thyroid-lecture甲状腺疾病.ppt

DiseasesofThyroid,DiseasesofThyroid,Dysfunctions:Hyper;HypothyroidismInflammatory:Acute;SubacuteThyroiditis;Hashimotos;RiedelsNeoplasm:Adenoma;carcinoma,SurgicalAnatomyandPhysiology,Thefunctionofthethyroidglandistosynthesize,store,andsecretethehormonesthyroxine(T4)andtriiodothyronine(T3).Iodideisabsorbedfromthegastrointestinaltractandactivelytrappedbytheacinarcellsofthethyroidgland.Itisthenoxidizedandcombinedwithtyrosineinthyroglobulintoformmonoiodotyrosine(MIT)anddiiodotyrosine(DIT).ThesearecoupledtoformtheactivehormonesT4andT3,whichinitiallyarestoredinthecolloidofthegland.Followinghydrolysisofthethyroglobulin,T4andT3aresecretedintotheplasma,becomingalmostinstantaneouslyboundtoplasmaproteins.,Thefunctionofthethyroidglandisregulatedbyafeedbackmechanismthatinvolvesthehypothalamusandpituitary.Thyrotropin-releasingfactor(TRF)isformedinthehypothalamusandstimulatesthereleaseofthyrotropin(TSH)fromthepituitary.ThyrotropinbindstoTSHreceptorsonthethyroidplasmamembrane,stimulatingincreasedadenylatecyclaseactivity.ThisincreasescAMPproductionandthyroidcellularfunction.,HyperthyroidismorThyrotoxicosis,Hyperthyroidismisusuallycausedby1.adiffuselyhypersecretinggoiter(Gravesdisease)orby2.amultinodulartoxicgoiter(Plummersdisease).3.Molepregnancy(rare).4.TSH-secretingpituitarytumors,strmaovarii,orotherdisorders.Inallforms,thesymptomsofhyperthyroidismareduetoincreasedlevelsofthyroidhormoneinthebloodstream.,ClinicalFindingsSymptomsandSigns:AThyroid：enlargedwithacceleratebloodstreamBEye：exophthalmosCAutonomicnever：Nervousness,increaseddiaphoresis,activatedonbehavior,hardlyfallingsleep,heatintoleranceDCardiovascularsystem：tachycardia,palpitations，HR100/m，eveninrestEBMR：increasedsignificantly，wild+20-30%，middle+30-60%，severe+60%Othersfatigue,andweightloss，increasedpeptidemenoupausesyndrom,flushedandstaringappearance.Theskiniswarm,thin,andmoist,andthehairisfine.,Thecausesofhyperthyroidismareremainedunknown.Long-actingthyroidstimulator,LATSThyroidstimulatingantibody,TSAbThyroidstimulatingimmunoglobulin,TSITheycouldbecombinedwiththereceptorofTSH,increaseadenylatecyclaseactivityanfconsequentlygenerategreatamountofT3T4,ThepatientonthevergeofthyroidStormhasaccentuatedsymptomsandsignsofthyrotoxicosis,withhyperpyrexia,Tachycardia,cardiacfailure,neuromuscularexcitation,delirium,orjaundice.,Treatment,AntithyroiddrugRadioiodineSubtotalthyroidectomy*,Managementaboutsurgery,Indicationsandcontraindications,IndicationsToxicmultinodulegoiterForGravesdisease*Enlargedgoiter,resistanttoradioiodine;*Withsymptomsoftracheoesophagealpressure;*Childrenorteenagers?*Concernofmalignancy;*Fearfulorrefusedtoradioiodinetherapy;*Pregnantpatientswhosesymptomsaredifficultlycontrolled;,Preoperativepreparation,Subtotalthyroidectomyshouldbeperformedafterthyrotoxicsisiscontrolledmedically.*Propylthiouracila.inhibitthyroidhormonesynthesisb.limitperipheralconversionofT4toT3*Lugolssolutioncontainiodine5gmper100mla.decreasethevascularityb.inhibitT3and/orT4releasingfromThyroglobulin,butnotthesynthesisingofthem.,ExtentofSurgery,IncisioncollarincisionStrapmuscleroutinelysectionedCarotidsheathcarotidA.jugularV.vagusN.RecurrentLaryngealNeverParathyroidpreservation,Collarincisionismade2cmabovesuprasternalnotch.Theprincipleoftheresectionisexcisionofmostofeachlobe,isthmus,pyramidallobe,divisionandligationofSuper.TVessels,middlethyroidvein,infer.Tveinwithremnantofeachshouldweighapproximately3-4grams.TheITA,RLN,externalbranchofSLNandparathyroidshouldbeleftintact.,Complications,Hemorrhage,hematomaInfectionInjuryofRLNand/orSLNHypocalcemiaThyrotoxicstormAirwayobstructionHypothyroidismRecurrenthyperthyroidism,Benignneoplasms,AdenomaFollicularPapillaryAtypicalTeratoma,ClinicalFeatures,1.Mass,growslowly,remainundetectedforyears,discoveredincidentallybythepatientsthemselvesordoctor,2.Localcompressivesymptomsorpain3.Undergohemorrhage,necrosis,calcification,orcysticdegeneration4.Hemorrhageintotheadenomacausepain,tendernessandincreaseinsize.,Treatment,CloselyfollowedforthosewhomareconfirmedasadenomabyaspirationcytologyorotherbiopsytechniquesSugicalresectionforthoseadenomaswithenlargedprogressively,causecompressivesymptomsorleadtothyrotoxicsis,Cold70%notaccumulateradioactiveiodineWarm20%uptakeequivalenttotheremainingnormalthyroidtissueHot5-10%hyperfunction,Foradenomascintiscan,Managementofthyroidnodules,Cyst,simpleormixedThyroidadenomaColloidnoduleThyroditisInfectionDevelopmentabnomalitiesCarcinoma*Thyroidlymphoma,Management,Noninvasiveevaluation1.Thyroidfunctionbeoflittlevalueinestablishingthebenignormalignantnodule2.Ultrasonographyhelpfulclassificationofsolid,cystic,ormixed3.Thyroidscintiscanisotopes125I99mTColdwarmhot4.Thyroidhormonesuppressiontest,Management,NeedlebiopsyFNAB,cytologylargeneedlehistologycutting-needlebiopsyhistologyBeacceptedasthemostprecisediagnosticscreeningprocedurefordifferentiatingbenignfrommalignantthyroidnodule.Safeinexpensiveaccurate,Thyroiditis,AcutesuppurativethyroiditisSubscutethyroiditis(DeQuervainsdisease)Chronicthyroiditis(Hashimotosdisease),AcuteThyroiditis,Clinicfeatures*Acuteonset,tendness,enlargement,warmth,erythema,neckpain*Thyroidfunctionisusuallynormal*Ultrasonographymaydemonstratepartiallycysticmass*FNA,polymorphonuclearleukocytesandorganismmaydefound,AcuteThyroiditis,Treatments*Appropriativeantibioticsagainstthecausativeorganism*Thyroidabscessesshouldbedrained,DeQuervainsdisease,ClinicfindingsAcutepainwithradiationtojawandears,markedtenderness,dysphagia,enlargedgland,nofeverorleukocytosisisnotedHyperthyroidismispresented,serumT3,T4increasedbutRAIUandTSHdecreased,DeQuervainsdisease,Treatmen