Despite the fact that patients with bulimia nervosa are generally unremarkable in physical appearance and often have no external signs of a disorder when examined physically, many peculiar findings might be present which are as mentioned further.
Bilateral parotid enlargement, largely consequent to non-inflammatory stimulation of the salivary glands might be observed [8].

In patients who are too involved in self-induced vomiting, erosion of the inner surface of teeth, loss of the tooth enamel, periodontal diseases, and extensive caries might be found.
Russell’s sign manifests itself by making the knuckles scarred, calloused and having abrasions as a result of repeated induced vomiting [9]. 

Other dermatological manifestations may include telogen effluvium, acne, xerosis , nail dystrophy, and scarring due to cuts, burns, and other trauma [10]. 

Other vague but helpful findings that reflect the intensity of the disorder include hypotension, bradycardia/tachycardia and hypothermia. Pedal edema, is frequent among patients who have abused diuretics, laxatives, or both; it is also seen in those with protein malnourishment resulting in hypoalbuminemia.

Patients with bulimia nervosa and suffering from the issues of being overweight have increased number of fat folds that aid humidity and maceration along with bacterial and fungal overgrowth, stretch marks striae because of skin overextension and various other problems related to increased weight [10].

• Weight Loss

  The overweight or obese patients were clearly entering treatment with two explicit treatment goals—abstinence from bulimic behaviors and weight loss. Our intervention, however, was not designed for weight loss. [doi.org]

  Glucagon-like peptide-1 (GLP-1) receptor agonists, marketed for type 2 diabetes and chronic weight management, produce weight loss in a dose dependent manner and have favorable psychiatric adverse event profiles. [ncbi.nlm.nih.gov]

  This is characterized by weight loss often due to excessive dieting and exercise, sometimes to the point of starvation. People with anorexia feel they can never be thin enough and continue to see themselves as “fat” despite extreme weight loss. [webmd.com]

• Amenorrhea

  Feeling deeply depressed, agitated or anxious when they can’t work out • Suffering from health problems such as dehydration, exhaustion, injuries, osteoporosis, arthritis • Isolating from others • Overly focused on appearance • Overly self-critical • Amenorrhea [ulifeline.org]

  Symptoms common in anorexia nervosa include amenorrhea, abdominal discomfort, bloating or constipation, and cold intolerance. [ncbi.nlm.nih.gov]

  Bone mineral changes in young women with hypothalamic amenorrhea treated with oral contraceptives, medroxyprogesterone or placebo over 12 months. Am J Obstet Gynecol. 1997;176:1017–25. PubMed CrossRef Google Scholar 44. [dx.doi.org]

A comprehensive blood chemistry panel is important for detecting possibly occult metabolic complications. Due to increased vomiting, there are chances of developing hypokalemic metabolic alkalosis. In patients with heavy laxative abuse, normokalemic metabolic acidosis can take place. Other conditions like hyponatremia, hypocalcemia, hypophosphatemia, and hypomagnesemia should also be examined for. Patients with remarkable intravascular depletion can manifest elevated BUN levels (blood urea nitrogen).

Complete blood cell count is used for assessing anemia or any occult hematologic disorders.

Urinalysis may help in finding the urine specific gravity that may reflect the state of hydration.

Co-morbid substance abuse may be checked using a urine toxicology screen [11].

Pregnancy test should be done to rule out a pregnancy in those female patients complaining about amenorrhea.

Hyperamylasemia is seen in about 30% persons with significantly high vomiting because of salivary gland hypersecretion.
An electrocardiogram (ECG) should be done to rule out any type of cardiomyopathies as there are chances of arrhythmias.
A dual energy absorptiometry (DEXA) scan should be done to rule out osteoporosis.

• Renal Biopsy showing Juxtaglomerular Hyperplasia

  The patient showed chaotic binge/purges and chronic severe hypokalemia after recovery from AN at age 26 years, and renal biopsy showed juxtaglomerular hyperplasia, which was diagnosed as pseudo-Bartter's syndrome. [ncbi.nlm.nih.gov]

Bulimia nervosa is managed optimally using a multiple specialty team. A team of healthcare providers is needed to treat bulimia. This includes the primary care provider, nutritionist, psychotherapist, and psychiatrist. Various other specialists might also be needed for these patients depending on other complications.

Main non-pharmacologic treatment for bulimia nervosa includes:

• Cognitive-behavioral therapy (CBT) helps to recognize unsound, negative ideas and behaviors and substitute them with good, positive ones.
• Interpersonal psychotherapy (IPT) addresses difficulties in close relationships, and helps in improving communication and problem-solving skills.
• Nutritional rehabilitation counseling in which the dieticians and health-care providers design a safe eating plan to help get back a healthy weight, achieve normal eating habits and maintain good nutrition.
• Family therapy that helps parents act to stop their teenager from continuing unhealthy eating behavior and aids the teen to get control on their own eating habits. Finally, it helps the family to deal with problems that bulimia can occur on the teen's growth and development and her family.

Medications used in treating bulimia nervosa include the following:

• Fluoxetine is an FDA-approved drug for bulimia nervosa therapy.
• Antidepressants have a vital role in treatment of bulimia; [12] they can help patients with significant associated symptoms like depression, anxiety, or impulsive disorder symptoms.

