Medical Complications in Patients with Eating Disorders: An ER Perspective

A healthy-looking young woman comes into the emergency room complaining of lightheadedness, dizziness, tiredness, dehydration and constipation. She tells you she doesn’t know what’s wrong, but what she is not telling you is that she has an eating disorder. How do you find out? More importantly, how do you avoid complications that may arise from using conventional treatments for patients without eating disorders?

I often come across questions posted on websites and forums asking if others have experienced a particular symptom, what could be causing it and whether going to the hospital is necessary. I am not a physician, not training to be a physician and not doing research in anything directly relevant to medicine or health. Moreover, I always use caution when answering questions online – the best advice is to go see a doctor (but of course, that’s not always possible, unfortunately).

My goal with this post is to do a brief overview of some common health complications faced by eating disorder sufferers, their underlying causes and some advice on proper treatment/management.

This information is coming from a paper by Mascolo and colleagues which was written for ER physicians who may be unfamiliar with eating disorders. Nonetheless, I think will be useful for patients and caregivers (particularly if (or when?) you meet clinicians who may not know much about eating disorders).

The authors organize the content based on complications common in anorexia nervosa and bulimia nervosa. Most patients, however, fall somewhere between AN and BN, and so the complications listed below are not exclusive to one disorder.

Patients with eating disorders commonly complain about dizziness, fatigue, dehydration, palpitations (irregular heartbeat), syncope (fainting), seizures and muscle spasms. The notes below explain some of the possible causes for these symptoms.


physical exam findings

  • malnutrition leads to a decrease in muscle mass, including the heart muscle, this in turn leads to a  decreased ability of the heart to contract and pump blood, resulting in:
    • decreased blood pressure, or hypotension  (often less than 90/50 mm Hg)
    • decreased heart rate, or bradycardia (< 60 beats/min)
  • symptoms resulting from hypotension and bradycardia should be monitored
  • authors warn that rapid amounts of intravenous fluids (IVF) should not be administered as it can lead to heart failure in patients with reduced heart muscle mass

cardiac dysrhythmias (irregular heartbeat)

  • a risk for patients with <70% of ideal body weight, can lead to sudden death
  • an electrocardiogram (EKG) should be done if patient complains of weakness, fainting, or palpitations

chest pain

  • could be due to mitral valve prolapse (seen in 30-50% of patients with severe anorexia)
  • authors note that this is usually benign (unless accompanies by dysrhytmias)
  • an electrocardiogram should be done to exclude acute coronary syndrome (though unlikely in young patients)

muscoskeletal complaints

  • osteoporosis is a common and often irreversible complication in anorexia nervosa
  • 6 month duration of the illness is often enough to detect significant bone density loss
  • peak bone mass is reached by around 20 years of age, patients with AN in adolescence do not reach the peak bone mass
  • bone density scan is recommended, particularly if there are complains about hip/lower back pain

refeeding syndrome

  • can occur in starved individuals when refeeding is accomplished too quickly as a result of rapid changes in fluid and electrolyte levels, can lead to heart failure
  • risk factors: <70% of IBW (ideal body weight), little to no caloric intake for 10 days, and abnormal electrolytes (potassium, phosphorus or magnesium)
  • (more on refeeding syndrome) [note: I am planning a more in-depth post on refeeding syndrome at a future point]

liver function

  • hypoglycemia (low blood sugar), which can lead to seizures, can be a sign of liver dysfunction
  • liver failure can also occur and cn be detected by elevations in liver function tests
  • importantly, liver dysfunction can negatively affect metabolism of medications

When it comes to complications occurring in bulimia nervosa, the authors focus on two main ones: “complications associated with the usage of IVF to correct dehydration and electrolyte disorders” and “gastrointestinal, associated with self-induced vomiting and the abuse of laxatives.

