Can bulimia cause elevated liver enzymes?

Can Bulimia Cause Elevated Liver Enzymes?

Yes, bulimia can cause elevated liver enzymes, though this occurs in only about 4% of eating disorder patients and is typically mild. 1, 2

Mechanism and Frequency

• Liver enzyme elevations in bulimia result from hepatocyte injury caused by malnutrition, purging behaviors, and metabolic stress, with ALT (SGPT) being the most frequently elevated enzyme. 2
• The prevalence is relatively low—only 4.1% of eating disorder outpatients show abnormal liver enzymes at presentation. 2
• Elevated SGPT is the most common enzyme abnormality and correlates with lower body weight and BMI, indicating that malnutrition itself drives hepatocyte damage. 2

Clinical Pattern

• When liver enzymes are elevated in bulimia, they are typically mild elevations (not exceeding 1000 IU/mL in most cases), contrasting with the severe transaminitis seen in acute liver failure. 2, 3
• The enzyme pattern does not follow a specific diagnostic signature unique to bulimia—elevated liver chemistries in bulimic patients are often due to causes other than the eating disorder itself. 2
• Purging behaviors (vomiting, laxative abuse) can indirectly affect liver function through electrolyte disturbances and dehydration, though direct hepatotoxicity from purging is not the primary mechanism. 1

Diagnostic Approach Per Guidelines

The American Psychiatric Association mandates that laboratory assessment of patients with possible eating disorders must include a comprehensive metabolic panel with liver enzymes as part of the initial evaluation. 1

• Obtain ALT, AST, and GGT along with electrolytes, renal function tests, and complete blood count at initial presentation. 1, 4
• Look for hypokalemia and hypochloremic alkalosis, which indicate active purging behaviors and may contribute to metabolic stress on the liver. 4
• Rule out other causes of transaminitis including alcohol abuse (which can synergize with bulimia to accelerate liver damage), viral hepatitis, autoimmune hepatitis, metabolic syndrome/NAFLD, and medication/supplement toxicity. 1, 5, 2, 6

Critical Clinical Pitfalls

• Do not assume elevated liver enzymes are benign or solely attributable to the eating disorder without excluding other etiologies—studies show that liver abnormalities in bulimic patients are frequently due to concurrent conditions rather than bulimia alone. 2
• Alcohol abuse combined with bulimia can dramatically accelerate liver damage, with case reports documenting rapid progression to cirrhosis in young patients with both conditions. 6
• Starvation-induced liver injury can paradoxically worsen after initiating refeeding, so monitor liver enzymes serially during nutritional rehabilitation. 7, 3
• Severe transaminitis (>1000 IU/mL) with acute liver failure is extremely rare in eating disorders and should prompt urgent investigation for alternative diagnoses including ischemic hepatitis, drug-induced liver injury, or acute viral hepatitis. 3

Management Implications

• When elevated liver enzymes are identified in bulimia patients, treatment focuses on the underlying eating disorder with cognitive-behavioral therapy and consideration of fluoxetine 60 mg daily. 1
• Nutritional rehabilitation should proceed cautiously to avoid refeeding syndrome, which can itself cause liver enzyme elevation distinct from starvation-induced hepatocyte injury. 7, 3
• Serial monitoring of liver enzymes during treatment helps distinguish between persistent starvation effects (enzymes remain elevated despite refeeding) versus refeeding syndrome (enzymes worsen with nutritional support). 7
• Most cases resolve with treatment of the eating disorder and weight restoration, as the liver injury is typically reversible when malnutrition is corrected. 8, 3