Table 18.1 Nomenclature of bone tumors
Bulimia nervosa
BASIC INFORMATION
DEFINITION
Bulimia nervosa is the episodic uncontrolled ingestion of large quantities of food followed by recurrent inappropriate compensatory behavior to prevent weight gain such as self-induced vomiting, diuretic or cathartic use, or strict dieting or vigorous exercise.
Like anorexia nervosa, bulimia nervosa is predominantly a disorder of young, white, middle- and upper-class women. It is more difficult to detect than anorexia, and some studies have estimated that the prevalence may be as high as 19% in college-aged women.
WORKUP
• The following questions are useful to screen patients for bulimia:
1. “Are you satisfied with your eating habits?”
2. “Do you ever eat in secret?”
• Answering “no” to the first question and/or “yes” to the second question has 100% sensitivity and 90% specificity for bulimia. The SCOFF questionnaire can also be used as a screening tool for eating disorders.
• A diagnosis can also be made using the following DSM-IV diagnostic criteria for bulimia nervosa:
1. Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time)
2. A feeling of lack of control over eating behavior during the eating binges
3. Self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or rigorous exercise to prevent weight gain
4. A minimum of two binge-eating episodes a week for at least 3 months
5. Persistent overconcern with body shape and weight
• The following questions are useful to screen patients for bulimia:
1. “Are you satisfied with your eating habits?”
2. “Do you ever eat in secret?”
• Answering “no” to the first question and/or “yes” to the second question has 100% sensitivity and 90% specificity for bulimia. The SCOFF questionnaire can also be used as a screening tool for eating disorders.
• A diagnosis can also be made using the following DSM-IV diagnostic criteria for bulimia nervosa:
1. Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time)
2. A feeling of lack of control over eating behavior during the eating binges
3. Self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or rigorous exercise to prevent weight gain
4. A minimum of two binge-eating episodes a week for at least 3 months
5. Persistent overconcern with body shape and weight
LABORATORY TESTS
• Electrolyte abnormalities secondary to vomiting (hypokalemia and metabolic alkalosis) or to diarrhea from laxative abuse (hypokalemia and hyperchloremic metabolic acidosis)
• Hyponatremia, hypocalcemia, hypomagnesemia (caused by laxative abuse)
• Elevated cortisol, decreased LH, decreased FSH
TREATMENT
Treatment of bulimia nervosa and bulimarexia requires supportive care and psychotherapy. Individual, group, family, and behavioral therapy have all been utilized. Antidepressant medications may be helpful. The best results have been with fluoxetine hydrochloride and other SSRIs. Although death from bulimia is rare, the long-term psychiatric prognosis in severe bulimia is worse than that in anorexia nervosa.
NONPHARMACOLOGIC THERAPY
• Cognitive behavioral therapy to control abnormal behaviors
• Use of food diaries, nutritional counseling, and planning meals at least a day in advance is useful to counter abnormal eating behaviors
• Correction of electrolyte abnormalities
ACUTE GENERAL Rx
• SSRIs are generally considered to be the safest medication option in these patients. They are useful in severely depressed patients and in those who fail to benefit from cognitive behavioral therapy.
• Prompt recognition and treatment of complications:
1. Ipecac cardiotoxicity from laxative abuse
2. Electrolyte abnormalities
3. Esophagitis and Mallory-Weiss tears; esophageal rupture from repeated vomiting
4. Aspiration pneumonia and pneumomediastinum
5. Menstrual irregularities (including amenorrhea)
6. GI abnormalities: acute gastric dilatation, pancreatitis, abdominal pain, constipation
CHRONIC Rx
• Psychotherapy continued for years and focused specifically on self-image and family and peer interactions is an integral part of successful recovery.
• Family therapy is also recommended, especially in younger patients.
DISPOSITION
Course is variable and marked by frequent recurrence of exacerbations.
• Electrolyte abnormalities secondary to vomiting (hypokalemia and metabolic alkalosis) or to diarrhea from laxative abuse (hypokalemia and hyperchloremic metabolic acidosis)
• Hyponatremia, hypocalcemia, hypomagnesemia (caused by laxative abuse)
• Elevated cortisol, decreased LH, decreased FSH
TREATMENT
Treatment of bulimia nervosa and bulimarexia requires supportive care and psychotherapy. Individual, group, family, and behavioral therapy have all been utilized. Antidepressant medications may be helpful. The best results have been with fluoxetine hydrochloride and other SSRIs. Although death from bulimia is rare, the long-term psychiatric prognosis in severe bulimia is worse than that in anorexia nervosa.
NONPHARMACOLOGIC THERAPY
• Cognitive behavioral therapy to control abnormal behaviors
• Use of food diaries, nutritional counseling, and planning meals at least a day in advance is useful to counter abnormal eating behaviors
• Correction of electrolyte abnormalities
ACUTE GENERAL Rx
• SSRIs are generally considered to be the safest medication option in these patients. They are useful in severely depressed patients and in those who fail to benefit from cognitive behavioral therapy.
