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Bulimia nervosa differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Differential Diagnosis

Differences from Anorexia Nervosa

The main criteria differences involve weight: an anorexic must have a body mass index of less than 17.5. Typically an anorexic is defined by the refusal to maintain a normal weight by self-starvation.

Another criterion which must usually be met is amenorrhea, the loss of a female’s menstrual cycle not caused by the normal cessation of menstruation during menopause for a period of three months. Generally the anorexic does not engage in regular binging and purging sessions. If binging and purging occurs but rarely, and the patient also fails to maintain a minimum weight, they are classified as a purging anorexic, due to the underweight criterion being met and cessation of menstruation. [2]

Characteristically, bulimics feel more shame and out of control with their behaviors, as the anorexic meticulously controls their intake, a symptom that calms their anxiety around food as s/he feels s/he has control of it, naΓ―ve to the notion that it, in fact, controls him/her. For this reason, the bulimic is more likely to admit to having a problem, as they do not feel they are in control of their behavior. The anorexic is more likely to believe they are in control of their eating and much less likely to admit that a problem exists.

Anorexics and bulimics have an overpowering sense of self determined by their body and their perceptions of it. They trace all their achievements and successes to it, and so are often depressed as they feel they are consistently failing to achieve the perfect body. Bulimics feel that they are a failure because s/he cannot achieve a low weight, and this outlook infiltrates into all aspects of their lives. Anorexics cannot see that they are underweight and constantly work towards a goal that they cannot meet. They too allow this failure to define their self worth. As both the anorexic and bulimic never feel satisfaction in the more important part of their lives, depression often accompanies these disorders.[3]

Other Differentials

Bulimia nervosa should also be differentiated from other diseases that cause chronic nausea and vomiting.Β The differentials include the following:[4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35]

Disorder Clinical features Laboratory findings
Chronic nausea Vomiting Diarrhea Retching Lethargy Social withdrawal Photophobia Epigastric pain/burning Lanugo hair Hypogonadism Russel’s sign Body mass index (normal range: 18.5 to 24.9) Complete blood count (CBC) Electrolyte imabalance Lipase and amylase levels Gastric scintigraphy Ambulatory esophageal pH and impedance testing
Gastroparesis βœ” βœ” (within 1 hour of eating) – βœ” βœ” – – βœ” – – – ↓ βœ”
  • Normal (maybe elevated if chronic renal failure is the cause of gastroparesis- usually less than threefold)
  • Periodic measurement of radiolabeled solid meal: Β 
    • Grade 1 (mild), 11%-20% retention at 4 h
    • Grade 2 (moderate), 21%-35% retention at 4 h
    • Grade 3 (severe), 36%-50% retention at 4 h
    • Grade 4 (very severe), > 50% retention at 4 h
  • Impedance testing (antroduodenal manometery): Loss of normal fasting migratory motor complexes (MMCs) and reduced postprandial antral contractions and, in some cases pylorospasm
Anorexia nervosa βœ” βœ” βœ” – βœ” βœ” – – βœ” βœ” – ↓ βœ”
  • Increased
Bulimia nervosa βœ” βœ” βœ” βœ” βœ” βœ” – – – βœ” βœ” Normal βœ”
  • Increased
Rumination syndrome βœ” βœ” (Regurgitation more common- within minutes of meal intake) βœ” – βœ” βœ” βœ” βœ” – – – ↓
  • Normal
 βœ”
  • Normal
  • Esophageal pH: Fall in esophageal pH immediately after reguritation (occurs while patient is awake and erect; this is in contrast to GERD, where reflux occurs diurnally and supine position)
Functional dyspepsia βœ” βœ” βœ” βœ” – – – – – – – Normal
  • Normal
 βœ”
  • Esophageal pH: May be decreased if patient develops reflux
Cyclic vomiting syndrome βœ” βœ” – βœ” βœ” – – – – – – ↓ βœ”
  • Rapid or normal
  • Esophageal pH: Decreased
Pancreatitis βœ” βœ” βœ” βœ” βœ” – – βœ” – – – Normal βœ”
  • Increased
  • Not indicated
  • Esophageal pH: Normal
Gastric outlet obstruction βœ” βœ” (within 1 hour of eating) – – – – – βœ” – – – ↓ βœ”
  • Esophageal pH: Increased
  • Esophageal manometery: Β  High manoraetric score

