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Integrative approach to diarrhea in the equine

Diarrhea is common in horses, and can be stubborn to treat. Alternative therapies offer a safe and effective way to resolve the problem.

The horse’s digestive tract is very complex, sensitive to its environment, and prone to complications. It is also abused with an overabundance of antibiotics, non-steroidal anti-inflammatories, de-wormers and many other drugs. Additionally, horses are often under stress, either for performance or in the way they are housed and handled. One of the common signs of an imbalanced digestive tract is diarrhea. An integrative approach to treatment is the most effective way to manage most cases.

Diarrhea symptoms

A horse’s manure can vary significantly though the year, depending on the main roughage source. Hay-fed horses can have very dry fecal balls, while fresh spring grass-fed horses almost always have loose wet stool. Alfalfa hay-fed horses may have naturally loose manure. If you are unsure about the effects of the feed on a patient, check the other horses on the same roughage regime. From a holistic perspective, it is important to ask and observe the details of the stool condition -- odor, frequency and consistency. Ask about signs of discomfort before, during and after the stool passes. This could be seen as restlessness, moving around quickly as the stool ends, circling the stall before defecating, or making grimacing faces during the passing. It is helpful to observe the color and moisture of the tongue and gums. TCVM practitioners are trained to incorporate that information, but all practitioners can benefit from this information. As treatment progresses, how does the tongue color and moisture change? Clients can be taught to observe these details and report changes.

Acute diarrhea

Diarrhea diseases in the horse can be life-threatening and are most often treated in hospital settings. The most serious are Salmonella, Clostridium difficile and Potomac Horse Fever. Coronavirus is being recognized as not just an opportunist, but an actual pathogenic cause of diarrhea. Parts of the country with sandy soil also see diarrhea associated with sand ingestion and accumulation. Antibiotics have been shown to be one of the most important causes of serious colitis in horses.1

Chronic diarrhea

The symptoms of chronic diarrhea in horses range from watery fluid passing with formed feces to projectile diarrhea. The majority of cases seen by integrative practitioners are chronic and non-life threatening, with some being very long-standing and unresponsive to conventional treatment. Ulcers are commonly associated with loose stool in some horses. These are usually hind-gut ulcers, but can occur anywhere in the digestive tract. Testing with the Succeed Fecal Blood Test is a non-invasive, low-stress method to determine if ulcers could be the cause. Endoscopy can also be performed. One of the most common complaints is stool that is partially formed, but accompanied by a significant amount of acrid, brown watery fluid that can build up in the tail and is difficult to remove in the winter. This is most common in the cooler seasons of the year. Some horses seem to be triggered by eating hay, and are non-symptomatic on grass. Older horses, especially those in their 20s and above, may have poorly-formed stool or the above symptoms of partially formed combined with watery fluid. These horses may have an aging digestive tract, with a weaker microbiome, or a poorly-functioning enzyme system. Horses fed a wet diet due to a lack of teeth may be getting more water than they can process, with diarrhea as the result.

The horse’s microbiome

The genetic makeup of the microbiota is called the microbiome.2 The microbiota grow on prebiotics, not on the intestinal wall. Populations of microbiota are quite variable between horses, even among those kept on similar feeding programs.3,4 There is a great deal of variation throughout the digestive tract of each horse. Because they reproduce rapidly, microbial populations are susceptible to changes in diet and environment. Research into equine microbial populations using DNA testing is just beginning, as it the understanding of how the balance of microbes relates to health and disease.5,6,7 The normal pH of the intestinal tract changes from acidic in the stomach and upper small intestine, to alkaline in the large intestine. The microbial balance helps keep the pH in the correct range, and and pH keeps the microbes in balance. When microbial populations move to incorrect locations in the gut, the tissue may become inflamed, leading to diarrhea.

An organic garden for your horse

A new idea I have for restoring the natural soil-based microbiome in horses is to plant a corner of the property as a high quality organic garden, using grasses and herbs that horses naturally will eat. Allow ten minutes of grazing per day to provide natural microbe populations that cannot be supplied from a package.

Causes of diarrhea

Many factors can lead to loose stools or diarrhea in horses.
  1. Feeds, feed changes and variations in forage have been shown to change the microbiota significantly.8 Some horses adapt well, while others develop wetter-than-normal manure. Excessive grain affects the microbiota and can lead to changes in stool consistency. Food allergies or intolerances to common feed ingredients, especially alfalfa, can lead to inflammation and diarrhea.
  2. Glyphosate, the herbicide used in genetically modified organism (GMO) feeds has been shown to increase ulceration of the intestinal tracts of pigs.9 Diarrhea was not one of the symptoms in the pigs; however, inflammation of the intestinal tract in the equine can lead to loose stool.
  3. Drugs, especially NSAIDs, can lead to diarrhea in sensitive individuals. Along with antibiotics, these drugs are implicated in inflammatory lesions throughout the digestive tract, and changes in the microbiota.1
  4. Weather changes, especially cold and damp conditions, lead to stool changes. TCVM pays particular attention to weather effects, and clinically this author sees many more cases of diarrhea during such conditions. Large swings in temperature and barometric pressure are also a factor.

General review of TCVM and digestion

A useful way to understand the workings of the gut is to take a Traditional Chinese Veterinary Medicine (TCVM) perspective. The treatment choices do not need to be Chinese. It is beyond the scope of this article to give a complete lesson in Chinese Medicine, but here is a summary.
  • The Stomach (ST) receives and ripens incoming food and drink. The pure or clear part descends to the Spleen (SP) while the turbid part goes to the small intestine. The energy of the ST needs to move in a downward direction to accomplish this.
  • The SP is responsible for generating and containing the Blood and keeping fluids in the proper place. A SP Qi deficiency can allow too much fluid to escape through the digestive tract, leading to diarrhea.
  • The Kidney (KI) Yang provides Fire for digestion and vaporizes the water in the lungs, allowing it to descend and dispersing the fluids in a downward direction (the natural direction of the lungs). The KI Yang also assists the SP Yang in vaporizing the fluids. If the Yang is deficient, the fluids escape downwards.
  • The Liver (LV) governs the smooth movement of Qi through the vessels and organs and also stores the Blood. The SP has a close relationship with the LV. The LV maintains an upward Qi flow and releases bile to help digestion. When the LV Qi stagnates (a common occurrence in the equine) it over-controls the SP and damages it. This can lead to ulcers, and loose stool. The LV is the Chinese organ most affected by stress, hence the prevalence of ulcers in modern horse-keeping.
  • The Large Intestine (LI) reclaims and excretes downward the more solid parts of the food and drink, and reabsorbs water from the waste material.

Products for diagnosing and treating equine diarrhea

Succeed Fecal Blood Test, succeedfbt.com Spore Probiotics, microbiomelabs.com/products/megasporebiotic/ Minerals for bacterial communication -- Restore, restore4life.com Western herbal formula -- Digest Support, hiltonherbsusa.com/us-horse-supplements-es/digestion-supplements-for-horses-es/digest-support-for-optimum-digestive-health Psyllium-based product -- Assure Plus, arenus.com/assure-plus/ Organic enzyme product, abcplus.biz/Organic_Equine_Digestion_Enzyme_Product

Treating equine diarrhea

Acute, severe cases are best treated in a hospital setting with access to intravenous fluids, along with acupuncture, probiotics, fecal transplants and antibiotics if needed. In some cases, the antibiotics are the cause of severe diarrhea and the treatment needs to be done without them. Replenishing the microbiome is perhaps the most important aspect of treatment, since the microbial population has been compromised.

