甲亢hyperthyroidism.ppt

甲亢甲亢hyperthyroidismhyperthyroidismReview contents:Thyroid anatomyThyroid anatomy(position,shape)(position,shape)Thyroid Thyroid-human bodys largest endocrine gland-human bodys largest endocrine gland organs with the most abundant blood supply organs with the most abundant blood supply The The structure structure and and function function unit unit of of the the thyroid thyroid gland gland-thyroid folliclethyroid folliclethethe height height of of follicle follicle epithelial epithelial cells cells is is in in direct direct proportionproportion with with thyroid thyroid function,function,the the sizesize of of follicular follicular cavity cavity is is inversely proportionalinversely proportional with the thyroid function.with the thyroid function.Thyroid hormone secretion Thyroid anatomy(position,shape)anterior pituitaryparaventricular nucleusHypothalamus Anterior PituitaryThyroid glandTRH+TSHThyroid-T4,T3-SRIFn n5-deiodination(outer 5-deiodination(outer ring)ring)T T3 3 activen n5-deiodination(inner 5-deiodination(inner ring)ring)rT rT3 3 inactiveThyroid hormone metabolismRegulatory mechanismsRegulatory mechanismsDefinitionn nHyperthyroidismHyperthyroidism HyperthyroidismHyperthyroidism refers refers to to hyperfunction hyperfunction of of the the thyroid thyroid by by a a variety variety of of causes,causes,which which synthetizes synthetizes and and secrets secrets too too much much thyroid thyroid hormone hormone(TH)(TH),leading leading to to a a series series of of clinical clinical syndrome,with syndrome,with the the increased increased excitabilityexcitability of of bodys bodys nervous nervous system,system,circulation circulation system system and and digestive digestive system system and and hypermetabolismhypermetabolism as the main performance.as the main performance.n nTypical manifestations:Typical manifestations:thyroid hormone hypersecretion syndrome,diffusing thyroid thyroid hormone hypersecretion syndrome,diffusing thyroid enlargement and eye signenlargement and eye sign.Etiological classification Six big types Six big typesn nThyroid Thyroid hyperthyroidismhyperthyroidismn nPituitary Pituitary hyperthyroidismhyperthyroidism hyperthyroidismhyperthyroidismn nTumor Tumor accompanied accompanied syndrome syndrome and/or and/or HCG HCG related related hyperthyroidismhyperthyroidismn nStruma Ovarii Struma Ovarii with hyperthyroidismwith hyperthyroidismn niatrogenic iatrogenic hyperthyroidismhyperthyroidismn ntemporal temporal hyperthyroidismhyperthyroidism：subacute thyroiditissubacute thyroiditis chronic lymphocytic thyroiditis chronic lymphocytic thyroiditis1、Graves disease2、Toxic multinodular goiter3、Toxic Adenoma 4、Multiple autoimmune endocrine syndrome with hyperthyroidism5、Thyroid carcinoma(follicular thyroid carcinoma)6、Neonatal hyperthyroidism 7、Iodine-induced thyrotoxicosis8、TSH receptor gene mutation induced hyperthyroidismGraves Diseasen nGraves Graves Disease Disease GDGD：also also called called toxic toxic diffuse diffuse goiter goiter or or Basedow diseaseBasedow diseasen nrefers refers to to organ-specific organ-specific autoimmunity autoimmunity disease disease withwithTH TH hypersecretionhypersecretion.n nautoimmune autoimmune thyroid thyroid disorders disorders：Graves Graves diseasedisease、chronic chronic lymphocytic lymphocytic thyroiditis thyroiditis and and idiopathic idiopathic myxedema myxedema n noften often accompanied accompanied with with o other ther autoimmune autoimmune diseasedisease：Myasthenia Myasthenia gravis,gravis,systemic systemic lupus lupus erythematosus erythematosus(SLESLE)and autoimmune hemolytic anemia.and autoimmune hemolytic anemia.Thyroid hyperthyroidismAutoimmunity diseaseGraves DiseaseHigh metabolic syndromeThyroid enlargementPretibial myxedemainfiltrating exophthalmos otherhereditry susceptibilitymentaltraumainfectionHumoral immunity anomalyCellular immune anomalyTs cell functionthyroid stimulating antibody TSH receptorTSHantibodyhyperthyroidismFollicle epithelium antigenExtraocular muscle cell edemaretro-ocular fibroblastGraves Ophthalmopathy T cell recognitionEtiology and Pathogenesis t tcommon in common in femalefemale，male:female 1male:female 1：4646；t toccur occur at at every every ageage，common common at at the the age age of of 20402040.Clinical manifestation TH HypersecretionSyndrome goiterEye signSimple exophthalmiaInfiltrating exophthalmos pretibial myxedemaAutoimmune symptomsTH