Download - Structure and location of thyroid gland
Thyroid gland diseases. Diffuse toxic goiter. hypothyreosis. Endemic goiter. Etiology. Clinical picture.
Diagnostics. Complications. Principles of treatment. Thyrotoxic
crisis. Hypothyreoid coma. Emergency care
Structure and location of thyroid gland
Physiological actions of thyroid hormones
Protein metabolismProtein metabolism – – stimulation of protein synthesisstimulation of protein synthesis;; CarbohydrateCarbohydrate metabolismmetabolism – – acceleration of their resorption from acceleration of their resorption from intestine and consumption by a liverintestine and consumption by a liver;; Fat metabolismFat metabolism - - acceleration of lipolysisacceleration of lipolysis, , cholsterol synthesis and cholsterol synthesis and metobolismmetobolism;;Liquid exchangeLiquid exchange - - intensification of water evacuation by kidneysintensification of water evacuation by kidneysMineral homeostasisMineral homeostasis – – regulation of regulation of Са, К, Р, С Са, К, Р, Сl metabolism.l metabolism.Increased oxygen consumption with all tissues (except of brain tissue, spleen and testes); Increased heat production; Increased amount of catecholamine receptors in myocardium;Regulation of respiratory centre;Stimulation of erythropoiesis;Stimulation of bone tissue formation and resorption.
Influence of thyroid Influence of thyroid hormones on an hormones on an
organismorganism::
Influence of thyroid Influence of thyroid hormones on an hormones on an
organismorganism::Nervous system and psychicNervous system and psychicNervous system and psychicNervous system and psychic
Cardiovascular systemCardiovascular systemCardiovascular systemCardiovascular system
Skin and intertgumentsSkin and intertgumentsSkin and intertgumentsSkin and intertguments
Digestive systemDigestive systemDigestive systemDigestive system
Musculosceletal apparatusMusculosceletal apparatusMusculosceletal apparatusMusculosceletal apparatus
Reproductive systemReproductive systemReproductive systemReproductive system
Endemic goitreEndemic goitre
This is a disease manifested This is a disease manifested with thyroid gland enlargement. with thyroid gland enlargement. It develops in certain It develops in certain biogeochemical regions biogeochemical regions characterized by iodine characterized by iodine deficiency in the environmentdeficiency in the environment
EthiologyEthiology
• Iodine deficiency is the main obvious factorIodine deficiency is the main obvious factor• Additional factors:Additional factors:• deficiency of microelements deficiency of microelements cobalt, copper, fluorine, cobalt, copper, fluorine,
zinc, molybdenumzinc, molybdenum (participate in iodine metabolism) (participate in iodine metabolism);;Influence of Influence of strumogensstrumogens – – substances which decelerate substances which decelerate biosynthesis of thyroid hormonesbiosynthesis of thyroid hormones HHypersecretionypersecretion of of thyrotrophic hormone (TTH) by thyrotrophic hormone (TTH) by hypophysishypophysis
• Diseases of digestive tract, a liver with disordered iodine Diseases of digestive tract, a liver with disordered iodine absorption.absorption.
Palpation of thyroid glandPalpation of thyroid gland Position of patient is upright with relaxed neck muscles, the neck is
slightly bended forward.
Position of a doctor may be behind (I variant) or before the patient (II variant).
A doctor performs palpation with tip of his fingers. In I variant of palpation examiner puts four fingers of both hands (except of thumbs) in projection of left and right parts of cricoid process. In II variant the examiner puts thumbs of his fingers in the same points (see next pictures).
A patient is asked to swallow saliva (a gland goes up and becomes more accessible both a review and palpation).
During swallowing doctor’s fingers slide across thyroid gland lobes and the isthmus.
The following properties of the gland are to be assessed: location, pain, size, symmetry, consistency, structure (homogenous or with nodes).
