Unexplained Weight Loss
Unintentional weight loss is a non-specific symptom but may be indicative of a serious underlying pathology. Mastery of the approach to unintentional weight loss is important to recognize and treat comorbid illness.
Describe and discuss:
- anatomy, physiology, and pathophysiology of the gastrointestinal tract and digestion
- nutrition and caloric requirements
- ability to perform a complete medical history and physical exam
- ability to communicate with patients of diverse backgrounds
Apply Medical Knowledge in the Clinical Encounter
1. Describe the signs and symptoms that suggest clinically significant weight loss (5% of body weight over six to 12 months).
2. Describe the clinical features that help to differentiate one etiology from another.
3. Understand that rapid unintentional weight loss is associated with significant morbidity and mortality.
1. Obtain, document and present an age-appropriate medical history that includes:
- conditions that prevent food consumption
- persistent vomiting
- medication use especially polypharmacy in the elderly
- endocrine disorders
- chronic illnesses such as CHF, COPD, RA
- acute or chronic infection
- drug abuse, heavy smoking
- malnutrition, social isolation
- psychological stresses or diseases
2. Perform a physical exam to establish the diagnosis and severity of weight loss including:
- calculation of degree of weight loss
- assessment for signs of wasting; malnutrition; poor dentition or poorly fitting dentures; thyromegaly; abdominal masses, enlarged lymph nodes; pelvic masses in women; diabetic neuropathy; psychogenic symptoms, e.g., loss of tooth enamel, knuckle ulcerations and calluses
3. Generate a differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology of primary and secondary weight loss.
4. Recommend when to order diagnostic tests to discern causes of weight loss which may include CBC, chemistries, TFTs, liver tests, calcium, magnesium, phosphate, albumin, HIV test, autoimmune disease tests, CXR, abdominal imaging, EGD and/or colonoscopy.
5. Record, present, research, critique, and manage clinical information.
Develop and Implement a Management Plan
1. Make decisions about treatment of the underlying disorder.
2. Make decisions about caloric supplementation to achieve intake of 30-40 kcal/kg/day.
3. Make decisions about the indications for consultation with a dietician.
4. Make decisions about use of routine nutritional supplements.
5. Make decisions about indications for pharmacotherapy such as appetite stimulants.
6. Identify indications for temporary nasojejunal tube, or permanent cutaneous gastric or jejunal tube.
7. Access and utilize appropriate information systems and resources to help delineate issues related to weight loss.
8. Consider the cost-effectiveness of the management plan.
9. Plan for follow-up.
- Conditions that prevent food consumption: access to food, dysphagia, painful mouth, new orthodontic appliances or loss of teeth
- Loss of appetite (medication, depression)
- Persistent vomiting: pyloric stenosis, hiatal hernia
- Malabsorption: celiac disease, chronic pancreatitis, Crohn’s disease, gastrointestinal infection, gastrointestinal fistulas, carcinoid, intestinal hypermotility, hepatobiliary disease, food intolerance
- Medication: NSAIDs, SSRIs, antiepileptics, polypharmacy in the elderly
- Endocrine: diabetes mellitus, hyperthyroidism, Addison’s disease
- Malignancy: lymphoma, leukemia, carcinoma, sarcoma
- Systemic disease: heart failure, chronic respiratory disease, chronic renal failure, liver failure, rheumatoid arthritis, systemic lupus erythematosus, ischemic colitis
- Acute or chronic infection
- Drug abuse, heavy smoking
- Psychological: stressful life events, depression, anorexia nervosa, psychoses