Bulimia & Acid Reflux (Gastroesophageal Reflux Disease)

Eating disorders can increase the risk of developing gastroesophageal reflux disease (GERD) due to self-induced vomiting. Repeated vomiting weakens the digestive system and contributes to acid reflux. Cessation of vomiting helps most patients, while other patients may benefit from additional treatment like proton-pump inhibitors.

Gastroesophageal Reflux Disease & Bulimia Nervosa

Bulimia nervosa is an eating disorder characterized by repeating episodes of binge eating followed by compensatory behaviors. These behaviors are used to counteract the effects of eating to prevent weight gain or to reduce feelings of guilt. The most common compensatory behavior is self-induced vomiting, used by up to 90% of those with bulimia nervosa, up to 39% of patients with anorexia nervosa and up to 56% of those with other specified feeding or eating disorder (OSFED).¹

Can Bulimia Cause GERD?

When someone with an eating disorder vomits, stomach acid travels through the entire esophagus and mouth, which can cause inflammation and irritation of the mouth, larynx, and esophagus. Repeated episodes of vomiting can weaken the lower esophageal sphincter, leading to acid flowing back into the esophagus even when not vomiting, a condition known as gastroesophageal reflux disease (GERD).

Many people with bulimia report throat pain, chest pain, stomach pain and other uncomfortable symptoms related to GERD.

Bulimia Nervosa and GERD

GERD is a chronic condition characterized by the reflux of stomach contents into the esophagus, leading to various symptoms, including:²

• 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

Effects of Acid Reflux

Acid reflux can cause secondary symptoms such as difficulty swallowing, dental erosion and sleep disturbances. Inflammation around the throat may lead to dysphagia and voice changes.

Dysphagia increases the risk of aspiration pneumonia, which is linked to higher mortality. Over time, GERD can cause dental erosion (perimylolysis).³ Chronic exposure to stomach acid from vomiting softens the surface of the teeth.³ This can lead to hypersensitivity to heat, cold and sweets. It can also result in exposed dentin, increasing the risk of cavities.

Acid reflux & sleep

Acid reflux can also affect sleep and sleep quality, with evidence indicating a link between GERD and shorter sleep duration, difficulty falling asleep, nighttime arousals, poor sleep and early waking.⁴

Bulimia Nervosa & Barrett’s esophagus

Repeated self-induced vomiting can lead patients with bulimia to develop Barrett’s esophagus, a condition where the mucosal lining of the esophagus is damaged by acid reflux, creating a pre-cancerous state.^5,6 The chronicity of symptoms is a better predictor than symptoms alone for the development of Barrett’s esophagus.

While Barrett’s esophagus raises the risk of esophageal cancer, the overall risk remains low, with the annual risk of developing this cancer being as high as 0.33%.⁷

While the risk is low, it is recommended to follow up with a gastroenterologist to discuss screening for this condition.

Identifying Bulimia in those with GERD

Acid reflux is a common self-reported symptom of bulimia. Before many patients even seek treatment for their eating disorder, they often receive treatment for gastrointestinal (GI) issues, with a higher frequency of symptoms in patients with bulimia compared to those with anorexia nervosa.

Gastroenterologists and general practitioners should consider bulimia nervosa in patients with recurrent hypokalemia (low potassium) and metabolic alkalosis based on lab results. Other physical exam findings that may indicate bulimia include:

• Perimylolysis (enamel erosion)
• Poor mouth health
• Sialadenosis
• Recurrent epistaxis (nosebleeds)
• Scarring on the knuckles (known as Russell’s sign)
• Edema

A useful screening tool for eating disorders is the SCOFF questionnaire, which consists of five questions designed to identify potential cases and can be used in primary care or specialist settings.

How Other Eating Disorders Can Cause Acid Reflux

Patients with other eating disorders, such as anorexia nervosa or ARFID, who restrict their food intake, may also develop reflux due to weight loss-induced gastroparesis. In comparison to those with GERD caused by self-induced vomiting, the reflux tends to be milder.

Treating Acid Reflux & Bulimia Nervosa

Many patients notice improvement and relief of GERD symptoms after cessation of vomiting. However, in some patients, symptoms can continue.³ These patients may not respond to antacids and instead need:

• Higher-dose histamine-2 blockers (for example, famotidine)
• Proton-pump inhibitors (for example, omeprazole)

While both are effective treatments, trials in the general population have shown that treatment with proton-pump inhibitors is the more effective option for healing esophagitis and improving symptoms.³

If more severe symptoms develop or are present, such as dysphagia, bleeding anemia or persistent dyspepsia, further investigation with an endoscopy may be warranted.³

Getting Care for Bulimia Nervosa

Acid reflux from bulimia nervosa is a common issue, and support can make a real difference. Medical care can help ease discomfort and protect the esophagus, while nutrition guidance helps reduce symptoms and promote healing. With the right treatment and support, reflux can improve and recovery is possible.

References

1. Grave, R. D., Calugi, S., & Marchesini, G. (2009). Self-induced vomiting in eating disorders: Associated features and treatment outcome. Behaviour Research and Therapy, 47(8), 680–684. https://doi.org/10.1016/j.brat.2009.04.010
2. Acid Reflux & GERD. (2025, July 14). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/17019-acid-reflux-gerd
3. Nitsch, A., Dlugosz, H., Gibson, D., & Mehler, P. S. (2021). Medical complications of bulimia nervosa. Cleveland Clinic Journal of Medicine, 88(6), 333–343. https://www.acute.org/medical-complications-bulimia-nervosa
4. Fujiwara, Y., Arakawa, T., & Fass, R. (2012). Gastroesophageal reflux disease and sleep disturbances. Journal of Gastroenterology, 47(7), 760–769. https://doi.org/10.1007/s00535-012-0601-4
5. Barrett’s esophagus - Symptoms and causes. (n.d.). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/barretts-esophagus/symptoms-causes/syc-20352841
6. Spechler, S. J. (2013). Barrett esophagus and risk of esophageal cancer. JAMA, 310(6), 627. https://doi.org/10.1001/jama.2013.226450
7. Desai, T. K., Krishnan, K., Samala, N., Singh, J., Cluley, J., Perla, S., & Howden, C. W. (2011). The incidence of oesophageal adenocarcinoma in non-dysplastic Barrett’s oesophagus: a meta-analysis. Gut, 61(7), 970–976. https://doi.org/10.1136/gutjnl-2011-300730