5. Tiroida curs intreg.ppt
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Transcript of 5. Tiroida curs intreg.ppt
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Tiroida Tiroida
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Tiroida – notiuni de Tiroida – notiuni de anatomieanatomie
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Foliculul tiroidianFoliculul tiroidian
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Structura hormonilor Structura hormonilor tiroidienitiroidieni
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Etapele sintezei hormonilor Etapele sintezei hormonilor tiroidienitiroidieni
1.Captarea activa a iodului
2.Sinteza tireoglobulinei
3.Organificarea cu formarea tirozinelor
4.Cuplarea tirozinelor
5.Secretia in circulatie a hormonilor tiroidieni
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Mecanismul de actiune al Mecanismul de actiune al hormonilor tiroidienihormonilor tiroidieni
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Reglarea sintezei Reglarea sintezei hormonilor tiroidienihormonilor tiroidieni
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Evaluarea functiei Evaluarea functiei tiroidienetiroidiene
Determinarea valorilor hormonilor tiroidieniDeterminarea valorilor hormonilor tiroidieni
(T4, T3, legati de prot plasmatice sau liberi)(T4, T3, legati de prot plasmatice sau liberi) Evaluarea axului hipotalamo-hipofizo-Evaluarea axului hipotalamo-hipofizo-
tiroidian(TSH)tiroidian(TSH) Evaluarea metabolismului iodului si a Evaluarea metabolismului iodului si a
biosintezei hormonale (RIC)biosintezei hormonale (RIC) Determinarea anticorpilor tiroidieni (ATPO, Determinarea anticorpilor tiroidieni (ATPO,
AcTgl, TRAb)AcTgl, TRAb)
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Investigatii imagisticeInvestigatii imagisticeScintigrama cu I123 sau Tc 99m pertehnatatScintigrama cu I123 sau Tc 99m pertehnatat
1. Normal
2. Lobectomie stanga
3. Captare crescuta
4. Captare scazuta
5. Nodul cald
6. Nodul rece
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Investigatii imagisticeInvestigatii imagistice Ecografia tiroidiana-pozeEcografia tiroidiana-poze
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Punctia cu ac finPunctia cu ac fin
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GusaGusa
Stadializarea gusiiStadializarea gusii (OMS)(OMS)
- Gradul 0 – fara gusaGradul 0 – fara gusa- Gradul 1 – gusa Gradul 1 – gusa
palpabila (1A, 1B)palpabila (1A, 1B)- Gradul 2 – gusa vizibilaGradul 2 – gusa vizibila- Gradul 3 – gusa mareGradul 3 – gusa mare
CauzeFiziologice – pubertate, sarcina
Autoimune – Boala Graves
– Boala Hashimoto
Inflamatorii – tiroidita acuta
Deficitul de iod (gusa endemica)
Dishormonogenezii
Gusogene
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Patogenia gusii Patogenia gusii endemiceendemice
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clinicaclinica
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Manifestari cliniceManifestari clinice Semne de compresieSemne de compresie
- esofagiana: disfagie- esofagiana: disfagie
- cai respiratorii: dispnee- cai respiratorii: dispnee
- neurologica: sd Claude - neurologica: sd Claude Bernard HornerBernard Horner
- vasculara: edem in - vasculara: edem in pelerina, semn pelerina, semn PembertonPemberton
Semne de disfunctie Semne de disfunctie tiroidiana tiroidiana (hipo/hiperfunctie)(hipo/hiperfunctie)
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Evaluare Evaluare Dozari hormonale (T4, T3, TSH)Dozari hormonale (T4, T3, TSH) Ioduria/24 ore (pt diagnosticul gusii Ioduria/24 ore (pt diagnosticul gusii
endemice)endemice)- >50 µg/g creatinina normal- >50 µg/g creatinina normal RIC (crescuta in gusa endemica)RIC (crescuta in gusa endemica) Scintigrama tiroidianaScintigrama tiroidiana Investigatii imagistice – ecografie, Investigatii imagistice – ecografie,
