Medical Symptoms and Complications of Bulimia
Excerpt from The Parent’s Guide to Eating Disorders
by Marcia Herrin, EdD, MPH, RD and Nancy Matsumoto
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We have already explained that many of the symptoms of bulimia and anorexia overlap, especially among anorexics who purge, a subgroup described earlier. For ease of reading, we have separated the symptoms of bulimia from those of anorexia. But readers should understand that the following symptoms and lab findings described for bulimics also apply to purging anorexics. Extremely low-weight patients are more likely to experience the most dire consequences outlined here than those whose weight remains within a normal range.
Electrolyte and Mineral Imbalances
As we have said, in many ways the physiology of eating disorders is still a mystery to experts. Electrolyte imbalances, which can be detected by blood tests, are a case in point. Electrolyte imbalances are common among bulimics, since vomiting can cause them to lose valuable minerals. Yet for unknown reasons, not all bulimics develop these imbalances.
Electrolyte disturbances, most often in the form of severely low potassium levels, can cause a wide range of symptoms ranging from muscle weakness (bulimic patients may notice that they feel weak and tired), constipation, cloudy thinking and, in severe cases, cardiac arrhythmias that can cause sudden death. Often, however, eating-disorder patients report feeling fine, despite dangerously low potassium levels, and exhibit a sense of well-being that can be misleading.
In cases of dangerously low potassium levels, oral supplements or intravenous solutions are often prescribed to protect heart function, although these measures are short-term fixes that cannot solve the problems caused by repeated purging. Although over-the-counter potassium supplements are available, we urge you not to attempt independently to correct your child’s potassium imbalance because supplemental potassium can easily reach toxic levels. Restoring potassium levels must be undertaken under the supervision of a medical professional who can do frequent lab tests. If potassium is not restored properly, the patient is at a high risk for potentially fatal heart problems. One practical solution available to you at home is to encourage your child to eat potassium-rich foods. Almost all foods contain some potassium; fruits and vegetables are particularly good sources. Just helping your child to stop purging and to begin to eat a normal array of foods in normal amounts will go a long way in maintaining healthy potassium levels.
Even when potassium levels are normal, however, you cannot assume that a child is not purging. Many patients manage to maintain normal potassium levels despite significant purging. If, however, potassium is low and there is no other medical explanation, it is almost certain that the patient is either vomiting or abusing laxatives or diuretics.
Purging also throws the body’s acid-base balance off-kilter, which is reflected in another type of electrolyte disturbance, elevated bicarbonate levels in the blood. These laboratory values of low potassium and elevated bicarbonate levels could, to the unsuspecting or inexperienced doctor, incorrectly indicate a kidney problem, not surreptitious vomiting.
Although elevated serum bicarbonate is not as serious as the low potassium that can accompany purging behaviors, it is something that can be tested for, and is a much more reliable marker than potassium for purging behaviors. For this reason, some doctors order a serum bicarbonate test when they suspect purging, even though potassium levels are normal.
The important point to remember about purging is that lab and physical changes and serious medical problems are more likely to occur when a child or adolescent is at a very low weight. The normal or overweight child is protected to a certain extent simply because their bodies are healthier and stronger than the malnourished anorexic’s.
Sometimes the salivary glands, located below the ear and along the lower jawbone, may become visibly swollen, leading to the “chipmunk” cheeks of the bulimic. Parents may recognize this look since these parotid glands are those that are affected by mumps. The exact cause of this symptom is somewhat of a mystery. One theory is that the glands become irritated by regurgitated stomach acid that leaks through a duct in the throat. Another is that they are over-stimulated to produce enzymes to digest binged foods. It is likely that both theories are true.
The swollen parotid glands of bulimics may secrete abnormally high levels of amylase, an enzyme that digests carbohydrates. Elevated amylase levels, however, may also indicate a problem with the pancreas, such as pancreatitis or pancreatic gallstones. Blood tests can determine whether the high blood levels are from the salivary glands or the pancreas. Although it is rare, acute pancreatitis has been reported in connection with bulimia as well as in anorexia in the refeeding stage.
