The Side Effects of Purging on the Body

Purging related to eating disorders like bulimia nervosa and anorexia nervosa can lead to serious, whole-body complications impacting every organ in the body – from dental and gastrointestinal issues to cardiac and metabolic complications. Even though some of the complications of purging are dangerous, all of them are treatable or manageable. 

What are Purging & Compensatory Methods?

Purging, a form of compensatory behavior is a key feature found in various eating disorder diagnoses. Compensatory behaviors refer to actions aimed at compensating for food intake, preventing weight gain or alleviating feelings of shame or guilt. They are categorized into two types:

• Purging behaviors: any compensatory behavior that involves elimination to compensate for food intake; the most common forms of purging include self-induced vomiting, laxative misuse, diuretic misuse and enemas
• Non-purging behaviors: any type of compensatory behavior that does not involve purging, which may include food restriction or fasting, excessive exercise or diet pills

Purging & Eating Disorders

Bulimia nervosa

Bulimia nervosa is an eating disorder marked by recurrent episodes of binge eating followed by inappropriate compensatory behaviors such as purging.¹ It is usually linked to a strong fear of gaining weight and a distorted body image, despite often maintaining a normal weight. Self-induced vomiting is the most common purging method used by patients with bulimia.^2,3

Anorexia nervosa binge eating/purging subtype

Anorexia nervosa is an eating disorder characterized by restricted food intake leading to significantly low body weight, an intense fear of gaining weight and a distorted perception of body shape or size.¹

Anorexia nervosa includes two subtypes:

• Restricting subtype: where weight loss is achieved primarily through dieting, fasting or excessive exercise
• Binge eating and purging subtype: where an individual regularly engages in episodes of binge eating or purging behaviors

Purging disorder

Purging disorder is a pattern of behavior characterized by individuals engaging in purging behavior, such as self-induced vomiting or laxative misuse, without binge eating and without being low weight.¹ Purging disorder is not an independent diagnosis, but is often used to describe purging behavior that fits under the category of other specified feeding or eating disorder.

Complications of Purging

Ophthalmological complications

Red eyes (subconjunctival hemorrhage)

Forceful vomiting can cause the blood vessels in the eye to burst. During purging, the sudden increase in eye pressure causes blood vessels to rupture, turning the whites of the eye bright red.²

Oral & dental complications

Chipmunk cheeks (sialadenosis) hyperamylasemia

Chipmunk cheeks, also known as sialadenosis, are a hallmark of purging and cause enlargement of the parotid glands on both sides of the face when purging stops, which can be a major stressor for patients.²

Gingivitis & periodontitis

Purging through self-induced vomiting can lead to chronic gum irritation (gingivitis). Continuous exposure to stomach acid can cause inflammation and soreness. Dry mouth in patients who purge can also contribute to gingivitis.⁴ If untreated, it can progress to periodontitis, which is irreversible.

Enamel erosion (perimylolysis) tooth damage

Enamel erosion is the most common oral manifestation of people who engage in self-induced vomiting. Continuous contact between acidic vomit and the back surfaces of the teeth can lead to enamel deterioration, resulting in brittle teeth, cavities, and additional damage.²

Xerostomia

Xerostomia (dry mouth) can be associated with reduced salivary flow from chronic dehydration from purging.

Soft tissue damage

Pressure from vomiting and inserting a hand or object into the mouth can damage surrounding soft tissue, including blood vessels, causing redness, cuts, scratches and bleeding lesions.

Pharyngitis

Pharyngitis is often observed in individuals who induce vomiting due to irritation of the pharynx caused by contact with stomach acid.² This can lead to hoarseness, cough and dysphagia.²

Other oral & dental complications

Several other oral complications include bad breath and dry, cracked or inflamed lips.

Gastrointestinal Complications

Cathartic colon

Excessive and chronic use of stimulant laxatives can lead to colonic inertia, also known as cathartic colon, a condition where the colon cannot propel stool forward.² It is believed that this results from direct damage to the gut myenteric nerve plexus.

Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is among the most common complications in patients who purge, especially those with bulimia nervosa.² It is a chronic condition characterized by the reflux of stomach contents into the esophagus. Over time, repeated self-induced vomiting can weaken the esophageal sphincter, allowing contents to flow back into the esophagus.

Barrett’s esophagus

Because the esophageal mucosa of patients who induce vomiting is frequently exposed to acidic vomit, there may be an increased risk of developing Barrett’s esophagus.² Barrett’s esophagus is a condition in which the lining of the esophagus becomes more like the lining of the small intestine due to repeated exposure to stomach acid. Barrett’s esophagus is a pre-cancerous condition and requires treatment of the underlying cause to help reduce progression.

