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Chronic Diarrhea In A Dog

by jk176 - September 15, 2020 View Case Report

It's complicated. My questions/concerns are at the end. Sorry for the long post, but there is a lot of history:

Pepe
10.5 year old mn Dachshund
CC – diarrhea
Hx – chronic alopecia – most of head, body, limbs for many years
11/16/17 abd u/s – enlarged hyperechoic pancreas, thickened hypermotile and dilated small intestine, blood work at that time low albumin, low globulin, low total calcium, low creatinine, low cholesterol
11/20/17 endoscopy – diagnosed with PLE
Treated with prednisolone and atopica
10/19/19 – low proteins – prednisolone and Atopica doses increased

First visit: 6/5/20 – weight 11.3 lbs, eating well, PU/PD, large volume stool – no vomiting or diarrhea. Meds at that time: prednisolone 5 mg PO BID, Atopica 25 mg PO BID
Supplements Rx Clay 1/8 tsp SID, Tylan powder 1/8 tsp SID, Vet visbiome

Vetscreen/CBC
albumin/globulin wnl
ALT 152 (increased)
ALP 1853 (increased)
creat 0.4 (decreased)
wbc 24,410(increased)
neutrophils 22,410(increased)
monocytes 1454 (increased)

PE – no tongue and pulse data at this visit, mm pink, moderate dental calculus, nasal hyperkeratosis, full body alopecia, dry skin, scales, cranial abdominal organomegaly, no murmur, normal rhythm, lungs clear

Plan - decrease prednisolone to 5 mg PO SID and recheck in 2 weeks

Second visit:
8/8/20 – Pepe presented with loose stool like soft serve ice cream and weight loss – weight 9.6 lbs, normal appetite, not pu/pd, no vomiting

Vetscreen/cbc –
alb 2.6 (decreased)
ALP 848 (increased)
creatinine 0.3 (decreased)
wbc 18,600 (increased)
neutrophils 13392 (increased)
RBC 6.1 M (wnl)
HCT 42% (wnl)
MCV 70 (wnl )
MCHC 32 (wnl)
plt ct 595 (increased)

PE similar to first visit – tongue pale pink, Pulse choppy, deep, toned, nasal hyperkeratosis, cool dry pinnae, crusts at pinnal margins, body warm, feet – cool to neutral

Plan increase prednisolone to 5 mg PO BID
Dispensed Evergreen Si Miao San 100 gram bottle with 20 grams of Dan Gui added – dose ¼ tsp BID

third visit:9/12/20 weight 9.9 lbs
per owner doing well – normal appetite, thirst, occasional diarrhea, one episode of looking like he was going to vomit, nothing came out

Vetscreen/cbc –
albumin 3.0 (wnl)
creat 0.5 (wnl)
ALP 961 (increased)
wbc 15,700 (mildly increased)
neutrophils 14,601 (increased)
lymphocytes 471 (decreased)
RBC 5.6M (wnl)
HCT 45% (wnl),
MCV 81 (increased)
MCHC 29 (decreased),
polychromasia slight,
NRBC 5 (increased)
plt ct 732 (increased)

PE – tongue pink, pulses weak, toned, superficial – no change in nasal hyperkeratosis or alopecia or pinnal crusts

Assessment
diarrhea improves on higher doses of corticosteroids –indication for Si Miao San

alopecia, nasal hyperkeratosis, pinnal margins, cool feet/ears – blood deficiency/dryness

Concerns
blood deficiency signs will worsen with Si Miao San
damp signs will worsen with Di Gu Pi
Weight not improving, persistent intermittent diarrhea
NRBC, polychromasia new – occult GI bleed, bone marrow stimulation

What do you think it the best formula for this patient?

by naturevet

September 16, 2020

Hi there!

You don't mention the diet that is in use for this dog, but given the apparent response to Si Miao San, which in turn indicates Damp Heat as a primary issue for this dog, that would be the next step. That is, you should explore real food diet options for the dog, such as commercial raw or home cooked low starch diets. If the owner insists they must 'feed out of a bag', then about as processed as you can get without reawakening the inflammatory process is freeze-dried.