Most of the people with bulimia recoup, if they are treated earlier in life. Prognosis is better if the illness begins at the time of pubescence. Prognosis is bad if the person has other psychiatric problems too. The results are good if the person gets treatment for these psychiatric problems along with the process of treating bulimia.

Bulimia nervosa is commoner among persons whose occupations or hobbies require rapid gaining and/or losing weight, e.g. wrestlers, competitive bodybuilders [2]. Athletes in sports like running and gymnastics are especially prone to such eating disorders [3].

Media and advertisements endorsing the 'ideal' body are commonly considered to be the major factor in the rise of bulimia. Certain careers such as ballet dancing, modeling, and acting [4] also seem to possess a higher risk for such disorders. In humans, evidence from research suggests an association between polymorphism in ERβ (estrogen receptor β) and bulimia, which suggests that there is some correlation between sex hormones and bulimia nervosa [5].

In the US alone, prevalence of bulimia is 1% [6]. The lifetime prevalence for bulimia is 0.5% in males and 1.5% in females. Just like anorexia, bulimia nervosa occurs largely in women. Many of the reports propose the female-to-male ratio of 10:1.

The mean age of onset is 19.7. Bulimia is 5 times more common in cities compared to rural areas [7]. It occurs more frequently in developed countries.

Bulimia may develop after a very restrictive diet. Sometimes it is seen that binging is triggered due to a stressful event, where food makes one feel comfortable. The sense of guilt and feeling regretful of binging makes one purge so as to prevent weight gain. This marks the beginning of recurrent binging and purging which later becomes a routine.

As bulimia develops, one avoids meals while starting the day, but afterwards the person tends to binge in order to comfort herself, particularly when a stressful day ends.

When one vomits, endorphins are released from the body. Endorphins are natural chemicals which make us feel good. Ultimately, it becomes a habit for the person, to vomit so as to feel good, even when she hasn’t eaten much. Quickly the patients start losing control over this cycle of binging and purging. Regular vomiting, not eating anything, exercising a lot, or abusing laxatives, diuretics, or enemas can ultimately advance to grave, long-term health issues.

Once bulimia becomes a habit, it is very difficult to get back to normal eating without any assistance. This unhealthy eating habit may continue for years prior to the treatment.

There is no known way to prevent bulimia. Starting the treatment as early as possible is the best way to prohibit the progression of this disorder. Having knowledge of signs of bulimia and getting immediate medical attention can help avert long-term problems.

Bulimia nervosa is a kind of eating disorder that is characterized by binging and removing the food, or having a large quantity of food in a small duration followed by attempts to get rid of the food by purging, mostly by vomiting, or using a laxative, diuretic, or stimulant. Few of patients engage into excessive exercising due to huge concerns of body weight [1].

We see that bulimia mainly affects the women in our society. It is difficult to recognize if someone around us is suffering from it. If we pay attention, we come to know that these people have bouts of vomiting after eating or they even induce vomiting by pretending as if something is stuck in the throat. Sometimes you find that mostly their talks revolve around ways of losing weight that might even be unhealthy.

It is difficult for anyone suffering from bulimia to treat themselves but they can build their own treatment plan, like regularly going for the therapy sessions and sticking to the meal plans. It is important that the patient does not separate from friends and family members who wish good health for her. One must know that they always want the best for you and such caring, nurturing relations are good for recovery. Resist urges to weigh repeatedly or check the mirror frequently.

1. Hay PJ, Claudino AM. Bulimia nervosa. Clin Evid (Online). 2010 Jul 19;2010. pii: 1009.
2. Goldfield GS, Blouin AG, Woodside DB. Body image, binge eating, and bulimia nervosa in male bodybuilders. Can J Psychiatry. 2006 Mar;51(3):160-8.
3. Johnson MD. Disordered eating in active and athletic women. Clin Sports Med. 1994 Apr;13(2):355-69.
4. Ravaldi C, Vannacci A, Bolognesi E, Mancini S, et al. Gender role, eating disorder symptoms, and body image concern in ballet dancers. J Psychosom Res. 2006 Oct;61(4):529-35.
5. Hirschberg AL. Sex hormones, appetite and eating behaviour in women. Maturitas. 2012 Mar;71(3):248-56.
6. Hudson, JI, Hirpi, E, Pope, HG, et al. The Prevalence and Correlates of Eating Disorders in National Comorbidity Survey Replication. Biol Psychiatry. 2007 Feb 1;61(3):348-58.
7. van Son GE, van Hoeken D, Bartelds AI, van Furth EF, Hoek HW. "Urbanisation and the incidence of eating disorders". Br J Psychiatry. 2006 Dec; 189: 562–3.
8. Mandel L, Abai S. Diagnosing bulimia nervosa with parotid gland swelling. J Am Dent Assoc. 2004 May;135(5):613-6; quiz 655.
9. Glorio R, Allevato M, De Pablo A, et al. Prevalence of cutaneous manifestations in 200 patients with eating disorders. Int J Dermatol. 2000 May;39(5):348-53.
10. Strumia R. Dermatologic signs in patients with eating disorders. Am J Clin Dermatol. 2005;6(3):165-73.
11. Kruger D. Bulimia nervosa: easy to hide but essential to recognize. JAAPA. 2008 Jan;21(1):48-52.
12. Treatment of patients with eating disorders, third edition. American Psychiatric Association. Am J Psychiatry. 2006 Jul;163(7 Suppl):4-54.