Date post: | 17-Jan-2016 |
Category: |
Documents |
Upload: | marian-bailey |
View: | 215 times |
Download: | 1 times |
Approach to Unintentional Weight Loss
Thursday Morning Teaching March 20, 2015
Dave Davidson
Case 1
Karen – 43 yr old drug company consultant
PHE • 87 kg, smoker, wants to lose weight• presented 6 mo later with 1 mo hx of nausea,
vomiting, constipation & vague abdo pain• weight 73 kg
What would you do next?
Approach to Weight Loss NYD
Case 1
Karen• LUQ mass on examination
What next?
• abdo U/S- liver is inhomogeneous throughout in keeping with multiple
small ill defined liver metastases- nodules in spleen- large lobulated irregular LUQ cystic mass- multiple enlarged lymph nodes
Next?
Karen
- liver biopsy
- peripheral T-cell lymphoma
Case 1
Cancer (16%-36%)• weight loss and tumor size not related• mediated by incr. cytokines incl. TNF-alpha & IL-6• decreased calorie intake from anorexia and symptoms
caused directly by the cancer
• GI cancer most common • lung• lymphoma• renal • prostate
Unintentional Weight Loss
Case 2
Silvia – age 77, retired opera singer
• weight fell from 56 kg to 47 kg in 9 months
• “Says she is losing weight because she isn't eating and isn't eating because she has lost her sense of taste and food is unappealing.”
What would you do next?
Approach to Weight Loss NYD
Case 2
Silvia
• hx & px not contributory except for loss of taste
Next?
• Lab• CBC, lytes, ferritin, glucose, albumin, LFTs all
WNL; ESR 16
• weight has stabilized & pt remains clinically well
No Identifiable Cause (10%-36%)• Clinical def’n - loss of 5kg or more than 5% of
baseline weight in 6 – 12 months is clinically important and associated with incr. morbidity and mortality
• Loss of as little as 1kg or 3% may be significant in the frail elderly
• consider socioeconomic causes• consider combinations of causes especially in the
elderly• no weight loss (up to 50%)
Unintentional Weight Loss
“anorexia of aging” often multi-factorial• changes in smell & taste• difficulty chewing• slowed gastric emptying• neuroendocrine changes causing early satiety,
decreased appetite and enjoyment of food• primary malnutrition; usually insufficient quantity• psychological and social problems• MedicationsWhat do you think the next most common category is?
Unintentional Weight LossNo Identifiable Cause cont’d
Psychiatric (9% - 42%)
• depression• screen for e.g. PHQ-9
• mania
• delusional and paranoid ideas
• dementia (screen for e.g. MMSE/MOCA)
• GAD
Unintentional Weight Loss
Case 3
Sharon – age 26, dental hygienist, wt 45 kg• 5 kg weight loss, diarrhea & abdominal pain
Physical Examination• RLQ tenderness
LAB• Hgb 100, WBC 15,000, ESR 30, CRP 15, lytes &
extended lytes, albumin WNL
What investigations would you undertake now?
Approach to Weight Loss NYD
Case 3
SharonDI• abdo/pelvic U/S – right tubo-ovarian abscess• small bowel wall thickeningReferral to GI
• colonoscopy w/ intubation of ileum• ileal mucosal inflammation in cobblestone pattern• areas of normal mucosa (skip areas)
GI (6%-19%)• Loss of appetite in most GI diseases
• dysphagia, early satiety, vomiting & regurgitation, abdo pain, chronic inflammation, malabsorption, surgical & spontaneous fistulas & bypasses, superior mesenteric artery syndrome
• PUD• IBD (Sharon)• Hepatitis• Celiac disease
Unintentional Weight Loss
Case 4George – 54 year old w/ PH trigeminal neuralgia &
pre-diabetes• “concerned about weight loss; says his appetite is
normal, in fact he is eating ‘a lot’.”
