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) ETIOLOGY Pathophysiology result of a complex of psychosocial factors 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 Prognosis ~50% of patients with bulimia will recover fully ~30% of patients have partial recovery while 10-20% continue to have chronic symptoms