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 Gain

  Eventually, they will become locked into a compulsive cycle of bingeing and purging (getting rid of the food) or resorting to other ways of preventing weight gain. Attempts to break the cycle often fail. [bodywhys.ie]

  Material outcomes of concern included miscarriages, inappropriate weight gains (excessive or inadequate), complicated deliveries, and resumed and/or continued bulimic behaviors shortly after parturition. [ncbi.nlm.nih.gov]

• 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. [dx.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]

  These behaviours can become more compulsive and uncontrollable over time, and lead to an obsession with food, thoughts about eating (or not eating), weight loss, dieting and body image. [nedc.com.au]

• Underweight

  According to a 2012 study in the journal Biological Psychiatry, about 65 percent of people with bulimia are normal weight (with a body mass index between 18.5 and 29.9), and only 3.5 percent are underweight (with a BMI less than 18.5). [livescience.com]

  People with bulimia have a fear of gaining weight; however, that does not mean all people with bulimia are underweight. [bulimia.com]

  A person may be underweight but not always unless they are restricting their food together with binging and purging. The reason for this is the chemical changes in the body. [seedeatingdisorders.org.uk]

  By definition people are not underweight. Risk factors include being from a western culture, obesity, exposure to a restrictive dieting environment and low self esteem. [ncbi.nlm.nih.gov]

• Inflammation

  Physical effects of bulimia Some of the physical effects of bulimia nervosa may include: tooth decay inflamed, sore throat severe dehydration stomach ulcers inflammation of the oesophagus severe malnutrition brain dysfunction heart failure. [au.reachout.com]

  IAN transposition is a viable treatment option to enable installing fixed prostheses via dental implants, but the latter will clearly increase the risk of inflammation and interruption of mandibular continuity. [ncbi.nlm.nih.gov]

  Physical problems include: swollen fingers, caused by overuse of laxatives gingivitis, or inflammation of the gums inflammation of the esophagus swelling of salivary glands, near the cheeks irregular menstruation Damage to the bowel muscles can lead to [medicalnewstoday.com]

  The risks associated with bulimia nervosa are severe and may include: Chronic sore throat, indigestion, heartburn and reflux Inflammation and rupture of the oesophagus and stomach from frequent vomiting Stomach and intestinal ulcers Chronic irregular [nedc.com.au]

• Malnutrition

  Either chronic malnutrition, or refeeding after periods of malnutrition, may precipitate acute pancreatitis through several pathogenetic mechanisms. [ncbi.nlm.nih.gov]

  Malnutrition also causes morphological and functional pancreatic complications. [oatext.com]

  Physical effects of bulimia Some of the physical effects of bulimia nervosa may include: tooth decay inflamed, sore throat severe dehydration stomach ulcers inflammation of the oesophagus severe malnutrition brain dysfunction heart failure. [au.reachout.com]

  Bulimia symptoms also include severe malnutrition in the body, which in turn can cause a number of problems in the body. The excessive secretion of stomach acids can erode the inner wall of the stomach, causing ulcers. [newsmax.com]

• Bulimia Nervosa

  Symptoms of Bulimia: Someone with bulimia nervosa will suffer many side effects. [disabled-world.com]

  Bulimia Glossary Bulimia Nervosa Glossary of Terms (adapted from medicinenet) is provided below. [psychologistanywhereanytime.com]

  Statistics Bulimia statistics Mental health experts approximate that nearly 24 million people battle with eating disorders like bulimia nervosa. Studies have shown that 1% to 2% of young females meet criteria to be diagnosed with bulimia nervosa. [carolinaeatingdisorders.com]

  Late adolescent bulimia nervosa is associated with a 35-fold increase in risk for adult bulimia nervosa. [minddisorders.com]

• Nausea

  Nausea and stomach cramps are common symptoms of electrolyte imbalance. In most severe cases, nausea indicates heart failure--another potential cause of death associated with bulimia. [livestrong.com]

  Pancreatitis usually presents with abdominal pain, nausea, and vomiting. In patients with eating disorders who may already have exhibited these symptoms pancreatitis may not be considered. [ncbi.nlm.nih.gov]

