Investigation and management of unintentional weight loss in older adults

We were interested to read the comprehensive review of weight loss in
elderly people.

We have been impressed by the number of older people referred with
unexplained weight loss to our department who subsequently are found to
have Giant cell arteritis (Temporal arteritis). These patients may have
minimal symptoms and not have headache(1)but are at risk of visual loss
and permanent blindness. The Systemic nnflammatory disorders may only
represent 4% of patients with unexplained weight loss but this is a very
treatable condition with corticosteroids. If undiagnosed and/or untreated
there is high morbidity and mortality. We wish to bring to the attention
of your readers that connective tissue such as Giant cell arteritis may be
very insidious in onset and should be considered as part of the work-up in
a patient with weight loss. Inflammatory markers such as ESR and CRP may
be helpful although can be normal.

Ref: Arthritis and Rheumatism, June 1980 : L. A. Healey, K. Wiske :
Presentation of Occult giant cell arteritis

Investigation of weight loss

As a gastroenterology registrar I see a great deal of referrals for
weight loss both in the clinic and endoscopy suite. I was therefore
interested to read the guidance by McMinn et al.1 suggesting history,
examination, chest x-ray and faecal occult blood (FOB) testing as first
line investigations. Of concern was the observation that approximately 13%
of this population will have a gastrointestinal (GI) malignancy and 19% a
non-malignant GI pathology. Given the high incidence, it would be
invaluable to know the sensitivity of anaemia, CRP and ESR in this
population.

The database used to record endoscopy reports at our centre allows
the practitioner to record weight loss as an indication for the test.
Over the last year, 116 oesophagogastroduodenoscopies (OGD) were completed
for indications including weight loss with half (58) for isolated weight
loss. Five malignancies were found, all of whom had other symptoms (pain
or dysphagia) but only one had abnormal bloods (anaemia). Sixteen had
another GI pathology requiring further action (4 presented with isolated
weight loss, 3 being anaemic). One third of those with multiple
indications, including weight loss, were anaemic. In summary, 14% of
patients with weight loss (who received an OGD) had a non-malignant upper
GI pathology and 4% had an upper GI malignancy broadly consistent with the
published data 1 2.

Our colonoscopy reports do not allow weight loss to be recorded as an
indication. Over the last year, 131 patients had been assessed by the
colorectal cancer (CRC) MDT in this non-bowel cancer screening centre. 13
CRC patients had weight loss amongst their presenting complaints and 7 of
these had no distal metastasis. 5 of the patients with weight loss had
normal full blood counts and 3 of these did not have distal metastasis.
Only one patient had weight loss without another indication for
investigation. (CRC was diagnosed after imaging showed metastasis).
Although it is reassuring that patients with CRC presented with another
indication beside weight loss, this could be an example of sampling bias
given that colonoscopy is not recognised as an investigation for weight
loss.

This limited, superficial and retrospective data review does seem to
justify the approach of McMinn et al in selecting patients for OGD.
However, the finding that a significant proportion of patients with weight
loss attributable to CRC had normal blood tests and curable disease was
disconcerting given the low sensitivity of FOB (20% in asymptomatic
individuals3). McMinn asks whether and when "blind" investigations are
indicated. One study showed that when weight loss was confirmed 15 of 41
patients were found to have a GI malignancy (5 upper GI, 4 colonic and 6
pancreatic)2. We were unable to find the sensitivity of CT colonography
for pancreatic cancer but this test might be expected to have a high yield
in this circumstance. The potential early stage of some of these
malignancies should focus decision making on the time interval before
blind investigation is considered.

References

1. McMinn J, Steel C, Bowman A. Investigation and management of
unintentional weight loss in older adults. BMJ 2011: 754 - 759

2. Lankish PG, Gerzmann M, Gerzmann JF, Lehnick D. Unintentional weight
loss: diagnosis and prognosis. The first prospective follow-up study from
a secondary referral centre. J Intern Med 2001; 249:41-6

3. Graser A, Stieber P, Nagel D, Sch?fer C, Horst D, Becker CR et al.
Comparison of CT colonography, colonoscopy, sigmoidoscopy and faecal
occult blood tests for the detection of advanced adenoma in an average
risk population. Gut 2009 58(2):241-8

Jonathan Tyrrell-Price SpR gastroenterology, Imperial College Healthcare
NHS Trust, UK j.tyrrell-price@imperial.ac.uk

Anwen Hills FY1 Imperial College Healthcare NHS Trust, UK

Alison Varey FY1 Imperial College Healthcare NHS Trust, UK