Medical Complications of Eating Disorders with Purging

Guest Post by Sarah-Ashley Robbins, MD, Gaudiani Clinic

Bulimia nervosa is a serious eating disorder that is defined by recurrent episodes of binge eating with recurrent occurrences of compensatory purging behaviors such as self-induced vomiting, laxative/diuretic/enema abuse, overexercise, or fasting. While it is primarily a psychological disorder, it carries serious medical risks and complications. There is a lot of overlap in the diagnoses of eating disorders involving purging, and people can oscillate between diagnoses depending on behaviors and weight changes. I think it is important to note that the following information can apply to any of the eating disorders with purging including bulimia nervosa, anorexia nervosa-binge/purge type, and atypical anorexia with purging.

Why was it so important to you to start an outpatient eating disorder treatment center focused on the medical management of the patient and what makes the Gaudiani Clinic so unique?

The medical complications and treatment considerations for patients with eating disorders are very unique. It is rare to find a practicing physician today who got more than maybe one lecture in medical school (if that) about eating disorders. If they did get a lecture, it was likely more directed toward the psychological manifestations and complications rather than the medical concerns. The Gaudiani Clinic was started to help fill a gap in medical care as well as be a hub for education and dissemination of information about how to medically support those living with eating disorders. We have a robust network of higher level of care treatment opportunities in this country ranging from intensive outpatient to inpatient care, but many patients leave these treatment centers and come back to the outpatient world without adequate ongoing medical support. Our clinic can help break the cycle of the revolving door treatment model by giving sound medical support while an individual’s outpatient dietitian and therapist continue the focused work needed to guide someone into a more stable recovery state.

Patients with bulimia nervosa often experience oral complications resulting from frequent self-induced vomiting. Will you please walk me through the impact of purging and stomach acid on the salivary glands, jawbones, teeth, and soft tissue of the mouth?

Purging via self-induced vomiting can cause detrimental effects to the mouth. High levels of acid come up into the mouth with vomiting which can lead to tooth decay/cavities, enamel erosion, tooth sensitivity, and inflammation of the gums/soft tissues of the mouth. This can lead to the need for tooth extraction. The salivary glands try to increase production of saliva in response to chronic purging to try to compensate for this increase in acid and overall dehydration. This can lead to hypertrophy or enlargement of the salivary glands. The parotid glands, which sit on either side of the cheek towards the back of the jaw, can be noticeably enlarged (this is called sialadenosis) and make someone’s cheeks appear puffy. Chronic acid exposure to the back of the mouth and throat can cause hoarseness, sore throat, chronic cough, throat clearing, and difficulty with swallowing.

What types of unique GI complications are you looking for specific to patients with bulimia that other medical doctors without eating disorder specialty training may not detect?

Chronic vomiting can lead to a myriad of GI complications. Chronic (even if intermittent) exposure of the tissues of the esophagus to acid can lead to esophageal erosions, dysmotility, and Barrett’s esophagus which can be a precursor to esophageal cancer. Mallory Weiss tears (tears in the lining of the esophagus) can happen and are suspected if there is blood in the vomit. A rare but even more serious side effect is the risk for esophageal rupture (Boerhaave syndrome) due to recurrent vomiting. Chronic laxative misuse can also lead to many GI complications. A common side effect is colonic dysmotility or atonic colon (a completely inert colon) due to dependence on stimulant laxatives. Over time, the colon will require more and more laxatives to move stool effectively. This can make it difficult to come off laxatives. Atonic colon sometimes requires surgical intervention to remove dead bowel. Malabsorption of nutrients or medications via the GI tract is another complication we see with laxative misuse. We also see rectal prolapse where the rectum comes out of the body either with a bowel movement or spontaneously caused by long term misuse of laxatives and/or chronic vomiting.

Is it appropriate for non-eating disorder specialized primary care providers to consider the possibility of bulimia for adolescents and young adults who present with chronic acid reflux, difficulty swallowing, or having the sensation of something stuck in their throat?

Yes, screening questions such as “do you ever /have you ever engaged in self-induced vomiting” should be asked in this scenario. While people can and do have GERD without having an eating disorder, it is extremely common for people with purging eating disorders to have GERD due to the weakening of the lower esophageal sphincter.

What is your recommendation for routine screening for patients with bulimia nervosa who experience electrolyte imbalance attributed to dehydration and malnutrition?

Blood work should be obtained regularly to monitor electrolytes and hydration status. We are most interested in BUN, creatinine, potassium, sodium, bicarbonate, chloride, and phosphorus levels. Monitoring these labs can help guide necessary treatment. Any abnormal blood values/electrolyte abnormalities should be promptly treated (e.g., phosphorus and potassium repletion). An EKG should be performed periodically in those who purge as electrolyte abnormalities can cause EKG concerns such as long QTc or heart strain patterns. The physical exam is helpful as well. We assess the mouth (are mucous membranes dry?), capillary refill, skin turgor, cardiac status (tachycardia, arrhythmias, murmurs), distal pulses and extremities (cold, mottling, edema, etc.) to help determine the risk of electrolyte abnormalities and one’s hydration status.

Why is it crucial for the healthcare provider to have eating disorder training to properly assess and treat these acute issues as opposed to visiting the emergency room for IV hydration?

While IV hydration is sometimes helpful and warranted, this should be determined/recommended by one’s outpatient healthcare provider after a thorough assessment to ensure that other concerns are addressed promptly as well. The ER is not equipped to address the underlying causes and to provide the necessary follow up needed to ensure someone is getting all concerns addressed.

What are the major cardiovascular complications you are screening for in patients with bulimia who experience repeated purging?

Cardiovascular complications can occur in bulimia nervosa. We screen for tachycardia (elevated heart rate) which can be a sign of dehydration or arrhythmia from electrolyte imbalances. The heart muscles can be weakened by long term malnutrition which can present as bradycardia (low heart rate) at rest followed by a large jump in heart rate with minimal movement (i.e., walking across the room). In more severe cases, this can sometimes lead to heart failure. EKGs can elucidate arrythmias such as long QTc syndrome which can lead to deadly arrhythmias that can cause the heart to stop if not addressed promptly. We also look for hypotension (low blood pressure) and orthostatic abnormalities (blood pressure and heart rate changes seen with position changes) which can be caused by dehydration and have negative effects on cardiac function. Chronic purging with resulting dehydration or malnutrition increases one’s risk of passing out due to poor blood perfusion to the brain while upright.

If there is one thing you would like readers to know about eating disorders, what would it be?

You cannot tell if someone has an eating disorder by just looking at them. A well-informed healthcare provider knows we must ask specific questions about eating patterns, purging, exercising, bingeing, laxative use, etc. without assumptions to identify if an eating disorder is present. Knowing this history is the only way we can then do an adequate medical assessment. So many individuals with eating disorders and the medical complications that come with them are missed due to false assumptions that someone does not look “sick” or fit the body type(s) one might associate with eating disorders.

Published by: Merrit Elizabeth

Merrit Elizabeth is an Eating Disorder Recovery Coach certified by The Carolyn Costin Institute. She holds a master’s degree in Health Promotion Management and has years of experience working with women with eating disorders.

Posted on May 1, 2024.