Bulimia Nervosa Algorithm

Emergency management of patients with eating disorders involves consideration of the complications and effects of the disorder. Nutritional rehabilitation should be the primary goal of treatment in both anorexia and bulimia. Anorexics tend to need a very gradual introduction of macronutrients. Bulimics tend to need fewer calories initially, and it is important to normalize the eating pattern.

Normotensive, hypokalemic, hypochloremic metabolic alkalosis is typical of purging eating-disorder patients. They appear to adapt to these metabolic states, and treatment should consider the whole metabolic state. Automatic replacement of individual deficiencies should be discouraged, since this could be dangerous, with fluid overload and overcorrection as common complications.

Medications have been used in eating disorders. The most helpful in anorexia is cyproheptadine hydrochloride (Periactin). Antidepressants have proved useful in bulimics. Fluoxetine (Prozac), imipramine or desipramine, and phenelzine sulfate (Nardil) have been extensively evaluated and found to be useful. 8

Emergency management is best accomplished using total parenteral nutrition and slowly correcting the metabolic derangement. Cachectic patients do not need or secrete inducible enzymes, such as lipase or lactase. They have reduced gastric emptying and atrophy of the villi of the small intestines. The use of tube feeding can lead to hypertonic dehydration, hypernatremia, prerenal azotemia, and refeeding pancreatitis. Circulatory volume and caloric requirements should be advanced slowly. The refeeding syndrome, with severe cardiopulmonary and neurologic complications, has been described in anorexics and is associated with rapid electrolyte shifts, hypophosphatemia, hypokalemia, and hypomagnesemia.9 Anorexics usually present with bradycardia, and monitoring the pulse rate may be the simplest, noninvasive way of monitoring fluid replacement. Serum and urine electrolyte, phosphorous, and magnesium levels should be closely monitored.

A period of 48 h in an inpatient setting is essential to determine the extent and severity of the illness and its complications. Eating disorders units are specifically designed for such evaluations, but they can also be performed in a regular medical unit with involvement of a multidisciplinary psychiatric and internal medicine team.

Hospitalization is suggested for the following:

1. Weight loss greater than 30 percent over 3 months

2. Severe metabolic disturbance

3. Depression severe enough to be at risk for suicide

4. Severe binge eating and purging

5. Failure to maintain outpatient weight contract

6. Psychosis

7. Family crisis

8. Need to confront the patient's and family's denial

9. Need for initiation of therapy (individual, family, and/or pharmacotherapy) 10. Complex differential diagnosis

Treatment algorithms for anorexia nervosa and bulimia nervosa appear in Fig 2.8.3.-1 and Fig:,,i283-2..

Eating Disorder Algorithm
FIG. 283-1. Treatment algorithm for anorexia nervosa.
Gewichtsvertrag Anorexie
FIG. 283-2. Treatment algorithm for bulimia nervosa.

A trial of outpatient psychological treatment can be attempted if food restriction and weight loss are of less than 3 months' duration and if there is a very positive family support system. Referral to a local health professional who specializes in the treatment of eating disorders or to a self-help group can be obtained by contacting the following national organizations:

National Association of Anorexia Nervosa and Associated Disorders (ANAD) PO Box 7

Highland Park, IL 60035



Anorexia Nervosa and Related Eating Disorders, Inc. (ANRED)

PO Box 5102

Eugene, OR 97405


American Anorexia/Bulimia Association, Inc. (AABA) 165 W. 46th St. #1108 NeW York, NY 07666 212-575-6200

National Eating Disorders Organization (NEDO)

6655 S. Yale Ave.

Tulsa, OK 74136



Academy for Eating Disorders, Montefiore Medical Center (AED)

Bronx, NY 10467



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Breaking Bulimia

Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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