References

  1. ↑ Diagnostic and statistical manual of mental disordersΒ : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBNΒ 0890425558.
  2. ↑ Diagnostic Statistics Manual IV
  3. ↑ Durand, Mark, Barlow, David. “Essentials of Abnormal Psychology Fourth Ed.” Thomson Wadsworth, CA 2006, ISBN 0-534-60575-3
  4. ↑ Parkman HP (2015). “Idiopathic gastroparesis”. Gastroenterol. Clin. North Am. 44 (1): 59–68. doi:10.1016/j.gtc.2014.11.015. PMCΒ 4324534. PMIDΒ 25667023.
  5. ↑ Werlin SL, Fish DL (2006). “The spectrum of valproic acid-associated pancreatitis”. Pediatrics. 118 (4): 1660–3. doi:10.1542/peds.2006-1182. PMIDΒ 17015559.
  6. ↑ Noddin L, Callahan M, Lacy BE (2005). “Irritable bowel syndrome and functional dyspepsia: different diseases or a single disorder with different manifestations?”. MedGenMed. 7 (3): 17. PMCΒ 1681633. PMIDΒ 16369243.
  7. ↑ Gupta R, Kalla M, Gupta JB (2012). “Adult rumination syndrome: Differentiation from psychogenic intractable vomiting”. Indian J Psychiatry. 54 (3): 283–5. doi:10.4103/0019-5545.102434. PMCΒ 3512372. PMIDΒ 23226859.
  8. ↑ Sağlam F, Sivrikoz E, Alemdar A, KamalΔ± S, Arslan U, GΓΌven H (2015). “Bouveret syndrome: A fatal diagnostic dilemma of gastric outlet obstruction”. Ulus Travma Acil Cerrahi Derg. 21 (2): 157–9. PMIDΒ 25904280.
  9. ↑ Talley NJ (2011). “Rumination syndrome”. Gastroenterol Hepatol (N Y). 7 (2): 117–8. PMCΒ 3061016. PMIDΒ 21475419.
  10. ↑ Tutuian R, Castell DO (2004). “Rumination documented by using combined multichannel intraluminal impedance and manometry”. Clin. Gastroenterol. Hepatol. 2 (4): 340–3. PMIDΒ 15067630.
  11. ↑ Kessing BF, Smout AJ, Bredenoord AJ (2014). “Current diagnosis and management of the rumination syndrome”. J. Clin. Gastroenterol. 48 (6): 478–83. doi:10.1097/MCG.0000000000000142. PMIDΒ 24921208.
  12. ↑ Parkman HP (2009). “Assessment of gastric emptying and small-bowel motility: scintigraphy, breath tests, manometry, and SmartPill”. Gastrointest. Endosc. Clin. N. Am. 19 (1): 49–55, vi. doi:10.1016/j.giec.2008.12.003. PMIDΒ 19232280.
  13. ↑ Waseem S, Moshiree B, Draganov PV (2009). “Gastroparesis: current diagnostic challenges and management considerations”. World J. Gastroenterol. 15 (1): 25–37. PMCΒ 2653292. PMIDΒ 19115465.
  14. ↑ Mearin F, Camilleri M, Malagelada JR (1986). “Pyloric dysfunction in diabetics with recurrent nausea and vomiting”. Gastroenterology. 90 (6): 1919–25. PMIDΒ 3699409.
  15. ↑ Abell TL, Camilleri M, Donohoe K, Hasler WL, Lin HC, Maurer AH, McCallum RW, Nowak T, Nusynowitz ML, Parkman HP, Shreve P, Szarka LA, Snape WJ, Ziessman HA (2008). “Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine”. Am. J. Gastroenterol. 103 (3): 753–63. doi:10.1111/j.1572-0241.2007.01636.x. PMIDΒ 18028513.
  16. ↑ Jiang CF, Ng KW, Tan SW, Wu CS, Chen HC, Liang CT, Chen YH (2002). “Serum level of amylase and lipase in various stages of chronic renal insufficiency”. Zhonghua Yi Xue Za Zhi (Taipei). 65 (2): 49–54. PMIDΒ 12014357.
  17. ↑ Szmukler, G. I.; Young, G. P.; Lichtenstein, M.; Andrews, J. T. (1990). “A serial study of gastric emptying in anorexia nervosa and bulimia”. Australian and New Zealand Journal of Medicine. 20 (3): 220–225. doi:10.1111/j.1445-5994.1990.tb01023.x. ISSNΒ 0004-8291.
  18. ↑ Diamanti A, Bracci F, Gambarara M, Ciofetta GC, Sabbi T, Ponticelli A, Montecchi F, Marinucci S, Bianco G, Castro M (2003). “Gastric electric activity assessed by electrogastrography and gastric emptying scintigraphy in adolescents with eating disorders”. J. Pediatr. Gastroenterol. Nutr. 37 (1): 35–41. PMIDΒ 12827003.
