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Acute GI Bleed

by marneemadsen - January 30, 2010

HI Steve,
7 yr old F Pharoah Hound who had an acute GI bleed in early November. Clients were at agility show and suspect the dog could have been poisoned. She has had no previous health problems - great GI history (no hx vomiting, soft stools, etc) and top end agility athlete. The only thing strange in her history is that she had cycled very regularly every 6 months until Feb 09, and she has not cycled since. She has not ever been bred.

At the time of the episode, she had acute lethargy and passed two small, loose black stools. She also had two small bruises. She ended up receiving a transfusion and a complete workup. Her liver enzymes were normal at time of bleed and have been mildy elevated since then (alt 162, alp 230). She has also had mild azotemia since the event. She had endoscopy with stomach normal. Small bowel read as moderate, chronic LP enteritis with villi blunting and marked lymphangectasia. They found no evidence of the ulcer nor where the bleeding had occurred. She eats Orijen with buffalo meat, eggs, berries.

She bounced back quickly, but is slightly off in agility since restarting in the past couple of weeks.

I saw her on 12/22/09.
T = red to purple
P = deep, thin, slightly wiry

Pts = BL18T, BL20T, BL 19S, BL23, BL22.

No hair coat regrowth since treatment 6 weeks previously.

I started her on XYS for Blood Def,Spleen and to regulate cycle, but not sure if Ba Zhen San would have been better? And with the azotemia and pts, it seems TH is involved.

I will be seeing her again this week, but wondering if you can help me pull this picture together....

Internist wants her on Z/D, but I have encouraged her to stay on whole foods and less to no dry.

Thanks!

Marnee

by naturevet

January 31, 2010

Hi Marnee,

I think you started right where I would have. My only other thought is that YGJ is very good for gastric ulceration, which you must have had to get the GI bleed. So keep that one in mind, too. But with the Spleen points, active, XYS is a safe prudent place to start. It's hard to know whether the Kidney is cause (of Spleen deficiency or Liver Blood deficiency) or effect (of Spleen deficiency). As I understand it, can't azotemia arise from GI bleeds, and subsequent absorption of the blood. I can't recall, but that rings a bell somewhere. Anyway, I'd see what happens before doing much else, as you should end up making a dent in the problem with the XYS. Remember also Gui Pi Tang, and Bu Zhong Yi Qi Tang, for their ability to help the Spleen hold the Blood; their general BLood tonifying effects; in the case of BZYQT its Liver QI moving effect; and in the case of GPT it's Kidney tonifying effect. To my mind they are more apt to help with the problem than Ba Zhen Tang.

Hope that gives you some ideas. Let us know how it goes!

Steve

by marneemadsen

February 1, 2010

Steve,
Thanks so much.

Does everything stem from Spleen Qi Def/Spleen not holding Blood (the cessation of her cycle, the bleed)?

Is the inflammation/lymphangectasia in the small bowel from poor circulation to the bowel?

I think after a GI bleed, the BUN goes up disproportionately to the creatinine and resolves pretty quickly once the bleeding has stopped. This dog's azotemia has persisted for 6-8 weeks and actually got a little worse, though she is not showing signs.

I will see where she is today and they may have new labwork...

Thanks again,
Marnee

by naturevet

February 1, 2010

Hi Marnee,

I think either stasis or Spleen Qi not holding the Blood is plausible, and don't know yet which it is. XYS will definitely treat Stasis, so the response or lack thereof to the formula will tell us something. BZYQT treats both, making the distinction moot. In this case, I would wonder whether providing adequate Spleen support will eventually be enough to tonify the Kidney (and reverse the azotemia).

Thanks for refreshing my memory on the effects of digesting one's own blood supply. At least you know I'm not a vampire.

Steve

by marneemadsen

February 2, 2010

HI Again,
Quick update - I saw Bamba yesterday. She is having no symptoms, back to full speed and performance at agility. Stools perfect.

She still has not regrown any hair from clipping 11/1/09 at bleeding episode. Coat is sparse in some areas and a little dry.

