Losing weight, or losing weight, can be an intentional or unintentional phenomenon. A significant loss in body weight is considered to be a reduction in a patient’s typical body weight of at least 5% over a period of up to 6 months. Underweight is considered to be the weight for which the BMI is less than 18,5 kg / m2.
Basically, weight loss is the result of insufficient caloric intake in relation to the body’s energy requirements, or a disturbance in food intake (malabsorption of nutrients). However, it should not be forgotten that the caloric demand increases in the event of an increased metabolic demand. If in such a situation there is no adequate increase in caloric supply, then the energy balance will become negative, which will lead to increased fat burning and weight reduction.
When looking for the cause of weight loss, first of all, pay attention to the diet and determine whether it is appropriate both in terms of quantity, i.e. whether the calorific value of the consumed food is adequate in relation to the energy needs of a given person, and in terms of quality, i.e. whether there are deficiencies of specific nutrients (e.g. proteins, unsaturated fatty acids or vitamins). For this purpose, a thorough dietary interview should be carried out. At the same time, it is necessary to pay attention to the symptoms associated with losing weight, mainly in the gastrointestinal tract, which could suggest the occurrence of malabsorption disorders (such as vomiting, diarrhea, abdominal pain) and general symptoms (e.g. fever), as well as to inquire about previous diseases (in particular chronic, infectious or mental diseases), medications used or lifestyle changes (increased physical activity).
Table 10.1 summarizes the various causes of weight loss and weight loss, grouped to highlight the underlying underlying mechanism. However, it should be remembered that in the case of many of these conditions, several mechanisms leading to a negative energy balance may coexist, e.g. in Crohn’s disease, weight loss is, on the one hand, a consequence of malabsorption or a short time of passage of nutrients through the intestine, and on the other, abdominal pain and rapid satiety can reduce the amount of food consumed.
Physical examination may also reveal symptoms and signs of hypo – or avitaminosis, such as keratitis, corner of the mouth, and paraesthesia in addition to saggy, inelastic skin, absence of subcutaneous fat, and muscle wasting.
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Basic laboratory tests play an auxiliary role in the diagnosis of weight loss and weight deficiency. Urine testing can detect protein, glucose or amino acid leakage in the urine, as well as galactosuria or pentozuria, but it should be remembered that the latter two diseases are extremely rare in adults. The presence of starch grains, undigested meat fibers or excessive amounts of fat can be detected by examining the stool, which may indicate digestive disorders and food absorption disorders. This test also allows for the detection of blood in the stool or the presence of gastrointestinal parasites. In order to exclude liver diseases, the activity of transaminases (AST, ALT) and?gamma-glutamyltranspeptidase (GGTP) in serum, proteinogram and prothrombin index, which is a non-specific marker of the ability of the liver to synthesize proteins (in this case coagulation factors). Contrast and endoscopic examinations of the gastrointestinal tract or abdominal cavity imaging [USG, computed tomography ( TK)]. When celiac disease is suspected, in which – in addition to fatty stools, anemia, numbness of the limbs and diarrhea – severe vitamin and calcium deficiency (which may cause osteoporosis) is often found, the screening test is usually the determination of anti-gliadin antibodies and anti-smooth muscle endomysium . However, for the final diagnosis of celiac disease, a small intestine biopsy should be performed. When conducting differential diagnosis of weight loss, one should also remember about such diseases as: severe congestive heart failure, primary lung tumor or the presence of metastases, as well as chronic obstructive pulmonary disease. In these cases, increased respiratory effort may be the cause of the increased energy requirement, and weakness and shortness of breath may cause anorexia. Therefore, the chest X-ray should not be forgotten. Accelerated erythrocyte sedimentation (ESR) may suggest the presence of chronic infections or systemic diseases. An important element of the differential diagnosis may also be the determination of antibodies to HIV, because in the course of AIDS, weight loss may be significant, and its polyethiological background (gastrointestinal infections caused by e.g. Candida, Cryptosporidium, Herpes simplex, Kaposi’s sarcoma or lymphoma in the gastrointestinal tract, decreased appetite due to depression or encephalopathy).
When considering endocrine causes of weight loss, the first thing to consider is hyperthyroidism and metabolic decompensated diabetes due to the prevalence of diseases. In the case of hyperthyroidism, weight loss may be significant and occurs despite unchanged, and often even increased, appetite. The reason for losing weight in this case is the acceleration of the metabolic rate. Other common symptoms are irritability, nervousness, sweating, heat intolerance, muscle tremors, insomnia and palpitations. Physical examination usually shows tachycardia or rapid atrial fibrillation, fine-wave muscle tremors in the fingers, restlessness, warm and moist (“velvety”) skin, and the presence of a goiter. If hyperthyroidism is suspected, hormonal determinations should be made to assess the levels of TSH, FT4 and FT3. In order to accurately determine the cause of the disease, hormonal diagnostics should sometimes be supplemented with ultrasound examination of the thyroid gland, determination of the titre of anti-thyroid antibodies and possible fine-needle aspiration biopsy (BAC). If hyperthyroidism is suspected, the possibility of rare causes of hyperthyroidism, such as pituitary thyroid gland adenoma or ovarian goiter, should also be considered.
