Van Gool VJF, De Vries H, Bons SCS, Bastiaans JF Van
Ittersum FJ. Weight loss. GP Act 2003; 46 (1): 39-42. Unintentional weight loss
of more than 5% of the starting weight, arise in 6 months or less, may indicate
a serious disease. The causes range from severe organic disease (for example,
malignancies, gastrointestinal diseases, endocrine disorders, chronic
infections) to psychiatric disorders, particularly depression. Causes of weight
loss that are mainly in the elderly occur: inadequate care, dementia,
swallowing disorders, malignancies, heart failure, COPD and updating medication.
There is very little research available about the diagnosis in primary care
populations. Sometimes to explain the weight loss by a known condition. A
systematic history focused on the factors that influence body weight (intake,
absorption, consumption, loss) is by far the most important contribution to the
diagnosis. A complete physical examination provides independent of history
contribute to finding the cause, as well screenend blood and urine tests. A
chest X-ray is designated in the elderly with a view to the increased risk of
lung cancer. It does not make sense to do more extensive research specialist
when history not constitute indication of physical or additional studies
before. Expectant management is in place.
1. Summary
2. complaint problem
3. problem for differential diagnosis
4. Inadequate food intake
5. The core
6. Inadequate nutrient absorption
7. Increased energy consumption
8. Loss of nutrients
9. Methodology
10. Epidemiology
11. Diagnosis in general practice
12. History
13. Case history
14. Evidentiary
15. Evidentiary
16. Physical examination
17. Additional research
18. Specialist research
Of complaint to problem
Under the weight loss is in this article is understood to unintentional weight loss in adults aged more than 5% of the initial weight, arise in a period of 6 months or less. The criteria for abnormal weight loss walk attitudes greatly. A number of authors mention as a criterion 4-10% loss relative to the output, or of the ideal weight. In addition, 5% relatively common aangehouden.1-10 If time when the need arose, some authors give three months, others a year, most six months. The substantiation of these limits is relatively meager. Unintentional weight loss of 4% or more is associated with an increased mortaliteit.6,8 This is partly due to the underlying disease, such as malignancies. However, even after correction for known conditions unintentional weight loss is statistically significantly associated with an increased weight loss mortaliteit.6,11-14 often goes along with deficiencies of nutrients, for example, be included if insufficient nutrients. Losing weight by itself few complaints. However, it may be associated with the absence of menstruation. Relatively large weight loss can contribute to decubitus6,15 and to reduced bone mass and heupfracturen.8 Loss of muscle mass in case of severe weight loss is at the expense of the mobility in the elderly. Also, extreme weight loss an overall drag reduction as a result, the probability of developing leg ulcers and sepsis vergroot.8 Weight loss is discussed if the patient complains if his surroundings are apprehensive of, or when the doctor observes the self and there is no explanation. In patients in care or nursing homes leads sometimes just by regularly weighing weight loss on track.
From problem to differential diagnosis
The potential causes of unintentional weight loss involve various orgaansystemen.1,8-10,15-17 a rational layout of the causes is based on how the human body deals with nutrients and energy. The factors that determine the body weight, are: food intake, nutrient absorption, consumption of energy and loss of nutrients.
Inadequate food intake
A certain group of people is not in a position to obtain food by lack of funds or an inadequate health care system. Some people, such as severely mentally retarded or demented patients are not (any longer) be able to eat themselves. Anorexia (loss of appetite) plays a role in numerous gastrointestinal disorders, liver cirrhosis, renal insufficiency, severe heart failure, malignancies, drug addiction, alcohol abuse, depression and anxiety disorders. It may also be the result of medication. Extreme fatigue from a serious illness may also hinder the food. When people have problems with chewing, have bad teeth or a non-fitting dentures or when upper and lower jaw does not close properly, it can lead to insufficient food intake. In addition, should swallowing problems, as a result of esophageal obstruction or neurological disorders such as amyotrophic lateral sclerosis to be considered. Inadequate food intake may also occur due to pain, for example by an ulcer in the mouth or throat. Fear of pain after food intake can lead to inadequate nutrition, for example at reflux, peptic ulcer, colic due to gallstones or cholecystitis.
The core Unintentional weight loss of more than 5% within 6 months is by definition abnormal; there must always look for the underlying cause.
Organic causes are found in second-line select populations in 30-50% of patients.
When the diagnosis is the anamnesis far the most important source of information. It is discussed in any event: food intake, nutrient absorption, consumption of energy and loss of nutrients.
General physical examination and screenend blood and urine tests are recommended for all patients; the elderly is a chest X-ray meaningful.
Inadequate nutrient absorption
In severe vomiting, for example at hyperemesis gravidarum or obstruction of the
intestine, not enough food is ingested. Furthermore, this is the case with
malabsorption. Malabsorption may be partly the result of celiac disease
(glutenenteropathie), pancreatic insufficiency or resection of the stomach or
small intestine. If all of these conditions lead to complaints, thereby the
weight loss, moreover, does not have to be in the foreground. In inflammatory
bowel diseases such as Crohn's disease and ulcerative colitis are in addition
to any other malabsorption involved pathophysiological mechanisms, such as
anorexia, and inflammation of the intestine.