Mallory-Weiss syndrome

In rare cases, a sudden increase in pressure in the stomach or the lower part of the esophagus during vomiting can cause a tear in the lining of the upper gastrointestinal tract and lead to bleeding, known as Mallory-Weiss syndrome.² 

Boerhaave syndrome

Boerhaave syndrome is seen in patients who purge as well.² It is a rare condition with high mortality that causes spontaneous perforation of the esophagus, mainly due to straining or vomiting. This creates a hole through which the esophageal contents can pass into the chest between the lungs, increasing the risk of infection (mediastinitis) and other complications.

Pulmonary Complications

Pneumonitis & pneumonia

The greatest risk to the lungs during purging is aspiration, which can be deadly.⁵ Inhalation of vomit during purging can cause inflammation of lung tissue (pneumonitis) or lung infection (pneumonia) in individuals who purge.²

Pneumothorax

Pneumothorax, or lung collapse, can result from both purging and restricting behaviors. It may cause shortness of breath and in severe cases can be deadly.⁶

Pneumomediastinum

The increased intrathoracic and intra-alveolar pressures from retching can cause pneumomediastinum, a condition in which air is present within the chest cavity.² Research also suggests that this air may originate from the intestines and travel up to the chest cavity.⁷

Metabolic & electrolyte disturbances

Hypokalemia (low potassium)

Hypokalemia occurs with both self-induced vomiting and diuretic misuse.⁸ About 26% of patients with bulimia nervosa present with hypokalemia.⁸ Hypokalemia typically occurs for two reasons:

1. Direct potassium loss from gastric secretions through vomiting, intestinal secretions from laxative abuse, or urinary losses with abuse of diuretics.
2. The loss of intravascular fluid, which causes increased production of aldosterone and development of Pseudo-Bartter syndrome. Aldosterone causes to the kidneys to resorb sodium and chloride to help combat severe dehydration, hypotension and fainting. Aldosterone also promotes renal secretion of potassium into the urine, resulting in hypokalemia.

Hypokalemia can cause many complications, including:

• Muscle weakness
• Cardiac arrhythmias
• GI dysmotility
• Chronic kidney disease
• Death

Metabolic alkalosis

About 23% of patients with bulimia nervosa have metabolic alkalosis.⁸ Metabolic alkalosis and hypokalemia are connected. Low hydrogen ion levels (alkalosis) cause potassium to move into cells, which lowers the serum potassium.

Purging leads to the development of metabolic alkalosis, mainly due to aldosterone's effect, which causes the loss of potassium and hydrogen ions (acid) in the urine. The loss of hydrogen ions in the urine helps sustain the alkalemic state. Vomiting can also contribute to the development of an alkalotic state by causing the loss of hydrogen ions in the vomit.

Endocrine complications

Oligomenorrhea

There is also a link between vomiting behaviors and menstrual disturbances like oligomenorrhea (irregular menstruation).²Even vomiting just a few times a month can be linked to 1.5 times the risk of menstrual irregularity.⁹

Bone health

Studies examining the impact of bulimia nervosa on bone density have mixed findings.^10,11 Overall, it is likely that any effects on bone density are more related to the indirect effects of amenorrhea or increased cortisol levels that can be associated with purging.¹²

Pseudo-Bartter syndrome

All forms of purging cause dehydration, which contributes to the development of Pseudo-Bartter syndrome.² Pseudo-Bartter syndrome is a state of chronic dehydration associated with an upregulation of aldosterone, which acts to retain water and salt, increasing blood volume and blood pressure and helping to reduce the risk of fainting.

While this is initially positive, salt and water retention can lead to early edema during refeeding. Edema may last for weeks after stopping purging, causing emotional distress for patients, as the edema can sometimes be very severe.

Cardiovascular complications

Hypotension & tachycardia

Dehydration caused by purging reduces total blood volume, leading to lower blood pressure and a subsequent increase in heart rate (tachycardia). Low blood pressure can cause a range of symptoms:

• Blurred vision
• Dizziness and lightheadedness
• Fainting
• Fatigue
• Difficulty concentrating
• Nausea and other GI symptoms

QT prolongation

The electrolyte abnormalities associated with purging – especially hypokalemia – can cause QT prolongation, increasing the risk of more dangerous arrhythmias.² The QT segment lengthens with hypokalemia because of its effects on the ion channels in the myocytes. Many medications used to treat mental health conditions and complications of malnutrition can also lead to QT prolongation.

