Causes, symptoms, degrees and treatment of diffuse nodular goiter
Content:
- What is diffuse nodular goiter?
- Symptoms of diffuse nodular goiter
- Causes of diffuse nodular goiter
- Diffuse nodular goiter
- Diagnostics of the diffuse-nodular goiter
- Treatment of diffuse nodular goiter
What is diffuse nodular goiter?
Diffuse-nodular goiter is an endocrine disease in which the tissue of the thyroid gland grows, as well as the formation of nodular inclusions in the structure of the organ.
This form of the disease is also called mixed, since it combines features characteristic of diffuse (a general increase in tissue mass) and nodular goiter (the appearance of nodes in the structure of the gland).
With a mixed form of goiter, together with a general proliferation of thyroid tissues, an independent uneven increase in the formed nodes is observed. These factors make the disease specific and relatively easy to diagnose.
According to statistics, diffuse and diffuse-nodular pathologies of the thyroid gland are widespread. Among all endocrine diseases, they rank second, second only to diabetes, and account for about 45-50% of all cases of referral to a specialist.
In Russia, according to Rosstat, about 0.3% of the population, which is 500 thousand people, is observed by an endocrinologist for goiter. Of these, about an eighth of the cases are in the diffuse-nodular form of the disease.
Taking into account the attitude of the population to medicine and their health, there is reason to assume that the real morbidity figure is much higher than the official one.
Symptoms of the diffuse nodular goiter of the thyroid gland
As a rule, in the early stages of the development of the disease, symptoms are either completely absent, or so scarce that the patient does not attach much importance to the manifestations. As the pathological process develops, the intensity of the symptoms increases.
The growth of the thyroid gland and nodular neoplasms does not always cause increased secretion of hormones. Symptoms will vary depending on the level of production of active substances.
If hormone production is reduced:
- Hypothermia. Depending on how much the volume of thyroid hormone production is reduced, there is a bright (up to 35 ° C) or moderate decrease in body temperature. This process occurs due to a decrease in the metabolic rate due to a lack of triiodothyronine and thyroxine;
- Arrhythmia, hypotension. With diffuse nodular goiter, there are growing problems with the cardiovascular system. The pressure falls below normal numbers (up to 90/60), bradycardia (decreased heart rate) and arrhythmia are observed;
- The onset of edema;
- Sleep problems. At night the patient cannot fall asleep, while in the daytime he "tends to sleep";
- Obesity. Due to a decrease in the metabolic rate, body weight increases;
- Depressive states due to insufficient stimulation of the emotional centers of the brain;
- Lethargy, decreased intellectual ability and memory;
- Loss of skin elasticity, fragility of nails;
- Weakening of hair follicles and, as a result, hair loss;
- Decreased libido;
- Disruptions of the menstrual cycle;
- Deterioration of intestinal motility.
If the production of thyroid hormones exceeds the norm:
- Hyperthermia. Regardless of the presence of inflammatory processes, the patient has a periodic increase in body temperature (up to 37.0 - 37.7, subfebrile condition);
- Persistent tachycardia. With increased secretion of iodine-containing hormones, heart rate increases (about 100-120 beats per minute). This occurs paroxysm and is practically independent of physical activity;
- Strengthening psychomotor activity. The patient becomes overexcited and nervous. There is increased irritability and aggression;
- Irrepressible appetite. However, regardless of the amount of food consumed, body weight is steadily falling;
- Skin moisture. The activity of the sweat and sebaceous glands increases. More secret is allocated. The skin becomes moist and hot;
- Tremor of the limbs and head;
- The eyeballs protrude forward, exophthalmos appears;
- Frequent diarrhea, abdominal pain and general indigestion.
If hormone production is not impaired:
- Prolonged paroxysmal cough, dry, without sputum. It is caused by irritation of the trachea by enlarged thyroid tissues;
- Feeling of fullness and heaviness in the neck for a long time;
- Shortness of breath and suffocation when changing head position;
- Feeling of a coma when swallowing;
- Sore throat;
- If the goiter reaches the advanced stages, it becomes visible to the naked eye;
- Voice changes, up to and including its complete loss.
