Those who self-induce vomiting to purge are at risk of multiple potentially fatal conditions:

- Hypokalemia
- Hypochloremia
- Hyponatremia
- Metabolic alkalosis

Self-Induced Vomiting Metabolic/Electrolyte Complications

Diuretic abuse can lead to numerous electrolyte imbalances and dangerous metabolic alkalosis, although some complications can be avoided with the use of diuretics that do not affect potassium, such as spironolactone, in replacement of other diuretics. Sodium chloride is lost in urine, causing intravascular volume depletion which in turn leads to elevated aldosterone levels. High serum aldosterone then causes hydrogen and potassium to be excreted via urination, which can lead to metabolic alkalosis.

Diuretic Abuse Metabolic/Electrolyte Complications

Laxative abuse can result in several electrolyte imbalances and acid-base disorders. The resulting acid-base disorder may be a means of indicating the duration of laxative abuse:

- Hypokalemia
- Hypochloremia
- Hyponatremia
- Non-anion gap metabolic acidosis
- Metabolic alkalosis

Laxative Abuse  Metabolic/Electrolyte Complications 

Pseudo-Bartter syndrome results from chronic dehydration and thus sometimes presents in eating disorder patients, especially those who purge. It may cause hypokalemia and other electrolyte imbalances, and swelling when purging stops as a result of elevated aldosterone levels causing retention of water and salt. This edema, which can lead to weight gain and resulting emotional distress, can be avoided by less aggressive methods of fluid replacement such as a slow saline infusion of 50mL/hr in conjunction with 50-400mg low-dose spironolactone. These medications should then be gradually tapered off.
	


Pseudo-Bartter Syndrome (PBS) in Eating Disorder Patients

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

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

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.

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

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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