Anorexia

Anorexia, a lack of appetite in the presence of a physiologic need for food, is a common symptom of GI and endocrine disorders and is characteristic of certain severe psychological disturbances such as anorexia nervosa. It can also result from such factors as anxiety, chronic pain, poor oral hygiene, increased body temperature due to hot weather or fever, and changes in taste or smell that normally accompany aging. Anorexia also can result from drug therapy or abuse. Short-term anorexia rarely jeopardizes health, but chronic anorexia can lead to life-threatening malnutrition.

History and physical examination

Take the patient’s vital signs and weight. Find out previous minimum and maximum weights. Ask about involuntary weight loss greater than 10 lb (4.5 kg) in the last month. Explore dietary habits, including what the patient eats and when. Ask what foods he likes and dislikes and why. The patient may identify tastes and smells that nauseate him and cause loss of appetite. Ask about dental problems that interfere with chewing, including poor-fitting dentures. Ask if he has difficulty or pain when swallowing or if he vomits or has diarrhea after meals. Ask the patient how frequently and intensely he exercises.

Check for a history of stomach or bowel disorders, which can interfere with the ability to digest, absorb, or metabolize nutrients. Find out about changes in bowel habits. Ask about alcohol use and drug use and dosage.

If the medical history doesn’t reveal an organic basis for anorexia, consider psychological factors. Ask the patient if he knows what’s causing his decreased appetite. Situational factors—such as a death in the family or problems at school or at work—can lead to depression and subsequent loss of appetite. Be alert for signs of malnutrition, consistent refusal of food, and a 7% to 10% loss of body weight in the preceding month. (See Is your patient malnourished? page 54.)

Medical causes

Acquired immunodeficiency syndrome (AIDS)

An infection or Kaposi’s sarcoma affecting the GI or respiratory tract may lead to anorexia in a patient with AIDS. Other findings include fatigue, afternoon fevers, night sweats, diarrhea, cough, bleeding, lymphadenopathy, oral thrush, gingivitis, and skin disorders, including persistent herpes zoster and recurrent herpes simplex, herpes labialis, or herpes genitalis.

Adrenocortical hypofunction

In adrenocortical hypofunction, anorexia may begin slowly and subtly, causing gradual weight loss. Other common signs and symptoms include nausea and vomiting, abdominal pain, diarrhea, weakness, fatigue, malaise, vitiligo, bronze-colored skin, and purple striae on the breasts, abdomen, shoulders, and hips.

Alcoholism

Chronic anorexia commonly accompanies alcoholism, eventually leading to malnutrition. Other findings include signs of liver damage (jaundice, spider angiomas, ascites, edema), paresthesia, tremors, increased blood pressure, bruising, GI bleeding, and abdominal pain.

Anorexia nervosa

Chronic anorexia nervosa is an eating disorder that begins insidiously and eventually leads to life-threatening malnutrition, as evidenced by skeletal muscle atrophy, loss of fatty tissue, constipation, amenorrhea, dry and blotchy or sallow skin, alopecia, sleep disturbances, distorted self-image, anhedonia, and decreased libido. Paradoxically, many patients exhibit extreme restlessness and vigor and may exercise avidly; many also have complicated food preparation and eating rituals.

Appendicitis

Anorexia closely follows the abrupt onset of generalized or localized epigastric pain, nausea, and vomiting. It can continue as pain localizes in the right lower quadrant (McBurney’s point) and other signs and symptoms—abdominal rigidity, rebound tenderness, constipation or diarrhea, slight fever, and tachycardia—appear.

Cancer

Chronic anorexia may be accompanied by weight loss, weakness, apathy, and cachexia.

Chronic renal failure

Chronic anorexia is common and develops insidiously in chronic renal failure. It’s accompanied by changes in all body systems, such as nausea, vomiting, mouth ulcers, ammonia breath odor, metallic taste, GI bleeding, constipation or diarrhea, drowsiness, confusion, tremors, pallor, dry and scaly skin, pruritus, alopecia, purpuric lesions, and edema.

Cirrhosis

Anorexia occurs early in cirrhosis and may be accompanied by weakness, nausea, vomiting, constipation or diarrhea, and dull abdominal pain. It continues after these early signs and symptoms subside and is accompanied by lethargy, slurred speech, bleeding tendencies, ascites, severe pruritus, dry skin, poor skin turgor, hepatomegaly, fetor hepaticus, jaundice, edema of the legs, gynecomastia, and right-upper-quadrant pain.

