Bulimia and Acid Reflux (Gastroesophageal Reflux Disease)

Bulimia Nervosa & Acid Reflux (Gastroesophageal Reflux Disease)

Bulimia nervosa is an eating disorder characterized by cyclical episodes of binge eating and compensatory behavior. 

Compensatory behaviors are eating disorder behaviors used to counteract the effects of eating to avoid weight gain or alleviate feelings of guilt. The most common compensatory method is self-induced vomiting, which is used by up to 86% of those with an eating disorder.

Can bulimia cause GERD?

When a person with an eating disorder throws up, acid travels through the entire esophagus and mouth, which can cause inflammation and irritation of the mouth, larynx and esophagus. Repeated episodes of vomiting can cause weakening of the lower esophageal sphincter, causing acid to flow upwards into the esophagus even when not vomiting, known as GERD. Many individuals with bulimia report throat pain, chest pain, stomach pain and other uncomfortable symptoms related to GERD.

Bulimia nervosa & GERD

GERD is a chronic condition characterized by the reflux of stomach contents into the esophagus, causing a range of symptoms, including:

• Heartburn (painful burning sensation in the middle of the chest/esophagus)
• Odynophagia (painful swallowing)
• Dysphagia (trouble swallowing)
• Acid regurgitation
• Chest pain
• Hoarseness or cough
• Tightness in throat

Effects of acid reflux

Acid reflux can cause secondary symptoms as well, like difficulty swallowing, dental erosion and sleep problems. Inflammation around the throat can lead to dysphagia and voice changes. Dysphagia lends itself to aspiration pneumonia, which is associated with increased mortality.

Over time, GERD can cause dental erosion (perimylolysis). Chronic exposure to stomach acid from vomiting causes the surface of the teeth to soften. This can result in hypersensitivity to heat, cold and sweets. It can also lead to exposed dentin, which increases the risk for developing cavities.

Acid reflux & sleep

Acid reflux can also impact sleep and sleep quality, with evidence suggesting an association between GERD and shorter sleep duration, difficulty falling asleep, arousals during sleep, poor sleep quality and waking up early.

Bulimia nervosa & Barrett’s esophagus

Repeated self-induced vomiting can cause patients with bulimia to develop Barrett’s esophagus, a condition where the mucosal lining of the esophagus becomes damaged by acid reflux, causing this pre-cancerous condition. Chronicity of symptoms is a better predictor than symptoms regarding development of Barrett’s esophagus.

While Barrett’s esophagus increases the risk of esophageal cancer, the risk is small. Potentially up to 14% of those with Barrett’s esophagus will develop esophageal adenocarcinoma in their lifetime, and annual risk of developing esophageal adenocarcinoma may reach 3%.

While the risk is low, follow up with a gastroenterologist is recommended to discuss screening for this condition.

Identifying Bulimia in those with GERD

Acid reflux is a common self-reported symptom of bulimia. Before many patients even seek treatment for their eating disorder, many of them receive treatment for gastrointestinal (GI) issues, with an increased frequency of symptoms in patients with bulimia compared to those with anorexia nervosa.

Gastroenterologists and general practitioners should consider bulimia nervosa in individuals with recurrent hypokalemia (low potassium) and metabolic alkalosis on labs. Other physical exam findings suggestive for bulimia can include:

• Perimylolysis (enamel erosion)
• Poor mouth health
• Sialadenosis
• Recurrent epistaxis (nosebleeds)
• Scarring on the knuckles (known as Russell’s sign)
• Edema

A useful screening tool for eating disorders is the SCOFF questionnaire, which is a 5-question questionnaire designed to raise suspicion that an eating disorder exists and can be used in primary care or specialist settings.

How other eating disorders can cause acid reflux

Patients with other eating disorders, like anorexia nervosa or ARFID, who restrict food intake may also develop reflux due to weight loss-induced gastroparesis. Compared to those with self-induced vomiting-related GERD, the reflux tends to be milder.

Treating acid reflux & bulimia nervosa

Many patients will see improvement and alleviation of GERD symptoms after cessation of vomiting. However, in some patients, symptoms can persist.

These patients may not respond to antacids and instead need:

• Higher-dose histamine-2 blockers (for example, famotidine)
• Proton-pump inhibitors (for example, omeprazole)

While both are effective treatments, trials in the general population have established that treatment with proton-pump inhibitors is the more effective option for healing esophagitis and improving symptoms.

It has also been demonstrated that empiric treatment for a couple weeks with a proton-pump inhibitor is cost-effective prior to pursuing endoscopies or other diagnostic workup when symptoms fail to resolve with medication.

If more severe symptoms are present or develop, such as dysphagia, bleeding anemia or persistent dyspepsia, further work up with an under endoscopy may be warranted.

Last Reviewed: October 2024 by Dennis Gibson, MD, FACP, CEDS

References

• Barrett’s esophagus - Symptoms and causes. (2022, March 5). Mayo Clinic. 
• Denholm, M., & Jankowski, J. (2011). Gastroesophageal reflux disease and bulimia nervosa - a review of the literature. Diseases of the Esophagus, 24(2), 79–85. 
• Fujiwara, Y., Arakawa, T., & Fass, R. (2012). Gastroesophageal reflux disease and sleep disturbances. Journal of Gastroenterology, 47(7), 760–769. 
• GERD (Chronic Acid Reflux): Symptoms, Treatment, & Causes. (2019, June 12). Cleveland Clinic. 
• Nitsch, A., Dlugosz, H., Gibson, D., & Mehler, P. S. (2021). Medical complications of bulimia nervosa. Cleveland Clinic Journal of Medicine, 88(6), 333–343. 
• Spechler, S. J. (2013). Barrett Esophagus and Risk of Esophageal Cancer. JAMA, 310(6), 627.