Is diffuse nodular non-toxic goiter dangerous or not? Suppressive therapy with L-thyroxine. Indications for surgical removal of goiter

non-toxic diffuse goiter 1 degree and other degrees implies a condition in which the size of the thyroid gland increases, but its function does not change. Most often, this type of disorder is found in young people, as well as in women during puberty, during pregnancy and lactation, during menopause. An increase in the size of the gland can occur evenly or with the formation of nodes, but the level of hormones always remains normal.

In this article, we will talk about the causes of non-toxic goiter, as well as consider its types and the symptoms that accompany them.

Forms of non-toxic goiter and its causes

Not toxic goiter accompanied by an increase in the size of the gland, while maintaining its function.

Non-toxic goiter can be:

  • diffuse;
  • single node;
  • multi-site;
  • colloidal.

The reason is most often Not enough iodine in the body (see). Iodine deficiency occurs due to the small amount of iodine in the food and water consumed, as well as its low content in environment. Postponed irradiation of the head and neck, exposure to an excess amount of goitrogenic substances are also attributed to the causes influencing the development of the disease.

Various inflammatory, infectious and neoplastic processes are not the main cause of the development of non-toxic goiter, but may be predisposing factors, just like frequent stressful situations, aggravated heredity and regular hypothermia.

Clinical manifestations of various forms of non-toxic goiter

Due to iodine deficiency in the tissues of the thyroid gland, a decrease in the concentration of iodinated lipids occurs, with a normal content of which the activity of locally located growth factors is inhibited. With an insufficient content of iodinated lipids, thyrocyte division occurs and the number of thyroid cells increases, which causes hyperplasia.

Various forms of non-toxic goiter have characteristics and the symptoms that we will consider:

  1. Non-toxic diffuse goiter- the disease manifests itself gradually, with a feeling of discomfort in the throat, later there is perspiration, there may be pain, as the thyroid gland grows, problems arise when swallowing food and water. Due to pressure on blood vessels And vocal cords there is a feeling of pulsation in the neck, the voice changes timbre and becomes more hoarse. If the size of the goiter reaches an impressive size, asthma attacks may occur (see), shortness of breath appears, and the mobility of the tongue is impaired.
  2. Non-toxic colloid goiter- occurs if the colloid accumulates in the follicles. The follicle is functional unit thyroid gland, shaped like a sac no larger than 1 mm in size. Inside it consists of cells - thyrocytes, and outside - of blood vessels and nerve endings. A colloid is a substance having a jelly-like consistency and contains iodine and amino acids. The occurrence of goiter occurs if the process of outflow of colloid from the follicles is disturbed.

Non-toxic cellular goiter or colloid goiter is found when an enlarged thyroid causes discomfort. There is a feeling of squeezing the neck, there are difficulties in swallowing, a tickle or lump is felt in the throat. Often the disease is accompanied by headaches and dizziness, as the enlarged gland compresses the nerves and blood vessels.

Diffuse euthyroid goiter

Version: Directory of Diseases MedElement

Nontoxic diffuse goiter (E04.0)

Endocrinology

general information

Short description


Diffuse euthyroid goiter- general diffuse enlargement of the thyroid gland (thyroid gland) without disturbing its function. The most common cause is iodine deficiency.
The formation of endemic goiter is a compensatory reaction aimed at maintaining a constant concentration of thyroid hormones in conditions of iodine deficiency.
Clinical symptoms may be absent, manifested by a cosmetic defect of the neck ("thick" neck) or a syndrome of compression of the trachea, esophagus, which directly depends on the degree of enlargement of the thyroid gland.

Classification

A diffuse increase in the volume of the thyroid gland with preserved function is observed both in endemic goiter (occurs in iodine-deficient regions, and in sporadic goiter (not associated with a lack of iodine in the environment, but due to congenital or acquired defects in the biosynthesis of thyroid hormones).

Etiology and pathogenesis


Etiology
The most common cause of an enlarged thyroid gland (goiter) is iodine deficiency.
A goiter detected in conditions of iodine deficiency is designated by the term endemic, and in regions with normal iodine intake - sporadic.
Quite rarely, endemic goiter is associated not with iodine deficiency, but with the action of other goiter factors (flavonoids, thiocyanates).
The etiology of sporadic goiter is poorly understood and appears to be heterogeneous. In some cases, it is associated with congenital defects in the enzyme systems involved in the synthesis of thyroid hormones.

Pathogenesis
The pathogenesis of iodine deficiency goiter is the most studied. The formation of endemic goiter is a compensatory reaction aimed at maintaining a constant concentration of thyroid hormones in the body in conditions of iodine deficiency. TSH, as well as local growth factors (IGF-1, epidermal growth factor, fibroblast growth factor, transforming growth factor ß) contribute to an increase in the proliferative activity of thyrocytes. Iodized lipids (iodlactones) are powerful inhibitors of the production of local growth factors.

Epidemiology


Diffuse euthyroid goiter develops more often in individuals young age up to 20 years - in 50% of cases, in another 20% of cases - up to 30 years
It is 2-3 times more common in women than in men.
As a rule, euthyroid goiter occurs during periods increased need in iodine - sexual development, pregnancy and lactation.

Factors and risk groups


Main risk group development of iodine deficiency diseases:
- children under the age of 3 years;
- pregnant women;
- breastfeeding;

A group of special risk for the formation of the most threatening medical and social consequences of iodine deficiency:
- girls during puberty;
- women of childbearing (fertile) age;
- pregnant and lactating;
- children and teenagers.