Repeated vomiting among bulimics and purging anorexics will inevitably lead to serious dental problems. An increase in cavities or extreme sensitivity of the teeth to heat and cold are often the first dental complications. The teeth may become chipped and ragged looking (especially if a spoon is used to induce vomiting) and the front teeth can lose their natural shine as the enamel, battered by repeated exposure to gastric acid, softens. The lingual, or back side of the front teeth, which faces the tongue, and the occlusal, or the flat top of molars, also lose their enamel and begin to take on a yellowish hue. As the enamel becomes thinner and thinner, you can see through it to the dentin, or core of the tooth. In severe cases, even the dentin is eroded as well, and the pulp of the tooth is exposed. This is extremely painful, and the tooth usually dies as a result.
The gums of bulimics are often sore and may even bleed, usually the result of “toothbrush trauma.” In their efforts to clean their teeth and mouths after vomiting, bulimics will often brush their teeth vigorously immediately after purging, adding significantly to existing dental damage. Some bulimics have such naturally resilient teeth that despite significant purging, it takes longer than usual for damage to occur. At first, my patient Kerrie told me how odd it made her feel to hear her dentist compliment her on her wonderful teeth and their apparent health. She and I knew that she was throwing up regularly, yet even her own dentist saw no dental signs of bulimia. A good report from your child’s dentist doesn’t necessarily mean that your child is not purging.
In bulimics who have been vomiting for about four years or longer, dental fillings, which are more resistant to the effects of gastric acid than dental enamel, are likely to project above the surface of the teeth as the enamel around them erodes. Dental cavities may increase, probably because of the exposure to sugary binge food combined with the softening effect vomiting has on tooth enamel.
If you suspect your child has an eating disorder, you should alert your child’s dentist at the earliest opportunity. The dentist can look for any telltale signs of purging, and if such signs are present, can discuss preventive measures available to protect the teeth. Protective measures include using a fluoride or a baking soda rinse, or rinsing with water after purging rather than brushing (which can damage teeth softened by stomach acid). Your child can also minimize erosion of their dental enamel by avoiding acidic foods, such as citrus fruits or juices and even diet or regular colas.
If your child is having difficulty giving up purging, talk to your dentist about the possibility of dental sealants to protect her teeth from stomach acids. Sealants, which were developed to protect the teeth of children prone to cavities, are clear coatings that dentists bond into the grooves of teeth that are particularly subject to decay. While sealants clearly are protective, some dentists are reluctant to use them as they may reduce the bulimic’s incentive to recover. Another problem is that sealants are difficult to apply well on the teeth that need them the most. If they are poorly applied, they can make dental hygiene more difficult for the patient.
An alternative to sealants that dentists prefer to use is custom-made, fluoride-filled dental trays (similar to mouthguards or the cosmetic teethwhitening trays now used by dentists) that actually protect the teeth from direct contact with purged stomach fluids and improve the resistance of the enamel to acid dissolution.
Another advantage of enlisting your dentist in your cause is that your child may be more willing to listen to him or her talk about the high risk of future dental problems than you. Hearing from a dental authority that the appearance and health of their teeth may be permanently affected by purging can have quite a positive impact on the child who is just starting to experiment with purging.
Throat and Esophageal Problems
Chronic, self-induced vomiting leads to a number of problems that result from the sensitive tissues of the throat coming in contact with harsh stomach acid. Swallowing may become painful or difficult. Hoarseness and a chronic sore throat are common.
Bulimics who frequently self-induce vomiting will experience a diminished gag reflex. Because of this, or because in some cases bulimics are not able to “learn” to throw up easily, they may resort to forcefully stimulating their throats to induce vomiting. They may use elongated objects to do this. I have even had two patients who after accidentally swallowing either a toothbrush or a spoon have had to have the “instrument” surgically removed. Behaviors such as this can sometimes lead to injuries to the surfaces of the back of the throat, which can in turn become infected.
