Syspath: Endocrine 2

The Thyroid Gland and Aging

• The thyroid gland shrinks and shifts lower in the neck with age.
• Hormone levels potentially decrease slightly, but vital function speed undergoes minimal change.
• As age increases, disorders of the thyroid become more prevalent.
• Hyper- and hypothyroidism often go undiagnosed in older individuals.
• Thyroid dysfunction has a larger effect.
• Look for symptoms that mimic aging.
• Watch for malaise and an inability to complete Activities of Daily Living (ADL).
• Adults 65+ need yearly screening for TSH levels.

Hypothyroidism Defined

• Underactivity of the thyroid is caused by structural or functional changes.
• The underactivity can result in inadequate hormone production.
• Dysfunction location can be anywhere along the hypothalamic-pituitary-thyroid axis.
• Primary hypothyroidism: thyroid gland issue
• Secondary hypothyroidism: pituitary gland issue
• Tertiary hypothyroidism: hypothalamus gland issue
• Hypothyroidism is common, especially in older people and women.
• 10% of the female population is affected.

Causes of Hypothyroidism

• Primary Causes include diseases:
• The most common, Autoimmune (Hashimoto thyroiditis) in North America
• Absence/loss of thyroid parenchyma or hypertrophy of thyroid gland
• Iodine deficiency is most common worldwide
• Surgical or radiation-induced ablation of tissue
• Congenital agenesis/dysgenesis
• Drugs (lithium, iodides)
• Secondary Cause Pituitary failure (lesion, tumor)
• Tertiary (rare) Cause Hypothalamic failure

Common Signs and Symptoms of Hypothyroidism

• Fatigue
• Weight gain
• Trouble tolerating cold
• Joint and muscle pain
• Dry skin or dry, thinning hair
• Heavy or irregular menstrual periods
• Fertility issues
• Slowed heart rate
• Constipation
• Depression

Other Signs and Symptoms of Hypothyroidism

• May be mistaken for depression/dementia, especially in older persons
  • Mental slowing, apathy, tiredness
• Potential goiter
  • Hoarsening of voice
• Drooping eyelids
• Pale, puffy face
• Muscle weakness in extremities
• Carpal Tunnel Syndrome

Myxedema

• Myxedema describes severe hypothyroidism.
• Also describes dermatological changes from severe hypothyroidism.
• Increased TSH levels lead to mucopolysaccharides depositing in the dermis.
  • The mechanism is not fully understood.
• This causes non-pitting edema.
• The edema can occur in the face, causing puffiness around the eyes.
• Edema can also occur in the lower limb (pretibial myxedema).

Complications of Hypothyroidism

• Cardiovascular disease
• Infertility
• Myxedema coma (decompensated thyroid)
  • Includes Bradypnea, seizures, lower back pain, hyponatremia and decreased blood flow to the brain.
  • Triggered by physical stress, infection, injury, surgery.

Hypothyroidism Diagnosis

• Thyroid blood panel includes TSH, T3, T4, and free T4.
• Often includes antithyroid antibody tests.
• Yearly testing is required for people 65+.
• Every 5 years is suggested for healthy individuals 35 and older.

Hypothyroidism Treatment

• Hormone replacement
  • Often synthetic T4 (Synthroid)
• Dosage starts low and is gradually increased until TSH levels are Within Normal Limits (WNL).
• Increased dosage may be needed during pregnancy.
• IV T3 and T4 may be required in emergency situations.

