Causes, symptoms, diagnosis and treatment of endemic goiter
Endemic goiter is a chronic disease of the thyroid gland, characterized by an increase in its size (goiter), as well as a violation of its function due to iodine deficiency.
According to statistics provided by the World Health Organization, more than 750 million people living in areas with iodine deficiency have goiter and various degrees of functional insufficiency of the gland. Of these, 42 million have been diagnosed with acquired mental retardation.
The most unfavorable in terms of iodine content in the environment in the Russian Federation are the Republic of Karelia, the valleys of the Siberian rivers, the Volga region and the Caucasus.
Content:
- Symptoms of an endemic goiter
- Causes of endemic goiter
- The degree of endemic goiter
- Diagnosis of endemic goiter
- Treatment of endemic goiter
- Memo to a patient with endemic goiter
- Prevention of endemic goiter
Symptoms of an endemic goiter
The clinical picture of endemic goiter of the thyroid gland is formed by the following groups of symptoms:
- Local symptoms (from the side of the gland);
- Symptoms associated with a violation of the synthesis of thyroid hormones;
- Symptoms of damage to other organs and systems.
Local symptoms
Local symptoms of endemic goiter include:
- The most important local symptom in endemic goiter is the enlargement of the thyroid gland. In the initial period of the disease, on examination, this can be overlooked and, only during palpation, the increased lobes and isthmus are determined. Over time, due to the continuous growth of the gland, it becomes visible on examination and is visualized as a tumor-like formation in the neck, in front of the trachea.
- The patients themselves begin to notice that it is difficult for them to wear clothes with high collars and sleep on their stomachs.
- Also, a common symptom with goiter is a feeling of foreign body pressure on the trachea and pharynx, difficulty swallowing.
- In some cases, the gland reaches such a size that it can squeeze the surrounding tissue, causing vascular and respiratory failure.
- The enlarged gland acquires a dense consistency. During auscultation of the vessels above it, the vascular noises are heard with a stethophonendoscope.
Symptoms associated with impaired synthesis of thyroid hormones
Endemic goiter occurs against the background of hypofunction of the thyroid gland, which synthesizes hormones based on organic iodine.
The thyroid hormones are triiodoteranin and tetraiodoteranin. They regulate protein, carbohydrate, mineral, fat and heat metabolism, the work of the reproductive, nervous and other systems.
With a deficiency of these hormones, the following clinical symptoms may develop:
- From the side of carbohydrate metabolism: impaired utilization of glucose into liver glycogen. As a result, all sugars entering the body follow the path of lipogenesis with the formation of both external and visceral (on internal organs) fatty deposits.
- From the side of protein metabolism: change from anabolic to catabolic orientation. As a result, the volume of muscle tissue decreases and, accordingly, muscle strength decreases.
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Fat metabolism: not only an increase in deposits on the body, but also an increase in the amount of fatty substances in the blood - cholesterol, triglycerides, fatty acids, as well as low and very low density lipoproteins. With an increase in their concentration, there is a risk of atherosclerosis, angina pectoris and, in the end, myocardial infarction.
- Peripheral and central nervous system: decrease in all types of activity, lethargy, drowsiness, decreased memory and the ability to perceive information.
- Cardiovascular system: decreased heart rate and strength, chest discomfort, pressure on the heart, interruptions in its work.
- Musculoskeletal system: increased excretion of calcium from bones - fragility of bones and their slow growth (in children), muscle weakness, lag in physical development.
- Heat exchange: a decrease in heat production - a constant feeling of coolness, cooling of the extremities.
- Reproductive system - infertility in men and women, spontaneous abortion and fetal malformations, the birth of children weighing more than 4500 g.
Causes of endemic goiter
As mentioned above, the cause of endemic goiter is iodine deficiency in the human body.
Iodine deficiency can be acute, in which case the body mobilizes all compensatory capabilities and, with the rapid resumption of iodine intake, returns the thyroid gland to a state of euthyroidism (normal functioning) and damage to other organs does not occur.
