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CASE REPORT: BLADDER DAMP HEAT and PHLEGM IN A HORSE


PRESENTED BY: ANTONIO ALFARO, DMV, MSc.
CHI-INSTITUTE OF TRADITIONAL CHINESE VETERINARY MEDICINE.
CLASS: MIXED PRACTICE CLASS 8.
ADDRESS: SAN JOSÉ, COSTA RICA.

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Telephone: (506) 8381 1353, 2203 5764

INTRODUCTION:

Brownie is a 12 year old mixed Quarter Horse/ Thoroughbred gelding, used for jumping at 1.0 to 1.20 meters. His performance is not being considered good but has no recent history of musculoskeletal problems, only a grade 1 “hike” with the right hind, is observed at trot.  He works 5 times a week. He is not considered a top performer and usually refuses fences.  He had a previous episode of hematuria about 2 month before the initial consultation. At that time no effort was made to define the origin of the condition and it was treated by fluids and non steroidal anti-inflammatory drugs, and no other complains were registered by his veterinarian. Two days before my evaluation, Brownie presented some difficulty urinating at first but them copious hematuria after exercise was observed and it was treated for rabdomyolisis by one veterinarian without success. His groom complains of frequent, difficult and stinky urination but has not seen or has put attention as if blood comes out of it.

Generally, Brownie is a quiet horse that runs away from examination, trembles, defecates and sweats when placed in an enclosed examination area and the vet is around or any stranger. When one shows up at his stall he goes and “hides” in a corner. He allows needles anywhere and does not complain.

July the 3d, 2005.

Initial Visit:

Examination:
Overall, Brownie is alert and has a good Shen.
Tongue appearance is red, appears thick, grease and sticky
His ears are hot at four fingers.
Pulse Quality is deeper on the left, but rapid, and smooth in general.
Scanning thru his meridians, low grade sensitivity and fasciculation was obtained at LI 18,  LI 16, GB 21, TH 15 and PC 9, ST 10, BL 23, 26, 28, 35 and 36 and at  Ba-Jiao specially at right side. While doing this I bled the respective ting points with the owner permission and got rid of the functional obstruction and BL 23, 26 and 28 kept sensitivity and also Ba-Jiao at right side. While checking on Mu points, there was reactivity at CV 3, LIV 14 and GB 24. By bleeding LIV 1 bilaterally, some of the reactivity at these 2 last points diminished.

Assessment and Treatment:

Major complaint is Hematuria of unknown origin.
Secondly, points and meridian reactivity were found on regular Traditional Chinese Veterinary Medicine (TCVM) evaluation related to Functional Obstruction at cervical and front and posterior limbs and are not going to be assessed here except when needed to explain the TCVM Diagnosis.

TCVM Diagnosis:
BLADDER DAMP HEAT with PHLEGM as primary complaint.  Kid Qi and Yin Deficiency leading to anterior and posterior Qi stagnation and Bony Bi at Right lumbosacral area.

TCVM Analysis:
For several years, Brownie has been used as a jumper horse. Unfortunately for him, no regular veterinary check ups are a part of his athletic life. Years of training and competition and living in a well known humid area in Costa Rica, predisposes Brownie to Damp conditions. One can assume from his history of bad performance that this horse had suffer from Wind invasion into his exterior causing stiffness and then sore muscles and joints and Bi-syndromes as Wind-Cold-Damp, Damp dominating,   since dampness makes it difficult for one to move, resulting in bad performance or generating Qi stagnation as seen anteriorly in his cervical area and posteriorly on his right lumbosacral area. Bad performance, stiffness, cervical and lumbosacral pain with left pulse weaker, supports Kidney Qi and Yin deficiency, and being not so much a muscular type, we could also assume some Spleen Qi deficiency. Damp can obstruct the flow of water and generate heat, Spleen Qi deficiency fails to transform and transport fluids and, also, as a result of the stress imposed upon sporting horses, Damp-Heat in the Liver or Middle Jiao could transfer Heat into the Lower Jiao, blocking the water pathway, causing disuria, stranguria and damaging the blood vessels causing Hematuria. Damp is a Yin pathogen, so it goes down, it is difficult to resolve and in chronic conditions generates heat. “Where there is Bleeding there is Heat”.   Hematuria is not usually seen in sporting horses except those of endurance competitions, but where hemoglobinuria is a characteristic of Rhabdomyolysis in those cases. This particularity called my attention.
Since Brownie was presented with a sticky greasy tongue and maybe because of its pulse being smooth as if slippery, I thought about Phlegm.  Since a disharmony of Qi of Spleen, Kidney, Lung and Triple Heater could lead to a perturbed fluid metabolism generating internal Heat, and since Heat could act on even normal fluid to produce Phlegm, and Phlegm could be substantial and manifest itself as tumors, a Urinary Bladder tumor was considered. Thus far, at the moment the thing to do was:
To try to stop bleeding by acupuncture
To prescribe an appropriate herb therapy
To dispel Heat and Dampness
To objectively see Phlegm
To plan a course of Treatment.
To recommend on Brownie’s musculoskeletal problems.

