Practice scenario: Unintentional weight loss

Problem representation

A 22-year-old female presents with a four-month history of unintentional weight loss with associated tiredness.

Hypothesis generation

Medically, unintentional weight loss is generally defined as loss of more than 5 per cent of usual body weight over six to 12 months. This is common in older adults, especially those in high-risk populations such as nursing home residents.

An assessment for the presence of cancer is always a high priority, although there are a wide range of causes of unintentional weight loss. Dementia and depression should be considered in elderly patients, and eating disorders in younger adults. However, in up to 25 per cent of cases no identifiable cause can be found.

Likely diagnosis

• Anxiety 
• Depression
• Eating disorder

Possible diagnosis 

• Addison’s disease 
• Alcohol use disorder
• Coeliac disease
• COPD
• Dementia 
• Diabetes
• Heart failure 
• Hyperthyroidism
• Medicines 
• Parkinson’s disease
• Peptic ulcer disease
• Inflammatory bowel disease (IBD)
• Serious infection (e.g. HIV, TB)

Critical diagnosis

• Endocarditis 
• Malignancy

Continued information gathering

Given you are dealing with a young adult female, you can rule out a number of conditions that are associated with older age (e.g. COPD, dementia, heart failure, Parkinson’s disease, peptic ulcer disease, endocarditis and malignancy). Grace only takes the contraceptive pill, so medicines can be ruled out as well.

Early thoughts should be around mental health conditions as tiredness and losing weight are both symptoms associated with generalised anxiety or depression. On questioning it appears that Grace’s mental health is fine, and anxiety and depression are not the cause of her symptoms. We do know that eating disorders can occur in young women, so GI symptoms and menstrual history need to be explored.

Grace tells you that her periods are normal but she has been feeling bloated and getting lower abdominal pain. She does not report any change in bowel habits. She reconfirms that she has not been trying to lose weight.

Normal periods coupled with good mental health seem to discount an eating disorder.

Problem refinement

Grace has symptoms of unintentional weight loss, tiredness and GI discomfort. This could suggest hyperthyroidism (fatigue and weight loss are common) but other symptoms such as insomnia, altered periods and palpitations are usually present and these have not been reported.

IBD also seems unlikely as persistent diarrhoea is a common presenting problem. Likewise, a serious infection can be discounted as these are associated with systemic upset such as fever and malaise. Thirst and excessive urination is associated with Addison’s disease and diabetes, but Grace says she hasn’t experienced these.

Alcohol use disorder and coeliac disease now seem the only plausible diagnoses. When asked about her alcohol consumption Grace describes a social drinking pattern and does not drink every day. This suggests that her symptoms may be due to coeliac disease.

Red flags

Malignancy and endocarditis were initially ruled out based on Grace’s age. After questioning, she does not exhibit symptoms of malignancy such as melaena, persistent cough, dysphagia or haematuria. In endocarditis, one would expect to see fever and night sweats.

Management: Self-care options

A gluten-free diet would need to be followed. Signpost Grace to organisations where more information is available. However, before this is instigated, she needs to have a confirmed diagnosis via serological testing.

Prescribing options

If a diagnosis is confirmed, then gluten-free products can be prescribed on the NHS. A person with coeliac disease may need to try a range of products to find those which are acceptable.

Safety netting and next steps

You share your thoughts that it could be coeliac disease but tell Grace that tests are needed to confirm if this is indeed the cause of her symptoms. You explain that she will need to see her GP as soon as possible so her symptoms can be assessed further and tests arranged if necessary.

Now check your knowledge on unintentional weight loss by answering these multiple choice questions:

1. Which ONE of the following can present with unintentional weight loss and increased appetite?

a. An adverse drug reaction

b. Cancer

c. Depression

d. Hyperthyroidism

e. None of the above

2. People with unintentional weight loss and fever,
fatigue and night sweats may have which ONE of the following disorders?

a. Addison’s disease

b. Cancer

c. Diabetes

d. Heart failure

e. Hyperthyroidism

3. Adverse drug reactions are known to cause anorexia and/or decreased appetite. Which ONE of the following is most likely to cause weight loss?

a. Bupropion

b. Digoxin

c. Exenatide

d. Levodopa

e. Zonisamide

4. Type 1 diabetes can present with a range of signs and symptoms. Which ONE of the following is least likely?

a. Blurred vision

b. Excessive thirst

c. Fatigue

d. Polyuria

e. Weight loss

5. In which ONE of the following would appetite be increased?

a. Adverse drug reactions

b. Anxiety

c. Cancer

d. Depression

e. Hyperthyroidism

Answers: 1.d 2.b 3.e 4.a 5.e