甲亢Hyperthyroidism

Yu Yu(Fanny),Hyperthyroidism,2012.10.29,Review contents:,Thyroid anatomy (position, shape) Thyroid - human bodys largest endocrine gland organs with the most abundant blood supply,The structure and function unit of the thyroid gland - thyroid folliclethe height of follicle epithelial cells is in direct proportion with thyroid function, the size of follicular cavity is inversely proportional with the thyroid function .,Thyroid hormone secretion,Thyroid anatomy (position, shape),anterior pituitary,paraventricular nucleus,Thyroid,5-deiodination (outer ring) T3 active5-deiodination (inner ring) rT3 inactive,Thyroid hormone metabolism,Regulatory mechanisms,Comparison of T3 and T4,T4,T3,Name,thyroxine,triiodothyronine,Origin,Protein affinity,Free concentration,thyroid,T4 deiodination in peripheral tissue,strong,weak,0.03%,0.3%,Half-life period,long（1w）,short（1d）,strong（TH 65%）,weak,activity,Definition,Hyperthyroidism Hyperthyroidism refers to hyperfunction of the thyroid by a variety of causes, which synthetizes and secrets too much thyroid hormone (TH), leading to a series of clinical syndrome,with the increased excitability of bodys nervous system, circulation system and digestive system and hypermetabolism as the main performance.,Typical manifestations: thyroid hormone hypersecretion syndrome, diffusing thyroid enlargement and eye sign.,Etiological classification,Six big typesThyroid hyperthyroidismPituitary hyperthyroidism hyperthyroidismTumor accompanied syndrome and/or HCG related hyperthyroidismStruma Ovarii with hyperthyroidismiatrogenic hyperthyroidismtemporal hyperthyroidism：subacute thyroiditis chronic lymphocytic thyroiditis,1、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 hyperthyroidism,Graves Disease,Graves Disease GD：also called toxic diffuse goiter or Basedow disease,refers to organ-specific autoimmunity disease withTH hypersecretion.,autoimmune thyroid disorders ：Graves disease、chronic lymphocytic thyroiditis and idiopathic myxedema,often accompanied with other autoimmune disease：Myasthenia gravis, systemic lupus erythematosus (SLE) and autoimmune hemolytic anemia.,Thyroid hyperthyroidism,Autoimmunity disease,Graves Disease,High metabolic syndrome,Thyroid enlargement,Pretibial myxedema,infiltrating exophthalmos,other,hereditry susceptibility,mentaltrauma,infection,Humoral immunity anomaly,Cellular immune anomaly,Ts cell function,thyroid stimulating antibody ,TSH receptor,TSHantibody,hyperthyroidism,Follicle epithelium antigen,Extraocular muscle cell edema,retro-ocular fibroblast,Graves Ophthalmopathy,T cell recognition,Etiology and Pathogenesis,common in female，male:female 1：46；occur at every age，common at the age of 2040.,Clinical manifestation,TH HypersecretionSyndrome,goiter,Eye sign,Simple exophthalmia,Infiltrating exophthalmos,pretibial myxedema,Autoimmune symptoms,TH HypersecretionSyndrome,hypermetabolismsyndrome,systemic symptoms,1. Thyrotoxicosis performance,(1) Hypermetabolism syndrome,(2) Psychology, nervous system,(3) Cardiovascular system,(4) Digestive system,(5) Motor system,(6) Genital system,(7) Hemopoietic system,hypermetabolismsyndrome,Afraid of hot, sweat, weak skin warm and humid,GTDM exacerbation,Totl cholesterol ,negative nitrogen balanceweight loss,proteolysis,lipodieresissynthesis,Sugar absorption utilizationglycogenolysis,heat productionheat lose,spirit, nerve,digestive system,motor system,genital system,hemopoietic system,Cardiovascular system,Nervousness, irritability, insomniaHand, tongue fine tremor,Palpitation,arrhythmiaSBP DBP pulse pressure,Eat more, easy hungerDefecate number increase,Limb muscle weaknesshypokalemia periodic paralysis,Menstruation to reduce or amenorrheaMale impotence, breast development,Total white blood cellsLymphatic and mononuclear cells,2. Goiter,Inspection: 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),Goiter,Diffuse, symmetric enlargementWith swallowing activities,Swelling degree and illness not parallel,tremor, murmurs inleft,right lobe,upper lower pole,Characteristics: diffuse symmetric enlargement,soft, no tenderness, move up and down with swallowing. Tremor and vascular murmur can be heard.,3. Eye sign,25%-50% with exophthalmossimple：dry、benigh、non invasiveinvasive：edematous 、malignant,Degree of exophthalmos,level 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 degree within 22mm.,level 2：With signs and symptoms. Soft tissue involvement,Degree