Libby, a college student, told me how embarrassed and scared she was to tell her roommate that she needed to go to the emergency room because she had swallowed her toothbrush. Once there, she was chagrined to overhear a doctor asking a group of interns if they could identify the object in her X-rays. None of them could; they had never heard of bulimics going to such lengths to purge.
Bulimics run the added risk of rare but potentially fatal complications such as tears in the esophagus from frequent vomiting. Tears are indicated when there is blood in the vomit. Although it is only in rare cases that the presence of blood indicates a life-threatening esophageal rupture or a tear serious enough to require immediate medical attention, any blood in the vomit should be taken seriously, and the child should be seen promptly by a medical professional. At the very least, the presence of blood in the vomit indicates significant purging.
Most bulimics find the presence of blood disturbing, something of a wakeup call telling them of the seriousness of their situation. Parents can use this opportunity to open a dialogue about the gravity of future problems if the bulimia is not addressed. Marta was sure she was dying when she first noticed traces of blood in the toilet bowl after she had vomited. Her parents made sure she was evaluated by a physician known for her work with eating-disordered patients.
Seeing a doctor with a special expertise in eating disorders is valuable in many different ways. When another of my patients, Bess, noticed blood in her vomit, her family doctor minimized the blood by saying, “It just looks like a lot of blood because it is diluted in water,” and noted that Bess had only microscopic abrasions in her throat that were nothing to worry about. Though this is often true in such situations, this physician missed a golden opportunity to get her to see the seriousness of her eating disorder.
Hand and Eye Problems
Bulimics who vomit by manually stimulating the gag reflex may develop calluses or scars on the backs of the fingers and across their knuckles from repeated contact with the teeth. Here again, experienced doctors will recognize these marks as “Russell’s sign,” named after the researcher, Gerald Russell, who first described it in 1979.
Eight months after she stopped purging, Sophie told me that one of the best things about her recovery was that she no longer had to make sure to keep her hands out of view. While she was bulimic, Sophie worried that eventually someone would figure out she was bulimic from how red and inflamed the backs of her hands had become.
Vomiting, and the increased pressure on the eyes that it causes, is the likely source of burst blood vessels in the eyes of bulimics and purging anorexics. Known as conjunctival hemorrhages, this reddening of the eye is usually transient; and although scary-looking, it is not dangerous. As with esophageal tears, such hemorrhages can present an opportunity for you to discuss the disorder with your child, sometimes even providing the excuse your child has been looking for to accept help from you.
One of my patients suffered another more serious consequence from forcible vomiting: a retinal detachment, which required laser surgery to repair.
Another eye-area symptom is petechiae. These small red dots are caused by minute amounts of blood that escape into the skin around the eyes when vomiting is forcefully induced.
Lucy’s reddened eyes were the first clue her parents had that she was engaged in self-induced vomiting. They knew that she was anorexic, but Lucy told me she was a master at hiding the evidence of her purging and had successfully kept that part of her disorder a secret. Then her mother confronted her about her hemorrhages and wondered “out loud” if Lucy could possibly be vomiting. Lucy confessed immediately, relieved she could finally allow her parents to help her with her purging habit.
Vomiting or chronic abuse of laxatives can result in gastrointestinal bleeding. Persistent vomiting can also cause the problem of spontaneous regurgitation, or reflux. Frequent purging causes the lower esophagus to relax, making it easy for the contents of the stomach to rise up into the throat or even into the mouth. When the bulimic leans over after eating, or burps, for example, sometimes for no apparent reason, she will spontaneously vomit.
Many bulimics experience this reflux as extreme heartburn. The esophagus becomes inflamed, which can, in serious chronic cases, progress to precancerous changes in the esophagus.
