Endocrine system

Teacher: Duan Dong

Endocrine Glands
Thyroid
Parathyroid
Adrenal glands

parathyroid adrenal glands

thyroid
Thyroid Gland
 I. Contents

The tests for diagnosing The therapy methods of

thyroid disease thyroid disease

nonimaging Imaging thyroid imaging

in vivo in vitro
 П. The anatomy of thyroid
 Thyroid is an important and largest endocrine
gland of human body .
 Located in the middle and anterior of the
neck,under the thyroid cartilage,and before the
trachea.
 Bilobed(right and left lobe,joined inferiorly and
medially by the isthmus,like a butterfly).
 Sometimes, a pyramidal lobe arising from the
isthmus or medial aspect of one lobe was found in
some normal people and patients with Graves’
disease.
 The normal weight of thyroid in adults is 25-30
gram.
Normal static thyroid image.The
pyramidal lobe was shown .
Ш. The physiology of thyroid

1.The main physiological functions of

thyroid include: trapping iodine from
circulating blood, synthesizing ,storing
and secreting sufficient amount of
thyroid hormone (TH).
TH can promote the normal growth and
the development of the body, the
maturation of brain, and regulate a
number of homeostatic functions of the
body ,including the production of energy
 Hyperthyroidism—TH
Besides the obvious goiter and ophthalmopathy ,
symptoms : nervousness,easy fatigability, excess
perspiration, heat intolerance ,tremor,palpitation
or tachycardia at rest,hyperkinesia, diarrhea,and
marked weight loss,et al.
 Hypothyroidism—TH
In children : development
retardation and obvious
mental retardation.
In adults : easy fatigability,
coldness, weight gain,
constipation, menstrual
irregularities, cool,rough
and dry skin, puffy face, etc.
2.The metabolism of iodine in the body.
Exogenous iodine
(water or foods)
Circulating
blood

I- trapped
selectively
target
Gastrointestinal organs thyroid
tract

TH
Transported by
plasma protein
(T3,T4,rT3) release

dejecta urine
3.the synthesis and secretion of TH
Inorganic iodide in circulating
blood Trapped selectively by thyroid
I-
peroxidase

Oxidation and linked

to thyroglobulin(TG) Organification

A series complex process

TH(T3,T4,rT3---combining with
TG)
Hydrolyze enzyme
TG

T3 T4 rT3 Circulating blood

 What is organification of iodine?
Inorganic iodide in circulating blood were
trapped selectively by thyroid, and in thyroid
cells, they will be oxidized and linked to the
tyrosine residues of thyroglobulin (TG)
immediately under the role of peroxidase, this
process was called "organification of iodine".
4.The structures of T3 and T4

I I
NH2
HO
O CH2-CH-COOH T4
I I
I
I
NH2
HO
O CH2-CH-COOH T3

I
5.The hypothalamus-pituitary-
thyroid axis

hypothalamus TRH

stimulate
suppress

pituitary TSH
stimulate
suppress

thyroid TH
 IV.The tests of thyroid
Radioactive iodine uptake test
Perchlorate washout test
TH suppression test
In vivo
TSH stimulation test
Thyroid imaging

Measurement of serum TSH

TRH stimulate test
In vitro Measurement of serum T3 and T4
Measurement of serum TG
Measurement of TGAb,TPOAb and TRAb
1.The radioactive iodine
uptake test(RAIU)
 (1). Principle
• Radioactive iodine (131I or123I ) can be trapped and
accumulated selectively by thyroid when entering the
body ,and the amount of radioactive iodine trapped by
thyroid can reflect the function of thyroid.
• Radioactive iodine decayed with gamma(r) rays.
• Detecting the r-rays emitting from the radionuclides in
the thyroid with certain nuclear device, then we can
evaluate the function of thyroid.
r r
131
I or I
123 r 131
I or r
123
I

Trapped by thyroid
 (2).Methods
 Administrate radioactive iodine to the fasting patient by oral.
 Made a standard, which is equal to the administrated dose.
 Measure the radioactivity of the thyroid ,standard,and
background at 6,24 hours after oral administration
respectively.
 Calculate the percentage of radioactive iodine uptake(RAIU)
of thyroid as the follow formula.

