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Case Study

Acupuncture for the Treatment of Equine Chronic Diarrhoea

An eight year old thoroughbred gelding suffering from chronic diarrhoea of unknown etiology had proved unresponsive to conventional treatment. Traditional Chinese Medicine was used to establish a diagnosis of Spleen Qi Deficiency and Liver Qi Stagnation with the Liver invading the Spleen. Acupuncture incorporating dry needling, laser and moxa were used to tonify the Spleen Qi, dispel the Dampness and disperse the Liver Qi.

Fig 1.1 Eight year old thoroughbred gelding suffering from chronic diarrhoea

This eight year thoroughbred chestnut gelding used for dressage and eventing was presented for a second opinion after suffering from diarrhoea for six months. The animal suffered from intermittent diarrhoea with associated irregular bouts of a mild colic-type pain. Often the horse would adopt a semi saw-horse stance. Invariably there were unfavorable behavioral problems associated with these events. The horse resisted the bit and his overall performance level dropped. Faecal contamination through the tail and down over the hocks and the caudal aspects of the hind limbs had to be hosed off several times a day. The severity of the diarrhoea ranged from being profuse and watery to ‘cow pats’. Firmer stools were observed only once or twice a month. The diarrhoea would continue for some three to five days and on occasions would persist for some weeks. During these events the gelding’s appetite decreased and feed was often left in the bin. There was subsequent weight and condition loss.
The animal lived in a sub-tropical area with access to ten acres of poor quality pasture grown on coastal sandy loam in Central Queensland. The horse was purchased from a dressage trainer further north, where for the previous six years, he had access to good quality improved pastures grown on heavy clay soils in Brigalow country. The previous owner reported that there had never been a diarrhoea problem before his sale. The animal had not been raced or prepared for racing but was schooled in dressage after being broken in as a three year-old.

When the diarrhoea persisted for some weeks the owner consulted a veterinarian who performed a clinical examination. A blood sample was taken for haematology and biochemical analysis The results were generally unremarkable except for a slightly decreased serum albumin. The blood test was repeated four weeks later. The horse was treated with a trimethoprim sulphonamide injectable trimethoprim I/V daily for three days. There was no improvement evident and several repeat visits followed. On the subsequent visit a faecal sample was taken for culture with the intention to search for pathogenic levels of one of the serotypes of Salmonella known to cause protracted diarrhoea. The second blood test revealed an elevated PCV and a marginally elevated ALP. There was no evidence of salmonellosis in the culture. The vet recommended the horse be supplemented with a haematinic (Blud satchets, one daily for 6 days) and a probiotic (Protexin) three times a week. The horse was wormed at six weekly intervals with varied anthelmintics delivered as a paste. The owner had found the horse was sensitive to grain or starch in his diet which tended to produce looser stools. Removal of all grain from his diet resulted in a lack of energy and sluggishness on the bit. Good quality lucerne hay exacerbated the diarrhoea. Poorer quality lucerne hay or oaten hay did not result in firmer stools.

The diarrhoea bouts continued into autumn and winter. By July the horse was not able to be used in competition or lessons. At this stage the owner submitted a hair sample for analysis to Col Ogle’s Hair testing . The result of this test was “Some acidity in gut. A small ulcer in stomach” The owner purchased Ogle’s Formula White and Formula Blue. The owner was of the opinion the horse was better after using these products but the droppings were largely still described as ‘cow pats’.

In late July the owner sought a second opinion. The breathing could be described as weak. The pulse was taken at the sub-mandibular artery was 31 and could be described as slow and empty. The coat over the dorsal top-line was roughened and scaly, muscle definition was poor. The animal looked depressed, tucked up in the abdomen and had scaly roughened skin over the dorsal thorax. The mucus membranes were slightly pale with a capillary refill time just over one second. The tongue colour was normal without a coating. There were no warm or inflamed areas and the lower limbs and body were cold despite the animal being rugged.
Intestinal sounds were evident on both sides of the abdomen at intervals of fifteen to 20 seconds (slightly increased). There was evidence of watery dark diarrhoea around the anus. The owner reported the faeces the gelding was producing were sometimes putrid smelling and somewhat black. The malodorous diarrhoea was not noted at treatment times. Whereas the diarrhoea was present day and night the animal seemed to be better in the mornings but was always sullen and depressed by feed time in the evenings.

When palpated the horse elicited distinct pain at LIV 14 on the near side as well as BL 21 bilaterally. The Liver Mu point produced a jump reaction with the horse moving away quickly to avoid discomfort. The Spleen Mu point, LIV 13 was tender bilaterally, but not as tender as LIV 14. The continuing darkened to black faeces were suggestive of blood loss in the alimentary tract. In view of the previous faecal culture and the blood tests undertaken as well as the associated poor performance problems, picky appetite a diagnosis of gastric-duodenal ulceration was made. This was supported by the intermittent colic, and persisting diarrhoea. Diagnosis can be confirmed by endoscopy. In this case a suitable endoscope was not available.

Traditional Chinese Medicine

In TCM using the Eight Principles Theory the horse had a disease which was Yin, internal, cold and empty or deficient. A diagnosis of Spleen Qi Deficiency and Liver Qi Stagnation with Liver invading the Spleen was made.

The loose stools indicate an interior Yang deficiency which has resulted in Yin excess. The palpable cold extremities and the exacerbation of the condition in winter indicate the imbalance is internal and cold. Examining the Zang-Fu organ syndromes allows further differentiation of the patterns involved.

