121. Thyroid_parathyroid Flashcards Preview

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Flashcards in 121. Thyroid_parathyroid Deck (46):
1

anatomical differences in dog vs cat thyroid glands

2 glandsdogs: communicate w ventral isthmuscats: lack isthmus, lack caudal thyroid artery

2

components of the carotid sheath

--common carotid artery--internal jugular vein--vagosympathetic trunk

3

blod supply to thyroid gland

cranial and caudal thyroid arteries (caudal is lacking in cats)cranial thyroid artery is the first branch of common carotid arterycaudal thyroid artery branches from brachiocephalic trunk

4

number of parathyroid glands

2 on each gland (4 total)1. extra capsular PTG---cranial (blood supply from cranial thyroid artery)2. intra capsular PTG--caudal and embedded(blood supply from vessels surrounding the parenchyma)variations exist

5

areas where ectopic thyroid tissue can be found

1. along trachea2. thoracic inlet3. mediastinal4. thoracic aorta(base of tongue to base of heart)ectopic parathyroid tissue is uncommon in dogs but up to 50% cats

6

thyroid gland hormones

--requires iodine to produce thyroglobulin (stored in follicles): contains precursors for thyroid hormone synthesis--T4, T3 (lesser extent) released into blood which are larger bound to proteins--T4 major secretory product BUT T3 is the most active form--production of hormones stimulated by TSH release by pituitary/TRH release by hypothalamus

7

parathyroid gland hormones

--PTH made, stored and secreted by chief cells of PTG--effects are to INCREASE Ca, DECREASE P (direct--bone, renal; indirect--GI)BONE: Ca, P resorption from increased osteoclastic activityRENAL: decrease excretion Ca, increase excretion P; activates vitamin D to calcitriol (1,25 dihydroxycholecalceferol)GI: calcitriol increases Ca and P absorption (INDIRECT)

8

most physiologic form of calcium in the body

ionized Ca ---most active

9

where is calcitonin from and what is its function?

thyroid gland parafollicular cells (C cells)increases with increase Ca in order to LOWER Ca levelsdecreases bone resorptionNO effect on kidney, GI

10

most functional thyroid tumors in cats are_____

BENIGN---adenoma, hyperplasia, goiterBILATERAL 70-90%one study said up to 25% could be carcinoma (70% metastatic rate)

11

prevalence of coexisting renal disease in cats with hyperthyroidism

40%may need pretreatment with methimazole and recheck blood work to see if hyperthyroidism was masking underlying renal disease

12

percentage of hyperthyroid cats that have hypokalemia

30%

13

screening test for hyperthyroid cats

--PALPATE (90% have nodule)--total T4--elevated in 90% cats with hyperthyroidism--other tests: free T4, TSH stimulation test, T 3 suppression test--scintigraphy: confirms and localizes (technetium 99m)-not affected by methimazole tx bc radio nucleotide gets trap it is a not a function; will normally highlight thyroid, salivary glands, and gastric mucosa but intensity will be greater in thyroid

14

considerations for anesthesia of a hyperthyroid cat

--avoid drugs that potentiate tachycardia/arrhythmias (ketamine, atropine)--beta antagonist if needed--supplement K if needed--ensure no previous renal insufficiency (pretreat with methimazole 2-3 weeks before sx)

15

methods of thyroidectomy

--intracapsular--rate of recurrence is high, but preserves extra capsular PTG--modified intracapsular*--extracapsular--no attempt to save PTG (may lead to hypoPTH)--modified extracapsular*

16

what is parathyroid autotransplantation

--left small or minced into small pieces--transplanted into a small incision on sternothyroideus/sternohyoideus muscle, then the muscle is closed--revascularized and functional in 7-21 days (need to treat for hypocalcemia in the meantime!)

17

complications of thyroidectomy

--hemorrhage--dyspnea--laryngeal paralysis--megaesophagus (if both vagus injured)--horners--hypothyroidism (rare in cats)--hypoparathyroidism--hypocalcemia--recurrence of dz (hyperthyroidism or carcinoma)

18

most serious complication of bilateral thyroidectomy

hypoPTH and resultant hypoCacats with ectopic PTH (up to 50%) is not enough to maintain normocalcemia78% dogs developed hypoCa with bilateral thyroidectomy/parathyroidectomy for carcinoma

19

clinical signs of hypoCa

--restlessness--muscle twitching--facial pruritis--panting--tetany

20

treatment for acute hypoCa

--Calcium gluconate 1 ml/kg IV slow with ECG or as a CRI in fluids--maintenance therapy with oral vitamin D and calcium; active form of vitamin D (calcitriol) can also be given orally hypoCa should resolve over 21 days, start taper over 8-16 weeks, maintain calcium in low normal range

21

recurrence rate of hyperthyroidism in cats following bilateral thyroidectomy

10%

22

what is the treatment of choice for hyperthyroid cats

radioactive iodine I-131permanent tx, make sure kidneys work(may need higher I 131 to treat carcinomas)

