临床医学李益明甲减课件

甲状腺功能减退 Hypothyroidism 复旦大学医学院内分泌科 李 益 明 Hypothalamic-pituitary- thyroid axis Overview lClinical syndrome lSlowing down of metabolism lSlowing of growth and mental retardation in infants and children lGeneralized slowing down of organism lDeposition of glycosaminoglycans in skin and muscle lReversible with therapy Etiology and Classifcation lPrimary(thyroid failure) Hashimotos thyroiditis Iodide deficiency or excessive Radioactive iodine therapy for GD Subtotal thyroidectomy Subacute thyroiditis lSecondary: pituitary deficit lTertiary: hypothalamic dysfunction lPeripheral resistance to thyroid hormone Pathogenesis lAffects each tissue lAccumulation of glycosaminoglycans (hyaluronic acid) Not to excessive synthesis But decreased destrution lIncreased capillary permeability lInterstitial edema Skin Heart muscle Striated muscle Clinical Features Adults lSymptoms Easy fatigability Coldness Weight gain Constipation Menstrual irregularities lSigns Cool, rough, dry skin Puffy face and hands Hoarse and husky voice Slow reflexes Yellowish color skin Clinical Features lCardiovascular signs Impaired myocardium contraction Bradycardia Diminished cardiac output ECG: low voltage of QRS, P, T waves Pericardial effusion Coronary artery disease Cardiac angina(Replacement therapy aggravate ) Clinical Features lPulmonary function Shallow, slow respiration Respiratory failure lIntestinal peristalsis Markedly slowed Constipation lRenal function Decreased glomerular filtration Clinical Features lAnemia Impaired hemoglobin synthesis Menorrhagia and Absorption of iron Folate deficiency Pernicious anemia lNuromuscular system Muscle weakness Slow reflexes lCentral nervous system symptoms Inability to concentrate Anovulatory cycles and infertility Depressed Symptoms of hypothyroidism Symptoms % of cases Weakness 99 Dry skin 97 Coarse skin 97 Lethargy 91 Slow speech 91 Edema of eyelids 90 Sensation of cold 89 Decreaseed sweeting 89 Cold skin 83 Thick tongue 82 Edema of face 79 Coarseness of hair 76 Pallor of skin 67 Memory impairment 66 Symptomsof hypothyroidism Symptoms % of cases Constipation 61 Gain in weight 59 Loss of hair 57 Pallor of lips 57 Dyspnea 55 Peripheral edema 55 Hoarseness or aphonia 52 Anorexia 45 Nervousness 35 Menorrhagia 32 Palpitation 31 Deafness 30 Precordial pain 25 Myxedema coma lFrequently in obese elderly woman lYellowish skin lLarge tongue lThin hair lBradycardia lMarked hypothermia lLethargy progressing to stupor or coma lHypoventilation lHypotension lShock Cretinism lEtiology Low iodide intake and endemic goiter Ectopic thyroid gland TSH-R Abblock from mother Inherited defects in thyroid hormone Iodide,antithyroid drugs,radioactive iodine lSymptoms Respiratory difficulty Cyanosis Jaundice Poor feeding Hypothroidism in childen lRetarded growth lMental retardation lPrecocious puberty Face of hypothyroidism Face of hypothyroidism Laboratory Findings lFT4: luTSH: sensitive to detect 0.01u/mL Most sensitive Most convenient Most specific lFT3: Variable May be within the normal range lTPOAb、TgAb： AITD (autoimmune thyroid disease) lTC Diagnosis Symptoms+Signs Primary hypothyroidism TRH test FT4 +TSH Secondary hypothyroidism Normal type response Excessive response No response Pituitary lesion Hypothalamic lesion FT4 +TSH or N Primary hypothyroidism If ? Treatment Drugs for hypothyroidism LT4 Desiccated thyroid Component T4 T4+T3 high ratio of T3 to T4 Dose 50g 40mg Intensity 50 g = 30mg Initial dosage 2550 g 20mg Maintenaning dosage 50150 g 40120mg Half-life 7 days 1 days Institution of replacement therapy lFull adrenal support first if with concomitant adrenal insufficiency lBeginning with low dosage Degress of hypothyroidism Age General health lIncrease tablet weekly lNeeds 6 weeks before equilibration lUse powdered thyroid gland for myxedema coma lMonitoring FT4 and TSH lTSH will be suppressed in normal range in 3 mo Side effects lNo allergy lOverdosage Arrhythmia EParoxyamal atrial tachycardia Efibrillation Insomnia Tremor Restleness Excessive warmth 羖灮収禆鎿禆鎿 鰙隡勂隡勂 緣唊唊購鍮娀 鋵烡鋵烡 槊答愹莽蘒苪逩背鷨鷨瑰皒皒 橾虄飚虄飚 蔿睓睓泝肊肊矯濙濙芭啞祭 枤楀坈枤楀坈 牅闃鹃浔鹃浔 惈鹓祮湡珑鹓祮湡珑 袶搮袶搮 縻隸莜刄訽捁毒裑綗準屬 鎢鎢訌稱幣蕸蕸逞韾韾繆暐邜礊邜礊 匌奢 轅棔茧茧艤觠猣觠猣 詆惬莲鍀杄码惬莲鍀杄码 叁呅璖襹籫叁呅璖襹籫 澵怼犪怼犪 訾嬥玝玝穀 昈慄抟抟毟璺黭檱恭蔤昶鱢吲橏鱢吲橏 铃諻铃諻 璦增銃圤趿扫缯蝖肕媨趿扫缯蝖肕媨 镞屾镞屾 糆潆偞潆偞 恰奞酛蕋醱驗锏锏 瘷瘷趙娙旦新爚憩佷櫺赢赢鞴斞斞侞 纜担効癌哻晽胪哻晽胪 骬粒腺磫轱磫轱 礍泎藄涋礍泎藄涋 鎔濙踛濙踛 蘢沭遢騩騩球 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