LO & WO WEEK 4 ENDOCRINOLOGY AND METABOLISM

LUKY ADLINO
1. EMBRYOLOGY OF THE THYROID GLAND AND PARATHYROID GLANDS

- First endocrine gland yang developed

- Thyroid glands appears as an epithelial (entodermal) proliferation in the floor of the
pharynx between the tuberculum impar and the copula at a point later indicated by the
foramen cecum
- Subsequently the thyroid descends in front of the pharyngeal gut as a bilobed
diverticulum . during this migration the thyroid remains connected to the tounge by a
narrow canal, the thyroglossal duct. This latter ducts disappears
- Frequently, lobus pyramidalis terbentuk dan ditemukan di antara sepanjang passageway
of the primitive ductus thyroglossus. Atau bisa terbentuk cysts.
- With further development the thyroid gland descends in front of the hyoid bone and the
laryngeal cartilages. It reaches its final position in front of the trachea in the seventh
week. By then udah terbentuk isthmus dan 2 lateral lobes. Thyroid begin to function at
end of the third months at which time the first follicles containing colloid become visible
- Follicular cells produce the colloid that serves as a source of thyroxine and
triiodothyronine. Parafollicular or C cells derived from the ultimobranchial body (5th
pharyngeal pouch) serve as a source for calcitonin
- Parathyroid gland berasa dari phayringeal pouch nomor 3 (parathyroid diverticle)
separate and migrate caudally menjadi inferior parathyroid gland
- Parathyroid diverticle 4 menjadi superior parathyroid gland
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2. ANATOMY OF THYROID AND PARATHYROID GLAND

- Weight about 20-25 g, is located below the larynx. The glandula thyroidea surrounds the
upper part of the trachea with bilateral lobes and an anterior isthmus.
- Terbungkus oleh capsule asli (fibrous) dan bersama laring, trakea, esofagus dan faring
terbungkus oleh loose connective tissue (part of pretracheal fascia)
- Suspensory ligament connecting thyroid dengan tracheal ring and cricoid cartilage at
dorsomedial kalau nelan ikut naik

- Placed at the posterior side of each glandular lobe there are two grain sized epithelial
bodies weighing 12-50 mg (parathyroid glands) which produce parathyroid hormone.
- On both sides the nervus laryngeus recurrens courses between the trachea and the
oesophagus , terletak diantara dua lapis fascia yang sudah disebutkan diatas
- Arteries of the thyroid glands through the arteria thyroidea superior from the a. carotis
externa as well as through the arteria thyroidea inferior from the truncus thyrocervicalis.
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Sometimes ada small arteria thyroidea ima from the brachiocephalic trunk also
contributes to the blood supply.

- Veins of the thyroid glands three paired veins collect the blood of the thyroid gland,
the vv. Thyroidea superior and media drain into the V. jugularis interna, where as the V.
thyroidea inferior leads the blood into the left V. brachiocephalica.

3. PHYSIOLOGY OF THYROID METABOLIC HORMONES

- Thyroid gland secretes two major hormones, thyroxine and triiodothyronine, commonly
called T4 dan T3 respectively. Both of this hormone profoundly increase BMR of the
body. Complete lack of thyroid hormones bisa menyebabkan turunnya BMR 40 -50%
while extreme excesses of thyroid secretion usually causes the BMR increase up to 60-
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100% above normal. Thyroid secretion di control oleh TSH dari anterior pituitary gland.
Thyroid also secrete calcitonin.
- Synthesis and secretion of the thyroid metabolic hormones. 93 persen metabolically
active hormone yang di sekresi oleh thyroid adalah thyroxine and 7 persen itu triiodo.
However almost all thyroxine nanti bakal diubah menjadi triiodo di tissues jadi
duaduanya penting. Fungsi keduanya sama tapi differ in rapidity and intensity of action.
Triiodo itu four times as potent as thyroxine, but it present in the blood in much smaller
quantities and persists for a much shorter time compared with thyroxine.
- physiological anatomy. Thyroid gland composed of large number of closed follicles that
are filled with a secretory substance called colloid and lined with cuboidal epithelial cells.
The major constituent of of colloid is the large glycoprotein thyroglobulin, which
contains thyroid hormones. Hormones yan udah di sekresi kalau mau dipake harus
diserap kembali melalui jalur follicular epithelium. Also contain C cells yang secrete
calcitonin.