In this case, the symptoms caused by hormonal disruptions are absent even in the later stages of the development of the disease. The manifestations are of a mechanical nature and are caused by the proliferation of the thyroid gland and compression of the adjacent organs.
Causes of diffuse nodular goiter
Endocrinologists at the moment have not established exactly why a mixed form of thyroid goiter occurs.
It is assumed that a whole complex of factors plays a role in the mechanism of the formation and development of pathology, including:
- The presence of certain diseases that cause changes in the thyroid gland;
- Unfavorable environmental factors;
- Genetic factors;
- Other endogenous factors.
Diseases and pathologies that cause the development of a pathological process:
- Excess colloid. Nodular changes, which, in addition to an increase in organ size, are characteristic of a mixed form of goiter, may be due to the accumulation of a specific gel-like liquid - a colloid - in the follicles of the thyroid gland. The appearance of nodes for this reason is observed in the vast majority of clinical cases - 92-95%;
- Benign tumors of the thyroid gland. They are much less common. The most common type is thyroid adenoma. As a result of a malfunction of the cells, their intensified division begins, which quickly becomes under the control of the immune system. The adenoma is encapsulated and takes the form of a nodular neoplasm on the surface of the thyroid gland;
- Malignant tumors of the thyroid gland (usually carcinomas). They are extremely rare. The process of their occurrence is similar to the mechanism of development of benign tumors, with the only difference that cell division occurs uncontrollably and the cells themselves are immature. As a result of the development of a cancerous tumor, nodes grow in the structure of the thyroid gland. Malignant tissue pushes the surrounding tissue of the gland, as a result of which the endocrine organ can increase in size;
- Tumors of the pituitary gland. As a result of stimulation of pituitary cells, an overly active production of a specific hormone occurs, which affects the thyroid gland. In response to the "signals", the iron releases more hormones and, unable to cope, grows. Diffuse and nodular changes occur;
- Thyroiditis, or Hashimoto's goiter. It occurs in isolated cases and is an autoimmune disease in which iodine-containing proteins circulate in the bloodstream. The mechanism of further development is similar to an allergic reaction. The body perceives protein as a "violator" and produces antibodies. As a result of the immune response, thyrocyte cells suffer. To produce more specific hormones, the thyroid gland grows in size by building up tissue. At the site of the dead thyrocytes, replacement scar tissue develops;
- In addition, a number of changes may not have direct biochemical causes. Thus, nodules in the thyroid gland can be cysts or tuberculous calcifications, which are mistaken for endocrine disorders.
Environmental factors:
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Iodine deficiency. For the normal secretion of iodine-containing hormones, it is necessary to consume foods rich in this element. Iodine also enters the body from drinking water. An unfavorable factor leading to the development of diffuse-nodular and other forms of goiter is a lack of iodine in the diet. The reasons may be in the specifics of the region of residence or in the wrong diet.
The norms of iodine consumption according to world standards are:
- Children under 5 years of age: 90 to 100 mcg per day;
- Children from 5 to 12 years old: 100-130 mcg per day;
- Adults: 130 to 160 mcg
- Women during pregnancy and lactation - from 160 to 200 mcg per day.
With a lack of iodine, the thyroid gland enlarges in order to absorb and convert more iodine. In addition to diffuse changes, in which the gland increases evenly, foci of nodular growths may occur.
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- Environmental factors. With the consumption of toxic substances contained in water, food and air, the activity of the thyroid gland decreases, or vice versa, it increases excessively. Particularly dangerous are salts of nitric acid (nitrates, salts with an acidic residue of NO3), an excess of calcium salts. The increased background radiation causes an increase in the concentration of free radicals in the body, which can lead to damage and mutation of the gland cells.
- Physical inactivity. Lack of physical activity causes stagnation.
Genetic factors
There is no evidence of a direct dependence of the occurrence of diffuse-nodular and other forms of goiter on the genetic component.
