Patricia Westmoreland, MD, returns to the Psychcast to conduct a Masterclass on treating bulimia. Dr. Westmoreland, an attending psychiatrist at the Eating Recovery Center in Denver, previously discussed eating disorders. She is an adjunct assistant professor in the department of psychiatry at the University of Colorado at Denver, Aurora, and has a private forensic psychiatry practice in Denver. Takeaway points Anorexia nervosa and bulimia nervosa can have life-threatening medical complications. All medical complications can resolve with consistent nutrition and full weight restoration. Eating disorders must be treated and associated behaviors stopped to prevent complications from returning. Anorexia-related medical complications usually are attributable to weight loss and malnutrition. Bulimia-related medical complications can occur at any weight, and are related to the mode and frequency of purging. Complications include metabolic abnormalities, such as electrolyte and acid-base disturbances, volume depletion, and damage to the colon. Patients with bulimia have a lower mortality rate than do those with anorexia. However, the mortality of patients with bulimia is two times higher than that of age-matched healthy controls because of acid-base disturbances and severe electrolyte abnormalities. The weight of the patients with bulimia does not matter. Acid-based disturbances and severe electrolyte abnormalities can kill patients at any time without warning and at any weight. Summary About 90% of purging behaviors consists of self-induced vomiting and/or laxative abuse. Self-induced vomiting can cause local complications such as gastric reflux, which can lead to dysphagia and dyspepsia; hematemesis from Mallory-Weiss tears in the esophagus; nosebleeds and subconjunctival hemorrhages; and parotid gland enlargement, known as sialadenosis, which is a chronic, noninflammatory cause of swelling of the major salivary glands. Systemic complications of self-induced vomiting include metabolic derangements, such as hypokalemia, metabolic alkalosis, and volume depletion, which can lead to pseudo-Bartter syndrome from chronic aldosterone secretion as the body attempts to maintain blood pressure; the syndrome is characterized by hyperaldosteronism, metabolic alkalosis, hypokalemia, and normal blood pressure. Treatment of local complications: Gastric reflux can be treated with proton pump inhibitors, and the patient should be screened for Barrett’s esophagus with esophagogastroduodenoscopy. Dental complications such as erosion of the enamel should be addressed with fluoride-based mouthwashes and toothpastes, and gentle toothbrushing. Parotid gland enlargement is treated by sucking on sour candies, applying hot packs, and using anti-inflammatory medications. Treatment of systemic complications: Hypokalemia, which is diagnosed on a basic metabolic panel, needs immediate repletion orally or intravenously. Depending on the severity of the hypokalemia, the patient may need cardiac monitoring in the hospital or ICU to prevent mortality from a lethal arrhythmia. In pseudo-Bartter syndrome, the elevated aldosterone does not normalize until a few weeks after purging stops, so individuals can develop edema and the other electrolyte abnormalities. Treatment is spironolactone, 25-200 mg/day. Complications from laxative abuse occur primarily from stimulant laxatives, which stimulate the myenteric plexus, the nerves of the intestines, and increase intestinal secretions and motility. Cathartic colon syndrome occurs from continued use of stimulant laxatives, which damage the nerves of the colon by rendering it incapable of peristalsis without continued use of laxatives. Individuals who abuse laxatives more than three times per week for at least 1 year are at risk of cathartic colon syndrome and need to stop laxatives immediately. References Westmoreland P et al. Medical complications of anorexia nervosa and bulimia. Am J Med. 2016;129(1):30-7. Mehler