Dr.

SUHAEMI, SpPD, FINASIM

H IP ER TIR O ID

The Thyroid G land

H ow is G oiter Related to
H yperthyroidism ?
Due to excessive stimulation by TSH

(thyroglobulin production, enlarged

follicles).
In this case, excessive stimulation of
the thyroid gland by TSH DOES result
in thyroid hormone secretion, since
iodine is available.

Pengertian
Istilah hipertiroidisme dan tirotoksikosis sering

dipertukarkan
Tirotoksikosis : berhubungan dengan suatu kompleks

fisiologis dan biokimiawi yang ditemukan bila suatu

jaringan memberikan hormone tiroid yang berlebihan
Hipertiroidisme : tirotoksikosis sebagai akibat dari

produksi tiroid itu sendiri sehingga menyebabkan

kadar hormon tiroid didalam darah berlebihan

Causes ofH yperthyroidism

1. Graves Disease Diffuse Toxic Goiter
2. Plummers Disease Toxic MNG
3. Toxic phase of Sub Acute Thyroiditis - SAT
4. Toxic Single Adenoma STA
5. Pituitary Tumours excess TSH
6. Molar pregnancy & Choriocarcinoma (

HCG)
7. Metastatic thyroid cancers (functioning)
8. Struma Ovarii (Dermoid and Ovarian tumours)
9. Thyrotoxicosis Factitia ; INF, Amiodarone,
SSRIs

Etiologi
Biasa
penyakit graves
nodul tiroid toksik
Tiroiditis

Tidak biasa
hipertiroidisme neonatal
hipertiroidisme faktisius
sekresi TSH yang tidak tepat oleh pituitaria
yodium eksogen

H ipertiroidism e dengan Penyakit

G raves
Suatu penyakit autoimun yang biasanya ditandai oleh

produksi autoantibodi yang memiliki kerja mirip TSH

pada kelenjar tiroid.
Autoantibodi IgG ini, yang disebut immunooglobulin

perangsang tiroid (Thyroid-Stimulating

Immunoglobulin) sehingga meningkatkan
pembentukan hormon tiroid,

EtiologiPeny.G raves
Penderita :

limfosit T mengalami perangsangan terhadap antigen

yang berada didalam kelenjar tiroid yang selanjutnya
akan merangsang limfosit B untuk mensintesis
antibodi terhadap antigen tersebut. Antibodi yang
disintesis akan bereaksi dengan reseptor TSH
didalam membran sel tiroid sehingga akan
merangsang pertumbuhan dan fungsi sel tiroid.

Thyroid Follicles

Patofl
ow
Hipotalamus
Thyrotropin-Releasing Hormone
kelenjar hipofisa
v

Thyroid Stimulating Hormone

Adanya autoantibodi reseptor pada sel folikel kel. tiroid

hormon tiroid dalam darah meningkat
Kadar TSH rendah

G raves D isease

123

or TC

Normal v/s
Graves
99m

Toxic M ultinodular G oiter (TM G )

Toxic M ultinodular G oiter

(TM G )

Thyroid Hormone Synthesis

Tanda & G ejala

Dua kelompok gambaran utama yaitu tiroidal dan

ekstratiroidal.
Ciri-ciri Tiroidal : goiter akibat hiperplasia kelenjar

tiroid dan hipertiroidisme akibat sekresi hormon tiroid

yang berlebihan.
Hipertiroidisme : mengeluh lelah, gemetar, tidak tahan

panas, berat badan menurun walaupun nafsu makan

meningkat, palpitasi, takikardi, diare serta atrofi otot.

Cont....
Manifestasi ekstratiroidal : oftalmopati (mata melotot,

fissura palpebra melebar, kedipan berkurang, lid lag

(keterlambatan kelopak mata dalam mengikuti gerakan
mata dan infiltrasi kulit lokal yang biasanya terbatas
pada tungkai bawah.
Gambaran klinik klasik dari penyakit graves antara lain

adalah tri tunggal: hipertitoidisme, goiter difus dan

eksoftalmus

System s Signs/Sx

Constitutional

Sweating, warm/moist skin, muscle

weakness, wt loss, appetite

CV

HR, high-output CHF, cardiomegaly,

pulm/periph edema, MVP, Afib, heart block,
dysrhythmias

Resistant to digitalis/ cardiac glycosides.

apathetic (i.e. blunted signs/sx)
hyperthyroidism in pts age>60, cardiac
manifestations predominate, e.g AFib.

Pulm

RR, min vent

System s Signs/Sx
Neuro

Anxiety, confusion, tremor, seizures

GI

Secretory diarrhea, alk phos

Heme

Wbc, Hb, Plts

Renal

K excretion, Na excretion.

