Thyroid disease
Introduction
Introduction to thyroid disease Thyroid diseases are mainly divided into two categories: medical treatment of thyroid disease and surgical treatment of thyroid disease. Medically treated thyroid diseases mainly include hyperthyroidism (commonly known as hyperthyroidism) and thyroid inflammation (including acute, subacute and chronic thyroid inflammation). Surgical treatment of thyroid diseases includes goiter and thyroid tumors. The main difference between the two is that the thyroid function of the thyroid disease treated by the internal medicine is abnormal, and the thyroid function test of the surgically treated thyroid disease is normal. But the two are not absolutely isolated, and the two can also change each other, especially the medical thyroid disease may also require surgical treatment. This article mainly introduces four types of thyroid diseases: goiter, hyperthyroidism (hyperthyroidism), thyroid inflammation, and thyroid tumors. basic knowledge Proportion of disease: according to different thyroid diseases, the proportion of illness is different Susceptible people: more in young adults Mode of infection: non-infectious Complications: hyperthyroidism
Cause
Causes of thyroid disease
Goiter can be divided into three degrees: can not be seen to be swollen but can reach I degree; can be seen swollen and can be touched, but within the sternocleidomastoid muscle is II degree; more than sternocleidomastoid muscle The reason is III degrees.
Common diseases that cause goiter are as follows:
1. Thyroid hyperthyroidism The thyroid gland is soft, and there may be tremors during palpation. It may be heard as a sputum-like vascular murmur, which is the result of increased blood vessels, thickening, and blood flow.
2. Simple goiter gland enlargement is very prominent, can be diffuse, but also nodular, without signs of hyperthyroidism.
3. When the thyroid cancer is palpated, the mass may have nodular sensation, irregular and hard. Due to slow development, the volume is sometimes small, and it is easy to be confused with thyroid adenoma and anterior cervical lymphadenopathy.
4. Chronic lymphatic thyroiditis (Hashimoto thyroiditis) is diffuse or nodular, easily confused with thyroid cancer. Because the enlarged inflammatory gland can move the common carotid artery to the back, the common carotid artery pulsation can be felt at the posterior edge of the gland, while the thyroid cancer often surrounds the common carotid artery in the cancer tissue. Can not touch the common carotid artery beat, can be used for identification.
5. Parathyroid adenoma The parathyroid gland is located behind the thyroid gland. When the adenoma occurs, the thyroid gland can be protruded. It also moves with swallowing when examined. It needs to be differentiated according to the clinical manifestations of hyperparathyroidism.
Prevention
Thyroid disease prevention
1. Try to avoid X-rays of head and neck in childhood.
2. Maintaining a happy spirit and preventing emotional internal injuries is an important aspect of preventing the occurrence of this disease.
3. For water and soil factors, pay attention to diet adjustment, often eat kelp, jellyfish, seaweed and use iodized salt. However, excessive intake of iodine is also harmful, and in fact it may be another predisposing factor for certain types of thyroid cancer.
4. Patients with thyroid cancer should eat nutritious food and fresh vegetables to avoid fatty, fragrant and spicy products.
5. Avoid the use of estrogen, because it plays a role in the development of thyroid cancer.
6. For thyroid proliferative diseases and benign tumors should go to the hospital for active and regular treatment.
7. After the postoperative radiotherapy and chemotherapy of thyroid cancer, the active use of Chinese and Western medicine prevention and treatment is an effective method to improve the curative effect.
8. Actively exercise and improve disease resistance.
Complication
Thyroid disease complications Complications, hyperthyroidism
1. thyrotoxic crisis (thyroid toxicity): also known as hyperthyroidism crisis, or rapidly developing hyperthyroidism or thyroid storm, is a serious complication of thyrotoxicosis in the severity of the disease, endangering the lives of patients. The disease is not common, but it is a serious complication of hyperthyroidism, and the mortality rate is very high. May occur in Graves' disease and toxic multinodular goiter.
2. Hyperthyroidism: Hyperthyroidism refers to cardiac enlargement, cardiac insufficiency, atrial fibrillation, angina, and even myocardial infarction caused by direct or indirect effects of thyroxine on the heart during hyperthyroidism. An endocrine and metabolic disorder of a series of cardiovascular symptoms and signs such as sick sinus syndrome and cardiomyopathy. The age ranged from 15 to 73 years. The length of the disease varied from a maximum of 34 years to a minimum of only half a month. The average duration of disease was 10.26 years. The average male disease duration was 6.65 years and the average female treatment duration was 9.15 years.
