Abstract

Introduction: The most common etiologies of acute pancreatitis are gallstones and alcohol consumption. However, in many cases an inciting cause is not identified. One potential cause that is not often overlooked is the presence of an eating disorder. Pancreatitis has been reported as a potential complication of both anorexia and bulimia1-3. Case Presentation: A 32-year-old, G3P1 female presented to the emergency department complaining of severe abdominal pain and profuse vomiting of two days duration. She described the pain as sharp, epigastric, radiating to the back, and exacerbated by eating. The vomitus had started out yellow in color but had progressed to having blood in it. She denied recent consumption of alcohol or a history suggestive of gallstones. Physical exam revealed a mildly overweight, tearful woman and was notable for poor dentition with enamel loss, enlarged submandibular salivary glands, and diffuse abdominal tenderness. She was afebrile and hemodynamically normal. Abnormal laboratory values included: 16.71 x 103/mm3 WBCs, a blood glucose level of 154 g/dL, an amylase level of 250 units/L, and a lipase level of 914 units/L. An ultrasound of the gallbladder was performed and was read normal. A CT scan of the pancreas was performed and revealed pancreatic edema and thickening consistent with acute pancreatitis. The patient was admitted to the hospital with a diagnosis of acute pancreatitis. Later that morning, an additional history and physical was taken by the internal medicine team. Tearfully, the patient made enigmatic comments regarding her “poor eating habits.” She made several references to times when she had vomited in the past. Upon being questioned further, she reluctantly revealed a seven-year history of induced vomiting with prolonged periods of fasting followed by binging and purging. The patient reported seeing blood in her vomitus on a regular basis for the past several years. She had never spoken to anyone about her disordered eating before. Psychiatry was consulted and she was diagnosed with Bulimia Nervosa. Discussion: Bulimia nervosa has a lifetime prevalence of about one percent in the general population4. It has been associated with a number of complications, including potentially fatal ones, such as electrolyte abnormalities, esophageal rupture, and pancreatitis. Patients with bulimia are typically of a normal weight and hide purging behaviors. This makes the diagnosis of bulimia difficult, and patients frequently go many years before being diagnosed. Signs of bulimia include salivary gland hypertrophy (sialadenosis), elevated amylase levels, a callus on the dorsum of the hand, and dental erosion. In female patients who present with acute pancreatitis without evidence of alcohol use or gallstones, an underlying eating disorder should be considered as a possible etiology. Investigation may present a unique opportunity for diagnosing these patients and providing psychiatric treatment that could prevent future complications and even death.