Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4S2018057
Abstract
The patient, an eight year old female spayed Domestic Long Hair cat, presented in late August 2018 after an episode of acute hemorrhagic diarrhea and vomiting. Diagnostic tests included a complete blood count (CBC), chemistry profile, feline specific pancreatic lipase assay (fPL), abdominal radiographs, and abdominal ultrasound, revealing a suspected diagnosis of irritable bowel disease (IBD). A combination of conventional allopathic medications with acupuncture, electroacupuncture, and diet modifications resolved the patient’s clinical signs within a month of treatment.
History
The patient, an eight year old female spayed Domestic Long Hair cat, presented in late August 2018, less than 24 hours after visiting another veterinary emergency hospital for an episode of acute hemorrhagic diarrhea, vomiting, lethargy, and inappetence occurring over a 24 hour period. Prior to presentation, the patient was a healthy cat. She was originally adopted from the Hawaiian Humane Society as a kitten and is an indoor only pet. She had been vaccinated with a combo feline viral rhinotracheitis, calicivirus, and panleukopenia vaccine (FVRCP) as a kitten, and once as an adult. She was also tested for feline immunodeficiency virus (FIV) and feline leukemia virus (FeLV) and was found to be negative for both. She was not on any flea, tick, or heartworm prevention, and was not taking any medications and/or supplements prior to presentation. The patient’s owners had introduced a new kitten to the household two weeks prior, fully vaccinated, dewormed, and tested for FIV/FeLV.
During the patient’s initial visit to the emergency hospital, a CBC, chemistry panel, and SNAP fPL assay were performed and all found to be within normal limits. Temperature, pulse, and respiratory rate were within normal limits. The patient was found to be mildly dehydrated (<5%) and uncomfortable upon abdominal palpation, but no other abnormalities on physical exam were noted. Abdominal radiographs were offered, but declined by the owners. Treatments included subcutaneous fluids (200mL NaCl 0.9%), a maropitant injection (4mg subcutaneously), Proviable probiotic paste orally, and Hill’s i/D feline diet. The patient was discharged with instruction to follow up with her primary veterinarian.
The following day, the patient presented for a follow-up exam. The patient continued to have frequent, small amounts of blood-tinged diarrhea. Her owners reported some decrease in the volume of blood in her stool, but no cessation in frequency and overall amount. Her vomiting has ceased, but she was was still lethargic and inappetent.
Physical Examination and Clinical Assessment
The patient was quiet, alert, and responsive on presentation. Skin turgor and moist mucous membranes suggested euhydration. Temperature was 100.3F, respiratory rate was normal, and pulse was slightly elevated at 200 beats per minute. Abdominal palpation was normal, but patient exhibited an exaggerated kyphotic posture during entire exam. Cranial nerve exam was normal; full neurologic exam could not be performed due to patient’s unwillingness to move or walk in exam room. Myotatic reflexes were not performed due to patient temperament. Muscle mass and tone of all four limbs were normal. All other physical exam findings were unremarkable.
Abdominal radiographs revealed mild to moderate diffuse dilation of loops of bowel, gas opacity within the stomach, and gas opacities within the lumen of the colon. A fresh fecal sample was unattainable at that time, and was not sent out for parasitic, bacterial, and/or fungal testing per owners’ request. Instead, empirical deworming with oral fenbendazole 50mg/kg once daily for 5 days was implemented. Oral metronidazole dosed at 10mg/kg twice daily for 5 days was also empirically started for anaerobic coverage, including possible Clostridium involvement. Owners were also advised to continue administering probiotics and bland diet as prescribed by previous veterinarian.
After completion of fenbendazole and metronidazole courses, the patient’s large bowel diarrhea and occasional vomiting did not cease. Further diagnostics, including an abdominal ultrasound with possible endoscopy was suggested, and the patient was referred to Veterinary Emergency and Referral Center for further diagnostic workup and Internal Medicine consultation.
Under the direction of a board-certified internal medicine specialist and radiologist, an abdominal ultrasound was performed one week after initial presentation, revealing a diffuse enteritis with prominent wall layering. Oral budesonide was then prescribed at 1mg/kg, as well as a hydrolyzed dry kibble diet (Royal Canin HP). An endoscopy and mucosal biopsies were declined by the owners. Differentials at the time included IBD v gastrointestinal lymphoma; a tentative diagnosis of IBD was made at the time.
The patient returned two weeks later after receiving two weeks of oral budesonide and a hydrolyzed protein diet, reporting almost complete resolution of clinical signs including large bowel diarrhea and vomiting. The patient was defecating regularly, although stool consistency was still intermittently soft-formed to slightly liquidy. Vomiting frequency had significantly decreased to twice over the last two weeks.
The owner’s had expressed their goal to wean the patient off long term oral steroids. A combination of acupuncture with electrical stimulation and diet changes was suggested.
