Treatment Of A Liver Shunt With Acupuncture
By Heather Matheson DVM; Tree of Life Veterinary Care
Courtenay, BC

Treatment of a PDA and liver shunt with acupuncture and botanical medicine

Abstract:
A thirteen week old Akita, Border Collie cross with vascular abnormalities, including a patient ductus arteriosus (PDA), an arterio-venous fistula within the liver and an intrahepatic portal shunt, presented with a history of hepatic encephalopathy. Treatment included acupuncture, herbal and one homeopathic remedy and extended over a four-month period. In this time the patient’s quality of life improved as witnessed by an increased appetite, improvement in mentation, weight gain and partial resolution of the PDA. In Western terms a diagnosis of hepatic encephalopathy secondary to portosystemic shunts described this patient’s condition whereas a diagnosis of Kidney Jing Deficiency was considered its Eastern diagnosis.

History:
Sadie, a thirteen-week-old female Akita, border collie pup weighing 9.6lbs (4.3Kg) was presented for acupuncture consultation. Sadie presented with a three-week history of restless episodes. The episodes began at approximately 7:00 PM and would last anywhere from three hours to all night. Typically Sadie would become very anxious, begin circling, appear blind with vacant eyes, pant, drool, scramble to get away from the owner or any restraint, and appear not to know the owner. The first episode occurred 24 hours after the initial distemper vaccination was given at a local veterinary clinic. There were no other past medical problems noted in the history.

Clinical Signs and Diagnostics
The owners obtained Sadie at seven weeks of age. Although ravenous, she remained thin, smaller and slower growing than her litter mates. She had a preference for cooler areas; drank large amounts of water; would lick everything (walls, floors, chairs etc); showed coprophagy and frequently got the hiccups after eating. Episodes or restlessness in the evening and night began at 10 weeks of age, 24 hours after the initial distemper vaccination was given.

A diagnosis of multiple congenital vascular abnormalities and secondary hepatic encephalopathy was made at another veterinary clinic. This diagnosis was based on the history, clinical signs and abdominal and thoracic ultrasound which showed multiple congenital abnormalities including, an arterio-venous fistula within the liver (originating from the celiac artery) and abnormal intrahepatic portal vessels with entrance into the caudal vena cava, typical of an intrahepic portal shunt. The abdominal vascular abnormalities were not considered surgically correctable and the owner sought an alternative approach. On clinical presentation this pup appeared extremely thin with a grade V1/V1 holosystolic (washing machine) murmur. Mentation, heart rate and temperature were all within normal ranges. 

On physical assessment Sadie was very thin, with a good hair coat. She had a “flirtatious” personality, trying to elicit attention and play but hiding under the chair or jumping away with any attempt to touch her. Eyes appeared clear but she had a “sleepy” look. A grade V1/V1 holosystolic murmur was both audible and palpable, lungs were audibly clear, heart rate was 160 bpm, and temperature was 38.3 degrees Celsius. Tongue was pale pink in the center with a red tip and red edges, no appreciable coating. Pulse was irregular in strength with a slight quiver.

Conventional Treatment:
Conventional treatment included a diet change to a commercial low protein diet, oral lactulose given twice daily, to effect, and the recommendation of humane euthanasia if hepatic encephalopathy was not controlled.

TCM Treatment:
According to the Traditional Chinese Medical philosophy the kidneys store the Jing or Essence. It is believed that this Essence is inherited from the parents and determines the development, growth and health of the individual. In the Western Medical philosophy one would probably call this the DNA or gene package. In the Traditional Chinese philosophy a deficiency of this Kidney Essence will result in a deficiency of the development and function of the organs such as the liver, heart, digestive network and ultimately the lungs. Seeing a problem in the liver and heart was not surprising and subsequently was not of great concern for the formulation of an approach to treat this patient from a Traditional Chinese Veterinary Medical perspective. It was seen that the underlying problem was the Kidney with secondary problems in the liver and heart.

