今日の臨床サポート

体重減少

著者: 山口征啓 健和会大手町病院 感染症内科

監修: 徳田安春 一般社団法人 群星沖縄臨床研修センター

著者校正/監修レビュー済:2021/07/14
患者向け説明資料

概要・推奨   

  1. 6~12カ月間で5%以上の体重減少は臨床上重要であるため、検査などを通して重要な疾患をスクリーニングすることが推奨される(推奨度1)。
  1. 体重減少を訴える患者の半数で実際には体重減少を認めないため、体重減少を訴える患者では、記録された体重を確認することが推奨される(推奨度1)。
  1. 最初の問診、診察、検査で異常を認めなければ、むやみに侵襲的検査を追加せずに、慎重に3〜6カ月経過観察することが勧められる(推奨度1)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
山口征啓 : 未申告[2021年]
監修:徳田安春 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った。フォローアップの期間、悪性疾患で頻度の高いものを最新の論文に基づき追加した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 体重減少は、通常の体重から6~12カ月間で5%以上、体重が減少することと定義される。ヒトの体重は40~50歳代で最大となり、その後10年当たり1~2kgずつ減少する。したがって、特に高齢者では生理的な体重減少と病的な体重減少とを区別する必要がある。
  1. 原因疾患は多岐にわたるが、3大原因は消化器疾患、悪性腫瘍、精神疾患であり、これに原因不明を加えたものが多くを占める。癌は原因のなかでは上位にくるが、大多数の患者は悪性ではない。
  1. 若年者では糖尿病、甲状腺機能亢進症、摂食障害を含む精神疾患、感染症(特にHIV)を考える。
 
  1. 6~12カ月間で5%以上の体重減少は臨床上重要であるため、検査などを通して重要な疾患をスクリーニングすることが推奨される。特にBMI<18.5kg/㎡では体重不足、栄養不良を考慮する[1]
  1. 体重は生理的に変動する。40~50歳代で最高になり、その後、10年当たり1~2kgずつ減少する。したがって、生理的な体重減少と病的な体重減少とを区別する必要がある。
 
  1. 癌、消化器疾患、精神疾患が3大原因である。
  1. 意図しない体重減少の原因は多岐にわたり、頻度も報告によって若干異なるが、癌、消化器疾患、精神疾患は、どの研究でも上位にくる。いくつかの観察研究では、癌3~36%、消化器疾患3~17%、精神疾患8~58%であると報告されている[1][2]
  1. 悪性腫瘍の中では肺がん、大腸がん、胃がん、食道がん、膵臓がん、リンパ腫の頻度が多い[3]
問診・診察のポイント  
 
  1. 体重減少を訴える患者の半数で、実際には体重の減少を認めない。体重減少を確認する。記録がなければ、ベルトの穴の位置が変わったかどうか、洋服のサイズが余るようになったかどうか問診する。

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文献 

著者: E P Bouras, S M Lange, J S Scolapio
雑誌名: Mayo Clin Proc. 2001 Sep;76(9):923-9. doi: 10.4065/76.9.923.
Abstract/Text Unintentional weight loss is a problem encountered frequently in clinical practice. Weight loss and low body weight have potentially serious clinical implications. Although a nonspecific observation, weight loss is often of concern to both patients and physicians. There are multiple potential etiologies and special factors to consider in selected groups, such as older adults. A rational approach to these patients is based on an understanding of the relevant biologic, psychological, and social factors identified during a thorough history and physical examination. The goal of this article is to discuss the clinical importance, review potential pathophysiology, and discuss specific etiologies of unintentional weight loss that will enable the clinician to formulate a practical stepwise approach to patient evaluation and management.

PMID 11560304  Mayo Clin Proc. 2001 Sep;76(9):923-9. doi: 10.4065/76.9・・・
著者: Grace Brooke Huffman
雑誌名: Am Fam Physician. 2002 Feb 15;65(4):640-50.
Abstract/Text Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. The leading causes of involuntary weight loss are depression (especially in residents of long-term care facilities), cancer (lung and gastrointestinal malignancies), cardiac disorders and benign gastrointestinal diseases. Medications that may cause nausea and vomiting, dysphagia, dysgeusia and anorexia have been implicated. Polypharmacy can cause unintended weight loss, as can psychotropic medication reduction (i.e., by unmasking problems such as anxiety). A specific cause is not identified in approximately one quarter of elderly patients with unintentional weight loss. A reasonable work-up includes tests dictated by the history and physical examination, a fecal occult blood test, a complete blood count, a chemistry panel, an ultrasensitive thyroid-stimulating hormone test and a urinalysis. Upper gastrointestinal studies have a reasonably high yield in selected patients. Management is directed at treating underlying causes and providing nutritional support. Consideration should be given to the patient's environment and interest in and ability to eat food, the amelioration of symptoms and the provision of adequate nutrition. The U.S. Food and Drug Administration has labeled no appetite stimulants for the treatment of weight loss in the elderly.