Clinical picture

Symptoms, course


The clinical picture of diffuse euthyroid goiter depends on the degree of enlargement of the thyroid gland, since its function remains normal.
By itself, the fact of a small increase in the thyroid gland with its normal function practically does not affect the work of other organs and systems.
In the vast majority of cases, in conditions of mild and moderate iodine deficiency, a slight increase in the thyroid gland is detected only with a targeted examination.
In conditions of severe iodine deficiency, the goiter can reach a gigantic size. It is also possible to manifest a syndrome of compression of nearby organs (esophagus, trachea), which is manifested by difficulty in swallowing and breathing, discomfort in the neck.

Diagnostics


Anamnesis. When collecting an anamnesis, it is necessary to take into account the region of residence, the number of pregnancies, and smoking. As a rule, diffuse euthyroid goiter is asymptomatic; with a significant increase in the size of the thyroid gland (TG), it can manifest itself as compression of the trachea and esophagus.

Physical examination. Palpation of the thyroid gland is the main method for assessing the structure of the thyroid gland and should be performed in all patients. If, based on the results of palpation, it is concluded that the size of the thyroid gland is enlarged or the presence of nodular formations is indicated, the patient is shown further ultrasound of the thyroid gland.

ultrasound thyroid gland
The study allows us to characterize the size, shape and volume of the thyroid gland, the presence of nodes in it, its topographic and anatomical relationship with other organs of the neck, echogenicity and echostructure.
With the help of ultrasound, the data of the palpation examination are specified and the degree of enlargement of the thyroid gland is determined. The volume of each share is calculated by the formula:


V = V of the left lobe + V of the right lobe
V shares = (a+b+c) x 0.479


The normal volume of the thyroid gland for Europeans in women is up to 18 ml, in men - up to 25 ml. The lower limit of normal thyroid volume has not been established.
In a child, the volume of the thyroid gland depends on the degree of physical development, therefore, before the study, the height and weight of the child are measured and the body surface area is calculated using a special scale or formula. In children, the volume of the thyroid gland is compared with normative indicators(depending on age or body surface area) obtained in regions without iodine deficiency.

thyroid scintigraphy carried out for the diagnosis of retrosternal goiter.

X-ray examination chest with contrasting of the esophagus with barium is recommended in the presence of goiter large sizes accompanied by symptoms of compression of the trachea and esophagus.

Laboratory diagnostics


The main hormonal markers in the diagnosis of thyroid diseases are TSH and free thyroxine(T 4).
With euthyroidism TSH level and free T 4 within normal limits.

Differential Diagnosis


Diffuse euthyroid goiter is differentiated from chronic autoimmune thyroiditis Autoimmune thyroiditis is a chronic inflammatory disease of the thyroid gland (TG) of autoimmune origin, in which, as a result of chronically progressive lymphoid infiltration there is a gradual destruction of the thyroid tissue, most often leading to the development of primary hypothyroidism
and sporadic goiter Sporadic goiter - a disease characterized by the occurrence of goiter, usually without pronounced dysfunction of the gland, developing in people living outside endemic goiter areas
.

Complications


The main complication of diffuse non-toxic goiter may be the phenomenon of compression of surrounding organs due to the large size of the goiter, in such cases it is indicated surgery.

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Treatment


The goal of treatment is a reduction in the size of the thyroid gland.

There are currently three options conservative therapy diffuse euthyroid goiter:
1. Monotherapy with iodine preparations.
2. Suppressive therapy with levothyroxine sodium (L-thyroxine).
3. Combined therapy with iodine and L-thyroxine.

1. Monotherapy with iodine preparations
At the first stage of treatment, the vast majority of children, adolescents and people under 45-50 years of age are shown to prescribe iodine at a dose of 100-200 mcg / day, which leads to a fairly rapid suppression of the hypertrophic component of the goiter (an increase in the size of thyrocytes).

Advantages of iodine therapy: etiotropic nature, safety, no need for dose selection and frequent hormonal studies. The duration of treatment is 1.5-2 years.
Efficacy is assessed 6 months after the start of treatment. If a trend towards a decrease in the size of the thyroid gland is detected, therapy is continued for 1.5-2 years. After the abolition of potassium iodide, it is recommended to use table salt, seafood.

2. Suppressive therapy with L-thyroxine

In the absence of the effect of monotherapy with iodine preparations after 6 months, L-thyroxine therapy is carried out in doses that allow maintaining the level of TSH at the lower limit of normal.
The goal of L-thyroxine therapy in diffuse euthyroid goiter is to maintain TSH within 0.1-0.4 mIU / l, which in adults requires the appointment of at least 100-150 μg of L-thyroxine.
The effectiveness of treatment is assessed after 6 months. When the normal volume of the thyroid gland is reached, L-thyroxine is canceled and iodine preparations are prescribed, against which the volume of the thyroid gland is controlled.

Disadvantages of suppressive therapy with levothyroxine sodium: a high likelihood of relapse of goiter after discontinuation of the drug, the risk of complications of drug-induced thyrotoxicosis, the need for dose selection, which requires frequent hormonal studies.
Suppressive therapy with levothyroxine sodium is not considered the treatment of choice for diffuse euthyroid goiter.

3. Combination therapy with iodine and L-thyroxine

Well established in clinical research combination therapy preparations of iodine and L-thyroxine (200 mcg of iodine and 100-150 mcg of L-thyroxine).
The main advantage of combination therapy is the rapid reduction of thyroid volume due to iodine, which prevents the decrease in intrathyroid iodine content that occurs with L-thyroxine monotherapy.
Perhaps the sequential appointment of L-thyroxine first, and then the addition of iodine. In the case of normalization of the volume of the thyroid gland, the intake of iodine in a physiological dose is prescribed for life.

