Hyperthyroidism is a common and frequently-occurring disease. According to the etiology, it can be divided into Graves disease (exophthalmos goiter or Basedow disease) and autonomic thyroid adenoma. Clinically, it can be divided into primary and secondary categories. Primary hyperthyroidism is the most common autoimmune disease, and secondary hyperthyroidism is rare, which is transformed from nodular goiter. Hyperthyroidism is an incurable disease. Although it is not a persistent disease, it is a hypermetabolic disease caused by excessive secretion of thyroid hormone.
At present, the prevalence rate of female population in China is 2%, and it is increasing year by year. Because people don't know enough about prevention, they often ignore the cure. The symptoms of hyperthyroidism suddenly increase to a life-threatening state (mainly manifested as high fever, sweating, extreme tachycardia, vomiting, diarrhea, irritability and even coma, which may lead to death if not rescued in time. )
In the process of recuperating hyperthyroidism, the patient's diet is particularly important. Because hyperthyroidism patients' demand for nutrients increases obviously due to hypermetabolism, if nutritional supplements are insufficient, emaciation will be more obvious, and even symptoms similar to advanced cancer will appear. Therefore, a reasonable diet is very important.
Patients should pay attention to the following aspects: the daily calorie intake is at least 2400 kcal for men and at least 2000 kcal for women. Eat more high-protein foods. Young patients need to eat more fatty foods, eat more fruits and vegetables rich in vitamins, and eat less spicy things, such as peppers, onions, ginger and garlic. Eat less foods containing more iodine, such as kelp, shrimp and fish. Try not to smoke, drink, and drink less strong tea and coffee. Patients should pay special attention to self-regulation of psychological mood and spiritual life level, keep their mood comfortable, cheerful and stable, and avoid colds, overwork and high fever.
Patients with hyperthyroidism should pay attention to:
L, taboo spicy food: pepper, raw onion, raw garlic;
2, taboo seafood: kelp, shrimp, hairtail;
3, taboo strong tea, coffee, tobacco and alcohol;
4. Keep calm and avoid fatigue.
At present, there are several ways to treat hyperthyroidism:
First, drug therapy: including antithyroid drug therapy, adjuvant therapy and nutritional intensive life therapy. Thiourea compounds are the main antithyroid drugs and the main methods of medical treatment. Adjuvant treatment is mainly symptomatic treatment such as propranolol and reserpine. Life therapy is to have a proper rest, have enough nutrition and calories in the diet, including sugar, protein, fat and B vitamins, and pay attention to avoid mental stimulation and fatigue.
In drug therapy, thiourea drugs are used to inhibit iodine tissue in thyroid and reduce the synthesis of thyroid hormone. However, these drugs do not inhibit thyroid iodine uptake and the release of synthetic hormones, so β -blockers such as propranolol and betaloc should be added at the initial stage of treatment. But it must be taken for a long time. Generally, the dosage can be gradually reduced in about one and a half to two years until the drug is stopped. However, about 1/3 to 1/2 patients will relapse, especially those with large necks or those who take more iodine in their diet (such as kelp, laver, iodized salt, etc.). In addition, a small number of patients will have skin itching, rash or leukopenia (easy to fever, sore throat), abnormal liver function and other drug allergy symptoms within two or three months before taking the medicine. If these phenomena occur, you should seek medical advice in time for further diagnosis and treatment. Indications for drug therapy:
(1) Graves hyperthyroidism, mild condition, small thyroid;
② Young (under 20 years old), pregnant, old and weak, or complicated with severe liver, kidney or heart disease, it is not suitable for operation;
③ preoperative preparation;
④ Recurrence after operation is not suitable for isotope therapy;
⑤ As an adjuvant therapy of radioisotope therapy.
Side effects of antithyroid drugs in the treatment of hyperthyroidism
Antithyroid drugs for hyperthyroidism: propylthiouracil, tabazole, etc. It can cause leukopenia, which usually occurs in the first few months after taking the medicine. If the drug is stopped in time, it will recover within 1 ~ 2 weeks, so it is necessary to check the blood picture regularly during the medication.
