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A 2 step procedure determined diagnosis in patients with unexplained weight loss
  1. Joseph J Nidiry, MD
  1. Howard University College of Medicine Washington, DC, USA

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 QUESTION: In patients admitted to hospital with unexplained weight loss (≥5% of usual body weight), what are the relative frequencies of different causes?

    Design

    Cohort study with a mean follow up of 22 months.

    Setting

    A secondary referral centre in Lüneburg County, Germany.

    Patients

    158 patients who were ≥18 years of age (mean age 68 y, 56% women) and had a weight loss of ≥5% of usual body weight ≤6 months before being admitted to hospital. Exclusion criteria were weight loss from a known cause or voluntary weight loss. Follow up was complete.

    Diagnostic strategy

    A 2 step diagnostic procedure was followed. While in the hospital, all patients received the first step: history and physical examination, chest radiography, electrocardiography, abdominal ultrasonography, standard laboratory tests, and tests for hyperthyroidism and occult blood in the faeces. Patients undiagnosed after the first step received secondary diagnostic tests determined on the basis of results from the first step: tests included gastroscopy, colonoscopy, faecal weight and fat estimations, and for cause of malabsorption (duodenoscopy, secretin pancreozymin testing, and enteroclysis when necessary) where indicated.

    Main outcome measure

    Diagnosis from the 2 step procedure.

    Main results

    During admission, the 2 step procedure achieved a diagnosis for 132 patients (84%) (table). During follow up, causes were determined for 7 of the 26 patients without a diagnosis from the 2 step procedure: hyperthyroidism (n=2), diabetes (n=2), depression (n=2), and voluntary weight loss (1 patient who had denied dieting at study inception).

    Diagnosis from a 2 step diagnostic procedure in 158 patients admitted to hospital with unexplained weight loss

    Conclusion

    In patients admitted to hospital with unexplained weight loss, a 2 step procedure provided a diagnosis in 84%.

    Commentary

    In this study of a differential diagnosis for unexplained weight loss, Lankisch et al are to be commended for exploring a clinical condition that has not been extensively covered in the medical literature. Despite attempts to develop evidence-based protocols and algorithms for the most cost effective and efficient diagnostic and therapeutic management of other common presenting problems, unexplained weight loss has not been well studied.

    Although some of the conclusions of the study are not surprising, the transferability of the findings from a German population to other populations needs further substantiation. In many locales, it is routine to check all patients with unexplained weight loss for infection, obtain a computed tomographic image of the abdomen to exclude occult malignancies, and evaluate for depression. However, such diagnostic tests as secretin pancreozymin are rarely done. Stratifying patients by age might have given a better indication for cause because unexplained weight loss tends to have different causes in different age groups.

    Establishing a cause and effect relationship between the findings and the weight loss can be difficult for some disorders, such as cancer of the prostate, although not in others, such as gastrointestinal diseases. The authors also note that, independent of the diagnosis, most surviving patients (96%) did not continue to lose weight. It is not obvious what to make of this observation, considering that it excludes the 50 (32%) patients who died in follow up. Regardless of its shortcomings, the study by Lankisch et al provides some direction in evaluating patients with a common presenting problem in primary care settings.

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    Footnotes

    • Source of funding: not stated.

    • For correspondence: Dr P G Lankisch, Medizinische Klinik, Staedtisches Klinikum Lüneburg, Boegelstrasse 1, D 21339 Lüneburg, Germany. Fax +49 4131 772 245.

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