SYMPTOM WEIGHT LOSS:
Weight loss is a progressive weight loss (unlike the constitutional thinness).
It is most often recent or semirécent: 2% of weight in a week, 5% in one month or 10% in six months. It requires careful diagnostic approach, emphasizing the annamnèse and clinical examination.
Weight loss can be the reason for consultation or discovered incidentally during consultation. Recall that taking weight is an essential step of the medical examination.
A semblance psychological context to explain the weight loss first examination must not overlook an organic underlying cause.
The principal causes are cancer, depression and digestive diseases (Table I). If weight loss is secondary to a known pathology, it is important to determine the extent of malnutrition in order to avoid the deleterious effects of this on the underlying pathology. Many diseases can be involved: digestive, inflammatory, infectious or cancerous … We must determine if the weight loss is only adaptive to the pathology or if there is a real disease malnutrition. The index used is the Nutritional Risk Index (NRI) of Buzby. It classifies patients into three groups:
– Group I: NRI> 97.5%: weight loss is adapative;
– Group II: 97.5> NRI> 83.5%: moderately malnourished;
– Group III: 83.5%> NRI: severely malnourished.
This simple index used to select patients candidates for renutrition and can also be easily used by any clinician very little training in the evaluation of nutritional practices.
Nutritional Index Buzby
NRI = 1.519 x albumin (g / L) + (actual / usual weight w) x 100
SURVEY ETIOLOGICAL:
It takes place in four stages, the interrogation and clinical examination is fundamental.
First step:
The first step is to ascertain the reality of weight loss and its magnitude by weighing, change clothing size, around the waist and comparison with earlier photographs. The calculation of body mass index (BMI: weight in kg divided by height squared in meters) and its comparison to normal values says malnutrition if BMI is less than 18.5 (see 20 or 22 at the about 70 years).
Second step:
The second step is anamnesis. The interrogation is fundamental:
– Medical and surgical history: tuberculosis, heart disease, respiratory, neoplasia, blood transfusion …
– Installation method of weight loss, accompanying signs such as fever, digestive disorders (including transit with diarrhea or change in the appearance of stools, nausea, vomiting), abnormalities of the menstrual cycle …
– State of appetite, quantifi cation ingesta, research gôut disorders and smell, eating habits (including plans);
– Alcohol, tobacco, drugs, prescription drugs or self medication;
– Changes in the family context, social or professional.
Step Three:
The third step is the full clinical examination.
He seeks the harmonious whether or not weight loss, muscle mass and analysis function, search skin abnormalities (melanodermia: in favor of adrenal insufficiency, depigmentation: in favor of hypopituitarism, jaundice: in favor of a biliopancreatic pathology, abnormal conjunctival pallor anemia in favor of subclinical bleeding or prolonged inflammatory syndrome). The lymph nodes are examined tumor syndrome is searched systematically. The thyroid is palpated and signs of hyperthyroidism sought.
The review will conclude with a heart and lung examination.
Step Four:
The fourth stage is that of the investigations, guided by clinical examination.
The initial biological assessment includes NFS platelets, serum electrolytes, transaminases and alkaline phosphatase, serum creatinine, blood urea nitrogen, ESR, CRP, TSH, serum albumin, transthyretin. The achievement of other reviews will be based on the results: specialized endocrine balance, thoraco-abdominal-pelvic scan in search of a deep neoplasia, high and low digestive endoscopy. Recall that a stool examination may reveal a parasitosis (taenia …) even in the absence of bowel dysfunction.
This step allows us to distinguish three clinical settings:
– Involuntary weight loss with anorexia;
– Weight loss with eating disorders (food restriction);
– Weight loss without anorexia do with overeating.
WEIGHT LOSS WITH ANOREXIA NOT VOLUNTARY:
In the absence of depressive signs:
This is the most common and most difficult situation. The etiological investigation should be systematic and guided by the patient’s symptoms. It will seek a visceral organic pathology.
In the presence of fever:
Fever is fundamental. It will first eliminate an infectious disease. If it lasts beyond three weeks, the investigation will be thorough: tuberculosis, HIV infection, subacute infective endocarditis (with the trap of endocarditis with negative blood cultures). An anti-infection treatment test is sometimes necessary. Fever may also accompany an infl ammatory disease: vasculitis (Horton’s disease in the elderly), Behcet’s disease, connective (systemic lupus), Still’s disease in adults or sarcoidosis. Solid cancers (kidney, liver) and hematological malignancies (lymphoma) can also be involved.
In the absence of fever:
In the absence of fever, we must first look deep neoplasia, including gastrointestinal (pancreas, stomach, small, colon …), sometimes difficult to demonstrate. A metabolic cause (hypercalcemia, adrenal insufficiency, pheochromocytoma) should also be mentioned.
In the presence of digestive or deficiency symptoms:
In the presence of digestive symptoms or deficiency, intestinal malabsorption should be sought (celiac disease, effects of digestive surgery …). The presence of postprandial abdominal pain and severe weight loss should suggest, in the context of vascular disease, chronic mesenteric ischemia whose confirmation is sometimes difficult.
Neurological signs:
Neurological signs are to be sought, the slow development of certain neurological pathologies sometimes leaving slimming foreground Parkinson’s disease, amyotrophic lateral sclerosis …
Other serious failures visceral:
Other serious organ failure can result in weight loss: respiratory failure, hepatic, renal, pulmonary hypertension, …
Thinning with depressive symptoms:
A depressive syndrome should be considered, knowing that all malnutrition is accompanied by some of the cause of depression more or less important.