The most serious side effects of western antithyroid drugs in the treatment of hyperthyroidism are leukopenia and agranulocytosis. Because of agranulocytosis, the whole body resistance is obviously reduced, which leads to serious infection all over the body and poses a great threat to life. Therefore, attention should be paid to the occurrence of agranulocytosis when taking drugs. If found in time, there are still many opportunities for cure. Granulopenia usually occurs in the first three months of medication, but it can also occur at any time after medication. Therefore, you should be especially vigilant during taking L-3 months.
There are two ways of agranulocytosis, one is sudden and generally cannot be prevented. The other is progressive, usually with leukopenia first, which can turn into agranulocytosis if the drug is continued. The latter mode of onset can be prevented by regular examination of white blood cells during medication. White blood cells 1 time can be checked every week during medication. If the white blood cell count is less than 3× 10 9/L, it is generally necessary to stop taking drugs for observation. If the white blood cell count is 3-4× 10 9/L, it should be checked every 1-3 days/time.
Once agranulocytosis occurs, antithyroid drugs should be stopped immediately and sent to the hospital for emergency treatment. Because the patient's resistance is too weak, he should be rescued in a sterile isolation ward and given a lot of glucocorticoid and antibiotics. After the cure, the patient can no longer use antithyroid drugs to treat hyperthyroidism.
(4) Whether patients with hyperthyroidism or hypothyroidism can have a normal sexual life. Whether patients with hyperthyroidism or hypothyroidism can lead a normal sexual life depends on their condition. Generally speaking, patients with mild or moderate or severe illness can have moderate sexual life if their pathological changes are controlled, their symptoms disappear and their life activities tend to be normal after treatment.
However, people should pay attention to the following issues:
① Hyperthyroidism patients have various nervous system symptoms, such as excitability, paranoia, allergy, fear and anxiety. Autonomic nerve excitability is enhanced, and palpitation and arrhythmia appear. In addition, there are neuromuscular dysfunction, limb trembling and weakness. Sexual excitement can often induce or aggravate the above symptoms.
② Some patients with hyperthyroidism and hypothyroidism have seriously affected the harmony of husband and wife's sexual life and can't have normal sexual life. Therefore, targeted treatment must be actively carried out to restore sexual function.
③ The menstrual cycle of hyperthyroidism patients is often irregular, and the cycle is prolonged, but also shortened, with less menstrual flow and even amenorrhea. So the chances of getting pregnant are not great. If you are pregnant, you have a greater chance of miscarriage. Male patients are characterized by azoospermia or oligozoospermia because of the inhibition of sperm production, and must be actively treated according to the etiology in order to achieve the purpose of fertility.
④ When the hyperthyroidism patients' condition is stable, that is, the clinical symptoms are basically controlled after repeated treatment, the total serum triiodothyronine (T3) or tetraiodothyronine (T4) all return to normal, and the thyroid iodine uptake rate reaches the normal level (4%-30% in 2 hours and 25%-65% in 24 hours). After stopping taking drugs for more than half a year, people can generally have a normal sex life. Because sexual life often makes hyperthyroidism relapse or aggravate, some patients take medicine for more than 1 year, and about 1/2- 1/3 people still relapse after stopping taking medicine, so the recovery of sexual life must be carried out under the supervision of doctors.
⑤ Hyperthyroidism patients take drugs for a long time, and the drugs they take, such as tabazole, β-blockers, reserpine and guanethidine, have teratogenic effects. Therefore, in order to avoid fetal malformation caused by drugs and whether you can get pregnant after resuming sexual life, you should accept the guidance of a doctor.
Isotope therapy: thyroid tissue is destroyed by radioactive iodine to achieve the purpose of treatment, which is called "intra-thyroid surgery". The thyroid gland has the ability to concentrate iodine and the biological effect of 13 1 iodine can emit β rays, which can destroy, shrink and reduce the secretion of thyroid follicular epithelial cells, thus achieving the therapeutic purpose. Usually patients only need to take it once, and if the effect is not good, they can add it again after half a year or a year. After treatment, the volume of thyroid gland will gradually shrink, and even some patients will have low function due to excessive damage of thyroid gland. The indications for this therapy are:
① Moderate Graves hyperthyroidism, over 30 years old;
(2) those who are ineffective after long-term treatment with anti-hyperthyroidism drugs, or who relapse after stopping taking drugs, or who are allergic to drugs;
③ Patients with heart, liver and kidney diseases who are not suitable for operation, those who relapse after operation or those who are unwilling to operate;
④ Some hyperthyroidism nodular hyperthyroidism.
