A. Physical wasting
Second, neuroendocrine and metabolic diseases caused by wasting
(a) hypothalamic syndrome (b) hypopituitarism
1, anterior hypopituitarism (Simmonds disease and Sheehan syndrome)
2, uremic wasting
(C) hyperthyroidism
(iv) chronic hyperalgesia (Addison’s disease)
(v) diabetes mellitus
(F) pheochromocytoma
(iii) malignant tumors
IV. Chronic infections
1.Tuberculosis
2.Chronic septic infection
3.Schistosomiasis
4.Parasitic diseases
5.AIDS
V. Digestive tract diseases
1.Mouth and pharynx diseases
2.Chronic gastrointestinal diseases
3.Chronic hepatobiliary diseases
4.Chronic pancreatic diseases
Sixth, anorexia nervosa (anorexia nervosa)
VII. Wasting due to severe trauma and burns
Eight, drug-induced wasting
Mechanisms
I. Inadequate caloric intake
(A) Insufficient intake of calories and protein
Under normal circumstances, eating is the only way to take in energy, nutritional deficiencies and wasting are mostly caused by inadequate calorie and protein nutrition, insufficient calorie intake, first by the adipose tissue to provide energy, protein to provide amino acids as a substrate for glycogen isogenesis, such as disasters, wars and poor production areas, calorie deficiency is known as wasting disease (Marimus), people show very obvious wasting, no edema; Insufficient protein intake is called Kwshior-kor disease, often with edema.
(B) Hypothalamic syndrome
A variety of factors lead to hypothalamic injury, the ventral lateral nucleus food bait center (anorexia center) damage, then the ventral medial nucleus satiety center (anorexia center) relative excitement and refusal to eat, anorexia, resulting in wasting, oral, pharynx, larynx, esophagus, cardia lesions lead to pharyngeal difficulties, affecting eating and wasting.
1, oral inflammation, ulcers, injury: such as riboflavin deficiency, oral ulcers due to leukoaraiosis, inflammation, niacinamide deficiency caused by tongue inflammation, dental and gingival lesions.
2, pharynx, throat inflammation, tuberculosis, cancer.
3, esophageal inflammation or stenosis, esophageal cardia carcinoma, achalasia or stenosis.
4, cerebral nerve palsy, ball palsy.
5, myasthenia gravis, polymyositis, systemic sclerosis, etc. causing esophageal muscle damage.
(D) Gastrointestinal diseases
Such as chronic gastritis, peptic ulcer, gastric cancer, pyloric stenosis, incomplete intestinal obstruction, after major gastrectomy, etc., often cause wasting due to insufficient nutrient intake.
(E) Malignant tumor
Wasting is often one of the main manifestations of malignant tumors, and the causes of wasting may be.
(1) Lack of appetite is the main factor, especially due to anxiety and treatment response, which aggravates the lack of appetite.
②The rapid growth of tumor consumes energy;
(3) Malignant tumor may produce a metabolic toxin, which decreases the utilization of glucose, increases the oxidative metabolism of free fatty acids, and increases the isomerization of amino acids and lactate to glycogen, and increases the ineffective consumption of ATP.
④Tumor secondary infection, bleeding and exudation make patients with middle and late stage malignant tumor more emaciated.
(vi) Chronic infection
Such as tuberculosis, schistosomiasis, typhoid fever, chronic septic infection, etc. cause patients to lack appetite, fever increases energy consumption, the first symptoms of AIDS patients are wasting, weakness, fever.
(vii) Chronic lesions of important organs or functional failure cause wasting
Such as heart failure resulting in liver and gastrointestinal congestion, edema, chronic pulmonary heart disease resulting in tissue ischemia, hypoxia, severe liver disease such as cirrhosis portal hypertension caused by gastrointestinal stasis edema, liver damage caused by bloating, nausea, and even vomiting, hypoproteinemia, renal failure uremia caused by nausea, vomiting, lack of appetite, etc. All of the above due to lack of appetite affects the intake of nutrients resulting in wasting.
(H) the use of certain drugs often cause lack of appetite and wasting
Such as long-term use of various antibiotics, sulfonamides for the treatment of various infectious diseases, long-term application of aminophylline, p-aminosalicylic acid, amyl chloride, estrogen, etc. can lead to epigastric distension, loss of appetite, thyroxine, amphetamines, etc. can cause a significant increase in metabolic rate, long-term application of laxatives affect the intestinal absorption function can lead to wasting.
