Nejm 2003;349:875; Peds 2003;111:e98

Cause:Self-induced vomiting; often use emetine and other meds

Pathophys:Diminished cholecystokinin production causes decreased satiety (Nejm 1988;319:683) and CNS serotonin

Female/male: >20:1; usually associated with anorexia; prevalence among young women = 1-3%; peaks at age 18 yr; 2% of college women are bulimic (Am J Publ Hlth 1988;78:1322)

Associated w childhood sexual abuse in 1/3 (Am J Publ Hlth 1996;86:1082)

Sx:Onset later than anorexia; compulsive eating binges followed by intense anxiety/guilt leading to purging

Si:Callus on back of hand from emesis induction; dental erosions from gastric fluids on teeth; enlarged salivary glands; low or normal weight; postural blood pressure drops

Chronic or episodic, associated with anxiety, depression, substance abuse, and promiscuity

CHF from starvation and ipecac myocardiopathy and myopathy (Nejm 1985;313:1457); aspiration pneumonias and Mallory-Weiss tears; hypokalemia and sudden death due to long QT syndrome (Ann IM 1985;102:49); esophagitis

Lab:

Chem:Amylase elevated, sometimes due to pancreatitis, but many times due to salivary origin (lipase and pancreatic fraction normal—Ann IM 1987;106:50); urinary emetine levels (Nejm 1996;334:47); lytes show: hypoK+, high HCO₃, hypoMg, normal anion gap acidosis w laxative use

Urine qualitative ipecac

Noninv:EKG at some regular interval (Ann IM 1985;102:49)

Rx:

Replace volume and electrolytes; calcium 1200-1500 mg po qd and vit D to prevent osteoporosis

PPI for esophagitis. Monitor patient for 1 h after eating in inpatient settings.

CBT and SSRIs (fluoxetine) established as effective in RCTs. Combination better than single modality.