HypersecretionSyndrome hypermetabolismsyndromesystemic symptoms1.Thyrotoxicosis performance(1)Hypermetabolism syndrome(2)Psychology,nervous system(3)Cardiovascular system(4)Digestive system(5)Motor system(6)Genital system(7)Hemopoietic systemhypermetabolismsyndromeAfraid of hot,sweat,weak skin warm and humidGTDM exacerbationTotl cholesterol negative nitrogen balanceweight loss proteolysislipodieresissynthesis Sugar absorption utilizationglycogenolysisheat productionheat losespirit,nervedigestive systemmotor systemgenital system hemopoietic systemCardiovascular systemNervousness,irritability,insomniaHand,tongue fine tremorPalpitation,arrhythmiaSBP DBP pulse pressureEat more,easy hungerDefecate number increaseLimb muscle weaknesshypokalemia periodic paralysisMenstruation to reduce or amenorrheaMale impotence,breast developmentTotal white blood cellsLymphatic and mononuclear cells2.GoiterInspection:diffuse symmetric enlargement,butterfly-shape,move up and down when swallowing.Palpation:soft,more tough with long illness,no tenderness,with tremor.Auscultation:vascular murmur(bruit)GoiterDiffuse,symmetric enlargementWith swallowing activitiesSwelling degree and illness not parallel tremor,murmurs inleft,right lobe,upper lower poleCharacteristics:diffuse symmetric enlargement,soft,no tenderness,move up and down with swallowing.Tremor and vascular murmur can be heard.3.Eye sign 25%-50%25%-50%with exophthalmos with exophthalmossimplesimple：drydry、benighbenigh、non invasivenon invasiveinvasiveinvasive：edematous edematous、malignantmalignantDegree of exophthalmosexophthalmoslevel 0：No physical signs or symptoms.The United States thyroid ophthalmopathy association:NOSPECS grade.level 1：Only signs,no symptoms.Signs only include upper eyelid contracture、gaze、exophthalmos exophthalmos degreedegree within 22mm.level 2：With signs and symptoms.Soft tissue involvement Degree of exophthalmosexophthalmoslevel 3：Proptosis22mmlevel 4：Extraocular muscle invalvementlevel 5：Corneal invalvementlevel 6：Sight loss or loptic nerve involvement Differentiate between simple and invasive exophthalmossimple/benigninvasive/malignant symptomno photophobia,watering,foreign body sensationconjunctival congestive edemaExophthalmia degreesymmetrypathogenesis18mm18mmobvious exophthalmoslead to hypophasisbilateral symmetrydegree inequality（3mm）Sympathetic nerve excitementautoimmunity Exophthalmia degree Exophthalmia degree18mm18mm twinkling eye movement decrease,gaze(twinkling eye movement decrease,gaze(Stellwag Stellwag syndromesyndrome)Poor convergence Poor convergence（MobiusMobius syndromesyndrome）P Palpebral fissure broadening,corneal margin alpebral fissure broadening,corneal margin exposed when look at the front horizontallyexposed when look at the front horizontally Upper eyelid contracture(Upper eyelid contracture(Von grafe syndromeVon grafe syndrome)When we look up When we look up,the forehead the forehead skin skin can not can not puckerpucker（JoffroyJoffroy syndromesyndrome）Simple/benign exophthalmosExophthalmiaExophthalmiaExopthalamos in Graves DiseaseLid Lag in Graves DiseaseProminent exophthalmos,activity limited,Prominent exophthalmos,activity limited,asymmetricasymmetricEyelids swelling,no closure,serious:eyeball Eyelids swelling,no closure,serious:eyeball fixationfixationPhotophobia,tears,diplopia,strabismus,eye Photophobia,tears,diplopia,strabismus,eye distending pain,stabbing pain distending pain,stabbing pain I Impaired vision,constriction of visual field mpaired vision,constriction of visual field Corneal exposed Corneal exposed、Ulcer oUlcer or r panophthalmitispanophthalmitis blindnessblindnessinvasive/malignant exophthalmosClinical manifestation of special typesn n1,Hyperthyroidism crisis serious performance,with high fatality rate n n2,Hyperthyroidism heart disease n n3,Indifferent hyperthyroidismn n4,T3 hyperthyroidismn n5,Gestation hyperthyroidismn n6、GRAVES ophthalmopathy with normal Thyroid function pretibial myxedemaanterior lower tibia 1/3 symmetry skin coarsening thickening，clear boundary Red brown or dark purple bumps rough nodulesSurrounding skin becomes thin,shiny，desquamation,hair follicle keratinizationanterior lower tibia 1/3 anterior lower tibia 1/3 symmetrsymmetry yskin coarsening thickeningskin coarsening thickeningclear boundary clear boundary,bumps bumps rough nodulrough nodulhyperesthesia or hyperesthesia or hypoaesthesia,hypoaesthesia,itchy sensation,itchy sensation,late