3. Thyroid eye disease: Thyroid eye disease is an invasive and inflammatory eye disease with thyroid dysfunction, mainly in Graves patients, and also in patients with normal thyroid function and primary hypothyroidism and Hashimoto's thyroiditis. In the latter only 3% of cases were associated with thyroid eye disease.
4. Hyperthyroidism: Hyperthyroidism Chronic myopathy is a common complication of neuromuscular involvement in hyperthyroidism. In the manifestation of weight loss in hyperthyroidism, hyperthyroidism is a decisive role in chronic myopathy. The disease occurs in 70%-80% of Graves' disease patients, mostly women.
5. Hyperthyroidism combined with periodic paralysis: Hyperthyroidism often decreases when hyperthyroidism is combined with periodic paralysis. Cyclic paralysis can occur before hyperthyroidism, or it can occur when the symptoms of hyperthyroidism are obvious or relieved. The disease is rare in countries such as Europe, America, and Australia, and China and Japan are both susceptible countries. Domestic reports of this disease account for about 3% of hyperthyroidism patients, middle-aged men are more common. Usually after symptomatic treatment and anti-thyroid drugs can be relieved. With the recurrence of hyperthyroidism, periodic paralysis may occur again.
6. Hyperthyroidism combined with pregnancy: the incidence of this disease can reach 0.8%, the most common Graves disease.
7. Leukopenia: hyperthyroidism itself, due to the expansion of peripheral blood vessels, or the influence of thyroid hormone on bone marrow, the relative or absolute number of leukocytes in peripheral blood can be reduced. Clinically, serum leukocytes are at the lower limit of normal values, after treatment. As the condition of hyperthyroidism improves, it can rise to normal levels.
8. Other complications: myasthenia gravis, pernicious anemia, vitiligo, Addison disease, diabetes, alopecia areata, rheumatoid arthritis, glomerulonephritis, scleroderma, lupus erythematosus, Sjogren's syndrome, idiopathic thrombocytopenic purpura It is not completely the same as autoimmune thyroiditis, which is associated with autoimmune thyroid disease. These complications are not common in the clinic.
Symptom
Symptoms of thyroid disease Common symptoms Hyperhidrosis Thyroid nodules Dysphagia Dysphagia Eyes Thousands of postpartum goiter
Simple goiter: The cause of simple goiter is related to the lack of iodine in the diet (such as mountain areas) and in some cases (such as gestation, growth and development). In patients with simple goiter, a swollen thyroid can be found in the neck. B-ultrasound can also confirm thyroid enlargement, but there is no nodule in the thyroid gland. Thyroid function is normal in patients with simple goiter, which is different from goiter caused by hyperthyroidism and Hashimoto's thyroiditis.
Nodular goiter: The most common form of thyroid disease. The cause is not very clear and may be related to endocrine disorders, high iodine diet, environmental factors, genetic factors and radiation exposure history. Patients with nodular goiter are usually diagnosed by physical examination or by themselves. The examination can touch the nodules above 1cm, the quality is soft or tough, the surface is smooth, the boundary is clear, and it can move up and down with swallowing. The thyroid function test indicators are within the normal range. B-ultrasound examination indicates normal or enlarged thyroid morphology, and one or more nodules may be present on one or both sides of the thyroid gland. These nodules may be cystic, mixed or substantial; they are elliptical. There may be a halo around the nodules. The shape may be irregular; the boundary may be unclear; the blood supply may be rich; the substantial nodules may have coarse calcification with sound shadows behind, but generally not accompanied by microcalcification.
Hyperthyroidism: more common in young and middle-aged women. The clinical manifestations are mainly caused by excessive thyroid hormones in the circulation. The symptoms are irritability, irritability, insomnia, palpitations, fatigue, heat, sweating, weight loss, excessive appetite, increased stool frequency or diarrhea, and rare menstruation in women. Physical examination Most patients have varying degrees of goiter, diffuse, moderate texture, and no tenderness. Some patients have exophthalmia.
Subacute thyroiditis: Subacute thyroiditis is often secondary to upper respiratory tract infections, often in the spring and autumn. Most of the subacute thyroiditis occurs in women aged 40-50 years. It is mainly characterized by neck pain, tenderness on the thyroid gland, and systemic inflammatory reactions such as fever and joint pain. Some patients may have hyperthyroidism. Most of the patients had tenderness in the thyroid gland on one side.