• regular tobacco & marijuana use
• stopped marijuana recently
• weight fell from 81 kg to 78 kg in 4 months
• physical exam unremarkable
Approach to Weight Loss NYD
Case 4
George
LAB: glucose 16.4
Endocrine & Metabolic (4% - 11%)• Diabetes Type 1 & 2
• malabsorption from intestinal autonomic neuropathy• gastroparesis
• Hyperthyroidism• Appetite may be increased or decreased (elderly)
• Hypercalcemia a, esp. if caused by cancer• Adrenal insufficiency a
• a anorexia, nausea & weight loss
Unintentional Weight Loss
Cardiac (2%-9%) & pulmonary (~6%)
• mechanisms not well understood• “cardiac cachexia” if severe CHF
• ?disuse muscle atrophy
• TNF-alpha elevation
• Pulmonary weight loss is proportional to disease severity
• ?disuse muscle atrophy
• TNF-alpha elevation
Unintentional Weight Loss
Case 5Richard – 49 year old unemployed chef w/ Type 1 DM &
chronic neck pain on opioids
• when last seen was successful at tapering & stopping opioid with help from a community pharmacist
• lost to f/u for 1 year • presented with 4 day hx of cough, fever, chills, vomiting &
obvious weight loss. Looked chronically & acutely ill. • weight not recorded.• O/E - decreased entry & crackles right base
Approach to Weight Loss NYD
Case 5
Richard• LAB
• WBC 14.6, glucose 32, pH 7.35, ketones neg
• CXR – RML & RLL pneumonia• managed w/ IV fluids, insulin & antibiotics in
hospital• discharged on hydromorphone (relapsed to using
high doses acquired on street)• referred to methadone clinic at his request
Substance abuse (4%-8%)
• amphetamines & cocaine• by stimulating satiety centre
• opiates
• alcoholism
• smoking
• cannabis withdrawal
Unintentional Weight Loss
Infection (2-5%)• HIV
• wt loss due mostly to decr. calorie intake in contrast w/ cancer where energy consumption increases
• rapid wt loss (>5% in 6 months) often due to 2’ary infections
• anti-retroviral therapy
• TB• chronic bacterial, fungal & parasitic diseases• lung abscess
Unintentional Weight Loss
Medications (~2%)• bupropion, fluoxetine & other SSRIs initially, lithium, L-dopa• metformin, L-thyroxine• digoxin, aspirin, diuretics, ACEI, Ca channel blockers• NSAIDS, bisphosphonates, allopurinol, colchicine• anticancer & antiretroviral drugs, opiates• iron, potassium• Rx drug withdrawal
• Neuroleptic withdrawal cachexia (typical anti-psychotics) and wt loss when stopping atypicals that have caused wt gain
Unintentional Weight Loss
Investigations• individualize based on the history, physical and your
differential diagnosis (symptom based)
Baseline diagnostic evaluation• CBC, ESR &/or CRP• lytes, creat/eGFR, glucose, calcium, LFTs, TSH, LD• HIV serology• CXR• FOBT?• further testing based on results of these tests
Approach to Weight Loss NYDSummary
Management• Identify and treat the underlying cause• Screen for depression & dementia• Exercise (physiotherapy referral)• Nutrition referral & counseling• Limited evidence & role for pharmacologic therapy
• mirtazapine (Remeron) for depression• THCs - dronabinol (Marinol), nabilone (Cesamet) for end
of life care (antinausea, analgesic, well-being)• megestrol (Megace) may be effective in LTC combined
with feeding assistance
Approach to Weight Loss NYDSummary
Unintentional Weight Loss Pearls
• Only a few diseases where weight loss is associated with increased appetite• Uncontrolled diabetes• Hyperthyroidism• Malabsorption syndromes• Marked increase in physical activity• Pheochromocytoma
• The differential for weight loss with decreased appetite is long• Cancer• No identifiable cause• Psychiatric• GI• Endocrine• Cardiopulmonary• Substance abuse• Infection• Medications
Unintentional Weight Loss Pearls
• Type 1 diabetics who reduce insulin to control their weight
• if using nutrition supplements (e.g. Ensure, Boost) give between meals
• serum prealbumin best marker for malnutrition & monitoring recovery
• In the elderly, if initial history, physical, & lab are normal 3 months of “watchful waiting” advised over further blind investigations
End
Unintentional Weight Loss Pearls