Signalment: Geriatric, M/N, DSH, Feline Immunodeficiency Virus (FIV) positive, rescue cat at local shelter.
Owner's Complaint: 7 month duration of megacolon, with partial perianal hernias due to straining, presented for euthanasia
History: This FIV positive cat, which entered the shelter at the end of 2008, had a previous history of chronic upper respiratory infection and intermittent ear infections. For the most recent seven month period he had required enemas under anesthesia as frequently as every two weeks for obstipation as well as catheterization for a secondary urinary blockage due to what was presumed to be neurogenic megacolon. He was able to urinate normally in between bouts of fecal distention of the colon but never fully emptied his bladder. The patient had been on long term therapy including cisapride and bethanacol, with the addition more recently of lactulose and occasionally miralax.
Physical examination: The patient presented for euthanasia on 1/31/11 and acupuncture was offered as an alternative .Physical examination revealed an overweight patient with body condition score of 4/5. Pain was evident on abdominal palpation, the colon firm and distended, and the bladder distended and unable to be expressed manually. The anus, although not completely lacking in tone, was visibly more flaccid than what would be considered normal. The anal area was distended and a large round fecal mass could be visualized and palpated just inside the anal opening. All other vital signs and systems were found to be within normal limits.
Diagnostics: Blood work indicated an elevated Total Protein at 9.2 G/DL (5.4-8.2 G/DL) and an elevated White Blood Cell Count at 21.9 x 109/L (5.5 – 19.5 x 109/L ) with increased granulocytes. Orthogonal radiographs (Figure 1) indicated moderate to severe ileus with medium sized, dense fecal balls throughout the colon with larger, very dense fecal balls in the distended distal colon and rectum. The bladder was also severely distended.
Figure 1. Lateral radiograph taken on 1/31/11 indicating obstipation, especially in the distal colon and rectum area and bladder distension.
Presumptive Diagnosis and Treatment: Neuropathy leading to megacolon/obstipation with secondary bladder atony. Medications were continued including bethanacol, cisapride, and lactulose. The patient was placed on Hill's Prescription Diet w/d (at an amount for weight loss) plus canned pumpkin twice per day.
Traditional Chinese Veterinary Medicine (TCVM) Examination: This is a geriatric cat with a chronic condition of obstipation and bladder atony, along with a history of chronic URI. His constitution is Earth as he is friendly and likes to be petted. The tongue is dry and purple and the pulses are deep and weak on both sides, but weaker on the right. He is neither heat nor cool seeking. He has seborrhea over his dorsum. He is painful in the perianal area (4/5) as well as tender on palpation of the BL-20 and BL-21, the spleen and stomach association points (3/5), and sensitive in the lumbosacral area (1-2/5).
TCVM Diagnosis: Spleen Qi Deficiency with Stagnation and Blood Deficiency
Local Points: BL-20/21
Pattern points: BL-17, SP-6/10, ST-36
Distal Points: ST-37
Symptomatic Points: BL-25, An-shen, GV-20, GV-1, Da-feng-men
First Treatment and Response (1/31/11): To help calm the patient, DN (dry-needle) acupuncture was performed. The dry needle acupuncture treatments were done for twenty minutes with the manipulation of twisting just at the beginning of the treatment. Aquaacupuncture (AA) was also performed using 0.1 mL of Vitamin B12 diluted to 0.2 mLs at GV-1 and BL-20 (bilaterally). No immediate response was noted except that the cat, although somewhat agitated to begin with, became visibly more calm about 8 minutes into the 20 minute treatment.
Second Treatment and Response (2/3/11): Manual extraction of hard fecal balls from a dilated distal colon and anus was performed. Cranioelectrical stimulation using an AlphaStim unit (Midwest Microcurrent) was performed for 20 minutes to help calm the cat after the procedure and before acupuncture was attempted. The DN and AA treatments were repeated as outlined in the first treatment, but DN was added bilaterally at BL-17, SP-6/10 to treat the blood deficiency. The patient's mucous membranes were visibly pinker after the treatment. Firm fecal balls were again manually extracted two days later and the patient was noted visibly clenching the anus after the procedure.
Third Treatment and Response (2/7/11): The patient had not urinated or defecated in two days so anesthesia was performed again and three firmer fecal balls and some softer stool were evacuated from the distal colon and the bladder was expressed (see radiograph in Figure 3). AA was performed and he urinated well after recovery. DN acupuncture was performed later that evening. The patient defecated five softer one inch stools immediately after the treatment and continued to urinate and defecate well for the next week.
Figure 3. Lateral radiograph taken on 2/7/11. Fecal and bladder distention are still present but the stool is much less firm
Fourth through Tenth Treatments and Response (2/14- 5/2/11): Acupuncture was performed again using the same AA and DN acupoints as outlined in previous treatments. The patient continued to do well with manual extraction needed only periodically during this time. The treatment plan is to continue DN and AA every 6 weeks for several treatments and then every 9 to 12 weeks, with adjustments made in frequency depending upon clinical signs.
Herbal Treatment: Fan Xie Ye (for constipation/ megacolon) was started on 2/12/11 but was not tolerated well (diarrhea) so then discontinued. The herbal formula was switched to Dang Gui Cong Rong to treat the Blood Deficiency which he was on until mid-June. This formula was started again 7/21/11.
Case Summary: As a cat with an Earth constitution, it is not surprising that this patient would have symptoms associated with the spleen and that he would evidence tenderness at the spleen and stomach diagnostic points of BL-20 and BL-21. As the spleen was deficient, it would also be expected that metal issues such as URI might become an issue in that the child element would override the deficient mother element. Although the bladder atony was likely secondary to chronic obstipation, it too might be explained since the water element is the grandchild of the earth or spleen element.
Impaction and constipation are part of the jie zheng or obstruction syndrome. The blood deficiency causes internal dryness in the large intestine which leads to impaction and obstipation. The Qi deficiency also leads to the inability to move the feces and eliminate them, resulting in impaction. The treatment strategies in this case were primarily to tonify Qi to promote defecation, and to help with local stagnation. Two points were also chosen to help with the URI and otitis, both of which also facilitate calming the patient.
This patient presented with megacolon with secondary bladder atony and also had a chronic history of URI. Acupuncture was elected as a last attempt to give him quality of life. Since treating his Spleen Qi Deficiency and Blood Deficiency he has been able to urinate and defecate on his own, producing 2-5 roundish fecal balls, several times per day. He has continued to receive lactulose, cisapride and bethanacol, and w/d and canned pumpkin twice per day. Approximately every 4-6 weeks he needs assistance removing retained fecal balls from the rectal area where it remains dilated due to perianal hernias. He currently has a BCS of 3/5, his haircoat is shinier and less dry, he is no longer tender over his dorsum, and his tongue is pinker. He also has had less issue with URI and overall, a much better quality of life, thanks to acupuncture and herbal therapy. As the first acupuncture case performed since beginning training, the journey and the outcome have been quite rewarding for the practitioner, the shelter, and most certainly the patient.