(ix) anorexia nervosa, patients in a state of emotional disturbance due to food refusal, weight can drop sharply.
Second, increased loss of nutrients
1, chronic inflammatory bowel disease caused by diarrhea, a large number of nutrients from the gastrointestinal tract and wasting, such as chronic enteritis, chronic bacillary dysentery, ulcerative colitis, intestinal tuberculosis ground Crohn’s disease.
2, after major resection of the small intestine, intestinal disease, blind floor syndrome small intestine is the main site of food digestion and absorption, small intestine lesions resulting in nutrient absorption disorders and wasting.
3, hepatobiliary and pancreatic system diseases, due to insufficient or lack of pancreatic exocrine and bile secretion, so that the digestion and absorption of food is impaired.
4, diabetes mellitus, wasting due to large amount of grapes excreted in the urine, chronic nephritis patients with large amount of proteinuria resulting in hypoproteinemia, the wasting is often masked by edema, large burns, exfoliative dermatitis, large areas of skin erosion, trauma with large amounts of plasma exudation resulting in energy loss.
C. Increased consumption due to increased metabolic rate
Hyperthyroidism or overdose of thyroxine, pheochromocytoma, a large number of catecholamines released into the blood circulation, all increase the metabolic rate, the breakdown of the three major nutrients and oxidative metabolism, despite the extra food, but still a significant weight loss, carcinoid syndrome patients wasting, in addition to diarrhea and malabsorption, increased metabolic rate is also a factor. Other factors include prolonged fever, excessive exercise, and chronic insomnia, which can lead to wasting due to excessive energy consumption.
Diagnosis of wasting.
I. Medical history
(A) Genetic and family history
There is often a family history of physical wasting without pathological manifestations, hyperthyroidism, diabetes mellitus, pheochromocytoma (multiple endocrine adenoma syndrome) often have a family history, certain malignant tumors have a family history of morbidity.
(B) Economic status and dietary habits
If the calorie intake is adequate, whether there is sufficient protein, whether the diet is partial or omnivorous, whether there is raw fish, shrimp, crab, raw vegetables, raw beef and mutton habits, such as raw water red rhizome, plum, root, etc.. Aquatic plants can cause ginger worm disease, parasitic in the small intestine, causing diarrhea, digestive disorders, malnutrition; raw food or eating uncooked fish, shrimp, crab, etc. can be infected with bilharzia; raw food or eating uncooked beef, pork can be infected with tapeworm disease; eating vegetables with parasitic eggs, fruits, unclean drinking water, etc. can be infected with cysticercosis, cysticercosis, ascariasis, etc. Roundworm disease, etc., can cause wasting.
(C) occupation of origin
In the south of China, there are more paddy fields, farmers or fishermen repeatedly contacted with schistosomiasis contaminated epidemic water, infected with schistosomiasis; pastoral areas, contact with cattle and sheep, livestock may be infected with cysticercosis, cysticercosis; hookworm disease and ascariasis to rural areas, severe infection can have wasting, and the disease can be caused by the disease.
(D) other medical history
Ask about history of sexual contact, history of male homosexuality, history of drug use or narcotics, use of unclean or shared needles, etc. can transmit AIDS.
(E) Pay attention to the age of onset of wasting and ask for concomitant symptoms
1, wasting with hyperphagia: Consider hyperthyroidism, diabetes mellitus, pheochromocytoma.
2, adolescent wasting, if accompanied by fever, night sweats, swollen lymph nodes, cough, should exclude tuberculosis; if accompanied by short stature, hepatosplenomegaly, and have been to schistosomiasis endemic areas, should exclude schistosomiasis or other parasitic diseases.
3, wasting accompanied by lack of appetite, nausea, vomiting, diarrhea or swallowing difficulties and other gastrointestinal symptoms should be excluded from gastrointestinal diseases.
4, women should ask about menstrual history, childbirth history, history of postpartum hemorrhage, if there is a history of wasting, amenorrhea, postpartum hemorrhage, should be considered Sihan’s syndrome.
