Download - Hipertiroid
![Page 1: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/1.jpg)
Hipertiroidisme
Kepaniteraan ilmu penyakit dalamRSUD CILEGON – UNIVERSITAS YARSI
![Page 2: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/2.jpg)
DEFINISI (Sudoyo,W Aru,dkk.2006)
TIROTOKSIKOSIS •Manifestasi klinis kelebihan hormon tiroid yang beredar dalam sirkulasi
HIPERTIROID •Tirotoksikosis yang diakibatkan hiperaktifitas dari kelenjar tiroid
![Page 3: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/3.jpg)
Tirotoksikosisvs
hipertiroidisme
• Apapun sebabnya, manifestasi klinisnya sama• Efek ini disebabkan ikatan T3 dengan T3-inti
makin penuh
(Sudoyo,W Aru,dkk.2006)
![Page 4: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/4.jpg)
THE THYROID GLAND
www.univ-st-etienne.fr/lbti/Mednucl/AtlasEnd/thyroide/
![Page 5: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/5.jpg)
O OH
I
I
IIOH
O
NH2
Thyroxine (T4)
O OH
I
I
IOH
O
NH2
3,5,3’-Triiodothyronine (T3)
THYROID HORMONES
![Page 6: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/6.jpg)
FEEDBACK REGULATIONTHE HYPOTHALAMIC-PITUITARY-THYROID AXIS
Hormones derived from the pituitary that regulate the synthesis and/or secretion of other hormones are known as trophic hormones.
Key players for the thyroid include:
TRH - Thyrophin Releasing Hormone
TSH - Thyroid Stimulating Hormone
T4/T3 - Thyroid hormones
![Page 7: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/7.jpg)
PITUITARY-THYROID AXIS
HM Goodman, BASIC MEDICAL ENDOCRINOLOGY 3rd Ed.
– –
+
![Page 8: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/8.jpg)
Negative Feedback Loop
![Page 9: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/9.jpg)
• Thyroid Disease Can Have Widespread Effects
Thyroid
• Increased LDL Cholesterol
• ElevatedTriglycerides
Liver
• Constipation
• Decreased GI
Activity
Intestines
• Decreased Fertility
• Menstrual Abnormalities
• May Harm Development of Infant
ReproductiveSystem
• Depression• Decreased Concentration• General Lack of Interest
Brain
• Decreased Heart Rate• Increased/Decreased
Blood Pressure• Decreased Cardiac
Output
Heart
• Decreased Function• Fluid Retention and
Edema
Kidneys
Thyroid Disease AffectsMany Body Systems and Overall Health
![Page 10: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/10.jpg)
Hormon tiroid berfungsi untuk mengendalikan kecepatan metabolisme tubuh. Hormon tiroid mempengaruhi kecepatan metabolisme tubuh melalui dua cara :1. Merangsang hampir setiap jaringan tubuh untuk menghasilkan protein.2. Meningkatkan jumlah oksigen yang digunakan oleh sel. (fitriani,2010)http://yosefw.wordpress.com/2008/06/10/penggunaan-obat-antitiroid-pada-pasien-hipertiroidisme/
![Page 11: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/11.jpg)
etiologi
![Page 12: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/12.jpg)
•
Etiologi
Hipertiroidisme primer : penyakit Graves, struma multinodosa toksik, adenoma toksik, metastasis karsinoma tiroid fungsional, struma ovarii, mutasi reseptor TSH, obat kelebihan yodium (fenomena Jod Basedow). 2
Tiroiditis silent, destruksi tiroid (tanpa amiodarone, radiasi, infark adenoma), asupan hormon tiroid yang berlebihan (tirotoksikosis factitia) 2
Hipertiroidisme sekunder: adenoma hipofisis yang mensekresi TSH, sindrom resistensi hormon tiroid, tumor yang mensekresi HCG, tirotoksikosis gestasional 2
![Page 13: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/13.jpg)
Lebih dari 90 % hipertiroidisme adalah akibat penyakit graves dan nodul tiroid toksik.