T still purplish, sl red with lavendar underside

P better on XYS - not nearly as full on wiry, but still deep, slightly thin and wiry

Pts - BL20T, BL23S, BL19S

Labs:
BUN now up to 60 - has gradually risen since episode on 11/01/09
Creat 2.4 (BUN:Creat seems a little high to me..maybe some ongoing bleeding?
ALP 226
Chol 557!
HCT 52
USG 1020 with 2-3+ protein (upcr pending)

I switched her to Gui Pi Tang thinking she needed more blood tonifying and to support spleen before I got labs back. Also added XCHT+QJ as it looks like we have PLN +/- PLE now and some Blood Stasis.

Unfortunately, this dog has been so healthy, no previous labs have ever been done, so we don't know if this all new.

Does the lack of hair regrowth have to be Blood Def? Any other possibilites? Can you be blood def at 52%? Or is it more Yin Def or Stasis preventing blood from getting to surface?

Anyway, wondering if any of that influences you one way or the other...it seems we need to tonify blood but not flood the glomerulus too much?

Thanks!
Marnee

by marneemadsen

April 13, 2010

HI Steve,
I have seen Bamba now a couple more times. She does now have PLN - her UPCR was 3.1 last month and is up to 4.1 now and the BUN has risen to 76, Creat is 2.9 and phosp is up to 6.9. It looks like from the labs there may still be some occult GI bleeding. The dog does not seem to know anything is wrong...winning all sorts of agility trials and the people say she is feeling better and better.

She has been on SRT, XCHT+QJ the past month. I did not realize it, but they were also still giving 1/4 tsp Gui Pi Tang twice daily. Her tongue is lavendar to purplish red. Last month her pulse was deep, thin and confined. Yesterday tongue same and pulse deep, softer and thin. Her coat that had not grown in since November (from IV cath and a patch on her chest where they shaved to monitor some bruising) is now filling in on the legs. The chest wall is still pretty bare.
Her stools are perfect, is not PU/PD (can go 12 hrs in house with no accidents), though her USG is 1.014. Her HCT dropped from the 50's to 46 this month.

I am pretty surprised her numbers were worse, but writing this out, I think she is having GI bleeding. Thinking your idea of YGJ might be good. What do you think? TH/GB active, BL23,18 sedate improves pulse, as well as BL19, 22.

Thanks so much,
Marnee

by naturevet

April 16, 2010

Hi there,

I'd try the YGJ.

In this case, you may have gotten all the mileage you can out of the anti-inflammatory approach, and be ready for the tonic phase. Any possibility of the reduction in blood count just being due to the renal issues? At any rate, when I seen anemia creeping into a kidney case, I immediately start thinking tonification. So I'd wonder about at least Rehmannia Eight, and reducing XCHT and SRT. If the dog seems better still, and renal values stabilize over the next few weeks, then the way forward is clear.

This shift can happen after years of using the anti-inflammatory formulas. I just had one Wheaton that I'd managed with anti-inflammatory formulas for six years, that is now reversing its azotemia (even after all this time) on Rehmannia Eight. The big clue to shift came when the dog seemed to worsen slightly after years of stability.

Hope this case works out as well for you as that one did for me. If the dog handled GPT well, it can probably handle decent-sized dosing of YGJ.

S

by marneemadsen

May 20, 2010

HI Again,
Bamba continues to give me pause.
YGJ for past month. Clients feel she is not quite as perky, though she still has minimal symptoms of any sort.

Albumin 3.0 (up from 2.7)
ALT 121
ALP 495
GGT 16
BUN 92
Creat 3.8
Phosph 7.1
Cholesterol 502 (4 hrs postprandial)
Lipase 741
HCT 48
UPCR 3.5 (down from last month)
USG 1015
Occult Blood 2+ (consistent)
She did have bacteria show up, but free catch and no active sediment at all.

Tongue purple underside
Pulse deep, thin, wiry
PTs, BL19S, BL23 T, BL20S

Coat still not growing in - it had started just a bit on the SRT.

I went back through her workup from the internist, and besides the IBD and lymphangectasia, they did note some decreaed corticomedullary distinction...maybe she has something worse going on.

So, I perfused the kidney and liver and they got worse, except the albumin and UPCR...

Back to XCHT? Maybe with BWDHW?