A blood sample was taken for reference before any treatment and catheterization and sterile collection of urine sample was submitted to the lab.

Acupuncture points used in this first session included:

Duan-Xue: stopping hemorrhage, GV, 5, 6, 7
LI 4, 11, GV 14, tip of Tail or Wei Jian, tip of Ears or Ear Jian to clear Heat and Damp, also BL 28 or Pang Guang Shu to clear Bladder Damp-Heat and Damp-Heat in the Lower-Jiao.
SP 6, 9 and CV 24 to clear Dampness
ST 40 and SP 3 for Phlegm
SP 3 and BL 20 to support SP Qi, to hold the Vessels, Prevents Hemorrhage
BL 17 and SP 10 to clear blood heat, to dispel stasis, to stop bleeding, to nourish, harmonize, invigorate Blood.

Herbs:
Yunnan Paiyao, for arresting hemorrhage, dispersing blood clots, activating blood and eliminating inflammation.
Eight Righteous Powder to clear Heat and Fire in the Lower Jiao.

Next day visit was very encouraging since the dribbling of bloody urine ( Video clip 1), had stopped. This was confirmed by the fact that Brownies “white socks” legs were clean.
Results from blood and urine analysis were within the normal range except for the obvious presence of excess blood in the urine and excess amorphous sediment. Culture was negative.

To find out whether Tan Yin was substantial or unsubstantial, a transrectal ultrasound was performed and a “cauliflower” appearing mass was evident, growing from the bladder floor. The mass is about 8 cm in diameter (Figure 1, 2 and 3, and Video clip 2). The animal was scheduled for bladder endoscope analysis the next day. While performing the transrectal ultrasound, bony abnormalities were seen on the lumbosacral transverse joint area with asymmetries between left and right, the right side being the abnormal one (Figure 4).

Endoscopy was performed under standard sedation and a biopsy was taken and submitted to histopathology. The result showed no signs of neoplasia and a diagnosis of a urinary bladder polyp growth was obtained.  It has been stated in TCVM that intra-abdominal masses from phlegm are usually benign. Tumor tissue and nodules are considered to be Blood Stasis and Stagnation.

Second Acupuncture visit: 12-07-05

Brownie has been good and without signs of major bleeding. He is not been ridden since the first visit. He is under stall surveillance and no intention in putting him under any exercise is considered yet.
Still, according to his stall caretaker, his urine is stinky and very concentrated looking with some blood coming at the end of the urination as can be observed (videoclip 1).

To reinforce his treatment, BL 17 and BL 28 were connected and electro acupuncture performed. Also and according to his initial evaluation, BL 23 and BL 26 were also interconnected to support his kidney. To strengthen and support Spleen issues as Blood forming organ BL 20 and 21 were also interconnected.
Kid 3 and 7 and 10 in conjunction with LIV 8 were done to support Kid issue and to strengthen Liver storage capabilities and Qi distribution together with LIV 3 and ST 36.
Acuapuncture with a Traumeel and D-5-W and B12 was done in Ba-Jiao, bilateral to support his Sacral Qi stagnation with BL 40 and 60.
BL 66 was bled to release heat from Urinary Bladder.

