Chinese Herbal Medicine Treatment for Idiopathic Hepatic Lipidosis in a Cat
A two year-old neutered female Domestic Long Hair cat was examined after her owner reported weight loss and anorexia. Clinical examination revealed marked jaundice. Subsequent conventional diagnostic tests by a feline veterinary specialist confirmed the cat was suffering from idiopathic hepatic lipidosis (HL). Although HL is the most common type of liver disease of North American cats, it is much less common in Australia. The cat was placed on a Chinese herbal formula known as Wei Ling Tang (Calm the Stomach and Poria Decoction) and she responded within three days and started eating again. The treatment was continued for a total of eight weeks. Follow-up laboratory blood profile has revealed complete resolution of her hepatobiliary disease.
Yoyo, a two year-old neutered female Domestic Long Hair cat was first examined at an emergency house call on New Year’s Day (1 January 2007). Her owner reported Yoyo had become near complete anorexic in the 48 hours prior to the consultation. Yoyo was an average indoor cat that loved attention according to her owner and weighed 5.5kg before she became ill. She shared the environment with two other cats living in an apartment and was fed with dry cat food (a commercial supermarket brand). She had gradually become inappetant over the week prior to presentation and her weight had dropped to 3.5kg when examined.
Physical examination of Yoyo revealed marked jaundice that was very obvious on her mucous membranes and sclera. No other abnormality was detected at the time other than cachexia and mild dehydration. There was no exposure to any known toxin. Urinalysis performed on a urine sample collected at the time revealed concentrated urine with bilirubinuria. Differential diagnoses of liver disorder or haematological disorder (haemolysis) were considered.
From a Traditional Chinese Medicine (TCM) viewpoint, Yoyo’s tongue appeared to be red, moist and swollen at the time which indicated Damp Heat accumulation. Her pulse was soft, wiry and rapid (PR >200) which also reflected excess Heat. Yoyo was admitted into a veterinary hospital the next day (2 January 2007) for blood collection and to initiate supportive intravenous fluid therapy. Her serum biochemistry panel was characterised by hyperbilirubinaemia, marked increase in aspartate aminotransferase (AST), alkaline phosphatase (ALP), and alanine aminotransferase (ALT) activities. This suggested extensive liver damage and jaundice consistent with cholangiohepatopathy. Mild increase in creatinine kinase (CK) reflected muscle wasting. Hypocholesterolaemia and low normal urea also suggested the liver might be failing.
Once haemolysis which causes pre-hepatic jaundice has been ruled out, Yoyo’s fluid rate was increased to 1.5 times maintenance rate for the first 12 hours (Hartmann’s solution) to address her hydration deficit. Then her fluid rate was reduced to 9ml/hr for maintenance (0.9% sodium chloride with potassium chloride added). Yoyo was also medicated with amoxy-clavulanate injection daily and Milk Thistle extract 1750mg orally twice daily. The antibiotic amoxy-clavulanate was selected as an empiric choice for suspect cholangiohepatitis. While Milk Thistle (Silybum marianum) supplement is a common western herbal treatment for liver disease (Dhiman and Chawla, 2005) which acts as hepatoprotectant with antifibrotic properties (Lieber et a.l, 2003) and promotes hepatocellular regeneration (Weiss et al., 2000). Referral of Yoyo to a veterinary specialist for further investigation was recommended to her owner but was declined at the time.
Four days after initial admission, Yoyo showed no clinical improvement and stayed completely anorexic. A repeat blood panel revealed persistent severe hepatopathy with decreased urea which was likely due to decreased formation by the liver indicating liver failure. At this point Yoyo’s owner decided to seek veterinary specialist’s advice. An abdominal ultrasound was performed by a veterinary specialist at North Ryde in Sydney. The liver was isoechoic with the spleen but was homogenous in appearance. There was no other significant finding within the abdomen. Ultrasound guided fine needle aspirates were obtained from the liver and submitted for cytology. The pathology report indicated most hepatocytes were markedly swollen and rounded due to the presence of a single large or multiple smaller lipid vacuoles. These findings were consistent with hepatic lipidosis (HL).
HL is a condition characterised by severe hepatocellular lipid accumulation, intrahepatic cholestasis and impaired liver function. Hepatic fat accumulation occurs when there is increased fatty-acid mobilisation to the liver, generally during periods of starvation (Mansfield, 2004). There is no breed predisposition but cats are often obese at onset of the disease and have experienced a stressful event, then become anorexic and lose weight rapidly (Nelson and Couto, 1992). Other possible causative factors include carnitine deficiency, weight loss, insulin deficiency and possibly other intrinsic hepatic factors (Mansfield, 2004).