tranzit baritat esofagian (compresie), tranzit baritat esofagian (compresie), TC sau RMN in gusi plonjanteTC sau RMN in gusi plonjante
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Evaluare imagisticaEvaluare imagistica
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Diagnostic pozitiv al gusei Diagnostic pozitiv al gusei endemiceendemice
Gusa + deficit de iod + criteriul Gusa + deficit de iod + criteriul epidemiologic (>5% au gusa in zona epidemiologic (>5% au gusa in zona geografica respectiva)geografica respectiva)
Complicatii Complicatii
-- Hipo/ Hipertiroidism (mai ales dupa Hipo/ Hipertiroidism (mai ales dupa aport crescut de iod)aport crescut de iod)
- Fenomene de compresiuneFenomene de compresiune TratamentTratament
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Hipertiroidismul Hipertiroidismul
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ClasificareClasificare Cu RIC crescut (tiroida cu functie crescuta)Cu RIC crescut (tiroida cu functie crescuta)- Boala BasedowBoala Basedow- Adenomul toxicAdenomul toxic- Gusa polinodulara hipertiroidizataGusa polinodulara hipertiroidizata- TSH crescut (adenom hipofizar, alte TSH crescut (adenom hipofizar, alte
neoplazii)neoplazii) Cu RIC scazut Cu RIC scazut - Distrugeri tiroidiene inflamatorii (tiroidita Distrugeri tiroidiene inflamatorii (tiroidita
acuta, subacuta)acuta, subacuta)- Hipertiroidism iod-indusHipertiroidism iod-indus- Tireotoxicoza factitiaTireotoxicoza factitia- Struma ovariiStruma ovarii
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Boala Basedow - Boala Basedow - patogenie patogenie
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Manifestari cliniceManifestari clinice
Semnele si simptomele de Semnele si simptomele de hipertiroidismhipertiroidism
Gusa Gusa OftalmopatieOftalmopatie Mixedem pretibialMixedem pretibial Acropatie tiroidianaAcropatie tiroidiana Manifestari clinice ale altor afectiuni Manifestari clinice ale altor afectiuni
autoimune asociateautoimune asociate
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Manifestari clinice in Manifestari clinice in hipertiroidismhipertiroidism
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Manifestari cliniceManifestari clinice
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Oftalmopatia GravesOftalmopatia Graves
Factori de risc:
-Fumatul
-Sexul feminin
-Radioiodterapia
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SeveritateSeveritate Index de activitate clinicaIndex de activitate clinica
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Diagnosticul bolii GravesDiagnosticul bolii Graves
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Alte investigatiiAlte investigatii
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Investigatii diagnostice in Investigatii diagnostice in oftalmopatia Gravesoftalmopatia Graves
Evaluare functionala tiroidiana, AcEvaluare functionala tiroidiana, Ac Examen oftalmologicExamen oftalmologic Examen CT sau RMN orbitar Examen CT sau RMN orbitar
(demonstreaza afectarea musculaturii (demonstreaza afectarea musculaturii sau a tesuturilor moi orbitare, sau a tesuturilor moi orbitare, diagnostic diferential)diagnostic diferential)
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Tratamentul Tratamentul hipertiroidismului din boala hipertiroidismului din boala
GravesGraves1. Medicamentos 1. Medicamentos a.a. Antitiroidiene de sinteza – derivati de tiouree Antitiroidiene de sinteza – derivati de tiouree
(MTU, PTU)(MTU, PTU)
– – derivati de derivati de imidazolimidazol
a.a. Beta-blocanteBeta-blocante
b.b. Anxiolitice, hipnoticeAnxiolitice, hipnotice
2. Radioiodterapie2. Radioiodterapie
3. Chirurgical3. Chirurgical
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Efectele antitiroidienelor de Efectele antitiroidienelor de sintezasinteza
Efecte adverse:Reactii alergice
Agranulocitoza
Hepatotoxicitate
Prognostic bun pentru obtinerea remisiunii:
-Gusi mici
-Boala controlata cu doze mici de ATS
