Transcript Endemic goiter

TASHKENT MEDICAL ACADEMY
Lecture for students 4 course on
the topic:
Endemic goiter
Done by: assoc. prof. Muhtarova M. Z.
Map prevalence of iodine deficiency
disorders in the world
Severe iodine deficiency (goiter> 30%)
Mild iodine deficiency (goiter 5-19,9%)
Moderate iodine deficiency (goiter 20-29,9%)
No iodine deficiency (goiter <5%)
Iodine deficiency disorders (IDD)
According to WHO, IDD
are the most common
non-communicable
diseases of man
Iodine deficiency - the
most common cause of
mental retardation, which
can be prevented
The risk of insufficient consumption of iodine is present
at the world at:
• 1.5 billion people,
• 655 million people in the world have an endemic
goiter,
• 43 million people have mental retardation of various
degrees
• 30 million people have cretinism due to iodine
deficiency
(WHO, 1994).
In all territory of the CIS
iodic deficiency is defined
Why?
• In the fertile soil and
vegetation almost no iodine
• The vegetative and animal
food contains not enough iodine
• Limited consumption of fish
and seafood
• Lack of mass iodine
prophylaxis through salt
iodization
The main problems related to
iodine deficiency in the CIS
•High
prevalence of endemic goiter:
-from 15% to 40% in some regions;
-in mountain areas frequency of goiter rate can
vary from 25-40% to 80%-64.
•The lack of objective information on the
problem of iodine deficiency among the
population
Regulation of the function of
the thyroid gland
ТРГ
Hypothalamus
Pituitary Gland
ТТГ
T3,T4
FT3, FT4
Thyroid gland
T3 =
Triiodothyronine
T4 =
Thyroxin
FT3, FT4
T3,T4
Blood (transport system )
Peripheral tissues
Thyroid and pregnancy.
Fetus
16-17 week fetal
thyroid fully
differentiated and
starts to function
actively
The main effects of thyroid
hormones
Ensure the formation of the nervous system
and the skeleton in the perinatal period,
• Increases oxygen consumption in all tissues
except the brain, spleen, testes,
• Increases the production of heat,
• Have positive chronotropic and inotropic effects
on the myocardium,
• Increases receptor sensitivity to
catecholamines;
•
The main effects of thyroid
hormones
Increase the number of catecholamine
receptors in the heart muscles,
• Regulates the activity of the respiratory center,
• Stimulates erythropoiesis,
• Speeds up the metabolism and clearance of
hormones and drugs, leading to a compensatory
increase in the rate of their production,
• Stimulates both the formation and bone
resorption.
•
Endemic goiter
Iodine deficiency,
• Iodine deficiency develops as a result of those
living in iodine-deficient regions,
• Endemicity is an area, if the prevalence of
thyroid enlargement even 1 degree is 5% or
more in children and adolescents, or 30% or
more of adults living in the area.
•
Goiter development is
contributed by
Insufficient exposure:
-protein;
-- vitamin A;
-- bromine;
-- zinc;
-- Cobalt;
-- copper;
-- Chromium.
Goiter development is
contributed by
Excessive intake of:
-Calcium
-- Fluoride
-- Chromium
-- Manganese
Goiter development is
contributed by
Strumogen substances contained in plants:
- Turnip;
-- Radishes;
-- Radish;
-- Peanuts;
-- Carrots;
-- Soy;
-- Beans;
-- Cauliflower;
-- Peaches;
-- Mango.
Goiter development is
contributed by
Poor social and living and sanitary
conditions:
- In the water there are products of protein
breakdown (thiourea, thiouracil,
urochrome) helminthic and
- bacterial contamination of the
environment.
The severity of iodine
deficiency
•Mild
form - goiter occurs from 10 to 30% of the
population, the average urinary iodine excretion is 5090 mg / l. Hypothyroidism and cretinism are missing.
•Medium form - the frequency of goiter and 50%, the
level of urinary iodine excretion is reduced to 20-49%
mg / l. There may be cases of hypothyroidism.
•Severe form - the frequency of goiter can reach
almost 100% of the average level of urinary iodine
excretion less than 20 mg / l. Cretinism occurs with a
frequency of 1 to 10%.
Mechanisms of adaptation to
deficiency of iodine
•In
response to iodine deficiency and reduced levels of
thyroid hormone increases the level of TSH, which
leads to increased capture of iodine and thyroid
hormone synthesis, followed by hyperplasia or
hypertrophy of parenchymal cells,
•Increased
synthesis and metabolism of thyroid
hormones in response to an increase in TSH enhances
the process of circulation of iodine, that allows the body
to do smaller amounts of iodine;
Mechanisms of adaptation to
deficiency of iodine
•Changes
the character of the synthesis of
thyroid hormones, thyroid gland begins to
produce triiodothyronine, which consumes
less synthesis of iodine;
•Accelerating
transformation into liver
thyroxine in a more biologically active
hormone triiodothyronine.
Inspection of patients with
diseases of a thyroid gland
•Studying
of the
anamnesis.
•Palpation of the thyroid
gland.
•Ultrasound examination.
•Hormone research.
•Scintigraphy.
•Puncture biopsy.
Palpation of the thyroid gland
The upper pole
The lower pole
Classification of endemic goiter
(Nikolayev O. V., 1955)
•0
degree - Thyroid not palpable;
•1 degree - an enlarged thyroid gland is well
detectable, especially the isthmus,
•2 degree - an enlarged thyroid gland is clearly
determined not only feeling, but also clearly visible
when viewed during swallowing, and
•3 degree - an enlarged thyroid gland with the
formation of a 'thick neck',
•4 degree - Form the neck dramatically changed,
clearly visible goiter,
•5 degree - goiter reaches a very large size;
Classification of goiter
(WHO, 1994)
•0
degree – no goiter;
•1 degree - greater than the size of the
share of the distal phalanx of the thumb.
Goiter palpable, but not visible;
•2 degree - goiter palpable and visible to
the eye;
Classification by structural changes
•Diffuse
goiter;
•Nodular goiter;
•Mixed goiter.
Classification by functional changes:
•Euthyroid goiter,
•hypothyroid goiter;
•hyperthyroid goiter.
Ultrasound examination of the
thyroid gland
•Ultrasonic
'slice' of the thyroid gland and
surrounding structures
The surface of the skin
Thyroid lobe
Blood vessel
Trachea
Basic laboratory indicators
indicators
norm
TSH
0,4 - 4 MU/l
General Т4
5,5-1mkg/DL
77-142 nmol/l
FreeТ4
0,8-1,8 ng/DL
10-23 pmol/l
General Т3
0,9-1,8 ng/ml
1,4-2,8 nmol/l
Free Т3
3,5-8,0 ng/l
5,4-12,3 pmol/l
Thyroid volume
•For
calculation of the
volume of the thyroid
gland add two volumes of
shares, the size of the
neck is neglected.
•Ml
volume fraction =
[(SHP x DP x TA) (SL x L
x TL)] x 0,479
Patients
Normal
volume of
thyroid (ml)
Children 6-10
years
<8
Children1114 years
<10
15-18 years
<15
Women
<18
Men
<25
How does the goiter develop?
Deficiency of iodine +
hereditary predisposition
the Increase of a
thyroid gland
the Normal size:
Men – up to 25 ml,
Women up to 18 ml
Iodine deficiency goiter
When iodine deficiency is a
compensatory enlargement of the
thyroid gland - formed goiter
Long-lived iodine deficiency leads
to the formation of thyroid
nodules
In some individuals formed the
functional autonomy of the thyroid
gland, most often seen in
multinodular toxic goiter
Special risk group for the most threatened in the
medico-social consequences of goiter
Teenage girls,
 women of childbearing age,
 pregnant and nursing women,
 children and adolescents

