Question Details
Icterus In A Dog
by bfellis - February 25, 2023    View Case Report
Moe is a 4 yr MN 24 lb white doodle of some type (apparently with some Bedlington Terrier as you will soon learn) that presented 1/20/23 with inappetance, vomiting phlegm mucus but no bile the 2 weeks prior to presentation.He has always been a picky eater, but owner found a soft kibble that he liked and was well tolerated until now. He is BAR and YELLOW!! ALT=338, ALKP=1036, GGT=21, T.bili=12.0, Total pro=8.4 with 5.1 Glob and 3.3 Albumin. I did my attempt at US and saw a mottled liver and hyperechoic GB.
DDx Acute on chronic hepatitis, dehydration. Placed on IV fluids for the day, submited Lepto PCR and gave Convenia to cover bases until diagnosis arrives and sent home with Goodness Gracious Turkey and Cerenia. T=pale yellow, dry; P=broad, full toned that softens with pressure on GB34, Rx Xiao Chai Hu at 1/4 tsp bid for Shao Yang disharmony/hepatitis.

1/21/23 Lepto PCR= negative

1/23/23 some improvement in activity but still really jaundice.Won't eat Goodness G, refused herbs no matter how small of dose, no vomiting on cerenia, Added Pepcid and Entyce as patient still not wanting to eat (except bacon that owner fed-insert face plant emoji here:)

1/24/23 still not wanting to eat, added Ursodiol at 125mg bid for GB sludge.

1/25/23 more lethargic, only will eat a little egg, cheese and of course--bacon. Owner wants to try acupuncture to see if that will help.
Still has blatant Shao Yang pulse that softens with GB34 (sedation),added GV 9 for jaundice, GV3 tonify Yang, sedate BL19, tonify ST 36 (I wasnt sure wether to tonify or sedate this one-I tonified to enhance the action of the point ? Even though I should have been sedating the Yang Ming-how does that all work together?) , ST 44 was needled and LI 11 was tonified- not sure why, but thats what I recorded) I bled Shan Gen with a 27" GA hypodermic.B13 in BL18 and BL 20. Seriously considering referral, but also Moe is showing some improvement.

1/26/23 owner called to report improved appetite and energy..really feeling good about response to AP as they have not seen these behaviors in a few weeks, but waxed and waned over the next few days. (Shao Yang , anyone? still refuses the XCH)

1/30/23 still not wanting to eat, vomited clear mucus on Cerenia yesterday (still on pepcid and ursodiol as well) wants AP to make it all better again. Moe is eating a little better and put on 0.5 lbs in a week. T=yellow, pale, dry, P=thin, toned and softens with sedation of GB 30, HR =84-Moe is a very easy going pup, really good for exam, needles.
AP: GV 20 (T), GV 3 (T), GB 30 (S), ST36 (S)- in retrospect, I probably I shouls have tonified Yang Ming and Shao Yang, but pulse did not say so when needling GB30- a skill that will arrive with more practice...Shan Gen (T), LIV 3 (s) B12 in BL 18, 19, 20 and 21. I also used cold laser to treat abdomen and noted Moe got a little nauseous if laser near xyphoid on midline). Plan to continue Cerenia, Entyce, Pepcid and Ursodiol and added Marbofloxacin as suggested by a colleague in case of bacterial infection in hepatobiliary tree-this is why I despise IM cases- all the pills. CBC shows mild non regenerative anemia. Profile did not change significantly, Tbili down from 13.2 to 10.7 was biggest bright spot in this case.

2/15/23 pulled trigger and went to MedVet. They added Prednisone at 5mg sid and metronidazole and D/C Moarboflox. Sheduled biopsy for 2/16.

