Bulimia nervosa is an eating disorder characterized by the consumption of large quantities of food in a single session that is followed by compensatory purging behaviour like vomiting, usage of laxatives and enemas or fasting and excessive exercise. Bulimia nervosa and others eating disorders (such as closely related anorexia nervosa) often go hand in hand with other mental diseases such as obsessive-compulsive disorder (OCD), anxiety or depression. It may also be perceived as risk factor for development of other diseases that can be relevant to reproduction.
Primary cause of bulimia nervosa has the socio-cultural origin and it mainly affects adolescent women but it may also affect opposite gender even though it is less frequent in men. Bulimia develops as a response to social pressure that values thinness (especially promoted by social media) as physical attractiveness, which plays an important role in modern societies. The socio-psychological pressure also affects the biological aspects of the body. For example, the function of one of the main neurotransmitters called serotonin is being modulated like in case of anxiety disorder or depression. Since serotonin release is united with decreased tension, the feeling of pleasure and improvement of well-being, its modulation can have quite negative influence on a human well-being. On the other hand, the development of bulimia may be based also on genetic predispositions. It has been revealed that tenth chromosome incorporates some genes that take part in the onset of bulimia.
There are effective treatments for the medical complications of bulimia nervosa. With early recognition and appropriate medical treatment, patient with bulimia nervosa may achieve successful treatment outcomes. Bulimia nervosa requires complex treatment with focus on main complications (laxative abuse, dental and gastrointestinal complication and electrolyte imbalance) combined with psychotherapy. Some additional examinations are often performed to estimate the development of some related disorders such as upper endoscopy as investigation of potential oesophageal carcinoma development.
For patients with bulimia nervosa, treatment of their acid reflux symptoms follows the usual treatment plan generally used for any patient with this disorder, namely proton pump inhibitors, head of bed elevation and minimizing oral intake within a few hours of going to sleep. In addition, treatment of the dental consequences of self-induced vomiting largely revolves around ensuring good dental hygiene to reduce the harmful effects of stomach acid on teeth enamel. Brushing lightly with a fluoride-based toothpaste soon after vomiting is the current practice. Also, the sialadenosis which can often develop with abrupt cessation of self-induced vomiting, is treated with sialagogues such as tart candies, warm packs applied to the sides of the face multiple times per day and low dose anti-inflammatory agents such as ibuprofen. For refractory cases, a trial of prescription pilocarpine (sialogen) should be initiated before consideration of surgical treatments.
For those patients with bulimia nervosa who purge via stimulant laxative abuse, the treatment challenge which evolves is how to successfully “detox” them before they develop the cathartic colon syndrome, wherein their colon is relegated to an inert tube incapable of propagating fecal material resulting in severe constipation. Nevertheless, adequate fluid intake should be encouraged along with regular daily usage of an osmotic laxative, such as polyethylene glycol, to obligate intraluminal colonic absorption of water to assist with soft stools and successful defecation, even if that is not on a daily basis. Using the osmotic laxative, three to four times per day may be needed for those patients with a long history of daily stimulant laxative abuse.
All modes of purging, which are engaged in excessively, will result in hypokalemia (the condition in which the concentration of potassium (K+) in the blood is low) and metabolic alkalosis (a metabolic condition in which the pH of tissue is elevated beyond the normal range), although milder cases of diarrhea from laxative abuse, will cause a non-anion gap acidosis (acidosis that is not accompanied by an abnormally increased anion gap ). The mainstays of treatment for the hypokalemic metabolic alkalosis due to vomiting and diuretic abuse are intravenous saline and potassium. However, the efficacy of potassium repletion will be abrogated unless there is concomitant attention to correcting the hypovolemia (a decrease in volume of blood plasma) via saline and reducing aldosterone secretion.
Polycystic ovary syndrome (PCOS), Amenorrhea
Bulimia may induce hormonal changes in the body through unhealthy way of alimentation. These hormonal changes can affect also the reproduction system leading to impairment of its function. The eating disorder is often connected with hormonal imbalance of metabolic hormones such as insulin. Insulin disturbances often lead through hormonal cascade to imbalance of reproductive hormones such as follicle-stimulating hormone or luteinizing hormone. These directly influence the function of reproductive system and may lead to reproduction disorders such as polycystic ovary syndrome (PCOS) or amenorrhea (the cessation of menstrual cycle).
