Involuntary Weight Loss

Differential Overview

❑ Diabetes

❑ Depression

❑ Inadequate intake

❑ Drugs

❑ Hyperthyroidism

❑ Occult cancer

❑ Low cardiac output

❑ Anorexia nervosa

❑ Malabsorption

❑ Chronic infection

❑ Adrenal insufficiency

❑ Emphysema

Diagnostic Approach

Cachexia is accelerated loss of lean body mass in the context of a chronic inflammatory response, caused by a combination of decreased intake (with decreased appetite) and increased metabolic rate. The cause of the weight loss will usually be evident, based on concurrent symptoms. If not, first document that weight loss has occurred by using prior records of measured weights or the discovery of loose-fitting clothes (tightening belt notches) or dentures. If the cause is not found on the first pass, document the weight and re-examine several weeks later.

Weight loss in patients with congestive heart failure, cirrhosis, and
uremia may be masked by fluid retention, but temporalis and limb wasting will be prominent. Weight loss in malignancy of more than 5% of body mass prior to treatment portends a poor prognosis.

Clinical Findings

Diabetes  At the onset, weight loss is primarily caused by osmotic diuresis with polyuria/nocturia. Later glycosuria produces caloric loss, combined with the increased catabolic state of insulin deficiency and glucagon excess. In a patient with new diabetes and prominent weight loss, consider underlying pancreatic cancer.

Depression  It is recognized by sadness, anhedonia, anorexia, and sleep
disturbance.

Inadequate intake  Common causes include painful oral lesions (phenytoin gum hypertrophy, vitamin deficiency glossitis, heavy metal intoxication, candidiasis, poor dentition), solitary living in the elderly, early dementia, food fads, abnormal taste (hepatitis, zinc deficiency, drugs), or abdominal pain associated with eating (intestinal ischemia). With protein-calorie
malnutrition, the skin is dry and baggy. There is weakness, tremor, polyuria, edema, and ascites.

Drugs  Weight loss is associated with cholestyramine, digoxin, diuretics, oral hypoglycemics, cytotoxics, amphetamines, and sibutramine.

Hyperthyroidism  Despite an increased appetite, weight loss occurs. Tachycardia, fine tremor, silky skin, and eye signs (exophthalmos or lid lag) are useful clues. Apathetic hyperthyroidism can occur in elderly patients producing listlessness and tachycardia or atrial fibrillation.

Occult cancer  Pancreatic cancer is the prototype, with aversion to food, and weight loss (20 to 40 lbs.) that precedes visceral pain or jaundice, and is not proportional to size of the tumor. Weight loss is usually marked in gastric and pancreatic cancer, moderate in prostate, colon, and lung cancer, and mild in breast cancer.

Low cardiac output  Easy fatigability, dyspnea on exertion, bibasilar rales, peripheral edema, third and/or fourth heart sounds, and jugular venous distension are found.

Anorexia nervosa  The patient is preoccupied with body weight, yet is unconcerned about being obviously very thin. There is usually overactivity, often the form of vigorous exercise, despite cachexia. Secretiveness leads to the false appearance of involuntary weight loss. The SCOFF questionnaire is helpful in screening: 1) Do you make yourself Sick because you feel uncomfortably full? 2) Do you worry you have lost Control over how much you eat? 3) Have you recently lost more than One stone (14 lbs or 7.7 kg) in a three month period? 4) Do you believe yourself Fat when others say you are too thin? 5) Does Food dominate your life?

Malabsorption  Fat malabsorption produces sticky and greasy stools, borborygmi, abdominal distension, and vague abdominal pain. Malabsorption is also associated with loss of lipid-soluble vitamins, which sometimes produces peripheral neuropathy, anemia, dermatitis, or bleeding. Sprue causes a malabsorption syndrome, bone pain with compression deformities, and anxiety/depression.

Chronic infection  Fever is the key sign. Common occult causes include bacterial endocarditis, osteomyelitis, tuberculosis, and HIV.

Adrenal insufficiency  Fatigue, hypotension, and hyperpigmentation—especially when seen in the palmar creases or buccal mucosa—are important findings.

Emphysemia  Cachexia occurs in “pink puffers.” The patient will have a smoking history, a barrel chest with reduced breath sounds, and will be dyspneic on exertion.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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