A two-year-old, 4.5 pound, female Maltese dog was presented with a history of elevated liver enzymes since puppyhood. Her previous veterinarian had diagnosed her with suspected hepatic microvascular dysplasia, based upon her liver values. On presentation, she had retained deciduous canine teeth, and was not spayed. Her owner was trying to stabilize her liver enzymes so that she might be safely spayed and have her deciduous teeth removed.
Western Physical Examination, Diagnosis and Treatment
The physical examination was normal. She was, however, small for her age and breed. She was alert and hydrated, with a normal heart rate, respiratory rate and temperature, and slightly thin with a body condition score of 4/9. She had retained her upper deciduous canine teeth bilaterally. She had been monitored for vaccine status with yearly vaccine titers, and was currently maintained
on heartworm preventatives, but not flea preventatives. A bloodwork from her previous veterinarian revealed liver values of ALT = 1363 U/L (12-118) and BUN = 48 mg/dL (6-31). She was started on a moderate protein diet with 14% dry matter protein. The recheck test four months later showed improved but still elevated values of ALT = 428 U/L (12-118) and normal BUN. The owner declined further workup, which would include a bile acids test, an abdominal ultrasound and a liver biopsy.
The patient was described to be an easy-going dog that got along with everyone, except her owner, with whom she became very aggressive and nervous. Even without the owner in the exam room, she was resistant to handling, and mildly aggressive. She had a history of excessive ocular redness and discharge, which had been improved on organic dog food with added turkey meat.
Her tongue was pink with a lavender center. The pulse was wiry and slightly rapid. She showed no Ah Shi point sensitivities.
TCVM Diagnosis and Analysis
A TCVM diagnosis of Liver Qi Stagnation and Kidney Jing Deficiency was determined based upon tongue, pulse, and clinical signs. Animals with a Wood personality are predisposed to Liver Qi Stagnation. Liver Qi Stagnation occurs with stress, which can be caused by emotional stresses, drug therapies, overvaccination, or insults from or imbalances with other Zang-Fu organs. Kidney Jing Deficiency was diagnosed based on her small stature, retained deciduous teeth, and suspected congenital hepatic microvascular dysplasia. These symptoms indicated a lack of Essence (Jing) leading to a failure to grow and thrive. The Kidneys house the Jing, and is the mother element to the Liver.
Inherent weakness of the mother element can predispose the son element to imbalance. With this patient, inherent constitutional Liver imbalance, as well as a lack of nourishment from the Kidneys had led to Liver Qi Stagnation. Stagnant Liver Qi generates Heat, which can rise up and cause redness in the eyes. The lack of free-flowing Qi and Blood in the Liver can also damage the organ, leading to an elevation of liver enzymes.
The owner approved an initial treatment plan consisting of acupuncture, food therapy, and Western supplements. The goal of the treatment was to dissipate Liver Qi Stagnation, disperse Heat, and tonify Kidney Jing. Later, the owner consented to the addition of Chinese herbal medicines.
On initial treatment, her ALT was 428 U/L (12-118). She was started on Denamarin (90mg s-adenosylmethionine, 9mg silymarin)
1 PO SID. Dry needle acupuncture was performed on the following points: BL-18, BL-20, BL-23, ST-36, LI-11, LIV-3 and GV-20. The owner was instructed to supplement the food with turmeric, sesame seeds and cooked whole eggs, and when possible, alternate commercial dog food with a home-cooked moderate protein diet consisting of beef, turkey, sweet potato, and bok choy as the base.
Six weeks later the TCVM exam revealed a normal tongue, with slightly wiry but not fast pulses. The owner reported that she was not as “angry”, and was producing a more formed and vigorous stool. The ALT was 175 U/L (10-100). Acupuncture was performed every 3 weeks for 2 treatments at the same points as listed above, with BL-20 and LI-11 being replaced by SP-6, Bai-hui, and BL-47. At the end of this treatment cycle, her ALT decreased to 155 U/L (10-100), and she was scheduled for spaying and removal of her deciduous teeth.
The patient was brought in 6 months later for the surgery. The surgery was uneventful and her ALT was 136 U/L (5-107). The five-month-post-surgery ALT was 218 U/L (10-100), with an increased eye discharge. At that time the owner elected to monitor and continue Denamarin.
Two months later, her ALT climbed back to 279 U/L (10-100) and AST to 61 U/L (0-50). Her tongue was red, and her pulse was rapid and wiry. She was very aggressive and protective, and she had started vomiting. So the owner elected to pursue Chinese herbal medicine, and she was started on Chai Hu Shu Gan teapills
from Jing Tang Herbal at 1 teapill PO SID. Acupuncture was performed to address Liver Qi Stagnation/Heat and Liver Invading Spleen, using points An Shen, GV-14, BL-18, BL-20, HT-7 ST-36, CV-12 and LIV-3. The treatment was repeated after 3 weeks, dropping HT-7 and CV-12 since she was no longer vomiting and was not as “angry”.
After two months of herbal therapy, her liver enzymes became normal, with an ALT value of 58 U/L (10-100). The owner reported that she was clinically normal, so herbs and supplements were discontinued. The patient has remained clinically normal for 21 months.
This patient was a dog with elevated liver enzymes from a young age, suspected to be the result of hepatic microvascular dysplasia (HMD). This congenital disease usually results from a portal vein shunt, or diffuse hyperplastic blood vessels in the liver parenchyma that leads to poor hepatic perfusion. With traditional Western medicine, this disorder can be treated with surgical correction, if portal vein anomalies is the cause; but in the case of diffuse hyperplastic blood vessels, there is no known cure. Supportive care includes low protein, high complex carbohydrate diets, and judicious use of antibiotics and lactulose. Instituting a moderate protein diet had improved this patient’s liver enzymes, but did not normalize them.
In Traditional Chinese Medicine, Blood carries Qi to the whole body, and Qi propels the normal circulation of Blood. The lack of adequate blood flow as seen with HMD will lead to Qi Stagnation in the Liver. In addition, Kidney Jing Deficiency in patients with congenital diseases will cause failure of the Kidneys to nourish the Liver, further aggravating the inadequate Qi and Blood flow in the liver. As Liver Qi stagnates, it causes emotional signs of aggression and anger as seen in this patient. Lack of proper Liver function can also damage Spleen Qi via the Ke Cycle. Liver is the grandmother of Spleen, and when it is unable to control its grandchild, the Spleen cannot adequately perform the duty of maintaining a smooth descending flow of food, leading to the vomiting seen in this patient.
The underlying congenital Kidney Jing Deficiency in this patient was addressed with acupuncture and food therapy. Chicken eggs and sesame seeds were used to tonify Kidney Jing, and turmeric for Liver Qi stagnation. The owner was encouraged to feed home-cooked meals using neutral or cooling foods that tonify Qi whenever possible.
Initially, acupuncture was used to address the Liver Qi Stagnation.
The Western supplement Denamarin was prescribed to address the secondary liver inflammation and oxidative damage.
Because HMD is not considered inflammatory, this supplement was not successful at maintaining the liver enzymes once acupuncture was discontinued. It was the addition of Chinese herbal medicine Chai Hu Shu Gan which addresses Liver Qi Stagnation that brought the liver enzymes level back to the normal range.
Herbal Ingredients of Chai Hu Shu Gan (Jing Tang Herbal)