Post on 26-Feb-2018
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INVOLUNTARY
WEIGHT LOSSan approach to diagnosis
Gatot Sugiharto, MD, Internist
Internal Medicine Department
Faculty of Medicine, Wijaya Kusuma UniversitySuraaya
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Introduction
Involuntary !eight loss is a challengingprolem
"his has serious health implications, !ith
the ris# of patient moridity andmortality
"he #ey to the diagnosis of involuntary
!eght loss is a careful and completehistory and physical e$amination%
"he approach egins roadly and then&uic#ly focuses on speci'cs derived from
the initial evaluation%
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!"nition
Signi'cant !eight loss( loss of )*
ody !eight in + days, -%)* in .days, or /* in /0 days
Severe !eight loss( loss of more than
)* ody !eight in + days, morethan -%)* in . days, or more than/* in /0 days%
#
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$
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Initia% E&a%uation'1(
A. Quantify loss.2 loss of )* of the aselineody !eight 3not ideal ody !eight4 issigni'cant
1.5an the !eight loss e veri'ed6 Serialmeasurements are est, ut other mar#ers includenumerical estimates and changes in clothing or eltsi7e%
2.Up to 8)* of cases !ith documented !eight loss
and thorough evaluation, no cause is ever found3.Is there a physical cause6 9ne:third of cases !ill
e caused y depression, dementia, or socialfactors
)
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B. Categories of weight loss can e divided intofour major categories( d!cr!as!d inta*!+incr!as!d nutri!nt %oss+ incr!as!d ,!ta-o%icd!,and+ and i,pair!d a-sorption
C. Special considerations
1.2 tailored approach in the elderly
2."he approach in human immunode'ciency virusinfection and ac&uired immunode'ciency syndrome is
more comprehensive#% Special attention is given to disease:speci'c
infections, nutritional changes, and neoplasia%
/
Initia% E&a%uation'2(
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Histor0 Initia% data
A. Is the loss intentional ?5onsider dieting,diuretics, and eating disorders%
B. What is the patients a!erage daily or wee"lyinta"e ?5onsider fre&uency of meals, appetite
changes, and di;culty !ith food preparation%C. #o$acco% alcohol% and drug historiesare very
important and fre&uently lead to other concerns%
&. Chronic conditions?Medical, surgical,
psychiatric, and family histories are al!ays pertinent%'. Social factorsinclude stress, isolation, and thecost and e
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Histor0 ta*ing'1(3
Is th!r! 4!&!r5 Suggest an infectious disease, such as tuerculosis,
2IDS, rucellosis, and typhoid fever
5ollagen diseases and neoplasms should not e
forgotten
Is th!r! anor!6ia5 2nore$ia may e related to a ferile process, ut if
there is no fever one should consider the possiility
of 2ddison=s disease, anore$ia nervosa, Simmonds=disease, drug ause, poisoning such as arsenicpoisoning, scurvy, malasorption syndrome, uremia,and liver failure, neoplasm%
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Histor0 ta*ing'2(7
Is th!r! %0,phad!nopath05 Generali7ed lymphadenopathy should suggest
leu#emia, sarcoidosis, and lymphoma, as !ell asinfectious disease processes%
Is th!r! an a-do,ina% ,ass5 2n adominal mass may e an enlarged spleen, a
pancreatic carcinoma, an enlarged liver, or renal mass%
"hese masses !ould suggest disease of those organs%
Mass also may e a carcinoma of the stomach orintestine%
Is th!r! h0p!rpig,!ntation5 >yperpigmentation !ould suggest 2ddison=s disease%
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Is th! app!tit! nor,a% or incr!as!d5 2 normal or increased appetite in the presence of !eight
loss should suggest hyperthyroidism and diaetes mellitus%
May e ta#ing thyroid hormone medication in increased
&uantities% Is th! th0roid g%and !n%arg!d5
?nlarged thyroid !ould suggest hyperthyroidism
2 focal thyroid mass !hich might e a to$ic adenoma%
Is th! ch!st 69ra0 a-nor,a%5 5@A anormality !hich may induce !eight loss are
carcinoma of the lung, tuerculosis, congestive heartfailure, pulmonary emphysema, and 'rosis%
Histor0 ta*ing'#(
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:asic ph0sica% !6a,ination
A. (ele!ant physical )ndings!ill epresent in ..* of cases
B. Quantify lossy serial !eight
measurements%
C. Chec" the !ital signs*temperature,lood pressure, and respiratory and
heart rates% 5onsider determiningo$ygen saturation%
&. +erfor, a physicale-a,ination%!ith emphasis on areas
suggested y clues from the history%