Increased consumption of energyThis is the case of hyperthyroidism, serious infectious diseases such as AIDS and tuberculosis, malignancies and COPD in the final phase. Even more energy is consumed in excessive physical activity and use of drugs like ecstasy and amphetamines, especially when combined with extreme long-term effort, for example when dancing at raves.
Loss of nutrients
This can occur with diabetes mellitus, where much glucose in the urine disappears as a result of hyperglycemia exceeded the renal threshold for glucose: glycosuria. In diabetes mellitus, play in the weight decrease, moreover, the increased loss of water with the urine and increased proteolysis and lipolysis a role. One speaks of a protein-losing enteropathy in protein loss from severely damaged intestinal mucosa as a result of extensive enteritis such as Crohn's disease and colitis. In many diseases such as malignancies and serious infectious diseases such as AIDS, multiple pathophysiological mechanisms involved. Side effects of drugs can cause nausea or vomiting (eg antibiotics or NSAIDs), anorexia (eg, digoxin), altered taste (eg, ACE inhibitors or metformin) and dysphagia (eg potassium or iron preparations) .16
Methodology
Every contribution in the series diagnostics are written according to strict criteria. This contribution is based on a Medlinesearch over the period 1985 to September 2002 for guidance, review and empirical research. It became a keyword for the complaint: weight loss combined with the search for the family medicine family practice, primary care, or epidemiology / decision making: incidence, sensitivity, specificity either the diagnostic process: diagnosis differential, history-taking, physical examination and laboratory tests.
In a number of conditions on weight loss occurs despite the fact that the same or a larger amount of food is ingested. This is the case in diabetes mellitus, hyperthyroidism, malabsorption syndromes, and malignant lymfoom.1,9
Epidemiology
On the occurrence of unintentional weight loss in the general population No figures are available. The incidence of episodes in which at the start of the weight loss as a contact episode reason is listed explicitly appeared in the Transition Project to be 3.4 per 1000 enrolled patients per year: 2.5 in men and 4.2 in women; with over 65 4-8 per 1000 per jaar.18 This incidentally does the criterion of 5% within 6 months not being used. The Transition Project gives hyperthyroidism (4%) and diabetes mellitus (4%) as final diagnoses in episodes where the patient for weight loss came at the GP. At 63% the symptom diagnosis weight loss was maintained, which means there is no explanation found was.18
So far there is only one study on the causes of weight loss in general practice available; this was only focused on ouderen.7 in seven general practices in the US causes weight loss were retrospectively assessed in 45 patients aged 63 and older. It was found in 16% malignancy and 31% other organic cause. At 18% depression was determined in 9%, and the weight loss was interpreted as a side effect of a medicament. The weight loss remained at 24% unexplained. In 30-50% of patients who were referred for an organic cause unintentional weight loss was gevonden.4,5-19 It was a malignancy in 19-36%. In these studies, other organic diagnoses were made more often (30-49%). It mainly related to disorders of the gastrointestinal tract. Unexplained weight loss remained at 16-26% .4,5-19
In studies in the elderly the following causes were relatively frequently identified: malignancies, poor diet, chewing or swallowing problems, dementia, depression and updating medicatie.7,16-20
Diagnosis in general practice
History
A part of the unintentional weight loss is a direct consequence of all known conditions, such as malignancies, severe chronic lung or heart disease, severe infections, such as tuberculosis and AIDS, and inflammatory processes such as Crohn's disease. Even in depressed patients, weight loss in the second instance proceedings. In a known malignancy can also occur as a result of chemotherapy weight loss.
anamnesis
Evidentiary
In this article, the evidence is expressed using the following letters: sufficient probative evidence or circumstantial evidence consensus guidelines and standards
When weight loss is not explained by any known disorder, a thorough and systematic history is essential. The patient history with respect to the recommendations from the literature as are volgt.1,9-16,17, 21 First of all, will be necessary to quantify the weight loss. Is there talk of weight loss? How is determined the weight loss (more spacious fitting clothing?). Is always used the same scale? How much weight loss is occurred and how much time? Secondly, whether the patient should be asked itself has an explanation for the obvious for weight loss, such as additional efforts (eg moving, intense workout) or recent diarrhea or flu. Because weight loss is a nonspecific complaint, it is to inform important to additional complaints which could give direction to the search for causes. A changed defecation and rectal bleeding, for example, a colorectal carcinoma point and recurrent pneumonia or haemoptysis in a smoker at a bronchial carcinoma. As there are weight loss are often few leads, the doctor is compelled systematically to take a history, focused on the pathophysiological mechanisms. Inadequate food intake. It estimates that the power supply in terms of quantity and variety is adequate. Sometimes it may thereby a dietitian be helpful. One asks about the availability of food and drink and inquires about financial or physical barriers to get food. Is there decreased appetite? Are there problems with chewing or swallowing? Food intake leads to pain? It should also be examined whether this could mean dementia, depression or chronic anxiety. Are there indications of alcohol abuse or drug addiction? Inadequate absorption of nutrients. At constant intake will actually reduced food intake always accompanied by increased presence of nutrients in the faeces, leading to abdominal cramps and steatorrhea. This is the typical form of relief which much fat is not included: it is voluminous, mummy-like, gray, stinks, sticks to the pot, floats on the water and let this vetoogjes behind. Increased energy consumption. Is there anxiety, tremor, diarrhea, palpitations and heat intolerance? This indicates hyper-thyroid disease. If the doctor suspects that the patient has AIDS, he must consider the risk of HIV positivity and ask for diarrhea, cough and recurrent (lung) infections. Loss of nutrients. Increased thirst and increased urination in unchanged or increased food intake indicate diabetes mellitus. Diarrhea and abdominal pain suit inflammatory bowel disease.