-TRAb nedetectabili
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Radioterapie cu I131 Radioterapie cu I131 - forma preferata de tratament in SUAforma preferata de tratament in SUA- interzis la gravide, se evita la copii, interzis la gravide, se evita la copii,
pacienti cu oftalmopatiepacienti cu oftalmopatie Interventie chirurgicala – Interventie chirurgicala –
tiroidectomie totala sausubtotalatiroidectomie totala sausubtotala
Posibile complicatii – Posibile complicatii – hipoparatiroidismulhipoparatiroidismul
– – pareza de nerv pareza de nerv recurentrecurent
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Tratamentul Tratamentul oftalmopatieioftalmopatiei
Simptomatic: lacrimi artificiale, Simptomatic: lacrimi artificiale, ochelari de protectie, etcochelari de protectie, etc
Corticoterapie locala sau sistemica Corticoterapie locala sau sistemica (orala sau pulsterapie IV)(orala sau pulsterapie IV)
Radioterapie localaRadioterapie locala Interventii chirurgicale: blefarorafie, Interventii chirurgicale: blefarorafie,
decompresie orbitaradecompresie orbitara
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Adenomul toxic (sindromul Adenomul toxic (sindromul Plummer)Plummer)
Definitie: Forma de tireotoxicoza Definitie: Forma de tireotoxicoza determinata de un adenom cu determinata de un adenom cu secretie autonomasecretie autonoma
Hipertiroidismul poate fi determinat Hipertiroidismul poate fi determinat de un nodul cald dar nu toti nodulii de un nodul cald dar nu toti nodulii calzi determina hipertiroidism!calzi determina hipertiroidism!
- De obicei > 3 cmDe obicei > 3 cm Mecanism patogenic – mutatie Mecanism patogenic – mutatie
activatoare a receptorului de TSHactivatoare a receptorului de TSH
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ScintigramaScintigrama – nodul cald – nodul cald hipercaptant, restul tiroidei nu hipercaptant, restul tiroidei nu capteazacapteaza
EcografiaEcografia – nodulul cu structura – nodulul cu structura densa/mixta, circulatie accentuatadensa/mixta, circulatie accentuata
Tratament – radioiodterapie
– chirurgical (ablatia adenomului)
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Gusa multinodulara Gusa multinodulara hipertiroidizatahipertiroidizata
Forma de tireotoxicoza aparuta la Forma de tireotoxicoza aparuta la pacienti cu gusa veche multinodulara, pacienti cu gusa veche multinodulara, de obicei varstnicide obicei varstnici
Semne de hipertiroidism + gusa Semne de hipertiroidism + gusa multinodularamultinodulara
Scintigrama: captare neomogena, zone Scintigrama: captare neomogena, zone hiper- si hipocaptantehiper- si hipocaptante
Posibil factor precipitant: aportul de Posibil factor precipitant: aportul de iodiod
Tratament: radioiodterapie/ interventie Tratament: radioiodterapie/ interventie chirurgicala (mai alesin gusile mari)chirurgicala (mai alesin gusile mari)
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HipotiroidismulHipotiroidismul
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Hipotiroidismul - cauzeHipotiroidismul - cauze PrimarPrimar
1.1. Autoimun (tiroidita Hashimoto)Autoimun (tiroidita Hashimoto)
2.2. Deficitul de iod (gusa endemica)Deficitul de iod (gusa endemica)
3.3. Dupa terapia hipertiroidismului (radioiod sau Dupa terapia hipertiroidismului (radioiod sau interventii chirurgicale)interventii chirurgicale)
4.4. Anomalii congenitale ale sintezei hh tiroidieniAnomalii congenitale ale sintezei hh tiroidieni
5.5. Tiroidita subacutaTiroidita subacuta Secundar (Hipopituitarism prin adenoame Secundar (Hipopituitarism prin adenoame
hipofizare sau terapia ablativa pituitara)hipofizare sau terapia ablativa pituitara) Tertiar (Leziuni hipotalamice – rar)Tertiar (Leziuni hipotalamice – rar) Sindromul de rezistenta la hormonii tiroidieniSindromul de rezistenta la hormonii tiroidieni
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Semne clinice de Semne clinice de hipotiroidismhipotiroidism