- Iodine is required for formation of thyroxine. To form normal quantities of thyroxine,

sekitar 50 mg iodine dalam bentuk iodides are required each year. Atau sekitar 1 mg per
minggu. Fate of ingested iodides orally and absorbed from GIT sama kaya chlorides.
Biasanya di eksresi oleh kidneys setelah dipake oleh thyroid gland.
- Iodide pump (sodium iodide symporter). The first stage in the formation of thyroid
hormones is transport of iodides from the blood into the thyroid glandular cells and
follicles the basal membrane of the thyroid cell punya kemampuan khusus untuk pump
dia masuk ke interior cell this pumping is achieved by the action of a sodium-iodide
symporter dimana dia cotransport satu iodide ion along with two sodium ions across the
basolateral membrane into the cells (menggunakan bantuan ATPase pump, jadi si
sodium-iodide ini merupakan secondary active pump) this process (concentrating
iodides di dalam cell) called iodide trapping. In a normal gland, dapat
mengkonsentrasikan iodide 30 kali dibanding konsentrasinya di dalam darah. Saat
maximally active, bisa sampe 250 kali konsentrasi nya. Rate of iodide trapping ini diatur
oleh beberapa faktor yang utama itu TSH, konsentrasi TSH tinggi maka dia akan kerja
keras, sebaliknya kalau TSH gada maka iodide pump nya ga aktif iodide dikeluarin
lewat apical membrane dengan bantuan chloride-iodide ion counter-transporter molecule
called pendrin. Thyroid epithelial cells juga secrete thyroglobulin (contains amino acids
dari tyrosine)
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- Thyroglobulin and chemistry of thyroxine and triiodo formation. Pembentukan
thyroglobulin oleh thyroid cells ER dan golgi nya secrete a large glycoprotein
molecule called thyroglobulin. Each thyroglobulin consists of 70 tyrosine amino acids,
and they are major substrates that combine with iodine to form the thyroid hormones.
Thus the thyroid hormones form within the thyroglobulin molecule.
- Oxidation of the iodide ions. First essential step itu adalah conversion dari iodide ions
ke oxidized form of iodine, which is then capable of combining directly with the amino
acid tyrosine. This oxidation of iodine is promoted by the enzyme peroxidase and its
accompanying hydrogen peroxide which provide a potent system capable of oxidizing
iodides. The peroxidase bisa terletak di apical membrane and attached to it jadinya deket
dengan tempat keluarnya thyroglobulin. Kalau gada peroxidase maka formation of
thyroid hormones falls to zero.
- Iodination of tyrosine and formation of thyroid
hormones (Organification of thyroglobulin).
Binding of iodine dengan thyroglobulin molecule
is called organification of the thyroglobulin. Iodine
intinya bakal gabung dengan tyrosine di dalam
thyroglobulin. Tyrosine is first iodized to
monoiodotyrosine then to diiodotyrosine. Major
product nya kan T4 dimana terbentuk dari two
molecules of diiodotyrosine are joined together.
Sedangkan yang T3 itu terdiri dari mono dan
diiodo.
- Storage of thyroglobulin. The thyroid gland itu
beda diantara gland2 endocrine lainnya, dia bisa
store large amounts of hormone. Jadi setelah
terbentuk, satu molecule thyroglobulin itu bisa
mengandung 30 T4 dan few T3, kalau sudah di
store, itu bisa digunakan hampir 2-3 bulan,
makanya nanti kalau synthesanya berkurang
sewaktu-waktu, physiological effects of deficiency
ga observed sampe beberapa bulan kedepan.
- Release of thyroxine and triiodo from the
thyroid gland. Most of the thyroglobulin is not
released into the circulating blood, instead di
cleaved dari thyroglobulin dulu baru nanti free
hormones yang released. Jadi prosesnya berlangsung seperti ini, apical surface dari
thyroid cells sends out pseudopods extensions that close around small portions of the
colloid to form pinocytic vesicles that enter the apex of thyroid cell (dimakan kedalam sel
menggunakan kaki semu) then lysosomes in the cell cytoplasm immediately fuse with
these vesicle to form digestive vesicles multiple proteases among the enzymes digests
the thyroglobulin molecules and release T4 and T3 in free form diffuse through the
base of the thyroid cell into the surrounding capillaries thus the thyroid hormones are
released into the blood.
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- some of the thyroglobulin in the colloid enters the thyroid cells by endocytosis after
binding to megalin (protein) terbentuk megalin-thyroglobulin complex inside the cell
bisa keluar released into capillary blood.
- Di dalam thyroglobulin, ga semua mono and diiodo dijadikan hormones, banyak juga
yang tersisa, begitu thyroglobulin dipecah di digest maka mono dan diiodo ini keluar
juga, lalu bisa di pakein deiodinase enzyme untuk memecah iodine nya dan bisa dipake
buat masuk cycle lainnya.

