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Decreased appetite

Medicine > Gastrointestinal

Differential Diagnosis Schema 🧠

Gastrointestinal Causes

  • Gastritis/peptic ulcer disease: Epigastric pain, nausea, early satiety, and potential weight loss
  • Hepatitis: Jaundice, malaise, nausea, right upper quadrant pain, and loss of appetite
  • Pancreatitis: Severe epigastric pain radiating to the back, nausea, vomiting, and anorexia
  • Inflammatory bowel disease: Abdominal pain, diarrhea, blood in stool, and anorexia, often with weight loss
  • Gastroesophageal reflux disease (GERD): Heartburn, regurgitation, and a decreased appetite due to discomfort after eating
  • Malignancy (e.g., gastric cancer, pancreatic cancer): Weight loss, early satiety, abdominal pain, and progressive anorexia
  • Celiac disease: Diarrhea, bloating, weight loss, and anorexia, often with malabsorption-related symptoms
  • Cholecystitis/cholelithiasis: Right upper quadrant pain, nausea, vomiting, and anorexia, particularly after fatty meals
  • Irritable bowel syndrome: Abdominal discomfort, altered bowel habits, bloating, and sometimes reduced appetite
  • Liver cirrhosis: Jaundice, ascites, variceal bleeding, and anorexia, often with malnutrition

Endocrine and Metabolic Causes

  • Diabetes mellitus: Polyuria, polydipsia, weight loss, and anorexia, particularly in poorly controlled cases
  • Thyroid disorders (hyperthyroidism, hypothyroidism): Hyperthyroidism often presents with weight loss despite increased appetite, while hypothyroidism can cause weight gain and decreased appetite
  • Adrenal insufficiency: Fatigue, weight loss, hyperpigmentation, hypotension, and anorexia
  • Chronic kidney disease: Uremia leading to nausea, vomiting, metallic taste, and decreased appetite, often with weight loss
  • Hypercalcemia: Nausea, vomiting, constipation, polyuria, and anorexia, often due to malignancy or hyperparathyroidism
  • Hypocalcemia: Numbness, muscle cramps, and anorexia, often due to hypoparathyroidism or renal failure
  • Nutritional deficiencies (e.g., vitamin B12 deficiency): Fatigue, pallor, neurological symptoms, and reduced appetite
  • Electrolyte imbalances (e.g., hyponatremia, hyperkalemia): Nausea, vomiting, fatigue, and decreased appetite, often secondary to other systemic conditions

Psychiatric Causes

  • Depression: Persistent low mood, anhedonia, fatigue, weight loss, and significant loss of appetite
  • Anxiety disorders: Worry, panic attacks, nausea, and reduced appetite, often associated with gastrointestinal symptoms
  • Eating disorders (e.g., anorexia nervosa, bulimia nervosa): Intense fear of weight gain, body image distortion, and severe restriction of food intake leading to decreased appetite
  • Dementia: Cognitive decline, memory loss, and neglect of self-care, including reduced interest in food
  • Schizophrenia: Delusions, hallucinations, social withdrawal, and neglect of self-care, often resulting in reduced appetite and weight loss
  • Grief and bereavement: Emotional distress, loss of appetite, and weight loss following the death of a loved one
  • Substance misuse: Alcohol or drug abuse leading to poor nutritional intake, reduced appetite, and weight loss
  • Psychosocial stressors: Financial difficulties, relationship problems, or work-related stress contributing to loss of appetite

Infectious Causes

  • Tuberculosis: Chronic cough, night sweats, fever, and weight loss, with significant anorexia
  • HIV/AIDS: Persistent fever, weight loss, diarrhea, and anorexia, often with opportunistic infections
  • Viral hepatitis: Jaundice, malaise, nausea, right upper quadrant pain, and decreased appetite
  • Endocarditis: Persistent fever, night sweats, weight loss, and anorexia, often with a new or changing heart murmur
  • Mononucleosis (Epstein-Barr virus): Sore throat, lymphadenopathy, fever, and anorexia, often with significant fatigue
  • Sepsis: Systemic infection leading to fever, tachycardia, hypotension, and anorexia, often with multi-organ dysfunction
  • Malaria: Cyclical fever, chills, sweating, and anorexia, particularly in travelers to endemic areas
  • Gastroenteritis: Nausea, vomiting, diarrhea, and loss of appetite, often with dehydration
  • Chronic fungal infections (e.g., histoplasmosis, coccidioidomycosis): Persistent cough, fever, weight loss, and anorexia, particularly in immunocompromised individuals
  • Chronic parasitic infections (e.g., schistosomiasis, leishmaniasis): Weight loss, anemia, fatigue, and anorexia, particularly in endemic areas