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Investigatii diagnosticeInvestigatii diagnostice
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TratamentTratament Substitutiv cu L-Thyroxina (aprox Substitutiv cu L-Thyroxina (aprox
1,7µg/kg /zi) – t 1,7µg/kg /zi) – t 1/21/2 lung lung Se incepe cu doze mici care se cresc Se incepe cu doze mici care se cresc
treptat, la copiidoze mari de la inceputtreptat, la copiidoze mari de la inceput Urmarire: TSHUrmarire: TSH
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Coma mixedematoasaComa mixedematoasa Stadiul final al hipotiroidismului Stadiul final al hipotiroidismului
netratatnetratat
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Managementul comei Managementul comei mixedematoasemixedematoase
Internare in TI pentru suport Internare in TI pentru suport ventilatorventilator
Tiroxina IV – doza de incarcare 300 – Tiroxina IV – doza de incarcare 300 – 400 µg iv apoi 50 µg iv zilnic400 µg iv apoi 50 µg iv zilnic
Glucocorticoizi (HHC 50-100 mg la 8 Glucocorticoizi (HHC 50-100 mg la 8 ore)ore)
Restrictie lichidiana (hiponatremie)Restrictie lichidiana (hiponatremie) Tratamentul afectiunii precipitanteTratamentul afectiunii precipitante
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Tiroidite Tiroidite
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Tiroidita subacutaTiroidita subacuta Debut dupa un episod de IACSR, cu febra, Debut dupa un episod de IACSR, cu febra,
curbaturacurbatura Cresterea rapida de volum a tiroidei, difuza sau Cresterea rapida de volum a tiroidei, difuza sau
localizata, localizata, dureroasa, dureroasa, consistenta fermaconsistenta ferma Posibile semne de hipertiroidism (prin distructiePosibile semne de hipertiroidism (prin distructie
foliculara)foliculara)
Histologic: Histologic: Distrugere a Distrugere a foliculilor tiroidieni, foliculilor tiroidieni, infiltrat inflamator, infiltrat inflamator, prezenta fagocitelor prezenta fagocitelor si a celulelor si a celulelor multinucleatemultinucleate
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Explorari diagnosticeExplorari diagnostice• VSH mult crescut, sd inflamatorVSH mult crescut, sd inflamator• RIC scazutRIC scazut• T4, T3 posibil crescute, TSH posibil supresat initialT4, T3 posibil crescute, TSH posibil supresat initial• Ecografie: aspect neregulat al zonei afectateEcografie: aspect neregulat al zonei afectate
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Tratamentul tiroiditei Tratamentul tiroiditei subacutesubacute
Tratament Tratament antiinflamatorantiinflamator : AINS : AINS (cazuri usoare), corticoterapie (cazuri (cazuri usoare), corticoterapie (cazuri mai severe)mai severe)
Evolutie: de obicei Evolutie: de obicei
autolimitanta, rareori autolimitanta, rareori
progreseaza spre progreseaza spre
hipotiroidism permanenthipotiroidism permanent
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Tiroidita acutaTiroidita acuta
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Tiroidita HashimotoTiroidita Hashimoto
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Manifestari cliniceManifestari clinice• Gusa de dimensiuni variabile (poate Gusa de dimensiuni variabile (poate
lipsi)lipsi)• Eutiroidism sau hipotiroidismEutiroidism sau hipotiroidism ParaclinicParaclinic• Anticorpi anti peroxidaza si Anticorpi anti peroxidaza si
tireoglobulinatireoglobulina• TSH normal sau crescutTSH normal sau crescut Histologic: infiltrat limfoplasmocitarHistologic: infiltrat limfoplasmocitar Evolutie – posibil spre hipotiroidismEvolutie – posibil spre hipotiroidism Tratament – substitutiv cu L-TiroxinaTratament – substitutiv cu L-Tiroxina
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Asocieri autoimune in boala Asocieri autoimune in boala HashimotoHashimoto