In patients with subacute thyroiditis, erythrocyte sedimentation rate increases, blood FT3, FT4 is normal or slightly elevated, TSH is normal or slightly decreased; serum TPOAb is often transiently elevated. B-ultrasound can be found that the thyroid volume is increased, the lesion area inside the gland is hypoechoic or unevenly fused, the boundary is unclear, the shape is irregular, and there may be localized calcification.
Chronic lymphocytic thyroiditis: also known as Hashimoto's thyroiditis. More common in women, good age 30-60 years old. Common symptoms are general malaise, most patients do not have neck discomfort, but a small number of patients have partial pressure and neck pain. Physical examination of the thyroid is mostly bilateral symmetry enlargement, and the isthmus also increases. The texture is tough, the surface is smooth or nodular. A small number of patients may have enlarged lymph nodes in the neck, but they are soft.
Thyroid function test, blood T3, T4, FT3, FT4 and TSH are generally normal at the beginning of the disease, but with the development of the disease, TSH gradually increases, and finally T3, T4, FT3, FT4 gradually reduce hypothyroidism. Thyroglobulin antibodies (TGAb) or thyroid peroxidase antibodies (TPOAb) are always elevated. B-ultrasound found diffuse thyroid enlargement or nodular enlargement, uneven echo, and a grid-like or patchy echo. Glandular blood supply is generally abundant.
Thyroid neoplasms: benign thyroid tumors are mainly thyroid adenomas. Most occur in young adults. The clinical manifestations were mostly pre-neck masses, which grew slowly and had no symptoms. The surface of the physical examination has a smooth surface, soft or tough texture, clear boundaries, and can move up and down with swallowing. Such as adenoma hemorrhage, the mass can be rapidly increased, with local pain, these symptoms can generally disappear within 1-2 weeks.
The general indicators of thyroid function test are in the normal range, but for high-function adenomas, T3, T4, FT3, FT4 can be increased, and TSH can be reduced. B-ultrasound examination of the thyroid is mostly single nodules, but also multiple; for substantive or mixed, mostly oval, clear boundaries, regular shape, peripheral vibrato, blood supply or rich. Generally, thyroid adenomas with a diameter of 10 mm or less are recommended for observation and regular B-ultrasound follow-up. Surgery may be considered if the adenoma has recently increased rapidly or has symptoms of compression or has a malignant tendency during follow-up or is diagnosed as a highly functional adenoma.
Examine
Examination of thyroid disease
1. Serum total T3 (TT3): The normal range is 1.6-3.0 nanomoles/liter. The increase is the most sensitive indicator for the diagnosis of hyperthyroidism. It can also be used to determine whether there is recurrence of hyperthyroidism. It is also seen in hyperthyroidism and multiple thyroid nodules. The knot is swollen. Reduced in hypothyroidism, acromegaly, cirrhosis, nephrotic syndrome and so on.
2. Serum total thyroxine (TT4): 65-155 nanomoles / liter is normal, elevated in hyperthyroidism, primary biliary cirrhosis, pregnancy, oral contraceptives or estrogen. Reduced in thyroid dysfunction, iodine-deficient goiter.
3. Serum free thyroxine (FT4): 10.3-25.7 pmol / liter, elevated in hyperthyroidism, thyroid hormone insensitivity syndrome, multinodular goiter. Reduce the incidence of thyroid dysfunction, the use of anti-thyroid drugs, glucocorticoids and other drugs.
4. Serum free T3 (FT3): 6.0-11.4 pmol / liter, elevated in hyperthyroidism, thyroid hormone insensitivity syndrome. Lowering suggests low T3 syndrome, advanced stage of chronic lymphocytic thyroiditis, and application of glucocorticoids.
5. Serum anti-T3 (rT3): 0.2-0.8 nanomoles / liter, the diagnosis of hyperthyroidism reached 100%, but the elderly, non-thyroid diseases and drugs can also increase it, such as diabetes, acute myocardial infarction, oral propranolol Lol, albendril and the like. Hypothyroidism, chronic lymphocytic thyroiditis, and drug effects can reduce it.
