Sequelae of Eating Disorders on Imaging

INTRODUCTION:
Feeding and eating disorders (EDs) are defined by the Diagnostic and Statistical Manual of Mental Disorders as "a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning." EDs cause the highest mortality of any mental health condition, with anorexia nervosa carrying a 5-10% mortality rate within 10 years of diagnosis. Females are approximately ten times more likely to be affected than males, though incidence in males is increasing. Risk factors include genetic predisposition, body image disturbances, and comorbid psychiatric conditions such as anxiety or depression. Disorders such as anorexia nervosa and bulimia nervosa lead to multisystem complications, many of which can be detected on imaging before clinical recognition. Patients may deny symptoms, minimize severity, or be misdiagnosed, placing radiologists in a pivotal role for early detection. Familiarity with subtle imaging clues is therefore essential to guide timely management and multidisciplinary intervention. This review was conducted by searching PubMed for literature on common imaging findings in eating disorders, which were then cross-referenced with Radiopaedia and RSNA RadioGraphics to identify representative imaging examples.

MAIN BODY:
Restricting Behaviors: The systemic effects of restrictive eating largely result from chronic malnutrition, electrolyte imbalances, hormonal dysregulation, and metabolic alterations. Musculoskeletal findings are common, with osteopenia and osteoporosis predisposing patients to insufficiency fractures, particularly in the spine and pelvis. Central nervous system abnormalities, including brain atrophy with ventricular enlargement and widened sulci, can mimic early neurodegenerative disease, though these changes are often reversible with nutritional rehabilitation. Gastrointestinal complications include dysmotility and superior mesenteric artery syndrome, which arises due to loss of mesenteric fat. Cardiac imaging may reveal "small heart syndrome," pericardial effusions, or mitral valve prolapse, reflecting cardiovascular strain. Cross-sectional imaging often demonstrates diffuse subcutaneous fat loss, providing an indirect marker of malnutrition. Renal and hepatic complications, such as nephrolithiasis, electrolyte-related injury, and hepatic steatosis, may also be observed. Purging Behaviors: Purging behaviors, including self-induced vomiting, laxative use, or diuretic abuse, produce additional organ-specific complications. Repeated vomiting increases the risk of esophageal rupture and Mallory-Weiss tears. Gastrointestinal manifestations can also include acute gastric dilatation following binge episodes, which may progress to necrosis or perforation. Pulmonary complications such as aspiration and emphysema-like changes may occur secondary to connective tissue damage. Classic dental and ENT findings include enamel erosion and parotid gland enlargement, particularly in bulimia. Imaging can provide clues to these subtle but characteristic changes, alerting radiologists to the presence of an eating disorder. Integration of findings from both restrictive and purging behaviors is critical, as patients may present with vague or nonspecific complaints.

CONCLUSION:
EDs produce subtle but characteristic imaging findings across multiple organ systems that may mimic other pathologies such as malignancy, chronic infection, or sequela substance-related disease. Radiologists must synthesize clinical context with imaging findings to detect these disorders early. Timely recognition not only improves diagnostic accuracy but can redirect workup, facilitate life-saving psychiatric intervention, and positively influence long-term outcomes.