Significance of involuntary weight loss and its causes

Weight loss may be voluntary or involuntary.Voluntary weight loss occur due to dieting,exercise, starvation or decreased intake in older people.If the weightloss is involuntary particular attention should be given since it may be an indicator of underlying serious disease.Weight loss can be identified from the hospital or general practice weight record.In some patients weight loss occur without an underlying cause,which is regained and stabilise over time.

What is significant weight loss?

Loss of weight more than 4.5 kg or more than 5% of one’s body weight over a period of 6–12 months is called significant weight loss

Important causes of weight loss are the following.

They belong to four main groups 

1.Cancer

2.Chronic infection and inflammation

3.Metabolic disorder such as diabetes, hyperthyroidism

4.Psychiatric disorders

Cancer

It is the cause of involuntary weight loss in upto 25% of cases. Following are the malignancies which are frequently associated with weight loss.

Gastrointestinal, liver, blood, lung, breast, genitourinary, ovarian and prostate.20% of cancer death is due to severe weight loss and cachexia.

Gut problems(gastrointestinal)

Almost any disease of gut can result in weight loss.

Inflammatory bowel disease, Crohn’s disease or ulcerative colitis cause loss of appetite, fear of eating,loss of protein and nutrients from body. Malabsorption, peptic ulcer, pancreatitis Obstruction/constipation, pernicious anemia are the most common gut problems leading to weight loss.

Infections

Tuberculosis, parasites, fungal diseases, subacute bacterial endocarditis, and HIV are common treatable causes.

Endocrine and metabolic

Hyperthyroidism, diabetes mellitus, pheochromocytoma, adrenal insufficiency

Chronic heart and lung disease

Causes weight loss due to increased metabolic demand, decreased food intake due to disease and decreased appetite

Psychiatric causes

Significant weight loss is seen associated with depression and isolation so that patient fail to take care of nutritional needs. Bereavement is also a well known cause of weight loss.Alcoholism is an important cause of weight loss due to  malnutrition and self neglect .Other psychiatric disease causing weight loss are anxiety and paranoia, anorexia nervosa, bulimia

Neurologic disease

Stroke, parkinson’s disease, neuromuscular disorders and dementia

Old age

Decreased taste and smell, functional disabilities, age related change in body all result in poor nutrition

Drugs

Cause loss of weight due to decreased appetite, nausea, vomiting, stomach ulceration, diarrhea, dry mouth, altered taste all these are more common in elderly who are on 5 or more drugs .Examples are sedatives, antibiotics, nonsteroidal antiinflammatory drugs, serotonin reuptake inhibitors, metformin levodopa ,angiotensin-converting enzyme Inhibitors.

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Heartburn more information

Heartburn is a common problem seen in general population. It is a burning sensation felt behind the central part of upper chest (retrosternal area), usually seen after meals or awaken the patient from sleep. This is due to regurgitation of small amout of acid and undigested food, and not associated with act of vomiting or retching. Other sumptoms include increased salivation and sensation of lump in the throat.

Mimickers of heartburn

Due to the presence of discomfort in the upperchest and the presence of symptoms at neck and shoulder it may be mistaken for heartdisease.

Pain at night that is relieved by food or antacid is seen in peptic ulcer disease.

Pain on swallowing indicate malignancy or active inflammation.

Pain that is aggrevated by meals and not interfering with daily activities is seen in nonulcer dyspepsia.

Conditions where you get heartburn

Upper gut (gastrointestinal) disorders

• Peptic ulcer disease

• Acute gastritis

• Gall bladder stones

• Oesophageal spasm

• Non-ulcer dyspepsia

• Irritable bowel syndrome

Other gut  disorders

• Pancreatic disease (cancer,chronic pancreatitis)

• Colonic carcinoma

• Hepatic disease (hepatitis,metastases)

Systemic disease

• Renal failure 

• Hypercalcaemia

Drugs

• Non-steroidal antiinflammatory drugs(NSAIDs)

• Corticosteroids

• Iron and potassium supplements

• Digoxin

Others

• Psychological (anxiety,depression)

Conditions associated with heartburn

Reflux esophagitis is more in the lying down posture (supine position), and is increased by bending forward and after large meals.Patients also experience chest discomfort, nocturnal cough, hoarseness of voice , repeated clearing of throat and frothy mucus in the throat.