Acupuncture

Acupuncture has been clinically shown to be an effective adjunct to treating acute diarrhea, and is used at several universities with trained clinicians.10 Acupuncture can also be a first-line treatment for many chronic cases, and may be all that is needed. To be effective, an accurate TCVM diagnosis is made and points are selected based on the diagnosis. Several universally useful points include ST 36, BL 20 and 21, SP 6 and 9, LI 10 and GV 1.

Probiotics

The most important GI supplement is a good probiotic formula. Horses in general are treated with antibiotics for every little cut and scrape, not to mention every upper respiratory infection. In many cases, supplementation with a probiotic will be the key to repairing gut function and may be the only extra supplement needed. Any horse showing signs of ill health would do well with at least two months of probiotic treatment. Useful probiotics usually contain some or all of these beneficial bacteria: Lactobacillus acidophilus, L. plantarum, L. casei, Enterococcus faecium, Bifidobacterium thermophilum and B. longum. A Lactobacillus Acidophilus fermentation product can also be used to stimulate bacteria growth. Many probiotics are poorly-made and unstable, so by the time they are purchased and used, they may or may not contain active ingredients. Beware of heavily-preserved formulas and those with artificial flavorings and sweeteners.

Prebiotics

Prebiotics are usually short-chain fructo-oligosaccharides that support the growth of probiotic bacteria. They can be quite beneficial in a formula. The microbiome is often best supported with some of the newer products that include soil organisms, the spores of the microbes or the minerals that form the communication network for the bacteria.

Fecal transplantation

Fecal transplantation has been performed for many years in equine practice.11 Most of the research and clinical papers have focused on severe, acute cases, or antibiotic-induced colitis. As microbiota DNA analysis becomes more available, it will be possible to accurately select healthy donor horses, and potentially commercialize a fecal microbiota for easy administration.

Herbal supplementation

Herbs from many traditions can be used to treat diarrhea. Horses are easy to feed with herbs since they are capable of digesting raw plant material. In many cases, horses will selectively choose the herbs they need and reject those they don’t. Some horses are quite picky and will not eat any form of the herb, but they are usually the exception rather than the rule. A horse that eats herbs well, then refuses them, likely does not need that formula anymore. Dosing is generally two to four times the human dose, whether the herbs are raw or in tincture form. Horses are quite sensitive to the energy of herbs, and in many cases will respond to even lower doses. Herbs can be mixed with palatable feeds or mixed with liquid and syringed into the mouth. Western herbal mixes can contain herbs such as yarrow, mullein, hops, marshmallow, meadowsweet or cinnamon if a warming herb is needed. Formulations prepared with the knowledge of the energetics of herbs are usually more effective than just symptomatically using them. High cannabinoid-containing hemp has anti-inflammatory action in the gut, and early usage in the equine shows promise as an herbal support to the gut. Chinese formulas are selected based on the TCVM diagnosis, which can be SP Qi Deficiency, SP Yang Deficiency, or a formula to clear Heat in an infectious cause of diarrhea.

Additional supplements

Simple nutritional supplements can be very effective depending on the clinical presentation. Psyllium and probiotics can help not only with sand accumulation, but also with soothing and healing the gut wall.12 Enzymes can be useful especially for older horses whose overall body functions are failing, or those that have long-standing absorption problems.

Homeopathy

Homeopathy can be very useful in the treatment of diarrhea. Simple cases can be treated with remedies such Arsenicum Alb, Sulphur, Veratrum Alb and Lycopodium. There are many choices in the Materia Medica, so it is important to use the details of the condition to pick the remedy. For example, Arsenicum Alb works very well with projectile diarrhea in Potomac Fever, or in horses that are restless and thirstless, while Sulphur works with cases that have extremely offensive-smelling diarrhea, that may or may not be profuse.

Chiropractic

Chiropractic is not often thought of as a treatment for diarrhea, but itshould be considered in chronic situations. A horse that is not responding well to other treatment, should be checked to ensure his spine has normal motion throughout, especially in areas from the sixth thoracic vertebra and down, where various spinal nerve roots affect the digestive tract.

Conclusion

Diarrhea in the equine is a common, and at times, challenging condition. Daily assaults on the digestive tract through extensive use of drugs, poor feeding regimes and stress affects the microbiome in a negative manner. Natural approaches to treatment are more cost-effective, successful and healthier for the horse than the typical drug regimen. Many horses need ongoing support, since the conditions surrounding the diarrhea are often unavoidable, and a natural approach offers safe and effective therapies. ________________________________________________________ 1Gustafsson, Agneta. “Antibiotic associated diarrhea in horses”. Acta Universitatis agriculturae Sueciae. Veterinaria, 1401-6257; 166 (2004). 2Costa MC, Weese JS. “The equine intestinal microbiome”. Animal Health Research Reviews 13(1); 121–128. 3Al Jassim RAM, Andrews FM (2009). “The bacterial community of the horse gastrointestinal tract and its relation to fermentative acidosis, laminitis, colic, and stomach ulcers”. Veterinary Clinics of North America: Equine Practice 25: 199–215. 4Perkins et al. “Equine Stomachs Harbor an Abundant and Diverse Mucosal Microbiota”. ncbi.nlm.nih.gov/pmc/articles/PMC3318809/. 5Ericsson AC et al. “A Microbiological Map of the Healthy Equine Gastrointestinal Tract”. journals.plos.org/plosone/article?id=10.1371/journal.pone.0166523. 6Venable EB. “Role of the gut microbiota in equine health and disease”. animalsciencepublications.org/publications/af/articles/6/3/43. 7Proudman CJ et al. “Characterization of the faecal metabolome and microbiome of Thoroughbred racehorses”. Equine Vet J. 2015 Sep;47(5):580-6. Epub 2014 Sep 29. ncbi.nlm.nih.gov/pubmed/25041526. 8Respondek F, Goachet AG, Julliand V. (2008) “Effects of dietary short-chain fructooligosaccharides on the intestinal microflora of horses subjected to a sudden change in diet”. J Anim Sci 86, 316–323. 9Carman JA et al. “A long-term toxicology study on pigs fed a combined genetically modified (GM) soy and GM maize diet”. Journal of Organic Systems, 8(1), 2013. 10Xie H. 2010. “Treatment of Diarrhea in hospital settings”. Personal communication. 11Mullen KR, Yasuda K, Divers TJ, Weese JS. (2016). “Equine faecal microbiota transplant: Current knowledge, proposed guidelines and future directions”. Equine Vet Educ. doi:10.1111/eve.12559. 12Sahagun AM, Vaquera J, Garcia JJ, Calle AP, Diez M, Fernandez N, Loro JF, Portilla HO, Sierra M. “Study of the protective effect on intestinal mucosa of the hydrosoluble fiber Plantago ovata husk”. BMC Complement Altern Med. 2015; 15: 298.   *This article has been peer reviewed.
 
A shared space practice model

It takes time to develop a veterinary practice based on a shared space model, but it has many benefits, including a decrease in overhead and an increase in offered services.

Most veterinary practices have owners and associates. New services can only be offered if someone at the practice learns them, or patients are referred out. If clients are looking for services that the existing staff cannot offer, a shared space practice model can help solve the problem. For many years, I ran the Holistic Medicine “department” at a large specialty hospital in the Northern Virginia area. While the public saw the facility as one practice with one name, the group was actually a collection of separate practices working out of a shared space. The proximity to other service providers can offer a variety of treatment options to clients, and also lets them know about your own services for future use. [caption id="attachment_3860" align="alignright" width="300"] Dr. Kocen treating a dog with acupuncture. Rooms are designed to be comfortable for the animals so they are easier to treat.[/caption] At the specialty hospital, our practice offered acupuncture, homeopathy and Chinese herbal medicine. There was another practice offering rehab, but if I thought patients would benefit from therapeutic massage or chiropractic, for example, I had to refer them to someone outside the practice. This wasn’t a problem, but I didn’t know the hours, fees or areas of service of these mostly house-call practitioners. And I frequently ran out of their cards to give to clients.

