Anorexia Nervosa and Bulimia

Slide 1 · Anorexia Nervosa and Bulimia

Nutritional pathology · endocrine, hematologic and systemic complications

Dr Abu Suraih Sakhri

MBBS, MD (Pathology)

www.abusuraihsakhri.com

Slide 2 · Learning objectives

Distinguish severe food restriction from binge–purge behavior.

Explain the endocrine and skeletal consequences of nutritional depletion.

Recognize gelatinous transformation of bone marrow as a morphologic finding.

Connect purging-associated hypokalemia to cardiac and visceral complications.

Slide 3 · Eating disorders within nutritional pathology

Malnutrition can arise from inadequate food intake, impaired absorption, excess loss or increased nutrient requirements.

The Robbins section places anorexia nervosa and bulimia among causes of self-imposed dietary disturbance.

These disorders require a behavioral assessment as well as evaluation of systemic consequences.

Slide 4 · What an adequate diet must supply

Energy from carbohydrates, fats and proteins

Amino acids and fatty acids for synthesis

Vitamins and minerals for metabolism and structure

Nutritional injury follows failure to meet one or more of these requirements.

Schematic

Slide 5 · Primary and secondary malnutrition

Primary insufficiency

One or more essential dietary components are not ingested in sufficient amounts.

Self-imposed restriction is included among possible causes.

Secondary insufficiency

Nutrient intake may be adequate, but absorption, storage or utilization is impaired.

Excess losses and increased metabolic needs also contribute.

Slide 6 · Self-imposed restriction is a distinctive pathway

Body-image and weight-related concerns can drive harmful eating behaviors.

Primary nutritional insufficiency can follow these behaviors even without food scarcity.

Pathologic consequences may extend to endocrine, cardiac, skeletal and hematologic systems.

Slide 7 · Anorexia nervosa: Restrictive phenotype

Defining behavior

Severe restriction of food intake.

Significant loss of body weight follows.

Pathologic consequence

Clinical effects resemble those of severe nutritional deprivation.

Endocrine suppression and marrow abnormalities are prominent.

Slide 8 · Bulimia: Binge–purge phenotype

Binge episodes

Episodes of uncontrolled intake of large quantities of food.

A predominance of carbohydrate-rich food.

Compensatory behavior

Self-induced vomiting or misuse of laxatives.

The aim is to prevent weight gain following bingeing.

Slide 9 · Behavioral distinction: Intake and compensation

Dimension

Anorexia nervosa

Bulimia

Dominant pattern

Severe food restriction

Recurrent bingeing followed by purging

Weight course

Marked weight loss

Weight often remains near normal

Medical emphasis

Multisystem starvation effects

Purging-related injuries and electrolyte loss

Slide 10 · Body-image concerns are a common context

Preoccupation with body image and thinness in both syndromes.

The reported population is predominantly previously healthy young females.

These descriptors are epidemiologic observations, not restrictions on who can be affected.

Slide 11 · Textbook epidemiology and prognosis

Bulimia is described as more common than anorexia nervosa and generally having a better prognosis.

Bulimia in 1–2% of females and 0.1% of males.

The mean age at onset reported is approximately 20 years.

The exceptionally high mortality associated with anorexia nervosa.

Slide 12 · Neurobiology remains incompletely understood

The supplied Robbins section does not establish a single causal neural pathway.

Altered serotonin metabolism is offered as a possible contribution.

Behavioral phenotype and clinical sequelae are better defined here than molecular etiology.

Slide 13 · Nutritional depletion: A pathologic sequence

Sustained inadequate nutrient intake

Mobilization of body fat and muscle protein

Weight loss and generalized weakness

Context from the nutritional-diseases section of Robbins.

Schematic

Slide 14 · Somatic and visceral protein compartments

Somatic compartment

Skeletal muscle is the principal store.

Catabolism is expressed as reduced muscle mass.

Visceral compartment

Liver and other visceral organs form this compartment.

Plasma proteins provide an imperfect clinical reflection.

Slide 15 · Why skeletal muscle wasting occurs

Energy intake inadequate

Somatic proteins are catabolized

Amino acids become an energy substrate

The mechanism is for severe dietary deficiency.

Schematic

Slide 16 · Why subcutaneous fat diminishes

Sustained energy shortfall

Mobilization of subcutaneous fat

Reduced fat stores and weight loss

Source-based nutritional physiology; Avoid assuming every patient has identical morphology.