Drugs-There is relaxation of muscle of the lower part of esophagus which is increased by anticholinergics, theophylline, meperidine, calcium-channel blockers, chocolate, peppermint, tobacco and alcohol.

Direct injury to mucosa may be caused by Tetracycline, aspirin, iron.

Gastritis is associated with constant epigastric discomfort relieved by food or antacids.

Pregnancy -Heart burn is more common in pregnancy because of increased pressure in the abdomen and relaxation of lower esophageal sphincter due to hormonal change in pregnancy.

Aerophagia there is recurrent burping due to swallowed air due to anxiety, carbonated beverages, gum chewing

Indicators of early evaluation of heartburn are the following

1. Difficulty in swallowing 

2. Severe nausea 

3. Vomiting 

4. Weight loss 

5. Bleeding

6. Lack of response to treatment ,

7. Aggrevation of  symptoms with exertion ( seen in heartdisease )

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Treatment of heartburn and Gastro esophageal reflux disease

Aims of treatment is adequate symptom control.

For most patients, the aim is acceptable symptom control.

General measures for managing gastro-oesophageal

reflux disease

Obese and overweight people are advised to lose weight, this will help in better symptom control.

Patients are advised to  raise the head end  of the bed on 15 cm wooden blocks.This has been found to be useful

Medications - Avoid non-steroidal anti-inflammatory drugs.

Avoid or reduce dose of nitrates, calcium channel antagonists, and anticholinergics.

Patients are advised to avoid or reduce smoking,large evening meals, food or drink within 3 hours of bedtime  should be avoided - Small frequent meals are better in these patients.

Fats or chocolate should be reduced or avoided.

Problem producing food and drinks are avoided especially citrus fruits, fruit juices, tea, coffee, peppermint, onions, garlic, cinnamon, cloves

Antacids and analgesics.

Short term relief is obtained with antacids. Many people on self medication are on this drugs. Antacids form a layer over the stomach content and help to reduce the reflux. Better when given with food.

Acid suppression therapy

H2 receptor Inhibitors  and the proton pump inhibitors are the two major groups.  Proton pump inhibitors are more rapid and effective in symptoms  relief and  healing oesophagitis.

The optimal daily dose  of proton pump inhibitors are given below

Omeprazole 20 mg.

Lansoprazole 30 mg

Pantoprazole 40 mg.

Rabeprazole 20 mg.

Motility modifying drugs

Metoclopramide and Domperidone are the agents, they are useful in symptom control but not useful in healing esophagitis. Metoclopramide is particularly useful GERD ,however, these drugs may be more useful in heart burn with nausea or early satiety.

Surgery

Indicated only in those people require long term medical therapy. Conventional and Laparoscopic anti-refluxsurgery is useful.

Indications for surgical treatment

Patients poorly responding to medical treatment and patients with persisting reflux that is regurgitation of gastric contents without symptom of heartburn especially at night may get benefit from surgery.

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Do you have acidity ? Omeprazole to reduce acidity.

Omeprazole Proton pump inhibitor is a common drug used for acidity and ulcer disease. Ulcer occur in that part of gut exposed to acid from stomach. Omeprazole inhibit the last stage of acid secretion. Depending upon the dose the strength of action vary. It can even completely stop the acid secretion from stomach. Omeprazole does not inhibit the mobility of stomach.

It is orally given and 50% is absorbed, excretion from the body is through  liver and kidney. No dose reduction is required in elderly and in renal impairment.

After intake, action start in 1 hour and reach maximum in 2 hours and last for 3 days.

Dosage

Available as 10 mg and 20 mg capsules.Capsules should not be opened or chewed.It should be taken before meals.

Side effects

Side effects are minimal

Following side effects are seen in 3 to 5 percentage of people.

1. Nausea (a tendency to vomit)

2. Loose stool

3. Headache.

4. Abdominal pain.

5. Dizziness.

Rare side effects

1. Rash

2. Liver function changes.

3. Low blood count

4. On prolonged treatment atrophic gastritis occurs.

Precaution should be taken by patients who are on the following drug.

1. Diazepam

2. Phenytoin

3. Warfarin.

Uses of Omeprazole

1. Ulcer disease-it produce fast pain relief. Fast healing is seen  at dose 40 mg per day. Stomach ulcer require treatment for 4 to 8 weeks. But ulcer in the intestine need only 2 weeks.