Reaching out to other practitioners

While the arrangement I had was working, the limitation to offering additional services prompted me to think about opening my own practice. I wasn’t in a positon to hire practitioners to provide other services. So I thought about developing my own holistic practice based on the shared space model. I called some of the practitioners I was already referring clients to, and asked if they would interested in using my proposed new facility a day or two per week. Several of these practitioners worked with horses as well as small animals, so they were based away from areas of denser population; this reduced their ability to work with small animals, required lots of driving, and limited the number of clients they could see in a day. The advantage of sharing a space meant they would be able to use an existing small animal facility without having to build and maintain one themselves, or pay full time rent for a space they would use only part time. I explained that a shared space facility would also increase exposure to their services among clients coming in to see someone else. Those clients might consider using their services or inform friends that these services were available. In turn, those referrals would be exposed to our other services. The advantage to the practice owner is that fees from the associates help defray expenses. In our case, the expenses were to be used to build out and maintain a clinic. We would all benefit from the clients of other practitioners seeing the services we offer, and they referrals they would send. As you may imagine, the prospective associates had many questions: they wanted to know what limitations there might be on the services they could offer, what services they could get for their fees, what access they could have when we weren’t there, and how much it would cost.

Protocols in a shared space practice

Coming from the world of the “referral hospital”, I was used to clients having diagnostics done before they arrived for initial consultations. I also recommended that they have their regular vet do any follow-up diagnostics. We also did not do annual exams, nor dispensed conventional medications. Since clients returned to their “regular vets” for these services, it let the conventional veterinarians follow the progression of holistically-treated cases and see the pets getting better. Since I was not competing with them for the services they offer, they were more likely to refer cases to me. [caption id="attachment_3858" align="alignleft" width="300"] In a shared office space, rooms can be chosen that are appropriate for the modality. This room is often used for chiropractic (Dr. Bierly) and physical therapy.[/caption] In our current shared space practice, practitioners are allowed to offer any treatment options they think the patient needs, apart from conventional therapies. They may do diagnostics but we are not staffed to provide conventional medicine assistance. The two associates who offer chiropractic are also certified in acupuncture, so even though my own practice already offers acupuncture, the associates are not limited to offering just the therapy they list as their primary therapy. It is also understood that no one has an exclusive right to any therapy. We have two chiropractors and two massage therapists, but they come in on different days. We have another practitioner who offers acupuncture and Chinese Herbal Medicine, as does my practice. She has a strong interest in cancer treatment so we are happy to refer cases to her. I don’t see any of this as competition, but as providing a wider array of services. Ultimately, it would be great to have all therapies available every day. Each associate makes his/her own appointments and takes his/her own fees. We list all the practitioners on our website, with links to their own websites, so clients can learn more about them and what services they offer. We all try to mention the other practices in our space whenever we are at promotional events, so that everyone benefits.

Building a group takes time

Over time, I have found that each associate views the arrangement differently. Some have complained about slow growth of their clientele. For each individual practice to grow, however, the practitioners should ideally reach out to the public, to human practitioners in their fields, and to the general veterinary community. It is unrealistic to think that increased clients will come entirely from internal referrals. Not working to grow an individual practice can have a negative impact on the other practices in the shared space. Therefore, even though each practice is separate, there should be an understanding that supporting the facility as a whole will help everyone. We have had a few practitioners start and leave, but most have stayed. A few I spoke to decided that what we had was not for them. In time, however, I think the “right” group of people will find us, and help us develop this practice to reach its full potential.
 
Building good behavior in your patients – strategies for stocking your pharmacy
Most animals are relinquished to shelters because of behavioral issues. Many clients simply tolerate unwanted behaviors in their pets, while you and your staff are often stressed by poor patient behavior in the clinic. And it doesn’t stop there. Studies have documented the impact of emotional and mental health in animals on physical ailments. Addressing these issues can provide a major income source for your practice, and also increase client retention. The key is to create a receptionist-technician-veterinarian team to identify problem animals, treat them, then follow up on a regular basis. Starting conversations with clients when they first acquire young animals or adopt older ones is mandatory if your goal is to maximize patient health in your practice. You probably already suggest basic training classes, or perhaps offer them at your clinic. You also suggest treatments for animals with specific behavior problems or refer them to specialists. Three approaches can improve your success in this area:
  1. Therapeutic product sales
  2. Classes and associated services – Reiki, Tellington T-Touch, massage, basic training, “handle me”
  3. Treatment with holistic modalities.

1. Therapeutic products that help with emotional and behavioral issues

Create a sales strategy based on the behavior problems you see in your clinic. Start with “Build Good Behavior”, then move to treatment of specific behavior problems. I’ll cover a few common conditions and some products that would help. Companies will be mentioned below, and you will discover more as you read and learn about different modalities. Articles in IVC journal, Animal Wellness, Equine Wellness and JAHVMA, along with speakers at the annual AHVMA conference address in more detail the different modalities for treating training and behavior issues. Begin by looking at the companies you already order from. They may have behavior products you have not considered. For example, you may be using VeteriScience’s Glycoflex, but have never ordered Composure (for calming, barking, help with training). Next, pick one of the following categories and explore the different companies whose products address that approach

Flower essences

I would suggest starting with these since there are never any side effects and the products are labeled for their use (e.g. Scaredy Cat, Training, Anxiety, Aggression, etc.).Flower essences: There are many companies that offer flower essences, including Bach, Living Tree Orchid Essences, Perelandra and the Flower Essence Society (for training). If you’re looking for essences labeled for specific animal problems you can check out Jackson Galaxy Essences, Green Hope Essences, Anaflora (the formulator is also an animal intuitive), Pet Essences and Alaskan Essences.

Essential oils

These are excellent for emotional problems and can facilitate learning as well. Good quality is essential, even within reputable companies. Some study is needed to learn how to select oils, how to use them with cats, and their multiple uses for physical and behavioral issues. You can find out more from the Veterinary Medical Aromatherapy Association, Dr. Melissa Shelton (animalEO) and Doterra. Oils can be administered multiple ways, including orally, on collars or crates, or through petting and diffusion. One good source of these support products is Blue Sky Textiles. Mellow Dog Essential Oil Spray and Blend by LifeFORCE Pet Health are formulated to soothe dogs in times of stress. Its counterpart, Mellow Cat, has been safely tested on felines.

Cannabis

It’s proving to offer amazing results for anxiety and stress problems, along with its many physical benefits. Check out books and products by Dr. Robert Silver at Well Pet Dispensary, or look into Therabis’ Calm and Quiet, or oils from the Medicinal Cannabis Dispensary.

Western herbs

They can be used in two main ways: individual herbs chosen from your studies, and combinations labeled for specific behavior problems. Again, quality is critical. Are the herbs raised organically and sustainably? If wild-crafted (harvested from the wild), is it being done in a sustainable way? Many courses are available, on-ine and onsite, from the Veterinary Botanical Medical Association (VBMA), the College of Veterinary Botanical Medicine and the College of Integrative Veterinary Therapies. When purchasing herbal combinations, be sure ask about sourcing. Greg Tilford of Animals’ Apawthecary is a leader in the herbal field for animals, and his combination herbal products are labeled for specific conditions; he has also authored an excellent book, Herbs for Pets. Herbalist & Alchemist has high quality single herbs and has been a regular vendor for decades at the AHVMA conferences. Other companies to check out include Veterinary Botanicals and Pet Wellness Blends.