PMID 11871682  Am Fam Physician. 2002 Feb 15;65(4):640-50.
著者: M P Thompson, L K Morris
雑誌名: J Am Geriatr Soc. 1991 May;39(5):497-500.
Abstract/Text Significant unexplained and unintentional weight loss was found in 45 elderly patients who were identified by computer search of the diagnostic files of seven family practice centers. We performed a case series chart review study which revealed that 24% of the 45 cases had no definitive etiology for the weight loss after two years of extensive clinical investigation. Depression was found to be the most common diagnosis made (18%) followed by cancer (16%). Only four patients died during the study period and all had cancer. The most prevalent diagnosis in this group of ambulatory elderly patients did not prove to be cancer, as often though, but rather "unexplained weight loss." CT scans were not found to be helpful as screening tests in the evaluation of weight loss. Using the data from this study, the diagnostic evaluations of elderly patients with unexplained weight loss may be more efficiently directed.

PMID 2022802  J Am Geriatr Soc. 1991 May;39(5):497-500.
著者: Ian J Davis, Shannon J Marek, Subbaramiah Sridhar, Thad Wilkins, Sherman M Chamberlain
雑誌名: J Am Board Fam Med. 2011 Mar-Apr;24(2):218-9. doi: 10.3122/jabfm.2011.02.100166.
Abstract/Text INTRODUCTION: Weight loss is a commonly used indication for colonoscopy.
METHODS: This is a prospective case study of colonoscopies from 1998 to 2009. Descriptive statistics were used to evaluate age, sex, colonoscopy indications, and findings. Multiple logistic regression analysis was used to determine the odds of colorectal cancer (CRC) based on age, sex, and weight loss.
RESULTS: We reviewed 6425 colonoscopies. The mean age of patients was 57.4 years (SD, ±13.5 years), and 55% of patients were women. One hundred thirty-six (2.1%) of these had unintentional weight loss; for 32 patients (0.4%), unintentional weight loss was the only indication for the procedure. CRC was diagnosed in 116 patients (1.8%), but CRC was not detected in any patients for whom unintentional weight loss as the only indication for colonoscopy.
CONCLUSION: Based on our prospective case study, unintentional weight loss alone was not associated with CRC.

PMID 21383224  J Am Board Fam Med. 2011 Mar-Apr;24(2):218-9. doi: 10.3・・・
著者: P Lankisch, M Gerzmann, J F Gerzmann, D Lehnick
雑誌名: J Intern Med. 2001 Jan;249(1):41-6.
Abstract/Text OBJECTIVES: To establish the incidence and causes of unintentional weight loss and to compare prognoses.
DESIGN: Prospective.
SETTING: Secondary referral centre.
SUBJECTS: 158 patients (89 female, 56%; 69 male, 44%) referred by general physicians for unexplained weight loss or for other reasons. In the latter case, weight loss was established after admission to hospital. Follow-up lasted for up to 3 years.
MAIN OUTCOME MEASURE: Determining the course of weight loss in patients with diagnosed and undiagnosed causes.
RESULTS: The cause of weight loss was established in 132 (84%) patients and remained unclear in 26 (16%). Reasons were non-malignant (60% of patients) and malignant (24%) diseases. Psychological disorders represented 11% of the non-malignant group. A gastrointestinal disease caused weight loss in 50 (30%) patients. Of malignant disorders, 53% (20 of 38 patients) were gastrointestinal. Amongst the non-malignant group, 39% (30 of 77 patients) had somatic disorders. The prognosis for unknown causes of weight loss was the same as for non-malignant causes.
CONCLUSION: Contrary to common belief, weight loss is not usually due to a malignant disease. A gastrointestinal tract disorder accounts for weight loss in every third patient. If minimal diagnostic procedures cannot establish a diagnosis, then endoscopic investigation of the upper and lower gastrointestinal tract and function tests should be performed to exclude malabsorption.

