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Thursday, 28 November 2013

Thyroid Disease: Postoperative hypothyroidism

Thyroid is one of the largest endocrine glands found in the neck, below the Adam’s Apple with the function of regulating the body use of energy, make of proteins by producing its hormones as a result of the stimulation of thyroid-stimulating hormone (TSH) produced by the anterior pituitary.
Thyroid disease is defined as a condition of malfunction of thyroid. Hyperthyroidism is a condition in which the thyroid gland is over active and produces too much thyroid hormones. Hypothyroidism is a condition in which the thyroid gland is under active and produces very little thyroid hormones. Thyroid cancer is defined as condition in which the cells in the thyroid gland have become cancerous. 
Postoperative hypothyroidism
Hypothyroidism is not a rare condition, since it represents about 10% of thyroid diseases. It is more frequent in women (F/M = 5/1), and in patients older than 60 years of age. Postoperative hypothyroidism is secondary to thyroidectomy, and the incidence varies, with a reported range between 14% and 75%. (a).
 A. Symptoms
Symptoms may be related to the amount of thyroid removed, the experience of the surgeon, age of patient, the function of remaining thyroid, and duration of postoperative observation, according to the study by the Università degli Studi di Roma La Sapienza(a), including the below but not limit to
1. Weight gainand fatigue
In a prospective observational research design where 198 consecutive breast cancer patients receiving adjuvant chemotherapy were monitored from start to end and 6 months post-therapy on changes in anthropometics, fatigue, nutritional intake, physical activity, thyroid and steroid hormones, found that a weight gain over >5 lb in 22.2% of this patient population with a significant and progressive gain of 6.7 lb (P < 0.0001) at 6 months. Ninety four percent of all patients reported fatigue and 56% of patients reported lowered physical activity. A significant reduction in serum free and total estradiol (P < 0.0001) was observed indicative of reduction in ovarian function with 86% amenorrehic at the end of treatment. A significant reduction in mean serum triiodothyronine uptake levels (P < 0.05), in addition to a significant increase in TBG (P < 0.0001) from baseline to end of chemotherapy, was observed. In addition 20-25% of this patient group was already diagnosed with clinical hypothyroidism at diagnosis and treated. Changes in fatigue frequency and serum sex-hormone-binding globulin (SHBG) were variables significantly predictive of weight gain (P < 0.0001)(1).
2. Vitiligo and alopecia areata
There is a report of the parents of an 18-year-old woman had noticed white hair while combing their daughter’s hair 12 years ago. They found tiny white spots on her scalp, but she was asymptomatic. The spots have since progressed. Examination of the affected skin on the scalp was marked by the presence of a chalky/ivory white macule, 8 to 10 cm in diameter, conforming to that of segmental (zosteriformis) vitiligo (Figure 1). The lesions were located on the temporoparietal region of the scalp. The hair over the macules was white (leukotrichia) and dry, coarse, and brittle. The patient’s nails were thin and dull. Her thyroid profile revealed the following: triiodothyronine, 1.12 nmol/L (0.95-2.5 nmol/L); thyroxine, 69.21 nmol/L (60.0-120.0 nmol/L); and thyroid-stimulating hormone, 6.26 microIU/mL (0.25-5.00 microIU/mL), indicative of primary hypothyroidism(2).
3. Chronic constipation
Geriatric patient educational material and a general practice review suggest insufficient dietary fiber intake, inadequate fluid intake, decrease physical activity, side effects of drugs, hypothyroidism, sex hormones and colorectal cancer obstruction may play a role in the pathogenesis of constipation, according to the study by the University of California at Los Angele(3).
4. Urticaria and puffiness of hands and feet, yellow ivory skin, coarse rough dry skin, alopecia periorbital edema, amenorrhe, dysparunia, PCO, PMS and Breast tenderness, menstrual irregularities and infertility
