Patient Information Series
Amy H. Olson, LCSW
Medical Care and Complications of Bulimia Nervosa and Anorexia, Purging Type
Dear client,
This information is being provided as a support in your recovery from Bulimia Nervosa (BN). You
are advised to secure regular medical monitoring, even if you are feeling OK. Current guidelines
recommend you see you physician every 3-4 months, even if medically stable, as 32 % of BN
patients will have a significant medical complication that requires treatment (de Zwann & Mitchell,
1999). Your physician will adjust this timeframe based on the severity and nature of your symptoms.
This handout is not comprehensive nor a substitute for your doctor’s advice, it is simply a
summary of the most common complications I’ve seen in my own practice. I hope that our
discussion about what to expect, and things to report to your physician, will reduce worries about
securing medical monitoring.
Remission of symptoms is not expected overnight; in fact recovery is a long process for most
people. Your role is to do your best to protect your health by monitoring any problems secondary to
your eating disorder, informing your physician and practicing good self-care at home. The initial
visit with your physician should include the standard tests below. The rest of the hand out will
highlight common problems by bodily system.
Recommended examinations:
Weight and height
Pulse and blood pressure (often sitting, standing and lying down)
State of hydration
Cardiac examination (EKG)
Abdominal examination
CBC with differential (complete white and red blood cell count)
Serum electrolytes (potassium and bicarbonate levels)
Calcium, magnesium and phosphorus
Additional tests may be required if you are underweight
Reviewed in this handout:
Electrolyte abnormalities
Gastrointestinal issues
Cardiovascular issues
Oral and dental issues
Gynecological and endocrine issues
Electrolyte abnormalities
Low Potassium. Purging through vomiting, laxative and/or diuretics can cause a disruption of fluid
homeostasis in the body. The most common electrolyte abnormality seen in BN patients is
hypokalemia (low potassium). This risk for this abnormality is even greater if you are anorexic and
purging. Hypokalemia is dangerous because it causes weakness, lethargy, cardiac complications
and renal failure. Hypokalemia is one of the major causes of death in patients who have eating
disorders (Pomeroy & Mitchell, 2002).
Your physician will take blood to determine your serum electrolytes. Mild to moderate depletion of
potassium may require oral supplementation while severe abnormalities will require intravenous
supplementation.
Gastrointestinal Issues
Acid Reflux. Your physician will take a history of any GI problems you may be experiencing. The
most common symptoms of BN patients include sore throat, hoarseness and acid reflux, and can
range from mild to severe. Sometimes these symptoms remain for a while after cessation of
purging. Acid reduction medicines are often prescribed.
If you begin a course of treatment with an acid reducer and do not find relief in several weeks,
you should contact your physician. Also, if bleeding occurs when you vomit this needs to be
reported immediately. Both can be signs of more severe esophageal damage that warrants further
investigation (Waldholtz, 1999).
Bloating. GI motility can be an issue, especially if you are below normal weight and purging. This
delayed emptying of the stomach, called gastroparesis, causes you to feel bloated and easily full
when you eat. Bloating improves with weight restoration and normalization of eating patterns, but
usually takes 4-6 weeks or return to your natural healthy weight.
If you experience pain while eating, be assured this will progressively improve and will only
resolve through eating. Your physician may make suggestions such as eating liquids first during
mealtimes or dividing calories into several small meals throughout day (Waldholtz, 1999). If the pain
is so severe it prevents you from eating contact your physician immediately.
Constipation. The electrolyte imbalance caused by vomiting and the delayed gastric motility
caused by restrictive eating can both slow bowel transit time. It is common for BN patients to
complain of too infrequent or too small bowel movements. Please keep in mind that “…bowel
patterns in healthy ambulatory patients may vary anywhere from three times per day to three times
per week…” (Waldholtz, 1999, p. 91).