Schematic

Slide 17 · Nutritional wasting: Syndrome versus etiology

Morphologic/functional pattern

Loss of subcutaneous fat, skeletal muscle and weight.

May be accompanied by anemia and other nutritional abnormalities.

Underlying cause

Marasmus is a childhood severe-malnutrition syndrome.

Anorexia nervosa is a behavioral disorder that can produce starvation-related injury.

Slide 18 · Anorexia affects multiple organ systems

Reproductive

Amenorrhea; Reduced gonadotropins

Thyroid-related

Cold intolerance; Bradycardia; Constipation

Skeleton

Reduced bone density

Marrow/blood

Anemia; Lymphopenia; Gelatinous change

Fluid/cardiac

Dehydration; Electrolyte changes; Arrhythmia

Slide 19 · Reproductive-axis suppression

Reduced hypothalamic GnRH secretion

Reduced LH and FSH

Menstrual suppression / amenorrhea

This endocrine sequence is specifically described for anorexia nervosa.

Schematic

Slide 20 · Amenorrhea: The proximate hormonal mechanism

Reduced GnRH secretion lowers luteinizing hormone and follicle-stimulating hormone.

Diminished gonadotropin stimulation is associated with loss of normal menstrual cycling.

Amenorrhea as a frequent clinical feature of anorexia nervosa.

Slide 21 · Interpreting amenorrhea in anorexia nervosa

Its biological relevance is the suppressed hypothalamic–pituitary–gonadal axis.

The coexistence of marked nutritional depletion supports an energy-related endocrine mechanism.

Clinical interpretation still requires assessment of the full eating-disorder phenotype.

Slide 22 · Menstrual findings in bulimia differ

Robbins observation

Menstrual irregularities can occur.

Amenorrhea is described in fewer than half of affected patients.

Mechanistic explanation

Body weight often remains near normal.

Gonadotropin levels may also stay near normal.

Slide 23 · Reproductive endocrinology: Contrasting patterns

Finding

Anorexia nervosa

Bulimia

Nutritional state

Severe weight reduction typical

Weight often near normal

GnRH/gonadotropins

Suppressed reproductive axis

Often closer to normal

Amenorrhea

Very common description

Reported in <50%

Slide 24 · Thyroid-associated systemic effects

Reduced thyroid hormone release

Slowed systemic functions

Cold intolerance · bradycardia · constipation

This cluster to decreased thyroid hormone release.

Schematic

Slide 25 · Cold intolerance and bradycardia

Cold intolerance

Part of the endocrine pattern described in anorexia nervosa.

In clinical reasoning, it should prompt assessment for broader nutritional effects.

Bradycardia

Commonly accompanies the same low-thyroid-hormone pattern.

Cardiac risk also requires attention to electrolyte disturbances.

Slide 26 · Constipation as an endocrine-associated manifestation

Constipation among findings associated with reduced thyroid hormone release.

This links gastrointestinal symptoms to systemic endocrine disturbance.

Constipation alone is nonspecific and should be interpreted with nutritional and behavioral history.

Slide 27 · Hair and skin changes in nutritional depletion

Hair changes and dry, scaly skin are noted in anorexia nervosa.

Robbins groups these findings with the reduced thyroid-hormone-related syndrome.

Cutaneous findings support the recognition of systemic illness but lack standalone specificity.

Slide 28 · Integrated endocrine phenotype

Hypothalamus

Reduced GnRH

Gonadotropins

Reduced LH and FSH

Reproductive system

Amenorrhea

Thyroid-associated effects

Cold intolerance · bradycardia · constipation

Skeleton

Reduced estrogen contributes to bone loss

Slide 29 · Anorexia nervosa and reduced bone density

Reduced estrogen levels

Increased skeletal vulnerability

Loss of bone density

The bone-loss effect to postmenopausal osteoporosis.

Schematic

Slide 30 · Why estrogen loss matters for bone

Estrogen deficiency is the mechanism proposed for reduced bone density.

The analogy is acceleration of bone loss after menopause.

Low bone density is an important consequence even when the presenting complaint is behavioral or menstrual.

Slide 31 · Dehydration accompanies restrictive illness

Dehydration is frequently present in anorexia nervosa.

This can coexist with electrolyte abnormalities and multisystem nutritional consequences.

The clinical pattern cannot be inferred from body weight alone.

Slide 32 · Hypokalemia creates electrical instability

Low serum potassium

Greater susceptibility to cardiac arrhythmia

Potential sudden death

The arrhythmic hazard is shared by anorexia nervosa and bulimia.

