What is the workup for a patient with early satiety and weight loss?

Workup for Early Satiety with Weight Loss

In a patient presenting with early satiety and weight loss, malignancy must be excluded first through upper endoscopy, with particular attention to gastric and pancreatic cancer, followed by evaluation for chronic mesenteric ischemia in elderly patients with atherosclerotic risk factors, and then assessment for gastroparesis or functional dyspepsia if structural disease is ruled out. 1, 2

Initial Diagnostic Priorities

Rule Out Malignancy First

• Upper endoscopy with biopsy is mandatory as the initial diagnostic test to exclude gastric adenocarcinoma, which classically presents with early satiety and weight loss >10% 2, 3
• Gastric cancer patients typically present with anorexia, early satiety, and weight loss, often with advanced disease at presentation 3
• Consider pancreatic malignancy evaluation with CT abdomen/pelvis if endoscopy is negative, as pancreatic cancer causes gastric outlet/duodenal obstruction in up to 10% of patients, manifesting as early satiety, nausea, postprandial vomiting, and weight loss 1
• In women, evaluate for ovarian cancer with pelvic imaging, as advanced disease causes early satiety through ascites and abdominal masses 2

Chronic Mesenteric Ischemia in Appropriate Populations

• In elderly patients with atherosclerotic risk factors, history of weight loss, and early satiety, chronic mesenteric ischemia should be strongly considered 1
• The classic triad includes postprandial abdominal pain 30-60 minutes after eating, weight loss, and food avoidance, with early satiety as an associated symptom 1
• CTA abdomen and pelvis provides the best accuracy for grading mesenteric vessel stenosis with sensitivity and specificity of 95-100%, superior to MRA and ultrasound 1
• US duplex Doppler can serve as initial screening with peak systolic velocity cutoffs of 295 cm/s for 50% stenosis and 400 cm/s for 70% stenosis in the superior mesenteric artery 1

Secondary Evaluation for Motility Disorders

Gastroparesis Assessment

• Gastric emptying scintigraphy is the gold standard for diagnosing gastroparesis and must be performed for at least 2 hours, with 4-hour testing providing higher diagnostic yield 2
• Gastroparesis presents with early satiety, postprandial fullness, nausea, vomiting, bloating, and abdominal pain without mechanical obstruction 2
• Early satiety severity in gastroparesis correlates with gastric retention severity, decreased BMI, and reduced quality of life 4
• Common etiologies include diabetic gastroparesis (25% of cases), idiopathic, medication-induced, and post-surgical 2

Functional Dyspepsia Consideration

• Functional dyspepsia is diagnosed when upper endoscopy excludes structural disease and presents with bothersome epigastric pain, postprandial fullness, or early satiation 2
• Impaired fundic accommodation occurs in 40% of functional dyspepsia patients and is associated with early satiety and weight loss 5
• The presence of early satiety as a severe symptom is a good predictor of impaired accommodation 5

Special Population Considerations

Cancer Patients

• In patients with known cancer, assess for cachexia using weight loss criteria: >5% or >2% in patients with BMI <20 kg/m² or skeletal muscle depletion 1
• Evaluate for constipation first, as this is a reversible cause that must be addressed before considering prokinetic agents 1
• Early satiety in cancer patients correlates with anorexia severity and limits nutritional intake, though patients rarely volunteer this symptom 6
• Consider pancreatic enzyme replacement with pancrelipase if exocrine pancreatic insufficiency is present, as this can improve digestion and nutrient absorption 1

Cardiac Amyloidosis

• GI symptoms occur through multiple mechanisms: mucosal involvement causing malabsorption, neuropathic involvement causing dysmotility, and vascular involvement causing ischemia 1
• Modified body mass index (serum albumin × BMI) <600 kg/m²·g/L indicates poor nutritional status and poor prognosis 1
• Endoscopy with Congo red staining is the gold standard for confirming GI amyloid deposition, though this only demonstrates mucosal involvement 1

Critical Pitfalls to Avoid

• Never assume functional dyspepsia or gastroparesis without first excluding malignancy through endoscopy, as gastric cancer can present identically 2, 3
• Do not overlook chronic mesenteric ischemia in elderly patients with atherosclerotic disease, as this requires urgent vascular intervention 1
• Avoid initiating prokinetic therapy before ruling out mechanical obstruction, as this can worsen outcomes 2
• In cancer patients, address reversible causes (constipation, depression, pain, nausea) before attributing symptoms to cachexia or initiating appetite stimulants 7