I am hoping to get some guidance for a case – 4 year old ME Ridgeback “Krueger”. I've tried to summarise his complex history!!
Owner got him as a pup and he had chronic intermittent diarrhoea. He was treated for isospora and faecal sample at this time also showed clostridial overgrowth.
From this time he has had intermittent diarrhoea (often haemorrhagic) with pools of mucus, which responds well to carafate. He also had persistently elevated liver enzymes and hypercalcaemia.
In 2020 he saw an internal medicine specialist and paired bile acids were elevated. Suspected diagnosis at this time (3 years ago) was intrahepatic PSS with gastric ulceration. There was no known cause for the hypercalcaemia, which has since resolved. Owner has not pursued further diagnostics for PSS.
I first saw Krueger 3 years ago as owner came for diet advice for the chronic intermittent diarrhoea. He has been going reasonably well on a fresh food diet (but can only tolerate limited ingredients) and Marshmallow Root tincture and gut support (pre and probiotics, bone broth). Owner then moved away until recently.
In the last 6 months has had intermittent episodes of blood in urine and multiple courses of antibiotics (which he does not tolerate well- GI upset and eats grass++). On urine analysis there has also been very high white cell numbers. No urine culture has been performed. Episodes do coincide with stressful events. Urine always been checked post antibiotic courses and no bacteria seen, and haematuria resolves. Most recent episode started after an abdominal and prostate exam. During these episodes there is no urgency, no pollakuria or stranguria.
I saw him about 2 weeks ago, just after he finished his last course of antibiotics, and he had no clinical signs of haematuria and was well within himself. Bloods at this time showed liver enzymes within normal limits, normal calcium, slightly lowered albumin and cholesterol levels.1 week ago (after the abdo and prostate exam) he had another episode of haematuria, and is now currently lethargic, uncomfortable and inappetant. The owner has found the only thing that seems to give him relief from discomfort is the Marshmallow Root glycetract (not sure if this is helping GIT or bladder). Ultrasound performed yesterday shows normal prostate, sediment in bladder but no other abnormalities, urine has blood and inflammatory cells but no bacteria.
When I saw him 2 weeks ago his pulse was deep and soft, poor tone, thin, quite fast, and small for a big dog. His tongue is very small, very pale, light lavender in colour and flabby.
I diagnosed him with Qi and Blood Deficiency, Liver Blood Deficiency and Damp / Damp Heat in Bladder. As there was no acute urinary issue at this time, I started him on Dang Gui Shao Yao San thinking this would address the Liver Blood Deficiency but deal with some Damp. I also started Wei Ling Tang for the GI issues plus ability to deal with some urinary issues. I did think of YGJ with the good response to carafate and demulcent Marshmallow, but thought this could be too cloying and could worsen the haematuria.
I’m feeling pretty confused about the haematuria. It doesn’t seem typical of Damp Heat as no urgency, but does have haematuria and has previously had bacteria and currently has inflammatory cells present. He’s got some history of Damp Heat with blood and mucus in diarrhoea, but overall seems more Blood Deficient than Damp.
I’m not sure if an underlying Blood Deficiency could now be causing Blood Stagnation and I should consider SFZYT, or if this would exacerbate any tendency toward Damp. Or in this current acute phase consider SMS, but would this reduce blood flow to liver and GIT so making these signs worse?
Or perhaps I should consider a Shao Yang formula, but the tongue and pulse didn’t seem to fit. Would XCHT (maybe add some Dang Gui?) be suitable here, or even San Ren Tang if some Dampness? Previous hypercalcaemia would fit with Shao Yang Disharmony too, but would this be decongesting to the liver and so make a possible PSS worse?
Wondering if I should stop the DGSYS/WLT if there is now active haematuria with inflammatory cells. I am seeing Krueger tomorrow.
Really not sure which direction to head in, and going round in circles!!
Thanks for any guidance.
Sophie