Features of observation of elderly patients
In persons over 60 years of age with goiter big size with or without nodal changes, active surveillance is most justified, which includes ultrasound and TSH determination at intervals of 1-2 years.

Treatment during pregnancy
For all pregnant women living in an iodine-deficient region, along with iodized salt, it is advisable to prescribe 250 micrograms of iodine. During pregnancy, the treatment of choice is iodine monotherapy, less often combined therapy with iodine and L-thyroxine. In both cases, it is necessary to control the function of the thyroid gland, since for a short period of pregnancy there is no significant decrease in the volume of the thyroid gland, and with sufficient consumption of iodine, the volume of the thyroid gland naturally increases somewhat.

Surgery with diffuse euthyroid goiter, it can be indicated only with its gigantic size and / or with symptoms of compression of surrounding organs.

Forecast


The prognosis for diffuse euthyroid goiter is favorable. Normalization of the volume of the thyroid gland occurs after 1.5-2 years of treatment. To exclude the recurrence of the disease, it is recommended to constantly eat iodized salt.

Hospitalization


Hospitalization is not shown.

Prevention


The goal of prevention is to normalize the consumption of iodine by the population. The need for iodine is:
- 90 mcg per day - at the age of 0-59 months;
- 120 mcg per day - at the age of 6-12 years;
- 150 mcg / day - for adolescents and adults;
- 250 mcg / day - for pregnant and lactating.

Ensuring normal consumption of iodine in the regions of iodine deficiency is possible through the introduction of methods of mass, group and individual prevention.

Mass prevention
Universal salt iodization is recommended by WHO, the Ministry of Health of the Republic of Kazakhstan and the Russian Federation as a universal and highly effective method of mass iodine prophylaxis.
Universal salt iodization means that virtually all salt for human consumption (i.e. sold in stores and used in Food Industry) must be iodized. To achieve an optimal intake of iodine (150mcg/day), WHO and the International Council for the Control of Iodine Deficiency Diseases recommend adding an average of 20-40 mg of iodine per 1 kg of salt. Potassium iodide is recommended as an iodized supplement.
In the future, mass iodine prophylaxis leads to a significant decrease in the prevalence of all forms of goiter.

Group and individual iodine prophylaxis carried out at certain periods of life (pregnancy, breastfeeding, childhood and adolescence), when physiological need in iodine increases, and consists in taking pharmacological agents containing a physiological dose of potassium iodide.
In groups increased risk allowed to use only pharmacological agents containing a precisely standardized dose of iodine. In these population groups, the prevalence of endemic goiter is especially high, and, therefore, taking drugs with an accurate dosage has not only preventive, but also therapeutic value.
Recommended doses of potassium iodide for prophylaxis in high-risk groups:

Potassium iodide for a long time inside 50-100 mcg / day. - children under 12 years old;
- 100-200 mcg / day. - adolescents and adults;
- 200 mcg / day. - pregnant and lactating women.

Information

Sources and literature

  1. Braverman L. Diseases of the thyroid. - Humana Press, 2003
  2. Valdina E.A. Diseases of the thyroid gland. Guide, St. Petersburg: Peter, 2006
  3. Dedov I.I., Melnichenko G.A. Endocrinology. National leadership, 2012.
  4. Dedov I.I., Melnichenko G.A., Andreeva V.N. Rational pharmacotherapy of diseases endocrine system and metabolic disorders. Guide for practicing doctors, M., 2006
  5. Kubarko A.I., S.Yamashita Thyroid gland. Functional aspects, Minsk-Nagasaki, 1997
  6. Cattail W.M., Arches R.A. Pathophysiology of the endocrine system / per. from English. ed. Smirnova N.A., M.: Binom publisher, St. Petersburg: Nevsky dialect, 2001 (with completed justification form) goes until March 29, 2019:[email protected] , [email protected] , [email protected]

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Nontoxic goiter is an enlargement of the thyroid gland that is not accompanied by hormonal disorders. Another name for the disease is a simple goiter. The main reason for its development is heredity, drugs and adverse living conditions. However, women get sick 10 times more often than men, which makes it possible to suspect the role of estrogen in the development of this pathology.
The main symptom that patients complain about is a visual increase in the front of the neck. Also, patients may be disturbed by sore throat, cough, difficulty swallowing, etc. In order to make an accurate diagnosis, it will be necessary to undergo ultrasound and other studies.

Features of the treatment of non-toxic goiter are that it is very important not to harm the patient and not to disturb hormonal background. Therefore, it is highly undesirable to prescribe hormonal drugs or surgery. Waiting tactics are used. To prevent further development disease, we recommend using folk remedies which return the thyroid gland to normal size.

Causes of non-toxic goiter and risk factors

In the past, the most common cause of non-toxic goiter was iodine deficiency. However, at present, this problem has been overcome in almost all regions of our country (produced iodized salt preventive measures are being taken). Therefore, other reasons come to the fore:

  • hereditary predisposition;
  • autoimmune disorders;
  • Hashimoto's thyroiditis;
  • slight disturbances in the production of thyroid hormones (at the same time, the hormonal background is not disturbed, but the thyroid gland turns on a compensatory mechanism and begins to increase in size);
    birth defects of certain enzymes;
  • long-term use some pharmacological preparations;
  • constant contact with chemicals having a goiter effect.

