Emergent Management of Bulimia Nervosa
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When a patient with bulimia nervosa is seen in an emergency situation, it is important to address the potential for other risk-taking behaviors. The patient should be interviewed away from friends or family, and suicide risk should be specifically assessed. [1, 2, 3, 4]
Potential life-threatening toxic ingestions should also be addressed. Toxicity from ingestion of substances such as ipecac has been associated with severe cardiac disease.
Acute pancreatitis should be considered. The ability to recognize acute pancreatitis may be impaired because of the assumption that an elevated amylase level is due to vomiting. Serum lipase levels should be obtained or computed tomography (CT) considered if epigastric tenderness is significant.
Comprehensive recommendations for the management of bulimia nervosa have been provided by the American Psychiatric Association (APA) in Practice Guidelines for the Treatment of Patients With Eating Disorders, Third Edition.
It is the position of the American Dietetic Association that nutrition intervention, including nutritional counseling by a registered dietitian (RD), is an essential component of team treatment of patients with anorexia nervosa, bulimia nervosa, and other eating disorders (EDs) during assessment and treatment across the continuum of care. [5]
Complications of bulimia that are treatable in the emergency setting may include volume depletion, electrolyte abnormalities, esophagitis, Mallory-Weiss tear, esophageal or gastric rupture (see the image below), pancreatitis, arrhythmia, [6] and adverse effects of medications (eg, ipecac or appetite suppressants).
Associated illnesses, including depression, anxiety disorders, and substance abuse, increase the risk of other illness and injury [7] —hence the recommendation to question patients directly regarding suicidal ideation.
Patients should be warned against the use of diet pills and amphetamines, as well as energy pills and diet teas that claim to be all-natural. All-natural supplements often contain herbal forms of caffeine and ephedrine and have been associated with hypertension and cerebrovascular accident.
As new therapies to treat bulimia are introduced, their potential adverse effects must be taken into account. Such adverse effects may include nephrolithiasis, glaucoma, seizure, and metabolic derangement.
Patients with eating disorders who are seen for an apparently unrelated problem benefit from being seen by an emergency physician who can promptly recognize an eating disorder and can provide appropriate initial management and suitable referral. Diagnostic criteria have been published by the APA. [8]
For patients who are unable to halt the dangerous sequence of dieting, binging, and purging, admission to a psychiatric unit may be necessary to break the cycle. [9] Psychiatric hospitalization may also be necessary for patients who have severe depression and suicidal ideation, experience a greater than 30% weight loss over 3 months, fail to maintain an outpatient weight contract, or are involved in a family crisis. [10]
Admission to a medical facility is warranted for patients with significant electrolyte or metabolic disturbance or another physical complication of binging or purging (eg, Mallory-Weiss tear, esophageal rupture, or pancreatitis).
All patients suspected of having an eating disorder should be referred to a psychiatrist for further evaluation. If possible, arrangements should be made for follow-up within 2 days.
Gordon KH, Simonich H, Wonderlich SA, Dhankikar S, Crosby RD, Cao L, et al. Emotion Dysregulation and Affective Intensity Mediate the Relationship Between Childhood Abuse and Suicide-Related Behaviors Among Women with Bulimia Nervosa. Suicide Life Threat Behav. 2016 Feb. 46 (1):79-87. [Medline].
Smith CE, Pisetsky EM, Wonderlich SA, Crosby RD, Mitchell JE, Joiner TE, et al. Is childhood trauma associated with lifetime suicide attempts in women with bulimia nervosa?. Eat Weight Disord. 2016 Jun. 21 (2):199-204. [Medline]. [Full Text].
Mascolo M, Trent S, Colwell C, Mehler PS. What the emergency department needs to know when caring for your patients with eating disorders. Int J Eat Disord. 2012 Dec. 45(8):977-81. [Medline].
Trent SA, Moreira ME, Colwell CB, Mehler PS. ED management of patients with eating disorders. Am J Emerg Med. 2013 May. 31(5):859-65. [Medline].
Ozier AD, Henry BW, American Dietetic Association. Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011 Aug. 111 (8):1236-41. [Medline].
Suri R, Poist ES, Hager WD, Gross JB. Unrecognized bulimia nervosa: a potential cause of perioperative cardiac dysrhythmias. Can J Anaesth. 1999 Nov. 46(11):1048-52. [Medline].
Levinson CA, Zerwas S, Calebs B, Forbush K, Kordy H, Watson H, et al. The core symptoms of bulimia nervosa, anxiety, and depression: A network analysis. J Abnorm Psychol. 2017 Apr. 126 (3):340-354. [Medline]. [Full Text].
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.
Burton AL, Abbott MJ, Modini M, Touyz S. Psychometric evaluation of self-report measures of binge-eating symptoms and related psychopathology: A systematic review of the literature. Int J Eat Disord. 2016 Feb. 49 (2):123-40. [Medline].
Grall-Bronnec M, Guillou-Landreat M, Vénisse JL. [Emergency situations concerning eating disorders]. Rev Prat. 2008 Jan 31. 58(2):161-5. [Medline].
Rebeka Barth, MD Staff Physician, Summit Alta Bates Hospital
Rebeka Barth, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Emergency Medicine Residents’ Association
Disclosure: Nothing to disclose.
Rebecca Smith-Coggins, MD, FACEP Professor, Department of Surgery/Emergency Medicine, Associate Dean for Medical Student Life Advising, Stanford University School of Medicine
Rebecca Smith-Coggins, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Academy of Sleep Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Robert Harwood, MD, MPH, FACEP, FAAEM Senior Physcian, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine
Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Council of Emergency Medicine Residency Directors, American College of Emergency Physicians, American Medical Association, Phi Beta Kappa, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Sanz Laniado Medical Center, Netanya, Israel
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Samuel M Keim, MD, MS Professor and Chair, Department of Emergency Medicine, University of Arizona College of Medicine
Samuel M Keim, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Tammy Foster, MD, to the development and writing of the source article.
Emergent Management of Bulimia Nervosa
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