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Basic la$oratory tests
A.Deate continues regarding the most useful and cost:eIE antiody titer needsto e done in selected clinical circumstances
3.5hest radiograph, ?5G, B9F are often useful
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Co,prehensi!e analysis
B. Further testing should e done onlyas directed ythe initial 'ndings%
1.When indicated, endoscopy, and colonoscopy,esophagogram, a small o!el series, ariumenema, and a sigmoidoscopic e$amination%
2.5omputed tomography and other e$pensive
investigations are seldom ene'cial in theasence of a speci'c 3often guideline:ased4indication
1#
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Us!4u% T!sts
"uerculin test 3tuerculosis4
Glucose tolerance test 3diaetesmellitus4
Serum amylase and lipase levels
3chronic pancreatitis, pancreaticneoplasm4
Drug screen 3drug ause4
>IE antiody titer 32IDS4
Stool for fat and trypsin3malasorption syndrome4
Stool for ova and parasites3parasites infestation4
d:@ylose asorption test3malasorption syndrome4
Urine ):>I22 3carcinoid
Bone scan 3metastatic malignancy4
5" scan of the adomen 3malignancyascess4
ymphangiogram 3>odg#in disease,
metastatic malignancy4
5" scan of the rain 3pituitary tumor4
ymph node iopsy 3lymphoma,
malignancy4
Serum 2D> level 3diaetes insipidus4
Serum cortisol level 32ddison disease,hypopituitarism4
Serum gro!th hormone, > or FS>
3Simmonds disease4
1$
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iagnostic ass!ss,!nt.
"he integration of history, e$amination, and laoratory datausually reveals the cause for involuntary !eight loss%
A. Cancer%including gastrointestinal malignancies, accountsfor /.* to +.* of cases, and other gastrointestinal
diseases account for another /* to 8+*B. If the initial steps are not conclusi!e%the est
approach is careful oservation% Follo!:up e$aminationsand testing should e done monthly for . months% If aphysical cause e$ists, it !ill almost al!ays e found !ithin
this timeC. If an organic cause is present%this simple approach !ill
'nd it more than -)* of the time
&. If an organic cause is not identi)ed in ,onths%oneis unli#ely to e found "hese undi
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i;!r!ntia% iagnosis'1(
2n#ylosing spondylitis Bilateral lesions of the lateral
hypothalamus 3hypothalamicanore$ia4
Decreased food
inta#eHmalnutrition2dominal angina2nore$ia of aging5hronicHrecurrent
nauseaHvomiting
DementiaH2l7heimer=sdisease
?sophagealdiseaseHdysphagia
?sophagitis
CeoplasmCeuromuscular
Medications2ngiotensin:converting
en7yme inhiitors3distortion of taste4
2ntidepressants5lonidineDigo$in
Consteroidalantiinammatory agents
Sedatives"heophylline
9structive gastrointestinal
disease 3including pyloricostruction due to chronicpeptic ulcer disease4
9ral diseaseoose denturesJoor or asent teeth9ther oral diseases
1/
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Jain Joor social situation Jostantrectomy
3especially Billroth II4
or gastrectomy Joverty Unpalatale diets ?ndocrine disorders
2drenalinsu;ciency
Diaetes mellitusDiaetic
neuropathic cache$ia>ypercalcemia
?$tensive e$ercise
Infection, especially2meic ascess
Bacterial endocarditis
5hronic suppurative pleuropulmonarydisease 3e%g%, emphysema4
5ryptosporidiosisFungal diseases
Giardiasis
>uman immunode'ciency virus 3>IE4
Mycobacterium avium pulmonary
infectionsJarasitic infestationsJaraspinalHepidural ascess
"uerculosis
Eisceral leishmaniasis
1
i;!r!ntia% iagnosis'2(
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MaldigestionHmalasorptionInammatory o!el
diseaseJernicious anemia
Malignancy, especially
BiliaryBreastGastrointestinalGlucagonoma>epatic
eu#emiaymphomaMyelomaJancreaticJulmonary
Somatostatinoma
Myelo'rosis Myotonic dystrophy Jar#inson=s disease Jin# disease 3mercury
poisoning in children4
Jsychiatric disease2nore$ia nervosa2n$iety disordersBulimia5onversion disorders
DepressionManipulative ehaviorsJsychosisHparanoiaSchi7ophreniaSustance ause
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i;!r!ntia% iagnosis'#(
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Severe chronic organ failure>eart failure 3cardiac
cache$ia4
>epatic diseaseJulmonary diseaseAenal failure
Systemic lupuserythematosus
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i;!r!ntia% iagnosis'$(
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i;!r!ntia% O&!r&i!yperthyroidism
9ccult cancer
o! cardiacoutput
2nore$ia nervosa
Malasorption
5hronic infection
2drenal
insu;ciency
?mphysema
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=a>or caus!s o4
2#