6. Thyroid stimulating hormone (TSH): sensitive TSH (sTSH): 0.4-3.0 milliunits per liter, hypersensitive TSH (uTSH): 0.5-5.0 milliunits per liter. Elevation is seen in hypothyroidism, simple goiter, hyperpituitarism, thyroiditis, etc. Lowering the general blood uTSH <0.5 milliunits / liter can be diagnosed as hyperthyroidism. However, the decrease in TSH is also seen in hypopituitarism and hypercortisolism.
Diagnosis
Diagnosis of thyroid disease
Diagnosis of hyperthyroidism:
First, the main points of the consultation
1 Pay attention to the patient whether they are afraid of hot sweating, palpitations, chest tightness, hand tremors, loss of weight, excitement, irritability or anxiety, whether the frequency of stools is not formed.
2 Whether there are large neck, protruding eyes, whether there is fear of light, tearing, double vision and so on.
3 If you are a woman, you should ask if you have rare menstruation, amenorrhea, infertility, etc. If you are a male, ask if you have breast development or impotence.
4 with or without episodes of hypokalemia, muscle weakness and weakness.
5 In the past, there was no history of hyperthyroidism. If so, ask patients about the past treatment, the drugs used and the effects.
6 Whether there are long-term use of iodine-containing drugs (such as amiodarone), iodine-containing contrast agents, health products containing kelp or seaweed, if any, should ask for the specific name, dosage and time.
Second, check the main points
(1) Pay attention to skin temperature and humidity.
(2) Pay attention to the observation of eye signs.
Most of the eyes were moderate or severe progressive unilateral or bilateral bulging eyes, and the protruding eyes were mostly 19~20mm. Eyelid edema, eye movement limited. Due to eyeball protrusion, eyelid contraction, eyelid closure is poor or unable to close, cornea is exposed, corneal dryness, inflammation, ulceration, corneal perforation and blindness. If there is evidence of eye disease and elevated thyroid hormone, the diagnosis of Graves' disease can be determined.
(3) Observe the size, texture, presence or absence of nodules, tenderness, auscultation with or without vascular murmur or tremor. If the patient has tenderness in the thyroid gland, it is indicated as subacute thyroiditis.
(4) Observe whether there is tachycardia, arrhythmia (atrial fibrillation), heart failure and water pulse, femoral artery sound, capillary pulsation.
(5) Hand tremor test, some patients have hyperthyroid myopathy, muscle weakness, muscle atrophy, periodic paralysis, clubbing, and sputum mucinous edema.
Third, further inspection
1. Determination of serum thyroid hormone and thyrotropin
Serum total T3 (TT3), total T4 (TT4), free T3 (FT3), free T4 (FT4), and anti-T3 (rT3) levels were elevated. The TT3 and TT4 indicators are stable and reproducible. They can best reflect the thyroid function status except for the influence of thyroid-binding globulin (TBG). Under normal circumstances, the changes of the two are parallel, but TT3 is mild to hyperthyroidism. The diagnosis of recurrence after hyperthyroidism is more sensitive. FT3 and FT4 are not affected by the concentration of TBG in the blood, and can more accurately reflect the functional status of the thyroid than TT3 and TT4. The serum thyroid stimulating hormone (TSH) level is lowered, and the highly sensitive TSH (sPSH) determined by immunochemiluminescence has become the internationally recognized first choice for the diagnosis of hyperthyroidism. The hyperthyroidism patient sTSH<0.l mU/L, because sTSH is a diagnosis The most sensitive indicator of hyperthyroidism, therefore, is also used as a single indicator to screen for hyperthyroidism in the population.
2. Thyroid autoantibodies
More than 95% of patients were positive for thyroid peroxidase antibody (TPO-Ab); 50% of patients were positive for anti-thyroglobulin antibody (TgAb); thyroid stimulating antibody (TSAb) positively supported the diagnosis of nail disease was Graves disease; Thyroid stimulating receptor antibody (TRAH) positive is the same as TSAb positive, 60%-90% of initial Graves disease is TRAb positive.
3. Thyroid B ultrasound
The size, shape, presence or absence of nodules, blood flow, etc. can be measured. B-ultrasound examination of hyperthyroidism showed an increase in thyroid volume, abundant blood flow, and even a "flame". B-ultrasound is extremely valuable for finding thyroid nodules that are not accessible to the hand. B-ultrasound examination of the eye can detect extraocular muscle hypertrophy early, assist in the diagnosis of Graves' ophthalmopathy, and help to determine the extent of the lesion and observe its changes.
