Fakhri Mubarok 1510211033

 an enlarged thyroid gland and may be diffuse or nodular

(consisting of a solitary or multiple nodules)
 refers to an enlarged thyroid gland.
 Biosynthetic
defects, iodine
deficiency,
autoimmune
disease, and
nodular diseases
can each lead
to goiter,
although by
different
mechanisms.
EPIDEMIOLOGI
 The prevalence of goitres and thyroid nodules was reported as 15%
by the Whickham survey in North East England. Goitres are clinically
visible in 7% of the population and are palpable (and not visible) in
8%.
 Prevalence increases with age, iodine deficiency and previous
exposure to ionizing radiation.
 The Himalayas and the Andes are the most important goitrous
areas in the world today. Iodine deficiency is also seen in central
areas of Asia, Africa and Europe
 ETIOLOGI
 Defisiensi yodium  pd sbgian besar gondok endemik; <50 ug/hr
 AIU : Th.Cl x PII
 Produksi hormon <<  produksi TSH ↑
 Kadar yodium intrathyroid renah  >> jar lbh sensitif thd stimulasi TSH
 Faktor genetik
 Faktor goitrogenik
 Asupan iodida
 Lithium karbonas & unidentified goitrogens such as goitrin, an organic compound found in
certain roots and seeds; and cyanogenic glycosides, found in cassava and cabbage, that
release thiocyanate that can exacerbate the effects of iodide deficiency
 Compounds such as phenols, phrhalares, pyridines, and polyaromatic hydrocarbons found in
industrial waste water are weakly goitrogenic.
 Faktor geologik
 Mikroorganisme  genus Paracolobactrum; Clostridium perfringens
 Faktor sosial ekonomi
 Tiroiditis Hashimoto
 Tiroiditis subakut
 Sintesis hormon tdk adekuat akibat cacat bawaan
pd enzim2 tiroid yg dibutuhkan u/ biosintesis T3 &
T4
 Defisiensi bawaan pd reseptor T4 pd membran sel
 Neoplasma
 Dishormonogenesis tiroid
 GOITER DIFUS NONTOKSIK
When diffuse enlargement of
the thyroid occurs in the
absence of nodules and
hyperthyroidism
 Simple goiter 
the absence of
nodules
 Colloid goiter 
the presence of
uniform follicles
that are filled with
colloid.
 is more common in
women than men
Manifest Klinis
 >> asymptomatic. Examination of a diffuse goiter
reveals a symmetrically enlarged, nontender, generally
so gland without palpable nodules.

 Goiter is defined, somewhat arbitrarily, as a lateral

lobe with a volume greater than the thumb of the
individual being examined. If the thyroid is markedly
enlarged, it can cause tracheal or esophageal
compression. These features are unusual, however, in the
absence of nodular disease and fibrosis.
Diagnosis
 Respiratory flow measurements
 CT/MRI
 Thyroid function tests  a low total T4, with
normal T3 and TSH, reflecting enhanced T4 → T3
conversion.
 Ultrasound is not generally indicated in the
evaluation of diffuse goiter unless a nodule is
palpable on physical examination.
Therapy
 Iodine replacement
 Surgery  is rarely indicated for diffuse goiter.
Exceptions include documented evidence of tracheal
compression or obstruction of the thoracic inlet
 Subtotal or near-total thyroidectomy
 Surgery should be followed by replacement with
levothyroxine
GOITER MULTINODULAR NONTOKSIK

 occurs in up to 12% of adults. MNG

is more common in women than men
and increases in prevalence with
age.
 It is more common in iodine-deficient
regions but also occurs in regions of
iodine sufficiency,  reflecting
multiple genetic, autoimmune, and
environmental influences on the
pathogenesis.
 Histology reveals a spectrum of
morphologies ranging from
hypercellular regions to cystic areas
filled with colloid. Fibrosis is often
extensive, and areas of hemorrhage
or lymphocytic infiltration may be
seen
Gejala klinis
 Asymptomatic & euthyroid.
 If the goiter is large enough, it can
ultimately lead to compressive symptoms
including
 difficulty swallowing
 respiratory distress (tracheal compression),
 plethora (venous congestion)
 Symptomatic MNGs are usually
extraordinarily large and/or develop
fibrotic areas that cause compression.
 Sudden pain
 Hoarseness
Diagnosis
 Thyroid architecture is distorted, and multiple
nodules of varying size
 Pemberton’s sign
 TSH level; thyroid function is usually normal
 Pulmonary function testing
 CT/MRI
 Barium swallow
 USG
Tatalaksana
 Levothyroxine
 Radioiodine  Dosage of 131I depends on the size
of the goiter and radioiodine uptake but is usually
about 3.7 MBq (0.1 mCi) per gram of tissue
 When acute compression occurs, glucocorticoid
treatment or surgery may be needed
PATOGENESIS
 Dyshormonogenesis or severe iodine deficiency ↑TSH secretion 
induces diffuse thyroid hyperplasia, followed by focal hyperplasia
with necrosis and hemorrhage  the development of new areas of
focal hyperplasia.
 Initially, the hyperplasia is TSH dependent, but later the nodules
become TSH independent, or autonomous.
 Thus, a diffuse nontoxic TSH dependent goiter may progress over an
extended period of time to become a toxic multinodular TSH-
independent goiter.
 The mechanism for the development of autonomous
growth and function of thyroid nodules
 may involve mmarions that activate the G protein in the
cell membrane.
 Mutations of this gene, called the gsp oncogene,
have been found in a high proportion of nodules
from patients with multinodular goiter.
 Chronic activation of the G, protein results in thyroid
cell proliferation and hyperfuncrion even when TSH
is suppressed.
MANIFEST KLINIS
 The gland may be relatively firm but is often soft or
rubbery in consistency.
 May become progressively larger, so that in long-
standing cases, huge goiters may develop and extend
substernally to the level of the aortic arch.
 Facial flushing and dilation of cervical veins on lifting
the arms over the head is a positive Pemberton sign 
indicates obstruction to jugular venous flow
 Pressure symptoms in the neck, particularly on moving
the head upward or downward, and of difficulty in
swallowing.
 Vocal cord paralysis
DIAGNOSIS & THERAPY
 Normal FT4 and, usually,
normal levels of TSH. The
increased mass of thyroid
tissue may compensate for
inefficient synthesis of
hormone.
 Thyroid ultrasound

 Levotiroksin  dosis 0.1-0.2

mg/hr
 Pembedahan 
tiroidektomi subtotal
GOITER MULTINODULAR TOKSIK
 the presence of functional autonomy in toxic MNG
 The patient is usually elderly and may present with atrial fibrillation or
palpitations, tachycardia, nervousness, tremor, or weight loss.

 The management of toxic nodular goiter may be difficult, because patients

are often elderly with other comorbidiries.
 Control of the hyperthyroid state with antithyroid drugs followed by
radioiodine is the therapy of choice. If the goiter is very large,
thyroidectomy can be contemplated if the patient is a good surgical
candidate.
 REFERENSI
 Ilmu Penyakit Dalam – FKUI
 Harrison’s Endocrinology
 Lecture Notes –
Endocrinology and
Diabetes
 Greenspan’s Basic and
Clinical Endocrinology 9th
Edition