Consequences of chronic
iodic deficiency
Pregnancy and breast-feeding thyroid
dysfunction in women, violations of
intellectual and physical development
 children's age learning disabilities,
developmental disorders, euthyroid
goiter
 Adults memory loss, infertility,
fatigue, thyroid
 Mature multinodular toxic goiter

Disease (condition) associated with
endemic goiter
A reduction of intellectual capacity of
a population
 infertility, inability pregnancy, high
perinatal and infant mortality demographic problems
 worsening the health of the people :
a high level of morbidity, high level
chronic diseases, increase in
cardiovascular diseases

A simple solution to a
complex problem

Restores iodine deficiency: mass
iodine prophylaxis (iodized salt);
Group iodine prophylaxis (iodide 100,
Iodide 200); Individual iodine
prophylaxis (iodide 100, Iodide 200).
Contraindications to iodine
preparations

Thyrotoxicosis of any etiology

Nodular goiter with increased
accumulation of radioactive isotope
(hot site) or decrease in basal TSH
concentrations less than 0.5 Miu/l.
Criteria for elimination of iodine deficiency
diseases, proposed by WHO, UNICEF and
ICCIDD (1999)
Iodization of salt> 90% (the
proportion of households consume
iodized salt)
 goiter prevalence <5% (the
proportion of pupils who have goiter)
 urinary iodine of 100-300 mg / l
(reflects real iodine in the body)

Methods of iodic preventive
maintenance







The mass – introduction of salts of
potassium (iodide or potassium iodated) in
the most widespread food:
In bread;
In water;
In salt, at:
- easy iodic insufficiency of 10-25 mg/kg;
- average weight - 25-40 mg/kg;
- at the heavy – from 45 to 60 mg/kg.
Methods of iodic prevention





The group – purpose of the preparations
containing iodine to groups of the population with
the greatest risk of development of iodic
deficiency diseases.
At easy or moderate deficiency of iodine daily
additional amount of iodine is appointed:
- children of dopubertatny age - 50-100 mkg;
- teenagers – 150-200 mkg;
- pregnant and feeding – 200-250 mkg.
Methods of iodic prevention
The individual – prescribe transferred
a strumectomy, to immigrants, and
persons with existence of goitrogenic
factors in a life or production.
 Prescribe an antistrumin or iodide a
potassium in a dose not less than
150-200 mgk per day.

Methods of iodic prevention


At group and individual it is possible to apply
lipodol – the iodated oil in capsules to intake or in
ampoules for in/m introductions. 1 ml of a capsule
contains 0,3 g of an iodine 1-2 times a year are
accepted. At in/m preparation introduction – the
effect proceeds within 2-3 years.
Action duration lidopidol it is bound to that the
iodated fatty acids of a preparation are used for
synthesis of a fatty tissue and the iodine slowly
arrives in a blood channel in process of a fat
metabolism.