Esophageal adenocarcinoma may arise as a result of Barrett’s esophagus which refers to the change in the mucosal lining type due to chronic and repetitive abnormal acid exposure.
The most severe, albeit very rare, acute consequence of self-induced vomiting, is oesophageal rupture caused due to vommiting. This syndrome manifests with chest pain, shortness of breath, and the very unique complaint of painful yawning in a patient who is tachypneic (fast breathing), tachycardic (increased pulse frequency) and appears to be in significant distress.
Gingivitis (gum disease) and periodontal disease may result from repeated exposure to gastric acid. This causes chronic gum irritation and bleeding.
Sialadenosis (hypertrophy of the salivary glands) can be often seen in bulimic persons. It has been hypothesized that sialadenosis may be the result of either regurgitation of acidic contents, consumption of carbohydrate dense foods over a short period of time (binges) or the result of pancreatic proteolytic enzymes coming back into the mouth during vomiting.
The inflammation of oesophagus may appear as result of GERD and related exposure to gastric acid.
Gastroesophageal reflux (GERD)
A chronic condition of mucosal damage caused by gastric acid coming up from the stomach into the esophagus. GERD is usually caused by changes in the junction between the stomach and the esophagus.
As the alimentation has great impact on whole body it is no wonder that there is quite large list of complications related with bulimia (Pic. 1). There may appear dermal complications such as alopecia (a loss of hair), xerosis (dry skin), nail fragility and others cutaneous manifestations. The mechanical induction of vomiting by inserting fingers into the mouth may result in the appearance of callous formations on the dorsal part of the hand. This characteristic finding is referred to as Russell’s sign (Pic. 2). The changes of skin are most apparent when the body mass index (BMI) drops below 16.
Bulimia may also affect eyes, ears and nose. Self-induced vomiting may result in subconjunctival haemorrhage or recurrent epistaxis (nose bleeding). Subconjunctival haemorrhage consists of red patches in the white of the eyes and it is benign. Recurrent seizures of nose bleeding should prompt inquiry about purging.
Bulimia is also affecting the throat area. Acid reflux, as a result of frequent bouts of self-induced vomiting and damage to the esophageal sphincters, affect areas of the pharynx and larynx and is referred to as laryngopharangeal reflux (LPR). Regurgitated acidic contents may come into contact with the vocal chords and surrounding areas, resulting in hoarseness, dysphagia (difficulty of swallowing), chronic cough, a burning sensation in the throat or repeated sore throats.
Lungs may be also affected by self-induced vomiting. In patients who purge via self-induced vomiting, aspiration of regurgitated food is a possibility. Another pulmonary complication of self-induced vomiting is pneumomediastinum, which is the dissection of air through the alveolar walls, due to retching.
Dehydration as a result of repeated episodes of vomiting can result in cardiac complications such as tachycardia, hypotension and others. Cardiac complications may also appear after usage of specific medications to induce vomiting. These were originally used to treat acute toxic ingestions such as syrup called ipecac.
Bulimia is also related with dental, gastrointestinal, laxative abuse complications and imbalance of electrolytes which are quite characteristic for bulimia.
Several abnormalities in the oral cavity have been reported including dental erosion, reduced salivary flow rate, tooth hypersensitivity, dental caries, periodontal disease, and xerostomia (dry mouth).
Dental erosions typically occur on the lingual surface of the maxillary teeth. Though mandibular teeth may also be affected (Pic. 3), but they are believed to be somewhat protected from gastric acid exposure by the tongue. Erosions may be apparent as early as six months after onset of regular self-induced vomiting. The rate and severity of erosions may ultimately be determined by duration of illness, types of food consumed, oral hygiene, frequency of vomiting and baseline quality of the tooth structure.
Patients who induce vomiting will commonly complain of symptoms consistent with dysphagia (difficulty in swallowing), and odynophagia (painful swallowing). These complaints generally imply abnormalities of the esophagus (throat). With repetitive vomiting, the esophageal epithelium suffers repeated abnormal exposure to acidic gastric contents. Consequences of this can include esophageal erosions and ulcers, Barrett’s esophagus and bleeding.
