内科学教学课件：Hyperthyroidism

Hyperthyroidism

EndocrinesystemGlands+CellsHormonesEndocrineSystem&HormonesHypothalamusPituitaryTargetorganHormoneTRHTSH

ThyroidTH(T3,T4)ParathyroidPTHCRHACTHAdrenalglandGlucocorticoid,Aldosterone,CatecholamineGnRHFSH,LHOvaryEstrogen,ProgestegoneTestisTestosteroneGHRH,GHRIHGH

PRH,PRIHPRL

ADH

OXT

Feedbackisthemainregulationmechanismofendocrinesystem.NegtivefeedbackPositivefeedbackNegtivefeedback:Themechanismofkeepbalancebyfirstexcitementandthenrestrain.TRHTHHypothalamusPituitaryThyroidTHSecretionRegulation

TSHDefinition

Thyrotoxicosisistheclinicalsyndromethatrusultfromelevatedcirculatingthyroidhormones.Hyperthyroidismisconsideredfordisordersthatresultfromoverproductionofhormonebythethyroidglanditself,ofwhichGraves,diseaseisthemostcommon.HyperthyroidismNon-hyperthyroidismClassification

(thyrotoxicosis)HyperthroidismØ

Gravesdisease(GD)Ø

ToxicmultinodulargoiterØ

PlummerdiseaseØ

IIHØ

HashitoxicosisØ

InfanthyperthyroidismØ

TSHsecretarycelltumororhyperplasiaNon-hyperthyroidismØ

Throiditis(Subacutethyroiditis/Silentthroiditis/Chroniclymphocyticthroiditis/Postpartumthyroiditis)Ø

THreplacementØ

EctopicTHsyndrometal.Graves’disease(GD)Introduction

GDisthemostcommoncauseofhyperthyroidism.（80%）Manifestation:thyrotoxicosis,diffusedgoiter,ocularsign,pretibialmyxedema.EtiologyandpathogenesisInheritanceImmune:TRAb(TSHreceptorantibidies)isspecificfordiagnosisofGravesdisease.TSAbstimulatingantibodyTSBAbstimulatingblockingantibodyEnvironmentTRHTSHT3,T4NormalFeedbackTRAb(TSAb/TSBAb)T3,T4Graves’DiseaseTSHTRHSymptomsfatigueheatintolerance,heavysweatinghungry,polyphagia,weightlossnervousness,emotionallability,insomnia(失眠）palpitationloosestool（稀便）,frequencyofdefecationmyopathy,thyrotoxicperiodicparalysis,myastheniagravisOligomenorrhea（月经稀少）signsCardiovascularsystemtachycardiaarrhythmia,atrialfibrillation(Af)heartenlargementwidepulsepressureDiffusedgoitrediffused,Soft,painlessthrillonpalpationvascularbruit

OveractivityofthethyroidglandOcularsignnon-infiltrativeexophthalmus（突眼）Infiltrativeexophthalmos(Gravesophthalmopathy,GO)Infiltrativeexophthalmos(Gravesophthalmopathy,GO)Symptom:pain,poorvisualpower,easilyfatigueoftheeyes,narrowvisualfield,conjunctivitis,chemosis（球结膜水肿）,cornealulcer（角膜溃疡）,periorbitalswelling（眼眶肿胀）.Mechanism:autoimmunereaction

inflammationandhypertrophyofthetissuesaroundtheeyescausingswellingPretibialmyxedemaDermopathy（皮肤病变）ofGD,autoimmunereaction.Skinraisedthickeded,nodule,orangeappearance.1/3,dorsumoffoot（足背）.Earlyfeatureofpretibialmyxedema:thickeningoftheskinoverthelowerlegsSpecialclinicalmanifestationandtypeSpecialclinicalmanifestationThyroidcrisisPrecipitatingfactor:infection,operation,wound,psychologicalHighfever,heavysweating,HR(140↑),restless,delirium（谵妄）,nausea,vomiting,diarrhea,heartfailure,shock,comaHyperthyroidismheartdiseaseHeartfailure(young/old)ArrhythmiaGravesophthalmopathy,GO25-50%GD,malepatientiscommon.EGO(euthyroidGD),labtest:T3,T4:normal,TSH↓,TRAb(+).SpecialtypeApathetichyperthyroidismOldpatientInsidious（隐袭的）onset:apathy,fatigue,somnolence（困倦）,slowreaction,weightloss.PregnancyhyperthyroidismTBGHCGinfanthyperthyroidismpostpartumhyperthyroidismT3hyperthyroidismandT4hyperthyroidismTT3↑,FT3↑,TT4,FT4normalTT4↑,FT4↑,TT3,FT3normalLaboratoryexaminationTHdeterminationTSH↓ismostsensitive,FT3↑FT4↑.Radiology:Ⅰ131

,ECT,CT,MRI.TRAb:identifythecauseofhyperthyroidismTSAb:80-100%GDpatient(+)DiagnosisDiagnosisprocedureDeterminationthyrotoxicosisIdentifycauseofthyrotoxicosisIdentifycauseofhyperthyroidismDiagnosisofhyperthyroidismHyperthyroidismsyndromeGoiterFT4↑,TSH↓DiagnosisofGD

ItishyperthyroidismDiffusedgoiterWithinfiltrativeexophthalmosPretibialmyxedemaTRAb(+),TSAb(+)OtherthyroidautoimmuneAb(+)DifferentialdiagnosisThyroiditisCommon:manifestationofthyrotoxicosis,TH↑,goiterDifference:history,signofthyroidgland,I131uptakerate↓.IdentifycauseofhyperthyroidismECT,ultrasoundTreatmentGeneraltreatmentTreatmentofhyperthyroidismAnti-thyroiddrug(ATD)Radioactiveiodine(RAI)treatmentSurgeryOthertherapytreatmentofthyroidcrisisAnti-thyroiddrug(ATD)

MechanismInhibitTHsynthesisPTUinhibitingtheperipheralconversionofT4toT3DrugPTU,50mg/tabMMI,5mg/tabIndicationMild,moderatecaseMild,moderategoiterPregnant,oldman,impropertooperationforseverediseaseRelapsefollowsurgeryImpropertoRAIPreoperationpreparation,RAItherapyadjuvant（辅助的）

treatmentDosageandduration①Treatmentperiod:MMI10-20mgQd/PTU50-150mgBidorTid.T3,T4testing/4W②Maintainperiod:MMI5-10mgQd/PTU50mgBidorTid.12-18MT3,T4testing/2MSideeffectLeucocytopenia:NEU<1.5×109/LHepaticdysfunctionAllergicreaction:drugrashVasculitis（血管炎）RemissionWithdrawal:1YFT3,FT4,TSH(-)Radioactiveiodine(RAI)treatment

Indication

GD(Ⅱ)HyperthyroidismheartdiseaseGONEU<1.5×109/LAllergySeverecardiac,hepatic,orrenaldysfunctionRelapsefollowdrugorsurgeryImpropertosurgeryContraindicationPregnant,lactationEffectCurerate85%ComplicationThyroiditisThyroidcrisisGOHypothyroidismSurgery

IndicationVerylargegoiterSeverehyperthyroidism,drugfailure(non-effective,relapse).PoststernalthyroidglandwithhyperthyroidismNodulargoiterwithhyperthyroidismPregnancy(ATDnoeffect)ContraindicationSevereinfiltratedexophthalmos