Palpation may be performed, if a doctor
stands behind or before the patient, his arms are put at
the zone of projection of the gland
Classification of thyroid gland Classification of thyroid gland enlargementenlargement ( (WHPOWHPO, 1995), 1995)
Degre Characteristics 0 Thyroid gland is not palpate, its sizes
are less then a medial phalange of human’s thumb
I а Thyroid gland is more than a distale phalange medial phalange of human’s thumb, a gland may be palpated bu is not visible in any position of patient’s head
І б Thyroid gland is palpable and visible in if the patient bends his head backward
II Thyroid gland is palpable and visible in any position of a patient
ІІІ «Sick neck», changed configuration of te neck, thyroid gland is visible t te distance
Classification of thyroid gland Classification of thyroid gland enlargementenlargement ( (WHPOWHPO, , 20012001))
Degree of enlargement – 0Goitre is absent (sizes of both lobules
don’t exceed medial phalange of human’s
thumb
Degree of enlargement - І Thyroid gland is palpable but is not
visible in normal position of patient’s
neck: nodal formations which don’t cause
thyroid gland enlargement
Degree of enlargement - ІІ Thyroid gland is visible in any position of
the patient
Diagnostics
•1. Anamnesis – residence in endemic region
• 2. Palpation of thyroid gland – thyroid gland is enlarged, painless, homogenous, mild-elastic
• 3. Level of thyroid hormones: Т4,Т3 - normal, ТТH normal or increased3. Ultrasound examination of thyroid gland
Nodal goitre
Treatment
• 1. 1. Thyroid hormonesThyroid hormones – – L-thyroxinL-thyroxin - 5 - 500-100 -100 ммcgcg//dd;;2. 2. Iodinum preparationsIodinum preparations – 1 – 10000-200-200 м мcgcg//dd
• Prophylaxis of iodine defficiensyProphylaxis of iodine defficiensy• Iodinum-containing productsIodinum-containing products ( (saltsalt, , bredbred, , milkmilk); );
22. . Iodinum preparationsIodinum preparations:: iodide potassiumiodide potassium, , lipiodollipiodol 100-200 100-200 ммcgcg//dd..
Epidemiology
Spreading of thyrotoxicosis is about 0,5 %
DTG often develops in the age 20-50 years.
Females develop this disease in 5-7 times
more often than males
Diffuse toxic goitre (DTG)Diffuse toxic goitre (DTG)
Ethiology and provoking factors
stress;Infectious diseases;insolation;smocking;Inflammatory processes in thyroid
glandHormonal disbalanceheredity
Pathogenesis
• Deficiency of T-supressors
• CD4+, CD8+
• T- and B-lymphocytes recognizing thyroid gland antigens
• antigenspecific stimulation of B-lymphocytes
• Production of stimulating antibodies to TTH receptors
Clinical patternComplaints
• Nervous system –tearfulness, depression, deranged sleep, irritability, oversweating
Cardiovascular system – Permanent palpitation, periodical
intermissions, dyspnea• Metabolism – poor tolerance to heat, low body weight while
appetite is increased, muscular weakness
Digestive tract - increased appetite; abdominal pain; periodical
diarrhoea
Ophthalmopathy – feeling of protrusion of eyes, dacryagogue;
photophobia
Interguments – brittle hair, loosing hair.
Objective examination
Red dermographism.
Cardiovascular system – tachicardia, extrasystoly, atrial
fibrillation; Intensification of І heart sound, systolic murmur, Heart failure; Systolic arterial hypertension Sex glands – Disorders of menstrual function and
problems with pregnancy in females, impotence in males Nervous system – Emotional lability, irritability; Tremor of the body (symptom of «telegraph post»)
especially nails of hands (Mary symptom).
• Metabolism – subfebrile body temperature, skin is warm
Low body weight.
Ostheoporosis.