Repeated episodes of vomiting can lead to dehydration, as mentioned above, and subsequent upregulation of the secretion of the renin-angiotensin-aldosterone steroid hormone system. Aldosterone is secreted by the adrenal glands and results in increased renal absorption of sodium and bicarbonate and subsequent water retention. This results in a metabolic alkalosis (elevated pH values in the body) and low serum potassium values. Taken together, this phenomenon is referred to as pseudo-Bartter’s syndrome. Additional potassium losses arise out of the actual vomitus. The majority of patients with bulimia, who vomit only occasionally, will have normal serum electrolytes, in contrast to those who vomit excessively or those who do so very regularly for a long period of time.
Laxative abuse related complications
While less common than self-induced vomiting, abuse of laxatives is the second most commonly utilized mode of purging in patients with bulimia nervosa. Of the various classes of laxatives, the ones most abused by bulimic patients and the ones associated with most of the medical complications, are the stimulant laxatives. They act rapidly and directly to stimulate colonic motility, producing a large volume of watery diarrhea.
The medical complications of laxative abuse can be divided into two main categories, those due to effects on the gastrointestinal system and those due to electrolyte disturbances. The gastrointestinal effects of laxative abuse include melanosis coli, cathartic colon and functional impairment of the colon. Melanosis coli is a dark brown discoloration of the colonic mucosa. There is no indication that melanosis coli has any significant pathophysiologic consequences. In contrast, the cathartic colon syndrome is a serious complication, involving loss of normal colonic peristalsis because of long-term habituation to stimulant laxatives. The result is a dilated, atonic colon, which is incapable of propagating faeces. This means that slowed or absent transit occurs through some or all segments of the colon, leading to hard, infrequently passed stools and refractory constipation wherein the colon is converted to an inert tube. With truly prolonged abuse of these laxatives, the cathartic colon syndrome is potentially irreversible.
Unhealthy exaggerated concern about self-appearance, other mental disorders (especially eating disorders, depression and anxiety) and family history (incidence of eating disorders in family).
There is no guaranteed or known way to prevent bulimia. Nevertheless, it is crucial to keep a healthy view of self and others. Besides that, having a healthy approach to lifestyle can prevent the onset of disorder. Also, if the problem is detected, it is recommended to seek a professional help and start the treatment as early as possible.
Obviously bulimia has a great impact on function of whole body and the function of reproductive system is not an exception. Among other factors, the proper function of reproductive system is dependent on the homeostasis, hormonal balance and mental health of the body. All these aspects are negatively influenced by bulimia directly or indirectly, as described above. This means that bulimia is to be connected with lower conception rates and some reproduction related disorders such as polycystic ovary syndrome (PCOS). It is suggested that bulimia is the risk factor of PCOS development as overeating and starving episodes impair insulin sensitivity and are associated with ovarian morphology changes. The impact of bulimia on reproduction capability depends on the severity of bulimia and the time of its lasting. If successful conception happens, there is still a great health risk to the fetal development if bulimia is not treated properly.
Although the relation between eating disorders, mood disorders and fertility in men is still poorly understood, it is obvious that bulimia in man may also have negative impact on fertility similarly to bulimia in women. Impulsive overeating and purging impairs hormonal metabolic balance which also affects sex hormone production important for proper function of gonads. As mentioned in description, bulimia often goes hand in hand with anxiety and depression. Both of this mental diseases are related with lower testosterone levels impairing spermatogenesis leading to reduced sperm concentration. Bulimia related depression may be also connected with reduced sperm motility or development of erectile dysfunction.
Bulimia is related with increased rate of fertility treatment due to reproduction related health complications. It can be related to dysfunction of ovaries, irregularities of menstruation cycle or decreased oocyte quality. Even if bulimic women manages to conceive, it usually takes longer time to make it happen. On the other hand, the pregnancy of a women suffering from bulimia is a risky one with many potential complications. Even though, it is possible for bulimic pregnant women to bear a child, if proper medical attention is given to her. It includes a complex medical treatment with great attention to alimentation related issues and professional mental health care.