Purging affects all major organ systems. Side effects of purging range from clinically insignificant presentations in the eyes to serious dental, gastrointestinal, cardiac and metabolic complications, some of which may continue to persist even have purging stops.

Purging and Eating Disorders

Compensatory behaviors are any eating disorder behaviors used to compensate for food intake, prevent weight gain or to relieve feelings of shame or guilt. Compensatory behavior is an essential criteria present in multiple eating disorder diagnoses.

Compensatory behaviors are divided into two categories: purging behaviors and non-purging behaviors:

• Purging behaviors involve elimination to compensate for food intake; the most common forms of purging include self-induced vomiting, laxative misuse, diuretic misuse and enemas
• Non-purging behaviors include any type of compensatory behavior that does not involve purging, which may include food restriction or fasting, excessive exercise or diet pills

Purging in diagnostic criteria

There are several eating disorders that feature purging within the diagnostic criterion. While bulimia nervosa (BN) is typically associated with purging, other eating disorders like the binge eating/purging subtype of anorexia nervosa (AN) and other specified feeding or eating disorder (OSFED) often feature purging behaviors.

Bulimia nervosa

Bulimia nervosa is an eating disorder characterized by cyclical episodes of binge eating and compensatory behaviors. A binge eating episode is eating an amount of food in a discreet amount of time that is definitively larger than what most individuals would eat in a similar period under similar circumstances. Binge eating episodes are also accompanied by a feeling that one cannot stop eating or control what or how much they are eating.

Individuals with BN will engage in recurrent inappropriate compensatory behaviors to prevent weight gain, including purging. The binge eating and compensatory behaviors with BN occur, on average, at least once a week for 3 months. Some patients with bulimia experience long term effects of their disorder. 

Anorexia nervosa binge eating/purging subtype

Anorexia nervosa is an eating disorder categorized by:

• Restriction of energy intake relative to requirements, leading to a significant low body weight in the context of the age, sex, developmental trajectory, and physical health
• Intense fear of gaining weight or becoming fat or persistent behavior that interferes with weight gain
• Feeling disturbed by one’s body weight or shape, self-worth influenced by body weight or shape, or persistent lack of recognition of seriousness of low bodyweight

Anorexia nervosa is further divided into two subtypes:

• Restricting type (AN-R)
• Binge-eating/purging type (AN-BP)

AN-BP is categorized by the above criteria, combined with regularly engaging in binge-eating or purging within the last 3 months.

Other specified feeding or eating disorder (OSFED)

According to the DSM-5, the category of OSFED is applicable to individuals who are experiencing significant distress due to their disordered eating but who do not meet the full criteria for a diagnosis of AN, BN or avoidant restrictive food intake disorder (ARFID).

Purging disorder (PD) is a pattern of behavior characterized by individuals engaging in purging behavior, such as self-induced vomiting or laxative misuse, without experiencing eating binges or being underweight. Purging disorder is not an independent diagnosis but is often used to describe purging behavior that doesn’t align with another eating disorder diagnoses.

H2: Health consequences of purging

Purging can cause complications across the entire body, ranging from clinically insignificant presentations in the eyes to serious and deadly gastrointestinal and metabolic complications.

H3: Ophthalmological complications: Red eyes (subconjunctival hemorrhage)

Forceful vomiting can cause the blood vessels of the eye to burst. During purging, the sudden increase in pressure of the eye causes the blood vessels to rupture, causing the sclera (white portion) of the eye to turn bright red.

Oral & dental complications

Purging through self-induced vomiting causes various oral complications. Unlike many complications seen in eating disorder patients, some of the oral complications are irreversible and will require further intervention.

Chipmunk cheeks (sialadenosis) & hyperamylasemia

Chipmunk cheeks, also known as sialadenosis, is a common sign of purging and causes enlargement of the parotid glands on both sides of the face when purging stops, which can be a major stressor for patients. It is thought to occur due to either a backup of saliva that is no longer needed, cholinergic stimulation of the glands or hypertrophy of the glands to help meet demands of increased saliva production. Excess vomiting can also be associated with development of hyperamylasemia.

Gingivitis & periodontitis

Purging through self-induced vomiting can cause chronic irritation of the gums (gingivitis). Chronic irritation from exposure to stomach acid can cause inflammation and pain of the gums. Gingivitis can also be caused by dry mouth (xerostomia) in patients who purge. If left untreated, it can develop into periodontitis (degradation of the jawbone), which is irreversible.