The following conditions are not suitable for this treatment: ① pregnancy and lactation; (two) under the age of 20; ③ Peripheral white blood cells < 3000/m3 or neutral <1500/m3; ④ Severe heart, liver and renal failure; ⑤ Severe infiltrative exophthalmos; ⑥ Hyperthyroidism crisis.
The above treatment methods are not isolated, and they often need to cooperate with each other in clinic to achieve the best treatment effect.
Third, the recurrence rate of surgical treatment after subtotal thyroidectomy is low, but the operation is destructive and irreversible, which can cause some complications and should be carefully selected. There are indications that:
(1) people with moderate or severe hyperthyroidism, who are ineffective after long-term medication, relapse after drug withdrawal, or have to take drugs for a long time;
② Patients with huge thyroid gland or symptoms of oppression;
③ substernal goiter with hyperthyroidism; ④ Nodular goiter with hyperthyroidism.
Those who are not suitable for surgical treatment are: ① those with infiltrative exophthalmos; (2) Patients with serious complications of heart, liver, kidney and lung, poor general condition and unbearable surgery; ③ Early pregnancy (first 3 months) and late pregnancy (last 3 months); ④ Mild patients are expected to be relieved by drug treatment.
Surgical treatment of hyperthyroidism
(1) Current status of surgical treatment: Subtotal thyroidectomy is still a common and effective method to treat hyperthyroidism. Anti-thyroid drugs can not cure hyperthyroidism radically, nor can they replace surgery. According to statistics, about 50% of cases treated with antithyroid drugs alone cannot return to work, while only 5% of cases are treated by surgery. Therefore, if the curative effect of antithyroid drugs cannot be consolidated after 4 ~ 5 months, surgery should be considered.
For surgical treatment, except for adolescent patients, those with mild illness and those with other serious diseases that are not suitable for surgery, surgical treatment can be performed. For secondary hyperthyroidism and hyperfunctional adenoma, antithyroid drugs or 13 1 iodine have no significant effect, and there is also the possibility of malignant transformation, so surgical treatment is more suitable. Patients with left ventricular enlargement, arrhythmia or even arrhythmia should be cured by surgery. Trying to completely cure the above-mentioned heart symptoms and then performing surgery is putting the cart before the horse, which will lead to the deterioration of the condition.
As for pregnant women, hyperthyroidism will have adverse effects on pregnancy, causing abortion, premature delivery, intrauterine death, pregnancy poisoning and so on. Pregnancy may aggravate hyperthyroidism. Therefore, surgical treatment should still be considered in the early and middle pregnancy, that is, 4 ~ 6 months; There is little interaction between late hyperthyroidism and pregnancy, and surgery can be performed after delivery.
(2) Preoperative preparation and its importance: When the basal metabolic rate of hyperthyroidism patients is high, the risk of surgery is high. Therefore, full and perfect preoperative preparation is very important.
1. First of all, we should do a good job in patients' ideological work and eliminate patients' worries and fears. People who are nervous, uneasy and insomnia can be given sedatives and sleeping pills. People with heart failure should be given digitalis preparation; Patients with atrial fibrillation can be treated with propranolol or quinidine.
2. Preoperative examination: In addition to comprehensive physical examination, it should also include: ① basal metabolic rate determination, T3T4 examination and 13 1 iodine absorption test. Additional patients should be reviewed regularly. ② Laryngoscopy to determine vocal cord function. (3) ECG examination, and check in detail whether the heart is enlarged, murmur or arrhythmia. ④ When there is retrosternal goiter, X-ray film of neck should be taken, and the patient should swallow the developer to determine the compression degree of trachea and esophagus.