of exophthalmos,level 3：Proptosis22mm,level 4：Extraocular muscle invalvement,level 5：Corneal invalvement,level 6：Sight loss or loptic nerve involvement,Differentiate between simple and invasive exophthalmos,simple / benign,invasive/malignant,symptom,no,photophobia, watering, foreign body sensationconjunctival congestive edema,Exophthalmia degree,symmetry,pathogenesis,18mm,obvious exophthalmoslead to hypophasis,bilateral symmetry,degree inequality（3mm）,Sympathetic nerve excitement,autoimmunity,Exophthalmia degree18mm twinkling eye movement decrease, gaze(Stellwag syndrome) Poor convergence（Mobius syndrome）Palpebral fissure broadening, corneal margin exposed when look at the front horizontally Upper eyelid contracture(Von grafe syndrome) When we look up, the forehead skin can not pucker（Joffroy syndrome）,Simple / benign exophthalmos,Exophthalmia,Exophthalmia,Exopthalamos in Graves Disease,Lid Lag in Graves Disease,Prominent exophthalmos, activity limited, asymmetricEyelids swelling, no closure, serious: eyeball fixationPhotophobia, tears, diplopia, strabismus, eye distending pain,stabbing pain Impaired vision, constriction of visual field Corneal exposed、Ulcer or panophthalmitis blindness,invasive/malignant exophthalmos,Clinical manifestation of special types,1, Hyperthyroidism crisis serious performance, with high fatality rate,2, Hyperthyroidism heart disease,3, Indifferent hyperthyroidism,4,T3 hyperthyroidism,5, Gestation hyperthyroidism,6、GRAVES ophthalmopathy with normal Thyroid function,pretibial myxedema,anterior lower tibia 1/3 symmetry,skin coarsening thickening，clear boundary Red brown or dark purple bumps rough nodules,Surrounding skin becomes thin, shiny，desquamation ,hair follicle keratinization,anterior lower tibia 1/3 symmetryskin coarsening thickeningclear boundary , bumps rough nodul,hyperesthesia or hypoaesthesia ,itchy sensation,late stage:orange dermoid, bark,Laboratory test of Hyperthyroidism,1、TT3、TT4、FT3、FT42、TSH3、Thyroid iodine uptake4、T3 inhibition test5、TRH StimulationTest 6、Thyroid antibody：significance in early diagnosis, drug withdrawal,and recurrence.,99.95%T499.5%T3-TBG、ALB.,TT4、TT3,FT4、FT3,Pregnancy, estrogen, viral hepatitis,Androgen, low protein, prednisone,TBG: thyroxine -binding globulin,TSHmost sentitive,Thyroid stimulating hormone （TSH）Theoretically: TSH is a sensitive index which reflects hypothalamus-pituitaria-adrenal gland axis function ,in thyroid hyperthyroidism TSH level will be reduced due to feedback inhibition , which can be used to identify the etiology of hyperthyroidism.,In fact: the accuracy of low TSH is affected by the sensitivity of detection method, general test method cant distinguish between thyroid hyperthyroidism and normal person.,Functional test TRH Stimulation Test,time,正常 甲亢,TSH,Thyroid autoantibody test,TSAb(Thyroid Stimulating Antibody) is an important index reflecting disease activity, relapse and drug withdrawer after treatment.,Thyroglobulin antibody (TGAb) thyroid antimicrosomal (TMAb)： 50% 90% of GD patients is positive, but with low concentration.,Thyroid iodine131absorption rate,Thyroid nuclide scan(ECT),after iodine uptake3h25%，24h45%earlier peak,technetium uptakeparameter10,affected by iodized food, drug nephrotic syndromestress and malabsorption,less affected repeatable in the short termnot used in thyroid cancer,function,image,function,Identificate thyroid nodule,differentiate goiter、thyroiditis、iodine-induced hyperthyroidism,Image examination,Functional testIodine absorption rate determinationNormal：3h5% 25%；24h20% 50%,absorption rate,3h,24h,正常甲亢,25%,75%,50%,Diagnosis,functional diagnosis “Thyroid hyperthyroidism”,etiological diagnosis“autoimmunity disease”,T3、T4TSH ,TSAb ,invasive exophthalmos,Pretibial myxedema,TH hypersecretion syndrome,Graves Disease,go to the ward,Treatment,drug therapy,Radioactive 131 I treatment,surgical treatment,positive curative effect,safe to use,treatment course long,High recurrence rate,Simple safe and effective,high cure rate,morecomplications,high incidence of Hypothyroidism,Indication,drug therapy,Radioactive 131 I treatment,surgical treatment,basic treatment, 25,Moderate to severe hyperthyroidism,poor drug effect,Drug allergy or refusal,Unfavorable surgery or postoperative relapses,High function nodules,Before and after radiation,substernal Goiter with hyperthyroidism,Nodular goiter with hyperthyroidism,antithyroid drugs,blockers,Thyroid Tablets