If you have been abusing laxatives, you must stop immediately as you induce Cathartic Colon
Syndrome, which in severe cases is irreversible. You must have physician support to discontinue
laxative abuse. When you stop using laxatives you will feel pain and bloating, fear something is
wrong and be tempted to restart. Your bowels should return to normal in about 3 weeks. Your
doctor may prescribe a non-stimulating laxative, bulking agents, lots of water and moderate exercise
Cardiovascular Issues
Cardiac abnormalities. All methods of purging can result in hypokalemia (low potassium), which
can induce heart problems, especially if you are underweight. Laxatives, diuretics and/or ipecac
abuse particularly increases the risk for cardiac complications, as does the frequency of any
purging behavior (Powers, 1999). Your physician will order an EKG to review any cardiac
arrhythmias and will assess your blood pressure and pulse at each visit.
If you are experiencing fatigue, lightheadedness, cold extremities, heart palpitations, chest pain,
leg cramps/pain report this to your physician immediately. Your treatment may involve potassium
supplementation, reduced exercise, medications and weight restoration.
Oral and Dental Issues
Enamel erosion. Repeated contact with gastric acids will cause enamel erosion in 38% of BN
patients. The most effective way to prevent and treat this erosion is cessation of vomiting. While
you are working towards this goal you will want to avoid brushing with fluoride toothpaste after
vomiting and instead rinse with a baking soda solution to neutralize acid (1 teaspoon per quart of
water) (Steele & Mehler, 1999).
Enlarged salivary glands. Self-induced vomiting will lead to enlarged salivary glands in up to 50%
of BN patients. It is generally painless but apparent on physical examination and is mostly a
cosmetic concern. Swelling usually begins a few days after purging and is related to frequency of
vomiting. Swift resolution results from cessation of purging. While you are working towards this goal,
hot compresses and tart candies may bring some relief. Your physician or dentist can recommend
medications or procedures for very severe cases.
Gynecological and endocrine issues
Amenorrhea. Cessation of menstrual periods can be due to multiple factors including
environmental stressors, depression and low body weight. Amenorrhea is less common in BN
patients who maintain a normal weight, although irregularity is common. Women who are
underweight have depleted fat stores, which are needed to produce the hormones required for
menstruation. If your doctor determines that low estrogen is a contributing factor you may be
administered estrogen therapy in the form of a contraceptive pill.
Osteopenia and Osteoporosis. If you are underweight with amenorrhea the resulting hormone
abnormalities lead to low bone density. The bone loss can be profound and irreversible. Your
doctor will monitor your bone density by conducting regular bone scans. Calcium, vitamin D or other
medications may be prescribed. (Hofeldt, 1999).
References
de Zwann, M. & Mitchell, J.E. (1999). Medical evaluation of the patient with an eatingdisorder: An
overview. In Mehler, P.S. & Anderson, A.E. (Eds.), Eating Disorders:Medical Care and
Complications (pp. 44 –62). Baltimore, MD: The Johns Hopkins University Press.
Hofeldt, F.D. (1999). Gynecology, endocrinology, and osteoporosis. In Mehler, P.S. & Anderson,
A.E. (Eds.), Eating Disorders: Medical Care and Complications (pp. 118 –131). Baltimore, MD: The
Johns Hopkins University Press.
Pomeroy, C. & Mitchell, J.E. (2002). Medical complications of anorexia nervosa and bulimia
nervosa. In Fairburn, C.G. & Brownell K.D. (Eds.), Eating Disorders and Obesity: A Comprehensive
Handbook (2nd ed.) (pp. 278 -285). New York: The Guilford Press.
Powers, P. (1999). Eating disorders: Cardiovascular risks and management. In Mehler, P.S. &
Anderson, A.E. (Eds.), Eating Disorders: Medical Care and Complications (pp. 100- 117).
Baltimore, MD: The Johns Hopkins University Press.
Steele, A. W. & Mehler, P.M. (1999). Oral and dental complications. In Mehler, P.S. & Anderson,
A.E. (Eds.), Eating Disorders: Medical Care and Complications (pp. 144 - 152). Baltimore, MD: The
Johns Hopkins University Press.
Waldholtz, B.D. (1999). Gastric complaints and function in patients with eating disorders. In
Mehler, P.S. & Anderson, A.E. (Eds.), Eating Disorders: Medical Care and Complications (pp. 86
–99). Baltimore, MD: The Johns Hopkins University Press.