Another complication that requires immediate attention is gastric rupture, which occurs when the stomach becomes so full it literally bursts. Sometimes an extremely large binge cannot be purged because it changes the pressure in the gut, making it impossible to vomit. Lisa had to be rushed to the emergency room one weekend after bingeing on a big bowl of chocolate chip cookie dough. The dough expanded in her stomach, causing it to rupture.
Bulimics who chronically abuse laxatives may become dependent on them to stimulate bowel movements. As the colon stretches and loses its muscle tone, sufferers may experience chronic and severe constipation and an uncomfortable sense of fullness and even pain. In severe cases of long-standing laxative abuse, adult patients have been known to permanently lose bowel function and be doomed to life with a colostomy bag.
The feeling of emptiness and even the changes in body weight patients experience after self-induced vomiting and/or laxative or diuretic abuse convinces them that they have rid their bodies of binge calories. In fact, however, their main achievement is a temporary reduction in body fluid. Researchers have proven that the stomach and intestines retain significant calories in spite of self-induced vomiting. Laxatives rid the body of only about 10 percent of calories consumed, and diuretics have no effect whatsoever on caloric retention. The chronic purger, however, is often convinced that she is losing weight because she feels lighter after purging. She eventually discovers that purging does not rid her body of all the calories consumed during bingeing, and that the ironic fate of most bulimics is weight gain.
Purging can sometimes even cause the exact opposite effect that the anorexic or bulimic desires. Chronic vomiting and laxative or diuretic abuse leads to dehydration. Dehydration, in turn, stimulates the body’s renin-aldosterone system, which helps the kidneys regulate the body’s fluid and electrolyte balance. The result is “rebound water retention,” where the kidneys begin to reabsorb fluid to make up for what was lost by purging. A vicious cycle begins in which the fluid and electrolyte losses of purging cause the body to hold on to even more water and electrolytes. The bulimic feels as if she is “retaining” water, which, in fact, she is. This is a situation that might tempt the bulimic to try a different form of purging, such as diuretics, when previously she may have used self-induced vomiting or laxatives. The dehydration continues or worsens, and the cycle starts over again.
Diuretics are rarely used by children and young adolescents because they are less likely to be aware that diuretics can dramatically affect body weight by causing loss of fluid. Younger patients, just by virtue of being younger, are also less likely to have access to prescription diuretics. Most young patients who do abuse diuretics take over-the-counter brands such as Aqua-Ban and Diurex, which their mothers may have on hand for premenstrual water retention. I advise parents not to keep diuretics and laxatives in easy view in the family medicine cabinet.
Abusing diuretics signals a serious problem that should be addressed immediately. Nonprescription pills, in and of themselves, are not very effective, and consequently, rarely cause health problems; what they can do, however, is confound the doctor’s assessment of a patient’s urinalysis by masking indicators of chronic vomiting. Doctors often routinely check the urine of bulimic patients. Simple tests can show if the patient is chronically vomiting. If the patient is using diuretics, however, the diuretics change urine chemistry, resulting in false normal readings. If you or your child’s doctor suspects diuretic abuse, urine can be tested for this.
Prescription diuretics are far more dangerous than over-the-counter brands, sometimes causing weakness, nausea, heart palpitations, frequent urination, constipation, and abdominal pain. Chronic use can permanently damage the kidneys, potentially leading to a lifetime of dialysis. Parents or any adults, for that matter, should not leave their prescription medications in view or in reach of children, in order not to tempt a susceptible child. Several patients have told me that they helped themselves to Grandpa’s or Great Aunt Annie’s prescription diuretics.
Kidney and Pancreatic Problems
Purging can lead to impaired kidney function caused by chronic dehydration and low potassium levels associated with purging or the abuse of diuretics. As we noted, chronic abuse of diuretics has caused some patients to require dialysis.