Risk factors include bad habits (especially smoking), frequent stress, untreated infectious and inflammatory diseases, micronutrient deficiencies (except iodine, selenium, calcium and magnesium are important for thyroid health) and age over 40 years.

Pathogenesis

The development of the disease takes place against the background of a violation of biosynthesis TSH hormones and metabolism of iodine in the blood. The level of hormones rises slightly (but at the same time is within the normal range), which stimulates the thyroid gland to turn on the compensatory mechanism and increase in size. In this case, the function of the organ is not violated.

As a result of the increase (hyperplasia), the tissues of the thyroid gland suffer. They appear hemorrhages and necrosis. The number of foci of pathology is increasing. If a violation is observed in one of the cell clones, then hyperplasia will be nodular in nature. In this case, the nodes can accumulate iodine (so-called hot nodes), do not accumulate iodine (cold nodes), or consist of a colloidal fluid (colloidal node). Over time, if the disease is not treated, the thyroid gland will not be able to perform its role normally, and the non-toxic goiter will turn into toxic (hormone-dependent).

signs

Usually the thyroid gland slowly increases in size and does not hurt on palpation. Pain is possible only if there is hemorrhage in the parenchymal tissue. One of the main signs of the disease is a visual enlargement of the neck in front. If the goiter greatly increases in size, it can compress the trachea, recurrent laryngeal nerve and other neighboring organs, which will lead to coughing, a change in the timbre of the voice, reddening of the face, dizziness, etc. Other possible symptoms:

  • characteristic wheezing or wheezing when breathing (especially when lying down);
  • fatigue;
  • sleep problems;
  • night sweats;
  • sensation of a foreign body in the neck;
  • difficulty swallowing;
  • cold and heat intolerance;
  • increased irritability;
  • constipation.

Not all of these symptoms will necessarily be observed in the patient. It all depends on the size of the goiter and its variety.

Classification of non-toxic goiter

There are several varieties of non-toxic goiter, depending on the nature of tissue damage.

  1. Diffuse non-toxic (sporadic) goiter of the thyroid gland. A type of NZ, in which the thyroid gland evenly increases, no nodes, cysts, hemorrhages, necrosis and other changes were found in the parenchymal tissue. This is the most common and harmless form of the disease.
  2. . One of the cells of the thyroid gland develops pathological process, it divides, turning into a knot. Over time, the size of the node increases more and more, disfiguring the neck.
  3. Multinodular goiter. As the name implies, this is a disease in which several nodes grow in the thyroid tissue at once.
  4. Diffuse-nodular goiter. Two processes are combined here at once: the thyroid gland increases in size, and one or more nodes grow in its tissues.
  5. Colloidal nodular goiter. It develops as a result of excessive accumulation of colloid (a viscous protein substance) in the follicles.
  6. Simple non-toxic goiter. It subdivides into diffuse and spherical shape. Such a goiter does not pose a health hazard, and often disappears on its own. It is a simple non-toxic variety that is most often found during pregnancy or during puberty.

There are also 3 stages of goiter, depending on its size (zero, first and second). Zero stage is not visible or palpable, the disease can be detected incidentally during ultrasound or other instrumental research. The first stage is palpable, but almost invisible visually. The second stage spoils the shape of the neck, it is noticeable to others.

Laboratory data and diagnostics

For diagnosis, the doctor will interview the patient, collect an anamnesis, palpate and send for an ultrasound scan. If cancer is suspected, a biopsy is done. Scintiography, CT and MRI will be useful - they will give more knowledge about the nature of the lesion.

Laboratory data is a blood test for thyroid hormones. They should be in order.

Non-toxic means not dangerous?

A goiter is dangerous if it reaches a large size and presses on the respiratory organs or blood vessels. There is also a risk that the nodular form will develop into cancer. So patients should do everything to cure this disease.

How to prevent the appearance of the disease?

healthy image life - the best prevention. You must ensure that your body receives a sufficient amount of iodine. Also very important:

  • treat all infections and inflammations in time;
  • once a year to be checked by an endocrinologist;
  • if possible, avoid contact with hazardous chemicals;
  • once a year to go to the sea;
  • prevent depression and stress.

It has been established that tobacco smoke negatively affects the functioning of the thyroid gland, so try to say goodbye to this bad habit.

Treatment with traditional methods

Surveillance tactics are usually used. The patient must adjust his diet and remove risk factors. Once every six months, he is examined by an endocrinologist. The doctor makes sure that the goiter does not increase and does not stop in malignant neoplasm.

If the goiter has reached a large size, the patient is prescribed an operation to complete removal thyroid glands. But this is an extreme measure, since in order for the body to function without a thyroid gland, the patient will have to take hormonal drugs all his life. This is fraught side effects and a significant deterioration in well-being.

Treatment of nodular non-toxic goiter with folk remedies

Treatment with folk remedies helps patients avoid surgery, eliminate unpleasant symptoms gradually return the thyroid gland to normal sizes. We will offer the most effective recipes.

cherry blossom tea

Prepare young cherry branches (dry them and chop them into pieces no more than 0.5 cm). Every day, brew tea from cherry twigs in the ratio of 1 tablespoon of raw materials to 2 cups of water. Boil the mixture for half an hour over low heat. Drink half a glass three times a day. Treatment must be long in order to fully restore thyroid function.

Slates kelp

To make up for iodine deficiency and remove constipation associated with non-toxic goiter, you need to take dry kelp shales daily. They are sold in pharmacies or traditional healers. It is best to eat them at night in a tablespoon, washed down with plenty of water. For children, the dosage is reduced. You can take kelp for as long as you like, it is not addictive and does not harm the body.