  They also result in nausea, vomiting, photophobia, malaise, or, less commonly, neck pain. Sentinel bleeds precede aneurysm rupture by a few hours to a few months, with a reported mean of two weeks prior to discovery of the SAH. [case.edu]

  "Anti-Nausea Drug Promising in Treatment of Bulimia Nervosa." American Family Physician 62 (September 1, 2000): 1156. ORGANIZATIONS Academy for Eating Disorders. [minddisorders.com]

• Diarrhea

  They act rapidly and directly to stimulate colonic motility, producing a large volume of watery diarrhea. [jeatdisord.biomedcentral.com]

  Other possible digestive issues include diarrhea, bloating, and constipation. Bloody vomit can occur if continued retching and vomiting result in a tear through the esophagus. [medicalnewstoday.com]

  Physical/Medical Complications Fatigue and lack of energy Amenorrhea (loss of menstruation) and irregular menstruation Dizziness Headaches Dehydration Constipation and diarrhea Shortness of breath Irregular heartbeats Depression Tears of esophagus Hair [mirror-mirror.org]

  Acid can also: irritate or tear your esophagus rupture your esophagus and cause blood in vomit irritate your stomach cause stomachaches, heartburn, and acid reflux damage the intestines and cause bloating, diarrhea, or constipation Putting a finger down [healthline.com]

• Regurgitation

  Mandel, 59, praised fan favorite Stevie Starr — "The Regurgitator" — a professional who swallows objects whole and well, regurgitates the items. Only Mandel's praise fell flat. [usmagazine.com]

  Patients with bulimia nervosa (BN) may show dental erosion, resulting from the effect of acid regurgitation. Asymptomatic bilateral parotid swellings may also be present. Other signs include serum electrolyte imbalance and Russell's sign. [ncbi.nlm.nih.gov]

  The fact that she has been utilizing the dangerous Bulimic practice of staying thin by eating and then regurgitating it back out in the bathroom. [imdb.com]

  Pulmonary In patients who purge via self-induced vomiting, aspiration of regurgitated food is a possibility. [jeatdisord.biomedcentral.com]

• Gagging

  But when bulimia is in the picture, overeating isn't a sometime thing.The young women who suffer from the binge-and-purge eating disorder scarf down huge quantities of food several times a day - and then gag themselves to vomit away all the unwanted calories [cbsnews.com]

  The condition generally arises from the afflicted's knuckles making contact with the incisor teeth during the act of inducing the gag reflex at the back of the throat with their finger(s). [en.wikipedia.org]

  Physical signs include Swollen parotid glands Scars on the knuckles (from repeatedly inducing vomiting by using fingers to trigger gag reflex) Dental erosion Clinical criteria for diagnosis of bulimia nervosa include the following: Recurrent episodes [merckmanuals.com]

  Physical signs include Swollen parotid glands Scars on the knuckles (from repeatedly inducing vomiting by using fingers to trigger gag reflex) Dental erosion Clinical criteria Clinical criteria for diagnosis of bulimia nervosa include the following: Recurrent [msdmanuals.com]

• Parotid Swelling

  Asymptomatic bilateral parotid swellings may also be present. Other signs include serum electrolyte imbalance and Russell's sign. [ncbi.nlm.nih.gov]

  Vomiting induced hypokalemic alkalosis and parotid swelling. Practitioner. 1977;28:267–8. Google Scholar 61. Levin PA, Falko JM, Dixon K, Gallup EM, Saunders B. Benign parotid enlargement in bulimia. Ann Intern Med. 1980;93:827–9. [doi.org]

  [Crossref] Mandel L, Kaynar A (1992) Bulimia and parotid swelling: a review and case report. J Oral Maxillofac Surg 50: 1122-1125. [oatext.com]

• Hunger

  (especially when caused by brain lesions) Type of: hunger, hungriness a physiological need for food; the consequence of food deprivation [vocabulary.com]

