Weight loss

Probability diagnosis

Stress and anxiety (e.g. redundancy, divorce)

Depressive illness

Non-coping elderly/dementia

Eating disorders: anorexia nervosa/bulimia nervosa

Serious disorders not to be missed

Chronic heart failure

Malignant disease, including especially:

• stomach

• pancreas

• lung

• myeloma

• caecum

• lymphoma

Infection:

• HIV infections (AIDS, AIRC)

• tuberculosis

• hidden abscess

• infective endocarditis

• brucellosis

• others e.g. overseas acquired infection

Pitfalls (often missed)

Drug dependence (esp. alcohol)

Malabsorption states:

• ?intestinal parasites/infestations

• coeliac disease

Other GIT problems (e.g. inflammatory bowel disease)

Chronic kidney and hepatic failures

Connective tissue disorders (e.g. SLE, RA)

Dementia

Rarities:

• malnutrition

• Addison disease

• hypopituitarism

Masquerades checklist

Depression

Diabetes

Drugs: adverse effects/substance abuse (see list)

Anaemia

Thyroid disorder (hyperthyroidism, Addison disease)

UTI

Is the patient trying to tell me something?

A possibility. Consider stress, anxiety and depression. Anorexia nervosa and bulimia are special considerations.

Key history

Document the weight loss carefully and evaluate the patient’s recordings. Determine food intake and obtain the help of an independent witness such as a spouse or parent (if possible). Food intake may be reduced with psychogenic disorders and cancer but increased with endocrine disorders such as diabetes and hyperthyroidism, and with steatorrhoea.

Document drug history.

Key examination

Consider:

• vital parameters (e.g. BMI, pulse, BP, temperature, urine analysis (dipstick))

• thyroid and signs of hyperthyroidism

• abdominal examination (e.g. organomegaly, masses)

• rectal examination

• look for acid dental erosion on surface upper teeth (bulimia).

Key investigations

Consider:

• FBE

• ESR/CRP

• thyroid function tests

• U&E

• HIV

• blood sugar

• faecal occult blood

• CXR

• endoscopy upper GIT

• specific imaging (e.g. CT scan abdomen).

Diagnostic tips

Any loss of more than 5% of body weight is significant.

• The most common cause in adults of recent weight loss is stress and anxiety.

• Two conditions commonly associated with weight loss are anaemia and fever; they must be excluded.

• Ask patients what they believe is the cause of their weight loss.

• An anxiety state and hyperthyroidism can be difficult to differentiate clinically.

• Drug use causing weight loss includes opioids, amphetamines, alcohol, laxatives, digoxin, cytotoxics, NSAIDs, theophylline.