Juice treatment

With any form of non-toxic goiter, juice treatment helps. Juice from raw potatoes- Take it in half a glass once a day on an empty stomach. You can also make mixtures of carrot, celery, beetroot, spinach juices. It is useful to add a tablespoon of dandelion grass juice, nettle leaves, chokeberry fruits to the drink.

silvery cinquefoil

Patients are well helped by tea from the dry grass of silver cinquefoil. To prepare it, boil water, pour 2 pinches of chopped grass into a mug and pour boiling water over it. After 10 minutes of infusion, the tea will be ready. Drink 2-3 servings per day. Treatment must be prolonged in order to fully restore the thyroid gland.

Compresses for large goiter

Sometimes a non-toxic goiter grows to a large size and gives large nodes. Then funds are needed not only for internal, but also for external application. We give several recipes for compresses.

  1. grind raw onion in a blender and mix with the same amount of honey. Add a couple of drops of iodine. Put the resulting slurry on gauze and apply to the sore spot. Keep the compress for about two hours. Repeat the procedure every 2 days.
  2. Oak bark helps a lot. You must boil it in a small amount of water, and then apply the softened bark to the neck and wrap it with oilcloth (hold for at least an hour). Such compresses can be done every day until the thyroid gland begins to decrease.
  3. With nodular non-toxic goiter, make an ointment from hop cones. To do this, grind the plant, mix with lard and boil for 1 hour on low heat. 10 minutes before the end of cooking, add lanolin (10 g of lanolin is enough for 500 ml of the mixture). Strain, cool, place in a glass jar. Spread your goiter in the evening, apply oilcloth on top.
  4. Juniper berry ointment has helped many patients. To prepare it, mix 1 part crushed fruit with 3 parts butter, boil for 20 minutes, strain. Spread on the neck in the evening and apply a diaper on top.

Make compresses from the ointment until the goiter begins to decrease.

Diffuse non-toxic goiter

With an increase in the thyroid gland of I-III degree, the appointment of potassium iodide is indicated (100-200 mcg of iodine per day). Surgical treatment in the volume of subtotal resection of the thyroid gland is necessary only for large goiters.

Diffuse toxic goiter

Diffuse toxic goiter (Graves-Parry-Basedow disease) - genetically determined autoimmune disease. It is manifested by persistent excessive production of thyroid hormones by a diffusely enlarged thyroid gland under the influence of specific thyroid-stimulating autoantibodies with impaired functional state various organs and systems, primarily the cardiovascular and central nervous system. The disease often manifests itself between the ages of 16 and 40, predominantly in females.

Etiology and pathogenesis

The main role in the development of the disease is given hereditary predisposition. 15% of patients with diffuse toxic goiter have relatives with the same disease, about half of the relatives have circulating thyroid autoantibodies in their blood. Provoking factors - mental trauma, infectious diseases, pregnancy, admission large doses iodine, massive insolation, etc.

According to modern ideas, in this disease TSH receptors of thyrocytes serve as primary autoantigens. Congenital deficiency of T-suppressors contributes to the survival and proliferation of "forbidden" clones of T-lymphocytes interacting with autoantigens. As a result, in immune response B-lymphocytes responsible for the formation of autoantibodies are involved. With the participation of T-helpers, B-lymocytes and plasma cells secrete thyroid-stimulating autoantibodies (autoantibodies to the TSH receptor). They bind to TSH receptors of thyrocytes and have a stimulating effect on the thyroid gland, similar to the action of TSH: they activate adenylate cyclase and stimulate the formation of cAMP.

As a result, the mass and vascularization of the thyroid gland increase, and the formation of thyroid hormones increases. Excessive synthesis of thyroid hormones activates catabolic processes, oxidative phosphorylation changes, which leads to disruption of energy accumulation in cells. As a result of these processes, the development muscle weakness, subfebrile body temperature appears, patients progressively lose weight.

Clinical picture

Clinical symptoms are due to the influence of excess thyroid hormones on various organs and systems of the body. The complexity and multiplicity of factors involved in pathogenesis determine the diversity clinical manifestations diseases. When analyzing complaints and results objective examination identify symptoms that can be combined into certain syndromes.

The thyroid gland, as a rule, is enlarged due to both lobes and the isthmus, palpation elastic consistency, painless, shifts when swallowing.

Defeat syndrome of cardio-vascular system manifested by tachycardia atrial fibrillation, the development of dyshormonal myocardial dystrophy ("thyrotoxic heart"), high pulse pressure. Cardiac disorders are associated both with the direct toxic effect of hormones on the myocardium, and with hard work heart due to the increased needs of peripheral tissues for oxygen in conditions of excessively intensive metabolism. As a result of an increase in shock and minute volumes heart and blood flow acceleration, systolic blood pressure rises, at the apex of the heart and above carotid arteries listen to systolic murmur. The mechanism for reducing diastolic blood pressure is associated with the development of insufficiency of the adrenal cortex and insufficient synthesis of glucocorticoids - the main regulators of the tone of the vascular wall.

The syndrome of hypocorticism, in addition to reduced blood pressure, is also characterized by hyperpigmentation skin. Often there is pigmentation around the eyes - a symptom of Jellinek.

