• Rapid consumption of large amounts of food in discrete periods of time, usually less than 2 hours.
• Fear of being unable to stop eating.
• Food of high caloric value, often swallowed without chewing.
• Associated feelings of guilt, anxiety, and depression.
• Frenzied quality, often occurring alone and secretively.

• Some authors posit that bulimic behavior services unmet needs, such as providing intense stimulation to relieve tension.
• Personality traits of low self-esteem, self-regulatory difficulties, frustration intolerance, and impaired ability to recognize and directly express feelings have been described in patients with bulimia nervosa.

• Onset in late adolescence to early adulthood (range: 13–58 years of age)
• Females account for 90% to 95% of cases
• Affects 1% to 3% of young females in Western countries
• Ten times more common than anorexia nervosa

• Aspiration pneumonia
• Pneumomediastinum

• Pancreatitis
• Parotid-gland enlargement
• Gastric and esophageal irritation
• Mallory-Weiss syndrome
• Paralytic ileus (due to laxative abuse)
• Cathartic colon

• Hypokalemia (due to laxative abuse)
• Electrolyte imbalances, including hypomagnesemia
• Fluid imbalances
• Hyperamylasemia

• Enamel erosion
• Caries and periodontal disease

• Very low mortality: 0.3%
• No studies of long-term prognosis in adolescents
• Adult studies:
  • Normal weight at follow-up (24 and 72 months)
  • 29% to 87% reported binge eating at follow-up (2–35 months)
  • 28% to 77% reported at least one vomiting episode at follow-up (12–50 months)
  • 3% to 13% reported laxative abuse at follow-up (12–50 months)

• Psychogenic vomiting

• Gastrointestinal obstruction
• Hiatal hernia

• Eating habits
• Rituals, behaviors
• Body image
• Actual and desired weights, minimum and maximum weights
• Use of laxatives, diuretics, diet pills, emetics
• Presence of binge or purge behavior
• Menstrual history
• Use of exercise

• Weakness or fatigue
• Headaches
• Abdominal pain, fullness, or nausea
• Constipation

• Mood disorder
• Substance abuse
• Anxiety
• Personality disorders
• Suicidal tendencies

• Medical and psychiatric histories

Finding: Vital signs
Significance: Check for hypotension

Finding: Edema of hands and feet
Significance: Evidence of low albumin

Finding: Calluses on knuckles or hands
Significance: Russell sign

Finding: Muscle cramps or weakness
Significance: Hypokalemia

• How much do you want to weigh?
• How do you control your weight?
• How do you feel about yourself?
• How often do you vomit, use diuretics or laxatives?

Test: CBC
Significance: Iron deficiency anemia

Test: Electrolytes, including calcium, magnesium, and phosphate: abnormalities may occur as a result of prolonged vomiting or use of laxatives
Significance: Iron deficiency anemia

Test: BUN and creatinine
Significance: Fluid imbalance and dehydration common

Test: Glucose
Significance: Patient may be hypoglycemic

Test: Cholesterol, lipids
Significance: Evidence of malnutrition

Test: Amylase
Significance: Pancreatitis

Test: Total protein, albumin
Significance: Evidence of malnutrition

Test: Liver function tests
Significance: Evidence of malnutrition

Test: Urine toxicology screen, optional
Significance: May be positive, as this disorder often is associated with substance abuse

Test: ECG with rhythm strip
Significance: May reveal cardiomyopathy caused by use of ipecac for emesis

• Upper GI series with small-bowel follow-through, optional

• Outpatient therapy
• Behavioral treatment with initial goal of breaking or decreasing the binge-purge cycle
• Individual psychotherapy
• Family treatment
• Group therapy
• Emphasize bingeing, not purging, as primary target symptom

• Antidepressants
  • Decrease the binge-purge behavior
  • Improve attitudes about eating
  • Lessen preoccupation with food and weight
  • Fluoxetine (Prozac), sertraline (Zoloft), and fluvoxamine (Luvox) have been used with good results in patients with bulimia nervosa.
• Stool softeners may be used for constipation, but avoid laxatives.
• Hospitalize in cases of:
  • Hypovolemia
  • Severe electrolyte disturbances
  • Intractable vomiting
  • Acute psychiatric emergencies (e.g., suicidal ideation, acute psychosis)
  • Medical complication of malnutrition (e.g., aspiration pneumonia, cardiac failure, pancreatitis, Mallory-Weiss syndrome, etc.)
  • Comorbid diagnoses that interfere with the treatment of the eating disorder (e.g., severe depression, obsessive-compulsive disorder, severe family dysfunction)

• Reduction in binge and purge episodes may take months or years.
• Behavioral and thought disorders associated with bulimia nervosa may be of long duration.

• Weight loss or major weight fluctuations
• Electrolyte abnormalities
• Muscle cramps
• Fatigue
• Depression or mood disturbance
• Willful behavior or acting out

• Emphasize healthy self-esteem and body image during visits with preadolescents and adolescents.

• During treatment, patients and their families may cause “splitting” of the hospital staff. To avoid this, always be supportive and maintain consistency in stating goals.

Q: How do I determine if a patient has anorexia with vomiting, or bulimia?
A: The key feature of bulimia nervosa is the binge episode, which distinguishes it from anorexia nervosa. If there are not at least two binge eating episodes per week for at least 3 months, the diagnosis is not bulimia.

Q: What laboratory abnormalities should I look for in my patients with bulimia?
A: Electrolyte abnormalities, particularly hypokalemia. Patients may develop a hypochloremic metabolic alkalosis. If electrolytes are significantly abnormal, the patient should be hospitalized until they have normalized.