ירידה חריגה במשקל

Unintentional weight loss is a decrease in body weight that is not voluntary. Weight loss is a very nonspecific symptom but may be indicative of a serious underlying pathology. Weight loss will occur with inadequate food intake, malabsorption, increased metabolism, or a combination of factors.

אטיולוגיה

There are many causes of abnormal weight loss, including:¹

• Loss of appetite and conditions that prevent food consumption - לדוגמה:

  • דיספגיה.

  • Painful mouth sores.

  • Newly applied orthodontic appliances, or loss of teeth.

• Persistent vomiting - לדוגמה:

  • Pyloric stenosis.

  • Hiatus hernia.

• תת ספיגה - לדוגמה:

  • מחלת צליאק.²

  • Chronic pancreatitis.

  • מחלת קרוהן.

  • Gastrointestinal infection.

  • Gastrointestinal fistulas.

  • Carcinoid disorders.

  • Intestinal hypermotility.

  • Hepatobiliary disease.

  • Food intolerance.

• תרופות - especially polypharmacy in the elderly.³

• Endocrine - לדוגמה:

  • סוכרת.

  • Hyperthyroidism.

  • Addison's disease.

  • Gut hormone tumours (eg, VIPoma).

• ממאירות - לדוגמה:

  • לימפומה.

  • Leukaemia.

  • Carcinoma.

  • Sarcoma.

• Systemic disease - לדוגמה:

  • אי ספיקת לב.

  • Chronic respiratory disease.

  • מחלת כליות כרונית.

  • Liver failure.

  • דלקת מפרקים שגרונית.

  • Systemic lupus erythematosus.

• Acute infection.

• Chronic infections and infestations - לדוגמה:

  • Tuberculosis.

  • HIV (one in ten in one study).⁴

  • Parasitic infections.

• Drug abuse, heavy smoking.

• Malnutrition, social isolation.

• פסיכולוגי - לדוגמה:

  • Stressful life events.

  • דיכאון.

  • Anorexia nervosa.

  • Psychoses.

  • Manipulative behaviour, food phobias.

• מחלת פרקינסון.⁵

הצגה

• Patients may realise themselves that they have lost weight or this may be brought to their attention by friends or family.

• A clinician may note that the patient has dramatically lost weight or notice that their clothing is loose-fitting.

• The clinical assessment includes both consideration of possible physical causes as well as careful evaluation of possible psychological causes such as depression. It is very important to avoid inappropriate, unnecessary and potentially harmful investigations.

• The presentation will depend on the underlying cause.

• A thorough history and examination are essential in establishing the underlying cause and identifying appropriate investigations.

• Associated symptoms may include:
  

  • תסמינים במערכת העיכול.

  • Lethargy, weakness.

  • An underlying condition - eg, respiratory, neuromuscular.

  • Alcohol or drug abuse.

  • Dementia - mental state assessment may be indicated.

  • Anorexia nervosa.

אבחנה מבדלת

Severe generalised muscle wasting is also seen as part of a number of degenerative neurological and muscle diseases and in cardiac failure (cardiac cachexia).

חקירות

• FBC: reduced haemoglobin may occur with chronic disease, malabsorption, chronic kidney disease, liver failure.

• Raised erythrocyte sedimentation rate (ESR): nonspecific indicator of disease, malignancy, infection, connective tissue disorder.

• Renal function and electrolytes: may indicate chronic kidney disease, Addison's disease.

• Fasting blood glucose: diabetes mellitus.

• LFTs, clotting screen: liver failure.

• TFTs: thyrotoxicosis.

• CXR: malignancy, tuberculosis.

Other investigations will depend on the context of the weight loss. Possible further investigations may include HIV serology, endoscopy and autoimmune disease screen.

ניהול

• Any suspicion of cancer as the underlying cause should prompt urgent referral for further assessment in secondary care.⁶

• Management is otherwise directed at the cause of weight loss and may include physical, psychological and social (eg, 'meals at home scheme', respite care) interventions.

• The elderly are particularly at risk and nutritional evaluation should be part of any routine geriatric assessment.⁷

סיבוכים¹

• Elderly patients with unintentional weight loss are at higher risk of infection and depression.

• Abnormally low body weight is a predictor of increased mortality.