by hyperaldosteronism, metabolic alkalosis, hypokalemia, and normal
- Treatment of local complications: Gastric reflux can be treated
with proton pump inhibitors, and the patient should be screened for
Barrett’s esophagus with esophagogastroduodenoscopy. Dental
complications such as erosion of the enamel should be addressed
with fluoride-based mouthwashes and toothpastes, and gentle
toothbrushing. Parotid gland enlargement is treated by sucking on
sour candies, applying hot packs, and using anti-inflammatory
- Treatment of systemic complications: Hypokalemia, which is
diagnosed on a basic metabolic panel, needs immediate repletion
orally or intravenously. Depending on the severity of the
hypokalemia, the patient may need cardiac monitoring in the
hospital or ICU to prevent mortality from a lethal arrhythmia. In
pseudo-Bartter syndrome, the elevated aldosterone does not
normalize until a few weeks after purging stops, so individuals can
develop edema and the other electrolyte abnormalities. Treatment is
spironolactone, 25-200 mg/day.
- Complications from laxative abuse occur primarily from
stimulant laxatives, which stimulate the myenteric plexus, the
nerves of the intestines, and increase intestinal secretions and
motility. Cathartic colon syndrome occurs from continued use of
stimulant laxatives, which damage the nerves of the colon by
rendering it incapable of peristalsis without continued use of
laxatives. Individuals who abuse laxatives more than three times
per week for at least 1 year are at risk of cathartic colon
syndrome and need to stop laxatives immediately.
Westmoreland P et al. Medical complications of anorexia nervosa
and bulimia. Am
J Med. 2016;129(1):30-7.
Mehler PS, Walsh K. Electrolyte and acid-base abnormalities
associated with purging behaviors. Int J
Eat Disord. 2016 Mar;49(3):311-8.
Gibson D et al. Medical complications of anorexia nervosa and
Psychiatr Clin North Am. 2019 Jun;42:263-74.
Sato Y, Fukado S. Gastrointestinal symptoms and disorders in
patients with eating disorders. Clin
J Gastroenterol. 2015 Oct;8(5):255-63.
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