Hospitalisation and placement of a percutaneous gastrotomy (PEG) tube for feeding was strongly recommended by the veterinary specialist but was declined by Yoyo’s owner due to financial constraints.
Yoyo’s condition can be summarised using TCM Eight Principle Diagnosis (Maciocia, 1989):
- It was a Deficient condition characterised by its chronicity and cachexic muscle wastage from Spleen Qi deficiency.
- It was an Internal condition because of the Zang Fu pathology in the Spleen, Stomach and Liver.
- The dysfunction of Spleen and Stomach precipitated Dampness and Phlegm blocking the Middle Burner causing anorexia and lethargy. Jaundice was also a sign of Damp Heat.
- It was overall Yin in nature because of the apparent Internal pathology.
After further discussion, Yoyo’s owner agreed to treat her with alternate therapy using Chinese herbal remedy. Wei Ling Tang (Calm the Stomach and Poria Decoction) was commenced orally twice a day (on 8 January 2007).
Wei Ling Tang (Calm the Stomach and Poria Decoction) is a combination of two sub formulas, Ping Wei San (Harmonise the Stomach Powder or Magnolia and Ginger Formula) and Wu Ling San (Powder of Five Drugs with Poria or Hoelen Five Formula). Yoyo was treated with one pill of each of the following:
Ping Wei San (Harmonise the Stomach Powder or Magnolia and Ginger Formula) contains:
- Cang Zhu (Atractylodes rhizome) 36mg
- Hou Po (Magnolia bark) 36mg
- Chen Pi (Citrus peel) 24mg
- Gan Cao (Licorice root) 24mg
- Sheng Jiang (Ginger rhizome) 12mg
- Da Zao (Jujube fruit) 36mg
Wei Ling Tang (Calm the Stomach and Poria Decoction) contains:
- Bai Zhu (White Atractylodes rhizome) 42mg
- Fu Ling (Poria root) 42mg
- Ze Xie (Alisma rhizome) 34mg
- Zhu Ling (Polyporus sclerotium) 34mg
- Gui Zhi (Cinnamon twigs) 17mg
From a TCM perspective, Atractylodes and Magnolia both dry Dampness. Magnolia additionally disperses stasis from the abdomen while Atractylodes warms the Spleen and Stomach. Citrus assists in moving of Qi of the abdomen. Ginger and Jujube tonify the Stomach and Spleen respectively. Licorice tonifies the Spleen and Stomach Qi while also harmonising the formula as a whole (Marsden, 2006). Alisma, Poria and Polyporus in Wu Ling San (Powder of Five Drugs with Poria or Hoelen Five Formula) drains Damp. White Atractylodes tonifies the Spleen to reduce the production of Damp. Cinnamon activates the Damp draining action of the diuretics, especially in Alisma, and warms the Yang of the Middle Burner and normalise the production and discharge of urine by the Bladder (Marsden, 2006).
The combination of the two formulas creates a synergistic reaction where Wu Ling San (Powder of Five Drugs with Poria or Hoelen Five Formula) assists Ping Wei San (Harmonise the Stomach Powder or Magnolia and Ginger Formula) in drying Dampness and tonifying the Digestive Qi, while Ping Wei San (Harmonise the Stomach Powder or Magnolia and Ginger Formula) helps Wu Ling San (Powder of Five Drugs with Poria or Hoelen Five Formula) tonify the Spleen Qi and relieves obstructions secondary to Damp accumulation (Marsden, 2006).
Therefore, Wei Ling Tang’s (Calm the Stomach and Poria Decoction) overall TCM functions include rectifying Qi and transform Phlegm, drains fluid and strengthens Spleen and Stomach and aids the flow of Yang. It is indicated where there is Spleen and Stomach Damp blocking the Middle Burner (Xie, 2004) which corresponds to the clinical signs seen in HL – anorexia, weakness and jaundice.
On the second day after receiving the herbal formula, Yoyo started licking the gravy off a tin food offered (a commercial supermarket brand). By the third day, she started eating both tin food (Hills prescription A/D) and dry cat food (Hills Science Diet Feline Hairball Control Adult). A week later, she started to gain weight and her energetic self had gradually returned according to her owner. She was examined two weeks later with still a hint of jaundice on her mucous membranes but there was no laboratory testing performed at the time due to owner’s financial constraints. Subsequent weekly follow-up phone contacts with the client were made to ensure Yoyo was on track to recovery. The herbal formula Wei Ling Tang (Calm the Stomach and Poria Decoction) was continued twice a day for eight weeks in total and it was the only treatment the cat received during the period.