Congenital Hypothyroidism

• Congenital Hypothyroidism develops in infancy or early childhood.
• It results from prolonged iodine deficiency often found in:
  • Himalayas, China, Africa, and mountainous regions
• May result from congenital errors in metabolism and enzyme deficiencies.
• Signs and symptoms of Congenital Hypothyroidism:
  • Stunted physical and mental growth
  • Impaired development of skeletal system and central nervous system
  • Coarse facial features
  • Protruding tongue

Hashimoto’s Thyroiditis

• Hashimoto’s Thyroiditis is also known as Hashimoto’s disease.
• It is a chronic, autoimmune inflammation of the thyroid gland in which:
  • The body is unable to recognize its own thyroid gland/enzymes.
  • Antibodies attack and destroy the gland:
  • Anti-TPO antibodies
  • Anti-Tg antibodies
• It is the most common type of thyroiditis and the most common cause of hypothyroidism in North America.
• Autoimmune disorder with family predisposition.
• People often have other endocrine disorders.
  • This includes diabetes, underactive adrenals, underactive parathyroid glands.
• People often have other autoimmune disorders.
  • This includes pernicious anemia, RA, Sjögren's syndrome, systemic lupus erythematosus.
• It is 7x more common in women, especially older women.
• Incidence is 0.8 per 1000 per year in men and 3.5 per 1000 per year in women.
• Disease usually develops in women ages 30 to 50.
• It usually has classic hypothyroid signs and symptoms:
  • Fatigue
  • Depression
  • Weight gain
  • Pale, puffy face
  • Bradycardia
  • Cold intolerance
  • Constipation
  • Dry, thinning hair and skin
• It may lead to a goiter.
• Includes Physical exam w/ palpable thyroid.
• Usually can do a serum thyroid panel to measure TSH, T3, and T4.
• And serum antibody tests and high inflammatory markers:
  • Anti-thyroglobulin and anti-TPO
  • CRP level and ESR
• There is no specific Treatment for the autoimmune reaction.
• Most develop hypothyroidism:
  • Requiring Lifelong hormone replacement (Synthroid)
• There are no contraindications to massage for Hashimoto's Thyroiditis.

Iodine Deficiency

• The thyroid contains most of the body’s iodine.
• Iodine is an essential component of T4 and T3
• Found in ocean/sea water.
  • Iodine enters soil near the sea through evaporation and rain.
• In North America, table salt is fortified with iodine.
• Low in iodine is rare in North America due to fortified table salt.
• Risk factors: high altitudes, far from the sea.
• Deficiency causes goiter, as thyroid tries to “capture” more iodine.
• Can result in:
  • Hypothyroidism because of the inability to make T4 and T3.
  • Hyperthyroidism resulting from autonomous growth/fxn occurring.
  • Can cause toxic goiter/hyperthyroidism.
• Diagnosis
  • Serum thyroid hormone tests high TSH, low T3/T4
  • Urine iodine test
  • Thyroid ultrasound
• Treatment
  • Oral iodine supplementation.
  • Obtained through diet.
• No contraindications with massage for Iodine Deficiency.

Hyperthyroidism

• Overactivity of thyroid gland leads to high levels of thyroid hormone.
• Affects ~1% of population, 10x more common in women.
• Is more common in those over 60.
• Most common cause: Grave’s disease.
• Causes
  • Grave’s disease is most common cause (Autoimmune hyperthyroid disease)
  • Toxic thyroid nodules (Plummer’s disease) is the second most common
  • Thyroid gland nodules that secrete TH without stimulation.
  • Thyroiditis may cause Inflammation of thyroid gland.
  • Could have eventual hypothyroidism due to depletion of hormones, or potential to return to normal function.
  • Inflammation due to toxic substances or radiation
  • Overactive pituitary gland (rare)
• General Signs and Symptoms of Hyperthyroidism :
• Weight loss
• Increased HR and BP, arrhythmias
• Hyperhidrosis
• Feeling of nervousness/anxiety
• Higher body temperature
• Tremors
• Frequent BM and diarrhea
• Uncontrolled hyperthyroidism can lead to a thyroid storm:
  • High blood pressure
  • High fever
  • Vomiting/diarrhea
  • MI
• Diagnosis can be:
  • Suspected based on SSx
  • Thyroid blood panel: TSH, T3, T4, and free T4 & often includes antithyroid antibody tests as well..
  • For Primary diagnosis look for Low TSH, high T3 and T4
  • For Pituitary; look for High levels of TSH, with high T3 and T4
  • Depending on the cause, may use imaging to scan the thyroid
• Treatment includes:
  • Beta-blockers (Slows HR, controlling BP, tremors, and anxiety.)
  • Anti-thyroid drugs Inhibit production of thyroid hormone, Radioactive iodine (po)
  • Destroys part of thyroid gland without effecting the body as a whole,and is not given to pregnant/nursing women crosses placenta and breastmilk and destroys infant thyroid. May set off radiation alarms for several weeks. Treatment Continued.
  • Thyroidectomy- Candidates: young with large goiter and drug allergy.
  • Often results in hypothyroidism and lifelong hormone replacement
• Complications include:
  • If untreated; places undue stress on heart and other organs CHF, stroke, renal failure

