Loss of Weight

1. Pursue an underlying cause in a patient with unexplained weight loss through history, physical examination (including weight) and appropriate investigations.
2. Maintain an ongoing record of patients’ weights so as to accurately determine when true weight loss has occurred.
3. In patients with persistent weight loss of undiagnosed cause, follow-up and reevaluate in a timely manner in order to decide whether anything needs to be done.

Definition

• Loss of ≥5% weight over 6-12 months

DDx

• Malignancy
• GI (PUD, celiac, IBD)
• Psychiatric (depression, eating disorders)
• Endocrine (hyperthyroidism, diabetes, adrenal insufficiency)
• Infectious (HIV, viral hepatitis, tuberculosis, parasite)
• Chronic disease (heart failure, renal failure, autoimmune)
• Neuro (stroke, dementia)
• Medications/substances

History

• Document weight loss
• Pattern of weight loss
• Intentional vs. Unintentional (r/o eating disorder)
• Dietary history
• GI symptoms (N/V/D, dysphagia, abdominal pain, early satiety)
• Malignancy (fever, fatigue, chills, night sweats)
• Psychiatric (depression, mood)
• Medication, Alcohol, Drugs
• Social (Income, Activity) and Function (Dementia)

Physical Exam

• Vital signs (Tachycardia), Temperature
• Weight, Height (BMI)
• Lymphadenopathy (r/o malignancy)
• Breast exam
• GI
  • Oral Cavity, Dentition
  • Abdominal exam (r/o masses)
  • Rectal exam
• Thyroid
• Cardiac, Respiratory, Neuro

Labs

• CBC (Hb, WBC)
• Chem (Creat, Calcium)
• Glucose, A1C
• TSH
• LFT (Alk Phos), Albumin
• ESR/CRP, LDH
• UA
• FOBT
• CXR
• Consider
  • PPD (TB), HIV, Hep C
  • Abdominal ultrasound
• Age-appropriate cancer screening

Treatment

• Limited evidence for nutritional and pharmacological agents
• Treat underlying cause
  • Consider Mirtazapine in Depression
• Watchful waiting 3-6 months
• Can consider exercise and nutritional supplements at meal times