Nutritional supplements

These are often needed, especially when pets are on a commercial diet. Again, quality is critical, as is palatability. Herbs or oils are often included in nutritional supplements. VetzLife, Rx Vitamins (products include vitamins and herbs, including hemp), Nutramax, Vet Classics and VetriScience are some examples of quality supplement companies.

2. Building basic good behavior with training and education

Our clients and staff often struggle because many dogs and cats are fearful or aggressive in the clinic, or will not let their feet, ears, mouth, belly, etc. be examined or treated, often even at home. They may have trouble riding in the car to and from the clinic (or anywhere else). Addressing this during every visit with every client – whether it’s a new puppy/kitten, a new adult, or a current patient -- until you have a super well-behaved animal, is well worth it. Step one: Have a staff member in charge of a program to train clients in helping their animals actually enjoy being handled by anyone, including themselves.  This includes handling for nail trims and dental checks. This program could include selling products to calm pets, increase trainability and break bad behaviors. Step two: Set up a system to identify each client who has not yet been through the program, and to follow up on progress. This is best done by the receptionist, who can also recognize training issues in the waiting room. Include a check box on the client’s file, or a tag in the digital records, so reminders can be easily sent. Step three: Encourage this training at every wellness exam, in blog posts, with annual exam cards, or on social media. It can be offered as a free clinic benefit, or charged for minimally, as it will make your job easier and increase client retention. This would be a job for all members of your team. The receptionist may have photos and testimonials in the office (on a bulletin board or in a scrapbook) and add them to the website as well. Classes and products
  • Offer classes in Reiki, animal communication, Tellington T Touch, massage and basic behavior training.
  • Have staff make videos of the classes or stage ones that demonstrate how to trim nails, take an animal’s temperature, brush teeth, clean the ears, hot pack and express the anal glands, examine the lymph nodes and extremities and maybe even take the pulse and palpate the abdomen. These videos can be sold or used as a practice promotion. Include transcripts of the videos for those who learn best from the written word.
  • Choose what therapies and companies you want to work with:
    • Flower essences: Remind people that some animals respond well while others seem unaffected. Flower essences are 100% safe and can be used frequently. You may decide to stock a few essences for basic good behavior that can be sold OTC at the front of the clinic. Since clients can usually buy them cheaper on the internet, you may opt to not carry them and provide websites in your handout. Some companies have affiliate programs so you can still monetize client purchases (usually only 5% to 20%). Administering flower essences one to five times a day for three weeks is a good trial; if those from one company do not seem as effective, try essences from another.
Bach Rescue Remedy (or emergency essences from other companies) can be used as follows -- put four drops in one ounce of water (you could also sell empty dropper bottles) and administer in water (but not the water bowl), in food, per os, or topically (especially for itchy skin and other skin and ear lesions). This can decrease anxiety in any situation, including at veterinary visits. To help pets learn faster, other flower essence combinations and single remedies can be tried by you or your clients. Have them keep good notes, maybe in a journal that you can sell, and schedule consults to evaluate the patient’s changes. Too often, the client focuses merely on the main complaint, so you or your staff can keep them looking at the whole animal in context. Some products to try include Training Formula (Jackson Galaxy Essences), Good Dog, Happy Feet, for nail trimming training and problems (Anaflora), Courage (Anaflora), Anxiety, Neediness (Green Hope Essences), Calm My Focus (Calm My Pet Inc.), Easy Learning (Alaska Essences), Best Behavior (Blackwing Farm)
  • Essential oils can also decrease anxiety and increase learning ability. Until you have studied with, or spoken to, experts in the field, use hydrosols in cats.
Lavender is great to decrease anxiety, while lemon is used to increase cognitive awareness. You can also try Focus (for dog and trainer) from Dr. Shelton, or LifeFORCE’s Good Dog Essential Oil Blend, which promotes mental balance and function.
  • Herbs to try include the Tranquility Blend by Animals’ Apawthecary; it’s useful for training problems caused by anxiety. Also consider Cognitive Function from Pet Wellness Blends.
  • Encourage the best possible diet (fresh ingredients are ideal) with minimal chemicals, GMOS or glyphosates, and consider selling general health supplements. Mental and emotional health need a good basic set of amino acids; Steve Brown reminds us that low tryptophan from too much fat in the diet could increase aggression in genetically inclined dogs. (com/can-high-fat-beef-based-raw-diets-lead-to-behavioral-issues-and-aggression-in-some-dogs/?hilite=%22steve%22%2C%22brown%22). There are many wonderful sources to boost the nutrition of a fresh food diet, including:
    • Herbal Multivitamin: Animal Essentials -- Green Alternative
    • Blue Green Algae – The Edge Up
    • Mushrooms – Mushroom Wisdom
    • CAS Options – Vet Classics: mushrooms and more
    • Kelp: Thorvin
    • Daily defense powder for cats and dogs: Glacier Peak Holistics

3. Treating Behavioral Problems

Some animals present for behavior problems so severe that there is no time for the above training approach. You need to have products on hand to temporarily address these issues while more individualized treatments are begun (homeopathy, TCVM, osteopathy, chiropractic, client training, referral to a behavioral specialist, etc.). Quantify each symptom along with the trigger and duration. Your intake needs to probe. The patient may present as aggressive, yet your questioning reveals timidity, fear biting, protective growling but no real anger. You would make different choices based on your assessment. One joy of prescribing the following is that they offer broad emotional support, so they don’t have to be as precise as the more curative modalities. Have clients keep a daily record of changes in all symptoms, not merely those that are of concern. Selling a journal or giving one to new clients can encourage record-keeping. Aggression -- can have many triggers, including reactions to rabies vaccination. Regardless of the cause, any of the following can be helpful for fear or aggression.
  • Flower essences
    • Bully, Scaredy Cat, Safe Space, Self-Esteem, Grouch, Nervous Nelly -- Jackson Galaxy Essences
    • Anxiety, Jealousy, Outburst -- Green Hope Essences
    • Aggression, Buddha Nature, Courage, Calm Kitty -- Anaflora
    • Out of Control, Anxiety and Fear, Calming Solution, Emotional Stability -- Pet Essences
    • Calm My Dog, Calm My Cat -- Dr. Pam Fisher’s Calm My Pet
    • Fruits of Courage -- Living Tree Orchid Essences
    • Drama Trauma, Confidence -- Blackwing Farms
  • Essential oils, single or in combination:
    • Calm-a-mile – Dr. Melissa Shelton
    • Chill-Out – Silk Road Oils
  • Herbs
    • Hemp, Tranquility Blend -- Animal Essentials
    • Pet Calming – Pet Wellness Blends
    • Calm and Quiet (hemp with nutritional additions) – Therabis
  • Nutritional supplements can be offered singly, or in combinations:
    • NutriCalm, NutriCalm for dogs, Rx B12 – Rx Vitamins
    • Soliquin (a combination many trainers find useful for helping anxious dogs and cats) -- Nutramax
    • @Eaze calming gel (herbs, oil and nutrients) -- VetzLife
  • Sound therapy can also help.
    • Sound and Beginning -- Silk Road Oils
    • Calm my Pet CD -- Calm My Pet
Separation anxiety – many of the above products will work, but also try:
  • Flower essences
    • Separation Anxiety -- Jackson Galaxy
    • Drama Trauma, Home Alone! -- Blackwing Farms
    • Loneliness/Home Alone -- Pet Essences
  • Music, EMF protection, hydrosols, and flower essences are also effective for separation anxiety.
Becoming certified in a deep healing modality will help you resolve most behavioral problems. While you are studying homeopathy, TCVM, chiropractic, botanical medicine or osteopathy, the gentle therapies highlighted in this article can help your patients much more safely than most drugs. They are also a great addition to conventional practices whose clients may be asking for alternatives to drug treatments for behavior problems.
 
