Management of Neurological Dysfunction after Portocaval Shunt Surgery by Acupuncture and Herbal Medicine
We have been operated on more than 170 portosystemic shunt (PSS) cases in dogs and cats until 2003. Twenty-three out of 154 canine and 5 out of 14 feline cases experienced postoperative variable degree of neurological dysfunctions after the surgery. This is called postligation neurological syndrome (PLNS). Two cats out of 5 that had neurological signs that developed into blindness. The incidence of PLNS is an uncommon complication in canine cases, however, it is common in cats following portosystemic shunt ligation. Following PSS surgery, the syndrome may develop within 1 to 3 days without biochemical abnormalities. Clinical signs vary from ataxia to generalized motor seizures and status epileptics (Yool and Kirby 2002). Once the seizures have started, it is extremely difficult to manage the seizures. Generally, the seizures management included administration of Diazepam, intravenous Phenobarbital, respiratory support by ventilation, fluids and nutritional support. One study indicated the treatment for seizure with phenobarbitone could not reduce the risk of neurological sequences (Tisdall et al. 2000).
The etiology of the seizures activity has not been determined, however, post surgical critical care management of corrections of hypoglycemia, hyperammonemia, and hypocalcemia were done and cardiopulmonary variables of hypotension and hypoxia had been controlled during surgery. Usually, the patents did well following surgery. After the patients recovered enough from surgery, the patients had feeding. However, after the feeding, some patients started changing mental condition gradually after the meal and showed ataxia. Then, gradually movement and conscious level decreased, muscle tone increased and then the seizures started. We carefully monitor the conscious level and movement after the meal. If any initial clinical signs of ataxia and decreased conscious level were observed, treatment with acupuncture and herbal medicine was started. Since we utilizing alternative treatments, the patients did not develop any seizures even though the patients experienced ataxia. Right after the ataxia started, acupuncture treatment and herbal medicine were applied and ataxia resolved in 6 to 24 hours. Two patients presented mild ataxia 1 month after the surgery however, the acupuncture resolved these symptoms. Treatment with acupuncture and herbal medicine can be used even when the seizures have started. However, the treatments should be started as soon as possible immediately after the initial clinical signs of ataxia are observed.
Acupuncture treatment consisted of a combination of several acupoints. The acupoints were chosen by sensing the energy flow to the head. They included GV 20, GB 20, LI 4 and other sensitive points in the head. GV 20 is a very useful point that eliminate liver fire, liver Yang rising and liver stagnation. GB 20 is also an excellent point that dispels internal wind, clear heat from the rostral part of body and clears the brain. LI 4 is the point that eliminates wind heat and pain from neck and head. GV 20, GB 20 and LI 4 were the important points for treating PLSS, however, sometimes other points on head were indicated. They may relate to Jin and/or spleen.
The herbal medicine of Huang Lian Jie Du Tang, which is Coptis and Scute Combination, was also given orally twice a day. The action of Huang Lian Jie Du Tang is to dispel noxious heat and toxins from all three burners.
The etiology of neurological dysfunction is difficult to explain by the theory of western medicine, however, energy medicine based TCM may be able to explain the etiology of seizer activity. After the ligation of the PSS, blood flow to the liver increase. Blood flow accompanies with Qi energy according to the TCM theory. So the more Qi flows towards the liver and the Liver Qi flows toward upward to the head. After the meal, the food must be processed for proper digestion. However, if Spleen Qi deficiency exsit, the Dampness and Phlegm are formed and accumulate in and obstruct the middle jiao (Wynn). The Spleen Qi must flow downward, however, if the Qi flow is obstructed in the middle jiao, the Qi flows upward carrying Dampness and Phlegm. A significant increased upward Qi flow by increased blood and Qi flow after the PSS correction and obstructed Qi flow at middle jiao resulted in convulsion and an unconscious state. There is some other herbal medicine combination for seizers like Ban Xia Bai Zhu Tian Ma Tang and Long Dan Xie Gan Tang, however, I only try Huang Lian Jie Du Tang and it works well.
The acupuncture treatments to the points eliminate excessive Qi energy flow and Dampness and Phlegm at each acupuncture point. GB 20 and GV 20 can mainly eliminate these Qi and the herbal medicine of Huang Lian Jie Du Tang can eliminate the Qi block at middle jiao. Thus AP eliminates the excessive Qi flow to the head and Qi blockage is eliminated by herbal medicine.
TCM theory is difficult concept to understand, however, AP and herbal treatment after PSS surgery eliminated the fatal out come of the neurological dysfunctions in many cases. Treatment by acupuncture and herbal medicine is recommended for the postoperative PSS surgical management.
1. D.A. Yool and B.M.Kirby. Neurological dysfunctions in three dogs and one cat flowing attenuation of intrahepatic portosystemic shunts. J.Small Anim Pract. 2002 43:171-76
2. P.L.C.Tisdall, G.B. Hunt, K.R. Youmans and R. Malk. Neurological dysfunction in dogs following attenuation of congenital extrahepatic portosystemic shunts. J. Small Anim Pract 2000. 41:539-546
3. S.Wynn and S. Marsden. Manual of natural veterinary medicine. Science and tradition. Mosby.