3. Drug preparation: Reducing basal metabolic rate is an important part of preoperative preparation. ① If the patient's basal metabolic rate is high, thiouracil drugs (methyl or propyl thiouracil, tabazole, etc. ) can be used. These drugs can prevent the organic process of iodine, so that iodine oxides can not combine with tyrosine. In addition, it is also the enzymatic hydrolysis product of thyroid peroxidase, which can effectively prevent the synthesis of thyroxine and has an important immune effect on thyroid lymphocytes. Because thiouracil drugs can cause goiter and arterial congestion, bleeding is easy to occur during the operation, which increases the difficulty and danger of the operation. Therefore, iodine must be added after taking thiouracil drugs. ② After the symptoms of hyperthyroidism are basically controlled, oral iodine solution (Lugo's solution) can be used, starting with 3 drops three times a day, and increasing by 1 drop every day until 16 drops, and maintaining this amount for 3 ~ 5 days. The effect of iodine on hyperplastic thyroid gland is to block the organic contact of normal iodine and the hydrolysis of thyroglobulin in the first 24 ~ 48 hours, thus inhibiting the release of thyroxine, degenerating follicular cells, reducing the blood supply of thyroid gland and becoming brittle. Therefore, the gland shrinks and hardens, which is conducive to surgical removal of the thyroid gland. ③ For the patients who can't tolerate the routine use of iodine or combined use of antithyroid drugs or have no obvious effect, iodine and propranolol can be used for preoperative preparation, and the dosage of propranolol is 40 ~ 60 mg every 6 hours 1 time. The half-life of propranolol is 3 ~ 6 hours. Therefore, the last oral propranolol should be taken 1 ~ 2 hours before operation; Atropine should not be used before operation to avoid tachycardia. Take propranolol for 4 ~ 7 days after operation. Propranolol is a β -receptor blocker, which can selectively block the effect of β -receptor in target tissue on catecholamine, inhibit the increase of adrenergic activity, reduce the effect of surrounding tissues on thyroxine and improve the symptoms of hyperthyroidism. Propranolol can not inhibit the release of thyroxine.
In recent years, it has been advocated to use propranolol alone as preoperative preparation for hyperthyroidism. The advantages are: on the one hand, it can shorten the preoperative preparation time, on the other hand, it will not affect the thyroid function, and the functional state of the residual thyroid can be known immediately after operation. However, most scholars believe that the indication of propranolol should still be limited to the above situation, that is, if it has no obvious effect on iodine, it should still be used with iodine. Propranolol alone is only suitable for preoperative preparation of patients with high functional adenoma.
(3) Timing of operation: 2-3 weeks after preparation of the above drugs. The symptoms of hyperthyroidism are basically controlled (the patient's mood is stable, sleep is improved, and weight is increased), the pulse rate is stable below 90 beats per minute, the fluctuation of pulse rate in the early, middle and late days does not exceed 65438 00 beats per minute, the basal metabolic rate is below +20% or the T3T4 value is in the normal range. Glands atrophy and harden, vascular murmur decreases, and surgery can be performed.
It should be noted that the "appropriate operation opportunity" is generally determined by whether the basal metabolic rate is close to normal, but it is not entirely based on this. At the same time, we should refer to the overall situation, especially the improvement of the circulatory system. The decrease of pulse rate and the recovery of pulse pressure are often important signs of proper operation opportunity.
(4) Key points of subtotal thyroidectomy:
1. Anesthesia: Local anesthesia is effective in most cases, and vocal cord function can be known at any time to avoid injury of recurrent laryngeal nerve. If the trachea is severely compressed or there is a large retrosternal goiter, intratracheal anesthesia should be considered in order to ensure the unobstructed respiratory tract during operation and reduce the burden on the heart.
2. The operation should be gentle and meticulous, and every step should be serious. ① The thyroid body can be separated by cutting from the two transverse fingers on the upper edge of the sternum, transecting or separating the muscles under the hyoid bone, and entering the space between the thyroid outer capsule and the lamina propria. ② Fully expose thyroid gland. Ligation and cutting off the superior thyroid artery and vein should be close to the superior thyroid pole to avoid damaging the superior laryngeal nerve. If the inferior thyroid artery is ligated, try to stay away from the back of the gland and close to the common carotid artery to ligate the trunk of the inferior thyroid artery. This can not only prevent the recurrent laryngeal nerve from being damaged, but also keep the branches of inferior thyroid artery anastomosing with the branches of larynx, trachea, pharynx and esophagus, and will not affect the blood supply of residual thyroid and parathyroid gland after resection. ③ The number of resected glands depends on the size of thyroid gland and the degree of hyperthyroidism. It is usually necessary to remove 80 ~ 90% of the glands, and the remaining glands on each side are of appropriate size, such as the size of the distal thumb of an adult. Too little gland resection is easy to cause recurrence, and too much is easy to cause thyroid dysfunction. In addition, the dorsal part of the gland must be preserved, so as to avoid the injury of recurrent laryngeal nerve and parathyroid gland. The isthmus of the thyroid gland also needs to be removed. ④ Hemostasis should be strictly stopped during operation, and large blood vessels (such as superior thyroid artery and vein, middle thyroid vein and inferior thyroid vein) should be double ligated to prevent slippage bleeding. The incision should be drained for 24 ~ 48 hours, so as to drain oozing blood in time. The neck space is small, and a small amount of hematocele can also compress the trachea.
