Involuntary Weight Loss.pptx

7/25/2019 Involuntary Weight Loss.pptx

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INVOLUNTARY

WEIGHT LOSSan approach to diagnosis

Gatot Sugiharto, MD, Internist

Internal Medicine Department

Faculty of Medicine, Wijaya Kusuma UniversitySuraaya

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Introduction

Involuntary !eight loss is a challengingprolem

"his has serious health implications, !ith

the ris# of patient moridity andmortality

"he #ey to the diagnosis of involuntary

!eght loss is a careful and completehistory and physical e$amination%

"he approach egins roadly and then&uic#ly focuses on speci'cs derived from

the initial evaluation%

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!"nition

Signi'cant !eight loss( loss of )*

ody !eight in + days, -%)* in .days, or /* in /0 days

Severe !eight loss( loss of more than

)* ody !eight in + days, morethan -%)* in . days, or more than/* in /0 days%

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Initia% E&a%uation'1(

A. Quantify loss.2 loss of )* of the aselineody !eight 3not ideal ody !eight4 issigni'cant

1.5an the !eight loss e veri'ed6 Serialmeasurements are est, ut other mar#ers includenumerical estimates and changes in clothing or eltsi7e%

2.Up to 8)* of cases !ith documented !eight loss

and thorough evaluation, no cause is ever found3.Is there a physical cause6 9ne:third of cases !ill

e caused y depression, dementia, or socialfactors

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B. Categories of weight loss can e divided intofour major categories( d!cr!as!d inta*!+incr!as!d nutri!nt %oss+ incr!as!d ,!ta-o%icd!,and+ and i,pair!d a-sorption

C. Special considerations

1.2 tailored approach in the elderly

2."he approach in human immunode'ciency virusinfection and ac&uired immunode'ciency syndrome is

more comprehensive#% Special attention is given to disease:speci'c

infections, nutritional changes, and neoplasia%

/

Initia% E&a%uation'2(


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Histor0 Initia% data

A. Is the loss intentional ?5onsider dieting,diuretics, and eating disorders%

B. What is the patients a!erage daily or wee"lyinta"e ?5onsider fre&uency of meals, appetite

changes, and di;culty !ith food preparation%C. #o$acco% alcohol% and drug historiesare very

important and fre&uently lead to other concerns%

&. Chronic conditions?Medical, surgical,

psychiatric, and family histories are al!ays pertinent%'. Social factorsinclude stress, isolation, and thecost and e


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Histor0 ta*ing'1(3

Is th!r! 4!&!r5 Suggest an infectious disease, such as tuerculosis,

2IDS, rucellosis, and typhoid fever

5ollagen diseases and neoplasms should not e

forgotten

Is th!r! anor!6ia5 2nore$ia may e related to a ferile process, ut if

there is no fever one should consider the possiility

of 2ddison=s disease, anore$ia nervosa, Simmonds=disease, drug ause, poisoning such as arsenicpoisoning, scurvy, malasorption syndrome, uremia,and liver failure, neoplasm%


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Histor0 ta*ing'2(7

Is th!r! %0,phad!nopath05 Generali7ed lymphadenopathy should suggest

leu#emia, sarcoidosis, and lymphoma, as !ell asinfectious disease processes%

Is th!r! an a-do,ina% ,ass5 2n adominal mass may e an enlarged spleen, a

pancreatic carcinoma, an enlarged liver, or renal mass%

"hese masses !ould suggest disease of those organs%

Mass also may e a carcinoma of the stomach orintestine%

Is th!r! h0p!rpig,!ntation5 >yperpigmentation !ould suggest 2ddison=s disease%


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Is th! app!tit! nor,a% or incr!as!d5 2 normal or increased appetite in the presence of !eight

loss should suggest hyperthyroidism and diaetes mellitus%

May e ta#ing thyroid hormone medication in increased

&uantities% Is th! th0roid g%and !n%arg!d5

?nlarged thyroid !ould suggest hyperthyroidism

2 focal thyroid mass !hich might e a to$ic adenoma%

Is th! ch!st 69ra0 a-nor,a%5 5@A anormality !hich may induce !eight loss are

carcinoma of the lung, tuerculosis, congestive heartfailure, pulmonary emphysema, and 'rosis%

Histor0 ta*ing'#(


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:asic ph0sica% !6a,ination

A. (ele!ant physical )ndings!ill epresent in ..* of cases

B. Quantify lossy serial !eight

measurements%

C. Chec" the !ital signs*temperature,lood pressure, and respiratory and

heart rates% 5onsider determiningo$ygen saturation%

&. +erfor, a physicale-a,ination%!ith emphasis on areas

suggested y clues from the history%

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Basic la$oratory tests

A.Deate continues regarding the most useful and cost:eIE antiody titer needsto e done in selected clinical circumstances