2. Gastroesophageal reflux (heartburn) - 20 to 60 mg per day.

3. Zollinger Ellison syndrome-60 to 120 mg per day.

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Causes of Loss of Appetite (anorexia)

Loss of appetite is called anorexia. A variety of disease can cause anorexia. It may be associated with significant weight loss. Anorexia should be differentiated from early satiety or painful swallowing. 

Following are the important cause of anorexia

Depression : Patients will have depressed mood ,disturbed sleep and inertia

Drugs : Certain drugs are well known to produce anorexia following are the common agents Digoxin, narcotics, diuretics, amphetamines, antidepressants (SSRIs), and antihypertensives (especially ACE inhibitors)

Anorexia nervosa : Patients usually avoid food than anorexia due to alteration in body perception. Seen in females they are usually very thin, hypothermic and will have constipation.

Congestive heart failure : Occur only in advanced heart failure. Patient will have leg edema and breathlessness.

Hepatitis : In patients with hepatitis anorexia occur prior to clinical jaundice. Patient will have associated right sided abdominal pain.

Cancer : Prominent in gastric and pancreatic cancer and in cancer with liver metastases. In these patients weight loss is out of proportion to anorexia.

HIV infection : Anorexia occur as a part of disease or due to opportunistic infection or due to side effects of drugs.

Uremia : Waxy oedema  sallow colour and  decreased urine output are seen.

Addison disease : It is due to deficiency of hormone cortisol. Patients will also have fatigue or tiredness low blood pressure increased skin pigmentation especially of palmar creases and buccal mucosa.

Mesenteric ischemia : patients will develop abdominal pain after food intake due to poor blood supply to intestine, so they avoid eating. Features of systemic vascular disease is found.

Hypothalamic lesion : Certain lesions of hypothalamus such as tumors can cause visual field defect and anorexia .

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Management of irritable bowel syndrome

IBS (Irritable bowel syndrome) is characterized by recurrent abdominal pain and alteration in bowel habits. After the diagnosis is made most important step is reassurance of the patient, because many patient will have a fear of colonic malignancy because of this symptom. In mild cases there is only symptoms at the time of stress, these people need not be treated. Those with severe  symptoms should receive treatment. All the symptoms will not be controlled with medication.

1. Patient counselling - This is done to reasssure the patient./

2. Lifestyle Changes - Since stress is part of normal life, in this modern era try to avoid stress as possible, you should spend time to relax, enjoy the life. Adequate sleep at night and regular exercise are also helpful. Patient should avoid tobacco, excessive use of caffeine and alcohol.

3. Diet  - Certain dietary recommendations are advised in people with IBS. Small frequent meals will help to reduce the symptoms. Food with low fat and high carbohydrate such as rice, cereals, vegetables and food with low fat and high protein (fish, skimmed milk and low fat cheese) may be advised. In patient with loosestools, fruits, fruit juices and dairy products are NOT advised. 

        

Certain patients have aggravation of symptoms after taking coffee, legumes, cabbage, disaccharide. Such patients should avoid these things. Excessive fructose and artificial sweeteners (sorbitol, mannitol) may produce loose stool, abdominal cramp and flatulence(feeling of fullness in abdomen) . Four week of very low carbohydrate  that is20 grams per day reduce symptoms in many patients.   

Medication used in the treatment of IBS.

1. Stool-Bulking Agents.

High fiber diet ,bulking agents such as hydrophyllic colloid help in relieving symptoms. It will increase the stool weight, decrease in colonic transit time ,improve constipation. It is also useful in diarrhea prone patients.

2. Agents to reduce abdominal pain(Antispasmodics).

These are given to reduce the abdominal pain. Majority experience pain shortly after food intake. So these drugs are given 30 minutes before food intake. Anticholinergic such as dicyclomine is beneficial.

3. Agents that reduce diarrhea(loose stools).

Antidiarrheal agents used to treat are loperamide, opiate, cholestyramine. Agents such as loperamide is useful especially in stressful situation.

4. Antidepressant Drugs.

Effect of anti depressant in IBS is independent of its antidepressant action. Abdominal pain also improves with anti depressants. Tricyclic anti depressants are used. Examples are desipramine, SSRI (Selective serotonin reuptake inhibitor) are also useful. mainly in IBS C patients.

