Manifestations of severe malnutrition include hypothermia, bradycardia and other arrhythmias, hypotension, hypothermia, and dehydration, especially in patients with anorexia nervosa. Brittle hair or nails, decreased fat stores, ­acrocyanosis, downy hair, yellow cutaneous discoloration (from hypercaro­tenemia), and loss of secondary sexual characteristics may be seen, especially in young patients with anorexia nervosa. Self-induced vomiting or regurgitation produces halitosis, pharyngitis, gingival or dental erosions from reflux of gastric acid, and also may lead to parotid swelling and abrasion or scarring of the knuckles from inserting the fingers into the mouth.

Additional testing

Laboratory, radiological, and endoscopic evaluations are guided by the history and physical examination, including associated symptoms, patient age, symptom duration, prior medical conditions, degree of malnutrition, and emotional factors (Figure 4.1). Laboratory studies should include a complete blood count; ­sedimentation rate, electrolytes, blood urea nitrogen (BUN), creatinine, total protein, and albumin; urinalysis; and liver chemistries. Radiography of the chest and abdomen can detect malignancy or obstruction. Specific blood testing can screen for thyroid disease, and human immunodeficiency virus (HIV) assays, tuberculosis quantiferon or placement of a purified protein derivative can test for infectious causes (i.e. AIDS and tuberculosis, respectively). In the absence of specific findings, routine screening for malignancy is indicated, including Papanicolaou smear in women, colonoscopy in persons older than 50 years, mammography in women older than 40 years, and prostate-specific antigen in men older than 50 years.

Other tests for organic disease may be indicated in some patients. If ­malabsorption is suspected, screening tests such as qualitative fecal fat, serum carotene, and prothrombin time may be obtained. Specific tests for small intestinal or pancreatic causes of malabsorption are ordered if results of ­screening tests are positive or if suspicion of malabsorption is high. If structural disease is suspected, abdominal computed tomography or ultrasonography may detect underlying malignancies, whereas barium radiography and endoscopy may define sites of obstruction. In patients with suspected anorexia nervosa, ­structural evaluation of the GI tract is considered because Crohn’s disease is in the differential diagnosis. Upper endoscopy or barium radiography should be ­performed with suspected rumination because esophageal disease can mimic this disorder.

When biological disease has been excluded, referral to a mental health ­specialist should be contemplated to exclude psychiatric causes of weight loss. Establishing a specific diagnosis using strict criteria (e.g. Diagnostic and Statistical Manual of Mental Disorders IV) benefits the patient by directing psychosocial treatment of the underlying condition.

Differential diagnosis

Unexplained weight loss may result from combinations of biological and behavioral factors. Hunger is a consequence of physiological processes, whereas appetite is more heavily influenced by environmental and psychological input, including the aroma and appearance of food and a person’s mood. Weight loss may result from decreased caloric intake, increased metabolism, or urinary or fecal loss of calories. In general, a person’s weight fluctuates by as much as 1.5% per day. A sustained weight loss greater than 5% warrants concern and possible investigation. In addition to anorexia, other symptom complexes contribute to weight loss, including nausea, vomiting, early satiety, postprandial abdominal pain, and altered consciousness. A variety of general medical, GI, and behavioral illnesses produce unexplained weight loss (Table 4.1). About half of all cases of unexplained weight loss are attributable to organic disease, whereas psychiatric conditions, especially in the elderly, comprise the majority of the remaining cases. Parkinson disease and Alzheimer disease are common neurological ­etiologies of weight loss.

Table 4.1 Causes of weight loss

General medical disorders

Related posts:

20: Disorders of Gastric Emptying 2: Approach to the Patient with Chest Pain 34: Structural Anomalies, Tumors, and Diseases of the Biliary Tract 39: Cholestatic Syndromes 36: Diseases of the Abdominal Cavity 32: Pancreatitis

Stay updated, free articles. Join our Telegram channel

Join