Maggie, an 11 year old, 10.5 kg., spayed female terrier mix presented with a 2 day history of anorexia and intermittent bilious vomiting. There was no known toxin or disease exposure. She shared her home with an indoor cat and a 10 year old Chihuahua. She led a sedentary life. Her previous history included chronic periodontal disease, obesity, now resolved, and a minor cruciate injury remised with rest and Chinese Herbs (Tendon Ligament formula from Jing Tang Herbal pharmacy.)
Clinical Signs and Diagnosis: Conventional (Western)
Significant physical exam findings included moderate periodontal disease with calculus and gingivitis, and palpable liver enlargement. She was normothermic. Radiographs confirmed hepatomegaly, with possible splenomegaly. The CBC was within normal limits. The chemistry profile revealed elevated liver enzymes with ALP greater than 2400, and ALT of 1591.
A bile acids test was abnormal with a fasting value of 386.1 and a post-prandial value of 440.9 The low dose dexamethasone test for Cushings disease was equivocal. The client declined referral for abdominal ultrasound and liver biopsy. A presumptive diagnosis of hepatopathy was made.
Clinical Signs and Diagnosis: Traditional Chinese Veterinary Medical (TCVM)
Maggie was presented on day 21 of illness for a TCVM consult. Her initial TCVM exam revealed a dry and red tongue, and a rapid and thready pulse. Her sclera were slightly red. Per her owner, she was cool-seeking and somewhat restless at night. She was a Fire constitution. She had occasional bouts of bilious vomiting. A diagnosis of Liver Yin deficiency was made.
Conventional Western Treatment:
Maggie was treated with allopathic medicine for the first 14 days. She received antibiotics, IV fluids, B vitamins, and milk thistle. Her hepatic values declined until day 21, when the numbers climbed again.
The TCVM diagnosis was Liver Yin deficiency. The goal of the treatment was to tonify Liver Yin, clear deficiency heat, and normalize the liver. Chinese herbs were the only treatment modality employed.
Yi Guan Jian (Jing Tang Herbal pharmacy) was started at a dose of 0.75 grams q. 12 hours on Day 27. The owners gave the herb inconsistently as she had bouts of anorexia during the first 2 weeks. Consistent administration started on Day 35. A chemistry panel on Day 43 revealed markedly decreased enzymes. At the last recheck on Day 95, the hepatic enzymes continued to decline. The herbal was continued with a follow up scheduled in 30 more days.
From the TCVM perspective, the patient exhibited signs of Yin deficiency. Her clinical signs of a red dry tongue with no coat, rapid thready pulse, evening restlessness, and cool seeking behaviors all supported this diagnosis. Liver Yin deficiency was reflected in her past ligamentous injury, as well as her current liver pathology. A Stomach Yin deficiency was supported by the chronic dental disease and gingivitis. It can also be presumed that she had a Kidney Yin deficiency, as Kidney is the mother to Liver, and they frequently go deficient in Yin together.
The Yin deficiency was likely rooted in the dry food chicken-based diet that is warm and dry and damages Yin fluids, and aging. There was also likely a component of Liver Qi stagnation engendering Fire and overcontrolling the Stomach causing vomiting.
The TCVM treatment focused on Chinese Herbal therapy. The herbal Yi Guan Jian was selected for Liver Yin deficiency. Also known as Linking Decoction, it nourishes Liver Yin and spreads Liver qi. Per Bensky, it treats "linked disorders of pain in the chest and hypochondria, acid regurgitation, and Liver dysfunction due to yin deficiency". Radix Rehmannia Glutinosae (Sheng Di Huang) and Fructus Lycii (Gou Qi Zi) are the emperors of the formula. They nourish Blood and Kidney Yin, which in turn nourish the Liver.
Radix Adenohorae seu Glehniae (Bei Sha Shen) and Tuber Ophiopogonis Japonici (Mai Men Dong) are the deputies and nourish Stomach and Lung Yin, strengthening them against an out of balance Liver. Radix Angelicae Sinensis (Dang Gui) tonifies and invigorates Blood. Jing Tang substitutes Taraxacum (Pu Gong Ying) for the traditional Fructus Meliae Toosendan (Chuan Lian Zi). Pu Gong Ying, or dandelion, enters the Liver and Stomach channels, and cools heat and detoxifies. Per Bensky, in modern China, Yi Guan Jian is used to treat chronic hepatitis and cirrhosis. He also mentions Dr. Qu Zhong-Shan adding Fructus Schisandrae Chinensis (Wu Wei Zi) because of it’s ability to lower transaminases in patients with persistently elevated liver enzymes.
With allopathic medicine, Maggie’s hepatic values decreased 20% in the first 2 weeks, and started to climb again at day 21. On day 35, 10 days after adding Yi Guan Jian, her values had decreased 73%. The reductions up to Day 14 could be attributed to antibiotics, milk thistle, or the body’s ability to heal itself.
As the enzyme values were starting to climb again at Day 21, and the only intervention was the Chinese herbal, it would seem that Yi Guan Jian contributed significantly to the reduction in the hepatic enzymes. The patient will continue to be monitored every 3 months.
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