A Medical lecture about weight loss and constipation by dr. Ali A. Ramadhan

1. 1
Weight loss
Dr. Ali A. Ramadhan
M.B.Ch.B., FIBMS, FKBMS (G & H)

2. 2
Overview
• Involuntary weight loss (IWL) of > 5% over 6
months is clinically significant.
• It often indicates the presence of an underlying
disease.
• IWL occur in up to 8% of all adult outpatients and
27% of frail persons ≥65 years.
• There is no identifiable cause in up to one-
quarter of patients despite extensive
investigation.
• Involuntary weight loss > 20% is often associated
with severe protein-energy malnutrition, nutritional
deficiencies, and multiorgan dysfunction

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Aetiology
• Physiological: dieting, decreased intake,
exercise or starvation. Evaluation by a
dietitian is often valuable.
• Pathological:
1.Chronic infections.
2.Cancer.
3.Gastrointestinal or endocrine causes
4.Systemic disease: Advanced cardiac, pulmonary, renal,
rheumatolgical or neurological disease
5.Medications
6.Psychiatric illness

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5. 5
Some easily overlooked causes of
unexplained weight loss
1. Depression/anxiety
2. Chronic pain or sleep deprivation
3. Psychosocial deprivation/malnutrition in the elderly
4. Systemic diseases: severe chronic obstructive
pulmonary disease, cardiac failure, diabetes
mellitus, hyperthyroidism, Addison’s disease, pan-
hypopituitarism.
5. Occult malignancy
6. Anorexia nervosa in atypical groups

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History• HPI:
1. Documentation that weight loss has actually occurred.
– In a study, only 50% of patients reporting weight loss
had true weight loss
– So previous weight records are important.
– Change in clothing or ring size, observation of a relative
or friend, and a numeric estimate of weight loss can be
helpful but are less accurate than weight records.
2. Appetite:
• Increased appetite in hyperthyroidism or DM
• Anorexia: infections, cancer, psychiatric illness
3. Diet and eating habits.
4. GI symptoms
5. Fever.

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History (Con.)
• ROS: for symptoms that can indicate
systemic diseases, cancers, or chronic
infections.
• PMHx: for systemic diseases
• PSHx: for GI surgeries
• Drug Hx: sedatives, nonsteroidal anti-
inflammatory drugs, serotonin reuptake
inhibitors, metformin, levodopa, digoxin…etc
• Socio-economic history: for any sources of
psychiatric problems.

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Examination
• General examination:
– Temperature: fever in infections, cancer,
rheumatological diseases
– Mouth: dental problems.
– Lymphadenopathy: lymphoma, leukemia, infections
– Hyperpigmentation: Addison
– Thyroid gland for goiter
• Abdomen: mass (GI malignancy) or hepato-
splenomegaly.
• Cardiopulmonary status.
• Neurological examination.

9. Question
• A young aged man presented with weight loss of 5
Kg over 6 months and he has good appetite. Which
of the following condition will usually cause such a
presentation:
A.Tuberculosis
B.Colorectal cancer
C.Depression
D.Diabetes mellitus
E.Brucellosis
TA: D
9

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Investigations
• Laboratory
– Complete blood count.
– Biochemistry: liver and renal function tests, blood
glucose, thyroid function tests.
– Erythrocyte sedimentation rate, C-reactive protein.
– Urinalysis for sugar, protein and blood.
• Radiology: Chest x-ray, abdominal ultrasound
– Other investigations will be needed according to
history, examination and clinical suspicion.
– Revisiting the patient’s history and reweighing at
intervals is very important.

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Management
1. Treat the underlying cause.
2. For unexplained weight loss, oral nutritional
supplements (eg high-energy drinks) may
reverse weight loss.
3. Appropriate exercise program can help in
those with wasting conditions
4. Appetite stimulant, anabolic, & anti-cytokine
agents are under investigation.

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13. 13
Constipation

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Definition
• Constipation is defined as infrequent
passage of hard stools.
• The traditional medical definition is less than
3 bowel movements/week.
• Patients may mean that they have straining,
hard stool, difficulty in evacuation, a
sensation of incomplete evacuation, perianal
discomfort

15. Aetiology
• Gastrointestinal disorders
1.Dietary: Lack of fiber and/or fluid intake
2.Motility: Irritable bowel syndrome, slow-transit
constipation, drugs, chronic intestinal pseudo-
obstruction
3.Structural: Colonic carcinoma, diverticular
disease, Hirschsprung’s disease
4.Defecation: Anorectal disease (Crohn’s,fissures,
haemorrhoids) or obstructed defecation
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16. Aetiology (Con.)
• Non-gastrointestinal disorders
1.Drugs: Opiates, anticholinergics, calcium
antagonists, iron supplements, aluminium-
containing antacids
2.Neurological: Multiple sclerosis, spinal cord
lesions, cerebrovascular accidents, Parkinsonism
3.Metabolic/endocrine: Diabetes mellitus,
Hypercalcaemia, hypothyroidism, pregnancy
4.Others: Any serious illness with immobility,
especially in the elderly, depression
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17. History
• HPI:
1.What the patient means by constipation?
2.The onset, duration and characteristics are
important:
– Neonatal onset suggests Hirschsprung’s disease.
– Recent constipation could be due to intestinal
obstruction, anorectal problems or drugs.
– Rectal bleeding, pain and weight loss may indicate a
structural lesion like cancer.
3.Revise the diet of the patient
• PMHx: endocrine or neurological diseases.
• Drug history 17

18. Examination
• For general medical disorders, as well as
signs of intestinal obstruction.
• Neurological disorders, especially spinal
cord lesions.
• Perineal and rectal examination for
sensation and anorectal problems.
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19. Question
• A 62 years old female who has been well until
before 2 months when she started to have
infrequent bowel motions associated with straining,
bleeding per rectum, weight loss and left sided
abdominal pain. The most likely cause of her
constipation is:
A.Hyperthyroidism
B.Irritable bowel syndrome
C.Colonic cancer
D.Pregnancy
E.Depression
TA: C
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20. Management
• Initial visit
1.Digital rectal examination & proctoscopy.
2.Routine biochemistry, including serum
calcium and thyroid function tests
3.Full blood count
4.Sigmoidoscopy
5.If these are normal, a 1-month trial of
dietary fiber and/or laxatives is justified.
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21. Management
• Next visit
• If symptoms persist, then examination of the colon
(by colonoscopy, barium enema or CT
colonography) to look for structural disease.
• Further investigation
• If no cause is found and disabling symptoms are
present, then investigation for possible dysmotility:
– ‘Slow transit’: intestinal marker studies
– ‘functional obstructive defecation’: anorectal manometry,
electrophysiological studies and magnetic resonance
proctography.
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23. Question
• All of the followings are part of initial visit
for assessment of constipation EXCEPT:
A.Digital rectal examination.
B.Thyroid function tests
C.Full blood count
D.Trial of dietary fiber
E.CT colonography
TA: E 23

24. Laxatives
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1. Bulk-forming laxatives: Methylcellulose, ispaghula
2. Stimulant laxatives: bisacodyl, Senna, Na picosulfate,
dantron (only for terminally ill patients), docusate
3. Faecal softeners: Docusate sodium, liquid paraffin,
arachis oil enemas
4. Osmotic laxatives:
a) Poorly Absorbed Ions: Magnesium salts, Sodium
sulfate, Na phosphate, Na citrate
b) Poorly Absorbed Sugars: Lactulose, Polyethylene
glycol
5. Peripheral opioid-receptor antagonists:
Methylnaltrexone
6. Others eg Cl- Channel Activator like Lubiprostone

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