The treatment principle according to TCM (traditional Chinese Medicine) was to nourish the Kidney Essence and to nourish the Heart Qi, Spleen Qi, and Liver Qi, nourish the Blood and promote the smooth flow of Qi through the three Jiaos. Optimed needles, 0.22 X 13mm, were placed at a depth of approximately 5mm; an even dry needle technique was utilized for all acupuncture sessions. The initial exam and treatment took place on August 27, 2003 with a total of seven acupuncture sessions extending over a four-month period. Dry needle technique consists of placing the needles in the appropriate acupuncture points without any electric stimulation and needles were left in place for approximately 15 minutes.

This being a weak and very young animal, attempts were made to use the minimum amount of needles. Points chosen were those having the greatest influence on the organs. For the record, the following points were used:
LIV 13 (Zhan Men, gate of symbol)
- Located on the lateral side of the abdomen, below the free end of the 12th rib (2). It promotes the smooth flow of Liver-Qi and benefits the digestive network (Spleen and Stomach) (5).
PC 6 (Nie Guan, inner pass)
Located just above the transverse crease of the carpus, between the tendons of the flexor digitorum superficialis and flexor carpi radialis (2). Used in cardiac disorders, regulates Heart Qi, decreases anxiety and calms the Shen (3).

SP 6 (San Yin Jiao, meeting of the three Yin)
Located just above the tip of the medial malleolus, on the caudal border of the tibia, on the line drawn from the medial malleolus to SP 9(2). Benefits Kidney function, Liver function and Spleen (Digestive) function (3).
CV 12 (Zhong Wan, middle stomach)
Located halfway between the umbilicus and the ziphoid process, on the midline (2).
Benefits the Spleen (digestive) (7).

Additional Treatment: 
The commercial low protein diet was continued and lactulose was maintained to effect. Vitamin E (400IU daily), milk thistle (10mg/kg twice daily), Coenzyme Q10 (30mg daily) and Gingko (0.5ml twice daily) were also started at the time of the initial examination. Homeopathically, treatment consisted of Silica 200CH (1 pellet twice a day for 3 days).
Sadie was reassessed 1-week post treatment. The owners reported no recurrence of anxiety episodes related to hepatic encephalopathy, an increase in activity and energy level and a weight gain of 4 lbs (1.8Kg) in a week. The above acupuncture treatment was repeated with the addition points.
BL 22 (San Jiao Shu, Triple Heater association point)
Located lateral to the caudal border of the spinous process of the 1st lumbar vertebra (2).
HT 7 (Shen Men, spirit gate)
Located on the transverse crease of the carpal joint, in the depression lateral to the tendon of the medial flexor carpi ulnaris (2). Calms the mind and nourishes Heart (8).
All oral medications were maintained as previously described with the addition of Astra Essence 1/4 tablet twice daily (Health Concerns) to nourish Kidney Essence.

September 10, 2003 and September 24, 2003 the acupuncture was repeated (LIV 13, SP6, PC6, CV12, HT7, BL22). Owners reported that Sadie was playing and thriving! Her weight continued to increase at a rate of 3 to 4 lbs per week; there was a decreased frequency of hiccups and no episodes of anxiety. The heart murmur improved from a grade V1 to grade three and the pulse was regular and strong. Oral medications were maintained but the dosage was increased slightly to accommodate the weight gain. Acupuncture sessions were changed from weekly to bimonthly at this point.

September 26, 2003, routine CBC, chemistry screen and bile acids revealed a non-regenerative anemia, low total protein, low urea and greatly increased bile acids (table1 & table 2).
Bimonthly acupuncture sessions continued for three additional treatments. Sadie continued to thrive and gain weight, and her heart murmur improved to a grade one. On December 22, 2003 the ultrasound was repeated. The PDA had reduced in size considerably and the liver showed no degeneration.
When Sadie went through her first heat cycle she developed ascitis. It was treated with abdominal centhesis and acupuncture. After her heat, the ascitis did not re-occur even in her subsequent cycles.Sadie continued to grow and develop and had a few set backs as she contracted fleas and lost most of her hair. Sadie recently had her third birthday and is a happy and thriving dog. Her heart murmur is no longer audible, but her liver enzymes continue to stay high; she subsequently developed ammonia crystalluria.

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