Skin is warm and moist, mild, velvet-like;
Pretibial myxedema
• Thyroid gland is enlarged, of solid-elastic
consistency, systolic murmur above it
• Sex glands – mastopathy, gynecomastia
Ophthalmopathy
• Exophthalmos* Dalrimpl’s sign (wide eye slits)
* Graefe’s sign (white space above cornea if a patient changes point of view from up to down)
* Mebius sign (convergention disorders)
* Elinek’s sign (eyelids hyperpigmentation)
* Stellwag’s sign (rare blinking)
* Rosenbach’s sign (tremor of closed eyelids)
* Kocher’s sign – exposure of the sclera between the lower edge of the upper eyelid and the upper edge of the iris when the eyes are fixed on the upwardly moved object
Laboratory and instrumental examination
• ECG: synus tachicardia, extrasystoly, paroxysmal tachycardia, atrial fibrillation;
Ultrasound examination of a heart: high heart output;
Rogr - cardiomegaly• Metabolism – Increased serum Ca, excretion
of Ca with urine • Digestive tract – Changes of indexes of liver
function
Ocular symptoms
Grefe’s sign
Degrees of severity of thyrotoxicosisMild
Heart rate - less than 100 b/min Body mass defficiensy - less than 10 % Work capacity - preserved or slightly limited
Moderate
Heart rate - 100 - 120 b/min Body mass defficiensy - 10 - 20 % Changes of other organs and systems - ophthalmopathy Work capacity - decreased
Severe
Heart rate - more than 120 b/min, atrial fibrillation Body mass defficiensy - more than 20 % Changes of other organs and systems - ophthalmopathy;
dystrophy of parenchimal organs Work capacity - lost.
Diagnostics of DTGAnamnesis
Provoking factors
Clinical pattern
Signs of thyrotoxicosis and diffuse enlargement of thyroid gland
Laboratory tests
1) Common and free Т3 і Т4 are increased;
2) Increased level of common Т3 and normal Т4 (Т3 – thyrotoxicosis)
3) Decreased level of thyrotrophic hormone (TTH)
4) Increased consumption of radioactive iodinum J131 with thyroid gland
5) High level of antibodies to TTH receptors
Instrumental diagnostics
1) Ultrasound examination of thyroid gland (enlargement and diffuse
decreased density);2) Scintigraphy (insuspiction on retrosternal
goitre and in nodal goitre)
3) Puncture biopsy of thyroid gland is executed for diagnostics of all nodal formations in the gland
Laboratory and instrumental examination
• ECG: synus tachicardia, extrasystoly, paroxysmal tachycardia, atrial fibrillation;
Ultrasound examination of a heart: high heart output;
Rogr - cardiomegaly• Metabolism – Increased serum Ca, excretion
of Ca with urine • Digestive tract – Changes of indexes of liver
function
Ultrsound examination of thyroid gland
Radioisotopic scanogrm of thyrid gland
Puncture biopsy of thyroid gland
Treatment
Antithyroid preparations (propilthiouracil, tiamazol (merkasolil) within 1-2 yearsMercasolil (5 mg) – 30-60 mg per os, gradually decrease dosage till 5-15 mg.Beta-adrenobloquers (metoprolol 50-200 mg/d, bisoprolol 5-10 mg/d, propranolol 80-120 mg/d
Surgical treatmentIndications
Large goitre (over 45 cm3);Compresstion or displacement of trachea,
esophagus or large vessels;Retrosternal goitre;Severe thyrotoxicosis with atrial
fibrillation;No stable effect of medicamentous
treatment.Intolerance of antithyreoid drugs, allergy;Nodal goitre with thyrotoxicosis.
Thyrotoxic crisis
Provoking factors
Trauma or rude palpation of thyroid gland;
Operation on thyroid gland or usage of J131 without previous
medicamentous correction;
Any operative treatment in persons with hidden and unrecognized
thyrotoxicosis;
Inflammatory and infectious diseases;
Abrupt stop of antithyroid drug therapy;
overheating;
Physical and psychic trauma;
Pregnancy and delivery.