Sindroame poliglandulare Sindroame poliglandulare autoimune: Boala Addison, autoimune: Boala Addison, DZ tip 1, hipoparatiroidism, DZ tip 1, hipoparatiroidism, insuficienta gonadica insuficienta gonadica primaraprimara
Afectiuni autoimune Afectiuni autoimune neendocrine: anemia neendocrine: anemia Biermer, trombocitopenii Biermer, trombocitopenii imune, vitiligo, boli imune, vitiligo, boli inflamatorii intestinale, inflamatorii intestinale, poliartrita reumatoidapoliartrita reumatoida
Poza vitiligo
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Nodulul si Nodulul si cancerul cancerul tiroidiantiroidian
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Criterii de suspiciune in Criterii de suspiciune in cancerul tiroidiancancerul tiroidian
Varsta tanaraVarsta tanara Sex masculinSex masculin Nodul solitarNodul solitar Nodul necaptant pe scintigramaNodul necaptant pe scintigrama Cresterea recenta sau rapida a nodululuiCresterea recenta sau rapida a nodulului Consistenta ferma/duraConsistenta ferma/dura Calcificari fine (corpi psamomma – cancer Calcificari fine (corpi psamomma – cancer
papilar) sau omogene, dense (medular)papilar) sau omogene, dense (medular) Expunere la radiatii a regiunii cervicale in Expunere la radiatii a regiunii cervicale in
antecedenteantecedente
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Evaluarea nodulului Evaluarea nodulului tiroidiantiroidian
Algoritm greenspanAlgoritm greenspan
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Carcinomul papilarCarcinomul papilar
Forma cea mai frecventa, bine Forma cea mai frecventa, bine diferentiatdiferentiat
Nodul rece pe scintigrama dar este Nodul rece pe scintigrama dar este radiosensibilradiosensibil
Histologic: tireocite asezate intr-un Histologic: tireocite asezate intr-un singur strat cu proiectii papiliformesingur strat cu proiectii papiliforme
Evolutie lenta, regionala, uneori se Evolutie lenta, regionala, uneori se poate dediferentiapoate dediferentia
Marker de recurenta: TgMarker de recurenta: Tg
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Carcinomul folicularCarcinomul folicular
Mai agresiv decat cel papilarMai agresiv decat cel papilar Uneori celulele neoplazice isi Uneori celulele neoplazice isi
pastreaza capacitatile fuctionalepastreaza capacitatile fuctionale Metastazeaza pe cale sangvinaMetastazeaza pe cale sangvina Este foarte greu de diferentiat de Este foarte greu de diferentiat de
adenomul folicular!adenomul folicular!
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Carcinomul medular Carcinomul medular tiroidiantiroidian
Originea in celulele parafoliculare tiroidieneOriginea in celulele parafoliculare tiroidiene Forma sporadica (80%) sau familiala (20%)Forma sporadica (80%) sau familiala (20%) Forma familiala: (1) fara alte afectiuni Forma familiala: (1) fara alte afectiuni
endocrineendocrine
(2) Sindromul MEN 2A: carcinom medular, (2) Sindromul MEN 2A: carcinom medular, feocromocitom, hiperparatiroidismfeocromocitom, hiperparatiroidism
(3) SindromMEN 2B: carcinom medular, (3) SindromMEN 2B: carcinom medular, feocromocitom, neurinoame mucoase multiplefeocromocitom, neurinoame mucoase multiple
Histologic: straturi celulare separate de un Histologic: straturi celulare separate de un material ce se coloreaza cu rosu de Congo material ce se coloreaza cu rosu de Congo (lanturi de calcitonina)(lanturi de calcitonina)
Markeri tumorali: ACE, calcitoninaMarkeri tumorali: ACE, calcitonina
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Carcinomul anaplazicCarcinomul anaplazic
Apare la varstniciApare la varstnici Evolutie extrem de agresivaEvolutie extrem de agresiva Rezistent la tratamentRezistent la tratament
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Tratament cancer papilar si Tratament cancer papilar si folicularfolicular
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Algoritm urmarireAlgoritm urmarire
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Managemenr cancer Managemenr cancer medularmedular