Evidentiary
In this article, the evidence is expressed using the following letters:
sufficient evidence
evidence or circumstantial evidence
consensus guidelines and standards
There is little research on the predictive value of medical history questions. Marton et al. Investigated in a specialized population of elderly patients with weight loss, the predictive value of diagnostic methoden.4 With respect to the medical history, they had found that an additional complaint about half of the patients with an organic cause indicative of a disease of a specific organ. The following anamnestic data discriminated statistically significant between organic causes (including cancer, infections and medication effects) and non-organic causes (psychiatric disorders and weight loss with about brightened cause) have smoked at least 20 pack-years, decreased activities tiredness, nausea or vomiting, recently increased appetite, cough recently changed.
Physical examination
Given the diversity of the causes is a general physical examination on his plaats.4,7-10,16-21 It must obviously height and weight recorded. Please make sure to use the same scale, to maintain the same degree of wearing of, for example, always weigh without shoes and (jacket) -jas. The normal inter-individual variation in body weight is 1 kg per day. Of particular interest are: overall impression (nutrition and hydration, anxiety, depression, signs of anxiety), oral cavity and pharynx; pulse frequency; temperature; lymph nodes; thyroid; heart; lungs; abdomen (DRE) and peripheral edema. In addition, it is guided by history and outcome of history. One must realize that weight loss can be masked by considerable edema.
Not much is known about the predictive value of the physical examination. In a specialized population appeared to contribute to the physical examination regardless of the outcome of the medical history to detect organic oorzaken.4 In a study in general practice was found in three of the seven patients with unintentional weight loss whose cancer was found abnormal physical -Diagnostic finding of the organ system available to zijn.7 In a population of patients referred for weight loss was 27% of those who turned out to have a malignancy with physical diagnostic examination a palpable swelling or enlarged liver vastgesteld.5
Additional research
If history and physical examination provide no evidence for a cause, the following additional research is recommended. This consensus is present predominantly in the specialist literature. This also applies to the general practitioner in connection with the relatively high pre-test probability of organic abnormalities (8-49%). 7,18Bloed- and urinalysis. These include ESR, Hb, blood glucose, TSH, alkaline phosphatase, ALT, AST and kreatinine.4,16-17,21-23 the urinalysis concerns sediment, nitrite, glucose and ketones. The CEA has a low sensitivity and specificity for individual patients to colorectal carcinoma to sporen.24X-thorax. With the aid of a thorax X-is to determine whether a lung carcinoma explains the weight loss. Authors are unanimous in their recommendation of this research related to the high incidence of longcarcinoom.4,16-17,21-23 The test characteristics of a chest X-ray generally disappointing. The sensitivity for lung cancer is 50-80%. Often the diagnosis of lung carcinoma, so gemist.24 In research on the value of diagnostic methods in patients with weight loss, this was the case even in all four patients who eventually proved to have a lung carcinoma. 4 Remarkably, afterwards a lung tumor often appears on the chest radiograph. The specificity of the CXR is 55-65%, which means that further (imaging) examination yet no malignancy in more than a third of cases gevonden.24 A CXR is also useful with a view to possible pulmonary tuberculosis.
If weight loss is the only symptom and the above-described diagnostic examination found no abnormalities, most authors found expectant management in place as unlikely that exhaustive search for a hidden malignancy something oplevert.4,15-17,22
specialist examination
The views on the significance of specialist research vary. unless giving the history or physical examination instructions to take further diagnostiek.4,5-7 example, if weight loss is associated with iron deficiency anemia, the studies carried out in selected populations provides no evidence for additional proceeds, it is for the hand to hebben.7 using endoscopy of the digestive tract caused to lokaliseren.19 A CT scan used for screening in 45 patients older than 63 years in US GP practices showed no additional value to the significance of complementary diagnostics in unintentional weight loss have so far in primary populations devoted no other scientific studies.
have now been published: De Jongh TOH, De Vries H, Grundmeijer HG, editors. Diagnosis of everyday complaints I. blocks for rational problem solving. Houten / Diegem: Bohn Stafleu Van Loghum, 2002. ISBN 90-313-3759-5. a number of chapters in the series Diagnostics H & W in this book appears in edited form.
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