4. ECG examination
The electrocardiogram of hyperthyroidism with periodic paralysis showed ST-segment depression, T-wave low-level and high-potential U-wave changes.
5. Electromyography
Patients with hyperthyroidism complicated with myasthenia gravis may experience action potential decay. The potential is normal at the beginning of detection, and the amplitude and frequency are gradually reduced, suggesting that the nerve-muscle junction is lesioned; patients with hyperthyroid myopathy may generally have a shortened action time of the average action potential. Myopathic changes such as potential voltage and multiphase potential increase.
6. Muscle biopsy The ultrastructural changes of muscle in patients with chronic hyperthyroid myopathy are mainly due to the loss of normal morphology of mitochondria. Large mitochondria can be seen, which contain non-parallel sputum, transverse tube expansion, and accumulation of microtubules in muscle fibers.
7. Newcastle test
Patients with hyperthyroidism complicated with myasthenia gravis showed significant relief of myasthenia gravis. Patients with hyperthyroidism with periodic paralysis did not respond to this test.
Fourth, diagnosis
1. Diagnostic procedure
1 Determine the presence or absence of thyrotoxicosis and determine serum TSH and thyroid hormone levels.
2 to determine thyrotoxicosis derived from hyperthyroidism.
3 determine the causes of hyperthyroidism, such as Graves disease, nodular toxic goiter, thyroid autonomic adenoma.
2. Diagnostic points
(1) Diagnosis of hyperthyroidism
1 high metabolic symptoms and signs; 2 goiter; 3 serum TT4, FT4 increased, TSH decreased. It can be established with the above three diagnoses. It should be noted that the high metabolic symptoms of indifferent hyperthyroidism are not obvious, only manifested as significant wasting or atrial fibrillation, especially in elderly patients; a few patients have no goiter; T3 hyperthyroidism only has elevated serum T3.
(2) Diagnosis of GD
1 diagnosis of hyperthyroidism; 2 diffuse enlargement of thyroid (confirmed by palpation and B-ultrasound), a small number of cases without thyroid enlargement; 3 eyeball protrusion and other infiltrative eye signs; 4 anterior mucinous edema; 5TRAb, TSAb, TPOAb Positive. Of the above criteria, 12 were diagnostic prerequisites and 345 were diagnostic aids. Although TPOAb is not a pathogenic antibody to this disease, it can crossover, suggesting that the disease itself is free of disease.
Simple goiter, neurosis, other causes of hyperthyroidism such as pituitary hyperthyroidism, autoimmune thyroiditis, subacute thyroiditis, etc., can be identified by appropriate special examination. Others such as weight loss, low heat must be differentiated from tuberculosis, cancer, etc.; diarrhea must be differentiated from chronic colitis; arrhythmia must be differentiated from rheumatic heart disease, myocarditis and coronary heart disease; unilateral exophthalmos must be differentiated from intraocular lens.
Toxic nodular goiter
There are multiple nodules or single nodules (toxic adenomas), and radionuclide scanning suggests localized nodules.
2. Subacute thyroiditis
Thyroiditis is mild to moderately swollen and may be tender. It usually relieves after 4 to 6 weeks. In the early stage, there may be hyperthyroidism, but the rate of thyroid absorption is lower.
3. Thyroid cancer
There is nodular enlargement in the thyroid area, and the texture is hard. The lymph nodes can be enlarged and fixed around. B-ultrasound scan and radionuclide imaging can help identify.
4. Simple goiter
Except for thyroid enlargement, there are no symptoms and signs mentioned above. Although the 131I uptake rate is sometimes increased, the T3 inhibition test mostly shows inhibition. Serum T3, rT3 were normal.
5. Neurosis
6. Autonomous high functional thyroid nodules
Radioactivity was concentrated on the nodules during scanning: repeated scans after stimulation with TSH showed increased radioactivity in the nodules.
7. Other
Tuberculosis and rheumatism often have low fever, hyperhidrosis and tachycardia. People with diarrhea as the main manifestation are often misdiagnosed as chronic colitis. The performance of senile hyperthyroidism is atypical, often with apathy, anorexia, and obvious weight loss, which is easily misdiagnosed as cancer. Unilateral invasive exophthalmos need to be differentiated from intraorbital and cranial low tumors. Hyperthyroidism with muscle disease needs to be differentiated from familial cycle paralysis and myasthenia gravis.
