A patient's QTc interval reflects the time it takes for ventricular depolarization and repolarization to occur, measured from the beginning of the QRS complex to the end of the T wave, corrected for their heart rate. In other words, it represents the time needed for the heart to reset between beats.

QT Corrected for Heart Rate (QTc) Interval

An arrhythmia refers to an irregularity in the heartbeat, either due to excessive slowness, excessive quickness, or disorganized beating. Though sometimes harmless and natural, they may also cause issues or even be fatal. Symptoms may include chest palpitations, heart rate changes, chest pain, difficult or discomfort while breathing, anxiety, sweating, fatigue, and unconsciousness.

Arrhythmia

Hypokalemia occurs when the blood contains too little potassium. Common causes of hypokalemia are a potassium-deficient diet or purging of ingested food. Urine potassium-to-creatinine ratios of <13 are often indicative that hypokalemia is resultant from eating disorder behaviors. If serum potassium levels are 2.5 mmol/L or more and no symptoms of hypokalemia are present, it can be treated with oral potassium supplements and purging cessation in bulimia nervosa patients. However, if serum potassium levels are <2.5mmol/L, potassium supplementation must be provided both orally and intravenously in a saline solution drip at no greater than 50-75mL/hr to restore intravascular volume while preventing hyperkalemia. Severe hypokalemia can lead to QT prolongation, TdP, other arrhythmias, and rarely, acute renal failure via hypokalemic nephropathy. 

Hypokalemia in Eating Disorder Patients

Purging via self-induced vomiting or abuse of laxatives or diuretics leave bulimia nervosa patients particularly vulnerable to electrolyte imbalances such as hypokalemia and resulting acid-base disorders. These imbalances may result in QT prolongation and potentially fatal arrhythmias. Patients who abuse ipecac to induce vomiting may suffer from  permanent conduction problems and cardiomyopathy since it contains emetine, a cardiotoxic alkaloid. Stimulant abuse can lead to palpitations, sinus tachycardia, and arrhythmias such as supraventricular tachycardia. Diet pill abuse is similarly associated with heart arrhythmias.

Kalamazoo College

Bulimia nervosa has potentially life-threatening consequences as it affects all the body's systems in multiple ways:

- Skin complications
- Oral complications
- Head/ear/nose/throat complications
- Cardiovascular complications
- Pulmonary complications
- Gastrointestinal complications
- Endocrine complications
- Metabolic/electrolyte complications
- Mental health complications

Bulimia Nervosa Complications

Nitsch, A., Dlugosz, H., Gibson, D., & Mehler, P. S. (2021). Medical complications of bulimia nervosa. Cleveland Clinic Journal of Medicine, 88(6), 333-343.

Medical Complications of Bulimia Nervosa

Bulimia nervosa patients may have Russell's signs from inducing vomiting. However, not all bulimia nervosa patients who self-induce vomiting will have Russell's signs, since they can be avoided through the use of tools or other means to cause nausea or vomiting.

Bulimia Nervosa Skin Complications

Bulimia nervosa patients may encounter numerous oral health complications, primarily due to frequent vomiting. Perimyolysis and other dental erosions of the upper teeth and tongue are common due to acidity in those who self-induce vomiting, along with cavities. Although enamel erosion is irreversible, complications can be prevented with regular, gentle fluorinated oral care. Patients may also experience trauma to the soft palate and pharynx due to the use of hands or tools to induce vomiting, in addition to the damage caused by the acidic vomit itself. Those who utilize dental prosthetics may damage them in the process of purging. 

Bulimia Nervosa Oral Complications

Bulimia nervosa patients may suffer from conjunctival hemorrhages and nose bleeds due to gagging and retching during self-induced vomiting. Furthermore, the acid in vomit may cause damage to the throat, contributing to hoarseness, coughing, dysphagia, and pharyngitis, although these symptoms can usually be treated simply by purging cessation, or through the use of proton pump inhibitors (PPIs). Sialadenosis occurs in over half of those who purge via self-induced vomiting, though it typically goes away on its own with continued cessation of purging behaviors.

Bulimia Nervosa Head/Ear/Nose/Throat Complications

Bulimia Nervosa Cardiovascular Complications

In bulimia nervosa patients who self-induce vomiting, pneumomediastinum may occur due to retching and gagging, though it may also result in anorexia nervosa patients due to malnutrition. Bulimia nervosa patients are also at increased risk of aspiration pneumonia and infection with Mycobacterium avium complex organisms.

Bulimia Nervosa Pulmonary Complications

Bulimia nervosa is associated with numerous gastrointestinal issues. These issues can be divided into two main subsections:

- Upper gastrointestinal complications
- Lower gastrointestinal complications

Bulimia Nervosa Gastrointestinal Complications

Bulimia nervosa patients' endocrine systems tend to be less affected than those or anorexia nervosa patients. However, they may still suffer from irregular menstrual patterns as opposed to the complete amenorrhea often seen in anorexia nervosa. Patients suffering from eating disorder-diabetes mellitus type 1 are also especially vulnerable to endocrine-related complications specifically related to their diabetes.

Bulimia Nervosa Endocrine Complications

Numerous metabolic and electrolyte-related complications can occur due to bulimia nervosa, contributing to its elevated mortality rates as such imbalances can result in potentially fatal cardiac issues. The electrolyte and metabolic complications that may arise are largely dictated by the method of purging:

- Self-induced vomiting metabolic/electrolyte complications
- Laxative abuse metabolic/electrolyte complications
- Diuretic abuse metabolic/electrolyte complications
- Pseudo-Bartter syndrome

Bulimia Nervosa Metabolic/Electrolyte Complications

Given the fact that bulimia nervosa often coincides with other psychiatric disorders, it makes sense that patients are at a greater risk of non-suicidal self-injury, suicidal ideation, and suicide which are thought to be largely due to increased impulsivity and feelings of shame and hopelessness. Among bulimia nervosa patients, approximately 33% have engaged in self-injury.

Bulimia Nervosa Mental Health Complications

Sudden death in bulimia nervosa often results due to electrolyte changes, especially hypokalemia, and resultant acid-base disorders. Although bulimia nervosa has a lower rate of mortality than anorexia nervosa, it may similarly lead to cardiac issues like arrhythmias, TdP, and ischemic heart disease which leave patients at a nearly eightfold increase in mortality risk compared to similar individuals without bulimia nervosa. 

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