Gastrointestinal (GI) Complications from Eating Disorders

Eating disorders can lead to various gastrointestinal issues. Disordered eating behaviors like restriction and purging disrupt normal digestive function. Chronic malnutrition can also impair gut motility and damage the lining of the stomach and intestines.

Gastrointestinal complications & eating disorders

Gastrointestinal symptoms are nearly universal among individuals with eating disorders. One study found that up to 97% of those with an eating disorder experienced a gastrointestinal (GI) issue before receiving treatment. Both food restriction and purging behaviors can causes serious stress on the gastrointestinal tract, leading to numerous complications of the esophagus, stomach and intestines.

Patients with eating disorders may seek out care or be referred to a gastroenterologist to address their uncomfortable gastrointestinal symptoms, emphasizing the important role of gastroenterologists in the identification of eating disorders.

How eating disorders affect the GI tract

Gastroparesis

Food restriction is almost universally followed by gastroparesis, or delayed gastric emptying. Symptoms of gastroparesis include:

• Bloating
• Fullness
• Nausea

Colonic inertia

Excessive and chronic misuse of stimulant laxatives can cause colonic inertia (cathartic colon), a condition whereby the muscles and nerves of the colon become incapable of moving stool efficiently through the bowels. It is suspected that this is due to direct damage to the gut myenteric nerve plexus. Recent pilot studies also suggest that cathartic colon can develop because of abuse of stimulant laxatives, and the condition is believed to be reversible with cessation of stimulant laxatives.

Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is one of the most common complications in eating disorder patients who purge through self-induced vomiting, although patients who restrict without purging also report increased symptoms of reflux.  Over time, recurrent self-induced vomiting can weaken the esophageal sphincter, causing the reflux of stomach contents into the esophagus, causing symptoms like heart burn, chest pain or persistent cough. Symptoms of reflux can also be functional in nature.

Superior mesenteric artery (SMA) syndrome

Significant weight loss causes atrophy of the mesenteric fat pad surrounding the SMA, causing the duodenum to become compressed between the abdominal aorta and the superior mesenteric artery.

Oropharyngeal dysphagia

Patients can have trouble swallowing and moving the food, liquid or saliva into the esophagus, also known as dysphagia. The muscle loss and weakness associated with severe food restriction and severe weight loss can impact the throat muscles responsible for swallowing.

Slow transit constipation

Similar to the slowed gastric emptying that develops from malnutrition, colonic transit also slows. This can lead to symptoms of constipation, although there can also be a significant functional component to these symptoms. Laxatives, such as MiraLAX, are often warranted to help maintain adequate bowel movements.

Starvation hepatitis

Starvation is commonly associated with a condition known as starvation hepatitis, wherein the liver is basically undergoing autophagy (or cell death) to help provide nutrients stored in the liver to the rest of the organs of the body. This resolves with adequate nutritional intake.

Other gastrointestinal complications

There are other miscellaneous complications that can occur independently or alongside other gastrointestinal complications:

• Sensation of having a lump or something stuck in the throat (globus sensation)
• Chronic cough
• Hoarseness and sore throat
• Indigestion
• Pain with swallowing (odynophagia)
• Irritation of the esophagus (esophagitis)
• Esophageal erosions and ulcers
• Melanosis coli (black discoloration of the intestine)
• Rectal prolapse
• Disorders of gut brain interaction

There are also some more severe, but rare GI complications that occur in patients with a history of purging, including:

• Barrett’s esophagus, a precancerous condition
• Esophageal cancer
• Mallory-Weiss syndrome
• Boerhaave syndrome, a rare condition of high mortality
• Electrolyte abnormalities, including hypokalemia and hypomagnesemia

References

• The Endocrinopathies of Anorexia Nervosa https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278909/
• Zipfel S, Sammet I, Rapps N, Herzog W, Herpertz S, Martens U. Gastrointestinal disturbances in eating disorders: clinical and neurobiological aspects. Auton Neurosci 2006; 129:99–106.
• Avoiding medical complications in refeeding from Anorexia Sachs K, Andersen D, Sommer J, Winkelman A, Mehler PS. Eat Disord. 2015; 23(5):411-21. Epub 2015 Mar 9.
• Benini L, Todesco T, Dalle Grave R, Deiorio F, Salandini L, Vantini I. Gastric emptying in patients with restricting and binge/purging subtypes of anorexia nervosa. Am J Gastroenterol 2004; 99:1448–1454.
• Soul S, Dekker A, Watson C. Acute gastric dilatation with infarction and perforation. Report of fatal outcome in patient with anorexia nervosa. Gut 1981; 22:978–983.