Clinical manifestation
Acute beginning; Nervous excitation or psychosis, fear of death; Skin is hot and moist, chande of profound sweating on
skin dryness, face is hyperemud, cianosis of limbs, tongue and lips are dry.
Muscular weakness, adynamia, pareses; Tachicardia, atrial fibrillation, elevation of BP with its
following sudden dropacute left entricular failure; Nausea, vomiting, diarrhoea
Lab tests
Anemia, leukocitosis, decreased hematocrit; elevated Т3
and Т4
Treatment
Inhibition of production and secretion of thyreoid hormpones;
Inhibition of nervous system irritation;
Restoration of adrenal glands function;
Correction of cardiovascular disorders;
Normalization of voter and salt metabolism acid-alkaline
balance;
Treatment of hypoxia, hypertermia
1. Complete physical and emotional rest. Mercasolil 20-30 mg per os.
2. Hydrocortison 200-400 мг (prednisolon 3-5
мг/кг), 0,05 % strophanthin 0,5 ml i/v.
3. Anaprilin 80 mg per os.
4. Reserpin 0,5 mg per os.
5. In nervous excitation – droperidol 2,5 mg.
6. Permanent oxygen therapy, applictaion of cold.
7. In low BP – cordiamin 2 ml subcutaneously.
Hypothyreosis
A disease caused by prolobged permanent thyroid hormones deficiency with following decrease of metabolism and functional disorders in different organs and systems
Epidemiology
Spreading in population 0,2 – 1 %;
Among newborns 0,025 % (1 : 4000);
People over 65 years – 2 – 4 %.
Subclinical and primary hypothyreosis is observed in 7-10 % females and 2 – 3 % males.
Ethiology of congenital hypothyreosis
Primary:
1) Abnormal thyroid gland development – dysgenesia;
2) Disorders of зу Т3 і Т4 syntesis;3) Defect of TTH receptors;4) Iodinum defficiency (endemic cretinism)
Secondary:
Congenital defects of hypophisis – isolated ТТГ defficiency
Tertiary:
Congenital defects of hypothalamus
Perypheral:
resistanse to thyroid hormons
Acquired hypothyreosis
Primary:
1) strumectomia;2) X-ray rtherapy of treatment with radioactive iodinum;
3) medicamentous-induced (зокрема, imidazol derivtives, litium preparation,
iodinum preparations, beta-bloquers, interferon, interleukin-2);
4) authoimmune thyreoiditis, infectious affections of the gland (tuberculosis,
scleroderma etc.);
5) trauma, hemorrhage, tumor;
6) Iodinum deficiency
Secondary
1) Brain commotion;
2) Tumors and metastases;
3) Brain hemorrage, thrombembolism, atherosclerosis;
4) Inflammations ( authoimmune and infectious);
5) Chemical intoxications including drugs (reserpin, parlodel,
apomorphin affect hypophysis, serotonin containing drugs –
affect ypothalamus)
Perypheral:
Inactivation of circulationg Т3, Т4, ТТH, resistance of receptors
Face in hypothyreosis
Hypothyreosis in bnewborns
Pretibial myxoedema
Pretibial myxedema
Clinical patternComplaints
• Metabolism – body mass gain• Skin – dryness, induration and change of color (“wax-
like”), rugged face features, enlargement of foots, speech is not clear, decreased hearing.
Nervous system - somnolence, indisposition, depression,
decreased memory and intellect, frequent headaches,
dizziness; sensitiveness to cold, parestesias, deranged
vision.
Musculoskeletal system – musculaer pains and crumps,
weakness.
• Cardiovascular system – pain in heart region, dyspnea in physical load.
• Digestive system – constipation, decrease appetite, nausea
• Respiratory system – frequent bronchitis exacerbations, pneumonias (body temperature is normal).
• Urogenital system – decreased diuresis, pyelonephritis, decreased potention in males, menstrual-ovarial cycle disorders in females.