Syndrome of damage to other glands internal secretion. In addition to the adrenal glands, the pancreas is often affected with the development of thyroid diabetes. The increased breakdown of glycogen with the entry of a large amount of glucose into the blood causes the pancreas to work in maximum stress mode, which ultimately leads to exhaustion. compensatory mechanisms and the development of insulin deficiency. The course of already existing diabetes mellitus in patients with diffuse toxic goiter worsens significantly. To correct hyperglycemia before surgery, such patients often have to be transferred from oral hypoglycemic drugs to fractional insulin administration.

From others endocrine disorders that can develop in patients with diffuse toxic goiter, it should be noted ovarian dysfunction with impaired menstrual cycle, fibrocystic mastopathy(thyrotoxic mastopathy, Velyaminov's disease), men may develop gynecomastia.

Syndrome of lesions of the central and peripheral nervous system. They note increased excitability, psychoemotional lability, decreased concentration of attention, tearfulness, fatigue, sleep disturbance, tremor of the fingers (Marie's symptom) and the whole body (telegraph pole syndrome), excessive sweating, persistent red dermographism, increased tendon reflexes.

The syndrome of catabolic disorders is manifested by weight loss with increased appetite, subfebrile temperature body and muscle weakness.

Syndrome of organ damage digestive system appears unstable chair with a tendency to diarrhea, bouts of abdominal pain, sometimes jaundice associated with impaired liver function.

Eye syndrome is manifested by the following symptoms.

  • Dalrymple's symptom (thyroid exophthalmos) is an expansion of the palpebral fissure with the appearance of a white strip of sclera between the iris and the upper eyelid.
  • Graefe's symptom - lag upper eyelid from the iris when fixing the gaze on an object slowly moving downward, while a white strip of sclera remains between the upper eyelid and the iris.
  • Kocher's symptom - when fixing the gaze on an object slowly moving upwards, a white strip of sclera remains between the lower eyelid and the iris.
  • Stelwag's symptom - a rare blinking of the eyelids.
  • Moebius's symptom - loss of the ability to fix the gaze at close range, due to the weakness of the adductors eye muscles eyeballs fixed on a closely located object diverge and take their original position.
  • Symptom Repnev-Melekhov - "angry look."

Their development is based on hypertonicity of the muscles of the eyeball and upper eyelid due to a violation of the autonomic innervation under the influence of an excess of thyroid hormones in the blood.

Thyroid exophthalmos in diffuse toxic goiter should be distinguished from endocrine ophthalmopathy- an autoimmune disease that is not a manifestation of diffuse toxic goiter, but often (40-50% of cases) is combined with it. With endocrine ophthalmopathy, the autoimmune process affects the periorbital tissues. As a result of infiltration of the tissues of the orbit by lymphocytes, deposition of acidic glycosaminoglycans secreted by fibroblasts, edema and an increase in the volume of retrobulbar tissue, myositis and proliferation connective tissue in the extraocular muscles. Gradually, infiltration and edema turn into fibrosis, changes in the eye muscles become irreversible.

Endocrine ophthalmopathy is clinically manifested by impaired functioning oculomotor muscles, trophic disorders and exophthalmos. Patients complain of pain, double vision and a feeling of "sand" in the eyes, lacrimation. Sometimes the disease will take a malignant course, asymmetry of apples develops up to the complete loss of one of them. According to domestic classification, there are three stages of endocrine ophthalmopathy:

  • I - swelling of the eyelids, a feeling of "sand" in the eyes, lacrimation;
  • II - diplopia, restriction of abduction eyeballs, gaze paresis;
  • III - incomplete closure of the palpebral fissure, corneal ulceration, persistent diplopia, optic nerve atrophy.

Another autoimmune disease that accompanies diffuse toxic goiter is pretibial myxedema (1-4%). In this case, the skin of the anterior surface of the lower leg is damaged, it becomes edematous and thickened. The condition is often accompanied by itching and erythema.

Saveliev V.S.

Surgical diseases

Colloidal in varying degrees proliferating nodular goiter, nodular colloid proliferating goiter, colloid nodular goiter, solitary nodule, simple sporadic goiter, simple nontoxic goiter

Version: Directory of Diseases MedElement

Nontoxic uninodular goiter (E04.1)

Endocrinology

general information

Short description


Non-toxic uninodular goiter- non-tumor disease of the thyroid gland (TG), pathogenetically associated with chronic deficiency iodine in the body, manifested by the formation of one nodular formation as a result of focal proliferation Proliferation - an increase in the number of cells of a tissue due to their reproduction
thyrocytes Thyrocyte - epithelial cell; thyrocytes form the walls of thyroid follicles
and colloid accumulation.

nodular goiter- collective clinical concept, which unites all palpable formations in the thyroid gland, which have different morphological characteristics. The term is used by clinicians prior to cytological verification of the diagnosis.

nodular formation(node) thyroid gland - a formation in the thyroid gland, determined by palpation and / or using any imaging method of research and having a size of 1 cm or more.

Classification

By degree of magnification:
- degree 0 - no goiter (the volume of each lobe does not exceed the volume of the distal phalanx of the thumb of the test person);
- degree 1 - the goiter is palpable, but not visible in the normal position of the neck, this also includes nodular formations that do not lead to an increase in the gland itself;
- grade 2 - goiter is clearly visible in the normal position of the neck.

By the number of nodules:
- nodular goiter - the only encapsulated formation in thyroid gland(solitary node);
- multinodular goiter - multiple encapsulated nodular formations in the thyroid gland, not soldered together;
- conglomerate nodular goiter - several encapsulated formations in the thyroid gland, soldered to each other and forming a conglomerate;
- diffuse nodular goiter(mixed) - nodes (node) against the background of a diffuse increase in the thyroid gland.