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I,pact o4 In&o%untar0W!ight Loss
2$
Jatient=s ris# of moridity and mortality increases%
"he clinician may 'rst notice that the patient islistless, apathetic, or !ea#, !hich may e associated!ith anemia
"he functioning of the diaphragm and thoracicmuscles may e diminished, !hich may causerespiratory compromise
With depletion of sucutaneous fat, the patient=s
s#in turgor may e impaired, especially in thee$tremities% Muscle !asting may occur, 'rst in the&uadriceps 3the gravityHalance muscles, !hich maycontriute to leaning or falls4
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2)
4 %
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2/
Jeripheral edema may occur, independent of heartfailure or any other cardiovascular disease due todecreased oncotic pressure and increased e$tracellularuid%
Jatient may e$perience glossitis, or crac#ing at theedges of the mouth, and he or she may lose hair or theluster of the hair may change%
Increased ris# for infection:particularly pneumonia:dueto compromised cell:mediated immunity%
Jrotein in the diaphragm and intercostal muscles haseen depleted, impairing the patient=s aility to deepreathe, e$pectorate, and clear microes from the lungs%
I,pact o4 In&o%untar0W!ight Loss
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?%inica% "nding'1(27
&ia$etesL( 2t the onset, !eight loss is primarily caused y osmotic diuresis
!ith polyuriaHnocturia% ater glycosuria produces caloric loss, comined !ith the increased
cataolic state of insulin de'ciency and glucagon e$cess%
In a patient !ith ne! diaetes and prominent !eight loss, considerunderlying pancreatic cancer%
&epression It is recogni7ed y sadness, anhedonia, anore$ia, and sleep
disturance%
Inade/uate inta"e 5ommon causes include painful oral lesions 3phenytoin gum
hypertrophy, vitamin de'ciency glossitis, heavy metal into$ication,candidiasis, poor dentition4
Solitary living in the elderly, early dementia, food fads, anormaltaste 3hepatitis, 7inc de'ciency, drugs4
2dominal pain associated !ith eating 3intestinal ischemia4%
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#8
&rugs Weight loss is associated !ith cholestyramine, digo$in,
diuretics, oral hypoglycemics, cytoto$ics, amphetamines,and siutramine%
0yperthyroidis, Despite an increased appetite, !eight loss occurs%"achycardia, 'ne tremor, sil#y s#in, and eye signs3e$ophthalmos or lid lag4
2pathetic hyperthyroidism can occur in elderly patientsproducing listlessness and tachycardia or atrial 'rillation%
ccult cancer Jancreatic cancer is the prototype, !ith aversion to food,
and !eight loss 38 to ls%4 that precedes visceral painor jaundice, and is not proportional to si7e of the tumor%
Gastric and pancreatic cancer, moderate in prostate, colon,
and lung cancer, and mild in reast cancer%
?%inica% "nding'2(
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#2
ow cardiac output ?asy fatigaility, dyspnea on e$ertion, iasilar rales, peripheral
edema, third andHor fourth heart sounds, and jugular venous distension arefound%
Anore-ia ner!osa
"he patient is preoccupied !ith ody !eight, yet is unconcernedaout eing oviously very thin%
9veractivity, often the form of vigorous e$ercise, despite cache$ia%
ala$sorption Fat malasorption produces stic#y and greasy stools, ororygmi,
adominal distension, and vague adominal pain 2ssociated !ith loss of lipid:solule vitamins, !hich sometimes
produces peripheral neuropathy, anemia, dermatitis, or leeding%
Sprue causes a malasorption syndrome, one pain !ithcompression deformities, and an$ietyHdepression%
?%inica% "nding'#(
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##
Chronic infection Fever is the #ey sign% 5ommon occult causes include
acterial endocarditis, osteomyelitis, tuerculosis,and >IE%
Adrenal insu4ciency Fatigue, hypotension, and hyperpigmentation
especially !hen seen in the palmar creases or uccalmucosaare important 'ndings%
',physe,ia 5ache$ia occurs in pin# pu
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=anag!,!nt#$
Identify and address the underlying cause
2ppetite disturance of depression may e reversedy antidepressant medications
Jancreatic en7ymes for pancreatic malasorption
Aeferral to nutritionist if necessary
Aeferral to social services if necessary
2nore$ia of malignancy and 2IDS can e treated!ith megestrol acetate or dronainol
2ggressive treatment of anore$ia nervosa, includingevaluation for electrolyte and cardiac disorders andconsultation !ith psychiatrist or psychologist
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Than* You#)
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