PMID 11168783  J Intern Med. 2001 Jan;249(1):41-6.
著者: Bruce Arroll, Natalie Khin, Ngaire Kerse
雑誌名: BMJ. 2003 Nov 15;327(7424):1144-6. doi: 10.1136/bmj.327.7424.1144.
Abstract/Text OBJECTIVE: To determine the diagnostic accuracy of two verbally asked questions for screening for depression.
DESIGN: Cross sectional criterion standard validation study.
SETTING: 15 general practices in New Zealand.
PARTICIPANTS: 421 consecutive patients not taking psychotropic drugs.
MAIN OUTCOME MEASURES: Sensitivity, specificity, and likelihood ratios of the two questions compared with the computerised composite international diagnostic interview.
RESULTS: The two screening questions showed a sensitivity and specificity of 97% (95% confidence interval, 83% to 99%) and 67% (62% to 72%), respectively. The likelihood ratio for a positive test was 2.9 (2.5 to 3.4) and the likelihood ratio for a negative test was 0.05 (0.01 to 0.35). Overall, 37% (157/421) of the patients screened positive for depression.
CONCLUSION: Two verbally asked questions for screening for depression would detect most cases of depression in general practice. The questions have the advantage of brevity. As treatment is more likely when doctors make the diagnosis, these questions may have even greater utility.

PMID 14615341  BMJ. 2003 Nov 15;327(7424):1144-6. doi: 10.1136/bmj.327・・・
著者: B Arroll, F Goodyear-Smith, N Kerse, T Fishman, J Gunn
雑誌名: BMJ. 2005 Oct 15;331(7521):884. doi: 10.1136/bmj.38607.464537.7C. Epub 2005 Sep 15.
Abstract/Text OBJECTIVE: To determine the validity of two written screening questions for depression with the addition of a question inquiring if help is needed.
DESIGN: Cross sectional validation study.
SETTING: 19 general practitioners in six clinics in New Zealand.
PARTICIPANTS: 1025 consecutive patients receiving no psychotropic drugs.
MAIN OUTCOME MEASURES: Sensitivity, specificity, and likelihood ratios of the two screening questions, the help question, combinations of the screening and help questions, and diagnosis by general practitioners.
RESULTS: The help question alone had a sensitivity of 75% (95% confidence interval 60% to 85%) and a specificity of 94% (93% to 96%). The positive likelihood ratio for the help question was 13.0 (9.5 to 17.8) and the negative likelihood ratio was 0.27 (0.17 to 0.44). The likelihood ratio for patients wanting help today was 17.5 (11.8 to 31.9). The general practitioner diagnosis had a sensitivity of 79% (65% to 88%) and a specificity of 94% (92% to 95%).
CONCLUSION: Adding a question inquiring if help is needed to the two screening questions for depression improves the specificity of a general practitioner diagnosis of depression.

PMID 16166106  BMJ. 2005 Oct 15;331(7521):884. doi: 10.1136/bmj.38607.・・・
著者: A Saremi, R L Hanson, D E Williams, J Roumain, R W Robin, J C Long, D Goldman, W C Knowler
雑誌名: J Stud Alcohol. 2001 May;62(3):294-300.
Abstract/Text OBJECTIVE: This study evaluated the performance of the CAGE questionnaire (a set of four questions about alcoholism) in an American Indian population.
METHOD: We analyzed data from a cross-sectional study of 275 individuals (179 women) aged 21 years or older. Alcohol dependence was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised (DSM-III-R), based on a detailed psychiatric interview using the Schedule for Affective Disorders and Schizophrenia-Lifetime Version. Accuracy of the CAGE questionnaire was quantified as sensitivity, specificity, likelihood ratios and the area under receiver operating characteristics (ROC) curves, using the DSM-III-R diagnosis as the reference.
RESULTS: Of participants interviewed, 85% of men and 53% of women had a diagnosis of alcohol dependence by DSM-III-R. A CAGE score of > or = 2 had a sensitivity and specificity of 68% and 93%, respectively, in men and 62% and 79% in women, for the diagnosis of alcohol dependence. CAGE scores of 0, 1 and > or = 2 were associated with likelihood ratios of 0.3, 0.3 and 9.5, respectively, in men and 0.4, 0.7 and 1.5 in women. The area under the ROC curve was 81% for men and 75% for women.
CONCLUSIONS: These findings suggest that the CAGE questionnaire is a valid screening method, in this population, for identifying people likely to have alcohol dependence.

PMID 11414338  J Stud Alcohol. 2001 May;62(3):294-300.
著者: L J Robbins
雑誌名: Geriatrics. 1989 Apr;44(4):31-4, 37.
Abstract/Text Weight loss among elderly patients is a common clinical problem that may herald numerous medical and psychosocial disorders. Up to 50% of patients claiming weight loss will not have their complaint corroborated by medical records or family members. Since modest weight loss may occur as a physiologic change with advancing age, the practicing physician must have a working definition of pathologic weight loss that triggers an appropriate diagnostic evaluation. After a careful initial history, physical exam, and a limited laboratory test battery, physicians will identify most patients with physical causes for weight loss. Like many other geriatric syndromes, weight loss may require the identification and correction of multiple contributing factors.

PMID 2647586  Geriatrics. 1989 Apr;44(4):31-4, 37.

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