Icterus, or Huang Dian syndrome, the yellow color to the mucous membranes associated with the accumulation of bilirubin, is the most significant physical finding in hepatobilliary disease.1 From the western medicine view, the causes of jaundice can be divided into three categories: (1) prehepatic, (2) hepatic, and (3) posthepatic.1 If a large amount of heme is needing to be processed, as in the case of hemolytic anemia, a prehepatic increase in bilirubin production (hyperbilirubinemia) will clinically manifest as jaundice.1 Hepatic causes of jaundice include problems with the uptake, conjugation or excretion of bilirubin, as well as intrahepatic choleostasis and any severe extrahepatic infection. 1Disruption of the normal flow of bile in the extrahepatic bile ducts will cause posthepatic hyperbilirubinemia.1In the presentation of an icteric patient, it is very important to obtain a western diagnosis to determine the presence of an acute infection, toxicity, or other potentially life-threatening conditions such as a gallbladder mucoceole.1Once initial western diagnosis have been performed and acute treatment provided, the road to recovery of the jaundiced patient can be long and frustrating for the patient, the owner and the veterinarian. This article discusses the treatment of the jaundiced patient through Traditional Chinese Veterinary Medicine (TCVM).
TCVM Physiopathology of Huang Dian
In TCVM the Gallbladder plays a role in the health or free flow of Liver Qi especially as it relates to the Spleen and Stomach.2It also controls decisiveness, provides Qi to the sinews and influences the quality and length of sleep.3The pathogenesis of jaundice is three-fold in TCVM, Liver Damp Heat, Dampness in the lower Jiao (Cold-dampness) and Spleen Qi Deficiency with Liver Qi Stagnation.2,3,4Diet, emotional strain and external pathogens, such as Damp and Damp-Heat, are the main etiologies behind the pathogenesis of jaundice.5
TCVM Pattern Differentiation and Treatment
Yang Jaundice (Liver Damp Heat)
Yang Jaundice, also known as Liver Damp Heat or Toxic Heat, includes symptoms including acute onset of rapid and severe jaundice (often described as a golden-yellow or fresh yellow color), a high fever, bleeding (including epistaxis or hematochezia), constipation or diarrhea, nausea or vomiting, abdominal distension, warm limbs, extremely malodorous stool/urine and injected sclera.4,5 Besides the association with acute onset hepatitis (due to viral, iatrogenic or other cause), this pattern is also associated with Gallbladder mucoceles or cholelithiasis.5 The tongue is a deep red with a yellow dry coat and the pulse is wiry. Treating the Damp Heat is done by clearing Liver Heat and general purging; acupoints to clear heat include GV-14, LI-4, LI-11, and Wei-Jian. 4 Clearing the Liver Damp Heat can be done using acupoints such as BL-19, BL-20, LI-11 and TH-6.2,4 Herbal recipes to treat this pattern include Long Dan Xie Gan or Artemisia Combination (modified Yin Chen Hao Tang).6 Food therapy would include foods to cool, tonify Yin and drain Damp.3,4
Yin Jaundice (Cold-Damp)
Dampness is accompanied by a dull yellow jaundice and prevents the Spleen Qi from descending, causing symptoms including diarrhea (especially watery stools), poor appetite and pain on abdominal palpation.4 Chronic course of Dampness is often combined with Cold, leading to Yin Jaundice. Edema and coldness in ears and back can also be seen with this pathology. "Yin jaundice" occurs during the advanced or fibrotic stages of chronic hepatitis.2 The tongue is swollen with a greasy coat and the pulse is weak and thin or soft and wiry.4 The treatment protocol involves clearing Dampness and warming the Interior with acupuncture points BL-18, BL-19, BL-20, LIV-13, GV-3, GV-4 and SP-6.2,4 The herbal therapy of choice is Yin Chen Zhu Fu; food therapy should include foods to drain Damp and warm the Interior.3,4,6
Spleen Qi Deficiency with Liver Qi Stagnation
Spleen Qi Deficiency with Liver Qi Stagnation is a prominent pattern in veterinary patients. Clinical symptoms include an acute onset of bright yellow jaundice, general malaise, inappetance, vomiting and diarrhea.4 Behavioral changes such as increased aggression, irritability, restlessness and hyperactivity indicate Liver Qi Stagnation; subsequently, patients with a Wood Personality (already prone to displaying these behaviors) are more susceptible to Liver Qi Stagnation.4Pain on palpation of the Liver channel, especially around LIV-13 and LIV-14 is indicative of Liver Qi Stagnation.4 If the Spleen Qi Deficiency is the dominating pattern, the tongue is pale and the pulse will be deep and weak. If the Liver Qi Stagnation is the dominating pattern, the tongue is red and the pulse is fast and thin.4 Acupuncture points include those to tonify Spleen Qi including BL-20, CV-6, ST-36 and SP-3; acupuncture points to clear the Liver Qi Stagnation include LIV-3, GB-34, GB-39 and GB-41.2,4 Herbal therapies for the Spleen Qi Deficiency include Si Jun Zi Tang or Shen Ling Bai Zhu. For the Liver Qi Stagnation, herbal therapies include Chai Hu Shu Gan, Xiao Yao San or Liver Happy (modified Chai Hu Shu Gan).4,6 To treat with food therapy, choose Qi tonics and neutral foods.
Stretch, a seven-year-old neutered English Bulldog, presented for a TCVM evaluation following an acute hepatic crisis that resulted in persistent jaundice and general malaise. His history was as follows. Stretch presented to an Emergency veterinary practice on Christmas with a 24-hour history of icterus, hematochezia, vomiting and inappetance. Stretch had possibly been exposed to building/roofing materials a few days prior. His physical exam was normal with the exception of severe jaundice of all mucous membranes, loose stool on the rectal exam (no blood was noted) and palpable liver margins beyond the costal arch. Stretch weighed 24.1kg.