3.5hest radiograph, ?5G, B9F are often useful

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Co,prehensi!e analysis

B. Further testing should e done onlyas directed ythe initial 'ndings%

1.When indicated, endoscopy, and colonoscopy,esophagogram, a small o!el series, ariumenema, and a sigmoidoscopic e$amination%

2.5omputed tomography and other e$pensive

investigations are seldom ene'cial in theasence of a speci'c 3often guideline:ased4indication

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Us!4u% T!sts

"uerculin test 3tuerculosis4

Glucose tolerance test 3diaetesmellitus4

Serum amylase and lipase levels

3chronic pancreatitis, pancreaticneoplasm4

Drug screen 3drug ause4

>IE antiody titer 32IDS4

Stool for fat and trypsin3malasorption syndrome4

Stool for ova and parasites3parasites infestation4

d:@ylose asorption test3malasorption syndrome4

Urine ):>I22 3carcinoid

Bone scan 3metastatic malignancy4

5" scan of the adomen 3malignancyascess4

ymphangiogram 3>odg#in disease,

metastatic malignancy4

5" scan of the rain 3pituitary tumor4

ymph node iopsy 3lymphoma,

malignancy4

Serum 2D> level 3diaetes insipidus4

Serum cortisol level 32ddison disease,hypopituitarism4

Serum gro!th hormone, > or FS>

3Simmonds disease4

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iagnostic ass!ss,!nt.

"he integration of history, e$amination, and laoratory datausually reveals the cause for involuntary !eight loss%

A. Cancer%including gastrointestinal malignancies, accountsfor /.* to +.* of cases, and other gastrointestinal

diseases account for another /* to 8+*B. If the initial steps are not conclusi!e%the est

approach is careful oservation% Follo!:up e$aminationsand testing should e done monthly for . months% If aphysical cause e$ists, it !ill almost al!ays e found !ithin

this timeC. If an organic cause is present%this simple approach !ill

'nd it more than -)* of the time

&. If an organic cause is not identi)ed in ,onths%oneis unli#ely to e found "hese undi


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i;!r!ntia% iagnosis'1(

2n#ylosing spondylitis Bilateral lesions of the lateral

hypothalamus 3hypothalamicanore$ia4

Decreased food

inta#eHmalnutrition2dominal angina2nore$ia of aging5hronicHrecurrent

nauseaHvomiting

DementiaH2l7heimer=sdisease

?sophagealdiseaseHdysphagia

?sophagitis

CeoplasmCeuromuscular

Medications2ngiotensin:converting

en7yme inhiitors3distortion of taste4

2ntidepressants5lonidineDigo$in

Consteroidalantiinammatory agents

Sedatives"heophylline

9structive gastrointestinal

disease 3including pyloricostruction due to chronicpeptic ulcer disease4

9ral diseaseoose denturesJoor or asent teeth9ther oral diseases

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Jain Joor social situation Jostantrectomy

3especially Billroth II4

or gastrectomy Joverty Unpalatale diets ?ndocrine disorders

2drenalinsu;ciency

Diaetes mellitusDiaetic

neuropathic cache$ia>ypercalcemia

?$tensive e$ercise

Infection, especially2meic ascess

Bacterial endocarditis

5hronic suppurative pleuropulmonarydisease 3e%g%, emphysema4

5ryptosporidiosisFungal diseases

Giardiasis

>uman immunode'ciency virus 3>IE4

Mycobacterium avium pulmonary

infectionsJarasitic infestationsJaraspinalHepidural ascess

"uerculosis

Eisceral leishmaniasis

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i;!r!ntia% iagnosis'2(


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MaldigestionHmalasorptionInammatory o!el

diseaseJernicious anemia

Malignancy, especially

BiliaryBreastGastrointestinalGlucagonoma>epatic

eu#emiaymphomaMyelomaJancreaticJulmonary

Somatostatinoma

Myelo'rosis Myotonic dystrophy Jar#inson=s disease Jin# disease 3mercury

poisoning in children4

Jsychiatric disease2nore$ia nervosa2n$iety disordersBulimia5onversion disorders

DepressionManipulative ehaviorsJsychosisHparanoiaSchi7ophreniaSustance ause

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i;!r!ntia% iagnosis'#(


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Severe chronic organ failure>eart failure 3cardiac

cache$ia4

>epatic diseaseJulmonary diseaseAenal failure

Systemic lupuserythematosus

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i;!r!ntia% iagnosis'$(


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i;!r!ntia% O&!r&i!yperthyroidism