RAIU(% = The counts of thyroid - the counts of background × 100%

) The counts of standard - the counts of background
What is background radioactivity?
It indicate the radioactivity that exist in the
natural environment. It may come from
universal rays or surrounding
radiopharmaceuticals, etc.
(3).The normal range of RAIU

6h ： 10% ～
35%
24h ： 25% ～
50%

Usually, RAIU will increase

gradually after oral administration
of radioactive iodine, and reach peak
value at 24 hours
(4).Factors affecting RAIU of thyroid.
Many foods and compounds (listed as
follow) can reduce the value of RAIU .
Seafoods: kelp,alga,oyster
Radiographic contrast agents
Oral iodides: such as Lugol’ iodine
Traditional chinese medicine containing iodide.
Antithyroid drugs(ATD)
Thyroid preparation
Others: ACTH,large dose of prophylactic , etc

Before the test,we should ask the patients whether they have
the history of being given these compounds by oral or iv.
(5).Clinical application of RAIU test.
A. To evaluate the function of thyroid.

The value of RAIU and peak

hyperthyroidism
value appear earlier (before 24h)

hypothyroidism The value of RAIU

RAIU should not be used to evaluate the

thyroid function along, and should be
combined with other tests.
 RAIU(%)
100%

hyperthyroidism

50% normal

hypothyroidism

0 6h 24h

Typical RAIU curve of hyperthyroidism

and hypothyroidism
B.To diagnose subacute thyroiditis
In the acute period of subacute
thyroiditis, the percentage of RAIU
usually is decreased. On the other
hand, the levers of serum T3 and T4
are increased obviously, we call this
representation “Separate
phenomenon”.
C.To calculate the dose of 131I
administration to the patients with
hyperthyroidism who prepare to
accept 131I therapy.
D.As a preparation for other
tests,such as perchlorate washout
test,TH suppression test,et,al.
(6).The contraindication

of RAIU test.
This test can be used to all
people safely , besides women in
pregnant or lactating period .
2. Perchlorate washout test
(1). The principle of the test.
• Inorganic iodide trapped by thyroid from blood will be
oxidated and linked to TG immediately( within a few
minutes)-----the organification of iodine.
• If the function of organification is impaired in some
thyroid disease, the iodide will still exist in the thyroid
with the manner of I-
• The perchlorate can inhibit the thyroid to uptake I-
from blood again and stimulate the I- leaking out from
thyroid,but no use to organified iodine.
• If with 131I, we can conclude whether there is a defect of
organification in the thyroid by comparing the change
of the RAIU of the thyroid between before and after
administration of perchlorate.
 (2).Methods
• Administrate radioactive iodine(131I) to a fasting
patient by oral.
• Measure the RAIU of the thyroid at 1h after the oral
administration of 131I(A).
• Administrate perchlorate(such as KCLO4 , 400mg)
to the patient by oral.
• At 2h after administration of perchlorate ,measure
the RAIU of the thyroid again(B).
• Calculate the washout ratio of radioactive iodine as
the follow formula.

A- B
the washout ratio = × 100%
A
(3).The normal range of the
washout ratio

<10% : normal
>10% : the function of organification is
impaired
>50% : the function of organification is
impaired obviously
(4). Clinical application.
This test is mainly used to diagnose the
disease with defect of organification of iodine
in the thyroid ,such as Hashimoto’s
thyroiditis, some congenital
hypothyroidism,etc.
3. TH suppression test
(1). The principle of the test.