There was a small weight gain on the SMS, so that is good. It helps reassure you are on the right track, as does the improvement in other lab indices. The upticks in ALP and the red count suggests it might be too soon for the Dang Gui, even though I completely see why you tried it. That doesn't mean you won't use it eventually, so perhaps just trying straight Si Miao San is called for during the next couple of weeks, with the view to eventually likely needing the version with added Dang Gui.

How to support peripheral circulation if we don't use a Blood tonic? You could look at using Qing Ying Tang with the Si Miao San, or even Minor Bupleurum. Right now, though, the pulse is nice and peripheral. With a diet change and continued SMS, maybe it will stay that way, so I would try those two steps first.

Note that other things that can cause hair loss in Chinese medicine include severe Heat (which you are treating with SMS) and Blood Stasis + deficiency, which you could potentially address with Qing Ying Tang.

There are a lot of other tacks you can explore with this case, but it's important to follow through with what you're doing now, given the comprehensive improvements in the most critical disease markers for this dog. I bet a diet change helps a tremendous amount

Hope that helps. Please keep us posted and feel free to ask for more advice as you go along. If you have a patient and invested owner, I bet you can knock this one out of the park!

Steve

by jk176

September 28, 2020

Thank you so much for your detailed reply, explanations and recommendations. I was really hoping to help improve Pepe's situation with Chinese herbal therapy and diet changes.

Sadly, I learned last week that Pepe passed away. When a fellow staff member called to let his family know the Si Miao San without any additives arrived, she was told he passed away. She called on 9/22/20. His owner was too distraught to go into details. I called and left a message but haven't heard back.

I don't know why he passed, but one possibility, a thromboembolic event, comes to mind. His platelets were elevated on his last cbc and he had nucleated rbcs. His blood proteins were normal, though.

I have had good success with Chinese Herbal Medicine and acupuncture and firmly believe in it and want/need to learn more to become a better practitioner.

I still have to ask if you think the Si Miao San with Dan Gui could have caused an adverse reaction in Pepe that may have led to his death?

Thank you again,
Jennifer

by naturevet

September 30, 2020

Hi Jennifer,

I've never seen SMS + Dang Gui to cause any side effects apart from a rare incidence of loose stools. It's important to remember that because herbs don't contain large amounts of any one compound, they cannot cause adverse reactions in the same manner as drugs, which can on occasion overwhelm the system. In the case of herbs, they cannot overwhelm the system, but instead at the most they can only accelerate disease processes that are already going on in the patient, but are currently subclinical. Even with that proviso, though, I've never seen a herb cause thromboembolism.

The high nRBC and platelet count makes me wonder if a hemolytic anemia was brewing at the time you saw him. Even if he was not anemic, it's a possibility. Often animals are actually hemoconcentrated before a crisis, due to a revving up of the bone marrow as animals try to compensate for the hemolysis that they 'know' is going on, but which is not clinically apparent. Even then, though, I've never seen a herbal formula precipitate that kind of problem, only treat it.

If the dog was actually anemic, then the other possibility, given the refractory diarrhea, is lead poisoning. I don't know if that is a possibility in this dog's environment. The house would have to be old, with flaking lead-based paint chips. Either that or the dog would have to have toys (usually made in China) that were coated in lead-based paint. As for the herbs, though, they are free of lead.

I'm also wondering if the owner just fatigued on managing the dog and had it euthanized at another clinic. Unless she was asked and denied it (out of a sense of guilt), then that possibility has to be entertained as well.

Hopefully this makes you feel a little better. This case would obviously have been a tremendous challenge for anyone. Please don't take it too hard, especially when all we have to go on regarding what happened is conjecture

Steve

Steve

by jk176

October 3, 2020

Hello Steve,

Thank you so much for your detailed reply and assessment.

Jennifer

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