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Dr. M a h a t m a SpPD
Fak.Kedokteran UMS
SURAKARTA
Outline
Pendahuluan
Pendekatan Struma
GAKI
Hipertiroid
Hipotiroid
Anatomi / histology
The hypothalamic-hypophyseal-thyroid axis
Mind its feedback mechanism
Biokimia produksi hormon tiroid
F i s i o l o g i
HIPOFISIS
TSH
MASUKAN PENGELUARAN
IODIUM IODIUM
1. METABOLISME
2. PERTUMBUHAN OTAK :
- Kecerdasan
- Saraf
Fisiologis : Schematic timing of mature in the human brain
F i s i o l o g i
Process Examples of Physiological Actions
Increased basal metabolic rate (BMR)
Pendekatan Struma
GAKI
Hipertiroid
Hipotiroid
- Struma Nodusa simple non toksik :
Colloid Nodule
- Struma Nodusa simple toksik :
Adenoma, Carcinoma
- Struma Nodusa multiple non toksik :
GAKI
- Struma Nodusa multiple toksik :
Adenoma, Plummer disease, Carcinoma
- Struma Diffusa simple non toksik :
- Struma Diffusa simple toksik
- Struma Diffusa multiple non toksik :
Hashimoto, Dishormogenesis, Iatrogenik, OAT
- Struma Diffusa multiple toksik :
Goiter disease
14
Anamnesis Dx fisik
Sejak kapan Morfologi
Nyeri spontan/ tidak Nodosa : multi/tunggal
Nyeri berpindah Difusa
Membesar cepat / lambat Nyeri
Keluarga Keras, kenyal, kistik, berbenjol
Radioterapi Melekat dengan sekitar
Perubahan suara Pendorongan trakea
Tanda toksik Pemberton’s sign
Bising (bruit)
Pemeriksaan penunjang
Yodium radioaktif
Menilai fungsi dan anatomi
Nodul dingin :
penangkapan yodium kurang dari sekitarnya
Nodul hangat
penangkapan yodium sama dengan sekitarnya
Nodul panas
penangkapan yodium lebih banyak dari sekitarnya
Ultrasonografi Biopsi aspirasi
jarum halus
( F N A )
Padat atau cair Jarum suntik no 22 –
Tidak bisa menilai 27
fungsi Aman, tidak nyeri,
Kista tiroid dilakukan di poliklinik
Adenoma tiroid / Kista : guna untuk
nodul padat diagnostik sekaligus
Tiroiditis terapeutik
Biokimiawi
Kadar Free T4 plasma
(peranan tiroglobulin)
Kadar TSHs plasma
Tiroglobulin plasma
Calsitonin
low TSH high Antibodi mikrosomal (TPO)
nml Antibodi tiroglobulin (TGO)
Free T4 ? Secondary Free T4
(central) dz high
2o Hypothyroid Subclinical
Subclinical 1o Hyperthyroid
Hyperthyroid Hypothyroid
RAIU None
diffuse
focal
Serum Thyroglobulin
homogeneous heterogeneous low high
Functioning
Adenoma
Grave’s Dz Toxic multinodular goiter Thyrotoxicosis factitia Thyroiditis
Iodine load Struma ovarii
Outline
Latar Belakang
Pendekatan Struma
GAKI
Hipertiroid
Hipotiroid
IDD Global Magnitude (1996)
MASUKAN PENGELUARAN
IODIUM IODIUM
HORMON TIROID
GONDOK
METABOLISME
HIPOTIROID PERTUMBUHAN
OTAK : - Kecerdasan
- Saraf
CRETINE
Apakah GAKI itu ?
Gangguan Akibat Kekurangan Yodium /
Gondok endemik
Kekurangan yodium bukan hanya gondok saja, namun
ada efek yang lebih jauh
Gondok endemik : bukan hanya kekurangan yodium
saja.