Of course, individuals with binge-purge type of anorexia nervosa are also at risk of suffering from the complications listed under “bulimia.”


pseudo-bartter’s syndrome

The authors wrote a nice description of what happens in pseudo-bartter’s syndrome and how to treat it appropriately:

Patients with non-bulimia nervosa who present to the ED with hypokalemia, metabolic alkalosis, and hypovolemia are often treated with large amounts of intravenous normal saline in order to restore volume. However, given the state of sodium avidity present with the upregulation of aldosterone, patients with bulimia nervosa retain salt and water leading to rapid accumulation of marked edema. It is not usual for patients with bulimia nervosa to accumulate 10 pounds of edema in 1 or 2 days with abrupt cessation of purging behaviors even in the absence of IVF administration. Reverting to the typical rate of IVF administration in a patient with bulimia will cause rapid weight gain, which is uncomfortable and emotionally distressing for patients with bulimia who have intense fears of gaining weight and body image issues. This distress has unfortunately led many patients with binge-purge anorexia and with bulimia not to seek emergent treatment for fear of edema development based on previous ED visits.

gastointestinal (GI) complaints

  • persistent self-induced vomiting can lead to: dysphagia, heartburn,hematomesis, hoarseness
    • dysphagia, heartburn and hoarseness are often due to gastric acid reflux
    • hematemesis is often due to Mallory-Weiss syndrome (self-healing if one stays away from vomiting)
  • laxative abuse can lead to: diarrhea, abdominal cramping and constipation
    • detoxing from laxative abuse can be very hard, the authors suggest using a nonstimulant laxative (“to combat constipation and bloating”) and keep hydrated

The authors caution ER physicians to be aware that “many patients with eating disorders are hesitant to present to an ED precisely because of prior mismanagement and bad experiences.” And so recognizing an eating disorder as the underlying cause of these symptoms is imperative.

When possible, it is important for the mental health providers of these patients to proactively alert the [ER physician] of the potential medical caveats in caring for such a population.

My advice is: don’t hesitate to tell clinicians about your eating disorder.

Yes, there is a chance they might know nothing about EDs and/or be completely dismissive – but if you don’t tell them, they wont even think about the possibility that your symptoms are related to an underlying eating disorder. Conversely, if you do tell them, they might seek advice or help from other physicians or educate themselves on the precautionary measures that need to take when treating patients with EDs. The best alternative, of course, is that they know exactly what to do, and by telling them, you are preventing the deadly consequences that can result from “treatment as usual” (i.e., for patients without eating disorders).


Mascolo, M., Trent, S., Colwell, C., & Mehler, P.S. (2012). What the emergency department needs to know when caring for your patients with eating disorders. The International Journal of Eating Disorders PMID: 22707235

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Tetyana is the creator and manager of the blog. She has an Honours BSc in Neuroscience and an MSc in Medical Science. She can be reached at tetyana[at]scienceofeds[dot]org.


  1. “The authors caution ER physicians to be aware that “many patients with eating disorders are hesitant to present to an ED precisely because of priormismanagement and bad experiences.” And so recognizing an eating disorder as the underlying cause of these symptoms is imperative.”

    While I do agree that it’s very important for doctors to know about the ED, the disorder can sometimes get in the way of a proper diagnosis. Not because the doctors are dismissive but because they incorrectly assume that is the ONLY underlying cause.

    I know of a cardiac patient who spent years being told that her heart damage must have been caused by anorexia. It turned out to be a genetic defect that could have been dealt with earlier if the doctors had been willing to look beyond that one factor.

    An eating disorder is a vital part of a person’s medical history, but it’s not the whole story.

    • Yes, that’s a very good point that I didn’t mention. Very true – thanks for pointing it out Missie!

  2. Tetyana, what are your thoughts on fasting? I have seen a book in the store that said anorexics/bulimics/very emaciated people should not fast (but what if you started the fast slightly emaciated?), but it didn’t discourage underweight people, diabetics, children etc from fasting, and I don’t have much medical knowledge but when I was in hospital with my ED I had issues with hypoglycaemia and I never even fasted for days at a time so I find it troubling? In this book the author said that there was a scientific study in which participants consumed no fluids or food for I think 12 days and experienced NO physical consequences. This seems absurd to me, yet fasting is recommended as a treatment for cancer etc. I’m probably going off topic but I get so frustrated with anti intellectualism/stupid crap, parents of autistic children giving their children bleach enemas because they think it will cure their autism (bleach is recommended for cancer too), doctors putting adult women at healthy weights on ‘feeding tube’ starvation diets, etc.