3. Strengthen postoperative observation and nursing, and pay close attention to the changes of patients' breathing, body temperature, pulse and blood pressure. After operation, continue to take compound potassium iodide solution three times a day, starting with 16 drops, and gradually reduce 1 drop every day. If propranolol is prepared before operation, take propranolol for 4 ~ 7 days after operation. The patient should take a semi-recumbent position to facilitate breathing and incision drainage. Help the patient to expectorate, and put a tracheotomy bag and gloves beside the bed to prevent the patient from choking.
(5) Major postoperative complications:
1. postoperative dyspnea and asphyxia: this is the most critical complication after operation, which mostly occurs within 48 hours after operation. The common causes are ① incision bleeding and trachea compression. It is mainly caused by incomplete hemostasis during operation or slippage of vascular ligature. ② Laryngeal edema. Mainly caused by surgical trauma or tracheal intubation injury. ③ Postoperative tracheal collapse. It is caused by long-term compression and softening of tracheal wall and loss of surrounding tissue support after operation.
The clinical manifestations are progressive dyspnea, dysphoria, cyanosis and even asphyxia. If it is caused by bleeding, there is swelling of the neck and bleeding at the drainage port. If this happens, the stitches should be removed at the bedside immediately, the wound should be opened and the hematoma should be removed. If the situation still does not improve, tracheotomy should be done immediately. After the patient's condition improves, he should be sent to the operating room for further examination and treatment.
2. Injury of recurrent laryngeal nerve: mainly caused by direct injury of surgery, such as cutting, sewing, pinching or overstretching; A few are caused by hematoma compression or scar tissue traction. The former showed symptoms immediately during the operation, while the latter showed symptoms a few days after the operation. If the recurrent laryngeal nerve is completely cut off or sutured, the injury is permanent, and most of the injuries caused by contusion, traction or hematoma compression are temporary. After acupuncture, physical therapy and other treatments, it can generally recover gradually within 3 ~ 6 months. The hoarseness caused by unilateral recurrent laryngeal nerve injury can be improved by excessive retraction of vocal cords to the affected side. Although the vocal cords of the affected side were still abducent after operation, the patient had no obvious hoarseness. Bilateral recurrent laryngeal nerve injury will lead to bilateral vocal cord paralysis, aphonia or dyspnea, which requires tracheotomy.
3. Injury of superior laryngeal nerve: It is mostly caused by ligation and cutting off the superior thyroid artery and vein, keeping the gland away from it without careful separation, and ligation of surrounding tissues. If the external branch of the superior laryngeal nerve is injured, it will paralyze the cricothyroid muscle, cause the vocal cords to relax and reduce the tone. When the upper pole of the thyroid gland is separated, the internal branch of the upper laryngeal nerve is sometimes damaged. Due to the loss of laryngeal mucosa sensation, patients lose reflex cough in the throat, which can cause swallowing and choking when eating, especially when drinking water. Generally, it can be recovered by acupuncture and physical therapy.
4. Tetany: when parathyroid gland is removed by mistake during operation, it can cause hypoparathyroidism and tetany when contusion or blood supply is affected.
Symptoms mostly occurred 1 ~ 2 days after operation. Mild people only have stiffness or numbness in the face or hands and feet, often accompanied by pressure in the precordial area; In severe cases, facial muscles and hand and foot convulsions (a painful spasm) may occur. It can attack several times a day, each time 10 ~ 20 minutes, or even several hours. Severe cases are accompanied by laryngeal and diaphragmatic spasm, which can cause suffocation and death. Cataracts in both eyes are often secondary in the late stage.
During the interval without tetany, the stress of neuromuscular increases obviously. If you tap the facial nerve and facial muscle in front of the ear, you will have a short-term spasm (Histotek sign), and if you press the upper arm nerve of the patient hard, it will cause hand rigidity (Trousseau sign).