In normal people, the function of

thyroid to uptake iodide and
synthesize TH are controlled by TSH
secreted by pituitary. If we
administrate sufficient exogenous TH
to the human body by oral, the
function of pituitary to synthesize and
secrete TSH will be suppressed by
negative feedback, and therefore the
RAIU of thyroid will be decreased
obviously. --- Normal suppresion
(1). The principle of the test.
In patients with hyperthyroidism, because there are
other pathological factors which can also stimulate
thyroid to uptake iodine and synthesize TH, which not
controlled by TSH, so the RAIU of the thyroid will not
be decreased after administrating sufficient exogenous
TH. --- No suppression
We can diagnose hyperthyroidism by comparing the
values of RAIU between before and after TH
administration.
 The sketch map of principle

hypothalamus TRH
Pathological stimulate
factors in the
body of pituitary TSH suppress
hyperthyroidism
stimulate
patients suppress

thyroid T3 T4
synthesize
Uptake
iodide

blood
Exogenous TH
(2).Methods
Measure the first 24h
RAIU(A)
Administrate TH(40mg tid)to
patient by oral for two weeks

Measure a 24h RAIU again (B)

Calculate the ratio of A-B

×100%
suppression = A
(3) Clinical application.
This test is mainly used for diagnosing of
hyperthyroidism

the ratio of suppression:

>50% : normal suppression,exclude
hyperthyroidism
<25% : no suppression, diagnose
hyperthyroidism .
25% ～ 50% : part suppression,suspicious
hyperthyroidism
4.TSH stimulation test
(2).Methods

Measure a first 24h

RAIU(A)
Administrate TSH(10U/d) to
patient by im for three days

Measure a 24h RAIU again (B)

Calculate the value of

= B-A
stimulation
(3).The clinical application of the test.

This test is mainly used to identify the

primary and secondary hypothyroidism.

secondary hypothyroidism > 11%

primary hypothyroidism <11%
Four in Vivo Tests
1. RAIU test: Evaluate the function of thyroid;
diagnose subacute thyroiditis; calculate 131I
dose for hyperthyroidism patients for 131I
therapy; as the preparation for other tests
2. Perchlorate wash out test: The defect of
organification of iodine
3. TH suppression test: Diagnose
hyperthyroidism
4. TSH stimulation test: Identify primary and
secondary hypothyroidism
5. Measurement of the
level of serum TSH
(1)TSH is a important glycoprotein synthesized
and secreted by pituitary, and this function of
pituitary is controlled by hypothalamus .
The main role of TSH is stimulating thyroid to
uptake iodine from serum and synthesize TH.
(2).The methods of determination
serum TSH.
The methods of Normal
characteristic
measurement range

Sensitivity is relatively low ;

RIA (Radio- Has overlap between the normal
＜ 10mIU/L
immuno-assay) people and the patients with
hyperthyroidism;

IRMA (Immuo- 0.3 ～

Sensitivity is relatively high
radiometric-assay, 5mIU/L
Rarely has overlap between the
sTSH) normal people and the patients;
(3). The clinical application
To diagnose hyperthyroidism(TSH ) and
hypothyroidism (TSH )
Identify primary and secondary
hypothyroidism by combining with the
levels of serum TH(T3,T4)
primary hypothyroidism: T3 T4
TSH
secondary hypothyroidism: T3 T4
TSH
6.The measurement of serum TH
(1)The type of serum TH
FT3(0.5%
TT3 )
BT3
Bond with plasma
Serum TH protein,mainly bond
BT4 with thyroid-binding-
TT4 globulin(TBG)
FT4(0.05%)

rT3
Usually, the concentration of serum TT4 is 60-80 times more
than TT3,but the activity of FT3 is 5 times more than FT4. And
rT3 is no biological activity,there is rarely necessary to measure
it.We usually measure the concentration of TT3,TT4,FT3 and
FT4 in clinical practice.
(2).The methods of determination
Phlebotomize (2-3ml) from a fasting patient ,and usually
measure the levels of TT3, TT4, FT3 and FT4 by RIA.

(3).Normal range of TH
TT3 1.0 ～ 3.2nmol/L
TT4 70 ～ 180nmol/L
FT3 3.2 ～ 9.2pmol/L
FT4 8.6 ～ 26pmol/L
(4).Clinical application:

A. Diagnose hyperthyroidism and hypothyroidism

hyperthyroidism ： TT3↑ 、 TT4↑ 、 FT3↑ 、 FT4↑

hypothyroidism ： TT3↓ 、 TT4 ↓ 、 FT3↓ 、 FT4↓

B. To the patients with hyperthyroidism and

hypothyroidism, it is used to observe the effect of
treatment and estimate whether the dose of drug
for therapy is suitable.
7.TRH stimulation test
 (1). The principle of the test.

