Weight loss

Question 1

Probability diagnosis

Answer 1

Stress and anxiety (e.g. redundancy, divorce)

Depressive illness

Non-coping elderly/dementia

Eating disorders: anorexia nervosa/bulimia nervosa

Question 2

Serious disorders not to be missed

Answer 2

Chronic heart failure

Malignant disease, including especially:

• stomach
• pancreas
• lung
• myeloma
• caecum
• lymphoma

Infection:

• HIV infections (AIDS, AIRC)
• tuberculosis
• hidden abscess
• infective endocarditis
• brucellosis
• others e.g. overseas acquired infection

Question 3

Pitfalls (often missed)

Answer 3

Drug dependence (esp. alcohol)

Malabsorption states:

• ?intestinal parasites/infestations
• coeliac disease

Other GIT problems (e.g. inflammatory bowel disease)

Chronic kidney and hepatic failures

Connective tissue disorders (e.g. SLE, RA)

Dementia

Rarities:

• malnutrition
• Addison disease
• hypopituitarism

Question 4

Masquerades checklist

Answer 4

Depression

Diabetes

Drugs: adverse effects/substance abuse (see list)

Anaemia

Thyroid disorder (hyperthyroidism, Addison disease)

UTI

Question 5

Is the patient trying to tell me something?

Answer 5

A possibility.

Consider stress, anxiety and depression.

Anorexia nervosa and bulimia are special considerations.

Question 6

Key history

Answer 6

Document the weight loss carefully and evaluate pt’s recordings.

Determine food intake and obtain the help of an independent witness such as a spouse or parent (if possible).

Food intake may be reduced with;

• psychogenic disorders
• cancer but

Food intake increases with endocrine disorders such as;

• diabetes
• hyperthyroidism
• steatorrhoea

Document drug history.

Question 7

Key examination

Answer 7

vital parameters (e.g. BMI, pulse, BP, temperature, urine analysis (dipstick))

thyroid and signs of hyperthyroidism

abdominal examination (e.g. organomegaly, masses)

rectal examination

look for acid dental erosion on surface upper teeth (bulimia).

Question 8

Key investigations

Answer 8

• FBE
• ESR/CRP
• thyroid function tests
• U&E
• HIV
• blood sugar
• faecal occult blood

CXR

endoscopy upper GIT

specific imaging (e.g. CT scan abdomen).

Question 9

Diagnostic tips

Answer 9

Any loss of more than 5% of body weight is significant.

The most common cause in adults of recent weight loss is stress and anxiety.

Two conditions commonly associated with weight loss are anaemia and fever; they must be excluded.

Ask pts what they believe is the cause of their weight loss.

An anxiety state and hyperthyroidism can be difficult to differentiate clinically.

Drug use causing weight loss includes;

• opioids
• amphetamines
• alcohol
• laxatives
• digoxin
• cytotoxics
• NSAIDs
• theophylline