A final blood profile was collected two months after the cessation of the treatment (four months after the initial diagnosis of HL) and Yoyo’s hepatic function was completely normal (12 May 2007). She was weighing 5.1kg at the time which was similar to that before her HL episode.
The main pathophysiological mechanism underlying feline HL is Spleen Qi Deficiency with the resultant elaboration of Phlegm and Dampness (Marsden & Wynn, 2002). In this case, the most tangible manifestation of Dampness is lipid deposits in the liver. Dampness can also cause loss of appetite and jaundice and the latter is considered to be a form of Damp Heat in Chinese medicine (Marsden & Wynn, 2002).
Wei Ling Tang (Calm the Stomach and Poria Decoction) is indicated in the management of any Liver condition, marked especially by Spleen Qi Deficiency with relative fluid Damp accumulations (Marsden, 2006). Therefore, Wei Ling Tang (Calm the Stomach and Poria Decoction) was the herbal formula of choice for Yoyo’s HL. Furthermore, from a TCM perspective, Atractylodes and Citrus peel contain bitter principles that stimulate gastric secretion, peristalsis and appetite, which was essential in treating Yoyo’s anorexia.
From a scientific viewpoint, studies of Atractylodes rhizome have shown it exhibits anti-hepatotoxic activity (Kiso, et al 1983 and 1985). While honokiol, a compound extracted from the Magnolia officinalis (bark), has a strong antioxidant effect (Chiu et al., 1997) and also exhibits potent hepato-protective properties (Cao et al., 2005). Result from another study suggested that a primary component of licorice root, glycyrrhizin, exhibits pro-apoptotic properties while its metabolite, 18 beta5 glycyrrhetinic acid, is a potent inhibitor of bile acid-induced apoptosis and necrosis in a manner consistent with its antioxidative effect (Gumpricht et al., 2005).
In conventional medicine, once a diagnosis of HL is made, the most important aspect of treatment is intensive nutritional support by feeding high protein, calorie dense food via feeding tubes (Nelson & Couto,1992 and Cornelius et al, 2000) except in cats that are already displaying severe hepatic encephalopathy in which protein restriction may be required (Mansfield, 2004). The mortality rate is estimated to be between 10 to 40 per cent in treated cats and up to 90 per cent if cats are untreated (Center, 2004).
The author of this article believed the TCM herbal formula, Wei Ling Tang (Calm the Stomach and Poria Decoction), has successfully stopped the progression of HL in the patient by actively stimulating the cat’s appetite and supported hepatocellular function and regeneration with its rich anti-hepatotoxic and anti-oxidative properties of the herbs within the formula.
Although hepatic lipidosis is the most common type of liver disease of North American cats (Nelson and Couto, 1992), it is much less common in Australia (Mansfield, 2004). Even with intensive care, approximately 35% of cats with HL die from the disease. Cats who do recover with conventional treatment generally do so in 3-6 weeks, however, some may need continued nutritional support for months (Cornelius et al., 2000). The pathogenesis of feline HL is not well understood. Obesity and anorexia are the primary risk factors for HL, however they may not be the only factors involved with this disease (Turner et al., 2005), as cats that are neither obese nor stressed occasionally develop HL just like the object of this case study.
The object was diagnosed with idiopathic HL using conventional diagnostic procedures and was subsequently placed on a Chinese herbal formula known as Wei Ling Tang (Calm the Stomach and Poria Decoction) which supports digestive functions and improves appetite. The cat, which had been completely anorexic, responded within three days and started eating again. After eight weeks of treatment, laboratory blood testing had revealed complete resolution of her hepatobiliary disease with all her hepatic enzymes activities within normal limits.
The successful treatment of this cat was an encouraging result given the fact that the object did not require further hospitalisation and had avoided invasive technique like nasopharyngeal tube or percutaneous gastrotomy tube placement for treatment. Perhaps her prognosis would be different if she was not hospitalised initially with supportive intravenous fluid therapy which may have delayed progression of the disease to hepatic encephalopathy due to progressive hepatocellular dysfunction. Nevertheless the Chinese herbal formula Wei Ling Tang (Calm the Stomach and Poria Decoction) has proved to be a valuable treatment for feline hepatic lipidosis considering the high mortality rate if cats are not treated with conventional method aggressively.
Anthony graduated from the University of Sydney in 1997. As well as being a small animal veterinary surgeon, he is a certified veterinary acupuncturist and has been trained in veterinary herbal medicines. Anthony is currently running a mobile vet service in Sydney and also works at All Natural Vet Care, Russell Lea.
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