Grave’s Disease

• Grave’s Disease is the Overproduction of thyroid hormone due to autoimmune stimulation of the thyroid gland.
• Anti-TSH receptor antibodies that stimulate the thyroid
• It is the Most common cause of hyperthyroidism in North America.
• Etiology has autoimmune disorder with family predisposition and people often have other endocrine disorders like Diabetes underactive adrenals and underactive parathyroid glands.
• People often have other autoimmune disorders: Pernicious anemia, RA, Sjogren's syndrome, systemic lupus erythematosus
• 4x more common in women and Affects about one in 200 people.

Signs and Symptoms Specific to Grave’s

• Has Myxedema which is cause because is TSH stimulates fibroblasts which means deposition of excessive connective tissue components leading to edema , which is Commonly occurs on the shins.
• Exophthalmos is another common symptom
  • Common on the shins and may lead to Forward protruding eyes or Puffiness around the eyes .
• Diagnosis requires Blood works
  • You are looking for high Serum levels for TSH, T3, and T4 and also conducting a Serum antibody tests and high inflammatory markers such as:
    • Anti-TSH receptor antibodies testing for Levels of CRP.

Treatments for Graves Disease

• Focuses on dealing with the autoimmune response.
  • Beta-blockers
  • Decrease amounts of anti-thyroid medications which help with Reduction of iodine in the diet or Thyroidectomy.
• No contraindications with massage.

Thyroid Cancer

• Is a malignant tumor of the thyroid gland
• Most significant risk factor is exposure to radiation, especially during childhood
• 53,990 new cases and 2060 cancer deaths per year in the US
• Women are 3x more likely to develop it.
• Common sign is a solitary nodule on the anterior throat in addition with signs of Dysphagia , Hoarseness and Neck pain.
• Diagnosis include Imaging and biopsy used to confirm diagnosis
• Treatements include
• Surgical excision of the tumor or of the thyroid. If there is a excision you require lifelong HRT with thyroid hormone plus Chemotherapy, radiation or radioactive iodine treatment.
• Prognosis depends on case by case basis.
  • Cases of Localized (only in the thyroid) have 100% 5-year survival rate. -Incases that are Regional for eg: Cancer has spread to nearby lymph nodes the have- 98%-year Survival rate. -Distal cases (metastasis to other organs have 54%-year survival rate.
• Massage is ok in cases when someone is diagnosed with Thyroid Cancer just note No contraindications

Disorders of the Pancreas

• Some disorders of the pancreas were already covered in GI pathologies such as and includes pathologies such as:
  • Pancreatitis
  • Cystic fibrosis
  • Pancreatic cancer
• Focus is on endocrine function of the pancreas, mainly diabetes mellitus.

Diabetes Mellitus

• Known as group of metabolic disorders characterized by hyperglycemia
• There are two main types or versions depending on underlying cause:
  • Type1 : Caused by autoimmune destruction of pancreatic beta cells leading to insulin deficiency
  • Type 2 Caused by insulin resistance plus linked or related metabolic Syndrome.