Schematic

Slide 33 · Sudden cardiac death is a major concern

Robbins explicitly identifies arrhythmias and sudden death among major complications.

Hypokalemia is identified as the key electrolyte disturbance passage.

The risk is clinically consequential in either eating-disorder phenotype.

Slide 34 · Two cardiac findings, different contexts

Bradycardia

Included among reduced-thyroid-hormone-related findings in anorexia.

Describes heart-rate reduction.

Arrhythmia susceptibility

Linked to hypokalemia in anorexia and bulimia.

May culminate in sudden death.

Slide 35 · Anemia may accompany anorexia nervosa

Anemia is among the hematologic abnormalities.

The source also reports reduced marrow hematopoiesis.

Anemia should be interpreted within the full nutritional and marrow context.

Slide 36 · Lymphopenia signals hematologic involvement

Lymphopenia among possible laboratory abnormalities.

It occurs in the setting of systemic nutritional illness and altered marrow function.

Its absence does not exclude anorexia nervosa.

Slide 37 · Hypoalbuminemia: Interpret in context

Hypoalbuminemia as a possible finding in anorexia nervosa.

Albumin reflects the visceral-protein dimension of malnutrition described in the parent section.

Not every patient with severe depletion has the same serum-protein pattern.

Slide 38 · Hematologic consequences of anorexia nervosa

Peripheral blood

Anemia

White-cell compartment

Lymphopenia

Plasma proteins

Hypoalbuminemia may occur

Bone marrow

Reduced hematopoiesis

Matrix

Gelatinous transformation

Slide 39 · Marrow suppression and gelatinous transformation

Reduced hematopoietic activity

Low marrow cellularity

Mucinous extracellular matrix deposition

This histologic pattern is called gelatinous marrow transformation.

Schematic

Slide 40 · Bone marrow: A distinctive morphologic pattern

Sparse hematopoietic cells

Reduced marrow cellularity

Mucinous extracellular matrix

Gelatinous transformation

Schematic — not a histologic specimen

Slide 41 · Why marrow gelatinization is diagnostically important

Decreased cellularity with deposition of mucinous matrix.

The resulting gelatinous transformation is emphasized as a highly characteristic finding.

The supplied text calls it “virtually pathognomonic”; This wording should not be interpreted as absolute diagnostic exclusivity.

Slide 42 · Bulimia: The recurrent behavioral sequence

Uncontrolled binge eating

Compensatory purging behavior

Recurrent exposure to electrolyte and mechanical injury

Vomiting, laxative misuse and diuretic use.

Schematic

Slide 43 · Bingeing in bulimia: Key Principles

Large amounts of food may be consumed during an episode.

Carbohydrate-rich foods are mentioned as commonly ingested.

The distinguishing pathologic issue is the compensatory purge and its consequences.

Slide 44 · Self-induced vomiting creates multiple hazards

Vomiting is a prominent purging behavior in the source description.

Repeated exposure can lead to electrolyte depletion.

Other described hazards include aspiration of gastric contents and gastrointestinal rupture.

Slide 45 · Laxatives and diuretics as purging methods

Laxative misuse

Specifically listed as a purging behavior.

Contributes to the spectrum of medical complications associated with repeated purging.

Diuretic misuse

Listed by Robbins as a chronic purging practice.

A clinically relevant contributor to electrolyte abnormalities.

Slide 46 · Bulimia: Electrolyte pathway to cardiac injury

Vomiting / laxative or diuretic misuse

Hypokalemia and other electrolyte imbalance

Arrhythmia susceptibility

Mechanistic risk is present even without marked underweight.

Schematic

Slide 47 · Aspiration during purging

Induced vomiting

Gastric contents enter respiratory tract

Pulmonary aspiration injury

Aspiration as a major complication.

Schematic

Slide 48 · Mechanical gastrointestinal injury

Frequent vomiting

Physical stress on upper gastrointestinal tract

Esophageal or gastric rupture

The anatomic complications without specifying rates.

Schematic

Slide 49 · Purging complications: Three pathways

Mechanism

Pathology or consequence

Clinical relevance

Electrolyte loss

Hypokalemia

Susceptibility to arrhythmia

Airway contamination

Pulmonary aspiration

Respiratory complication

Mechanical stress

Esophageal or gastric rupture

Acute visceral injury

Slide 50 · Near-normal body weight does not exclude bulimia

Body weight and gonadotropin levels may remain near normal.

Consequently, classic starvation signs may not be prominent.

The absence of marked weight loss cannot rule out serious purging-related complications.

