Tutorial #27: Unintentional Weight Loss

Question 1

Clinically significant weight loss is defined as loss of ___% of total body weight over ____ months.

Answer 1

5%; 6-12 months

Question 2

What are the most common etiologies of unintentional weight loss?

Answer 2

• Malignancy
• Non-malignant GI causes
• Psychiatric causes

Question 3

What malignancies are particularly associated with weight loss?

Answer 3

Gastrointestinal, pancreatic, lung, lymphoma, renal, and prostate cancers

Question 4

What are non-malignant GI diseases that can cause unintentional weight loss?

Answer 4

Peptic ulcer disease, diseases that cause malabsorption (eg, celiac disease), and inflammatory bowel disease (IBD).

Question 5

List symptoms that may suggest a non-malignany GI cause of weight loss.

Answer 5

• Anorexia,
• Abdominal pain,
• Early satiety,
• Dysphagia,
• Odynophagia,
• Diarrhea,
• Steatorrhea,
• Chronic constipation,
• Evidence of chronic bleeding

Question 6

What are common psychiatric illnesses that can cause unintentional weight loss?

Answer 6

• Depression
• Eating disorders
• Manic phases of bipolar disorder

Question 7

What endocrinopathies commonly cause unintentional weight loss?

Answer 7

• Hyperthyroidism
• Diabetes mellitus
• Adrenal insufficiency
• Pheochromocytoma

Question 8

What common chronic infectious etioligies can cause unintentional weight loss?

Answer 8

HIV, tuberculosis, Hepatitis C, helminthic infections

Question 9

What common advanced chronic disease can cause unintentional weight loss?

Answer 9

• Congestive heart failure
• Chronic lung disease
• Advanced kidney disease

Question 10

List important elements of the history for a patient with unintentional weight loss.

Answer 10

• Evaluation for eating disorders and intentional weight loss
• Pattern of weight loss
• Associated symptoms (i.e. malignancy, malabsorption, psychiatric disorders)
• Function and social factors

Question 11

What are the initial tests that are appropriate to order if a patient presents with clinically significant unintentional weight loss WITHOUT an obvious diagnosis?

Answer 11

• CBC with differential
• Electrolytes, calcium
• Glucose and HbA1c
• Renal function and urinalysis
• Hepatic function
• TSH
• Stool hemoccult
• ESR/CRP
• HIV
• Hepatitis C
• CXR
• Age-appropriate cancer screening

Question 12

How do you manage a patient with clinically significant unintentional weight loss without a suspected diagnosis or abnormal findings after a thorough assessment?

Answer 12

Watchful waiting for one to six months

Question 13

What are concerning features in a patient’s pattern of unintentional weight loss?

Answer 13

• Recent weight loss in a person whose weight has been stable for many years
• Weight loss that is progressive
• Extreme weight loss (i.e. >10% of total body weight)

Question 14

What associated symptoms for malignancy should be asked in a patient presenting with clinically significant unintentional weight loss?

Answer 14

• B symptoms (night sweats, fevers, fatigue)
• Age- and risk-factor related symptoms (i.e. bloody or dark stools in patients ≥50 years or at risk for colon cancer, or pulmonary symptoms in patients who are smokers or former smokers).

Question 15

List 5 prescription medications that may cause unintentional weight loss

Answer 15

• Analgesics and sedatives (NSAIDS, opioids, benzos)
• Antiglycemics/diabetes medications
• Antiepileptics/seizure mediations
• Antiinfective medications: Septra, metronidazole, lamivudine
• Cardiovascular medications: CCB, BB, ASA, statins, diuretics
• Chemotherapy
• Cholinesterase inhibitors used to treat dementia (eg, donepezil, rivastigmine, galantamine)
• Psychiatric medications: antipsychotics, lithium, SSRI, TCAs
  …there are many others

Question 16

List 5 non-prescription drugs that may cause unintentional weight loss

Answer 16

• Alcohol
• Cocaine
• Amphetamines
• Marijuana
• Tobacco

Question 17

List 3 functional causes of unintentional weight loss

Answer 17

• dysphagia
• poor dentition
• poor cognition/dementia

Question 18

What associated symptoms for diseases of malabsorption should be asked in a patient presenting with clinically significant unintentional weight loss?

Answer 18

• steatorrhea
• muscle loss
• watery diarrhea
• signs of nutrient deficiency (i.e. increased bruising from vitamin K deficiency)

Question 19

Which psychiatric disorder should always be screened for when a patient presents with clinically significant unintentional weight loss?

Answer 19

Depression

Question 20

What are clues for unintentional weight loss on physical exam?

Answer 20

• General appearance – a flat affect can be a sign of psychiatric disease.
• Head and neck – poor dentition is a common cause, less common include ophthalmoplegia, cheilosis and glossitis as signs of nutritional deficiency
• Cardiopulmonary – assess for CHF/COPD/chronic disease
• Abdominal examination – assess for liver disease or malignancy
• Cognitive and neurologic exam – underlying neuro disorder such as dementia or parkinsons
• Lymphadenopathy - for malignancy

Question 21

How would you manage a patient presenting with unintentional weight loss of less than 5% total body weight?

Answer 21

Patients with <5 percent loss of usual body weight can be closely followed; the interval of follow-up may vary depending on the patient’s age and comorbidities