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Updated: Dec 27 2021

Bulimia Nervosa

  • 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
  • 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
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