Pem eriksaan Lab

Kom plikasi
Krisis tiroid (Thyroid storm) merupakan eksaserbasi akut dari

semua gejala tirotoksikosis yang berat sehingga dapat

mengancam kehidupan penderita.
Demam tinggi, flushing dan hiperhidrosis.
Takhikardi hebat , atrial fibrilasi sampai payah jantung.
agitasi, gelisah, delirium sampai koma.
Gejala-gejala saluran cerna berupa mual, muntah,diare dan

ikterus.

Penatalaksanaan
Penatalaksanaan hipertiroidisme secara

farmakologi menggunakan tiga kelompok

yaitu:
- obat antitiroid
- pembedahan
- yodium radioaktif yang merusak
kelenjar tiroid.

sel-sel

O bat antitiroid
Bekerja dengan cara menghambat pengikatan
(inkorporasi) yodium pada TBG (thyroxine binding
globulin) sehingga akan menghambat sekresi TSH
(Thyreoid Stimulating Hormone) sehingga
mengakibatkan berkurang produksi atau sekresi
hormon tiroid.

Pem bedahan

Tiroidektomi subtotal merupakan

terapi pilihan pada penderita dengan

struma yang besar.

C linical Exam of Thyroid

C linical Exam of Thyroid

C linical Exam of Thyroid

Thyrom egaly

Thyroid Ophthalmopathy
Proptosis

Lid lag

O phthalm opathy in G raves

Periorbital edema and chemosis

O phthalm opathy in G raves

Occular muscle
palsy

Laka Laka Laka

Severe Exophthalm ia

M N G and G raves

Huge Toxic MNG

Diffuse Graves
Thyroid

H igher grades ofG oiter

Toxic MNG

(Diffuse) Graves

G rade IV Toxic M N G

Huge Toxic MNG

Huge Toxic MNG

Thyroid D erm opathy

Pink and skin coloured papules, plaques on the shin

G raves w ith Acropathy

Graves Goiter

Acropathy

Preoperative Preparation
Medical Therapy: Thyrotoxicosis
Goal: euthyroid. Resting HR best sign of acceptable

tx.
Traditional pre-op tx: Antithyroid meds >2 mos
before surgery, then may be stopped post-op.
Propylthiouracil or methimazole
Saturated KI sol
Li-carbonate (if I- allergy)
More recent preop tx: Treat x 7-14days w/
Saturated KI sol
Propanolol or nadolol: -blockers postop >7days.

Treatm ent O ptions

1. Symptom relief medications
2. Anti Thyroid Drugs ATD
Methimazole, Carbimazole
Propylthiouracil (PTU)

3. Radio Active Iodine treatment

RAI Rx.

4. Thyroidectomy Subtotal or

Total

5. NSAIDs and Corticosteroids for

AntiThyroid D rugs (ATD )

Imp. considerations

Methimazole

Propylthiouracil

Efficacy

Very potent

Potent

Duration of action

Long acting BID/OD

Short acting QID/TID

In pregnancy

Contraindicated

Safely can be given

Mechanism of action

Iodination, Coupling

Iodination, Coupling

Conversion of T4 to T3

No action

Inhibits conversion

Adverse reactions

Rashes, Neutropenia Rashes, Neutropenia

Dosage

20 to 40 mg/ OD PO

100 to 150mg qid PO

H ow long to give ATD ?

Reduction of thyroid hormones takes 2-8 weeks
Check TSH and FT4 every 4 to 6 weeks
In Graves, many go into remission after 12-18

months
In such pts ATD may be discontinued and followed

up
40% experience recurrence in 1 yr. Re treat for 3

yrs.
Treatment is not life long. Graves seldom needs

surgery
MNG and Toxic Adenoma will not get cured by ATD.
For them ATD is not the best. Treat with RAI.

Radio Active Iodine (RAIRx.)

I123 is used for Nuclear Scintigraphy (Dx.)
I131 is given for RAI Rx. (6 to 8 milliCuries)
Goal is to make the patient hypothyroid
No effects such as Thyroid Ca or other malignancies
Never given for children and pregnant/ lactating

women
Not recommended with patients of severe

Ophthalmopathy
Not advisable in chronic smokers

D ietary Advice

Avoid Iodized salt, Sea foods

Excess amounts of iodide in some
Expectorants, x-ray contrast dyes,
Seaweed tablets, and health food
supplements
These should be avoided because
The iodide interferes with or
complicates the management of
both ATD and RAI Rx.

Thyroid Storm
Preciptatnts of Thyroid Storm

(tabel 215-4)

Infection

Trauma

DKA

MI

CVA

PE

Surgery

Withdrawal of thyroid
med

Iodine administration

Palpation of thyroid
gland

Ingestion of thyroid
hormone

Unknown etiology (2025%)