TRH secreted by hypothalamus can stimulate

pituitary to synthesize and secret TSH ,and the
latter can stimulate thyroid to uptake iodide and
synthesize TH. On the other hand, TH can inhibit
the synthesis and secretion of TRH and TSH by
negative feedback.
 (1). The principle of the test.

If we observe the change of serum TSH lever

after administrating exogenous TRH by iv. We
can find the impaired part of the hypothalamic-
pituitary-thyroid axis.
 (2) ． Methods
Phlebotomize (2ml) from
a fasting patient

Administrating TRH(300ug) to the patient by iv

15min 、 30min 、 60min 、 120min

after iv adminitration

Phlebotomize(each time 2ml ) from the patient repectively

Measure the concentration of serum TSH of each time by RIA

or IRMA,and draw the curve of TRH stimulation.
(3) ． The clinical application
Usually, by observing the variety of TSH after administrating
exogenous TRH, the reaction of TSH to TRH can be classified into
four types as the following:
A. Normal reaction :
The value of TSH before the administration of TRH is less than
10mIU/L (by RIA),and it will be increased gradually after administration of
TRH, but it’s peak value is less than 35mIU/L ,and it’s peak time appear at
20 to 30 minutes after administration of TRH.

The normal reaction indicate that the function of hypothalamic-pituitary-

thyroid axis is normal, and we can exclude hyperthyroidism & hypothyroidism.
B. Active reaction :
The value of TSH before the administration of TRH(or baseline
value) is higher than the normal range(> 10mIU/L),and it will be
further increased after administration of TRH,it’s peak value is
more than 45mIU/L.

The active reaction was usually found in the patients with

primary hypothyroidism.
C. Lower or no reaction :
The value of TSH before the administration of TRH(or baseline
value) is very low,and after administration of TRH it will not be
increased, it’s peak value is less than 5mIU/L.

It was usually found in the patients

with hypothyroidism caused by the
disease of pituitary or the patients with
hyperthyroidism.
D. Delayed reaction :
The value of TSH before the administration of TRH is very low,
and after administration of TRH it will be increased gradually, but
it’s peak time will appear over 30 minutes after the administration of
TRH .

It was usually found in the patients with hypothyroidism

caused by the disease of hypothalamus.
8. The measurement of
serum thyroglobulin (TG)

TG is a glycoprotein stored in the follicular

lumen of thyroid cells, and very few in blood. If
there is a destroy of thyroidal cells in some disease
(such as thyroiditis, thyroid carcinoma), TG will
leak out from thyroid, and result to the rise of
serum TG.
The methods of determination : by RIA
Normal range : <11ng/ml
Clinical application
The measurement of TG is mainly used
to evaluate whether there is local
recurrent or distant metastases of
differentiated thyroid carcinoma after
total or subtotal thyroidectomy and
subsequent 131I ablation.
9.The measurement of
TGAb and TPOAb
The methods of determination : by RIA
Normal range :
TGAb<30% TPOAb <20%

Clinical application
TGAb and TPOAb are the antibodies of TG and
peroxidase respectively, they are abnormal
antibodies ,and should be very low in serum.The
rise of TGAb and TPOAb can be found in some
autoimmune thyroid disease(such as Hashimoto’s
disease or hyperthyroidism). So they can be used
to diagnose these disease as a assistant index.
10.The measurement of TRAb

(1).The methods of determination : by RRA

(2).Normal range :<10uIU/ml

(3).Clinical application:
TRAb (TSH receptor antibody) is an important
abnormal autoimmune antibody ,which may act
important roles in the occurrence, development,
reoccurrence and the prognosis of Graves’ disease.
(3).Clinical application:
It was demonstrated that TRAb will be
increased obviously in most patients with Graves’
disease, and with the improvement of the disease,
TRAb will be gradually decreased. It was suggest that
only when TRAb resume to the normal range, the
treatment with ATD to the patients of Graves’ disease
can be stopped, otherwise, the incidence of
reoccurrence will be very high.
Thank You