Etiology and pathogenesis


Etiology
The most common cause of the development of non-toxic nodular goiter is iodine deficiency.

Pathogenesis
In conditions of iodine deficiency, the thyroid gland is exposed to a complex of stimulating factors that ensure the production of an adequate amount of thyroid hormones in conditions of deficiency of the main substrate for their synthesis. As a result, there is an increase in the volume of the thyroid gland - a diffuse euthyroid goiter is formed. Depending on the severity of iodine deficiency, it can form in 10-80% of the total population.
Thyrocytes initially have different proliferative activity (have microheterogeneity). Some pools of thyrocytes capture iodine more actively, others rapidly proliferate, and others have low functional and proliferative activity. In conditions of iodine deficiency, the microheterogeneity of thyrocytes acquires pathological character: thyrocytes with greatest ability to proliferation, are more responsive to hyperstimulation. Thus, a nodular and multinodular euthyroid goiter is formed.


Epidemiology


Among the healthy population, during palpation of the thyroid gland, nodular goiter is recorded in 3-5% of the examined, with autopsy of the thyroid tissue, nodular formations are found in 50% of cases.
The prevalence of nodular goiter is higher in regions of iodine deficiency (from 10-40%), as well as in regions exposed to ionizing radiation.
The frequency of the disease increases with age and is higher in women than in men (1:10).

Factors and risk groups


Main risk group development of iodine deficiency diseases:
- children under the age of 3 years;
- pregnant women;
- breastfeeding;

A group of special risk for the formation of the most threatening medical and social consequences of iodine deficiency:
- girls during puberty;
- women of childbearing (fertile) age;
- pregnant and lactating;
- children and teenagers.

Clinical picture

Symptoms, course


The clinical picture of non-toxic single-nodular goiter depends on the location of the thyroid gland (normally located or dystopic) and the size of the node.
If the disease has developed in a normally located thyroid gland (TG), clinical picture determined primarily by the size of the node.

An intrathyroid node up to 1.5 cm in size does not cause any concern, and most often the patient is unaware of its existence. This kind of node is not determined by the doctor even during palpation and is detected only with ultrasound of the thyroid gland.

A large knot causes some deformation of the anterior surface of the neck and becomes noticeable to others and the patient himself.

A goiter of considerable size causes displacement or compression of neighboring organs, primarily the trachea, which can be manifested by difficulty in breathing and swallowing. In this case, the unilateral knot causes the trachea to shift to the healthy side without narrowing its lumen.
Significant functional impairment (stenosis Stenosis is a narrowing of a tubular organ or its external opening.
trachea, compression of the esophagus with symptoms of dysphagia Dysphagia - common name swallowing disorders
) occur mainly in goiters that have developed from dystopic or ectopic thyroid tissue.

Diagnostics


Anamnesis
The presence of nodular goiter in relatives, the presence of medullary cancer in the family, previous irradiation of the head and neck, living in regions of iodine deficiency and areas subjected to ionizing radiation should be taken into account.
Availability is important rapid growth, the rapid appearance of a "node" that the patient himself can note. Change of voice, choking when eating, drinking, voice change.

Physical examination
On examination, the patient's neck may not be changed, but the nodule may be seen with the head thrown back.
On palpation, nodular, diffuse and multinodular goiter can be distinguished. Palpation evaluates the soreness of the node, its consistency, displacement in relation to surrounding tissues, the spread of goiter behind the sternum (reachability of the lower pole when swallowing).
With a large node (more than 5 cm in diameter), neck deformity, swelling of the cervical veins may occur (rarely, only with very large nodes).
Signs of compression in the case of a large retrosternal goiter usually appear when the arms are raised above the head (Pemberton's symptom); develops hyperemia. Hyperemia - increased blood supply to any part of the peripheral vascular system.
face, dizziness or fainting.
Be sure to explore The lymph nodes neck.

Instrumental Methods:


1.ultrasound The thyroid gland is the most common thyroid imaging modality. Allows you to confirm or refute the presence of a nodular and / or diffuse goiter in a patient.
A distinctive and main feature of a true nodular goiter with ultrasound is the presence of a capsule. The capsule is the border of the node, which, as a rule, has a higher echogenicity than the actual tissue of the formation.

2. Scintigraphy Scintigraphy is a radioisotope method for visualizing the distribution of a radiopharmaceutical in an organism, organ, or tissue.
thyroid gland with technetium 99 mTc - a method for diagnosing the functional autonomy of the thyroid gland.
The main indications for the study in patients with nodular goiter are:
- decrease in the content of TSH (differential diagnosis of diseases occurring with thyrotoxicosis);
- suspicion of functional autonomy of the thyroid gland;
- large goiter with retrosternal distribution;
- goiter recurrence.
For primary diagnosis nodular goiter, this method is not informative and is used only according to indications.

3. Fine needle aspiration biopsy thyroid gland - a method of direct morphological (cytological) diagnosis in nodular goiter, allows for differential diagnosis of diseases manifested by nodular goiter and exclude malignant pathology thyroid.
Indications for carrying out:
- nodular formations of the thyroid gland, equal to or exceeding 1 cm in diameter (detected during palpation and / or ultrasound of the thyroid gland);
- incidentally diagnosed lesions of a smaller size with suspected malignant tumor thyroid (according to ultrasound data), subject to the technical feasibility of performing a puncture under ultrasound control;
- a clinically significant increase (more than 5 cm) in a previously detected nodular formation of the thyroid gland during dynamic observation.