Losing weight is also observed in decompensated diabetes, mainly type 1. The classic symptoms of this disease include polyuria, increased thirst (polydypsia), and feelings of fatigue and weakness. Weight loss is the result of increased catabolism of structural proteins and fats as a result of severe insulin deficiency, and of dehydration in severe hyperglycemia. The diagnosis of the disease is based on the blood glucose value. A detailed discussion of the criteria for diagnosing diabetes is provided in Chapter 9.
Pheochromocytoma is a tumor originating from pheochromocytoma, which produces and secrete catecholamines (adrenaline and noradrenaline, less often dopamine). Most often it is located in one or both adrenal glands (about 90%), and less often in the abdominal or thoracic part of the sympathetic trunk (with only about 5% of tumors located outside the abdominal cavity). It may occur sporadically or in families, as a component of various syndromes, e.g. multiple endocrine neoplasia type 2A or 2B (MEN 2A, MEN 2B) or von Hippel-Lindau syndrome. The characteristic symptoms are paroxysmal or unstable arterial hypertension. It is estimated that pheochromocytoma occurs in 0,1% of people with arterial hypertension. Characteristic sudden onset seizures occur in half of the patients and, in addition to the increase in blood pressure, include: headache, profuse sweating, pale skin, palpitations, restlessness, tremors, pain in the abdomen or chest, nausea and vomiting. The weight loss observed in these patients is the result of an increased metabolic rate. Due to the effect of released hormones on glycogenolysis and insulin secretion, hyperglycaemia is found in some cases. The basic diagnostic tests include the determination of free catecholamines 7 (adrenaline, noradrenaline, dopamine), methoxycatecholamines (metanephrine and normetanephrine) and vanillinmandelic acid in the daily urine collection, as well as the determination of the concentration of catecholamines and methoxycatecholamines in the serum. Recently, the determination of the concentration of methoxycatecholamines in the blood has been considered the most useful and recommended diagnostic method in the case of suspected phaeochromocytoma. In order to locate the lesion, imaging tests, such as CT or MRI, are performed, and in some cases scintigraphy using [131I] meta-iodobenzylguanidine (MIBG) can be used.
Anterior pituitary insufficiency is characterized by moderate weight deficiency, although mild obesity is observed in some cases. The cause of clinical symptoms is insufficient secretion of one or several pituitary hormones (GH, gonadotropins, TSH, ACTH, Prl) resulting from organic changes within the pituitary gland, such as tumors or infiltrative diseases (sarcoidosis, haemochromatosis, histiocytosis X), head trauma, infarction pituitary gland (Sheehan’s disease – postpartum pituitary necrosis), lymphocytic pituitary inflammation or infections (mycosis, tuberculosis, syphilis). Often the first abnormalities seen are symptoms of hypogonadotrophic hypogonadism, such as absence or sparse sexual hair, amenorrhea in women, and impotence or decreased libido in men. The typical symptoms of secondary adrenal insufficiency are anorexia, nausea and vomiting, general weakness, depression, as well as low blood pressure, tendency to orthostatic hypotension and muscle weakness. Similar symptoms occur in people with primary adrenocortical insufficiency (Addison’s disease), with the difference that in the latter case, a marked darkening of the skin is most often observed, and the dominant abnormality is water and electrolyte disturbances (hyponatremia, hyperkalemia, hypovolaemia), not usually occurring in secondary adrenal insufficiency due to preserved mineralocorticoid secretion. The differentiation between hypopituitarism and hypopituitarism (in this case mainly adrenal glands) is based on the determination of trophic hormones simultaneously with the hormones of the peripheral glands. Low levels of both are indicative of hypopituitarism, while in primary peripheral gland insufficiency, the concentration of the corresponding tropic hormone is increased. In some cases, differential diagnosis is a complex matter that requires appropriate dynamic tests – details on this can be found in the section on the assessment of pituitary function.
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Source: A. Cajdler-Łuba, S. Mikosiński, A. Sobieszczańska-Jabłońska, I. Nadel, I. Salata, A. Lewiński: “FUNCTIONAL DIAGNOSTICS OF HORMONAL DISORDERS WITH ELEMENTS OF DIFFERENTIAL DIAGNOSTICS; Czelej Publishing House