WEIGHT LOSS WITH FOOD BEHAVIOR DISORDERS (FOOD RESTRICTION):
Thinning with digestive or ENT symptoms leading to food restriction:
A dysgeusia, odynophagia, dysphagia, and senior dyspeptic disorders can lead the patient to restrict his diet.
It will have to carry an ENT examination with nasal endoscopy and / or upper GI endoscopy in search of food and annoying injury thus causing weight loss, especially if the patient is alcohol and tobacco.
Anorexia nervosa:
Eating disorders can be difficult to diagnose. Anorexia nervosa and eating disorders are associated with dietary restriction but it is most often minimized or even completely denied by the patient. In the context of a young woman, frequent hyperactivity contrast to the caricature thinness, denied, and maintaining a tone except in severe cases. The associated amenorrhea is suggestive.
Vomiting can be associated which can sometimes be suspected before an array of biological and hypochloremic hypokalemic alkalosis with chlorurie collapsed. The denial of problems and the refusal to consider a weight goal within the usual limits of normal confirms the diagnosis, which should not deprive research of organic pathology in sometimes secondary to underlying immunosuppression of undernutrition.
WEIGHT LOSS NOT DO WITH ANOREXIA BINGE:
Overeating is then a undernutrition compensation mechanism. This clinical situation is not common.
Diabetes mellitus:
This is the first etiology. It will seek a polyrurie, polydipsia and make a measurement of capillary blood glucose and urine examination to the test strip.
Weight loss may be indicative of diabetes or be a sign in a diabetic had a bad adaptation.
Hyperthyroidism:
Hyperthyroidism is sometimes evident in the clinical examination before a noisy table of Graves’ disease while it can be more difficult in a surrogate older person from a small beginner toxic thyroid nodule that a rapid clinical examination will not diagnosed. This means that the TSH should always be part of the descrambling balance of a weight loss.
Other endocrinopathies:
Another endocrine disorder such as Addison’s disease or ante-pituitary insufficiency may be involved and the balance will be guided by clinical and / or functional.
Weight loss association, headache, hypertension and sweating should suggest pheochromocytoma.
The use of expert advice endocrinological is required.
Parasitosis:
The last type of cause weight loss with binge consists of some intestinal parasites. Digestive disorders may be minimal or inapparent, hyper eosinophilia is not constant in a gastrointestinal infection by a nematode, the presence of rings in the stool is inconsistent if toeniasis. If the stool examination is negative, a test treatment can be tried in knowing that the tænia is usually resistant to conventional pesticides.
The treatment may involve the Trédémine® (nicolsamide). The night before, the patient will remain a light meal and fasting to 3 hours after the last dose, without eating or drinking. The treatment lasts one day at a dose of 2 tablets in the morning then 2 tablets on an empty stomach one hour later.
THERAPEUTIC MANAGEMENT:
The treatment of chokes must be adapted to each situation and in particular the underlying possible pathology. It must first be given priority: treatment of infection, neoplasia, opotherapy, psychiatric care …
Hospitalization is required when significant weight loss, especially if it is unexplained, markedly malnutrition, clinical signs in favor of organic pathology or the isolation of socio-emotional environment is necessary (as in anorexia nervosa of the young woman).
The conduct of refeeding is based index Buzby. Recall that the refeeding should be gradual and adapted to each patient. In large undernutrition, it must lead to a specialist in order to avoid complications refeeding syndrome (hypophosphatemia particularly its cardiac consequences).
For patients in Group I Buzby where weight loss is adaptive, food and dietetic follow with possible enrichment of meal is enough.
For patients in Group II of Buzby, perform a food and nutrition monitoring before discussing the appropriateness of artificial nutrition. The patients in group III must be immediately treated with nutritional assistance, emphasizing the oral supplementation or enteral nutrition.
Oral supplementation can appeal to dietary supplements such Fortimel® extra (2-3 Fortimel® day). In cancer, we can propose the Fortimel® Care: Care Fortimel® 2 daily (not to for the regime, without residue, in case of galactosemia and with caution in patients with bleeding disorders or on anticoagulants ). These supplements are covered by health insurance in case of tumors, hematological malignancies, cystic fibrosis, AIDS, of epidermolysis bullosa or neuromuscular disease. The Renutryl® 500 is also available at the dose of 1 to 6 boxes per day (cons in patients with lactose intolerance). The Cétornan® (oxoglurate ornithine against indicated for phenylketonuria) at a dose of 2 sachets per day can also be offered, but is only available in hospital pharmacies.
Enteral nutrition is conceived in a hospital specialist unit or as part of a homecare. The refeeding solutes are numerous: Sondalis®, Nutrison® … with various products adapted as appropriate (or not fibers, …) Their choice is the domain of the specialist. Parenteral nutrition in hospital (eg Kabiven®) requires if prolonged central line; the peripheral route can be used (Périkabivein®) just days because of the risk of peripheral vein thrombophlebitis.
CONCLUSION:
In over 20% of cases, the initial etiologic investigation is negative. It is then regularly review the patient in search of new signs, to guide further investigations. Any run diagnostic survey will be of greater profitability than blind search.The thoraco-abdominal CT scan may be repeated, including looking for a small cancer. The gastroduodenal endoscopy will also be repeated in search of a cardia cancer or gastric linitis ignored during a first examination. It is therefore rare that the evolutionary track does not allow a diagnosis in the 6 months following the start of the weight loss.