When blood calcium decreases, blood phosphorus increases, while urinary calcium and phosphorus excretion decreases.
Treatment: intravenous injection of 10% calcium gluconate or calcium chloride 10 ~ 20ml immediately at the onset. Oral calcium gluconate or calcium lactate 2 ~ 4g, 3 ~ 4 times a day. At the same time, vitamin D2 is added, 50,000 ~ 65,438+million units per day to promote its absorption in the intestine. The most effective method is oral administration of dihydrosterol (AT 10) oil, which has the special function of increasing blood calcium, thus reducing the pressure on nerves and muscles. In recent years, parathyroid transplantation with the same conductor is also effective, but it is not lasting.
5. Thyroid crisis: the cause has not yet been determined. In the past, it was thought that thyroid crisis was the result of excessive extrusion of thyroid tissue during operation, which prompted a large number of thyroid hormones to suddenly enter the blood. However, the thyroid hormone content in patients' blood is not necessarily high. So we can't simply think that thyroid crisis is simply the result of too much thyroid hormone in the blood. In recent years, it is believed that thyroid crisis is caused by insufficient secretion of adrenocortical hormone, and the synthesis, secretion and catabolism of adrenocortical hormone are accelerated in hyperthyroidism. After a long time, the function of adrenal cortex decreased, and the surgical trauma stress induced crisis. At the same time, due to insufficient preoperative preparation, the symptoms of hyperthyroidism have not been well controlled.
The clinical manifestations are high fever within 12 ~ 36 hours after operation, rapid and weak pulse (more than 20 times per minute/kloc-0), irritability, delirium and even coma, and frequent vomiting and watery diarrhea. Without active treatment, patients often die quickly. So in the event of a crisis, it is necessary to rescue and treat it in time.
Treatment measures include: ① taking 3 ~ 5ml of compound iodine solution orally. In case of emergency, 5 ~ 10ml 10% sodium iodide can be added into 500ml 10% glucose solution intravenously to reduce the release of thyroxine. ② Use β -blockers or anti-sympathetic drugs, commonly propranolol 5mg, plus 5% glucose solution 100ml intravenous drip, or take 40 ~ 80mg orally every 6 hours. Reserpine 2 mg intramuscular injection once every 6 hours. ③ Hydrocortisone, 200 ~ 400 mg per day, intravenous drip in several times. ④ Sedative: Lumina sodium 65,438+000 mg or half-dose Hibernation Mixture II is commonly used for intramuscular injection every 6-8 hours. ⑤ Cooling: Hibernating drugs are generally used for physical cooling to keep the patient's body temperature at about 37℃. ⑥ Intravenous infusion of a large amount of glucose solution to maintain water, electrolyte and acid-base balance. ⑦ Oxygen inhalation to reduce tissue hypoxia. Today, foxglove can be given for heart failure and furosemide for pulmonary edema.
6. Postoperative recurrence: The common causes of postoperative recurrence are: thyroid isthmus or pyramidal lobe is not removed; Either there are not enough glands removed until there are too many glands left, or the inferior thyroid artery is not ligated. Reoperation for recurrent thyroid often brings incalculable difficulties and easily damages recurrent laryngeal nerve and parathyroid gland. Therefore, non-surgical treatment is generally the main treatment for recurrent hyperthyroidism.
7. Hypothyroidism: due to excessive gland resection. Different manifestations of mucinous edema: edema of skin and subcutaneous tissue, especially the face, without dents, dry skin and loose hair. Patients often feel tired, indifferent, unresponsive, slow-moving and decreased libido. In addition, the pulse rate is slow, the body temperature is low, and the basal metabolic rate is reduced.
Treatment: Long-term use of thyroid dry preparation or thyroxine is generally effective.
There is no etiological treatment for the disease, and the long-term remission rate is only 30% ~ 50%. Permanent hypothyroidism may occur after isotope therapy; The operation is destructive and irreversible, which reduces the recurrence of postoperative hyperthyroidism and leads to postoperative hypothyroidism. So strictly speaking, the three treatments are not satisfactory. Most patients with this disease show an extremely benign process, and appropriate treatment plays an important role in achieving considerable remission of the disease. Patients and doctors should cooperate closely and choose the best treatment plan according to different people.