Objective examination
• Metabolism - hypothermia, overweight
Skin – dry, cold, yellow, it is nit possible to make skin fold, symptom of dirty elbows and колін; dryness and brittlessness of hair, psilosis, loosing of external parts od eyebroves; nails are sick, with streaks; face is pastous, enlarged lips and a tongue with teeth pattern, hoarse voice
Myxedematous edema (myxaedema)– accumulation of gucosaminoglacals (hialuronic and chondroitinsulfate acids), with accumulation of liquid and sodium in tissues (skin, subcutaneous fat, vocal slits, mucous memvranes.
Nervous system – disordered coordination, poor vision.
Digestive system –tonque enlqrgement with teeth patter on its sides, hepatomegaly, dyskinesia of bile dicts and intestine, ascites.
Cardiovascular system - bradicardia, extrasystoly
Apex beat is low, relative cardiac dullness borders are displaced, weak heart sounds, systolic murmur at the apex, signs of heart failure. BP low or normal.
Respiratory system – superficial breathing, pleuricy.
Thyroid gland – is of normal size or slightly enlarged,mild or of moderat density, painless.
Laboratory and instrumental diagnostics
• Blood – hyperlipoproteidemia, increased level of cholesterol and triglicerides. Anemia (normochromic, hypochromic iron-deffiicency or В12- iron-deffiicency)
Nervous system - Eectroencephalography: decreased amplitude of waves, narroving of vision fields, increased intraocular pressure.
Musculoskeletal system – osteoporosis, sinovial fluid.
Cardiovascular system - ECG: low voltage, sinus
bradicardia, disordered conduction ( P-Q
prolongation), extrasystoly.
Ultrasound of a heart – pericardial effusion, left
ventricular wall sickness.
Digestive system – achlorhydria and authimmune
gastritis.
Urogenital system - decreased diuresis, renal blood
flow and glomerular filtration, moderate proteinuria.
Dry hear
Falling of external eyebroves hair
Periorbital edema
Edematous face dry skin
Diagnostics
Changes of Т3, Т4, ТТH.
Subclinical hypothyreosis – increased TTH, normal Т4.
Primary hypothyreosis – increased TTH, decreased Т4.
Secondary hypothyreosis – decreased TTH, decreased Т4 thyroliberin test is negative
Tertiary hypothyreosis – decreased TTH, decreased Т4 thyroliberin test is positive
Treatment Ethiological treatment of the cause Pathogenetic thyroid hormones 1) poor Т4 (levothyroxin, L-thyroxin, euthirox) – for
prolonged замісної treatment;
2) poor Т3 (thriiodtironin) – is used for diagnostics;3) Combined preparations (tireocomb, tireotom, novotirol)
– is difficult to choose proper dosage.
Hypothyroid comaCauses : unproper treatment of hypothyreosisProvoking factors: overcooling, infections, physical trauna,
operations, myocardial infarction, stress, bleeding, usage of tranquillisers
Clinical manifestation: gradual beginning; affection of nervous system (weaklness, somnolence, inhivited conscioussness), hypothermia, cardiovascular disorders (marked bradicardia, weak heart sounds, hypotension), respiratoryt disorders (bradypnoe, hypercapnia), ishuria, dynamic intestinal obsruction.
- 3) lab tests: anemia, increasd ESR, low serum level of Т3 and Т4, hyperpotassiemia, acidosis, hypoxia.
Treatment
1. Corticosteroids – for prevention of adrenal insufficiency
(hydrocortison 100-150 mg or prednisolon 30-50 mg i/v.
2. 200 мcг of thyroxin, glucous 40% - 60 ml, ISS 500 мл, 5%
ascorbic acid 5 0 i/v.
3. Oxygen. Artificial lung ventilation.
4. In edema and high BP – diuretics (lasix 2 ml i/m), in hypotesion
- mesaton 1% - 0,5-1,0 ml i/v, corglivon 0,06% - 1,0.
5. Antibiotics.
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