4. Chest x-ray with barium contrast of the esophagus: recommended if the patient has a large nodular goiter, with a partially retrosternal nodular goiter.

5. MRI and CT. Indications for carrying out: individual cases of retrosternal goiter and common forms of thyroid cancer.

6. Consultation of other specialists: in case of compression syndrome, consultation of an otorhinolaryngologist is necessary.

Laboratory diagnostics


An assessment of the level of thyroid hormones in the blood is carried out.
If an altered TSH content is detected:

In the case of a decrease, the concentration of St. T 4 and St. T 3 ;
- with an increase, the concentration of St. T 4 .

Differential Diagnosis


Differential diagnosis is carried out with the following diseases:
- follicular adenoma;
- hypertrophic form autoimmune thyroiditis with the formation of false nodes $
- solitary cyst;
- thyroid cancer.

Fine-needle aspiration biopsy, as well as the results of ultrasound and thyroid scintigraphy, and hormonal studies help differentiate.

Complications


The risk of developing compression syndrome, according to some authors, is quite low.

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Treatment


Purpose of treatment- Stabilization of the size of the nodular formation of the thyroid gland (TG).
To date, there are several of the following approaches to treatment.

1.Dynamic surveillance - is the preferred strategy for small, non-toxic, single-nodular goiter, as there is currently no high-quality evidence that medical or surgical treatment has a significant benefit in prolonging patient survival.
Dynamic observation is understood as an assessment of the function of the thyroid gland (determination of the content of TSH) and the size of the nodular formation (ultrasound of the thyroid gland) once a year.

2. Suppressive therapy with levothyroxine sodium, the purpose of which is the suppression of TSH secretion. This approach is justified in the situation of a combination of solitary nodular goiter with diffuse increase thyroid volume.
Before prescribing therapy, the following aspects should be considered:
- therapy is effective only when prescribing such doses of levothyroxine sodium, at which a TSH concentration of 0.1-0.5 μIU / ml is achieved;
- this therapy cannot be applied for life;
- therapy is contraindicated in concomitant cardiac pathology, osteoporosis, functional autonomy of the thyroid gland, TSH concentration less than 1 µIU/ml.
With non-toxic single-nodular goiter, there are no compelling evidence effectiveness of potassium iodide.

3. Surgical treatment indicated for nodular goiter with signs of compression of surrounding organs and / or cosmetic defect, detected functional autonomy.
Postoperative prevention of recurrence of nodular goiter (in 50-80% of cases) includes the appointment of levothyroxine sodium with a suppressive goal (TSH less than 0.5 IU / l) at a dose of 2-4 μg / (kg × day).

4. Therapy radioactive iodine : in recent decades, the world has accumulated a lot of experience in the successful application of this method of treating small nodular goiter (less than 50 ml). The method allows within several months to achieve a decrease in thyroid volume by 40-50% even after a single injection of the isotope.

Forecast


The prognosis for non-toxic single-nodular goiter, confirmed cytologically, is favorable for life and working capacity. Over time, the development of functional autonomy of the thyroid gland is possible, which dictates the need for radical treatment (surgical or radioactive iodine therapy).

Hospitalization


Hospitalization in most cases is not indicated, except for cases of large nodular goiter with compression syndrome.

Prevention


The goal of prevention is to normalize the consumption of iodine by the population. The need for iodine is:
- 90 mcg per day - at the age of 0-59 months;
- 120 mcg per day - at the age of 6-12 years;
- 150 mcg / day - for adolescents and adults;
- 250 mcg / day - for pregnant and lactating.

Ensuring normal consumption of iodine in the regions of iodine deficiency is possible through the introduction of methods of mass, group and individual prevention.

Mass prevention
Universal salt iodization is recommended by WHO, the Ministry of Health of the Republic of Kazakhstan and the Russian Federation as a universal and highly effective method of mass iodine prophylaxis.
Universal salt iodization means that virtually all salt for human consumption (i.e. sold in stores and used in the food industry) must be iodized. To achieve an optimal intake of iodine (150mcg/day), WHO and the International Council for the Control of Iodine Deficiency Diseases recommend adding an average of 20-40 mg of iodine per 1 kg of salt. Potassium iodide is recommended as an iodized supplement.
In the future, mass iodine prophylaxis leads to a significant decrease in the prevalence of all forms of goiter.

Group and individual iodine prophylaxis is carried out at certain periods of life (pregnancy, breastfeeding, childhood and adolescence), when the physiological need for iodine increases, and consists in taking pharmacological agents containing a physiological dose of potassium iodide.
In high-risk groups, it is permissible to use only pharmacological agents containing a precisely standardized dose of iodine. In these population groups, the prevalence of endemic goiter is especially high, and, therefore, taking drugs with an accurate dosage has not only preventive, but also therapeutic value.
Recommended doses of potassium iodide for prophylaxis in high-risk groups:

Potassium iodide for a long time inside 50-100 mcg / day. - children under 12 years old;
- 100-200 mcg / day. - adolescents and adults;
- 200 mcg / day. - pregnant and lactating women.

Information

Sources and literature

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  10. Petunina N.A., Trukhina L.V. Diseases of the thyroid gland, M.: GEOTAR-Media, 2011
  11. Shulutko A.M., Semikov V.I. Benign diseases thyroid and parathyroid gland. Teaching aid, 2008
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  13. "Clinical guidelines for the diagnosis and treatment of nodular goiter" Mahmoud Kharib, Hossein Kharib, Thyroid International, No. 1, 2011 , [email protected] , [email protected]

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