Thanks again,
Marnee

by naturevet

May 22, 2010

Hi Marnee,

While the dog seemed worse clinically, the renal values are probably not significantly changed either way, so there is stability there. The exception might be the UPC ratio - a drop to 3.5 from 4.1 seems more substantial, as does the increase in albumin. So if the dog felt better on SRT, I'd return to it, yet I'd maintain your efforts at finding a safe way to increase renal perfusion.

I've used SRT with BWDHW simultaneously, and that has worked well for some animals in balancing the need for renal perfusion with the need for controlling inflammation. The other idea I have come up with, but haven't had a chance to try out much, is to add Dan Shen (Salvia) to SRT. Research has shown that the latter will also increase renal blood flow, yet the herb has been historically combined with SRT. It's also a blood mover and has a reputation for reducing fibrosis, which makes it an attractive consideration in treating renal disease.

So, two options for you. Probably BWDHW plus SRT is the safest surest choice.

S

by marneemadsen

June 22, 2010

Hi Steve,
I saw Bamba again. They thought she was definitely feeling better on BWDHW, SRT, and still half dose XCHT + QJ.

Her UPC dropped slightly from 3.5 to 3.3, but everything else is worse again.
HCT 39, down from 48
Amylase 1615
Lipase 759
Albumin down again to 2.7
BUN 119
Creat 3.8
Phosph 7.8
Chol 467
ALP 582
ALT 117
TT4 non-detectable
USG 1016

Could she be an atypical Addisonian? I usually would not think twice about the thyroid, but wondering if I should check?
They did a resting cortisol when this all started last fall that was normal, but her Na:K runs 27-30 consistently. Only 1+ blood in urine, so wondering if GI bleeding again?

Appreciate your ongoing help with this girl.

Marnee

I forgot to add the Dan Shen, but will do on next bottle. Tongue is still purpleish underside, but didn't seem as bad. Pulse superficial and slippery, but can move to deeper and having more tone.

by naturevet

June 22, 2010

With a non-detectable T4, that value definitely needs to be rechecked. If it's still ultra-low, I think we know what the next step is to enhance renal perfusion.

Definitely add the Dan Shen in there.

Until we've turned over these two stones, I wouldn't want to change too much just yet.

Steve

by marneemadsen

June 23, 2010

Hi Steve,
I still have some serum - is it worth checking a FT4ED now?

She is on BWDHW 1/2 tsp twice daily.

Thanks,
Marnee

by naturevet

June 23, 2010

For sure, I'd check the free T4. If it's also non-detectable, then the dog must be hypothyroid.

S

by marneemadsen

June 23, 2010

Steve,
Have you ever seen hypothyroidism manifest like this...IBD, lymphangectasia, PLN?

by naturevet

June 24, 2010

No, I haven't. But given how crucial thyroid hormone is for normal immune function, I'd act on it if FT4 is likewise non-detectable. You could run the case by Jean Dodds and see what she has to say about it as well, in the event that it occurs.

S

by marneemadsen

June 28, 2010

Steve,
FT4ED came back normal - low end of normal, but still - I would be afraid to throw thyroxine into this inflammed dog if she doesn't need it.

So, all the labs are worse except the UPC with more inflammation showing up in the amylase/lipase. Should I stick with the SRT, XCHT, BWDHW? I see her again tomorrow, but she apparently has felt good with this mix (she is not totally herself, though). I will add the Dan Shen to the SRT.

She has tolerated the blood/yin tonics I have thrown at her so far and with all the inflammation in kidneys and gut, would this be an appropriate case to try some ultra low dose pred?

Thanks again,
Marnee

by marneemadsen

June 29, 2010

Steve,
Just a quick note - pulses today deep, softer - just mild tone now. Tongue lavendar, less purple. Occasionally a little red during exam. Generalized progressive hair loss. Energy ok - not great, but better than before starting BWDHW a few weeks ago.

Marnee

by naturevet

June 30, 2010

Hi Marnee,

If the dog is feeling a little better, I'd probably give things another couple of weeks to assess your current mix. If the dog's GI is very bad, then I can see you using pred. But if GI symptoms are under control, I wouldn't mess with your possible early success.

The Dan Shen should be okay if you've added it.

S

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