Probiotics, the missing nutrients -- Part 1

A balanced intestinal microbiome is crucial to good health in dogs and cats, as well as in humans. Probiotics can play an important role in maintaining this balance.

Maintaining a healthy and balanced intestinal microbiome in our patients (and in ourselves) is becoming increasingly difficult. This can lead to a multitude of health issues, in which probiotics can be of significant assistance. In the first of this two-part article, we’ll look at the discovery of probiotics (see sidebar on page xx) and how they can alleviate microbial imbalance in the gut and support the integrity of the intestinal lining.

The microbiome

“The intestinal microbiota is the collection of the living microorganisms (bacteria, fungi, protozoa, and viruses) inhabiting the gastrointestinal tract.”1 The term “microbiome” includes the organisms, their interactions and their environment. Microbiomes are extremely unique between even closely-related individuals. Each gut hosts thousands of bacterial species and strains. There are between 100 and 150 times more bacterial genes than human genes in our bodies. And there is an intricate interaction between the host and both the intestinal bacteria and their genes. About 500 cultivable species of bacteria exist in the gut. An additional 1,000 species have been identified by modern molecular techniques (specifically ribosomal RNA sequencing, known as metagenomics). “This microbial community…varies quantitatively and qualitatively along with the different environments from the stomach, small and large intestines…. This complex community is metabolically active and contributes to homeostasis.”2 A functional microbiome breaks down foods to liberate more nutrients, manufactures several vitamins, inhibits disease-causing bacteria, and nourishes the enterocytes by producing the short-chain fatty acids used for fuel. Thus, the intestinal microflora maintains the integrity of the intestinal lining that protects the entire body from the inflammation associated with leaky gut syndrome.3 Furthermore, the microbiome acts as a detoxification organ; an imbalance in the bacteria can stress the liver. Gut bacteria influence the systemic immune system. They also affect brain chemistry and structure. Animals have co-evolved with their microbiomes, and so they have developed a symbiotic relationship with them.4 In fact, some researchers assert that the microbiome should be considered an organ of the body5 – an organ as vital as the kidneys or liver. At a phylogenetic level, the gastrointestinal microbiomes of humans, dogs and mice are similar.6 This indicates that microbiome research from one of these species applies to the others. In dogs and cats, more than ten bacterial phyla have been identified, with Firmicutes, Bacteroidetes, Proteobacteria, Fusobacteria and Actinobacteria constituting more than 99% of all gut microbiota.7 Some of the gut bacteria that are beneficial for people are also helpful for dogs. In one study, Lactobacilli were isolated from the jejunal chyme of five fistulated beagles. They found that Lactobacillus acidophilus was dominant.8 According to recent research, “The symbiotic relationship that exists between GI microbes and the host is critical for proper function of nutritional, developmental, immunological, and physiologic processes in animals, and thus contributes to host health… Decreased GI pH also results in decreased solubility of bile acids, thus decreased reabsorption and enterohepatic circulation of bile acids, increased absorption of minerals, and reduced absorption of ammonia.”9

The discovery of probiotics

The story of probiotics begins with Elie Metchnikoff (1845-1916). This Russian-born biologist was the first to understand the importance of white blood cells for immunity, which earned him the Nobel Prize in medicine in 1908. In fact, Metchnikoff is considered the “Father of Natural Immunity”. He noticed that Bulgarian peasant farmers were healthier, more robust, and lived longer than their city-dwelling countrymen. He insightfully realized their consumption of fermented foods, more specifically the bacteria those foods contained, was responsible for the farmers’ good health. Metchnikoff coined the word “probiotics” (literally “for life”) for the beneficial bacteria in fermented foods. He reasoned that for health, the intestines must harbor more “good” than “bad” bacteria. He said that “Death begins in the colon.” This statement echoes that of Hippocrates who said: “All disease begins in the gut.” The fermentation of food dates back 6,000 years when the Chinese began fermenting cabbage. A critical component of food safety, fermentation has been embraced by almost every culture around the globe. From Korean kimchi and Indian chutney to African garri and European pickled vegetables, to Hawaiian poi and the ubiquitous yogurt and sauerkraut, fermented foods are utilized worldwide. In some countries, the fermentation process involves burying the food, reminiscent of carnivores that bury their uneaten prey. When you think about it, it seems obvious that any other carnivore that wandered past a shallow grave would smell, exhume and consume its contents. So if predators don’t bury their leftovers to hide them, then why do they do it? Perhaps it’s to support fermentation, so the carnivores can benefit from probiotic bacteria. At the very least, it must be acknowledged that our pets’ ancestors of did not eat sterile food. Fermenting food involves creating an environment that promotes the growth of acid-forming bacteria. These microbes convert sugars into organic acids. The low pH that is created inhibits the growth of pathogenic bacteria, and thus keeps the food from spoiling. The formation of acid is also responsible for the ability of probiotics to kill off pathogenic bacteria in the gut. The balance of intestinal microflora has broad effects on an animal’s health, and on ours. There are 100 trillion microbial cells in our bodies. In fact, we consist of ten times more bacterial cells than human cells. So, at the cellular level, we are more bacterial than we are human! The same is no doubt true for pets.

Dysbiosis and leaky gut

The term “dysbiosis” is used to indicate a state of gastrointestinal microbial imbalance or maladaptation. Another common factor of dysbiosis is a serious decrease in microbiota diversity. According to recent research, molecular interactions link the gut microbiota with host energy metabolism, lipid accumulation and immunity. These researchers go on to state: “Altered gut microbial ecosystems have been associated with increased metabolic and immune disorders in animals and humans.”10 Unbalanced gut microbiota is associated with disorders such as obesity, diabetes mellitus, schizophrenia, autistic disorders, anxiety disorders, and major depressive disorders.11 Many GI diseases linked to dysbiosis lead to an increase in intestinal permeability, a condition commonly known as “leaky gut syndrome”. Certain pathogenic bacteria damage tight junctions and produce toxins that then pass into the systemic circulation. According to research, leaky gut may allow the passage of toxins, antigens or bacteria into the portal circulation and may play a pathogenic role in advanced liver cirrhosis and its complications. Furthermore, translocated bacterial antigens can result in a cross-reaction with the self-antigens and the induction of autoimmunity. A growing number of diseases have been shown to involve an increase in intestinal permeability related to changes in tight junction competency.12 In fact, when translocated bacterial antigens affect metabolically-active tissues, it may result in a chronic inflammatory state and impaired metabolic function.13 The solution to this problem is probiotics. Multiple studies show that probiotics decrease intestinal permeability.14,15

Messing with the microbiome

Modern medicine has found many ways to disturb the delicate balance of the microbiome. Obviously, antibiotic therapy of any kind indiscriminately kills the “good” bacteria along with the “bad”.   Other drugs also cause a deleterious change in the gut bacteria – these include NSAIDs, proton-pump inhibitors, antidepressants and laxatives. Researchers have concluded that, “Bacteria in the gastrointestinal tract reflect the combinations of medications that people ingest.”  Just about any pharmaceutical can lead to a state of intestinal dysbiosis.