The initial assessment was a hepatopathy with differential diagnoses of toxic, infectious or inflammatory cause. The initial diagnostics performed were bloodwork, radiographs and abdominal ultrasound. The bloodwork showed elevated Alkaline Phosphatase (ALPK) (1457 U/L), Alanine Aminotransferase (ALT) (1718 U/L), Cholesterol (406 mg/dl), and extremely elevated total bilirubin (TBILI) (26.1 mg/dl). The radiographs confirmed the palpable hepatomegaly. The abdominal ultrasound revealed a mottled liver with enlarged hepatic lymph nodes; no gallbladder or biliary obstruction was noted. FNA’s for cytology and culture were obtained. The initial western medical treatment included fluid therapy, IV antibiotics (Unasyn) and oral liver support (Ursodiol and Denosyl). The culture of the liver FNA was negative for both aerobic and anaerobic growth. The cytology revealed lymphoplasmacytic hepatitis and intrahepatic cholestasis. Stretch was sent home with Clavamox, Hill’s Science Diet L/D was started and an anti-inflammatory dose of Prednisone was suggested if Stretch was not improving at the re-check.
Two weeks later, Stretch remained icteric at his recheck though his appetite had markedly improved since the antibiotics had finished. Repeat bloodwork was performed to monitor Stretch’s hepatic parameters. The following values remained elevated though decreased from the bloodwork at initial presentation: ALKP (1100 U/L), ALT (1124 U/L), Cholesterol (678 mg/dL), and TBILI (12.9mg/dL). Stretch was discharged with Prednisone and Famotidine. At his one-month recheck, Stretch remained icteric, though improved; his weight was 20.7kg (a 3.4 kg loss in one month). Bloodwork revealed ALKP, ALT and Cholesterol elevated from the two-week recheck, however, the TBILI decreased by 50% to 6.3 mg/dL. Prednisone and Famotidine were continued. A repeat ultrasound and liver biopsy was performed at the six-week recheck. The biopsy revealed vacuolar hepatopathy. At that time, the Prednisone was decreased to 0.24mg/kg dose twice a day. Over two months later, bloodwork showed little to no change in liver values. A fasting panel was sent in 5 days later, again, little change was noted in the liver values. Stretch remained underweight.
Three months after the initial hepatic insult, Stretch presented for an acupuncture and herbal therapy consultation. The owner reported that normally Stretch bosses around the other dog (who is much bigger and younger than him) in the household; he is also notoriously stubborn about listening to commands—both his owners reported that even their friends know how stubborn he can be. He is generally active for a Bulldog breed but he has not been active since he first presented to the emergency room in December. Once Stretch began the Prednisone, his appetite returned, though he still was not the voracious eater he had been prior to the initial insult to his liver.
On TCVM Exam Stretch’s Shen was depressed and the owners reported this was abnormal, that he is usually much more active about greeting newcomers. Stretch had become cool seeking since the initial onset of liver disease symptoms. He had a soft coat, dry footpads and a wet nasal planum. His tongue was red, swollen and had a thin greasy coating; his gums and conjunctiva were extremely jaundiced. He had sensitivities along BL-18/19/20/21. His pulses were thin and weaker on the right.
The bossy, assertive and stubborn behavior traits point to Stretch being a Wood constitution; thereby potentially predisposing this patient to liver or gallbladder diseases. The initial insult to the Liver (either toxic or immune-mediated) manifested as Gallbladder Toxic Heat—seen by the acute onset of bright yellow jaundice, vomiting and bloody stools. Stretch was also on Prednisone, considered a "hot" drug in TCVM and likely contributing to the heat symptoms seen in Stretch after the initial Toxic Heat insult. The Gallbladder Toxic Heat (Yang jaundice) led to Dampness in the Lower Jiao and Spleen Qi Deficiency—seen as weight loss, inappetance and diarrhea. The treatment plan for Stretch was to clear heat, drain the damp, smooth Liver Qi flow, and tonify Spleen Qi.
The TCVM treatment included acupuncture, herbal and food therapy. Dry needles included GV-20, GV-14, BL-18/19/20/21, GB-34, and ST-36. Aqua acupuncture was performed with Vitamin B-12 at LIV-13, LIV-14 and GB-33. Liver Happy (1 gram twice a day) was prescribed to treat the Liver Qi Stagnation with Heat. Liver Happy (modified Chai Hu Shu Gan Wan) contains Cyperus (Xiang Fu Zi) and Citrus (Qing Pi) to soothe Liver Qi flow and resolve stagnation, as well as Paeonia (Bai Shao Yao) and Bupleurum (Chai Hu) to soothe the Liver Qi flow, and Gardenia (Zhi Zi) to clear Heat. Xiao Yao San (2 grams twice a day) was prescribed to soothe Liver Qi flow, resolve Stagnation and strengthen the Spleen. Xiao Yao San contains, among other ingredients, Atractylodes (Bai Zhu) and Poria (Fu Ling) to dry up Dampness and tonify Spleen Qi. It was decided that the goal was to wean Stretch slowly off of the Prednisone; at this visit the Prednisone was decreased from 5mg twice a day to 5mg once a day for one month. Denosyl (425mg) and Milk Thistle (300mg) were continued. Stretch was placed on a home cooked diet of cool and neutral foods with Qi and Yin tonics. This included turkey, rabbit, duck, barley, celery and carrots.