- Transport T4 dan T3 to tissues. T4 dan T3 itu bound to plasma proteins, more than 99
persen combines immediately with several of the plasma proteins yang semuanya
disintesa oleh liver. They mainly bind with thyroxine-binding globulin and much less so
with thyroxine-binding prealbumin and albumin.
- T4 dan T3 itu di release slowly ke tissue cells karena high affinity sendiri dari plasma
proteinnya. Setengah dari T4 di release ke tissue cells about every 6 hari. Kalau si T3 itu
cuma sehari sudah hilang setengah karena affinity kecil pas sudah sampe dia
kemudian di bind lagi with intracellular protein, jadi dipake pelan-pelan oleh cell
targetnya over a period of days to weeks.
- Thyroid hormones have slow onset and long duration of action. Ada long latent period
setelah di inject thyroxine. Once activity mulai kerja, mulai capai peak di hari ke 10-12
and then decreases with a half-life of 15 days. Sedangkan kalau triiodo lebih cepet dalam
waktu 6-12 jam uda kerja dan maksimal peak di hari ke 2 atau 3.
- Physiological function of the thyroid hormones
Thyroid hormones increase transcription of large numbers of genes general effect
of thyroid hormone is to activate nuclear transcription of large number of genes.
Thyroid hormones activate nuclear receptors, either attach langsung atau berada dekat
dengan DNA. Ada namanya thyroid hormone response elements on the DNA dimana
terdapat retinoid X receptor dan thyroid hormone receptor didalamnya. Setelah
binding thyroid dengan receptornya maka initiate transcription process terbentuk
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new intracellular protein. Masing-masing protein mempunyai respon yang beda-beda,
ada yang increased slightly ada yang increase 6 kali lipat.
Nongenomic thyroid hormones action, biasanya bekerja di cytosol tapi gake nucleus,
misalnya :
A. Thyroid Hormone (TH) increase the number and activity of mitochondria
increase in size and number of mitochondria, total membrane surface of the
mitochondria juga meningkat
B. TH increase active transport of ions through cell membrane increase activity of
Na-K-ATPase. Karena butuh ATP untuk mengerjakan ini maka produce heat dan
hipotesa berikutnya adalah menghasilkan peningkatan BMR
C. TH effect on growth anak-anak hypothyroid maka rate of growth nya retarded.
While in hyperthyroidism maka excessive skeletal growth. Keperluan lain adalah
growth and dev of the brain during fetal life
D. Stimulation on carbohydrate metabolism rapid glucose uptake by cell,
enhanced glycolysis, enhanced gluconeogenesis, increased rate of absorption from
the GI tract and even increase insulin secretion. Semua terjadi karena increase in
cellular metabolic enzymes caused by TH
E. Stimulation of fat metabolism lipids are mobilized rapidly from the fat tissue
which decreases the fat stores of the body, increase FFA concentration in the
plasma and greatly accelerates the rate of oxidation of the FFA by the cells
F. Effects on plasma and liver fats increased TH maka decreased cholesterol,
phospholipids, and TAG in the plasma even though increased FFA. One of the
mechanism kenapa bisa seperti itu adalah TH increase cholesterol secretion in the
bile and consequent loss di feces. A possible mech kenapa bisa increased
cholesterol secretion karena TH induces pembentukan LDL receptors di liver
cells.
G. Increase requirement for vitamins TH increased many bodily enzymes and
because the vitamins are essential parts of some of the enzymes or coenzymes,
TH increases the need for vitamin
H. Increased BMR kalau naik maka increase metabolism, kalau excessive
quantities of the hormone maka bisa berkerja 60-100 persen above normal
I. Decreased body weight kalau tinggi TH maka kurus tapi sebaliknya kalau
rendah TH maka nanti gemuk. However ini bisa discounter balance karena ada
mechanism dari appetite, appetite itu increased by TH
J. Increase blood flow and cardiac output increased metabolism in this tissue
resulting in more rapid utilization of O2 than normal, these effects causes
vasodilation in most body tissues, thus increasing blood flow. The rate of blood
flow ke skin membesar karena mau buang heat. Cardiac output naik karena