Misalnya ggn nutrisi, goitrogen, genetik
Neonatus Dewasa
Gondok neonatus * Gondok dng akibatnya
Hipotiroidisme neonatus * Hipotiroidisme
* Gangguan fungsi mental
SURVEY EPIDEMIOLOGI
KRITERIA PEREZ, 1960
Grade O : tidak teraba
Grade I : teraba dan terlihat dengan kepala ditengadahkan
I a : tidak teraba / jika teraba
tidak lebih besar dari tiroid normal
I b : jelas teraba dan membesar,
tidak terlihat walau kepala tengadah
Grade II : mudah dilihat dengan posisi biasa
Grade III : terlihat dari jarak tertentu
KRITERIA ENDEMIK
ENDEMIK GRADE I (RINGAN)
UEI > 50 ug I/gr kreatinin
Terus menerus,
sepanjang hidup
1. Epidemiological aspect iodine deficiency
2. Clinical aspects neurological and myxedematous
3. Pathologic aspects intrauterine and irreversible
ENDEMIC
ENDEMICCRETINISM
CRETINISM
a. Neurological endemic cretinism
Mental retardation, deaf-mutism
Hearing loss bilateral perceptive
spastic diplegia, squint etc
Hypothyroidism
Clinical hypothyroidism
29% in cretins
17% in non cretinous
Biochemical hypothyroidism
41% in cretins
27% in non cretinous
Outline
Latar Belakang
Pendekatan Struma
GAKI
Hipertiroid
Hipotiroid
Etiology
1 Grave’s disease
Autoimmune disease caused by antibodies to TSH receptors
Can be familial and associated with other autoimmune
diseases
2 Toxic multi-nodular goiter
5% of all cases
10 times more common in iodine deficient area
Typically occurs in older than 40 with long standing goiter
3 Toxic adenoma
More common in young patients, Autonomically functioning nodule
4 Thyroiditis Subacute
Abrupt onset due to leakage of hormones
Follows viral infection
Resolves within eight months
Can re-occur
5 Lymphatic and postpartum
Transient inflammation
Postpartum can occur in 5-10% cases in the first 3-6 months
Transient hypothyroidism occurs before resolution
6. Treatment Induced Hyperthyroidism Iodine Induced
Excess iodine indirect
Exposure to radiographic contrast media
Medication
Excess iodine increases synthesis and release of thyroid hormone in iodine
deficient and older patients with pre-existing goiters
vitiligo
Graves’ disease
premature ovarian
pernicious anaemia
failure
Addison’s disease
allergic alveolitis
Thyroid Hormone Excess Clinical Features
General Genitourinary
– Heat intolerance, fatigue, – Amenorrhea, infertility.
tremor.
Neuromuscular
Cardiovascular
– Proximal muscle weakness
– Tachycardia, heart failure. Psychiatric
Gastrointestinal – Irritability, agitation, anxiety,
– Weight loss, diarrhoea psychosis
Ophthalmological Dermatological
– Lid lag, ophthalmopathy – Pruritus, hair thinning,
onycholysis, vitiligo.
Normal High
- Subclinical Hyperthyroidism
hyperthyroidism Thyroid uptake
- Resolving
Hyperthyroidism
Low High
- Medication
- Pregnancy Measure thyroglobulin
DIffuse Nodular
- New thyroid
illness decreased Increased Graves Multiple One “hot” area
disease areas
Thyroiditis Toxic
Exogenous Iodide exposure Toxic multinodular adenoma
hormone Exrtraglandular goiter
production
Diagnosis klinis kecurigaan hipertiroidisme:
Indeks Wayne, Indeks New Castle
Diagnosis pasti dengan memeriksa :
kadar hormon beredar fT4, TSH
nilai tangkap yodium radioaktif leher ( )
etiologi : antibodi, ultrasonografi, scintigrafi
A. Normal
B. Graves’ Dz
C. Toxic Multinodular
D. Toxic Adenoma
E. Thyroiditis
Indeks diagnostik WAYNE hipertiroidisme
Gejala yang baru timbul Skor Tanda – tanda Skor
atau bertambah berat
ada tidak ada tidak
Treatments available
surgical
For Graves’ disease
radioiodine
Indication for Medical
Treatment Antithyroid Drugs
MMI, PTU
release
I- I+ T1 T2 T3 T4 T4
T3
transpor Oxidative Coupling
iodination
Li
PTU
propanlol
Rantai peptid tiroglobulin Na-ipodate
C.steroid
operasi SEL TIROID I131
T3
Sel somatik
Beta-blocker
Guna beta blockers pada hipertiroidisme
Medikal Surgikal
For severe thyrotoxicosis award the highest score, with intercurrent illness choose
which favor the diagnosis of thyroid storm . Score ≥ 45 highly suggestive, 25-44
suggestive impending and below 25 is unlikely to respresent thyroid storm. Note:
hyperthermia, consciousness, toxic signs
Prinsip pengobatan krisis tiroid
1. Cairan dan oksigen
2. Menurunkan kadar hormon (sol Lugol, PTU)
3. Mengelola hipertermi jangan aspirin
4. Memberi corticosteroid
5. Inderal atau betablocker non spesifik lain
Outline
Latar Belakang
Pendekatan Struma
GAKI
Hipertiroid
Hipotiroid
Hypothyroidism