Bulimia nervosa differential diagnosis

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


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, naïve 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. 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 ✔ (within 1 hour of eating) - - - - - -
  • Normal (maybe elevated if chronic renal failure is the cause of gastroparesis- usually less than threefold)
  • Periodic measurement of radiolabeled solid meal:  
    • 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 - - - -
  • Increased
Bulimia nervosa - - - Normal
  • Increased
Rumination syndrome ✔ (Regurgitation more common- within minutes of meal intake) - - - -
  • Normal
  • 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 - - - - - - - Normal
  • Normal
  • Esophageal pH: May be decreased if patient develops reflux
Cyclic vomiting syndrome - - - - - - -
  • Rapid or normal
  • Esophageal pH: Decreased
Pancreatitis - - - - - Normal
  • Increased
  • Not indicated
  • Esophageal pH: Normal
Gastric outlet obstruction ✔ (within 1 hour of eating) - - - - - - - -
  • Esophageal pH: Increased
  • Esophageal manometery:   High manoraetric score


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