bloodflow naik, maka sometime naik sampe 60 persen or more above normal
when excessive TH is present
K. Increase heart rate TH seem to have a direct effect on the excitability of the
heart and then increase heart rate
L. Increase heart strength increase enzymatic activity caused by increase thyroid
hormone production apparently increase the strength of the heart
M. Normal arterial pressure flow naik tapi pulse pressure juga often increase
makanya ttp stay normal
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N. Increase respiration increased rate of metabolism increases the utilization of
oksigen and formation of carbondioxide, this effects activate all the mechanism
that increase the rate and depth of respiration
O. Increase GIT motility in addition to increased appetite and food intake which
has been discussed, TH juga increase rate of secretion of the digestive juices and
the motility of the GIT. Hyperthyroidism therefore sering results in diarrhea vice
versa causes constipation
P. Excitatory mechanism of the CNS hyperthyroidism causes nervous and have
many psychoneurotic tendencies such as anxiety complexes, extreme worry,
paranoia
Q. Effects on function of the muscles slight increase in TH makes the mucles
react with vigor, when excessive muscle jadi weakened because of the excess
protein catabolism
R. Muscle tremor this tremor is believed to be caused by increased reactivity of
the neuronal synapses in the area of the spinal cord that control muscle tone.
Penting dilihat karena untuk melihat derajat keparahan hormone effect ke CNS
S. Effect on sleep hyperthyroidism memang cepat lelah tapi karena ada excitable
effect dari si hormone maka jadinya tetep susah tidur. Extreme somnolence itu
karakteristik dari si hypothyroidism
T. Effect on other endocrine gland increase TH also increase the rates of other
endo glands. Misalnya contoh karena TH naikin gula dalam darah maka perlu
juga insulin dikeluarin dari pancreas. Th juga berhubungan dengan berbagai
metabolic yang related to bone formation, increase the need of parathyroid
hormone
U. Effect on sexual function intinya kalau kekurangan TH maka jadinya libido
menurun, kalau pada wanita bila hypo maka bisa jadi menorrhagia atau bisa
polimenorrhea. Kalau hyper pada wanita menyebabkan oligomenorrhea bahkan
absent. Semua bisa kerja secara direct effect atau melalui jalur feedback
mechanism
- Regulation of TH secretion.
1) TSH increase TH secretion. TSH (thyrotropin) has following mechanism : A.
increased proteolysis of the thyroglobulin that has been stored in the follicles, B.
increase activity of the iodide pump which then increase the iodide trapping, C.
increase iodination of tyrosine to form thyroid hormones, D. increased size and
secretory activity of the thyroid cells, E. increase number of thyroid cells plus a
change from cuboidal to columnar cells
2) cAMP mediates the stimulatory effect of TSH. First TSH bind dengan receptor nya di
basal of the thyroid cells. This binding then activates adenylyl cyclase yang in turn
perbanyak cAMP. cAMP bekerja sebagai second messenger to activate protein kinase
dsb. The result is both an immediate increase in secretion of TH and prolonged
growth of the thyroid glandular tissue itself
3) TSH juga diatur oleh TRH from hypothalamus. TRH dihasilkan di median eminence
dari hypothalamus. First bind dengan TRH receptor di pituitary activates the
second messenger system of phospholipase phospholipase C then followed by
cascade of other second messenger leads to TSH release
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4) Exposure to cold sebagai salah satu well known mechanism sebagai stimuli untuk
keluarin TRH then TSH. Ini gara-gara adalah excitation dari hypothalamic center for
body temperature control
5) Various emotional stimuli juga bisa affect the output dari TRH and TSH. Excitement
and anxiety that greatly stimulate SNS cause an acute decrease in TSH mungki
karena uda cukup heat di dalam tubuh sehingga merupakan feedback mechanism
temperature lagi
6) Feedback effect of TH to decrease secretion of TSH. Increase Th di darah maka TSH
akan menurun konsentrasinya dengan tujuan maintain an almost constant
concentration of free TH in the circulating body fluids

