Ambulatory Report Pearls – Unintentional Weight Loss – 6.22.16

Thanks to Jon Chou for presenting a case of a 65 yo M h/o HTN, T2DM, Obesity, OSA presenting with intentional weight loss, which gradually became unintentional prompting a excellent thorough work-up and was ultimately found to have a pancreatic malignancy.
  • Pancreatic Malignancy is often difficult to diagnose early.
    • My own primary care patient had 2 Endoscopic Ultrasound FNAs which both were benign, and he was ultimately found to have metastatic pancreatic cancer.
    • Thank you again to Jon for sharing this difficult case and helping us all learn.
  • LT Pearl – When you have an unexpected increase in your A1c, consider pancreatic malignancy in your differential.  
  • Unintentional Weight Loss 
    • Generally defined as >5% of usual body weight loss over 6-12 months
    • First pass Dx work up: CBC, BMP, LFTs, TFTs, CRP, ESR, A1C or random glucose, LDH, UA, CXR, FOBT & age appropriate CA screening, t/c abd u/s (up to date also recommends HIV, HCV)
      • Prospective study of 101 pts (inpt & outpt) avg age 64yo and unintentional wt loss of 5% over 6-12mo – when baseline tests/eval dones (H&P, CBC,BMP,LFT, TFT, CRP, ESR, LDH, UA) –> find an etio in 73%.  All 22 pts with malignancy had abnl baseline labs.
        • NONE of pts with nl exams had malignancy (when had additional w/u with CT, endoscopy, colo, MRI, radionucliotide exam)
        • Tests with highest yield = hgb, CRP, LDH, ALBUMIN
        • Metalidis C, Knockaert DC, Bobbaers H, et al. Involuntary weight loss.  Does a negative baseline evaluation provide adequate reassurance? Eur J Intern Med. 2008;19 (5): 345-349.
    • Don’t forget to ask about Substance use & Mental illness —> both can cause significant weight loss!
    • AAFP has a great review of an approach to unintentional weight loss (some Table’s that I liked are pasted below)
    • UpToDate also has an approach which overlaps with the AAFP approach
      • 764DA606-18CB-410D-A92D-2F8A74EAE627
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