Health benefits of probiotics

Probiotics are defined as “live microorganisms, which when administered in adequate amounts confer a health benefit on the host.”16 The most commonly-used probiotic bacteria are species belonging to the genera Lactobacillus and Bifidobacterium for humans and Aspergillus, Bacillus, Enterococcus, Lactobacillus and Saccharomyces for animals.17 One key to the efficacy of a probiotic supplement is that it must provide an adequate number of bacteria. For people, the agreed upon range is 5-10 X 109 Colony Forming Units (CFUs), while pets need at least 1 X 108 CFUs. An ideal probiotic should have microbes that originate in the species being treated, and should also be nonpathogenic, resistant to digestion by gastric acid and intestinal enzymes, able to adhere to the intestinal epithelium, and capable of influencing host immune responses.18

Conclusion

In this article, we have reviewed the discovery of probiotics, as well as research documenting the importance to health of a balanced intestinal microbiome. We have seen how modern medical practices can disturb the microbiome, and looked at the role that probiotics play in mitigating dysbiosis and maintaining the integrity of the intestinal lining. In Part 2 of this series (IVC Journal, Summer 2018), we will delve more deeply into the research on probiotics and how they affect the immune system, microbiota-gut-brain axis, and systemic detoxification. We will further explore the influence of probiotics on such diverse conditions as chronic gastrointestinal disease, mood disorders/behavior, obesity, pancreatitis, diabetes mellitus and cancer. The sum of this research will allow the conclusion that probiotics are essential nutrients that are missing from modern conventional diets in both humans and pets. 1Honneffer JB, Minamoto Y, Suchodolski JS. “Microbiota alterations in acute and chronic gastrointestinal inflammation of cats and dogs”. World J Gastroenterol. 2014;20(44):16489-97. 2Ferreira CL, et al. "Terminology concepts of probiotic and prebiotic and their role in human and animal health." Rev Salud Anim. 2011;33(3):137-139. 3Suchodolski JS. “Companion animals symposium: microbes and gastrointestinal health of dogs and cats”. J Anim Sci. 2011;89(5):1520-30. 4Hooda S, Minamoto Y, Suchodolski JS. “Current state of knowledge: the canine gastrointestinal microbiome”. Anim Health Res Rev. 2012:13(1);78–88. 5O'Hara AM, Fergus S. “The gut flora as a forgotten organ”. EMBO reports. 2006;7(7):688-693. 6Swanson KS, et al. “Phylogenetic and gene-centric metagenomics of the canine intestinal microbiome reveals similarities with humans and mice”. ISME J. 2011;5(4):639-649. 7Suchodolski JS. “Companion animals symposium: microbes and gastrointestinal health of dogs and cats”. J Anim Sci. 2011;89(5):1520-30. 8Tang Y, Manninen TJ, Saris PE. “Dominance of Lactobacillus acidophilus in the Facultative Jejunal Lactobacillus Microbiota of Fistulated Beagles”. Appl Environ Microbiol. 2012;78(19):7156–7159. 9Hooda S, Minamoto Y, Suchodolski JS. “Current state of knowledge: the canine gastrointestinal microbiome”. Anim Health Res Rev. 2012:13(1);78–88. 10Boulangé CL, Neves AL, Chilloux J, Nicholson JK, Dumas ME. “Impact of the gut microbiota on inflammation, obesity, and metabolic disease”. Genome Med. 2016 Apr 20;8(1):42. 11Evrensel A, Ceylan ME. “The Gut-Brain Axis: The Missing Link in Depression”. Clin Psychopharmacol Neurosci. 2015;13(3): 239–244. 12Fasano, Alessio. "Leaky gut and autoimmune diseases." Clin Rev Allergy Immunol. 2012;42(1):71-78. 13Brown K, et al. “Diet-induced dysbiosis of the intestinal microbiota and the effects on immunity and disease”. Nutrients. 2012;4(8):1095-1119. 14Rosenfeldt V, et al. “Effect of probiotics on gastrointestinal symptoms and small intestinal permeability in children with atopic dermatitis”. J Pediatr. 2004;145(5):612-616. 15Madsen K, et al. “Probiotic bacteria enhance murine and human intestinal epithelial barrier function”. Gastroenterology. 2001;121(3):580-91. 16Nomoto K. “Prevention of infections by probiotics”. J Biosci Bioeng. 2005;100:583–592. 17Ferreira CL, et al. “Terminology concepts of probiotic and prebiotic and their role in human and animal health”. Rev Salud Anim. 2011;33(3):137-139. 18Dotan I, Rachmilewitz D. “Probiotics in inflammatory bowel disease: possible mechanisms of action”. Curr Opin Gastroenterol. 2005;21:426–430. *This article has been peer reviewed.
 
Strategies for managing pancreatitis in small animals

Herbal medicines and low-fat meat and vegetable diets can prevent pancreatitis in dogs and cats, and can also be used to resolve acute and chronic stages of the disease. 

Pancreatitis is commonly diagnosed and treated in small animal veterinary medicine. However, its causes and pathophysiology remain poorly understood, except to say that it is usually a sterile condition. The acute end of the disease spectrum is associated with high mortality, although there is good potential for complete recovery of organ structure and function if the animal survives. At the other end of the spectrum, chronic pancreatitis in either dogs or cats can cause refractory pain and progressive exocrine and endocrine functional impairment.1 Despite the importance of pancreatitis as a clinical syndrome, almost no trials of diets or drugs exist for its treatment and prevention, except for the critically ill patient. The prescription of low-fat kibble and canned foods, although common, is largely untested. Thus, any attempt to formulate an evidence-based approach to pancreatitis, whether using drugs, diet or natural therapies, must begin with a review of the current understanding of the disease’s pathophysiology. There is confusion in the veterinary literature about the definitions of acute and chronic pancreatitis, and there are very few studies on the pathophysiology of naturally-occurring pancreatitis in dogs and cats. But enough laboratory evidence has accumulated to formulate a likely model of pathogenesis.

Pathophysiology of pancreatitis

Part of the confusion surrounding pancreatitis may stem from the fact that the conditions that incite it vanish once the organ has become inflamed. Nitric oxide (NO) and its impact on micro-circulation appear to play a pivotal role in the pathogenesis of the condition.2,3 The onset of pancreatitis is marked by a lack of NO, whereas the acutely inflamed state is marked by an abundance of NO. Preventing and treating pancreatitis thus require almost opposite approaches. The role of the gut is also being explored as a source of oxidative stress which aggravates existing pancreatic inflammation.

Role of nitric oxide and endothelial dysfunction

There are two types of NO germane to the pathogenesis of pancreatitis:4
  • Inducible nitric oxide – of importance in the progression of pancreatitis
  • Endothelial – of relevance in the initiation of pancreatitis
Inducible NO is found in the pancreas parenchyma, where it regulates normal pancreatic exocrine secretion,5 both by boosting pancreatic microvascular blood flow and by directly regulating enzyme secretion. Normally, its presence is key to a properly functioning pancreas. When pancreatitis is in full swing, however, inducible NO levels are high. The pancreas becomes engorged with blood and edematous, enzymes are disgorged, and the pancreas becomes congested. Meanwhile, the strong free radical activity of NO further heightens inflammation, making NO an important target for future pharmaceuticals in the treatment of acute pancreatitis. The heightened levels of NO and blood flow during pancreatitis are in opposition to the state of reduced micro-circulation and NO levels that trigger pancreatitis to begin with.6 Before acute pancreatitis develops, there is:
  • Impairment of pancreatic micro-circulation in the early phase
  • Reduced blood flow
  • Increased platelet adhesion and clot formation.
These events are caused by a reduction of endothelial NO in the vasculature of the pancreas; this is known as endothelial dysfunction (ED). ED promotes the initiation of inflammation because of its associated:
  • Increased vascular permeability
  • Increased leukocyte-endothelial cell adhesion and leukocyte egress.
Experimental evidence supports the notion that a lack of endothelial NO, causing associated ED, is what triggers pancreatitis. Endothelial NO synthase reduces the severity of the initial phase of experimental acute pancreatitis.4 NO synthase inhibition by pharmaceuticals has been shown to trigger acute pancreatitis.7 In short, then, to support endothelial NO levels is to prevent ED; and to prevent ED is to prevent pancreatic inflammation. To resolve chronic pancreatitis, and to prevent its incidence in the first place, clinicians need to focus on the cause of ED. For the most part, ED in small animals is caused by diet.