Enamel erosion (perimylolysis) & tooth damage

Enamel erosion is the most common oral manifestation of people who engage in self-induced vomiting. Chronic exposure between acidic vomit and the backside of the teeth can cause deterioration of the enamel and lead to brittle teeth, cavities or further damage to the teeth.

Xerostomia

Xerostomia (dry mouth) can be associated with reduced salivary flow from chronic dehydration from purging. Reduced salivary gland function can also develop with chronic vomiting behaviors. This can also cause further damage to teeth.

Soft tissue damage

Pressure from vomiting and the act of inserting a hand or object into the mouth can cause damage to the surrounding soft tissue, including damaged blood vessels, redness, cuts, scratches or bleeding lesions.

Other oral & dental complications

Several other oral complications include bad breath and dry, cracked or inflamed lips

Read more about the effects of purging on one’s oral health here.

Gastrointestinal Complications

Gastrointestinal complications are one of the most common groups of complications in eating disorder patients. Self-induced vomiting can cause serious stress on the gastrointestinal tract, leading to numerous complications of the esophagus and the colon.

Cathartic colon

Excessive and chronic misuse of stimulant laxatives can cause colonic inertia, also known as cathartic colon, a condition whereby the colon becomes incapable of moving stool forward. It is suspected that this is due to direct damage to the gut myenteric nerve plexus.

A recent pilot study suggests 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 a chronic condition characterized by the reflux of stomach contents into the esophagus. Over time, recurrent self-induced vomiting can weaken the esophageal sphincter, causing contents to flow upwards into the esophagus. Similarly, laryngopharyngeal reflux that is more common in those who engage in vomiting behaviors is associated with hoarseness, dry cough and sometimes a globus sensation.

Barrett’s esophagus

Because the esophageal mucosa of patients who self-induce vomiting is frequently exposed to acidic vomitus, there may be an increased risk of developing Barrett’s esophagus. Barrett’s esophagus is a condition in which the lining of the esophagus becomes more like the lining of the small intestine due to repeated exposure to stomach acid. This is a pre-cancerous condition and requires treatment of the underlying cause to help reduce progression.

Mallory-Weiss syndrome

In rare instances the sudden rise in pressure in the stomach or the lower part of the esophagus during vomiting can cause a tear in the lining in the upper gastrointestinal tract and cause bleeding.

Boerhaave syndrome

Boerhaave Syndrome is a rare condition of high mortality resulting in spontaneous perforation of the esophagus primarily due to straining or vomiting. It creates a hole through which contents of the esophagus can pass into the chest (mediastinum), putting patients at risk of infection (mediastinitis) and other complications.

Other gastrointestinal complications

There are other miscellaneous complications that can occur independently, alongside or because of the aforementioned complications:

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

H3: Pulmonary Complications

Pneumonitis & pneumonia

The greatest risk to the lungs during purging is aspiration, or the inhalation of foreign materials. Inhalation of vomit during purging can cause inflammation of the lung tissue (pneumonitis) or infection of the lung tissue (pneumonia). Aspiration confers high mortality in those with eating disorders.

Pneumothorax

Pneumothorax, or collapse of the lung, can develop from both purging and restricting behaviors. This can present with shortness of breath and can be a medical emergency.

Pneumomediastinum

The increased intrathoracic and intra-alveolar pressures, due to retching, can cause pneumomediastinum, a condition in which air is present within the chest cavity, or the mediastinum. Research also suggests that this air may originate from the intestines and travel up to the chest cavity.

Metabolic & electrolyte disturbances

Many of the metabolic and electrolyte disturbances can be attributed to dehydration and malnutrition, with more severe electrolyte abnormalities associated with greater frequency of purging. Patients with a history of purging should be screened regularly for serum electrolyte disturbances.

Hypokalemia (low potassium)

Hypokalemia occurs with all three forms of purging. Hypokalemia from purging develops for two reasons[BB7] :

1. Direct potassium loss from gastric secretions through vomiting, intestinal secretions from laxative abuse, or urinary losses with abuse of diuretics.
2. The loss of intravascular fluid, which causes increased production of aldosterone and development of Pseudo-Bartter syndrome. Aldosterone causes to the kidneys to resorb sodium and chloride to help combat severe dehydration, hypotension and fainting. Aldosterone also promotes renal secretion of potassium into the urine, resulting in hypokalemia.