Key Points on Type 1 and Type 2 Diabetes

• Both disorders involve ongoing surveillance of blood glucose.
• The underlying causes and treatment is different.

Diabetes Mellitus Type I

• In essence autoimmune destruction of the pancreatic beta cells leading to the absence of insulin equals hyperglycemia

• One of the most chronic disease in childhood

• Can be onset in childhood or adulthood but is normally more common in childhood

• Genetics has a role but less so in type II diabetes.

• Etiology has autoimmune destruction of the pancreatic beta cells leading To absolute insulin deficiency

• Aprox, 300,000 Canadians are dealing with current issues with type 1 diabetes. Signs and Symptoms include :

• The following are amongst the most common :

  • Polydipsia
  • Polyuria
  • Polyphagia ( is excessive hunger or increased appetite and is one of the 3 main signs of diabetes)

• Weight loss

• Opportunistic infections such as- Candidiasis, Acute visual disturbances and Diabetic Ketoacidosis

Symptoms of Ketoacidosis

• Severe polydipsia
• Polyuria
• weight less. - And a Acidosis as this presents as fruity smelling breath, possible neurologic findings (drowsiness, lethargy).
• Patient SSX could Rapidly evolve in over - 24 hr period -Diagnosis includes these following lab results: Fasting glucose (on more than occasion), Random glucose, OGTT, Testing for autoantibodies
• Treatment
  • Continual Glucose monitoring with insulin therapy (Patient Education- hypoglycemia SSx, Blood Glucose Meter(BGM), glucose monitoring
• Massage will have local contraindications around the areas of insulin injection and glucose monitor/ insulin pump

Diabetes Mellitus Type II

• The development of insulin resistance due to long standing metabolic syndrome & results in Hyperglycemia in the process

• More common than type 1 diabetes Etiology of Type 2 also:

  • Involves Strong genetic role
  • DMII and often found accompanied by other signs of metabolic syndrome this is known as a HTN, Dyslipidemia and leads to Central obesity

• Signs and symptoms:

  • Is Asymptomatic (40%)
  • Common SSx : polyuria ( frequent urination), polydipsia ( increased thirst), Nactura ( frequent urination at night) And HTN , dyslipidemia.

• Acanthosis Nigricans skin condition on arm etc

• DMII very rare has DKA side effects.

Lab Test Diagnosis of Diabetes 2

• Fasting glucose measurements has to be taken on multiple tests.
• If you were to find glucose it is Random
• Some additional lab tests include;OGTT and testing level for Insulin or C-peptide and Testing for autoantibodies this will also involve HbA1c lab test.
• Complications in Type 2:
  • Cardiovascular disease Nerve damage in periphe Other nerve damage Arrhythmias and digestive ups (digestive upset) Kidney disease. And this is not all, Diabetes II can cause vision and skin issues amongst, and slow the healing to the touch.
• Treatment:
• Regular exercise that leads to weight loss in addition to proper Nutrition and if need be can take diabetes medication or insulin therapy: such as
  1. Metformin
  2. Sulfonylureas (glyburide) This can be an Advanced disease may require insulin therapy on the long term.
• Contraindications: Are present for anyone using insulin or has a glucose monitor.

Type I vs Type 2 Diabetes Mellitus

• DMI DKA presentation more likely with presence in The blood with no pancreatic autoAb, and this has patients are typically thin but also underweight.
• The ideal patient or case for the lab results above would show or present the case that the patient is very young from the age of 10.
• Genetics doesn’t seems to have a strong role with diabetes.

Contrast this with

• DMII:rare to have DKA but a possibility as it has no pancreatic autoAb with the Patients has seen to be obese or overweight with symptoms that are obvious.
• And in terms patient age its most likely that there is the current patient is after the age of 10 which is the beginning of puberty. -Has insulin resistance and the associated symptoms such as Acanthosis Nigricans and HTN in general and is tied in Dyslipidemia
• Genetics has Strong role