With chronic iodine deficiency, the situation is much more complicated. In response to a reduced intake of this element, hypertrophy occurs, that is, an increase in thyrocytes - cells synthesizing hormones. By increasing the volume of gland cells and enhancing their work, the relatively normal amount of hormones produced is stabilized for a while. But after a while, their fibrosis and the formation of nodes become inevitable.
With prolonged iodine deficiency, thyrocyte hypertrophy alone becomes insufficient. They not only increase in size, but also divide intensively. Thus, there are many times more enlarged and fibrosing cells, which means there are prerequisites for the development of diffuse-nodular goiter.
On the subject: Test to determine the level of iodine in the body
With the development of increasing iodine deficiency, the thyroid gland goes through several stages of changes in its structure: diffuse euthyroid goiter, then multinodular euthyroid goiter and, in the end, multinodular toxic goiter.
The most common causes of iodine deficiency
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Reasons for relative deficiency:
- Some medications that stimulate the elimination of iodine from the body;
- Diseases of the digestive tract, accompanied by malabsorption;
- Reception of enterosorbents;
- Chronic renal failure, accompanied by increased excretion of iodine;
- Congenital malformations of the gland (aplasia or hypoplasia);
- Transient conditions accompanied by iodine deficiency are Pregnancy, childhood, puberty, intense physical work and constant psycho-emotional stress.
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Reasons for absolute failure:
- Insufficient intake of iodine in the body with food;
- Insufficient intake of iodine in the body with water.
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Violation of the transfer of iodine from inorganic to organic:
- Energy imbalance;
- Chronic hypoxia
- Binding of iodine by strumogenic (goitrogenic) substances.
Let's consider in more detail the lack of iodine in food. Most residents of Russia practically do not have fresh high-quality seafood and fish in their diet. Also, few people think about buying iodized salt.
Of course, using only iodized salt will also not fill the iodine deficit, especially since iodine is a very volatile substance and quickly disappears from the structure of salt crystals when air enters them. Therefore, it is necessary to store such salt not in salt shakers and vases, but in metal or glass jars with a tight-fitting lid.
Eating large amounts of cauliflower, beans, peanuts and turnips threatens the development of iodine deficiency, since they contain many strumogenic substances that provoke an intensive growth of thyroid tissue.
The degree of endemic goiter
The World Health Organization proposed in 1994 the following classification of endemic goiter by degrees, which remains relevant to this day:
- 0 degree of endemic goiter - characterized by the absence of an increase in the volume of the thyroid gland; in this case, the volume of each of the lobes individually does not exceed the size of the extreme (distal) phalanx of the patient's thumb.
- 1 degree - there is a goiter, he did not see with the eye in the usual position of the subject's neck, but it is palpable well; the first degree also includes the nodular formations of the gland with the normal size of its lobes.
- Grade 2 - the goiter is well palpable and visible in the normal position of the patient's neck.
Diagnosis of endemic goiter
The initial stage in identifying endemic goiter is palpation. This method allows:
- Determine the size of the lobes and isthmus (if it is palpable);
- Assess the clarity of the boundaries with the surrounding tissues;
- Assess the consistency of the gland: the presence of seals, softening, nodules and their approximate dimensions;
- Assess the condition of regional lymph nodes, the presence of lymphangitis - inflammation of the lymphatic vessels extending from the thyroid and parathyroid glands.
In addition to palpation, ultrasound examination (echography) is a very informative, as well as accessible, method, which provides the following information:
- The exact width, thickness and height of the lobes;
- The dimensions of the isthmus;
- Complete data on the structure of the gland, its homogeneity;
- the presence of nodules and their exact size;
- The volume of individual lobes and the total volume of the thyroid gland;
- Condition of surrounding tissues.
Determination of the volume of the thyroid gland
The volume is calculated using the following formula:
The volume of one lobe = width * length * thickness * 0.48 (cm)
The total volume is equal to the sum of the volumes of both shares.