    • Sarah, I’m a bit confused. What is the rationale for fasting in the first place? I just don’t understand why anyone would fast unless you have a stomach ache or something, and if you eat, you throw up, so you kind of have to wait it out and not eat anything that might make it worse. As a treatment for cancer?!

      Books are not peer-reviewed and thus, there is tons of crap out there – yes, in Barnes & Noble, too. The best is when it says “scientists say” – what scientists? who? scientists aren’t a cohesive group of people and they have a spokesperson that speaks on behalf of all of them.

      There is lots of pseudoscience everywhere. In a (nearly/approaching) free market system, with little oversight into health and medical claims, and the ability of just about anyone to make a webpage, put some fake testimonials and sell water (or worse, poison), you are going to have a lot of people making unsubstantiated claims and making the big bucks, selling, well, bullshit “products”. And, like in cases of autism and cancer, people are desperate for a cure (understandably), with modern medicine not delivering what they want immediately (because science is hard), well, there’s a huge market for charlatans.

      Health-wise, I don’t know anything about fasting, though. Intuitively, it doesn’t sound like a good idea at all – but perhaps I’m wrong.

  3. I have been terrified by how ignorant many frontline medical professionals are about eds! I’ve been admitted to the ER quite a few times and none of them seemed to have any knowledge of what the safest protocol might be. I was always honest about having an ED, and usually my weight would have been a red flag anyway. They never checked things like electrolytes without me saying that was something that needed to be done, they never really understood either.

    I haven’t returned to the ER even when I’ve felt terrified since last time a few years ago. My case manager took me there because I’d been having chest pains. The registrar spent the next few hours every time he popped round, lecturing me on how selfish, manipulative and attention seeking I was, how I was wasting his time that should have been spent on real patients, and how I needed to go home and have a sandwich (yes he actually said all that, not just to me, but a friend of mine he called to come pick me up). I didn’t get an ECG. I didn’t get results of bloods taken. All they did was rehydrate me, and when that was over, let me go. (And hell did I want to go!)

    A few days later I was back, after collapsing, I did have very serious heart problems and spent a lot of time in the cardiac care unit for them. If that stupid doctor hadn’t been too busy being ignorant and stereotyping me he might have checked me for the problems and actually found them.

    I think it should be standard that every single nurse and doctor does at least an introductory/basic course of what to expect, what to look like, myths debunked, basic psychology of, etc etc etc of eating disorders – especially GPs and Emergency staff since they are often the first contact for ED patients!

    • I have had similar treatment from ER staff, and after that one experience would rather die than ever go back.

      I was at school that night, and binged so severely that I was unable to purge. It was so terrible that I could not even stand up and feared that my stomach would rupture. As embarrassing as this was, I called my mother to come take me to the emergency room.

      It’s probably because I was not bleeding, but we were ignored for a long time, even though I was in so much agony that I had to lay on the floor. And when I finally did see a doctor, and explained the problem, they showed absolutely no concern, treating me as if I was just being over dramatic and just needed to talk to a therapist. They gave me some medicine for my ‘gassy stomach ache’ and sent me on my way.

      I had hoped actually that they would pump my stomach, if only a bit to relieve the pressure.

      I ended up spending the next two days curled up on my mother’s bed waiting for the food to hopefully pass. I was so relieved when it was all over. I have to wonder if anything did tear, but at the least, I did not die of sepsis.

      My experiences IP were infinitely worse however. The way those nurses treated us was absolutely degrading. Also, they had a policy that you would not be allowed to shower for up to three days if you did not make weight. I have never felt more disgusting in my life. I quickly got out of there and dropped to a weight that could have very well killed me, and most definitely left no doubt to anyone that I was very ill (all this before the ER experience) -.-

      I have serious trust issues, of doctors in particular.

      • Melissa & Fiona: thank you so much for your comments.

        I’m really sorry you’ve both had such awful experiences :(. It is worse, too, knowing that many others have had similar experiences – or worse.

        Your experiences highlight once more the problem of mental health un-awareness in the medical profession. I don’t have answers on how to resolve it immediately, or quickly, but I do think sharing your experiences is important. It is important for others to know they are not alone, and hopefully the more people speak up, on-line, but more importantly to their doctors, nurses and treatment teams, the more likely we are to see changes? I hope, anyway.

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