Teaching Rounds Day 10/15
Weight Loss
2 Key Steps
2 Common Pitfalls
...and 1 intriguing question.
Weight Loss
2 Key Steps
2 Common Pitfalls
...and 1 intriguing question.
Not all weight loss is concerning.
>5% loss over several months should get us thinking about an underlying cause.
>5% loss over several months should get us thinking about an underlying cause.
Side note...
See how we snuck in the time course there?
If weight loss is at hand, the "When" of the problem representation = subacute/chronic.
We still have the "Who" and "What" to figure out.
See how we snuck in the time course there?
If weight loss is at hand, the "When" of the problem representation = subacute/chronic.
We still have the "Who" and "What" to figure out.
Key step 1 - Accuracy and Severity
In most patients with pathologic weight loss, cachexia and other markers (e.g., loose fitting clothes) will be apparent on exam.
Other strategies to evaluate weight loss
* Weight on the same scale
* Driver license picture
In most patients with pathologic weight loss, cachexia and other markers (e.g., loose fitting clothes) will be apparent on exam.
Other strategies to evaluate weight loss
* Weight on the same scale
* Driver license picture
What if it's intentional weight loss?
Teasing out between intentional and pathologic weight loss can be tough.
A couple of things to pay attention to:
Teasing out between intentional and pathologic weight loss can be tough.
A couple of things to pay attention to:
1. The rate - on occasion, the rate of weight loss is only compatible with a pathologic cause
2. The company it keeps - intentional weight loss is often accompanied by an increase in sense of well being, which is not usually the case in a pathologic cause.
2. The company it keeps - intentional weight loss is often accompanied by an increase in sense of well being, which is not usually the case in a pathologic cause.
Step 2 - Inflammation
The presence or absence of inflammation is a great way to filter through the extensive causes of weight loss.
Inflammation = increase caloric loss
No inflammation = decrease in caloric intake
The presence or absence of inflammation is a great way to filter through the extensive causes of weight loss.
Inflammation = increase caloric loss
No inflammation = decrease in caloric intake
How do we do establish the presence of inflammation?
So glad you asked <3!
So glad you asked <3!
In the world of chronic inflammation, trust the trifecta of
1. Cancer
2. Autoimmune
3. Chronic infection
1. Cancer
2. Autoimmune
3. Chronic infection
Side note...
How does an infection evade the immune system for so long?
It HIDES!
Where does it hide?
1. In a macroscopic pocket of pus = abscess
2. In a microscopic pocket of pus = inside our own cells! (viral & granulomatous infections)
How does an infection evade the immune system for so long?
It HIDES!
Where does it hide?
1. In a macroscopic pocket of pus = abscess
2. In a microscopic pocket of pus = inside our own cells! (viral & granulomatous infections)
Side note...
Seriously? A side note to a side note.
Whoops...😊
Many of the inflammatory diseases result in weight loss beyond just excess catabolism!
(e.g., anorexia; early satiety from splenomegaly, and many others...)
Seriously? A side note to a side note.
Whoops...😊
Many of the inflammatory diseases result in weight loss beyond just excess catabolism!
(e.g., anorexia; early satiety from splenomegaly, and many others...)
Ok. Ok.
Reeling myself in from the many side notes we could go on!
What if we don't find evidence of inflammation?
Reeling myself in from the many side notes we could go on!
What if we don't find evidence of inflammation?
Well, then, the driver of the weight loss is likely to be one of these 5 categories:
1. Reduced intake
2. Malabsorption - more here: bit.ly/2H3mcW3
3. Chronic advanced organ dysfunction
4. Meds
5. Endocrine - note: hyperthyroidism can be inflammatory.
1. Reduced intake
2. Malabsorption - more here: bit.ly/2H3mcW3
3. Chronic advanced organ dysfunction
4. Meds
5. Endocrine - note: hyperthyroidism can be inflammatory.
Owing to the associated ACUTE morbidity, make you sure you prioritize chronic mesenteric ischemia.
It runs the risk of an acute on chronic event - analogous to ACS superimposed on CAD.
It runs the risk of an acute on chronic event - analogous to ACS superimposed on CAD.
Side note...
Teasing out between all causes is incredibly tough.
Why?
Weight loss is like sinus tachycardia.
With this abnormality alone, all we know is there is SOMETHING wrong.
The journey to find the Dx requires studying other clues along the way.
Teasing out between all causes is incredibly tough.
Why?
Weight loss is like sinus tachycardia.
With this abnormality alone, all we know is there is SOMETHING wrong.
The journey to find the Dx requires studying other clues along the way.
Let's touch on a commonly overlooked cause
Food insecurity.
This @JAMA teachable moment is a must-read
bit.ly/38dLsVp
A number for you:
15 million Americans are without access to sufficient daily caloric intake.
This problem is certainly even worse globally.
Food insecurity.
This @JAMA teachable moment is a must-read
bit.ly/38dLsVp
A number for you:
15 million Americans are without access to sufficient daily caloric intake.
This problem is certainly even worse globally.
Pitfalls -
Let me reflect on t2 ways I could have done better with this work up in the past...
Let me reflect on t2 ways I could have done better with this work up in the past...
1. Underutilization of our incredible colleagues in social work, nutrition, speech therapy, dentistry, physical therapy and occupational therapy.
Take a second look at these causes and the crucial that our colleagues can play in the Dx and Rx.
Take a second look at these causes and the crucial that our colleagues can play in the Dx and Rx.
2. The search for the cause of weight loss can be clouded by complications related directly to the weight loss, and NOT the underlying diagnosis.
"There is no fat to strand...."
Check out this amazing case from @sanjaysaint
"There is no fat to strand...."
Check out this amazing case from @sanjaysaint
Let's summarize:
2 Key Steps
1. Establish Accuracy & Severity
You don't have to wait for a scale to do this; study the clues on exam and old photos as well.
2. Inflammation
The presence or absence of inflammation can help split this long DDx in half.
2 Key Steps
1. Establish Accuracy & Severity
You don't have to wait for a scale to do this; study the clues on exam and old photos as well.
2. Inflammation
The presence or absence of inflammation can help split this long DDx in half.
2 Pitfalls..
1. A multidisciplinary approach to the diagnosis and treatment of weight loss is crucial!
2. Rarely, your work up might be clouded by a consequence of the weight loss, and not the cause.
1. A multidisciplinary approach to the diagnosis and treatment of weight loss is crucial!
2. Rarely, your work up might be clouded by a consequence of the weight loss, and not the cause.
Ok...time for some esoteric diagnoses.
Many of the inflammatory causes of weight loss are life limiting if they go untreated.
Can you think of inflammatory causes of weight loss that can go undetected for > 5 years?
Some answers later today!
Thanks for joining us, friends!
Many of the inflammatory causes of weight loss are life limiting if they go untreated.
Can you think of inflammatory causes of weight loss that can go undetected for > 5 years?
Some answers later today!
Thanks for joining us, friends!