Crohn’s disease

Chronic anorexia causes marked weight loss in Crohn’s disease. Associated signs vary according to the site and extent of the lesion but may include diarrhea, abdominal pain, fever, abdominal mass, weakness, perianal or vaginal fistulas and, rarely, clubbing of the fingers. Acute inflammatory signs and symptoms—right-lower-quadrant pain, cramping, tenderness, flatulence, fever, nausea, diarrhea (including nocturnal), and bloody stools—mimic those of appendicitis.

Depressive syndrome

Anorexia reflects anhedonia in depressive syndrome. Accompanying signs and symptoms include poor concentration, indecisiveness, delusions, menstrual irregularities, decreased libido, insomnia or hypersomnia, fatigue, mood swings, poor self-image, and gradual social withdrawal.

Gastritis

In acute gastritis, anorexia may have a sudden onset. The patient may experience postprandial epigastric distress accompanied by nausea, vomiting (often with hematemesis), fever, belching, hiccups, and malaise.

Hepatitis

In viral hepatitis (hepatitis A, B, C, or D), anorexia begins in the preicteric phase and is accompanied by fatigue, malaise, headache, arthralgia, myalgia, photophobia, nausea and vomiting, mild fever, hepatomegaly, and lymphadenopathy. It may continue throughout the icteric phase along with mild weight loss, dark urine, clay-colored stools, jaundice, right-upper-quadrant pain and, possibly, irritability and severe pruritus.

Signs and symptoms of nonviral hepatitis usually resemble those of viral hepatitis but may vary, depending on the cause and the extent of liver damage.

Hypopituitarism

Anorexia usually develops slowly in hypopituitarism, which usually begins with hypergonadism. Accompanying signs and symptoms vary with the disorder’s severity and the number and type of deficient hormones. They may include amenorrhea; decreased libido; lethargy; cold intolerance; pale, thin, and dry skin; dry, brittle hair; and decreased temperature, blood pressure, and pulse rate.

Hypothyroidism

Anorexia is common and usually insidious in patients with thyroid hormone deficiency. Vague early findings typically include fatigue, forgetfulness, cold intolerance, unexplained weight gain, and constipation. Subsequent findings include decreased mental stability; dry, flaky, and inelastic skin; edema of the face, hands, and feet; ptosis; hoarseness; thick, brittle nails; coarse, broken hair; and signs of decreased cardiac output such as bradycardia. Other common findings include abdominal distention, menstrual
irregularities, decreased libido, ataxia, intention tremor, nystagmus, dull facial expression, and slow reflex relaxation time.

Ketoacidosis

Anorexia usually arises gradually in ketoacidosis and is accompanied by dry, flushed skin; fruity breath odor; polydipsia; polyuria and nocturia; hypotension; weak, rapid pulse; dry mouth; abdominal pain; and vomiting.

Pernicious anemia

In pernicious anemia, insidious anorexia may cause considerable weight loss. Related findings include the classic triad of burning tongue, general weakness, and numbness and tingling in the extremities; alternating constipation and diarrhea; abdominal pain; nausea and vomiting; bleeding gums; ataxia; positive Babinski’s and Romberg’s signs; diplopia and blurred vision; irritability, headache, malaise, and fatigue.

Other causes

Drugs

Anorexia may result from the use of amphetamines, chemotherapeutic agents, sympathomimetics such as ephedrine, and some antibiotics. It also may signal digoxin toxicity.

Radiation therapy

Radiation treatments can cause anorexia, possibly as the result of metabolic disturbances.

Total parenteral nutrition

Maintenance of blood glucose levels by I.V. therapy may cause anorexia.

Special considerations

Because the causes of anorexia are diverse, diagnostic procedures may include thyroid function studies, endoscopy, upper GI series, gallbladder series, barium enema, liver and kidney function tests, hormone assays, computed tomography scans, ultrasonography, and blood studies to assess nutritional status.

Promote adequate protein and caloric intake by providing high-calorie snacks or frequent, small meals. Encourage the patient’s family to supply his favorite foods to help stimulate his appetite. Take a 24-hour diet history daily. The patient may consistently exaggerate his food intake (common in patients with anorexia nervosa), so you’ll need to maintain strict calorie and nutrient counts for the patient’s meals. In severe malnutrition, provide supplemental nutritional support, such as total parenteral nutrition or oral nutritional supplements.

Because anorexia and poor nutrition increase susceptibility to infection, monitor the patient’s vital signs and white blood cell count and closely observe any wounds.

Pediatric pointers

In children, anorexia commonly accompanies many illnesses but usually resolves promptly. However, be alert for subtle signs of anorexia nervosa in preadolescent and adolescent girls.

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Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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