Differential diagnoses for mixed bowel diarrhea:
Vascular: r/o transient ischemia
Infectious: r/o rotovirus v girardiasis v clostridial overgrowth v cryptosporidium v toxoplasmosis v tritrichomoniasis v panleukopenia v coronavirus v feline immunodeficiency virus and feline leukemia virus
Neoplastic: lymphoma v adenocarcinoma v mast cell tumor
Iatrogenic/intoxication: r/o toxin/poison ingestion
Autoimmune: immunogenic food allergy
Trauma: r/o foreign body causing mechanical damage to mucosa v unknown abdominal trauma
Endocrine: r/o hyperthyroidism v diabetes
Myofascia: r/o chronic throacolumbar pain and restriction causing secondary elevation to sympathetic tone resulting in poor gastrointestinal mucosal health
Differential diagnosis for kyphosis:
Vascular: r/o fibrocartilagenous embolus
Infectious: r/o feline infectious peritonitis (mutated coronovirus strain) v diskospondylitis v fungal (histoplasmosis, coccidioides, blastomycosis) v toxoplasmosis v meningitis (less likely)
Neoplasia: r/o meningioma v other space occupying mass within abdomen v lymphoma
Degenerative: r/o Type I or II intervertebral disc disease localized (IVDD) to T3-L3, spinal cord arthritis, spondylosis deformans
Congenital: r/o normal breed confirmation, spinal muscular atrophy,
Trauma: r/o any type of accident
Endocrine/metabolic:
Myofascia: r/o thoracolumbar pain secondary to chronic gastrointestinal disease v kidney disease
Putative diagnosis
The patient was presumed to have IBD, based on clinical signs, ultrasonographic findings, signalment, and response to therapy. Gastrointestinal lymphoma was considered less likely due to complete resolution of clinical signs with treatment. Because IBD is often referred to as a disease complex, many of the bacterial and viral infectious and autoimmune differentials cannot be completely ruled out. The parasitic causes of large bowel diarrhea was ruled out with the use of deworming medications (fenbendazole) and metronidazole. Concurrent IVDD and thoracolumbar pain secondary to gastrointestinal disease also cannot be ruled out, as both could have been occurring concurrently.
Medical Decision Making
We discussed possibilities of the patient’s condition being acute and self-limiting v. a chronic manifestation like IBD v gastrointestinal lymphoma, and the need for further diagnostics if she did not improve clinically. We discussed treatment rationale of oral medications (steroids) and hypoallergenic diet v. acupuncture treatment and hypoallergenic diet. Neuromodulation rational with acupuncture included decreasing exaggerated sympathetic nervous system tone, stimulating the parasympathetic nervous system, and thus influencing gut motility. Other rationals included immune system modulation for possible IBD and gastrointestinal lymphoma component.
Acupuncture Treatment
Needle selection: Seirin 15mm 0.16 gauge coated
BL 20, 21: caudal thoracic and thoracolumbar spinal nn, for digestive problems
BL 25: back shu for LI, midlumbar spinal nn
BL 27, 28: S1/2 spinal nerve, small intestines
CV 12: caudal thoracic spinal nerves- abdominal problems, food absorption/assimilation
ST 40: fibular nerve, GI disorders
ST 25: front mu for LI, fibular nerve
CV 14: midthoracic spinal nn, abdominal problems relating to emotions
PC 6: median nerve, nausea/vomiting, cranial GI disorders
LV 3 : deep fibular nerve, hepatobiliary disorders
LV 13: caudal thoracic spinal nn, digestive problems, VO/DI, abdominal swelling
ST 36: fibular nerve, GI motility issues, immune/inflammatory
SP 6: tibial nerve, pelvic issues
CV 12: caudal thoracic spinal nerves, abdominal issues with food absorption and assimilation
GV 1- diarrhea, sacral spinal nerve
Bai Hui: mid-caudal lumbar spinal nerves, pelvic organ dysfunction
GV 14: cervicothoracic spinal nerves, immunologic disorders
Dry needled previous points, 3 sessions total over 3 weeks.
Week 1: all points, needled, no electroacupunucture used
Week 2: all points, electroacupuncture used with BL 23-52 @ 5 Hz for thoracolumbar pain and kyphosis, and also over BL 27-28 for modulation of sacral spinal nerves for small intestinal motility
Week 3: repeat of week 2
Outcome
Owners reported the patient to be much more comfortable and relaxed after each session, and that she enjoyed coming in for her treatments. Alabama’s diarrhea and soft stool were resolved by the second session, and vomiting and inappetence also ceased. Although the patient’s clinical signs were improved with oral steroids, the complete resolution of her clinical signs were in the absence of oral steroids, and with electroacupuncture and dietary changes. In conjunction with a hypoallergenic diet, the acupuncture sessions helped to encourage balanced parasympathetic/sympathetic tone, reduce exuberant immune system stimulation, and encourage normal gut motility.
I learned that you can see significant changes after one treatment of acupuncture in some cases. I always assumed it would take several treatments to effect change in the body (more of a cumulative effect). I also learned how powerful neuromodulation can be in effecting change within internal organs and the immune system. This will definitely shape the type of conversations I have with future clients and how I approach acupuncture as a “first line” treatment for my patients, and how effective it can be in treating not only orthopedic but internal medicine cases. It also helped to shed light on the fact that acupuncture can be used in conjunction with allopathic medicine to create even better results the patient .
References
Honneffer et al. Microbiotia alterations in acute and chronic gastrointestinal inflammation of cats and dogs. World J Gastroenterol, 2014 Nov 28; 20(44): 16489–16497.
Neurologic Disorders. Cornell Feline Health Center.
https://www.vet.cornell.edu/departments-centers-and-institutes/cornell-feline-health-center/health-information/feline-health-topics/neurological-disorders
Roudebush, P. Adverse reactions to foods: Allergies versus intolerance. In, Ettinger SJ, Feldman EC (eds) Textbook of Veterinary Internal Medicine, 6th ed., Elsevier, St. Louis, MO, pp 153, 2005.
Richter, K. Feline intestinal lymphoma. Vet Clin North Am Sm Anim Pract, 2003.
**Addendum: I would expect to see a thoracolumbar kyphosis on video while the patient is either sitting, standing, or walking. This may be due to the patient tensing its abdomen due to visceral pain, or tension created from increased sympathetic tone and signaling in the thoracolumbar area of the spinal cord.