It is essential to address the root cause of QT prolongation to prevent the development of other arrhythmias.

Dermatological signs

Periorbital petechiae & facial purpura

Self-induced vomiting can lead to small red dots or purple patches on the face.¹³ Purging can cause the capillaries in the face to burst, resulting in red speckles (petechiae) around the eyes or larger blood spots (purpura) under the skin of the face.¹³

Russell’s sign

Russell’s sign results from repeatedly inserting the dominant hand into the mouth and scraping the knuckles against the teeth during self-induced vomiting, leading to skin abrasions and calluses on the back of the hand and knuckles.¹³ Although common, this is rarely observed in a clinical setting.

Getting Help for Purging

Purging can lead to serious medical complications that require a higher level of care. Medical stabilization and nutritional rehabilitation are essential for managing life-threatening issues, preventing further complications and supporting long-term recovery. With the right care, recovery is possible.

Get started today with a free assessment.

References

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: APA.
2. Nitsch, A., Dlugosz, H., Gibson, D., & Mehler, P. S. (2021). Medical complications of bulimia nervosa.Cleveland Clinic Journal of Medicine88(6), 333–343. https://www.acute.org/medical-complications-bulimia-nervosa
3. Mehler, P. S., & Rylander, M. (2015). Bulimia Nervosa – medical complications. Journal of Eating Disorders, 3(1). https://doi.org/10.1186/s40337-015-0044-4
4. Spigset, O. (1991). Oral symptoms in bulimia nervosa A survey of 34 cases. Acta Odontologica Scandinavica, 49(6), 335–339. https://doi.org/10.3109/00016359109005929
5. DeLegge, M. H. (2002). Aspiration Pneumonia: Incidence, mortality, and At‐Risk populations. Journal of Parenteral and Enteral Nutrition, 26(6S). https://doi.org/10.1177/014860710202600604
6. Nitsch, A., Kearns, M., & Mehler, P. (2023). Pulmonary complications of eating disorders: a literature review. Journal of Eating Disorders, 11(1). https://www.acute.org/pulmonary-complications-eating-disorders-literature-review
7. Schulman, A., Fataar, S., Van Der Spuy, J., Morton, P., & Crosier, J. (1982). Air in unusual places: Some causes and ramifications of pneumomediastinum. Clinical Radiology, 33(3), 301–306. https://doi.org/10.1016/s0009-9260(82)80271-7
8. Mehler, P. S., Blalock, D. V., Walden, K., Kaur, S., McBride, J., Walsh, K., & Watts, J. (2018). Medical findings in 1,026 consecutive adult inpatient–residential eating disordered patients. International Journal of Eating Disorders, 51(4), 305–313. https://www.acute.org/medical-findings-1026-consecutive-adult-inpatient-residential-eating-disordered-patients
9. Austin, S. B., Ziyadeh, N. J., Vohra, S., Forman, S., Gordon, C. M., Prokop, L. A., Keliher, A., & Jacobs, D. (2008b). Irregular Menses Linked to Vomiting in a Nonclinical Sample: Findings from the National Eating Disorders Screening Program in High Schools. Journal of Adolescent Health, 42(5), 450–457. https://doi.org/10.1016/j.jadohealth.2007.11.139
10. NaesséN, S., CarlströM, K., Glant, R., Jacobsson, H., & Hirschberg, A. L. (2006). Bone mineral density in bulimic women – influence of endocrine factors and previous anorexia. European Journal of Endocrinology, 155(2), 245–251. https://doi.org/10.1530/eje.1.02202
11. Robinson, L., Aldridge, V., Clark, E. M., Misra, M., & Micali, N. (2016). A systematic review and meta-analysis of the association between eating disorders and bone density. Osteoporosis International, 27(6), 1953–1966. https://doi.org/10.1007/s00198-015-3468-4
12. Lawson, E. A., Donoho, D., Miller, K. K., Misra, M., Meenaghan, E., Lydecker, J., Wexler, T., Herzog, D. B., & Klibanski, A. (2009). Hypercortisolemia Is Associated with Severity of Bone Loss and Depression in Hypothalamic Amenorrhea and Anorexia Nervosa. The Journal of Clinical Endocrinology & Metabolism, 94(12), 4710–4716. https://doi.org/10.1210/jc.2009-1046
13. Strumia, R. (2005b). Dermatologic Signs in Patients with Eating Disorders. American Journal of Clinical Dermatology, 6(3), 165–173. https://doi.org/10.2165/00128071-200506030-00003