5, wasting with long-term fever: should consider tuberculosis, chronic purulent infections such as liver abscess, infectious diseases, connective tissue diseases, malignant tumors, especially malignant tumors of the liver, lungs and kidneys and leukemia, lymphoma, malignant histiocytosis, etc. can have long-term fever, but the onset of the disease is often preceded by wasting, weakness, lack of appetite, etc.
Second, physical examination
(A) Weight measurement
It should be carried out regularly and compared with the standard weight to understand whether the weight loss is progressive, so that the weight loss of common diseases such as diabetes mellitus, hyperthyroidism, malignant tumors.
(B) Detailed physical examination can often suggest early diagnostic clues
1, the wasting should be measured temperature, blood pressure a heart rate For long-term fever should consider the possible presence of chronic infection, tumor, connective tissue disease, hyperthyroidism, pheochromocytoma; for those who have hypertension (paroxysmal or persistent) should consider the possibility of pheochromocytoma.
2, examination of the oral cavity, skin, hair, lymph nodes, etc.: pay attention to the presence of malnutrition, vitamin deficiency, anemia, edema, etc. Hypopituitarism patients with reduced skin pigmentation, hair loss to pubic hair axillary hair more obvious skin pale, dry, lusterless and genital atrophy. Adison’s disease patients have hyperpigmentation of the skin, lips and oral membranes have pitting blue-black pigmentation of the skin with pressure and friction on the exposed areas, the halo, the perineum, the white line, etc. Hyperthyroidism patients have warm, moist, sweaty skin, tremors when extending the tongue and hands flat, increased heart rate, hyperacusis, etc. There may also be signs such as goiter and protrusion of the eyes. In carcinoid syndrome, there may be episodes of asthma, skin flushing, right heart valve murmur and hepatomegaly, etc. Purple skin spots, hemorrhagic spots and enlarged lymph nodes should be considered as hematological diseases and malignant tumors.
3, other systemic examinations: such as chest, abdomen and neurological examinations are important clues for early diagnosis.
Buy laboratory tests
(A) Blood, urine and fecal routine
1, blood routine abnormalities on the diagnosis of blood diseases, tumors, chronic infections, malnutrition is helpful.
2.Urinary routine and urine relative density test are useful for early diagnosis of renal lesions.
3.Fecal routine and occult blood test are useful for the diagnosis of intestinal inflammation, tumor and parasitic diseases.
(2) Increased blood sedimentation often indicates the presence of tuberculosis, tumor, connective tissue disease and various chronic infections.
IV Instrumental examinations
1. X-ray examination: cranial (pterygoid) chest X-ray, barium meal, barium enema, etc. are useful for the diagnosis of tuberculosis tumors and gastrointestinal lesions.
B-type ultrasound: endoscopy, radionuclide scan, CT MRI SPECT, etc. are important for tuberculosis, malignant tumors and other diseases that cause wasting.
Differential diagnosis of wasting.
I. Somatic wasting
The wasting is non-progressive, often with a family history, no etiology can be found.
Two organic disease wasting
(A) Hypothalamic syndrome
Patients show wasting, anorexia and refusal to eat, mental abnormalities, hypogonadism, abnormal thermoregulation and symptoms related to the cause (see section on hypothalamic syndrome).
(B) hypopituitarism wasting
1, uremia: refers to the syndrome caused by insufficient secretion of antidiuretic hormone (ADH) (pituitary uremia) or defective renal response to antidiuretic hormone (nephrogenic uremia) The causes of pituitary uremia are unknown (also called primary) accounting for 1/3 to 1/2 Hereditary (familial) uremia is rare (accounting for 1%) Secondary is more common because of tumors. Other conditions such as inflammation, granulomatous disease, hematological disease (leukemia), nodular disease, yellow tumor, etc. are also secondary to craniocerebral trauma and surgery. Clinical manifestations are polyuria, thirst, polyhydramnios, low urine relative density <1.006 Partial uremia can be up to 1.010 in severe dehydration Urine osmolality is <200min/kg Most of the heavier patients have anxiety, emaciation lack of sleep, lack of appetite, weakness, etc. The diagnosis is based on the section on abnormal urine volume.