9ccult cancer

o! cardiacoutput

2nore$ia nervosa

Malasorption

5hronic infection

2drenal

insu;ciency

?mphysema

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=a>or caus!s o4

2#


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I,pact o4 In&o%untar0W!ight Loss

2$

Jatient=s ris# of moridity and mortality increases%

"he clinician may 'rst notice that the patient islistless, apathetic, or !ea#, !hich may e associated!ith anemia

"he functioning of the diaphragm and thoracicmuscles may e diminished, !hich may causerespiratory compromise

With depletion of sucutaneous fat, the patient=s

s#in turgor may e impaired, especially in thee$tremities% Muscle !asting may occur, 'rst in the&uadriceps 3the gravityHalance muscles, !hich maycontriute to leaning or falls4


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2)

4 %


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2/

Jeripheral edema may occur, independent of heartfailure or any other cardiovascular disease due todecreased oncotic pressure and increased e$tracellularuid%

Jatient may e$perience glossitis, or crac#ing at theedges of the mouth, and he or she may lose hair or theluster of the hair may change%

Increased ris# for infection:particularly pneumonia:dueto compromised cell:mediated immunity%

Jrotein in the diaphragm and intercostal muscles haseen depleted, impairing the patient=s aility to deepreathe, e$pectorate, and clear microes from the lungs%

I,pact o4 In&o%untar0W!ight Loss


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?%inica% "nding'1(27

&ia$etesL( 2t the onset, !eight loss is primarily caused y osmotic diuresis

!ith polyuriaHnocturia% ater glycosuria produces caloric loss, comined !ith the increased

cataolic state of insulin de'ciency and glucagon e$cess%

In a patient !ith ne! diaetes and prominent !eight loss, considerunderlying pancreatic cancer%

&epression It is recogni7ed y sadness, anhedonia, anore$ia, and sleep

disturance%

Inade/uate inta"e 5ommon causes include painful oral lesions 3phenytoin gum

hypertrophy, vitamin de'ciency glossitis, heavy metal into$ication,candidiasis, poor dentition4

Solitary living in the elderly, early dementia, food fads, anormaltaste 3hepatitis, 7inc de'ciency, drugs4

2dominal pain associated !ith eating 3intestinal ischemia4%


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#8

&rugs Weight loss is associated !ith cholestyramine, digo$in,

diuretics, oral hypoglycemics, cytoto$ics, amphetamines,and siutramine%

0yperthyroidis, Despite an increased appetite, !eight loss occurs%"achycardia, 'ne tremor, sil#y s#in, and eye signs3e$ophthalmos or lid lag4

2pathetic hyperthyroidism can occur in elderly patientsproducing listlessness and tachycardia or atrial 'rillation%

ccult cancer Jancreatic cancer is the prototype, !ith aversion to food,

and !eight loss 38 to ls%4 that precedes visceral painor jaundice, and is not proportional to si7e of the tumor%

Gastric and pancreatic cancer, moderate in prostate, colon,

and lung cancer, and mild in reast cancer%

?%inica% "nding'2(


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#2

ow cardiac output ?asy fatigaility, dyspnea on e$ertion, iasilar rales, peripheral

edema, third andHor fourth heart sounds, and jugular venous distension arefound%

Anore-ia ner!osa

"he patient is preoccupied !ith ody !eight, yet is unconcernedaout eing oviously very thin%

9veractivity, often the form of vigorous e$ercise, despite cache$ia%

ala$sorption Fat malasorption produces stic#y and greasy stools, ororygmi,

adominal distension, and vague adominal pain 2ssociated !ith loss of lipid:solule vitamins, !hich sometimes

produces peripheral neuropathy, anemia, dermatitis, or leeding%

Sprue causes a malasorption syndrome, one pain !ithcompression deformities, and an$ietyHdepression%

?%inica% "nding'#(


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##

Chronic infection Fever is the #ey sign% 5ommon occult causes include

acterial endocarditis, osteomyelitis, tuerculosis,and >IE%

Adrenal insu4ciency Fatigue, hypotension, and hyperpigmentation

especially !hen seen in the palmar creases or uccalmucosaare important 'ndings%

',physe,ia 5ache$ia occurs in pin# pu


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=anag!,!nt#$

Identify and address the underlying cause

2ppetite disturance of depression may e reversedy antidepressant medications

Jancreatic en7ymes for pancreatic malasorption

Aeferral to nutritionist if necessary

Aeferral to social services if necessary

2nore$ia of malignancy and 2IDS can e treated!ith megestrol acetate or dronainol

2ggressive treatment of anore$ia nervosa, includingevaluation for electrolyte and cardiac disorders andconsultation !ith psychiatrist or psychologist

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Than* You#)

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Involuntary Weight Loss.pptx