This point combination was continued for two more weeks and then, a transrectal ultrasound was done.

29-07-05. The size of the polyp looks smaller and the bladder contents looked a little less echogenic.

Intravenous fluids were administered in order to appreciate the quality of the urine. Urine was mostly transparent but a bloody tinged sample came at the end.

Acupuncture was continued with the same protocol with extra acupuncture at ST 40 and SP 3 to get rid of Phlegm. GB 34 was also included to redirect Qi.

Herbs: Yunnan Paiyao was continued and Max Formula to soften the hardness and clear the nodules with Phelodendrum Huan Bai to enter the Kidney and Urinary Bladder and to clear Damp-Heat and inflammation were included.

Brownie was put back on training after his 6th acupuncture session and no signs of bloody urine have been seen.

An ultrasound was performed in November and the mass is still there but the bladder contents look clear which will be anaechogenic in ultrasound terminology.

19-12-2005:

Acupuncture is done every week and Herbs are as stated and acuapuncture is applied at Ba-Jiao, Bai-Hui, Shen-Shu, Shen-Peng and Shen-Jiao together with Ba-Shan, SI 9, GB 21, and DN at TH 5 and GB 41, SI 3 and BL 62, to balance and to take care of his musculoskeletal problems and the owner is happy and the performance improving each day as has been the trainer evaluation. The hiking has gone to an almost imperceptible irregular gait.
Neither stinky stall, nor bloody urine is now noticed after exercise.
Brownie will resume his normal training and competing status this incoming year.

Discussion:


Since I took the Chi-Institute training course in Mixed Veterinary Acupuncture in Class 8, in 2004, I have done several small animal and horse cases exclusively thru acupuncture. But this case called my attention since Urinary Bladder growths in horses are very rare. As a matter of a fact, Dr Virginia Reef of New Bolton Center states that neuplasia of the Urinary Bladder in Horses is very uncommon (Personal Communication, 2004). The detection of a pedunculated mass is more consistent with polypoid cystitis, and histopathology in this case agrees with it. This gives Brownie a good prognosis and management by acupuncture as done, is the most logical approach.
Understanding the TCVM pathology responsible for the substantial phlegm gives Brownie a longer usefulness as a sport horse, the possibility of reducing the mass and the control of the bleeding. Secondly, the acupuncture orientation of his low performance will make of him a happier animal and a better performer. Continuous evaluation and the good use of TCVM Diagnostics and Therapy will be part of this horse athletic life.

REFERENCES:

Fergusson, B. 2004. Yin Yang and Eight Principles, Five Elements, Zang Fu Physiology and Introduction to Acupuncture Points Notes. Mixed Practice Veterinary Acupuncture Training Program Class 8th, Session 1. Gainesville, FL, USA.

Maciocia, G. 1996. Os Fundamentos da Medicina Chinesa. Roca. Sao Paulo, Brazil.

Reef, V. B. 1998.   Equine Diagnostic Ultrasound. W B Saunders, Philadelphia.

Reef, V. B., J. Snyder, F. Wouk, A. Solano & A. Alfaro. 2004. Seminario-taller sobre anestesia, ultrasonido y artroscopia en equinos y oftalmología en caninos y equinos. Jun. 1-5. Universidad Nacional. Heredia, CR.

 Xuezhong, S. 1992. Fundamentals of Traditional Chinese Medicine. Foreign Languages Press, Beijing. People’s Republic of China.

Xie, Huisheng.  2004. Bi Syndrome Notes. Mixed Practice Veterinary Acupuncture Training Program, Class 8th, Session II, Gainesville, FL. USA.

Xie, Huisheng.  2004. Traditional Chinese Medicine Diagnosis Notes. Mixed Practice Veterinary Acupuncture Training Program, Class 8th, Session III. Gainesville, FL. USA.

Xie, Huisheng, and Preast, V. 2002. Traditional Chinese Veterinary Medicine. Fundamental Principles, Jing Tang. Volume 1. Beijing: Beijing University of Aeronautics and Astronautics Printing House.

Zhen, L.S. Pulse Diagnosis. Paradigm Publications, Brookline Massachusets. USA. 1985.
 

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