Hypokalemia can cause many complications, including:

• Muscle weakness
• Cardiac arrhythmias
• GI dysmotility
• Chronic kidney disease
• Death

Metabolic alkalosis

Metabolic alkalosis and hypokalemia are interrelated. Low hydrogen ion levels (alkalosis) cause potassium movement into cells, dropping the serum potassium.

Purging leads to the development of metabolic alkalosis, largely through the action of aldosterone, which causes loss of potassium and hydrogen ions (acid) in the urine. The loss of hydrogen ions in the urine maintains the alkalemic state. Vomiting can also contribute to development of an alkalotic state through the loss of hydrogen ions in the vomitus.

Endocrine complications

Amenorrhea

Although amenorrhea is commonly associated with weight loss, there is also an association between vomiting behaviors and menstrual disturbances. Even vomiting only a few times per month can be associated with 1.5x the risk of menstrual irregularity.

Bone health

Studies examining the impact of bulimia nervosa on bone density have mixed findings. Overall, it is likely that any effects on bone density are more related to the indirect effects of amenorrhea or increased cortisol levels that can be associated with purging.

Pseudo-Bartter syndrome

All forms of purging cause dehydration, which contributes toward the development of pseudoBartter syndrome, a state of chronic dehydration associated with an upregulation of aldosterone, which acts to retain water and salt, increasing the blood volume/blood pressure and helping reduce the risk for fainting.

While initially this is positive, the salt and water retention contribute to edema formation early in refeeding. Edema can persist for weeks after purging cessation, causing emotional distress for patients as the edema formation can sometimes be very aggressive.

Cardiovascular complications

Repeated purging can result in dehydration and hypokalemia, which can lead to decreased cardiovascular function and arrhythmias.

Hypotension & tachycardia

Dehydration from purging decreases the overall blood volume, leading to a drop in blood pressure and a subsequent increase in heart rate (tachycardia). Low blood pressure can contribute to a variety of symptoms:

• Blurred vision[BB8] 
• Dizziness and lightheadedness
• Fainting
• Fatigue
• Difficulty concentrating
• Nausea and other GI symptoms

QT prolongation

Electrolyte abnormalities (most notably hypokalemia) can lead to QT prolongation, which predisposes to more dangerous arrhythmias. The QT segment prolongs with hypokalemia, due to the effects this has on the ion channels located in the myocytes. Many of the medications used to treat comorbid mental health diagnoses and the medical complications of malnutrition also can cause QT prolongation.

It is necessary to treat the underlying cause of QT prolongation to avoid development of other arrhythmias. The malnutrition itself is an unlikely contributor to QT prolongation.

Torsades de pointes

Long QT interval (QT prolongation) puts patients at risk for a life-threatening arrhythmia known as Torsades de pointes, which is a type of polymorphic ventricular tachycardia. Hypomagnesemia, which can be seen with alcohol and diuretic misuse as well as from refeeding, can also predispose toward torsades de pointes. However, QT prolongation does not seem to be inherently related to anorexia nervosa and weight loss.

Dermatological signs

Eating disorders have many cutaneous manifestations which can help suggest this diagnosis. While most of them are associated with low weight and restriction, several of them are directly associated with purging.

Periorbital petechiae & facial purpura

Self-induced vomiting can cause small red dots or purple splotches around the face. Purging can cause the capillaries in the face to burst, causing red speckles (petechiae) around the eyes or larger spots of blood pooled under the skin of the face (purpura).

Russell’s sign

Russell’s sign develops from the repeated action of inserting the dominant hand into the mouth and scraping the knuckles across the teeth during self-induced vomiting, causing skin abrasions and calluses to form on the back of the hand and across the knuckles. However, this is rarely seen clinically.

References

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• Nitsch, A., Dlugosz, H., Gibson, D., & Mehler, P. S. (2021). Medical complications of bulimia nervosa. Cleveland Clinic Journal of Medicine, 88(6), 333–343. https://doi.org/10.3949/ccjm.88a.20168
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• Denholm, M., & Jankowski, J. (2011). Gastroesophageal reflux disease and bulimia nervosa - a review of the literature. Diseases of the Esophagus. https://doi.org/10.1111/j.1442-2050.2010.01096.x
• Auger, N., Potter, B.J., Ukah, U.V., et al. Anorexia nervosa and the long-term risk of mortality in women. World Psychiatry 2021;20(3):448-49.
• Strumia, R. (2005). Dermatologic Signs in Patients with Eating Disorders. American Journal of Clinical Dermatology, 6(3), 165–173. https://doi.org/10.2165/00128071-200506030-00003