Review Question - QID 220651

This patient with binging and purging behavior in the setting of dorsal hand calluses (Russel sign) most likely has bulimia nervosa.

Bulimia nervosa is an eating disorder that is characterized by binging and purging behaviors. During a binging episode, patients will describe loss of control and consumption of large quantities of food. During a purging episode, patients may vomit, use laxatives, exercise excessively, or engage in other methods of losing weight. Since patients engage in significant episodes of overconsumption, they are typically within the normal BMI range, unlike other eating disorders. Patients with bulimia nervosa will present with calluses on the back of the knuckles due to self-induced vomiting (Russel sign), parotid gland enlargement, enamel erosion, xerosis, hypokalemia, hypochloremia, and metabolic alkalosis. Treatment is with medical stabilization of the patient followed by selective serotonin reuptake inhibitors and cognitive behavioral therapy.

Harrington et al. review the evaluation, diagnosis, and treatment of eating disorders. They discuss how inpatient treatment may be required in order to stabilize the patient if the patient experiences complications. They recommend short-term psychotherapy and the use of psychotropic medications in patients with bulimia nervosa.

Figure/Illustration A is a clinical photograph demonstrating calluses of the dorsal hand secondary to self-induced vomiting (red circles). This is also called the Russel sign and is seen in patients with bulimia nervosa.

Incorrect Answers:
Answer 1: Anorexia nervosa is characterized by restrictive food intake leading to decreased body weight (low body mass index), fear of gaining weight despite being underweight, and a distorted perception of body image and weight. Patients may present with bradycardia, electrolyte abnormalities, and fine, soft body hair known as lanugo.

Answer 2: Binge eating disorder is characterized by eating large amounts of food over a short period of time and a lack of control over the rate or quantity of food intake. Patients also have feelings of disgust, depression, or guilt after eating. These patients do not have purging behaviors such as vomiting. While the patient claims the vomiting is related to alcohol intoxication, Russel sign suggests otherwise.

Answer 3: Patients with body dysmorphic disorder are preoccupied with
a physical defect that is either nonexistent or slight. Patients will engage in repetitive behaviors or mental acts at some point during the illness course to deal with this perceived deformity including mirror checking, skin picking, or excessive grooming.

Answer 5: While many college students can overindulge and become intoxicated, the excessive episodes of binging and self-induced vomiting are more consistent with bulimia nervosa. While the patient claims the vomiting is related to alcohol intoxication, the presence of Russel sign suggests otherwise.

Bullet Summary:
Bulimia nervosa presents with binging and purging and can present with enamel erosion, parotitis, and dorsal hand calluses.