Which digestive problems does bulimia cause?

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Bulimia nervosa (BN) affects as many as 300 women per 100,000 women between the ages of 16 and 20, according to onereport. (1)

One of the primary issues that occurs in those with bulimia are both upper and lower gastrointestinal (GI) symptoms. Digestive problems bulimia causes may include acid reflux, stomach pain, nausea, diarrhea, constipation, rectal prolapse (hemorrhoids), and Mallory-Weiss tears. 

However research findings have been mixed. Some studies posit that certain chronic behaviors of bulimia rarely lead to injuries. But others have found increased instances of gastrointestinal problems in those who have bulimia. (2,3)

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1. Acid reflux

Inflammation of the esophagus and heartburn/regurgitation is commonly reported in bulimia patients. 

One study suggested chronic and self-induced vomiting rarely leads to injuries of the mucosal lining. (2) Another hypothesized that alcohol, smoking, and nutritional deficiency could play more of a role than acidic damage through self-induced vomiting. (4)

Yet other studies have found increased instances of reflux, or heartburn, and other symptoms of gastric distress.

2. Stomach pain

Some of the most common and bothersome symptoms seen in bulimia patients are stomach fullness, pressure in the stomach, and nausea. When a huge amount of food is eaten during a binge, the person will feel the distention along with the pain in the stomach. This relieves itself when vomiting is induced. (5)

Researchers believe that an increased stomach capacity, plus diminished sensitivity to abdominal distention may play a role in the overconsumption. (6) However, they don’t have a solution for this yet.

3. Diarrhea, constipation and rectal prolapse (hemorrhoids)

One study reported a rate of 69% of patients with bulimia that had irritable bowel syndrome. (7) Others say that among bowel symptoms, constipation happens more often than diarrhea. 

When bulimia patients were tested for the time it takes food to pass through the GI tract, they found significantly lower times in the patients than in healthy controls in 67% of the cases. (8) This time is called the transit time of food through the GI tract.

Other studies showed the same percentage of cases of constipation in healthy controls as bulimic patients. It has been suggested that the development of constipation in bulimic patients is similar to that in those with anorexia nervosa (AN), as a result of poor nutrition, electrolyte disturbances from laxative abuse, and the effect of antidepressant medications. (5)

There’s also a proposed relationship between bulimia and rectal prolapse. During the process of vomiting, deep breathing happens before the actual vomiting. This protects the lungs from aspiration. It’s followed by a strong diaphragm contraction with all the abdominal muscles in an effort to expel the contents of the stomach. During the incident, there’s a high amount of pressure inside the abdomen. 

The repetition of all the intra-abdominal pressure, plus constipation, pelvic floor weakness, and overexercise, is thought to cause rectal prolapse. (9,10,11)

Purging behavior could also lead to chronic watery diarrhea, leading to dehydration and different electrolyte imbalances. (12,13)

Hemorrhoids occur for two primary reasons: not enough fiber in the diet and straining at the stool. 

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4. Abdominal distention (bloating)

Once food arrives in the GI tract, a lot of factors come together to make digestion possible. These factors include signals coming from the distension of the stomach, nutrient and non-nutrient elements, and gut hormones produced from the GI wall cells. 

The stomach is supposed to distend so food can be accepted. This happens via stimulation of the vagal nerve fibers and the perception of fullness that a person has. When both these come together correctly, meal size is controlled by the person. 

As the food starts moving out of the stomach, the distension reduces slowly and the signals for the distention move to the antrum of the stomach, and then the small intestine. The antrum plays a critical role in the feeling of fullness and meal termination. 

Dysregulations in these physiological processes, as well as in the nutrients influencing the motility of the food through the GI tract, can adversely affect eating behavior or provoke GI symptoms, such as bloating, nausea, and exaggerated feelings that the stomach is full. GI hormones also may play a role by altering appetite and energy intake. (5)

5. Mallory-Weiss tear

Tears in the esophagus due to vomiting that cause bleeding are called the Mallory-Weiss Syndrome. (14)

Additional digestive problems that can occur in those who have bulimia include: (3)

  • Delayed gastric emptying
  • Esophagitis, or inflammation of the esophagus
  • Gastric electrical dysrhythmia, which are abnormal stomach rhythms
  • Hyperamylasemia, or too much of a pancreatic enzyme called amylase, which causes inflammation
  • Salivary gland hypertrophy, or inflammation

Can the gastrointestinal tract tract heal after bulimia?