stage:late stage:orange dermoid,barkorange dermoid,barkLaboratory test of Hyperthyroidismyperthyroidismn n1 1、TT3TT3、TT4TT4、FT3FT3、FT4FT4n n2 2、TSHTSHn n3 3、T Thyroid iodine uptakehyroid iodine uptaken n4 4、T3 inhibition testT3 inhibition testn n5 5、TRH StimulationTest TRH StimulationTest n n6 6、T Thyroid antibodhyroid antibody y：significance in early significance in early diagnosis,drug withdrawal,and recurrence.diagnosis,drug withdrawal,and recurrence.99.95%T499.5%T3-TBG、ALB.TT4、TT3FT4、FT3 Pregnancy,estrogen,viral hepatitisAndrogen,low protein,prednisoneTBG:thyroxine-binding globulinTSHmost sentitiveThyroid stimulating hormone Thyroid stimulating hormone（TSHTSH）Theoretically:Theoretically:TSH is a sensitive index which reflects TSH is a sensitive index which reflects hypothalamus-pituitaria-adrenal gland axis function,in hypothalamus-pituitaria-adrenal gland axis function,in thyroid hyperthyroidism TSH level will be thyroid hyperthyroidism TSH level will be reducedreduced due due to to feedback inhibition feedback inhibition,which can be used to identify ,which can be used to identify the etiology of hyperthyroidismthe etiology of hyperthyroidism.In fact:In fact:the accuracy of low TSH is affected by the the accuracy of low TSH is affected by the sensitivity of detection methodsensitivity of detection method,general test method,general test method cant distinguish between thyroid hyperthyroidism and cant distinguish between thyroid hyperthyroidism and normal person.normal person.Functional test TRH Stimulation Test timetime正常正常 甲亢甲亢TSHTSHThyroid autoantibody testn nTSAbTSAb(Thyroid Stimulating Antibody)(Thyroid Stimulating Antibody)is an is an important index reflecting disease activity,relapse important index reflecting disease activity,relapse and drug withdrawer after treatment.and drug withdrawer after treatment.n nThyroglobulin antibody(TGAb)thyroid Thyroglobulin antibody(TGAb)thyroid antimicrosomal(TMAb)antimicrosomal(TMAb)：50%90%of GD 50%90%of GD patients is positive,but with low concentration.patients is positive,but with low concentration.Thyroid iodine131absorption rateThyroid nuclide scan(ECT)after iodine uptake3h25%，24h45%earlier peak technetium uptakeparameter10affected by iodized food,drug nephrotic syndromestress and malabsorptionless affected repeatable in the short termnot used in thyroid cancer functionimagefunctionIdentificate thyroid noduledifferentiate goiter、thyroiditis、iodine-induced hyperthyroidismImage examination Functional testIodine absorption rate determinationNormal：3h5%25%；24h20%50%absorption rate3h3h24h24h正常正常甲亢甲亢25%75%50%Diagnosisfunctional diagnosis“Thyroid hyperthyroidism”etiological diagnosis“autoimmunity disease”T3、T4TSH TSH TSAb invasive exophthalmosPretibial myxedemaTH hypersecretion syndromeGraves Diseasego to the wardTreatment drug therapyRadioactive 131 I treatmentsurgical treatmentpositive curative effectsafe to usetreatment course longHigh recurrence rateSimple safe and effectivehigh cure ratemorecomplicationshigh incidence of HypothyroidismIndicationdrug therapyRadioactive 131 I treatmentsurgical treatmentbasic treatment 25Moderate to severe hyperthyroidismpoor drug effect Drug allergy or refusalUnfavorable surgery or postoperative relapsesHigh function nodulesBefore and after radiationsubsternal Goiter with hyperthyroidismNodular goiter with hyperthyroidismantithyroid drugs blockers blockers Thyroid Tabletspropylthiouracil(PTU)Inhibit TH synthesistapazoleInhibit T4 toT3granulocytopeniahepatic lesionrelapserashDrug therapyblockblockAsthma or wheezing bronchitis 1 1 blockersblockersgoiter or exophthalmia aggravation after treatmenMethylthiouracil（MTU）Propylthiouracilum（PTU）Methimazole（tapazoleMM）CarbimazoleCMZ）Common drugs：Thioureas,imidazoleRadioactive 131 I treatmentMechanism contraindicationcomplicationThyroid take in concentrated iodinegreatly131I releaseradiationradiationdamage follicledamage follicle epithelium epitheliumInhibit thyroid endolymph cell antibody generationpregnancy、breast-feed25leukopeniaactive TBImportant organ failureSevere malignant exophthalmiahyperthyroidism crisisThyroid cannot take in iodinehypo-Radioactive thyroiditisOperative treatmentcontraindication preparationcomplicationSevere malignant exophthalmiaearly and late Pregnancy surgery intolerancemild illnessAnti hyperthyroidism drugsCompound Iodine Solution HR80b/mT3、T4 Normalairway obstruction thyroid crisisParathyroid functionHypothyroidism