However, at the genetic level, features are transmitted that cause an overactive thyroid gland. This is the rate of metabolic processes, and the susceptibility to iodine-containing hormones, etc. Thus, the disease itself is not transmitted, but a predisposition to it is transmitted.
Other endogenous factors
Among the many factors in the mechanism of development of pathology, the so-called triggers can be distinguished. Their role is to start the process.
- High psychological stress, trauma in the psychological sphere, stress. They cause a deterioration in the functioning of the nervous system, contribute to a reduced or, conversely, increased production of hormones.
- Immune problems. To a decrease in immunity, as well as chronic inflammatory processes in the neck, the body can react by launching a protective mechanism. The active growth of thyroid cells will begin.
- Hormonal disruptions and changes. Hormonal imbalance causes instability in the endocrine system.
At-risk groups
The risk group for the formation of a diffuse nodular goiter includes:
- Population of Eastern Europe and Asia. In these regions, the natural content of iodine salts in soil and water is minimal, therefore the risk of developing a mixed form of the disease is several times higher;
- People living in industrialized regions. Unfavorable environmental conditions, as mentioned above, increase the likelihood of developing endocrine disorders;
- Adolescents during puberty. During puberty, the body undergoes dramatic hormonal changes. The thyroid gland is working to the limit, and therefore, disturbances in its work may appear. Girls are more susceptible to the development of pathology than boys;
- Pregnant and lactating women. It is the thyroid gland that plays a special role in the pregnancy process. To fill the lack of hormones, the organ will enlarge;
- Women over 50. During menopause, a new hormonal surge occurs, as a result of which problems with the thyroid gland may occur;
- Heredity. The goiter in a diffuse-nodular form is not directly transmitted to the offspring. The form of the disease depends on the presence of triggering factors and the characteristics of the organism. A predisposition to goiter is transmitted. If one of the parents suffered from a similar pathology, the risk of a goiter in a child is about 25%, if both - up to 75%. The absence of a disease in the genus does not exclude the possibility of its development in offspring. With competent prevention, the onset of the pathological process can be avoided, regardless of the presence or absence of a predisposition.
According to statistics, most of the goiter is manifested in women (almost 3/4 of the recorded cases).
Grades of diffuse nodular thyroid goiter
The disease passes through 3 stages in its development (according to the classification of the World Health Organization). In domestic medical practice, the classification is carried out in more detail and includes 5 stages.
The subdivision of pathology into degree (stage) is based on three criteria:
- The presence of specific symptoms;
- Detection by palpation;
- The ability to view visually.
Grade 1 diffuse nodular goiter
According to the practical classification, it includes 0 and 1 degrees.
The course of the disease begins imperceptibly. Diffuse-nodular goiter of zero degree does not manifest itself in any way: neither by symptoms, nor during primary diagnostic procedures.
The process is usually slow and can last from six months to several years. Not detected on palpation. Often the very fact of the presence of the disease is revealed by chance, when examining individual organs and systems.
The onset of pathology can be diagnosed using ultrasound or hormonal tests.
Grade 1 goiter is better diagnosed. It is impossible to visually detect it, however, palpation reveals an enlargement of the thyroid gland, as well as the existence of nodes. Nodular formations can be both single and multiple.
If hypothyroidism occurs, already at the first stage, there is a characteristic symptomatology, but adjusted for a relatively mild course:
- Slight increase in body weight;
- An unexplained drop in temperature
- Chronic fatigue;
- Decrease in blood pressure.
2 degree diffuse nodular goiter
Covers 2nd and 3rd degrees in practical qualifications.
Diffuse nodular goiter of the 2nd degree has the following features:
- It is found even with superficial palpation;
- When swallowed, it becomes visible to the naked eye;
- Compression of the esophagus is observed, due to which the patient may have problems with swallowing;
- When tilting the head and trunk, pain occurs in the neck and head.