• Prompt recognition and treatment of complications:
1. Ipecac cardiotoxicity from laxative abuse
2. Electrolyte abnormalities
3. Esophagitis and Mallory-Weiss tears; esophageal rupture from repeated vomiting
4. Aspiration pneumonia and pneumomediastinum
5. Menstrual irregularities (including amenorrhea)
6. GI abnormalities: acute gastric dilatation, pancreatitis, abdominal pain, constipation
CHRONIC Rx
• Psychotherapy continued for years and focused specifically on self-image and family and peer interactions is an integral part of successful recovery.
• Family therapy is also recommended, especially in younger patients.
DISPOSITION
Course is variable and marked by frequent recurrence of exacerbations.
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EPIDEMIOLOGY & DEMOGRAPHICS
INCIDENCE/PREVALENCE: Affects 2% to 4% of female adolescents and young adults
PREDOMINANT SEX: Female:male ratio of 10:1
PREDOMINANT AGE: Adolescence to young adulthood; mean age of onset: 17 years
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Parotid and salivary gland swelling
• Scars on the back of the hand and knuckles (Russell’s sign) from rubbing against the upper incisors when inducing vomiting
• Eroded enamel, particularly on the lingual surface of the upper teeth; pyorrhea and other gum disorders possible
• Petechial hemorrhages of the cornea, soft palate, or face possibly noted after vomiting
• Loss of gag reflex, well-developed abdominal musculature
• Usually no emaciation; normal physical examination possible
Clinical Findings
Patients with bulimia nervosa typically consume large quantities of easily ingested high-calorie foods, usually in secrecy. Some patients may have several such episodes a day for a few days; others report regular and persistent patterns of binge eating. Binging is usually followed by vomiting, cathartics, or diuretics and is usually accompanied by feelings of guilt or depression. Periods of binging may be followed by intervals of self-imposed starvation. Body weights may fluctuate but generally are within 20-25% of desirable weights.
Some patients with bulimia nervosa also have a cryptic form of anorexia nervosa with significant weight loss and amenorrhea. Family and psychological issues are generally similar to those encountered among patients with anorexia nervosa. Bulimics, however, have a higher incidence of premorbid obesity, greater use of cathartics and diuretics, and more impulsive or antisocial behavior. Menstruation is usually preserved.
Medical complications are numerous. Gastric dilatation and pancreatitis have been reported after binges. Vomiting can result in poor dentition, pharyngitis, esophagitis, aspiration, and electrolyte abnormalities. Cathartic and diuretic abuse also cause electrolyte abnormalities or dehydration. Constipation and hemorrhoids are common.
ETIOLOGY
Etiology is unknown but likely multifactorial (sociocultural, psychologic, familial factors). Bulimia is much more common in Western societies where there is a strong cultural pressure to be slender. According to the American Psychiatric Association, patients with eating disorders display a broad range of symptoms that occur along a continuum between those of anorexia nervosa and bulimia.
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Schizophrenia
• GI disorders
• Neurologic disorders (seizures, Kleine-Levin syndrome, Klüver-Bucy syndrome)
• Brain neoplasms
• Psychogenic vomiting
INCIDENCE/PREVALENCE: Affects 2% to 4% of female adolescents and young adults
PREDOMINANT SEX: Female:male ratio of 10:1
PREDOMINANT AGE: Adolescence to young adulthood; mean age of onset: 17 years
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Parotid and salivary gland swelling
• Scars on the back of the hand and knuckles (Russell’s sign) from rubbing against the upper incisors when inducing vomiting
• Eroded enamel, particularly on the lingual surface of the upper teeth; pyorrhea and other gum disorders possible
• Petechial hemorrhages of the cornea, soft palate, or face possibly noted after vomiting
• Loss of gag reflex, well-developed abdominal musculature
• Usually no emaciation; normal physical examination possible
Clinical Findings
Patients with bulimia nervosa typically consume large quantities of easily ingested high-calorie foods, usually in secrecy. Some patients may have several such episodes a day for a few days; others report regular and persistent patterns of binge eating. Binging is usually followed by vomiting, cathartics, or diuretics and is usually accompanied by feelings of guilt or depression. Periods of binging may be followed by intervals of self-imposed starvation. Body weights may fluctuate but generally are within 20-25% of desirable weights.
Some patients with bulimia nervosa also have a cryptic form of anorexia nervosa with significant weight loss and amenorrhea. Family and psychological issues are generally similar to those encountered among patients with anorexia nervosa. Bulimics, however, have a higher incidence of premorbid obesity, greater use of cathartics and diuretics, and more impulsive or antisocial behavior. Menstruation is usually preserved.
Medical complications are numerous. Gastric dilatation and pancreatitis have been reported after binges. Vomiting can result in poor dentition, pharyngitis, esophagitis, aspiration, and electrolyte abnormalities. Cathartic and diuretic abuse also cause electrolyte abnormalities or dehydration. Constipation and hemorrhoids are common.
ETIOLOGY
Etiology is unknown but likely multifactorial (sociocultural, psychologic, familial factors). Bulimia is much more common in Western societies where there is a strong cultural pressure to be slender. According to the American Psychiatric Association, patients with eating disorders display a broad range of symptoms that occur along a continuum between those of anorexia nervosa and bulimia.
DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
• Schizophrenia
• GI disorders
• Neurologic disorders (seizures, Kleine-Levin syndrome, Klüver-Bucy syndrome)
• Brain neoplasms
• Psychogenic vomiting