While some of these digestive problems can be very serious, the GI tract can heal after bulimia. The GI tract is composed of mucosal membranes, and they heal relatively rapidly. It is best to seek professional help for treatment recommendations if you or someone you live is experiencing any of these symptoms or other symptoms that may indicate bulimia or another eating disorder is present.

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Keski-Rahkonen, A., Hoek, H. W., Linna, M. S., Raevuori, A., Sihvola, E., Bulik, C. M., Rissanen, A., & Kaprio, J. (2009). Incidence and outcomes of bulimia nervosa: a nationwide population-based study. Psychological medicine, 39(5), 823–831. https://doi.org/10.1017/S0033291708003942 
  2. Kiss, A., Wiesnagrotzki, S., Abatzi, T. A., Meryn, S., Haubenstock, A., & Base, W. (1989). Upper gastrointestinal endoscopy findings in patients with long-standing bulimia nervosa. Gastrointestinal endoscopy, 35(6), 516–518. https://doi.org/10.1016/s0016-5107(89)72901-1 
  3. Riedlinger C, Schmidt G, Weiland A, Stengel A, Giel KE, Zipfel S, Enck P, Mack I. Which Symptoms, Complaints and Complications of the Gastrointestinal Tract Occur in Patients With Eating Disorders? A Systematic Review and Quantitative Analysis. Frontiers in Psychiatry. 2020 Apr 20;11:195. doi: 10.3389/fpsyt.2020.00195. PMID: 32425816; PMCID: PMC7212454.
  4. Brewster, D. H., Nowell, S. L., & Clark, D. N. (2015). Risk of oesophageal cancer among patients previously hospitalised with eating disorders. Cancer Epidemiology, 39(3), 313–320. https://doi.org/10.1016/j.canep.2015.02.009 
  5. Santonicola, A., Gagliardi, M., Guarino, M., Siniscalchi, M., Ciacci, C., & Iovino, P. (2019). Eating Disorders and Gastrointestinal Diseases. Nutrients, 11(12), 3038. https://doi.org/10.3390/nu11123038 
  6. Walsh, B. T., Zimmerli, E., Devlin, M. J., Guss, J., & Kissileff, H. R. (2003). A disturbance of gastric function in bulimia nervosa. Biological Psychiatry, 54(9), 929–933. https://doi.org/10.1016/s0006-3223(03)00176-8 
  7. Dejong, H., Perkins, S., Grover, M., & Schmidt, U. (2011). The prevalence of irritable bowel syndrome in outpatients with bulimia nervosa. The International journal of eating disorders, 44(7), 661–664. https://doi.org/10.1002/eat.20901 
  8. Kamal, N., Chami, T., Andersen, A., Rosell, F. A., Schuster, M. M., & Whitehead, W. E. (1991). Delayed gastrointestinal transit times in anorexia nervosa and bulimia nervosa. Gastroenterology, 101(5), 1320–1324. https://doi.org/10.1016/0016-5085(91)90083-w 
  9. Malik, M., Stratton, J., & Sweeney, W. B. (1997). Rectal prolapse associated with bulimia nervosa: report of seven cases. Diseases of the Colon and Rectum, 40(11), 1382–1385. https://doi.org/10.1007/BF02050827 
  10. Guerdjikova, A. I., O'Melia, A., Riffe, K., Palumbo, T., & McElroy, S. L. (2012). Bulimia nervosa presenting as rectal purging and rectal prolapse: case report and literature review. The International Journal of Eating Disorders, 45(3), 456–459. https://doi.org/10.1002/eat.20959 
  11. Mitchell, N., Norris, M.L. Rectal prolapse associated with anorexia nervosa: a case report and review of the literature. Journal of Eating Disorders, 1, 39 (2013). https://doi.org/10.1186/2050-2974-1-39 
  12. Lasater, L. M., & Mehler, P. S. (2001). Medical complications of bulimia nervosa. Eating Behaviors, 2(3), 279–292. https://doi.org/10.1016/s1471-0153(01)00036-8 
  13. Roerig, J. L., Steffen, K. J., Mitchell, J. E., & Zunker, C. (2010). Laxative abuse: epidemiology, diagnosis and management. Drugs, 70(12), 1487–1503. https://doi.org/10.2165/11898640-000000000-00000 
  14. Forney, K. J., Buchman-Schmitt, J. M., Keel, P. K., & Frank, G. K. (2016). The medical complications associated with purging. The International Journal of Eating Disorders, 49(3), 249–259. https://doi.org/10.1002/eat.22504

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