  Modified entries © 2019 by Penguin Random House LLC and HarperCollins Publishers Ltd Word origin [1350–1400; ME ‹ NL ‹ Gk boulīmía extreme hunger, equiv. to bou- intensive prefix (deriv. of bou-, s. of boûs ox) + līm(ós) hunger + -ia -ia] Examples of [collinsdictionary.com]

  "ox-hunger," from bou-, intensive prefix (originally from bous "ox") + limos "hunger;" as a psychological disorder, technically bulemia nervosa. [web.archive.org]

  The term Bulimia comes from the Greek word for ‘ravenous hunger’, and many sufferers report feeling that they have little control over their hunger when they binge. [mirror-mirror.org]

• Preoccupation with Food

  This disorder is marked by an extreme preoccupation with food and hyper focus on body shape and weight. [carolinaeatingdisorders.com]

  In many cases, bulimia begins with a diet but the preoccupation with food and weight becomes obsessive and can take over the person’s life. [bodywhys.ie]

  Failure to deactivate the DMN and increased parieto-occipital activation required for alerting might be associated with a constant preoccupation with food or body image-related thoughts. [ncbi.nlm.nih.gov]

  […] or fasting Peculiar eating habits or rituals Inappropriate use of laxatives, diuretics, or other cathartics Irregular or absence of menstruation Anxiety Discouragement related to dissatisfaction with themselves and their bodily appearance Depression Preoccupation [stanfordchildrens.org]

  Symptoms of bulimia and other eating disorders include dramatic weight loss, a preoccupation with food, an excessive concern about one’s weight and body shape, and a propensity for making disparaging remarks about one’s own body or the shape and sizes [web.archive.org]

• Withdrawn

  Students who are bulimic may: have an intense fear of gaining weight or show signs of weight fluctuation make excuses to go to the bathroom immediately after meals spend a lot of time exercising or working out act withdrawn, anxious, depressed, and show [kidshealth.org]

  […] bathroom—sometimes with the faucet running, to mask the sound of vomiting Depression Anxious about eating, especially dining out in public Abuse of laxatives, enemas, emetics, diuretics Spends less time with family and friends; becomes more isolated, withdrawn [healthychildren.org]

  Common signs of low self-esteem or depression such as acting withdrawn or having frequent mood swings. Self-destructive behaviours such as substance abuse and self-harm. [psytherapy.co.uk]

  Three patients did not complete the study; one dropped out from the waiting-list group and two were withdrawn from treatment (owing to pregnancy, for one patient, and to new-onset psychosis, for the other patient). [doi.org]

  […] in the face, neck and jaw; some people also show growths/calluses on their hands and knuckles (used to induce vomiting) ritualistic patterns when eating, including only eating at certain times or avoiding certain food groups generally becoming more withdrawn [draxe.com]

• Denial

  A family can break through that denial and initiate treatment with an intervention. [americanaddictioncenters.org]

  […] food rules and rituals eating in secret binge eating eating a larger than normal amount of food feeling out of control vomiting after binging abusing laxatives, diuretics, diet pills denial of hunger drugs to induce vomiting compulsive exercise swollen [getcenteredcounseling.com]

  Like many other courageous individuals, I sought treatment, even though I was in complete denial. [nationaleatingdisorders.org]

  The full extent of the problem could be even higher because denial and stigma lead the statistics to understate the situation, although in 2011, the British Health Service reported a 66 percent increase in hospital admissions for men with eating disorders [yahoo.com]

  But Lee continued to be in denial about her bulimia despite the shock of losing her job. She did not manage to get her eating disorder under control until she was 29. [bbc.com]

• Social Isolation

  Symptoms Anorexy: Social isolation, compulsive exercise, laxatives and diuretic, terror to ascend of weight, sexual indifference, irritability, severe dysfunction of the corporal image. [europa.eu]

  They are also less socially isolated and more prone to impulsive behavior, drug and alcohol abuse, and overt depression. Anxiety (eg, concerning weight and/or social situations) and anxiety disorders may be more common among these patients. [merckmanuals.com]

  They are also less socially isolated and more prone to impulsive behavior, drug and alcohol abuse, and overt depression. Depression, anxiety (eg, concerning weight and/or social situations) and anxiety disorders are common among these patients. [msdmanuals.com]