In the study to  study is to highlight the presenting dermatologic and gynecologic manifestations of firstly-diagnosed hypothyroid females, showed that Compared to euthyroid cases, hypothyroid ones were presenting mostly with amenorrhea (OR=7.76). Other gynecologic manifestations that were prominent in hypothyroid cases were dysparunia, PCO, PMS and Breast tenderness. On the other hand, rate of menstrual irregularities and infertility were non-significantly different in both groups.hypothyroid women showed also significantly higher frequency of urticaria and puffiness of hands and feet (both were present in 16.7% in hypothyroid vs. 3.3% of euthyroid cases, p =0.007, OR=5.8). Hypothyroid cases showed also significantly higher frequency of yellow ivory skin (OR=5.4) and coarse rough dry skin (OR=3.8). On the other hand, alopecia and periorbital edema were observed only among cases of hypothyroidsm and none of euthyroid cases(4).
5. Depression
In the study to investigate the depression-like behavior performances of subclinical hypothyroidism (SCH) rat. SCH rat model induced by hemi-thyroid electrocauterization, and the behavior performances were measured by sucrose preference test, force swimming test (FST), and tail suspension test (TST). SCH rat model was established successfully by hemi-thyroid electrocauterization, found that SCH could result in depression-like behavior, accompanied with subtle hyperactivity of HPA axis. The reduced hippocampal T3 prior to the reduction of thyroid hormone in serum might be taken as an early sign of hippocampus impairment in the progression from SCH to CH(5).
6. Mood, declarative memory, motor learning and working memory
In a double-blinded, randomized, cross-over study of usual dose l-T(4) (euthyroid arm) vs. higher dose l-T(4) (subclinical thyrotoxicosis arm) in hypothyroid subjects, showed that The Profile of Mood States (POMS) confusion, depression, and tension subscales were improved during the subclinical thyrotoxicosis arm. Motor learning was better during the subclinical thyrotoxicosis arm, whereas declarative and working memory measures did not change. This improvement was related to changes in the SF-36 physical component summary and POMS tension subscales and free T(3) levels(6).
B. Causes of Risk factors
B.1. Causes 
Postoperative hypothyrosis was diagnozed in 76 (6.17%) out of 1231 patients operated upon for various diseases of the thyroid gland. Among causes of this complication the authors point to lymphoid infiltration of tissue and changes in autoimmune processes. Adequate operative methods, leaving sufficient quantity of the gland tissue with special reference to cellular and humoral immunity are considered as prophylactic measures, according to the study by Volokh IuA, Pak VP and Osipov DP(7).
B.2. Risk Factors
In the study to assess the incidence of hypothyroidism after hemithyroidectomy and to identify risk factors for the development of hypothyroidism including 90 patients who underwent a hemithyroidectomy from 1999 to 2004, found that the incidence of hypothyroidism developing during follow-up among the Hashimoto thyroiditis and multinodular goiter groups was 59% and 50%, respectively. Also, the patients who developed hypothyroidism were noted to have statistically significant higher preoperative serum thyrotropin levels (3.15 mIU/L vs 1.95 mIU/L; P< .001) than those who remained euthyroid(8). For more information of Complications, diseases associated, misdiagnosis, diagnosis, preventions and treatments, please visit General Health section of hypothyroidism
 
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Sources
(a) http://www.ncbi.nlm.nih.gov/pubmed/9072668 
(1) http://www.ncbi.nlm.nih.gov/pubmed/14997046
(2) http://www.ncbi.nlm.nih.gov/pubmed/21675503
(3) http://www.ncbi.nlm.nih.gov/pubmed/17219073
(4) http://www.ncbi.nlm.nih.gov/pubmed/21475555
(5) http://www.ncbi.nlm.nih.gov/pubmed/23794115
(6) http://www.ncbi.nlm.nih.gov/pubmed/18285414
(7) http://www.ncbi.nlm.nih.gov/pubmed/3232287
(8) http://www.ncbi.nlm.nih.gov/pubmed/16415427