the Thyroid2

Gland :
Diagnostic &
Therapeutic
Approach
Sub Bagian Metabolik Endokrinologi
Bagian Ilmu Penyakit Dalam
FK-Unand / RS M Jamil Padang

Normal thyroid
unpalpable
invisible

Penyebab struma

Fisiologis
Idiopatik
Defisiensi iodium
Penyakit Graves
Bahan goitrogenik
Gangguan pembentukan hormon
Tiroiditis
Tumor
Lain lain

Terminology
_ simple goiter
_ struma adolescent
_ endemic goiter
_ sporadic goiter
_ diffuse goiter
_ nodular goiter
_ toxic goiter
_ non toxic

 NON TOXIC GOITER

- Diffuse or Noduler
- Epidemiology : prev: 4 7 % ( USA ), : = 4 : 1
- Etio : - Multifactorial
- Clinical findings :
Normothyroidism
Gld. Thyroid : enlarge / compressing
Hormonal : T3 / T4 : n / low n
TSH : n / upper n

Progressivity

diffuse
nodoler
toxic or
malign.
Attention :
- noduler, solitary nodule, cold nodule

 Special attention for solitary nodule

Malign.

Surgical
Cold

FNB

Not clear
Benign

Scintigraphy Warm
Follow Up

Hot

Surgical
Follow Up
Follow Up

Supporting Examination
1. USG : cyst ?
2. Angiography : malign. or toxic ?
3. Radiology : calcific. , compression ?
4. Thyroid uptake: toxic ?

Treatment
- Conservative:
- observation: esp. pregnant,
adolescent
- supression: TSH suppr.
- Surgical:
- suspect malign: solitary nodule,
cold nodule, history of radiation,
young age
- sign or symptom of compression.

Grades of Hypothyroidism
Overt
Sympt/signs
minimal
Serum T4
Serum T3
Serum TSH
TSH resp TRH
n.

Mild

obvious
low
low
v. high
supra n.

low/n
normal
m. high
supra

Subclinical

Presubclin

none

none

normal

normal

normal

normal

s. high

normal

supra n.

supra n.

Subclinical
Hypothyroidism
ETIOLOGY
Usually : autoimmunity
Serum antithyroid autoantibodies ( AAB ) : +
( TPOAb > TgAB )
DEFINITION
The situation with normal serum fT4 and fT3
values and moderately high serum TSH.
Symptoms and signs: absent or vague

PREVALENCE
prevalence rate: males, 0.7 5.7 % ;
females, 3.0 13.6 %
over 60 years , men: 5.0 % ; women:
13.6 %
( Framingham Study,1985

DIAGNOSTIC
Without AAB

( Normal TSH 0.40 - 2.00 mU/l

repeat screening after 5 yrs. )

hyperthyroidism

0.04

normothyroidism

2.00

subclinical hypothyroidsm

- TSH < 0.40 mU/l: fT4 and fT3 to

confirmation subclinical or overt
hyperthyroidism

5.00

hypothyroidism

- TSH > 5.00 mU/ l : fT4 and fT3 to

confirmation hypothyroidism

Koutras, 1999

DIAGNOSTIC ( with AAB )

Screen with a sensitive TSH assay:

males > 50 yrs ; females > 35 yrs;
with lipid abnormalities;
symptoms and signs ass. with hypothyroidism
______________________________________
Serum TSH 2.01 5.00
Serum AAB
fT4 normal
Annual screening
If TSH > 4.00 mU/l
on two occasions:
treat with thyroxine

Serum AAB + and / or fT4

low or low normal and
TSH > 3.00 mU/l:
treat with thyroxine

Serum AAB +and / or fT4

low or low normal and
TSH 3.00 mU/l:
follow-up

KOUTRAS, 1999

TREATMENT

~ Levothyroxin ( Euthyrox )
~ Starting dosage: 12.5 g / day
~ May be increased gradually

Reason for treatment :

1. Frequently develop overt hypothyroidism,TSH
concentration will be a most powerful predictor
( Diez, 2004 )
2. May decrease the size of goiter ( if present ) in 77 % of
patients ( Romaldini , 1996 )
3. Associated with coronary artery disease in older person
( Hak, 2000 ; Mya, 2002 )
4. Treatment has a beneficial effect on LDL level and
cardiovascular mortality ( Meier,2001 )

 Toxic goiter

- Diffuse & Noduler

- T3 & T4 , TSH
- Autoimmune

Graves Disease
( Struma diffusa toksika )
autonom
autoimmune

Ophthalmopathy
exophthalmos ;
strabismus

Lid-lag retraction ; unilateral exophthalmos

Dermatopathy
( pretibial
myxedema )

Struma ( multi )
nodosa toksika

Toxic nodular goiter

autoimmune ( ? )
autonom
cardiovascular
abnormality

TREATMENT
1. Conservative : Obat antitiroid ( OAT )
- thiouracil ( PTU )
- Carbimazole ( Neomercazole )
- Methimazole
2. Surgical : based on indication
3. Radiotherapy: based on indication

Methimazole
Thiamazole ( Thyrozol )
Mekanism of action: - intratiroid hormogenesis

Rapid accumulation ( intratiroid )

Long duration ( intratiroid )
Single dose
Compliance
Efficacy
Initial dose : 10 -20 mg / day

 Thyroiditis
- Acute,

sub acute, chronic

- Transient
hyperthyroidism
Hypothyroidism
Etiology
- Microorganism, Virus,
autoimmune
eg.
Hashimoto ( kronis )
De Quervains ( sub akut )

 Thyroid Cancer
- Papillary mostly ( 70 % )
- Anaplastik (15%) high malignancy

STRUMA ENDEMIK
- Etio : Defisiensi Yodium
- Tingkat prevalensi struma beratnya
gejala klinis (GAKI = IDD)
- GAKI bersifat individual (Respons thd TSH)

The Spectrum of IDD

Foetus

Abortion, stillbirth, increased perinatal /infant

mortality
Endemic cretinism, subclinical cretinism, neurologic
and or
Myxoedematous features
Goitre, overt or subclinical hypothyroidsm,
Neonate
decreased IQ
Goitre, juvenile hypothyroidsm, delayed growth and
Infant /Child Adolescence, decresed IQ

Adult

Goitre and its complications, hypothyroidsm and its

effects

Langkah dalam
Mengatasi GAKY
Preventif
Garam yodium
Kebutuhan perhari bersifat individual (hamil
/menyusui minimal 150 ug/hr)
GAKY : - ringan, sedang dan berat (>30 %)
- berat : kretin endemik mulai muncul
(1 12 %)
Pencapaian sasaran dievaluasi dengan penurunan
TGR pada usia kanak-kanak (di Indonesia dari 27%
10% pada tahun 2000)
Substitusi terapi untuk keadaan hipotiroidi