Due to diffuse disorders, the secretion of active substances increases sharply, symptoms of hyperthyroidism appear:
- Exophthalmos (protruding eyeballs);
- Psychomotor disorders (excitability, aggressiveness, nervousness);
- Tremor of the limbs and head;
- The appearance of edema;
- Shortness of breath (because the trachea is compressed);
- Arterial hypertension.
The 3rd practical degree of the disease is characterized by pronounced functional disorders of the cardiovascular, endocrine and nervous systems. The goiter has a pronounced shape and structure. The convex formation changes the shape of the neck, visually making it look like a bird. Due to an excess of iodine-containing hormones, the skin may turn reddish. For the dermal integument, excessive dryness or, conversely, high humidity is characteristic.
Disorders of intestinal motility, alternation of constipation and diarrhea occur. There is a strong tremor. A persistent decrease in blood pressure is recorded against the background of the absence of other provoking diseases. There are violations of the heart (heart rate - either bradycardia, 40-60 beats per minute, or tachycardia - over 100 beats). Severe shortness of breath. When changing the position of the head - a sharp suffocation. Weight change against the background of increased appetite, as a rule, downward.
Grade 3 diffuse nodular goiter
Covers the 4th and 5th stages of the additional classification.
The criterion for referring the disease to the fourth stage is the shape and size of the diffuse nodular goiter. At the 4th degree, the goiter grows so much that it completely changes the shape of the neck. Symptoms, in general, remain the same as in grade 3.
The 5th stage is diagnosed with an extremely severe course. The disease affects many systems: nervous, endocrine, cardiovascular, digestive. At the final stage, cases of death are possible.
The goiter takes on a huge size and significantly changes the appearance of the patient. Severe compression of adjacent organs is observed. Voice becomes hoarse or absent. In addition to the already existing symptoms, there is a decrease in intelligence, memory, reproductive functions. In practice, both classifications are used, but the second allows a more detailed description of the process of the course of endocrine pathology.
Diagnostics of the diffuse-nodular goiter
Among the methods for diagnosing diffuse nodular goiter, the following are distinguished:
- Palpation. Palpation of the thyroid gland reveals the disease at the first stage. This method is not absolutely accurate, but it allows you to assess the state of the organ in general terms. On palpation, attention should be paid to seals over 1 centimeter in diameter. At the very first stage of the disease, with deep palpation, the isthmus of the thyroid gland is felt. At the second stage, hyperplasia is diagnosed with superficial palpation, and at later stages, palpation is no longer required to establish the presence of the disease;
- Contrast radiography. It is carried out to assess the functions and condition of the thyroid gland. The patient is injected intravenously with a radioactive isotope of iodine (iodine-123 or iodine-131). At intervals of time (2 hours, 4 and 24 hours), an organ is scanned using a specialized apparatus. Depending on the distribution, the rate of elimination, the amount of the radioisotope, the diagnostician makes a conclusion about the functions of the organ. This method allows you to reliably identify hypo- and hyperthyroidism;
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Hormonal tests. To analyze the content of thyroid hormones, venous blood is drawn. The study takes into account the following active substances: total and free triiodothyronine (T3), total and free thyroxine (T4), TSH, and the volume of calcitonin produced.
For a correct assessment of the results, it is necessary to take into account such factors as:
- The number of "living" functioning cells in the gland.
- Excess / deficiency of iodine in the diet on the eve of sampling.
- Floor.
- Age.
The table shows the normal values of hormones:
The name of the hormone min max Triiodothyronine (free) 2.7 petamol / liter 5.9 petamol / liter Triiodothyronine (generic) 1.2 nanomole / liter 2.2 nanomole / liter Thyroxine (free) 9 petamol / liter 22 petamol / liter Thyroxine (general) 54 nanomole / liter 156 nanomole / liter TSH 0.3 mU / l 4.1 mU / l Calcitonin 5.5 nanomole / liter 28 nanomole / liter - Ultrasonography. Ultrasound of the thyroid gland is one of the most common and effective methods for diagnosing diffuse nodular goiter. Up to half of all cases of the presence of the disease are recognized precisely by ultrasound;
- Biopsy. Biopsy using a fine needle (aspiration biopsy) has become widespread. Most often it is used to determine the contents of nodes and their origin. It can be combined with ultrasound examination to correct the entry into the pathological focus. The procedure itself is practically painless and does not require special training, while it is highly informative;
- Taking anamnesis. It is a standard procedure in the analysis of any disease. Diagnosis of problems with the thyroid gland is no exception;
- MRI and CT. Magnetic resonance imaging and computed tomography are used in the most difficult cases if there are difficulties with ultrasound diagnostics.
