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Bulimia and Acid Reflux (Gastroesophageal Reflux Disease)

By Dennis Gibson, MD, FACP, CEDS

What is Gastroesophageal Reflux Disease (GERD)?

Gastroesophageal reflux disease (GERD) is a chronic condition characterized by the reflux of stomach contents into the food pipe (esophagus).

The main symptoms of GERD include:

  • Heartburn (painful burning sensation in the middle of the chest/esophagus)
  • Odynophagia (painful swallowing)
  • Dysphagia (trouble swallowing)
  • Acid regurgitation
  • Chest pain
  • Hoarseness or cough
  • Tightness in throat

GERD can also have secondary effects, such as sleep disturbances, with clinical evidence suggesting an association between GERD and shorter sleep duration, difficulty falling asleep, arousals during sleep, poor sleep quality and waking up early.

 

GERD and Bulimia

In patients with bulimia, GERD is caused by self-induced vomiting and weakening of the lower esophageal sphincter, resulting in contents flowing upwards into the esophagus. Typically, the esophageal sphincter would prevent stomach contents and acid from moving up into the esophagus.

Patients without bulimia who only restrict food intake may also develop reflux due to weight loss induced gastroparesis; however, the reflux tends to be mild in comparison to those engaging in vomiting behaviors. In patients with self-induced vomiting, acid travels through the entire esophagus and mouth, which can cause more severe GERD symptoms, including inflammation of the vocal cords, laryngitis, sore throat and cough. Inflammation to the anatomy near the throat can lead to trouble swallowing and voice changes. Dysphagia lends itself to aspiration pneumonia, which is associated with increased mortality.

Although symptoms of GERD tend to be more prevalent in those with vomiting behaviors, upper endoscopy findings (a procedure to look at the esophagus/stomach) in those with bulimia do not always correlate with severity and frequency of vomiting. Therefore, an upper endoscopy should not be used to make a diagnosis of bulimia or engagement in vomiting behaviors. pH monitoring of the esophagus is the best diagnostic test in those with persistent symptoms suggestive of GERD.

 

Identifying Bulimia in Patients with Acid Reflux

Acid reflux is a common self-reported symptom of bulimia. Before many patients even seek treatment for their eating disorder, many of them receive treatment for gastrointestinal (GI) issues, with the rate of GERD being higher in patients with bulimia compared to those with anorexia nervosa (AN) and occurring about three times as frequently.

Bulimia should be a consideration in individuals with recurrent hypokalemia (low potassium) and metabolic alkalosis on labs. Other physical exam findings suggestive for bulimia can include perimylolysis and overall poor mouth health, sialadenosis, recurrent bouts of epistaxis (nosebleeds), scarring on the knuckles (known as Russell’s sign) and edema.

A useful screening tool for eating disorders is the SCOFF questionnaire, which is a 5-question questionnaire designed to raise suspicion that an eating disorder exists, and can be used in primary care or specialist settings.

 

Treating Acid Reflux and Bulimia

Many patients will see improvement and alleviation of GERD symptoms after cessation of vomiting. However, in some patients, symptoms can persist. These patients may not respond to antacids and instead need higher-dose histamine-2 blockers (for example, famotidine) or proton-pump inhibitors (for example, omeprazole). While both are effective treatments, trials have established that treatment with proton-pump inhibitors is the more effective option for healing esophagitis and improving symptoms.

It has also been demonstrated that empiric treatment for a couple weeks with a proton-pump inhibitor is cost-effective prior to pursuing endoscopies or other diagnostic workup when symptoms fail to resolve with medication. If more severe symptoms are present or develop, such as dysphagia, bleeding anemia or persistent dyspepsia, further work up with an under endoscopy may be warranted.

 

Barrett’s Esophagus

Repeated self-induced vomiting can cause patients with bulimia to develop Barrett’s esophagus, a condition where the mucosal lining of the esophagus becomes damaged by acid reflux, causing the lining to thicken and become red. Chronicity of symptoms is a better predictor than symptoms regarding development of Barrett’s esophagus. While Barrett’s esophagus increases the risk of esophageal cancer, the risk is small. Potentially up to 14% of those with Barrett’s esophagus will develop esophageal adenocarcinoma in their lifetime, and annual risk of developing esophageal adenocarcinoma may reach 3%. While the risk is low, follow up with a gastroenterologist is recommended to discuss screening for this condition.

 

Get Help for a Severe Eating Disorder

If you or someone you care about is experiencing severe medical complications due to an eating disorder, ACUTE can help. Reach out to us today to learn more about medical intervention for severe and extreme eating disorders with our experts at ACUTE. With proper care provided by experienced experts, we can help you restore your weight and regain your health.

 

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References

  • Barrett’s esophagus - Symptoms and causes. (2022, March 5). Mayo Clinic. 

  • Denholm, M., & Jankowski, J. (2011). Gastroesophageal reflux disease and bulimia nervosa - a review of the literature. Diseases of the Esophagus, 24(2), 79–85. 

  • Fujiwara, Y., Arakawa, T., & Fass, R. (2012). Gastroesophageal reflux disease and sleep disturbances. Journal of Gastroenterology, 47(7), 760–769. 

  • GERD (Chronic Acid Reflux): Symptoms, Treatment, & Causes. (2019, June 12). Cleveland Clinic. 

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

  • Spechler, S. J. (2013). Barrett Esophagus and Risk of Esophageal Cancer. JAMA, 310(6), 627. 

Written by

Dennis Gibson, MD, FACP, CEDS

Dennis Gibson, MD, FACP, CEDS serves as the Medical Director at ACUTE. Dr. Gibson joined ACUTE in 2017 and has since dedicated his clinical efforts to the life-saving medical care of patients with…

ACUTE Earns Prestigious Center of Excellence Designation from Anthem
In 2018, the ACUTE Center for Eating Disorders & Severe Malnutrition at Denver Health was honored by Anthem Health as a Center of Excellence for Medical Treatment of Severe and Extreme Eating Disorders. ACUTE is the first medical unit ever to achieve this designation in the field of eating disorders. It comes after a rigorous review process.

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