1. Involuntary weight loss of over 5% in 6 months often indicates an underlying disease and requires investigation of possible causes. Common causes include chronic infections, cancer, gastrointestinal issues, and systemic diseases. 2. A thorough history, physical exam, and basic lab tests are needed to evaluate for potential physiological or pathological causes of unexplained weight loss. Further testing like imaging may be needed depending on initial findings. 3. Constipation is defined as less than 3 bowel movements per week and can be caused by gastrointestinal, neurological, metabolic/endocrine issues or medications. Initial evaluation of constipation includes a digital rectal exam, blood tests, sigmoidoscopy and trial of fiber/laxatives. Further testing may be

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

3. 3
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

4. 4

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

6. 6
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.

7. 7
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.

8. 8
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

10. 10
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.

11. 11
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.

12. 12

13. 13
Constipation

14. 14
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
15

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
16

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.
18

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
19

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.
20

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.
21

22. 22

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
24
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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