Treatment of diffuse nodular goiter
Depending on the stage and severity of the disease, one or another type of therapy is performed.
Treatment of diffuse nodular goiter pursues three main goals:
- Elimination of specific symptoms to improve the patient's quality of life;
- Neutralization of factors that disrupt the functioning of the thyroid gland;
- A general decrease in the load on the organ in order to suspend the pathological process.
For treatment, both non-invasive conservative methods and surgical operations are used.
Conservative treatment consists of taking special medications. In modern practice, the following are used:
- Hormonal drugs that are aimed at stabilizing hormonal levels. Among them: Lyothyronine, Thyroidin, Iodtirox and many others. The funds of this group are very numerous and are prescribed by the attending physician;
- Iodine preparations to stimulate the independent work of the thyroid gland. Among them are Yodomarin, etc.
The course of treatment with hormonal drugs takes from six months to a year and does not give a 100% guarantee of cure for diffuse nodular goiter. The thyroid gland may stop producing hormones on its own, or a relapse may occur, then the treatment will have to be repeated.
Thyroid medications have a host of severe side effects. Their action affects many organs and systems. To "mitigate" undesirable effects, a course of maintenance therapy is required. Maintenance drugs are prescribed by the appropriate specialists: cardiologists, gastroenterologists, etc.
Thus, the conservative treatment of this ailment is complex and requires the participation of doctors of several specializations.
With diffuse nodular goiter of the 0th and 1st stages, specific therapy is not required. The process can slow down by itself or stop altogether. The main recommendation is to visit an endocrinologist once every six months.
At further stages, hormonal drugs cannot be dispensed with. In special cases, along with hormonal therapy, surgery is also performed.
The absolute indications for the operation are:
- Tumor neoplasms of malignant origin;
- A goiter of significant size (since there is compression of the surrounding organs and, as a result, a risk to the patient's life);
- Rapid growth of goiter;
- Multiple nodes against the background of significant diffuse changes in the thyroid gland;
- Cystic formations on the thyroid gland;
- Complex location of the goiter (behind the sternum, with displacement).
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Diet for diffuse nodular goiter
In addition to special therapy, it is necessary to support the body by prescribing a specialized diet for the patient. A well-chosen diet is no less important component of treatment than medications.
With diffuse-nodular goiter, the level of production of iodine-containing hormones can both increase and decrease:
- If the disease proceeds against the background of hyperthyroidism, the body suffers colossal energy losses. To replenish them, a high-calorie diet is required (at least 3.5 thousand kcal per day). Preference should be given to foods rich in carbohydrates, as well as salts and vitamins;
- Otherwise, if the hormones are not enough, the calorie content of the portions consumed must be reduced and a protein diet given preference.
Diffuse-nodular goiter in the later stages is characterized by disorders of the nervous system. For this reason, you should reduce the consumption of products that stimulate its active work: chocolate, tea, coffee, etc.
To stabilize the iodine level, products rich in salts of this element are suitable: fish (herring, cod, etc.), beets, garlic, kelp, dairy products (milk, sour cream), beef, bananas, citrus fruits (oranges and lemons).
Thus, diffuse nodular goiter requires increased attention. Diagnosis of the disease in the early stages is not very difficult for an experienced specialist. The arsenal of medicine has a large number of instrumental research methods.
Despite the insufficient knowledge of the mechanism of occurrence of the disease and methods of treatment, the level of development of science today is sufficient to stop the pathological process and restore the minimum acceptable standard of living of the patient.
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).