Key Points in History 🥼

Onset and Duration

  • Acute vs. chronic: Acute loss of appetite may suggest an infectious or gastrointestinal cause, while chronic loss may indicate malignancy, chronic disease, or psychiatric conditions
  • Associated weight loss: Rapid weight loss with decreased appetite is concerning for malignancy, chronic infection, or severe psychiatric illness
  • Seasonal variation: Appetite loss may be associated with seasonal affective disorder or depression during winter months
  • Relationship to meals: Early satiety or postprandial fullness may suggest peptic ulcer disease, gastritis, or malignancy
  • Impact on daily life: Assess the extent to which decreased appetite is affecting the patient’s daily activities and quality of life
  • Triggers: Recent life events, stress, or trauma that may be contributing to reduced appetite should be explored
  • Appetite changes with other symptoms: Assess for associated symptoms such as nausea, vomiting, abdominal pain, or changes in bowel habits

Background

  • Past medical history: Chronic illnesses such as diabetes, COPD, heart failure, or cancer may be associated with decreased appetite
  • Drug history: Medications that may reduce appetite include antibiotics, chemotherapy, digoxin, opiates, and certain psychiatric medications
  • Family history: Genetic predisposition to psychiatric conditions, malignancies, or chronic diseases that may cause decreased appetite
  • Social history: Assess for alcohol or substance misuse, social isolation, or financial difficulties that may impact nutritional intake
  • Travel history: Recent travel to endemic areas for infections such as malaria, tuberculosis, or parasitic diseases
  • Lifestyle factors: Diet, exercise, and overall physical activity level may influence appetite and should be explored
  • Psychosocial stressors: Relationship problems, bereavement, or work-related stress may contribute to reduced appetite
  • Dietary habits: Recent changes in diet, food preferences, or eating patterns should be assessed
  • Recent hospitalizations: A history of recent illness or surgery may lead to decreased appetite during recovery
  • Exposure to toxins: Potential exposure to environmental toxins or chemicals that could impact appetite

Possible Investigations 🌡️

Blood Tests

  • Full blood count (FBC): To assess for anemia, infection, or malignancy, which may be associated with decreased appetite
  • Urea and electrolytes (U&E): To assess renal function and electrolyte imbalances that could cause anorexia
  • Liver function tests (LFTs): To assess for hepatitis, cirrhosis, or liver malignancy
  • Thyroid function tests: To assess for hypo- or hyperthyroidism, which can impact appetite
  • Glucose levels: To assess for diabetes, particularly if hyperglycemia or hypoglycemia is suspected
  • C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): To assess for inflammation or infection
  • Calcium levels: To assess for hypercalcemia, which can cause nausea and anorexia
  • Vitamin B12 and folate levels: To assess for deficiencies that may cause decreased appetite and weight loss
  • HIV test: Consider in patients with risk factors for HIV, presenting with weight loss and anorexia
  • Autoimmune screen: To assess for conditions such as systemic lupus erythematosus (SLE) or rheumatoid arthritis, which may impact appetite
  • Tumor markers (e.g., CA 19-9, CEA): Consider in cases of unexplained weight loss and decreased appetite, particularly if malignancy is suspected
  • Serum cortisol levels: To assess for adrenal insufficiency, which may present with fatigue, weight loss, and anorexia
  • Blood cultures: If sepsis is suspected, particularly in patients with systemic symptoms such as fever and hypotension

Imaging and Special Tests

  • Abdominal ultrasound: To assess for hepatobiliary disease, renal pathology, or masses
  • Chest X-ray: To assess for pneumonia, tuberculosis, or malignancy, particularly in patients with respiratory symptoms
  • Upper gastrointestinal endoscopy: To assess for peptic ulcer disease, gastritis, or malignancy, particularly in patients with epigastric pain or weight loss
  • Colonoscopy: To assess for colorectal cancer, inflammatory bowel disease, or other lower GI pathologies in patients with weight loss and altered bowel habits
  • CT or MRI scan: To assess for intra-abdominal or thoracic malignancies, particularly in cases of unexplained weight loss and decreased appetite
  • Echocardiogram: To assess cardiac function in patients with heart failure or endocarditis who present with anorexia
  • Mantoux test or Quantiferon-TB Gold: To assess for latent or active tuberculosis in patients with chronic cough, weight loss, and decreased appetite
  • Cognitive assessment: To assess for dementia or delirium in elderly patients with anorexia and weight loss
  • Psychiatric assessment: To assess for depression, anxiety, or eating disorders in patients with significant weight loss and decreased appetite
  • Stool examination: To assess for parasitic infections or malabsorption in patients with diarrhea and anorexia

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Gastrointestinal