Diabetes, insulin resistance, and endothelial dysfunction

Veterinarians are used to thinking of pancreatitis as a cause of diabetes mellitus (DM), through the destruction of beta-islet cells. Diabetes mellitus is also an important precursor to pancreatitis, however, and not just a sequela.8 Diabetes often precedes pancreatitis because it is linked to ED. In Type 1 diabetes, ED is consistently found in advanced stages of the disease. For Type II diabetes, ED may even precede it.9 Both types of diabetes are the by-product of insulin resistance. Insulin resistance alters gene expression for a number of pathways known to culminate in ED, including:
  • Increased secretion of pro-inflammatory cytokines
  • Decreased secretion of adiponectin from adipose tissue
  • Increased circulating levels of free fatty acids
  • Post-prandial hyperglycemia.
At the same time, insulin resistance promotes diabetes. Once diabetes is present, increased intracellular concentrations of glucose metabolites in endothelial cells heighten their dysfunction by:
  • Impairing mitochondria function
  • Increasing oxidative stress
  • Activating protein kinase C, causing a halt in endothelial nitric oxide production.
The upshot of chronic insulin resistance is that:
  • Endothelin levels increase
  • Endothelial NO levels drop
  • Vessels constrict
  • White blood cells adhere to and move across blood vessels into the pancreatic interstitium
  • Platelets adhere to endothelial cells to form clots, aggravating any tendencies to hypoxia.
Subclinical pancreatitis can now begin and the animal is also more prone to severe acute episodes. Insulin resistance and subsequent ED are important targets for intervention in resolving chronic pancreatic inflammation, and preventing future episodes. While several herbal formulas can target these self-same pathways, instituting an appropriate diet will help guarantee lasting success in managing these cases.

Preventing pancreatitis with diet

Typically, veterinarians think to limit only fat intake in the animal’s food, but insulin resistance, obesity and a heightened predisposition to pancreatitis are not caused by high fat intake alone. Processed starch-based canned and kibble diets are arguably the most common cause of insulin resistance in veterinary medicine. Pancreatitis becomes a rare event when these diets are avoided. Commercial canned and kibble diets are rapidly absorbed and frequently carbohydrate-based, provoking a surge in post-prandial glucose that leads to chronically high insulin levels and eventually insulin resistance, with its attendant sequelae, including a systemic tendency to inflammation, including in the pancreas. Insulin resistance does not just result in diabetes mellitus, and can be presumed to be present in all overweight animals. In the author’s experience, a minimally processed (raw or homemade) balanced diet of meat and vegetables is of the most benefit in preventing pancreatitis in carnivores. Pancreatitis seldom occurs in animals fed these diets. Once acute pancreatitis is present, however, the familiar recommendation of nothing-per-os (NPO) applies.

Chinese herbs for pancreatic ailments

Targeting insulin resistance – Damp Heat formulas

Three Seeds Combination (San Ren Tang) Three Seeds Combination has a clinical reputation for reversing insulin resistance and Type II diabetes mellitus, particularly in the feline. Coix markedly increases insulin sensitivity and has been shown to reduce adipose tissue weight, leptin and insulin levels.10 The formula is anti-inflammatory, but also reduces predisposition to ED, thus helping to both resolve chronic pancreatitis and reduce the risk of future episodes. Animals needing this formula often have a wet, swollen and lavender tongue, although it can also be a mild red color. The pulse is usually deep and toned. Four Marvels Combination (Si Miao San) This formula is used to manage acute pancreatitis, whether mild or severe. It increases insulin sensitivity and studies have verified its benefits in pancreatitis through its antioxidant effects.11 The patient that benefits from Si Miao San has a tendency towards acute inflammation, oxidation and associated insulin resistance, usually manifesting as inflammation at multiple epithelial surfaces (especially the ears, skin, colon, biliary tree and bladder). Signs of Cushing’s can also occur. The tendency to acute inflammation is marked by a superficial and toneless pulse. The tongue is often red or purple-red.

Targeting endothelial dysfunction

Minor Bupleurum Minor Bupleurum interferes with the production of cytokines that promote ED.12 It is most helpful in resolving sub-acute to chronic pancreatitis, especially when due to systemic infection or immune dysregulation. These cases will often have inflammation manifesting in other organs, especially the liver and kidneys (as glomerulonephritis), but also including the eyes (glaucoma, uveitis), lungs (pneumonia, pneumonitis), nervous system (disc disease, vestibular disease), and even the skin. Occasionally, the animals have a prior history of cancer. Animals benefiting from Minor Bupleurum almost invariably have deep, toned strong pulses. One or more vagal symptoms are common, including chronic cough, vomiting, bloating and constipation. Glehnia and Rehmannia Glehnia and Rehmannia Combination, known also as Yi Guan Jian, contains two plants, Angelica and Rehmannia, that counter ED to restore normal micro-circulation and actively resolve chronic inflammation in a number of tissues.12 The formula is contraindicated in acute active pancreatitis, since the organ is now severely congested and edematous. It can resolve mild low-grade pancreatitis, and prevent recurrences. Animals that benefit from this formula have reduced circulation to epithelial surfaces, creating dryness, mild gastric inflammation, and irritable bowel syndrome. Animals often display mild to moderate liver enzyme elevations; older animals may have mild to moderate azotemia. Anemia and chronic weight loss may be present, as well as a tendency to timidity or anxiety. The pulse is often thin and the tongue pale, perhaps with a lavender center.

Targeting bacterial causes

Agastache Combination (Huo Xiang Zheng Qi San) Patients often have Damp Heat tendencies, yet do not respond to San Ren Tang and Si Miao San. Huo Xiang Zheng Qi San should be considered next, in case bacteria are inciting the inflammation. Agastache is a strong antimicrobial formula with a broad spectrum of effect against many species of viruses, nematodes, fungi and bacteria.13,14,15 Agastache also interferes with cell adhesion,16 thereby reducing white blood cell ingress into the interstitium, and subsequent inflammation. Consider this formula for chronic pancreatitis in young animals, especially if the disease is, or has been, associated with chronic refractory small bowel diarrhea or suspected small intestinal bacterial overgrowth.

Using herbs — administration via enema

While injectable forms of herbal medicine are not yet available for the NPO patient, quantities of the appropriate formula can be delivered to an acutely ill dog via enema. A patient’s response to an herbal formula delivered by enema is often rapid and dramatic, with enzyme elevations subsiding significantly and the patient stabilizing within a couple of days. Compounds in the formulas are absorbed across the large intestine mucosa into the portal circulation, and from there move rapidly to the systemic circulation, bypassing any gastroparesis. Method
  • Use two to three times the normal dose for the patient (see chart on page xx), and give TID to QID.
  • Suspend each dose in a maximum of 10 ml to 15 ml of warm water.
  • Instill into the transverse colon using a small rubber French feeding tube.
  • Use only granular extracts or crushed tablets, never liquid extracts, for administration via enema.
All the formulas in this article can be obtained in various formats from nphc.ca. Much more detail on veterinary clinical uses of these and other products can be obtained from the College of Integrative Veterinary Therapies, and from the Essential Guide to Chinese Herbal Formulas: Bridging Science and Tradition (S Marsden, 2014, published by CIVT).