2/18/23 Moe is still jaundice but eating well on 5 mg pred sid and I had added Denamarin which was well tolerated on an empty stomach (at 11pm) he presented for being unable to retract penis into sheath after biopsy. T=pale, yellow, P= full, toned mid deep, softens w/ GB34
AP: GV 20 (T), GV 3 (T) SP 4 (T), LIV 3(S), CV 6 (T), KID 3 (T),
BL 18(S) very little sensation to AP from L4 caudal until I needled KID 3, the Hun was aroused. Penis was lubricated and he can hold it in most of the time. P: continue Pred, Denamarin and I sent home 10 gm of Bao Hu Jiang Jun Tang at no charge just to see if the lil' dude will eat it.

2/19/23 Lo and behold Moe is finally down to protect his General!!! Taking 1/8 tsp bid with no problems!! plan to recheck Saturday after biopsy results return.

2/25/23 Dx Copper Storage Hepatopathy. Moe is eating better than ever!!they are cooking lean turkey with veggies and fruit. MedVet wants to put him on penicillamine- which is about $400/month and the RCVD Hepatic support canned exclusively (which is also abour $400/ month) He is still on Pred but no Cerenia or Pepcid or Ursodiol, just Denamarin Pred and BHJJT. I looked up diets on and they are pasta/rice/quinoa with eggs or cottage cheese and canola oil and their ration balancer-which i am willing to bet Moe will not likely eat.
1) So... any thoughts on diet, penicillamine (they also want high doses of Vit C and Zinc on an empty stomach--owners are so happy he is finally eating again and keeping his penis in and walking and being a dog again that they are hesitant to do this long term due to price and compliance with Moe being able to keep it down- Zinc on an empty stomach makes me want to puke- experience from CoVid remedies to keep us all alive and happy)
2)BHJJT appears to detoxify the liver.. do you think this is enough?
I was considering adding in XCH if he tolerates an increase in BHJJT to 1/4 tsp bid..Chai Hu and Gan Cao would be duplicated, but would this add another level of protection and toxin clearance for the liver?
3) sorry for the long post.. is all of this information useful to post? I suppose it will be more complete when transferring to cases on Cured there a way to enter all of the info from questions into cases without having to re-enter same info in a different format?
4) enough questions! enjoy your weekend and thanks again for your time and patience!!

by naturevet
February 27, 2023
Brett, I'm so glad the dog is feeling better! I have noticed most Cu toxicosis dogs are Shao Yang dogs, but that herbs are insufficient to control them. Once Penicillamine has chelated the copper, the herbs work better, allowing the drug and use of immune suppressants going forward to be reduced to minimal levels. Meanwhile, feel free to add some XCHT to the protocol, especially when the immune suppressant doses are lowered.

As for Zn on an empty stomach, given that it's purpose is to reduce absorption of copper, that doesn't seem likely to be very beneficial, if there is no copper to interfere with! It would seem wiser to give it with food (where he gets the copper from). As for the diet composition, it is definitely possible to feed a meat-based diet that is pretty low in copper, so the vegetarian approach is probably not absolutely necessary

Hopefully this information proves useful. It probably just corroborates what you're already thinking, but I guess it's nice to have reassurances anyway!

by bfellis
February 27, 2023
It sure does!! And I’m glad to hear your thoughts on Zinc. I couldn’t wrap my head around the empty stomach thing. Any suggestions on diet? My wife is taking the CIVT course in April- but are there any other sources until we get that course done?
by naturevet
February 28, 2023
Hi Brett:

For low copper meats, favour chicken, turkey and beef (e.g.,

Most vegetables are low in copper, although sweet potatoes appear to be contentious

CIVT has the Animal Diet Formulator, a 'build your own diet' program that you can sign up for, so you can create something that is balanced for the dog if you like

by bfellis
March 1, 2023
Excellent! Thank you!!

by bfellis
March 4, 2023
AP: Shan Gen, GV9 (Jaundice) GV3 (tonify Yang), BL 19 (sedate), ST 36 (T), GB34 (T)-softens toned pulse, ST 44, LI 11 (T), B12 aquapuncture- BL20, BL 18.
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