Long Term Effects & Complications of Bulimia

Bulimia Complications

Bulimia nervosa (BN) is a serious eating disorder characterized by a cycle of binge eating followed by purging. Binge eating refers to eating a large quantity of food in a short period of time, often followed by feelings of guilt or shame. Purging refers to behaviors people use to prevent weight gain, such as self-induced vomiting, misusing laxatives, exercising excessively, and/or misuse of diuretics also known as “water pills”. People with BN may engage in multiple forms of purging.

The dangerous purging behaviors associated with BN can lead to a host of medical complications that affect nearly all vital organs and bodily systems, leading to an increased mortality rate. Thankfully, many of the complications associated with BN are reversible with effective treatment, highlighting the importance of seeking help for bulimia nervosa before medical complications arise.

Long Term Effects of Bulimia

People with severe BN (8-13 binge/purge episodes per week), and extreme BN (14 or more binge/purge episodes per week) may experience both short- and long-term complications related to the eating disorder, depending on the type and frequency of purging. Unfortunately, some medical complications may persist even after stopping chronic purging behaviors. 

Digestive Complications

Purging through vomiting or laxative abuse can cause a wide range of complications in the gastrointestinal tract. Contact of gastric acid with the esophagus can contribute to increased symptoms of reflux, sometimes causing extreme damage to the lower esophageal sphincter that helps to protect the esophagus from stomach contents. Vomiting can sometimes cause Mallory-Weiss tears in the esophagus, which presents as blood-tinged emesis. Extreme vomiting could also predispose to esophageal rupture (Boerhaave’s syndrome), wish is associated with high mortality. Rectal prolapse may occur, where the rectum (the last part of the large intestine) slides out through the anal opening (although this can also be seen with malnutrition due to solely restricting). Chronic laxative abuse can lead to severe constipation, also known as cathartic colon syndrome; with this condition, the colon essentially shuts down and patients may need to have part or all of their colon removed in extreme situations. Dehydration can be common, as fluids and vital nutrients are lost at abnormally high rates with diarrhea, vomiting and laxative abuse. Additional gastrointestinal issues related to BN include:

• Gastroesophageal reflux (GERD)
• Pain with swallowing (odynophagia)
• Irritation of the esophagus (Esophagitis)
• Esophageal erosions and ulcers
• Pre-cancer changes in the esophagus (Barrett’s esophagus)
• Esophageal adenocarcinoma
• Gastric rupture
• Melanosis coli

Dental & Otolaryngological Complications

Purging through vomiting causes stomach acid to wear away at the tooth enamel. Teeth may chip or become so thin that they appear translucent. Chewing and eating may become difficult or even painful. Cavity risk increases along with other serious consequences, including:

• Tooth loss
• Reduced salivary flow rate
• Tooth hypersensitivity
• Gum disease (Periodontal disease)
• Dry mouth (Xerostomia)
• Perimylolysis
• Sialadenosis

Vomiting can also cause stomach acid to irritate the pharynx and/or larynx. Chronic acid reflux may appear, along with the following complications:

• Difficulty swallowing (dysphagia)
• Sensation of having a lump or something stuck in the throat (globus sensation)
• Chronic coughing
• Hoarseness and sore throat

Cardiac Complications

Bulimia nervosa can result in an electrolyte imbalance, potentially putting a dangerous strain on the heart, resulting in various cardiac arrhythmias. Other cardiac complications related to BN include:

• Increased heart rate (sinus tachycardia)
• Low blood pressure (hypotension)
• Reduced blood pressure upon standing (orthostasis)
• Prolonged QTc interval, due to electrolyte abnormalities or medications
• Passing out (syncope)
• Palpitations
• Ischemic heart disease, increasing the risk for heart attacks
• Atherosclerosis (thickened and diseased blood vessels)

Gynecological & Obstetric Complications

Menstrual cycles can become irregular (oligomenorrhea) or cycles may stop altogether (amenorrhea). Ovulatory dysfunction may result, resulting in increased rates of infertility, and studies suggest overall lower parity and childbirth at older ages; however, fertility is likely preserved upon recovery.  Furthermore, pregnant women who engage in bingeing and purging behaviors face additional complications for themselves and their unborn child, including an increased risk of:

• Miscarriage
• Premature birth
• Low birth weight

Dermatological Complications

Russell’s sign, the development of callouses on the dorsal aspect of the hand due to self-induced vomiting, is pathognomonic. Other complications may include:

• Sudden hair loss (alopecia)
• Inflammation at the corners of the mouth (Cheilosis)
• Orange discoloration of the skin (Carotenoderma), if consuming too much vitamin A

Emotional and Mental Health Effects

Most people experiencing complications related to bulimia nervosa will experience one or more distressing symptoms related to their emotional and mental health, including one or more of the following:

• Anxiety
• Depression
• Postpartum depression
• Substance use
• Low self-esteem and relationship issues

Pulmonary Complications

Bulimia nervosa can cause serious damage to the pulmonary system, at times leading to sudden onset respiratory distress. Stomach contents can leak into the lungs during vomiting (aspiration), irritating the lungs (pneumonitis) and can potentially cause infection of the lungs (pneumonia). Small breaks in the lung due to the increased pressure caused by vomiting can cause air to leak between the lungs and surrounding tissues (pneumothorax and pneumomediastinum, respectively), although this is also seen in patients who don’t engage in vomiting or other purging behaviors.

PseudoBartter Syndrome

The dehydration and intravascular depletion that develops from purging behaviors causes an up-regulation of a hormone called aldosterone that increases sodium and water resorption in the kidneys, thereby helping to maintain blood pressure and reduce risk of passing out (syncope). However, this hormone also can cause exuberant weight gain during the refeeding process, necessitating cautious use of IV fluids and judicious use of diuretics to help combat these hormonal effects.

Treating Bulimia and its Complications

If you or someone you know is suffering health effects from bulimia nervosa, know that most complications can resolve with time and effective treatment. Patients experiencing severe medical instability as a result of BN may require medical stabilization in order to become physically, nutritionally, and emotionally stable prior to entering a traditional eating disorder treatment program. In these settings, treatment teams deliver intensive dietary and psychiatric support as they pursue further testing and accurate diagnoses. Once medically stable, the patient can transition to the appropriate program to continue recovery.

Resources

• Gibson D, Workman C, Mehler PS. Medical complications of anorexia nervosa and bulimia. The Psychiatric Clinics of North America 2019;42(2):263-74.
• Mehler PS. Hypokalemia: A marker of covert bulimia nervosa. The American Journal of Medicine 2015;128(9):e37.
• Mehler PS, Rylander M. Bulimia nervosa – medical complications. Journal of Eating Disorders 2015;3(1):12.
• Morgan JF, Lacey H, Chung E. Risk of postnatal depression, miscarriage, and preterm birth in bulimia nervosa: Retrospective controlled study. Psychosomatic medicine 2006;68:487-92.
• Tabler J, Utz RL, Smith KR, et al. Variation in reproductive outcomes of women with histories of bulimia nervosa, anorexia nervosa, or eating disorder not otherwise specified relative to the general population and closest-aged sisters. International Journal of Eating Disorders 2018;51(2):102-11.
• Tith RM, Paradis G, Potter BJ, et al. Association of bulimia nervosa with long-term risk of cardiovascular disease and mortality among women. JAMA Psychiatry 2020;77(1):44-51.
• Trahan MJ. Pregnancy outcomes among women with bulimia nervosa [A217]. Obstetrics and Gynecology 2022;139(s5):63S.

Last Reviewed: November 2023 by Dennis Gibson, MD, FACP, CEDS