• Irritability

  Acid can also: irritate or tear your esophagus rupture your esophagus and cause blood in vomit irritate your stomach cause stomachaches, heartburn, and acid reflux damage the intestines and cause bloating, diarrhea, or constipation Putting a finger down [healthline.com]

  We describe a young woman with bulimia nervosa and irritable bowel syndrome who used rectal purging as a method of counteracting the effects of her binge eating and who underwent two corrective surgeries for rectal prolapse in a 15-month interval. [ncbi.nlm.nih.gov]

• Dizziness

  Dizziness or Mental Confusion Dizziness and mental confusion are additional symptoms of severe dehydration and electrolyte imbalance. [livestrong.com]

  […] to vomiting including swelling around the cheeks or jaw, calluses on knuckles, damage to teeth and bad breath Feeling bloated, constipated or developing intolerances to food Loss of or disturbance of menstrual periods in girls and women Fainting or dizziness [nedc.com.au]

  Common complications of bulimia nervosa include: mood swings, depression, anxiety irritable dizzy, headaches rashes and pimples swollen cheeks scars or calluses on the knuckles (Russell’s sign ) heartburn (acid reflux) low blood pressure stomach or intestinal [keltyeatingdisorders.ca]

  […] pain Menstrual irregularity or amenorrhea (females only) Irregular bowel movements Cognitive symptoms: Poor impulse control Desire to control situations and environment Fatigue Obsessions / compulsions / preoccupations with food, weight, or body shape Dizziness [carolinaeatingdisorders.com]

• Mental Distress

  The exam will also explore whether there are any other areas of mental distress, such as obsessive-compulsive disorder, an anxiety or mood disorder, or problems with substance use. [health.harvard.edu]

  Or he might also need medications to soothe his mental distress. [americanaddictioncenters.org]

  Your doctor will also explore whether you have any other areas of mental distress, such as obsessive-compulsive disorder, an anxiety or mood disorder, or problems with substance use. [drugs.com]

  In general, mindfulness, hypnotherapy, yoga, exercise, relaxation, massage, mirimiri and aromatherapy have all been shown to have some effect in alleviating mental distress. [mentalhealth.org.nz]

• Agitation

  • Missing important events, like school, work or social functions, in order to exercise • Exercising several hours a day • Exercising most days without taking a break • Exercising when they are sick, exhausted or injured • Feeling deeply depressed, agitated [ulifeline.org]

  […] impulse control Desire to control situations and environment Fatigue Obsessions / compulsions / preoccupations with food, weight, or body shape Dizziness Psychosocial symptoms: Feelings of ineffectiveness Overwhelming fear of gaining weight Irritability Agitation [carolinaeatingdisorders.com]

  Diet pills taken to excess can cause the body to become overactive and excitable Difficulties in sleeping Heart palpitations and permanent cardiovascular damage You become on edge and jumpy The mind becomes overactive and you become suspicious and agitated [firststepsed.co.uk]

  Medications may be used to control high blood pressure and prevent blood vessel spasm, seizure, agitation, and pain. What is the outcome of brain aneurysm? Brain aneurysms are deadly. [medicinenet.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]

  […] bleeding Fluctuations in weight Constipation due to laxative abuse Dehydration Low potassium levels Calluses or scars on hands or knuckles Bloodshot eyes Imbalanced fluids and/or electrolytes Irregular heartbeat Abdominal pain Menstrual irregularity or amenorrhea [carolinaeatingdisorders.com]

  Physical/Medical Complications Fatigue and lack of energy Amenorrhea (loss of menstruation) and irregular menstruation Dizziness Headaches Dehydration Constipation and diarrhea Shortness of breath Irregular heartbeats Depression Tears of esophagus Hair [mirror-mirror.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.

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.

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3. Johnson MD. Disordered eating in active and athletic women. Clin Sports Med. 1994 Apr;13(2):355-69.
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12. Treatment of patients with eating disorders, third edition. American Psychiatric Association. Am J Psychiatry. 2006 Jul;163(7 Suppl):4-54.