Updated: 10/19/2020

Bulimia Nervosa

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Snapshot
  • A 24-year-old woman visits her gynecologist for an annual visit. She has no physical complaints. Her BMI is 24 kg/m2. On exam it is noted that she has enlarged parotid glands and poor dentition.  Upon further questioning, she admits that she binges on pizza and pasta at least once or twice week. She admits to feeling guilty after these episodes of excessive consumption and takes laxatives after binging.
Introduction
  • Overview
    • bulimia nervosa is an eating disorder marked by recurrent episodes of binge eating accompanied by compensatory behaviors (e.g., purging)
  • Epidemiology
    • prevalence
      • 1% in the US
        • 0.5% for males
        • 1.5% for females
    • demographics
      • females > males
    • risk factors
      • jobs or hobbies that require rapid gain or loss of weight (e.g., wrestling and bodybuilding) or emphasize a thin body type (e.g., ballet and cheerleading)
  • Pathophysiology
    • result of a complex of psychosocial factors
  • Prognosis
    • ~50% of patients with bulimia will recover fully
    • ~30% of patients have partial recovery while 10-20% continue to have chronic symptoms
Presentation
  • Symptoms
    • recurrent episodes of binge-eating followed by compensatory behavior
      • eating a large amount of food in a discrete period of time
      • feeling loss of control during the episode 
      • common compensatory behaviors 
        • self-induced vomiting
        • laxative use
        • excessive exercise
        • restrictive eating
      • episodes occur at least once a week for 3 months
  • Physical exam
    • weight often normal or slightly above ideal body weight
    • parotid gland enlargement
    • dental cavities 
    • Russell sign
      • dorsal hand calluses from inducing vomiting
Studies
  • Basic metabolic panel
    • may show electrolyte abnormalities
      • hypokalemic metabolic alkalosis with significant vomiting
  • ECG
    • QT-interval prolongation, especially in the setting of hypokalemia, indicates serious risk for cardiac arrhythmias
Differential
  • Anorexia nerviosa
    • key distinguishing factor
      • food and calorie restriction; lower-than-normal BMI
  • Binge-eating disorder
    • key distinguishing factor
      • episodes of binging that are not accompanied by compensatory behaviors
Treatment
  • Stabilization
    • always stabilize the patient's volume status and replete electrolytes prior to psychiatric therapy
      • ringer lactate or normal saline
      • electrolyte repletion
        • potassium
        • magnesium 
        • calcium
  • Lifestyle
    • cognitive behavioral therapy
      • first-line treatment
  • Medical
    • selective serotonin reuptake inhibitors (SSRIs) (e.g., fluoxetine)
      • particularly helpful for patients with concurrent symptoms of depression and anxiety
      • indicated in patients who have suboptimal response to cognitive behavioral therapy
Complications
  • Electrolyte disturbances
    • hypokalemia
    • metabolic alkalosis

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Questions (3)
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(M2.OMB.18.1) A 17-year-old girl presents to her primary care physician with a concern for a puffy cheek. She has noticed she has had a puffy cheek for the past month despite exercising more often and eating a healthy diet. The patient states she is an otherwise healthy student, does not smoke, and is not sexually active. Her temperature is 97.9°F (36.6°C), blood pressure is 114/74 mmHg, pulse is 105/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for a healthy young woman with a nontender abdomen. Exam reveals the finding in Figure A as well as poor dentition. Her BMI is 26 kg/m^2 and she has normal development for her age. Laboratory values are ordered as seen below.

Hemoglobin: 10 g/dL
Hematocrit: 30%
Leukocyte count: 12,900/mm^3 with normal differential
Platelet count: 191,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 3.0 mEq/L
HCO3-: 29 mEq/L
BUN: 23 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.2 mg/dL
Ca2+: 10.2 mg/dL

Which of the following is the most likely diagnosis?

QID: 210744
FIGURES:
1

Anorexia nervosa

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(0/6)

2

Bulimia nervosa

50%

(3/6)

3

Sialolithiasis

17%

(1/6)

4

Suppurative parotitis

33%

(2/6)

5

Viral parotitis

0%

(0/6)

M 6 C

Select Answer to see Preferred Response

(M2.PY.16.32) A 22-year-old female college student comes to your clinic to establish care. She has no significant past medical history and her only complaint today is that she has had trouble maintaining a consistent weight. Her temperature is 98.6°F (37.0°C), blood pressure is 100/65 mmHg, pulse is 62/min, and respirations are 12/min. Her body mass index is 19.5. Her physical exam is significant for callused knuckles and dental enamel erosions. What laboratory abnormalities are likely to be found in this patient?

QID: 104306
1

Decreased chloride, decreased potassium, decreased bicarbonate

0%

(0/7)

2

Decreased chloride, decreased potassium, increased bicarbonate

71%

(5/7)

3

Decreased chloride, increased potassium, increased bicarbonate

14%

(1/7)

4

Increased chloride, decreased potassium, decreased bicarbonate

14%

(1/7)

5

Increased chloride, increased potassium, increased bicarbonate

0%

(0/7)

M 6 D

Select Answer to see Preferred Response

Evidence (3)
EXPERT COMMENTS (6)
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