Weightloss

Question 1

Differential diagnoses of weightloss

Answer 1

1. Intentional weight loss
2. Lung cancer
3. Liver Metastasis

Probability diagnosis
Stress and anxiety (e.g. redundancy, divorce)
Depressive illness
Non-coping elderly/dementia
Eating disorders: anorexia nervosa/bulimia nervosa

Serious disorders not to be missed  
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

Pitfalls (often missed) 
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

Masquerades checklist
Depression
Diabetes
Drugs: adverse effects/substance abuse (see list)
Anaemia
Thyroid disorder (hyperthyroidism, Addison disease)
UTI

Is the patient trying to tell me something?
A possibility. Consider stress, anxiety and depression. Anorexia nervosa and bulimia are special considerations

Question 2

Weightloss - Key history

Answer 2

Key history

Document the weight loss carefully and evaluate the patient’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 and cancer but increased with endocrine disorders such as diabetes and hyperthyroidism, and with steatorrhoea.
Document drug history

Question 3

Weightloss - Key PE

Answer 3

Key examination

Consider:
•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 4

Weightloss - Key investigations

Answer 4

Key investigations

Consider:
•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 5

Weightloss - Diagnostic tips

Answer 5

Diagnostic tips

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 patients 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