23

behavior of canine thyroid tumors

90% detected clinically are malignant (papillary, follicular, compact, or anaplastic)40% have detectable mets at time of diagnosismost are nonfunctional (10% functional--hyperthyroid: almost always associated with malignancy)

24

diagnostic approach for canine thyroid tumor

--PE (palpate cervical neck well)--cbc. chem. UA--coagulation panel--thyroid panel (<10% are functional but highly SP for malignancy)--thoracic imaging --cervical US +/- aspirate cytology (not often diagnostic) +/- biopsy (RISK HEMORRHAGE)--CT/MRI if indicated--scintigraphy if indicated

25

prognosis/MST of thyroid carcinoma in dogs following surgical removal and prognostic factors

DEPENDS ON MOBILITY *, SIZE, STAGEMST 3 yr if freely movableMST 6-12 months if invasive

26

metastasis and thyroid carcinoma

tumor size and bilateral disease are important factors< 23 cm cubed 15% met> 23-100 cm cubed 75% met> 100 cm cubed 100% metbilateral are 16x more likely to met

27

treatment of choice for thyroid tumors that are nonresectable or incompletely excised

radioactive iodine, I-131MST with mets 365 dayMST with local disease 840 days

28

what is euthyroid sick syndrome

decrease in thyroid tT4 concentration secondary to illness

29

systemic effects of hypothyroidism on surgical patients

--cardiovascular effects: decr contraction, incr vascular R, decr CO--coagulation effects: decr factor VIII --wound healing effects: delay healing, incr risk infection (decreases humoral immune response)

30

causes of hyperparathyroidism

1. primary : excessive production PTH from chief cells of PTG (adenoma 95%, solitary 50-90%): KEESHOUND (50x)2. secondary: renal or nutritional

31

pathophysiology of primary hyperPTH

1. skeletal effects (fibrous osteodystrophy) from excessive calcium resorption from bone2. renal effects: Ca resorption eventually decreases renal function (Ca xP product dystrophic mineralization and vasoconstriction to decr renal blood flow)-->eventually causes hypercalciuresis: stones, UTI, PU/PD inability to respond to ADH and diabetes insipidus

32

causes of hypercalcemia

G--granulomatous dzO--osteolytic diseases (OSA, osteomyelitis)S---spuriousH--hyperparathyroidism (primary)D--vitamin D toxicosis (rodenticide toxicity)A--Addisons (hypoadrenocorticism)R--renal secondary hyperPTH; renal failureN--neoplasia (LSA, AGASACA, MM, carcinomas), nutritional secondary hyperPTHI--iatrogenic, idiopathicT--trauma, hyperThermia

33

expected PTH and Ca for primary hypoparathyroidism

low PTHlow Ca

34

expected PTH and Ca for primary hyperPTH

hi or normal PTH (70% may be normal but still abN to see any PTH in the face of hyper Ca)hi Ca (increased ionized Ca)

35

expected PTH and Ca for renal failure

hi or normal PTH (renal secondary hyperPTH)normal to hi Ca (total increased but not ionized)AZOTEMIC, hi P

36

expected PTH and Ca for malignancy

low PTHhi Cahi parathyroid hormone related peptide

37

preoperative mgmt of a hypercalcemic patient

1. fluid diuresis-- NaCl2. loop diuretic---furosemide (watch K loss, may need to supplement)3. Calcitonin4. bisphosphonates5. GCC

38

intraoperative detection of abN parathyroid glands

--methylene blue (heinz body anemia, ARF)--unilateral thyroparathyroidectomy and histopath--guillotine area found on US (partial thyroidectomy in the area of suspected abN PTG)

39

re-testing PTH concentrations post op

if decreased by < 50% residual tissue likelyif decreased > 50% likely that all abN tissue removed

40

how many PTG can safely be removed

3if all 4 removed likely need permanent Ca/Vit supplementation in dogs (unlike cats that have ectopic tissue)

41

monitoring post op hyperPTH patient

--monitor Ca (total or ionized) 1-2 times a day for 5-7 days--calcitriol supplement--+/- oral Ca supplementGOAL: low normal calcium levels to stimulate other glands to work (total 8 mg/dL, ionized 0.8mmol/L)Gradual taper over 2-4 months; check calcium level prior to taper

42

what group of hyperparathyroid patients have the greatest risk of developing post op hypocalcemia

patients with total serum calcium >14 mg/dl or has more than one PTG mass and potentially longer duration of hyperCavitamin D/calcitriol can be started pre-op and continued post op +/- oral calcium supplementation

43

% of dogs developing clinically significant hypoCa post op

33% early as 12 hr or as late as 20 days

44

resolution of hyperCa in post op hyperPTH patients

94% resolve 1 week post op

45

recurrence of hyperCa and hyperPTH

8% within months to yearsKeeshounds

46

alternative therapies to surgical removal of the PTG

--US guided intralesional ethanol ablation (caustic)--US guided heat ablation

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