4. HYPOTHYROIDISM

- Congenital hypothy :
Prevalence. 1 in 4000 newborns, bisa transient especially if the mother punya
TSH-R blocking antibodies or has received antithyroid drugs. Bisa juga terjadi
secara permanent. Congenital abnormalities biasanya disebabkan oleh thyroid
gland dysgenesis (80-85%), then inborn errors of thyroid hormone synthesis (10-
15%) and TSH-R antibody-mediated in 5% of affected newborns. Developmental
abnormalities are twice as common in girls.
Clinical manifestation. Appear normal biasanya, dibawah 10% terdiagnose
based on the clinical features, which include prolonged jaundice, feeding
problems, hypotonia, enlarged tongue, delayed bone maturation, and umbilical
hernia. Typical adult features juga ada.
Diagnosis and treatment. Bisa berdampak pada sistem saraf nya (neurologic
complications) makanya segera harus dilakukan screening. Heel-prick blood
specimens measuring of TSH or T4 levels. When confirmed, T4 is instituted at a
dose of 10-15 µg/kg per day. T4 requirement tinggi during first year of life and
need a high level of circulating T4 to normalized TSH.
- Autoimmune hypothy :
Prevalence. The mean annual incidence rate of autoimmune hypothy is up to 4
per 1000 women and 1 per 1000 men.
Clinical manifestation. Summarized in the table.
Laboratory evaluation. Diagram.
Differential diagnosis. An asymmetric goiter may be confused with MNG or
thyroid carcinoma.
Treatment. If there is no residual thyroid function, the daily replacement dose
nya itu levothyroxine usually 1.6 µg/kg body weight (100-150 µg), ideally taken
before breakfast (30 min). in patients yang habis hyperthyro di operasi
memerlukan dose yang lebih sedikit (75-125 µg/d). Adult patient above 60 y.o
without evidence of heart disease may be started on 50-100 µg levothyroxine
daily. Kalau TSH naik maka increment dari levothyroxine sekitar 12,5-25 µg,
begitu juga kalau TSH turun, maka decrement levothyroxine nya sama aja dosis
penurunannya. Special consideration : during pregnancy levothyroxine levels
nya diangkat naik 50%, dengan target TSH tertentu. Kalau sudah birth maka
kembali ke prepregnancy levels of levothyroxine. In elderly biasanya require 20%
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less thyroxine than younger patients. Terutama pada pasien yang ada CAD
starting dose dari levothyroxine nya dimulai dari 12,5-25 µg/d with kenaikan
yang smaa tiap 2-3 bulan sekali dan dipantau TSH nya.
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5. THYROTOXICOSIS