Slide 51 · Why comprehensive psychological assessment is central

There are no specific signs or symptoms that independently establish bulimia.

Diagnosis therefore relies on comprehensive psychological assessment.

Clinical examination remains important for detecting electrolyte and visceral injury.

Slide 52 · Anorexia nervosa and bulimia: Pathology comparison

Domain

Anorexia nervosa

Bulimia

Behavior

Severe restriction

Bingeing followed by purging

Weight

Significant loss

Often near normal

Endocrine

GnRH suppression, amenorrhea

Menses often less disrupted

Morphology

Gelatinous marrow transformation

No specific morphologic hallmark cited

Major shared hazard

Hypokalemia → arrhythmia

Hypokalemia → arrhythmia

Slide 53 · Two routes to nutritional/cardiac harm

Anorexia nervosa

Sustained intake restriction causes profound nutritional depletion.

Endocrine and hematologic abnormalities accompany cardiovascular vulnerability.

Bulimia

Purging can cause serious electrolyte and tissue injury.

A near-normal weight can coexist with arrhythmia risk.

Slide 54 · Differential context: Malnutrition mechanisms

Cause category

Typical mechanism

Lecture relevance

Dietary insufficiency

Intake fails to meet needs

Anorexia restriction is a key example

Malabsorption / excess loss

Nutrients are not retained or absorbed

Alternative or additional pathology

Inflammatory catabolism

Illness-associated protein breakdown

Contrasts with primary restriction

Slide 55 · Clinical application: Restrictive phenotype

A young adult has marked weight loss after severe dietary restriction, menstrual cessation, cold intolerance and bradycardia.

Questions

Which endocrine pathway explains the menstrual change?

What skeletal and hematologic complications should be considered?

Reasoning: Reduced GnRH → reduced LH/FSH explains amenorrhea. Low bone density and gelatinous marrow changes are.

Slide 56 · Clinical reasoning: Marrow abnormality

A person with severe weight loss has anemia. Bone marrow assessment describes decreased cellularity and abundant mucinous matrix material.

Questions

Which marrow transformation does this suggest?

Why should it be interpreted with the history?

Reasoning: Gelatinous transformation of marrow. Its strong association with anorexia does not replace assessment of the full clinicopathologic setting.

Slide 57 · Clinical application: Binge–purge phenotype

A young adult with near-normal weight reports recurrent bingeing followed by induced vomiting and experiences an electrolyte abnormality.

Questions

Which eating-disorder phenotype fits the source description?

Why is apparent weight preservation not reassuring?

Reasoning: Bulimia is the described behavioral syndrome. Purging may cause hypokalemia and arrhythmia despite near-normal weight.

Slide 58 · Clinical reasoning: Complication pathway

A patient with recurrent self-induced vomiting develops acute respiratory symptoms or severe chest/upper-abdominal pain.

Questions

Which distinct complications are explicitly?

Why must electrolyte hazards also be considered?

Reasoning: Pulmonary aspiration and esophageal/gastric rupture are possibilities. Concurrent hypokalemia can predispose to arrhythmia.

Slide 59 · System-based clinicopathologic assessment

History

Restriction versus bingeing / purging

Nutritional status

Weight loss, fat and muscle depletion

Endocrine

Menstrual, thermal and bowel symptoms

Hematology / marrow

Anemia, lymphopenia, gelatinous change

Immediate harm

Electrolyte / cardiac and visceral complications

Slide 60 · High-consequence findings across the syndromes

Anorexia nervosa

Marked nutritional depletion with endocrine suppression.

Bone-density reduction and distinctive marrow pathology.

Hypokalemia-associated arrhythmia risk.

Bulimia

Recurrent purging with near-normal weight possible.

Hypokalemia-associated arrhythmias.

Pulmonary aspiration and gastrointestinal rupture.

Slide 61 · Three clinicopathologic conclusions

Anorexia nervosa: Profound food restriction can produce multisystem starvation effects, including endocrine and marrow abnormalities.

Bulimia: The binge–purge pattern produces dangerous electrolyte, pulmonary and gastrointestinal consequences even with near-normal weight.

Both syndromes: Hypokalemia-related arrhythmia and sudden death are essential complications to recognize.

Slide 62 · Reference

Robbins, Cotran & Kumar. Pathologic Basis of Disease. 11th ed. (2026).

Assigned reading: “Anorexia Nervosa and Bulimia” and relevant adjacent material in “Nutritional Diseases.”

Detailed source locations and morphology-figure provenance are recorded in the presenter notes.