Acute pancreatitis has been reported in connection with bulimia as well as in anorexia in the refeeding stage. With bulimia, pancreatitis is thought to be caused by the irritation of the pancreas by repeated bingeing and chronic diuretic abuse. With anorexia, pancreatitis is associated with malnutrition, although why it sometimes occurs during the refeeding stage is not well understood.
Menstrual Irregularities, Fertility, and Pregnancy
Menstrual irregularities or amenorrhea (cessation of menstrual periods) can occur among girls with bulimia, although it is unclear whether these symptoms are due to malnourishment, weight fluctuations, or emotional stress. Underweight bulimics are most likely to have menstrual irregularities.
If untreated, bulimia, like anorexia, may result in infertility for women of childbearing ages. Studies show that up to 60 percent of women seeking help through infertility clinics are suffering from either chronic, long-standing anorexia or bulimia. Remarkably, most recovered anorexics and bulimics are able to have healthy children.
For former eating-disordered patients who do become pregnant, pregnancy itself can stir up old eating-disordered behaviors, particularly bingeing and purging.
Paula came to see me years after I had treated her as a teenager for anorexia and bulimia. She had recovered, finished college, and now was married and pregnant with her first child. Paula felt at risk for a relapse after a serious bout of morning sickness landed her in the hospital. She and I decided to return to a food plan tailored to meet the increased nutrient needs of pregnancy. Paula delivered a beautiful baby girl, and I saw her several more times after that because she just wanted to be sure she was on the right track.
Eating-disordered patients who, unlike Paula, have not been able to shake their disorder before pregnancy have higher-than-average rates of miscarriages, premature births, and low birth-weight infants.
A Word about Ipecac
Although bulimics rarely make regular use of syrup of ipecac, experimentation with this common, nonprescription emetic (which many families have in their medicine cabinets as a precaution in case a toddler accidentally ingests a poison) is not unusual. As many as 28 percent of bulimics have experimented with ipecac, which is believed to have contributed to singer Karen Carpenter’s untimely death from an eating disorder in 1983.
Progressive weakening of skeletal muscles and heart problems have resulted from the abuse of ipecac. The cardiac problems are the most serious, in some cases resulting in sudden death. Cardiac involvement, which can be detected by an electrocardiogram (EKG), is indicated by difficult breathing, rapid heart rate, low blood pressure, and arrhythmias. Early signs of ipecac toxicity are weakness, aching, chest pain, gait abnormalities, tenderness, and stiffness, especially in the neck. Ipecac is particularly dangerous because it builds up in the body; doctors warn patients that taking it regularly, or even with some frequency, means they are building up a lifetime cumulative dose.
We advise parents who no longer have toddlers in the house to get rid of their supply of ipecac. As little as three standard one-ounce-sized (30 ml) bottles of ipecac, even if taken in small doses over a long period of time, are toxic enough to be fatal. If you suspect your child has used ipecac, an electrocardiogram, an echocardiogram, and a thorough medical evaluation are in order.
There has been far less research done among bulimics than among anorexics on the subject of cognitive impairment. One research group did, however, find impaired cognitive performance in chronic bulimics. Brain-imaging studies have also shown some structural changes in some but not all tested bulimics.
Insulin Refusal: A Dangerous Temptation for the Diabetic
Unfortunately, eating disorders are becoming increasingly common among insulin-dependent diabetic adolescents who have figured out that when they stop using insulin or reduce their dose, they lose weight. If a diabetic does not take insulin, then the basic cellular fuel—sugar—cannot enter the body’s cells and is excreted into the urine. Although the diabetic may continue to eat normally, her cells, in effect, starve and weight loss results. Most children, before they are diagnosed with diabetes, lose weight for this very reason.
The diabetic who fails to take insulin can suffer serious long-term consequences, including vision and heart and related circulation problems. In the short term, avoiding insulin can result in abdominal pain, nausea, blurred vision, headache, and general malaise. Diabetics with eating disorders have been found to have a higher rate of early eye, kidney, and nerve damage than do diabetics without eating disorders.