Oral dosing

Weight (kg) Weight (lbs) BID dose (mls) BID dose (550 mg tabs) BID dose (tsp granular extracts)
4 10 0.30 1.00 0.25
8 20 0.45 1.50 0.50
12 25 0.60 2.00 0.75
23 50 0.90 3.00 1.00
32 70 1.20 4.00 1.50
/5 150 1.80 6.00 2.00
120 250 2.40 8.00 3.00

Case example: Falco Teefy

Falco is a nine-year-old male neutered Border Collie cross who presented with a chief complaint of pancreatitis. Recent history included removal of an infiltrative lipoma from the caudal thorax, and episodes of a nocturnal hacking cough ending in the vomiting of foamy material. The pancreatitis seemed to gear up over a long period, with nausea, vomiting and pica occurring since the summer of 2016; it did not respond to antacids or anti-emetics. A protocol was eventually settled on, consisting of 0.2 mg/kg prednisone, a round of metronidazole and milk thistle. Two herbal formulas, Yi Guan Jian and San Ren Tang, were also initiated. Falco de-stabilized in October of 2016 when herb use became less consistent. Yi Guan Jian alone was resumed along with metronidazole and continued prednisone use. Although Falco seemed at first to improve again, he had to be hospitalized in November for pancreatitis. Clinical signs at that time included lethargy, fever, diarrhea and abdominal pain. ALP was increased to several times the normal value, and an enlarged liver was seen on ultrasound. A snap test showed a strong positive result for CPL and pancreatitis. Physical examination showed strong-toned mid-depth pulses that responded well to acupuncture of prominent Gall Bladder channel points. In addition to acupuncture, Falco was given anti-emetics, fluid therapy, hydromorphone and the typical low-fat bland processed diet. A derivative of Minor Bupleurum was introduced as the new herbal formula. [caption id="attachment_3848" align="alignleft" width="300"] Response of Falco’s ALP and CPL to Minor Bupleurum[/caption] Falco gradually improved over the next two weeks, but had no appetite for a bland diet, so a low-fat processed kangaroo diet was fed instead. Improvements in laboratory data steadily accrued even as improvements in symptoms were more erratic. Over the long term, prednisone was discontinued, and the combination of Minor Bupleurum and Three Seeds Combination proved sufficient to eradicate all symptoms. This use of herbs continues to date, as does the processed kangaroo diet.

Case discussion

It is common for veterinarians to manage problems in an integrative fashion, using both herbs and drugs together. In Falco’s case, the low doses of prednisone would have favored insulin resistance and ED, but were successfully countered with Yi Guan Jian and San Ren Tang, two formulas for chronic GI inflammation. When first one and then the other of these formulas were discontinued, the negative effects of the prednisone were no longer countered, and the pancreas erupted with inflammation, fueled by a high-fat, albeit raw diet. Minor Bupleurum was the main intervention that arrested symptoms and disease progression in Falco. Its use was indicated by the characteristic pulse, history of cancer, nausea, and the history of a chronic cough that ended in vomiting. Herb use should be continued as long as processed diets are fed, to counter the latter’s tendencies to promote inflammation and ED. The author acknowledges the contributions to this case study of Jana Teefy, AHT, RLAT, and Jennifer Marshall, BSc, DVM, both of Edmonton Holistic Veterinary Clinic.

Conclusion

Pancreatitis can be prevented in carnivores by using herbal medicines and low-fat meat and vegetable diets. Once these therapies are instituted, episodes of pancreatitis consistently cease. Herbal formulas may also be used to resolve acute and chronic stages of the disease, and work along with diet to eliminate the inciting factor of recurrent and chronic pancreatitis -- reduced endothelial nitric oxide. _________________________________________________________________ 1Watson P. “Pancreatitis in dogs and cats: definitions and pathophysiology”. J Small Animal Practice. 2015 Jan; 56(1):3-12. 2Mansfield C. “Acute pancreatitis in dogs: advances in understanding, diagnostics, and treatment”. Top Companion Anim Med. 2012 Aug; 27(3):123-32. 3Mansfield C. “Pathophysiology of acute pancreatitis: potential application from experimental models and human medicine to dogs”. J Vet Intern Med. 2012 Jul-Aug;26(4):875-87. 4DiMagno MJ. “Nitric oxide pathways and evidence-based perturbations in acute pancreatitis”. Pancreatology. 2007;7(5-6):403-8. 5Yago MD, Mañas M, Ember Z, Singh J. “Nitric oxide and the pancreas: morphological base and role in the control of the exocrine pancreatic secretion”. Mol Cell Biochem. 2001 Mar;219(1-2):107-20. 6Sunamura M, Yamauchi J, Shibuya K, Chen HM, Ding L, Takeda K, Kobari M, Matsuno S. “Pancreatic microcirculation in acute pancreatitis”. J Hepatobiliary Pancreat Surg.1998;5(1):62-8. 7Poulson JM, Dewhirst MW, Gaskin AA, Vujaskovic Z, Samulski TV, Prescott DM, Meyer RE, Page RL, Thrall DE. “Acute pancreatitis associated with administration of a nitric oxide synthase inhibitor in tumor-bearing dogs”. In Vivo. 2000 Nov-Dec;14(6):709-14. 8Davison LJ. “Diabetes mellitus and pancreatitis -- cause or effect?” J Small Anim Pract. 2015 Jan;56(1):50-9. 9Rask-Madsen C, King GL. “Mechanisms of Disease: endothelial dysfunction in insulin resistance and diabetes”. Nat Clin Pract Endocrinol Metab. 2007 Jan;3(1):46-56. 10Huang BW, Chiang MT, Yao HT, Chiang W. “The effect of adlay oil on plasma lipids, insulin and leptin in rat”. Phytomedicine. 2005 Jun;12(6-7):433-9. 11Shang SW, Yang JL, Huang F, Liu K, Liu BL. “Modified Si-Miao-San ameliorates pancreatic B cell dysfunction by inhibition of reactive oxygen species-associated inflammation through AMP-kinase activation”. Chin J Nat Med. 2014 May;12(5):351-60. 12Marsden S, Dodds J. “Chinese herbal medicine in autoimmune disease: case reports and speculated mechanisms of action”. JAHVMA, 2015 Winter; 38(31-37). 13Yang JL, Wang JL, Huang F, Liu K, Liu BL. “Modified Si-Miao-San inhibits inflammation and promotes glucose disposal in adipocytes through regulation of AMP-kinase”. Chin J Nat Med. 2014 Dec;12(12):911-9. 14Fan J, Liu K, Zhang Z, Luo T, Xi Z, Song J, Liu B. “Modified Si-Miao-San extract inhibits the release of inflammatory mediators from lipopolysaccharide-stimulated mouse macrophages”. J Ethnopharmacol. 2010 May 4;129(1):5-9. 15Luo TJ, Wang KZ, Zhao WW, Shang SW, Ye LF, Liu K, Liu BL, Huang F, Wang X. “Modified Si-Miao-San regulates adipokine expression and ameliorates insulin resistance by targeting IKKβ/Insulin receptor substrate-1 in mice”. Chin J Integr Med. 2014 Apr 16. 16Zielińska S, Matkowski A. “Phytochemistry and bioactivity of aromatic and medicinal plants from the genus Agastache (Lamiaceae)”. Phytochem Rev. 2014;13:391-416.