2, anterior pituitary hypofunction (Simmonds disease) due to postpartum hemorrhage is called Sheehan syndrome: is the most common one Other causes of pituitary tumors, craniocerebral trauma and surgical injury, infection or infiltrative lesions, after radiation therapy, etc., due to the anterior pituitary gland prohormone secretion is insufficient or lack of, causing its target gland hypofunction a secondary Russian gland, thyroid gland hyperalgesia group , Sheehan syndrome is caused by postpartum hemorrhage and manifests itself as postpartum absence of milk, amenorrhea, hair loss, genital atrophy, followed by hypothyroidism and hypoadrenocorticism, lack of appetite, emaciation, coldness, weakness, strength, low blood pressure, slow pulse rate, thin and pale skin, hypoglycemia, shock, coma in severe cases. The patient may have psychiatric symptoms, headache and hemianopia due to pituitary tumor, and CT and MRI may show the presence of tumor.
(C) Primary chronic hyperalgesia
Primary chronic hyperaldosteronism, also known as Adison’s disease, is caused by adrenal atrophy (autoimmune) and tuberculosis. The main manifestations are skin and tympanic membrane pigmentation, emaciation, weakness, significant loss of appetite, nausea, low blood pressure, and diagnosis based on.
①Characteristic manifestations:
Urinary 17-OHCS and urinary 17-KS levels are reduced. Plasma ACrIH levels are increased (morning normal values are 4.6~30.6 pmol/L i.e. 21~13 qpg/ml), ACTH excitation test plasma cortisol levels are still lower than normal (<413.85 nmol/L i.e. <15 mg/dl) Abdominal radiographs are seen in some patients in the adrenal region. Calcification.
(iv) Hyperthyroidism
Typical hyperthyroidism includes proptosis, enlargement of the thyroid gland with vascular murmur. There is no difficulty in diagnosing hyperthyroidism. In indifferent hyperthyroidism, there is no hyperphagia, no neurological or cardiovascular excitement, only cachexia, lack of appetite, and in some cases, atrial fibrillation, heart failure, and hypothermia. The diagnosis should be confirmed with the help of thyroid function tests.
(E) Diabetes mellitus
The onset of insulin-dependent diabetes mellitus (IDDM type l) is more rapid, often with obvious polyhydramnios, polyuria, polyphagia, weakness and wasting; non-insulin-dependent diabetes mellitus (NIDDM type 2) develops to a large number of diabetes when weight loss is faster. Blood glucose ≥11.1mmll/L (see section on diabetes)
(F) Chromophobe cell carcinoma
Tumors occurring in the adrenal medulla, sympathetic ganglion or other parts of chromophobic tissue due to paroxysmal or persistent secretion of catecholamines causing paroxysmal or persistent hypertension, headache, sweating, metabolic disorders, increased basal metabolic rate (hyperthyroidism), weight loss, etc., but normal thyroid function tests, the diagnosis is based on the section on hypertension.
Anorexia nervosa (psychogenic)
Most often seen in young women with psychological factors as a trigger, manifesting emotional disorders, fear of being too obese and refuse to eat, deny hunger, deny wasting, long-term refusal to eat, resulting in insufficient calories and protein nutrition, rapid weight loss and even cachexia, may have amenorrhea, slow heartbeat, lower body temperature, but no hair loss, may have increased hair, secondary sex characteristics development is normal, plasma FSH, LH, estrogen levels may be reduced, and the development of the second sex characteristics is normal. The thyroid function test and adrenal cortical function are normal, and the gonadal function can return to normal after the nutritional status is restored.
Other diseases causing wasting
1, chronic wasting diseases, malignant tumors, chronic infectious diseases, chronic infectious diseases such as AIDS and schistosomiasis, etc. See the relevant chapters for details of the diagnostic basis.
2, digestion and absorption disorders caused by wasting, mainly in the oral cavity and throat, esophageal cardia, gastrointestinal diseases, pancreatic and hepatobiliary diseases, see the relevant chapter.
V. Malnutrition wasting
Most commonly seen in infants and young children, famine, war, food plaque, lack of energy (or) protein, mainly manifest weight loss, emaciation, loss of subcutaneous fat, growth retardation, edema, organ dysfunction of various systems, accompanied by vitamin deficiency, anemia, low immunity prone to secondary infections, laboratory tests often anemia, plasma protein (especially clear protein) decreased, lower lipids, blood potassium, blood magnesium often The thyroid function may be low, and the adrenal cortex is normally responsive to ACTH.
Prevention of wasting.
Treatment of the primary cause and a combination of measures including improved nutrition, careful care and prevention of complications.