The lack of appetite, general fatigue, weak limbs and loose stools suggest a Spleen Qi deficiency. The persistent diarrhoea indicates that there is an accumulation Damp in the large intestine which has weakened the Spleen to the extent the Spleen is becoming Damp. A Qi Deficient Spleen will fail in its function of governing transformation and transportation of food. The reported malodorous diarrhoea usually indicates that Damp-Heat is invading the Spleen.[2]. Whereas this is a cold condition it is possible to have external Damp-Heat invading the spleen as well from time to time. The foul smelling faeces was not always present.

In TCM it is the function of the Liver to spread and ensure the flow of Qi and Xue. Stagnation causes pain, discomfort and agitation[3]. The colic like pain, reluctance and refusal to work indicate that there was a degree of mental irritation that points to Liver Qi Stagnation. In cases of chronic Spleen Qi Deficiency the Liver is said to be invading the Spleen as evidenced by the irritability, abdominal pain, diarrhoea and tiredness.

Treatment Principles

The treatment principles from a Western medical approach was to:
eliminate diarrhoea using absorbents and protectants
treat the gastric and duodenal ulceration
rebalance the micro-organisms and
make any necessary dietry adjustments

The gelding was dosed with 450gms anti-diarrhoea powder (Parnell Anti-Diarrhoea powder) for three consecutive days as well as being given a pro-biotic (Micro-Rebound, Micro Labs) on three occasions over a week. This treatment was augmented with Ulcergard Oral Paste of which 15ml was administered three times a day for 21 days. After this sucralfate tablets were administered daily for a further 2 weeks (Six tablets BID). These act as a gastric protectant.
By the 8th October the gelding had improved vastly, was better behaved and was much brighter. Micro-Rebound, B12, B1 and a supplement Cool Herbs were added to his diet each week. The improvement lasted only three weeks. By mid November the diarrhoea had returned and was treated again with Anti-diarrhoea powder. The severity of the diarrhoea was reduced for 3 days after the treatment finished.

A review of the horses diet was undertaken. Any feed other than grassy hay exacerbated the condition. It was difficult to get the horse to work at any useful level on a diet of grassy hay. It was decided to try to source some Mitchell grass hay and use Micro-rebound or Protexin once a week. Due to the dry conditions persisting it was impossible to source any suitable Mitchell grass or meadow hay. The diarrhoea persisted.

From an Eastern medical approach the treatment principles were to:

tonify Qi and Yang
re-establish and promote the flow of Qi
dispel dampness
promote the transformation and transportation function of the Stomach Spleen and Large Intestine
dispel Damp Heat
relieve distress and support emotions

From a TCM point of view strengthening and warming the Spleen will allow the food to be transformed and assimilated. This involves tonifying Spleen Qi. Wurth [4] suggests resolving the Dampness and clearing the Heat from the Spleen could be achieved using the reducing method on GB 34, LI 11, ST 44, and GV 9. Finally it would be necessary to disperse Liver Qi and harmonize the Liver. This could be achieved using LI 4, LIV 3, GB34, LIV 14, CV 12, SP 4 and PC 6.[4]

Acupuncture treatment began on 7th December 2001. The points selected for treatment were SP 1, Bai Hui, ST 36, BL 20, BL 21, LI 4, SP 6, LI 4 and LIV14. The rationale for using these points from a TCM basis is given in Table 2.1. The plan was to dry needle using Serin No 5(0.25) X 30mm needles and leave them in place for 20 minutes. When this was attempted the horse would not tolerate needles being placed in any points on the Bladder or Spleen meridians. Placing a needle in BL 21 resulted in the horse bucking and pulling away. There was no spinal pain detected from chiropractic examination. On this occasion three points were added to the Large intestine meridian (LI 16 LI 11 and LI 1) as well as ST 10 for dry needling and the balance of the points were treated using a medical laser (Therapower 200mW Infrared). Each point was treated for 10 seconds receiving some 2 Joules.

The second treatment was given on the 20th December. At this treatment the reaction was similar to the first treatment but the bucking was not as violent. The horse pulled away and showed signs of discomfort. The same points were treated. The rationale was to tonify the Large Intestine and harmonize the stomach, then when the animal was stronger and the condition not as severe to attempt to needle the remaining points on subsequent visits. The improvement in the horses demeanor and condition was evident at this stage (Fig 1.2). The horse passed normal firm stools on 24th December. On the third treatment on January 15th 2002 it was possible to dry needle all the points. (SP 1, Bai Hui, ST 36, BL 20, BL 21, LI 4, and LIV 14) On this occasion the needles were left in place and the following points were added to the Laser treatment CV 12, ST 25, LIV 8, PC 6, LIV 13 and SP 3.

After the second treatment the stools remained firm until 13th February. The treatment was the same as the previous with the exception that now the horse stood calmly, and became somewhat sedated throughout the therapy. It was decided at this time to suspend further treatment and see if the diarrhoea returned. Some looseness in the motions around March 22nd prompted a return visit. On examination the animal had gained weight and was no longer depressed. He was working well and did not resist the bit. The points LIV14, LIV 13 and BL 21 were not tender or reactive. The extremities were arguably cool considering the ambient temperature. It was decided to suspend the laser treatment and to insert dry needles and Moxa all points. The moxa was applied until the area around the point was palpably heated. The horse showed no discomfort and appeared to enjoy the treatment again becoming somewhat sedated.

The treatment was repeated on the 19th March and May 22nd. During this time the stools remained firm and the horse worked well.

Fig 1.2: Treating the gelding with acupuncture using needles and Laser. The
Improvement in condition and demeanor was evident by the second treatment.