![Page 14: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/14.jpg)
Signs and Symptoms Of HyperthyroidismSigns and Symptoms Of Hyperthyroidism
Bulging Eyes/Unblinking Stare
Menstrual Irregularities or
Light Period
Excessive Vomiting in Pregnancy
First-Trimester Miscarriage
Family History of
Thyroid Disease
or Diabetes
Nervousness
Irritability
Difficulty Sleeping
Swelling (Goiter)
Frequent Bowel Movements
Warm, Moist Palms
Hoarseness orDeepening of Voice
Difficulty Swallowing
Rapid or Irregular Heartbeat
Infertility
Weight Loss
Heat Intolerance
Increased Sweating
PersistentSore or Dry Throat
![Page 15: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/15.jpg)
Common Signs and Symptomsof Hyperthyroidism
• Nervousness• Irritability• Difficulty Sleeping• Bulging Eyes• Unblinking Stare• Goiter• Rapid Heartbeat
• Increased Sweating• Heat Intolerance• Unexplained Weight Loss• Scant Menstrual Periods• Frequent Bowel Movements• Warm, Moist Palms• Fine Tremor of Fingers
May Include:May Include:
![Page 16: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/16.jpg)
TABLE1.MAJOR SYMPTOMS AND SIGNS OF HYPERTHYROIDISM AND OF GRAVES’ DISEASE AND CONDITIONS ASSOCIATED WITH GRAVES ‘DISEASE 5
Manifestations of hyperthyroidismSymptomsHyperactivity, irritability, altered mood, insomniaHeat intolerance, increased sweatingPalpitationsFatigue, weaknessDyspneaWeight loss with increased appetite (weight gainin 10 percent of patients)PruritusIncreased stool frequencyThirst and polyuriaOligomenorrhea or amenorrhea, loss of libidoSignsSinus tachycardia, atrial fibrillationFine tremor, hyperkinesis, hyperreflexiaWarm, moist skinPalmar erythema, onycholysisHair lossMuscle weakness and wastingCongestive (high-output) heart failure, chorea, periodicParalysis (primarily in Asian men), psychosis*
![Page 17: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/17.jpg)
Manifestations of Graves’ diseaseDiffuse goiterOphthalmopathyA feeling of grittiness and discomfort in the eyeRetrobulbar pressure or painEyelid lag or retractionPeriorbital edema, chemosis, scleral injectionExophthalmos (proptosis)Extraocular-muscle dysfunctionExposure keratitisOptic neuropathyLocalized dermopathyLymphoid hyperplasiaThyroid acropachy
Conditions associated with Graves’ diseaseType 1 diabetes mellitusAddison’s diseaseVitiligoPernicious anemiaAlopecia areataMyasthenia gravisCeliac diseaseOther autoimmune disorders associated with the HLA-DR3Haplotype
![Page 18: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/18.jpg)
Diagnosis
• Diawali oleh kecurigaan klinis. Berdasarkan indeks klinis Wayne and Newcastle yang didasarkan anamnesis dan pemeriksaan klinis yang teliti.
• Dilanjutkan dengan pemeriksaan penunjang untuk konfirmasi diagnosis anatomis, status tiroid dan etiologi
![Page 19: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/19.jpg)
![Page 20: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/20.jpg)
![Page 21: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/21.jpg)
diagnosis
• Untuk fungsi tiroid diperiksa kadar hormon beredar TT4, TT3, dalam keadaan tertentu sebaiknya fT4 dan fT3, dan TSH
Untuk fase awal penentuan diagnosis, perlu T4, T3, dan TSH
Namun pada pemantauan hanya T4 saja.
![Page 22: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/22.jpg)
Investigations
• Thyroid function test:• TSH- Undetectable• T4 - Raised• T3 - Raised• RAIU- Raised• TSH-receptor antibodies(TRAb)-elevated in Graves’s
disease• Isotope scanning- Increased uptake
![Page 23: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/23.jpg)
Treatment of Hyperthyroidism
A n ti thy ro id d ru gsB e ta b lo cke rs
M E D IC A L
S u b to ta l thy ro id ec tom y
S U R G IC A L
R ad io ac tive io d ineL ug o l's so lu tion
IO D IN E
H Y P E R T H Y R O ID IS MT ype t i t le he re
![Page 24: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/24.jpg)
Anti thyroid drugs
• Chemically block hormone synthesis• Enhance evolution to remission• Best indicated for children,adolescents,young adults
and pregnant women.• Propylthiouracil-100-150mg every 6or 8 hrs• Carbimazole- 40-60mg daily initially for 3 weeks,then
reduce to 20-40mg for another 8 weeks and maintain at 5-20mg daily for 18-24 months.
• Methimazole-active metabolite of Carbimazole
![Page 25: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/25.jpg)
Duration of treatment
• 18-24 months• Side effects- Rash Leukopenia Agranulocytosis
![Page 26: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/26.jpg)
Control of adrenergic symptoms
• Adrenergic antagonists:• Propranolol-40-120mg/day
![Page 27: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/27.jpg)
Ablative therapy(Surgery & Iodine)
• Indications:• Relapse or recurrance following drug therapy• A large goiter• Failure to follow medical regimen.• Radioactive iodine is simple,effective and
economical
![Page 28: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/28.jpg)
Complications of ablative therapy
• Immediate complications of surgery:• Bleeding,injury to recurrant laryngeal nerve
and thyroid crises.• Other complications• Hypothyroidism• Radiation thyroiditis
![Page 29: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/29.jpg)
Complications of thyrotoxicosis• 1)Cardiac- Heart failure Atrial fibrillation
• 2)Thyrotoxic crises: or ‘storm’:• Fulminating increase in signs and symptoms of
thyrotoxicosis.• Occurs in medically untreated or inadequately
treated patients.May be precipitated by surgery or sepsis
• The syndrome is characterized by extreme irritability,delirium or coma,fever 41°C or more,tachycardia,restlessness,hypotension,vomiting and diarrhea.
![Page 30: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/30.jpg)
Treatment of thyroid crisis• Provide supportive care;• Treat dehydration• Administer glucose and saline• Vitamin B complex and glucocorticoids• Digitalization is required in those with atrial
fibrillation• Immediate and large doses of anti thyroid
agents(Eg-propylthiouracil 100mg every 2h)• Iodine intravenously or by mouth• Propranolol 40-80mg every 6h• Dexamethasone(2mg every 6h) and to be tapered
later.
![Page 31: Hipertiroid](https://reader035.vdokumen.com/reader035/viewer/2022062420/55cf9d27550346d033ac74b9/html5/thumbnails/31.jpg)
Treatment of ophthalmopathy and Dermopathy
• Methylcellulose eye drops• Tinted glasses• Persistant diplopia can be corrected by surgery• Papilloedema,loss of visual field or acuity requires
urgent treatment with prednisolone 60 mg daily.• Majority of patients require no treatment other than
reassurance.• Dermopathy of Graves rarely requires treatment