- Thyrotoxicosis itu keadaan di dalam darah excess of Thyroid Hormones, while

Hyperthyroidism itu adalah keadaan terlalu aktif dari thyroid gland. Most common cause
of thyrotoxicosis is hyperthyroidism that is caused by Grave’s disease.
- Grave’s disease :
Prevalence. Account 60-80% of thyrotoxicosis. Prevalence varies among
populations. Occurs in up to 2% in women but is one tenth as frequent in men.
Usually occurs between 20-50 years of age.
Clinical manifestation. Summarized in table.
Laboratory evaluation. Diagram.
Differential diagnosis. Diagnosis of Grave’s disease is straightforward in a
patient with biochemically confirmed thyrotoxicosis, diffuse goiter on palpation,
opthalmopathy, and often a personal or family history of autoimmune disorders.
Clinical features of thyrotoxicosis menyerupai beberapa kondisi seperti panic
attacks, mania, pheochromocytoma, and weight loss associated with malignancy.
The diagnosis of thyrotoxicosis can be excluded if the TSH and unbound T4 and
T3 levels are normal.
Treatment. The hyperthyroidism in Grave’s disease is treated by reducing
thyroid hormone synthesis, using antithyroid drugs, or reducing the amount of
thyroid tissue with radioiodine (131I) treatment or by thyroidectomy. These
differences membuktikan bahwa tidak ada single approach yang berhasil
menangani secara optimal, diperlukan multiple treatment to achieve remission.
The main antithyroid drugs are thionamides such as prophyltiouracil,
carbimazole, and the active metabolite of carbimazole, methimazole. All inhibit
the function of TP, reducing oxidation and organification of iodide.
Prophyltiouracil menghambat deiodinasi dari T4 menuju T3, namun side effect
yaitu hepatotoxicity sehingga dilarang buat ibu hamil first trimester, buat
treatment thyroid storm, and patient yang bisa ditangani dengan methimazole.
Kalau pake prophyltiouracil harus dipandu dengan cek fungsi hati. The initial
dose of carbimazole dan methimazole itu sekitar 10-20 mg every 8-12 jam.
Prophyltiouracil diberikan sebanyak 100-200 mg every 6-8 jam. Starting regiment
nya bisa di reduce semua sembari thyrotoxicosis diperbaiki. Sambil dikasih
levothyroxine juga boleh untuk menghindari drug-induced hypothyroidism.
Thyroid function test dilakukan 4-6 weeks setelah starting dose initiated.
Propranolol (20-40 mg every 6 hours) or other selective long acting β-blockers
such as atenolol may be helpful to control adrenergic symptoms, especially awal-
awal sebelum di treat pake antithyroid. Boleh dikasih anticoagulation with
warfarin bila ada indikasi atrial fibrillation. Radioiodine causes progressive
destruction of thyroid cells an can be used as initial treatment or for relapses after
antithyroid drugs. Carbimazole and methimazole must be stop for 4-5 days before
administration of radioiodine. Pregnancy and breastfeeding are absolute
contraindications to radioiodine treatment. Subtotal or total thyroidectomy itu
disarankan kalau uda gagal antithyroid drugs and menolak radioiodine. Careful
control of thyrotoxicosis with antithyroid drugs followed by potassium iodide is
needed prior to surgery to avoid thyrotoxic crisis and to reduce vascularity of the
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gland. In patients dengan hamil, minum obat antithyroid, harus di titer karena bisa
lewat plancenta ke bayi dan menyebabkan fetal hypothyroidism and goiter.
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6. THYROID STORM

- Thyrotoxic crisis is rare and presents as a life-threatening exacerbation of

hyperthyroidism, accompanied by fever, delirium, seizures, coma, vomiting, diarrhea,
and jaundice. The mortality rate karena cardiac failure, arrhythmia, or hyperthermia is
30% walau uda diobati.
- Usually di cetuskan oleh acute illness (stroke, infection, trauma, diabetic ketoacidosis),
surgery, or radioiodine treatment.
- Management requiring intensive monitoring and supportive care, identification and
treatmentof the precipitating cause, and measures that reduce thyroid hormone synthesis.
- Large doses of prophytiouracil (500-1000 mg loading dose and 250 mg every 4 h) should
be given orally or by nasogastric tube or per rectum. Kalau gaada pake methimazole juga
boleh in doses up to 30 mg every 12 h. one hour setelah prophytio, kasih iodide stable
jadi dia block thyroid hormone synthesis via the Wolff-Chaikoff effect (didiemin 1 jam
supaya antithyroid drugs nya kerja dulu biar iodine ga kepake buat synthesis lagi).
- Saturated solution of potassium iodide (5 drops every 6 h) or ipodate or iopanoic acid
(500 mg per 12 h) may be given orally.
- Propranolol should also be given buat menangani symptoms jantung (60-80 mg PO every
4 h)
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- Additional therapy measures including glucocorticoids (hydrocortisone 300 mg IV),
antibiotics if infection is present, cooling, oxygen, and IV fluids.