Normal indicators of the volume of the thyroid gland, depending on the age of the person:
| Age | Thyroid volume |
| 6 years | 4.8 - 5.5 ml |
| 8 years | 6.2 - 6.8 ml |
| 10 years | 7.7 - 9.1 ml |
| 12 years | 10.0 - 11.6 ml |
| 14 years old | 13.7 - 14.7 ml |
| 16 years | 15.2 - 16.1 ml |
The diagnosis of goiter in adults is established when the gland volume exceeds 18 ml in women and over 25 ml in men.
Additional methods for studying the state of the thyroid gland are:
- Study of the concentration of thyroid hormones in the blood (triiodoteranin and tetraiodoteranin), as well as pituitary thyroid stimulating hormone, which stimulates their synthesis;
- Excretion of iodine in the urine (up to 90% of iodine entering the body through the gastrointestinal tract is excreted by the kidneys);
- Magnetic resonance imaging and computed tomography (used in doubtful cases);
- Puncture biopsy to exclude a malignant neoplasm of the thyroid gland.
Treatment of endemic goiter
Treatment of endemic goiter must certainly be comprehensive and consist of adherence to the regimen, diet, drug therapy and, in some cases, surgical treatment.
Drug therapy for endemic goiter
Conservative therapy of endemic goiter is reduced to the appointment of thyroid drugs and iodine preparations.
In the Russian Federation, to date, only two drugs have been approved to replenish iodine deficiency - iodine balance and iodomarin. Iodaktiv, so often prescribed by Russian pediatricians and therapists, contains iodine associated with casein (cow's milk protein), and therefore is practically not absorbed.
At 0-1 stages of goiter, as well as with hypothyroidism for the first 6 months, only iodomarin (or iodine balance) is prescribed. In the absence of effect, they are combined with thyroid drugs.
In case of goiter of 1 and 2 degrees, the appointment of thioredine drugs is mandatory from the first day of treatment. They inhibit the production of thyroid-stimulating hormone from the pituitary gland, which stimulates the thyroid gland, and shrink it in size. In addition, they reduce the risk of developing autoimmune reactions that often accompany thyroid pathology.
The following drugs are used to treat endemic goiter:
- L-thyroxine is a synthetic tetraiodothyronine. Treatment begins with a daily dose of 0.05 mg, gradually increasing it to 0.1-0.2 mg per day for a week.
- Triiodothyronine is a synthetic analogue of thyroid triiodothyronine. The starting dose is 20 mcg, which is increased every 6-7 days.
- Thyroid forte is an analogue of L-thyroxine. Therapy begins with 20 mcg, gradually increasing to 80 mcg (2 tablets).
The duration of therapy for endemic goiter with these drugs is directly related to the severity of the disease and the degree of enlargement of the thyroid gland.
In mild cases, treatment takes 6 to 12 months. After that, a long-term dispensary observation of the patient begins with regular monitoring of the size of the thyroid gland and the level of hormones.
Surgical treatment of endemic goiter
If the enlargement of the thyroid gland is not associated with a violation of the differentiation of its cells (malignancy), then a partial resection is performed.
The indications for such an operation are:
- Strongly enlarged gland, compressing blood vessels, nerves, trachea;
- The presence of a single solid node (cold) in adolescence;
- Autonomous adenoma;
- Relapse of goiter.
In case of suspicion of adenocarcinoma - a malignant tumor, the thyroid gland is removed completely or subtotal resection is performed.
Radionuclide therapy for endemic goiter
In extreme cases, with frequent relapses, failure of drug and surgical therapy, as well as in old age, radionucleide therapy is performed, which slows down cell division and inhibits the growth of the gland.
It is very important not to forget about the presence of chronic pathology in a patient with goiter. This is especially true for diseases of the digestive system, accompanied by malabsorption syndrome - impaired absorption. In such cases, iodine doses are required that are several times higher than the dose for patients with normal absorption of substances from the intestine.
Diet
Since in 90% of cases, endemic goiter is provoked precisely by the lack of iodine intake into the body through the digestive tract, the diet is one of the key links in the treatment of this disease.
