Unintentional Weight Loss

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[edit] Unintentional Weight Loss

Glennon O'Grady

Unintentional weight loss (UWL) is defined as a documented 5% or more weight loss without a specific goal to lose weight. Self-reported weight loss is often unreliable. Weight loss can be verified by documenting clothes-size change or photographs, if the weight is not documented in the medical record. The medical literature is limited, with relatively few studies done on specific age groups of patients and minimal follow-up, making it difficult to define an evidence-based approach for a workup of UWL. The difficulty for physicians is clear: 25% to 30% of cases have no easily identifiable cause, and yet some of the causes are life threatening. Since failure to diagnose cancer is the most frequent cause for malpractice cases, the lack of applicable studies makes it difficult for the primary care physician to develop a cost-effective approach. Given the literature, it makes sense to stratify different risks of certain diseases and tailor the diagnostic workup by the prevalence of disease, taking into account the patient's age and risk factors. For example, in older age groups the risk of malignancy and Alzheimer's disease increases, whereas in younger groups depression and eating disorders are more frequent. Studies done in 1981^[1] and 1986^[2] found significantly different frequencies for the etiology of UWL. One study^[1] followed a younger all-male veteran population and had relatively fewer neurologic and adverse drug reactions as etiologies (Table 25-1). These studies were done prior to the human immunodeficiency virus (HIV) epidemic or in populations that were not at increased risk for HIV.

Table 25-1 Etiologies of Unintentional Weight Loss

[edit] History And Physical Examination.

History and physical examination can help differentiate the various etiologies for UWL and further refine the use of laboratory tests, x-rays, or procedures. The history should screen for depression, anxiety, and eating disorders. It should include a family history and a risk assessment for lung, gastrointestinal (GI), breast, prostate, and hematologic cancers. Symptoms of endocrine disorders should be elicited, especially thyroid disease and diabetes, which are the most common. A history of symptoms of malabsorption, vomiting, or difficulty chewing or swallowing is important, as well as detailed dietary and social histories that can identify nutritional deficiencies that may be related to financial or adverse living situations. The history should include symptoms or risk factors for any chronic disease, HIV, tuberculosis (TB), and parasites.

In addition to the general physical examination, there should be a specific focus on areas identified by the history. The examination should include screening for cancer, with breast, colorectal, lung, skin, and prostate being the most common. The mouth should be examined, with attention to dentition. A neurologic and mental status examination should assess for neurologic problems that might lead to poor swallowing mechanics and for Alzheimer's disease.

[edit] Medications.

Medications can cause anorexia, nausea, and vomiting or increased metabolism leading to UWL. Patients should be asked about erythromycin, tetracycline, nonsteroidal antiinflammatory medications, theophylline preparations, selective serotonin reuptake inhibitors, digoxin, amantadine, potassium, corticosteroids, oral contraceptives, metformin, amphetamines, decongestants, over-the-counter diet medications, and thyroid medications. Patients should be screened for substance use, including alcohol, cocaine, and narcotics.

[edit] Laboratory Tests.

Initial laboratory testing should include a complete blood count (CBC), thyroid-stimulating hormone (TSH), glucose, stool for guaiac, and urinalysis. If the history and physical examination point in a particular direction, appropriate testing should be considered. For example, diarrhea will lead to stool testing for signs of malabsorption or infection.

[edit] Infectious Diseases.

Any chronic infectious disease can be associated with UWL. The workup needs to be guided by

the history of travel and other risk factors. HIV is associated with a wasting syndrome and should be tested for if a patient has identifiable or suspected risk factors. The wasting syndrome is often associated with specific GI symptoms such as swallowing troubles, decreased appetite, or diarrhea. TB is also associated with weight loss as well as night sweats and is reasonable to screen for in high-risk populations.

[edit] Additional Tests.

Further workup may include chest x-ray and mammogram, which can help diagnose two of the most common cancers. Colonoscopy or upper endoscopy is indicated when labs show iron deficiency anemia or guaiac + stool. It should be noted that iron deficiency anemia is common in menstruating women. Although many physicians consider ruling out colon cancer in patients older than 40, colon cancer can occur in younger people as well.

[edit] Psychologic Evaluation.

If the history points toward depression and the physical examination and initial labs are normal, adequately treating the depression and following the weight are appropriate management. If there is no improvement or weight loss continues, consider further evaluation. It is appropriate to rescreen for psychosocial causes that may have been missed in the initial evaluation.

[edit] REFERENCES