5. Agent that reduce the flatulence

Patients are advised to eat slowly, avoid chewing gum and carbonated drinks. Antibiotics and pancreatic enzyme may be tried.

6. Modulation of Gut Flora.  

Antibiotic is used to treat a subset of people with IBS. The agent used is rifaximin. 

7. Serotonin Receptor Agonist and Antagonists

These agents are also tried in IBS. Chloride Channel Activators Lubiprostone is tried.

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Irritable bowel syndrome - understanding clinical features

Irritable bowel syndrome (IBS) is one of the common bowel problems. Other names are spastic colon, nervous bowel, mucous colitis, functional bowel disorder, intestinal hurry. Many persons suffering from this won’t disclose it to others and their doctors because of fear. Even though the symptoms are distressing many of them can be relieved with proper medication. About 20% of general population may be suffering from the disease but only 10% seek medical attention. This can occur at any age majority experience the first attack before 45 yrs. IBS is mainly a disease of young women. Understanding and treating the condition is important because it will affect the quality of life and frequent work absenteeism .This is a functional disorder of bowel without any structural abnormality.

Clinical features of Irritable bowel syndrome

IBS is characterized by recurrent abdominal pain associated with defecation and altered bowel habits. Symptoms vary from person to person . Predominants symptoms are abdominal pain, altered bowel habits, gas and flatulence, upper gastrointestinal symptoms. Even healthy people may  have occasional stomach upset and diarrhea , IBS  patients experience it more frequently.

1. Abdominal pain

It is the most common and key symptom of IBS. It can be colicky or cramp like mainly felt in the lower abdomen and is relieved by medication. Some patients experience a constant ache in the abdomen. Severity of pain varies from patient to patient. Usually pain is present only during wakeful hours and won’t disturb the sleep. Factors that aggravate pain include eating or emotional stress and it is  improved by passage of flatus or stools. In females during premenstrual and menstrual period worsening of symptoms can occur. 

2. Alteration in bowel habits 

One of the most consistent clinical features in IBS is alteration in bowel habit. Patient may experience diarrhea (IBS-D), or constipation (IBS-C) or a mixture of these (IBS-M ).The usual  pattern is constipation alternating with diarrhea,eithr of these symptom can predominate. In constipated patients stools may be hard with narrow caliber described as marble like or pencil thin. Patients also explain incomplete evacuation this will lead to repeated defecation .In some people diarrhea predominates. This is small volume loose stool. Usually there is no diarrhea at night. Emotional stress and eating will worsen the diarrhea. Passage of mucus per rectum can occur. Usualy there is no weight loss or malabsorption. Rectal bleeding is not seen. 

3. Gas and flatulence

Patients also complain of abdominal distension and flatulence, many patients complain of increasing gas, but that need not be present, there is alteration in bowel transit of intestinal gas and intolerance to gas. Those patients with bloating and abdominal distension experience less abdominal pain.

4. Upper gastrointestinal symptoms

About 25-50% of patients with IBS also experience dyspepsia, heartburn, nausea, and vomiting. The prevalence of IBS is more among patients with dyspepsia. 

Other coexisting conditions are fibromyalgia, non ulcer dyspepsia, chronic fatigue syndrome, headache, backache and dysmenorrhea in females. 

Stress  and IBS

Emotional factors are linked to IBS. Anger, anxiety may increase the bowel movements and produce diarrhea. Upto 50% of people may experience anxiety, depression, obsessive-compulsive disorder .Some patients also gives history of prior physical or sexual abuse.

Rome III criteria for diagnosis of irritable bowel syndrome

Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months, associated with two or more of the following:

• Improvement with defecation.

• Onset associated with a change in frequency of stool.

• Onset associated with a change in form (appearance) of stool.

Features supporting IBS

• Symptoms for more than 6 months.

• Frequent medical visits for non-gastrointestinal problems.

• Prior symptoms which are medically unexplained.

• Worsening of symptoms by stress.

Alarming features of IBS, if present immediately consult physician 

• Age more than 50 yrs.

• Male gender

• Weight loss

• Nocturnal symptoms ( Symptoms at night ) 

• Family history of colon cancer

• Anaemia – Decreased heamoglobin

• Rectal bleeding

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