7. RADIOIODINE

- Iodine, in the form of iodide, is made into two radioactive forms of iodine that are
commonly used in patients with thyroid diseases: I-123 (harmless to thyroid cells) and I-
131 (destroys thyroid cells). The radiation emitted by each of these forms of iodine can
be detected from outside the patient to gain information about thyroid function and take
pictures of the size and location of thyroid tissues. RAI is safe to use in individuals who
have had allergic reactions to seafood or X-ray contrast agents, since the reaction is to the
compound containing iodine, not the iodine itself. RAI is given by mouth in pill or liquid
form.
- I-123 is the usual isotope used to take pictures and determine the activity of the intact
thyroid gland (Thyroid Scan and Radioactive Iodine Uptake, RAIU), since it is harmless
to thyroid cells. No special radiation precautions are necessary after a thyroid scan or
RAIU using I-123. I-131 can also be used to take pictures of the thyroid gland, although
it is rarely used due to the harmful effects it has on thyroid cells.
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- THYROID TISSUE – I-131 is given to destroy overactive thyroid tissue or to shrink
thyroid glands that are functioning normally but are causing problems because of their
size. Patients are asked to follow some radiation precautions after treatment in order to
limit radiation exposure to others (see chart). I-131 may occasionally cause mild pain in
the neck that can be treated with aspirin, ibuprofen or acetaminophen. The RAI treatment
may take up to several months to have its effect. Frequently, the end result of RAI
treatment of hyperthyroidism is hypothyroidism, which is treated by thyroid hormone
replacement.
- THYROID CANCER – Large doses of I-131 are used to destroy thyroid cancer cells.
This is performed after the remaining thyroid cells (including any cancer cells) are
stimulated by raising TSH levels by either withdrawing the thyroid hormone pills or by
treating with recombinant human TSH. Patients are asked to follow some radiation
precautions after treatment in order to limit radiation exposure to others. Depending on
state regulations, patients may have to stay isolated in the hospital for about 24 hours to
avoid exposing other people to radiation, especially if there are young children living in
the same home.
- Although the treatments with 131-I are generally safe, RAI produces radiation so patients
must do their best to avoid radiation exposure to others, particularly to pregnant women
and young children. The amount of radiation exposure markedly decreases as the distance
from the patient increases. Patients who need to travel in the days after I-131 RAI
treatment are advised to carry a letter of explanation from their physician. This is because
radiation detection devices used at airports or in federal buildings may pick up even very
small radiation levels. Details should be discussed with a physician prior to, and at the
time of, the RAI treatment.
- In general, RAI is a safe and effective treatment for the thyroid disorders mentioned
above. Hypothyroidism is a common side effect of RAI for hyperthyroidism and always
seen after RAI for thyroid cancer. This is usually easily treated with thyroid hormone
replacement. Some studies suggest a slight increase in thyroid cancers may be seen after
RAI treatment for hyperthyroidism. Loss of taste and dry mouth due to salivary gland
damage may be seen. The use of lemon drops, vitamin C or sour stimulation to
potentially decrease the exposure of the salivary glands to RAI is controversial and
should be discussed with your physician. Importantly, once you have been treated with
RAI, regular medical follow-up is lifelong.
- RAI, whether I-123 or I-131, should never be used in a patient who is pregnant or
nursing. This protects the baby who would otherwise receive radioactive milk and the
mother’s breasts which concentrate RAI. Breastfeeding must be stopped at least 6 weeks
before administration of I-131 treatment and should not be restarted after administration
of RAI, but can be safely done after future pregnancies. Also, pregnancy should be put
off until at least 6 – 12 months after I-131 RAI treatment since the ovaries are exposed to
radiation after the treatment and to ensure that thyroid hormone levels are normal and
stable prior to pregnancy. There is no clear evidence that RAI leads to infertility.
- Men who receive RAI treatment for thyroid cancer may have decreased sperm counts and
temporary infertility for periods of roughly two years. Sperm banking is an option in a
patient who is expected to need several doses of RAI for thyroid cancer.
LO & WO WEEK 4 ENDOCRINOLOGY AND METABOLISM
LUKY ADLINO
8. LABORATORY FOR THYROID DISORDERS

- Several blood tests to check thyroid function, including the following:

a. TSH test
b. T4 tests
c. T3 test
d. thyroid-stimulating immunoglobulin (TSI) test
e. antithyroid antibody test, also called the thyroid peroxidase antibody test (TPOab)
- TSI Test. Thyroid-stimulating immunoglobulin is an autoantibody present in Graves’
disease. TSI mimics TSH by stimulating the thyroid cells, causing the thyroid to secrete
extra hormone. The TSI test detects TSI circulating in the blood and is usually measured
a. in people with Graves’ disease when the diagnosis is obscure
b. during pregnancy
c. to find out if a person is in remission, or no longer has hyperthyroidism and its
symptoms
- Antithyroid Antibody Test
Antithyroid antibodies are markers in the blood that are extremely helpful in diagnosing
Hashimoto’s disease. Two principal types of antithyroid antibodies are
a. anti-TG antibodies, which attack a protein in the thyroid called thyroglobulin
b. anti-thyroperoxidase, or anti-TPO, antibodies, which attack an enzyme in thyroid
cells called thyroperoxidase