The daily iodine requirement for a healthy adult is 140-150 mcg, for children - 100-120 mcg, and for infants - 50 mcg.
The following foods rich in organic iodine should be consumed:
- Oven baked potatoes contain up to 60 micrograms of iodine in one tuber, which is more than a third of the daily requirement.
- Prunes - One fruit contains approximately 3 mcg of iodine.
- Cranberries - 20-30 berries fully cover the daily requirement.
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Seafood:
- cod contains 99 mcg of iodine per 85 grams;
- shrimp - 35 mcg per 100 grams;
- lobster - 90 mcg per 100 grams;
- tuna - 17 mcg per 85 grams;
- dried seaweed gives the body up to 2500% of the daily intake of iodine, because 7 grams contains 4500 mcg.
- Oven baked turkey breast contains 35 mcg of iodine per 100 grams.
Iodine is also found in small amounts in milk, natural yogurt, chicken eggs, bananas, strawberries and sea beans.
It is worth excluding foods with strumogenic properties from your diet for the period of therapy: broccoli, cabbage, cauliflower, turnips, radishes, lettuce, corn, beans.
Mode
In this situation, one should adhere to a lifestyle in which meeting all the body's needs does not require the production of a large amount of thyroid hormones. It is worth limiting physical activity, excluding heavy physical and psycho-emotional stress, climate change, long flights, changing the daily routine and bad habits.
It is imperative to protect yourself from natural (see the subsection "Diet") and industrial strumogenic substances.
Industrial strumogenes are:
- Insecticides - chemical compounds used to kill insects;
- Herbicides - chemical compounds intended for the destruction of weeds, widely used in agriculture;
- Fungicides - substances for combating fungal diseases affecting plants;
- Halogenated organic compounds used in the chlorination of drinking water, waste water, as well as the cooling of various power plants;
- Phthalic esters, which are used in the automotive industry, construction and furniture production;
- Thiocyanate, a substance in tobacco smoke, competes with the thyroid gland to capture iodine.
On the subject: Effective recipes for traditional medicine for goiter
Memo to a patient with endemic goiter
- Follow your diet. Limit thyroid-stimulating foods. Introduce foods rich in organic iodine as much as possible (see the Diet section).
- Stick to a healthy lifestyle. Reduce the severity of the exercise, but do not completely eliminate it. Give preference to morning exercises, walking, yoga.
- Give up bad habits, especially smoking, as tobacco smoke contains strumogens.
- Take regular iodine and thyroid hormones. Preferred reception in the morning.
- Pay close attention to all the recommendations of your doctor, regularly come to him for examination.
- Be attentive to the sensations of your body. Describe in detail the moments that bother you to the doctor (heart attacks or, conversely, bradycardia, neck pain, general weakness, etc.), and also try to identify the reasons for their occurrence.
Prevention of endemic goiter
Prevention of endemic goiter is divided into mass, group and individual:
- Mass preventive measures include the production of iodized salt, iodized bread and confectionery, as well as promoting the control of iodine levels in food on television and radio.
- Group prophylaxis is carried out in risk groups: in organized groups of children's and preschool institutions, in schools, secondary technical and higher educational institutions, as well as with pregnant and lactating women. This also includes an explanatory conversation, and, according to the doctor's recommendation, controlled distribution of iodine preparations (Antistrumin, Yodomarin, Yodokomb).
- Individual prevention consists of eating foods rich in iodine and taking iodine supplements in risk groups and in endemic areas.
Mixed-fed children, if fed with unadapted milk formulas, need 90 mcg of iodine daily. Pregnant women, children and adolescents - 200 mcg per day.
The author of the article: Kuzmina Vera Valerievna | Endocrinologist, nutritionist
Education: Diploma of the Russian State Medical University named after NI Pirogov with a degree in General Medicine (2004). Residency at Moscow State University of Medicine and Dentistry, diploma in Endocrinology (2006).