  19. ↑ Ferholt J, Provence S (1976). “Diagnosis and treatment of an infant with psychophysiological vomiting”. Psychoanal Study Child. 31: 439–59. PMIDΒ 981449.
  20. ↑ Lee H, Rhee PL, Park EH, Kim JH, Son HJ, Kim JJ, Rhee JC (2007). “Clinical outcome of rumination syndrome in adults without psychiatric illness: a prospective study”. J. Gastroenterol. Hepatol. 22 (11): 1741–7. doi:10.1111/j.1440-1746.2006.04617.x. PMIDΒ 17914944.
  21. ↑ Koskenpato J, Kairemo K, Korppi-Tommola T, FΓ€rkkilΓ€ M (1998). “Role of gastric emptying in functional dyspepsia: a scintigraphic study of 94 subjects”. Dig. Dis. Sci. 43 (6): 1154–8. PMIDΒ 9635600.
  22. ↑ Urbain JL, Vekemans MC, Parkman H, Van Cauteren J, Mayeur SM, Van den Maegdenbergh V, Charkes ND, Fisher RS, Malmud LS, De Roo M (1995). “Dynamic antral scintigraphy to characterize gastric antral motility in functional dyspepsia”. J. Nucl. Med. 36 (9): 1579–86. PMIDΒ 7658213.
  23. ↑ Hejazi RA, Lavenbarg TH, McCallum RW (2010). “Spectrum of gastric emptying patterns in adult patients with cyclic vomiting syndrome”. Neurogastroenterol. Motil. 22 (12): 1298–302, e338. doi:10.1111/j.1365-2982.2010.01584.x. PMIDΒ 20723071.
  24. ↑ “Gastric outlet obstruction – an overview | ScienceDirect Topics”.
  25. ↑ Minami H, McCallum RW (1984). “The physiology and pathophysiology of gastric emptying in humans”. Gastroenterology. 86 (6): 1592–610. PMIDΒ 6370777.
  26. ↑ Humphries LL, Adams LJ, Eckfeldt JH, Levitt MD, McClain CJ (1987). “Hyperamylasemia in patients with eating disorders”. Ann. Intern. Med. 106 (1): 50–2. PMIDΒ 2431640.
  27. ↑ Hempen I, Lehnert P, Fichter M, Teufel J (1989). “[Hyperamylasemia in anorexia nervosa and bulimia nervosa. Indication of a pancreatic disease?]”. Dtsch. Med. Wochenschr. (in German). 114 (49): 1913–6. doi:10.1055/s-2008-1066848. PMIDΒ 2480214.
  28. ↑ Okada R, Okada A, Okada T, Okada T, Hamajima N (2009). “Elevated serum lipase levels in patients with dyspepsia of unknown cause in general practice”. Med Princ Pract. 18 (2): 130–6. doi:10.1159/000189811. PMIDΒ 19204432.
  29. ↑ Sansone RA, Sansone LA (2012). “Hoarseness: a sign of self-induced vomiting?”. Innov Clin Neurosci. 9 (10): 37–41. PMCΒ 3508961. PMIDΒ 23198276.
  30. ↑ Tack J, Caenepeel P, Arts J, Lee KJ, Sifrim D, Janssens J (2005). “Prevalence of acid reflux in functional dyspepsia and its association with symptom profile”. Gut. 54 (10): 1370–6. doi:10.1136/gut.2004.053355. PMCΒ 1774686. PMIDΒ 15972301.
  31. ↑ “gut.bmj.com” (PDF).
  32. ↑ Boles RG, Williams JC (1999). “Mitochondrial disease and cyclic vomiting syndrome”. Dig. Dis. Sci. 44 (8 Suppl): 103S–107S. PMIDΒ 10490048.
  33. ↑ Ranasinghe WK, Smith M (2013). “Gastric outlet obstruction with an elevated serum pancreatic lipase secondary to an infraumbilical hernia”. Ann R Coll Surg Engl. 95 (7): 122–4. doi:10.1308/003588413X13629960047795. PMIDΒ 24112485.
  34. ↑ Ui, Takashi; Shibusawa, Hiroyuki; Tsukui, Hidenori; Sakuma, Kazuya; Takahashi, Shuhei; Lefor, Alan K.; Hosoya, Yoshinori; Sata, Naohiro; Yasuda, Yoshikazu (2015). “Pretreatment of gastric outlet obstruction with pancrelipase: Report of a case”. International Journal of Surgery Case Reports. 12: 87–89. doi:10.1016/j.ijscr.2015.05.023. ISSNΒ 2210-2612.

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