Bulimia and the Damage Done

Recently in the office waiting area, I noticed a wheelchair-bound young woman who was very thin, weak and pale. Though she weighed less than 80 pounds, her ashen, grey skin made her stand out the most. I gathered that this patient had an eating disorder.

After consulting with multiple gastroenterologists–including a specialists in other states–she sought one of my colleagues for an evaluation of chronic nausea, vomiting and abdominal pain. The patient’s diagnosis was gastroparesis (slowed emptying of the stomach). Also believing she suffered from anorexia and bulimia, my colleague suggested psychiatric treatment, but the patient refused.

Soon after, I was called to the local Emergency Department to help a young woman with weight loss, vomiting and dehydration. It was the same patient that I saw in the office waiting area–only weaker and paler.

Bulimia is an eating disorder that involves cycles of secretive bingeing and purging. Purging is any inappropriate attempt to control weight, such as self-induced vomiting, abuse of laxatives/diuretics/enemas and excessive exercise. Like anorexia, bulimia is a psychiatric disorder.

Medical complications from bulimia affect many organ systems, depending on how—and how often—a patient purges. Gastroenterologists see many such cases. Most patients say they have heartburn and difficulty swallowing. This often happens when induced vomiting exposes the esophagus to too much stomach acid, causing irritation and inflammation. Habitual, self-induced vomiting also causes a loss of the gag reflex, swollen salivary glands and impaired movement of the muscles of the esophagus. Sometimes the vomiting can be so violent that it brings up blood.

Patients with bulimia sometimes end up with tears at the end of the esophagus, called Mallory-Weiss tears. Most will also experience stomach pains, bloating and gas. Those that abuse diuretics or laxatives experience diarrhea or constipation. Diarrhea can be controlled if the doctor learns of the laxative abuse and has a frank discussion with the patient. But constipation can develop into a permanent problem because the bowel has become dependent on laxatives to function. The dependency can be so severe that some patients develop very limited movement of the large intestine, called colonic dysmotility. The loss of electrolytes, especially potassium, from self induced vomiting and diarrhea also aggravates the constipation.

Gastrointestinal problems in bulimic patients are common, multiple and sometimes severe. Most will improve with the recognition of the complication and treatment. Treatment for patients with bulimia requires a multidisciplinary team of an internist, gastroenterologist, nephrologist, cardiologist and psychiatrist.

This post was written by Bethany DeVito, MD, gastroenterologist at North Shore University Hospital.

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