What are the appropriate management and treatment options for a patient experiencing self-induced emesis, potentially related to an eating disorder such as bulimia nervosa or other underlying medical conditions?

Self-Induced Emesis: Clinical Manifestations and Management

Self-induced vomiting most commonly occurs in the context of bulimia nervosa or purging disorder and requires immediate comprehensive assessment for life-threatening complications including electrolyte abnormalities, cardiac arrhythmias, and gastrointestinal injury, followed by coordinated multidisciplinary treatment incorporating medical stabilization, eating disorder-focused psychotherapy, and pharmacotherapy with fluoxetine 60 mg daily. 1, 2, 3

Physical Signs and Symptoms

Oropharyngeal and Dental Manifestations

• Russell's sign (calluses or scarring on the dorsum of the hand from repeated contact with teeth during self-induced vomiting) is a pathognomonic finding that should be specifically assessed during physical examination 1, 2
• Dental erosion affecting the lingual surfaces of teeth occurs from repeated acid exposure during vomiting 1, 4
• Parotid and salivary gland enlargement develops from chronic stimulation of salivary secretion 4, 5

Gastrointestinal Complications

• Gastroesophageal reflux disease results from repeated exposure of the esophageal mucosa to gastric acid 5
• Esophageal motility disorders can develop with chronic purging behavior 5
• Acute gastric dilatation and gastric perforation represent life-threatening complications that can occur with binge eating followed by purging 5
• Patients commonly report postprandial fullness, abdominal distention, abdominal pain, and early satiety 5

Metabolic and Electrolyte Disturbances

• Hypokalemia is the most critical electrolyte abnormality, carrying risk of fatal cardiac arrhythmias 1, 4, 5
• Metabolic alkalosis develops from loss of gastric hydrochloric acid through vomiting 4
• Hyponatremia, hypochloremia, and dehydration occur with chronic purging 1, 4
• Hyperamylasemia of salivary origin is regularly seen and may lead to erroneous diagnosis of pancreatitis 4

Immediate Medical Assessment

Vital Signs and Physical Examination

• Measure temperature, resting heart rate, blood pressure, orthostatic pulse, and orthostatic blood pressure to detect hemodynamic instability 1, 2
• Document height, weight, and BMI (or percent median BMI, BMI percentile, or BMI Z-score for children and adolescents) 1, 2
• Examine specifically for Russell's sign, parotid enlargement, and dental erosion as physical evidence of purging 1, 2

Essential Laboratory Testing

• Complete blood count to detect anemia, leukopenia, and other hematologic abnormalities 1, 2, 6
• Comprehensive metabolic panel including sodium, potassium, chloride, bicarbonate, liver enzymes, BUN, and creatinine to identify hypokalemia, hypochloremia, metabolic alkalosis, and renal dysfunction 1, 2, 6
• Electrocardiogram in all patients with severe purging behavior to assess for QTc prolongation and arrhythmia risk 1, 2, 6

Critical pitfall: Normal laboratory values do not exclude serious illness—approximately 60% of patients with eating disorders show normal routine laboratory values despite severe medical complications 2

Treatment Algorithm

Medical Stabilization

• Correct electrolyte abnormalities immediately, particularly hypokalemia, as this carries risk of fatal arrhythmias 1, 5
• Monitor QTc intervals continuously in patients with severe purging due to risk of sudden cardiac death 1, 2
• Ensure adequate hydration and assess renal function 1, 6

Psychotherapy (First-Line Treatment)

• Eating disorder-focused cognitive-behavioral therapy (CBT) is the cornerstone of treatment for bulimia nervosa and should be initiated immediately 1, 2, 7
• Family-based treatment should be offered to adolescents and emerging adults with an involved caregiver 1, 2, 7
• Treatment must normalize eating behaviors, eliminate purging, and address psychological aspects including body image disturbance 1, 2

Pharmacotherapy

• Fluoxetine 60 mg daily (administered in the morning) should be prescribed either initially or if minimal response to psychotherapy occurs by 6 weeks 1, 2, 7, 3
• This is the only FDA-approved medication for bulimia nervosa and the only dose (60 mg/day) proven statistically superior to placebo in reducing binge-eating and vomiting frequency 3
• For some patients, titrate up to the 60 mg target dose over several days 3
• Continue treatment for up to 52 weeks in responders, as maintenance treatment demonstrates sustained benefit 3

Multidisciplinary Coordination

• Establish a documented treatment plan incorporating medical, psychiatric, psychological, and nutritional expertise through a coordinated team 1, 2, 7
• Co-management with psychology or psychiatry is essential, as anxiety and depression are very common comorbidities 1

Prognostic Considerations

Mortality risk is substantial: Eating disorders have among the highest mortality rates of any psychiatric disorder, with death occurring from medical complications (particularly cardiac arrhythmias) or suicide 1, 2

Long-term monitoring is mandatory: Patients require periodic reassessment to determine ongoing need for treatment, as bulimia nervosa is a chronic condition with high recidivism rates 1, 3