Fatty liver and poorly controlled NIDDM

Chief Complaint: fatty liver and poorly controlled NIDDM

Western diagnosis: as above

Medical History: 55 yr old caucasion male. Morbidly obese.
First appointment on March 2004 pt's labs reflect triglyceride level of 1105, cholesterol of 230 and elevated AST (50's) and ALT (80's). Pt's record of blood sugars indicate his blood sugars were consistently in the high 230's. Pt was not (and is not) on any western medications. Even though pt had dangerously elevated triglycerides and blood sugars he consistently refused western medications. His MD finally referred him to acupuncture in the hopes that something could be done to stabilize the patient.

Patient does not drive and does not cook. He reports excessive appetite He either buys perpared meals at the deli counter of grocery store or goes out to eat. His only exercise was walking to the public bus.

Questioning exam: Chronic right flank pain. Chronic pain over kidneys. Wakes frequently and frequent night sweats. Short of breath with dry cough. Chronic fatigue. Verbalizes anger/frustration as well as fear of death (realistic considering his elevated labs).

Pulse exam: Pulses thin, tight and slightly rapid. Left sided chi pulse consistently the thinnest and weakest. Left sided guan pulse consistently the most prominent, however, often right sided cun pulse quite prominent too.
Abdmoninal diagonosis: exquisite tenderness in areas of Liv 13 and Liv 14, dull ache in area of GB25.

Tongue exam: Tongue body red. Anterior 2/3 peeled. Posterior 1/3 with dryish slightly yellow coat. Vertical cracks on the anterior 1/3 of tongue, bilateral (that is on both the left and right side of the tongue in the lung region). Tongue body shape normal (tongue is not swollen, scalloped or long). Slight quiver to tongue.

OM Diagnosis: Constitutional lung deficiency (vertical cracks lung area)

Stomach and lung yin xu (and by association kidney yin xu, though yin xu of kidney likely result of long-term lung yin xu) as evidenced by the red and peeled anterior 2/3 of tongue, the dry cough, night sweats, frequent hunger, slightly rapid pulse.

Liver qi stagnation as evidenced by reports of anger/frustation, fatigue, right flank pain, tenderness at Liv. 13 and 14, tight pulses, most prominent in left guan position, and abnormal liver enzymes. Some element of damp in lower jiao as evidenced by yellowish coat posterior 1/3 of tongue and high cholesterol and triglycerides.

Treatment Principle: Nourish yin, especially of lung and stomach, course liver qi, and drain damp accumulation in lower jiao. The damp accumulation in lower jiao is thought to be primarily a consequence of the depressive heat caused by the combination of the liver qi stagnation and the lung and stomach yin deficiency, so the treatment plan did not emphasize draining damp as once yin xu and liver qi stagnation is addressed it is likely the damp heat will more easily resolve.

Point Prescription: Patient seen weeklyfor first 3 months and then twice per month there after. Alternate between back and front treatments and add or subtract points depending upon specific complaints, but core point used are: Liv 13 &/or 14, Liv 3, LI4, LI11, GB34, Sp 9, Sp 6, CV 17, Cv12, Lu7, K6, K3, ST 40, Huatou at level of T17, T18, T19, Bl23, Du 4, Ren 4, Ren 5 (again, not all these points are used all the time, but they are the core points, some of which are used in each treatment depending upon patient's complaints and tongue and pulse signs). Used during every treatment are the following ear points: liver region, right ear; pancreas region right and left ears alternately; spleen region, depression region, anger region.

Herbal Formula: Initially started on combinaton of Six Flavored Tea and Free and Easy plus, 1/2 cup three times day. Pt remained on this formula for approximately 4 weeks and was then switched to the Pacific Biologics "Diabet" capsules, three capsules, three times per day and Health Concerns "Ecliptex", 1 pill 3 times per day. During periods of increased right flank pain pt is instructed to stop the Ecliptex and to take either 8 teapills (Plum Flower Brand) Shu Gan Wan 3 times per day or 8 teapills Free and Easy Plus 3 times per day (whether he takes the Shu Gan or the Free and Easy is determined by the severity of the flank pain). He takes these formulas until pain resolved and then goes back on the base formula of the Ecliptx and Diabet(for those not familiar with Diabet it is a modification for Jade Fluid decoction, with other herbs added for their emperical usefulness in treating yin xu type diabetes.

Lifestyle prescription: Pt put on a diet and exercise plan. Given the fact that pt historically did not exercise it was important to not give him unrealistic goals. Pt was simply instructed to walk for at least 20 minutes per day, at a brisk pace, 3-5 times per week, two hours after eating, eventually working up to walking 40 minutes per day, 3-5 times per week.
He was given rather detailed dietary instructions: Limit caloric intake to 1800 calories per day. Eat 5-6 small meals throughout the day. 10% of diet from protein, 50-60% of diet from complex carb's (pt provided with written info on what constitues complex carb's), 30% from "good fats" and to entirely avoid trans fats found in most prepared foods. He was advised to spread carbs out evenly throughout the day and of the importance of food combining of carbs and protein at each meal, and advised of food groups that slow the rate at which carbs are converted to sugar.
He was instructed on how to perform simple breathing exercises and advised to practice these techniques daily.

Results: After 2 months of treatment his daily blood sugars checked twice each day (fasting and 2 hours after evening meal) remained consistently in the 107-150 range. Pt no longer experienced night sweats and reported better sleep. After three months of treatment pt's lab results indicated that his ALT and AST had completely normalized (pt's MD, in fact, called me stating utter disbelief that in such a short period of time pt would exhibit normal liver enzymes...), pt trigylcerides dropped to the 300's, still considered high, but not as high as when he started treatment, and his cholesterol was 213. At this point we decided to add krill oil to his herb mix to enhance the effect on lowering his triglyerides. The most recent lab work done in October indicates that pt continues to have excellent control of his blood sugars as his GHb was 6.6. Unlike the daily blood sugars which just give you indication of blood sugar control at that point in time, the GHb gives an historical picture of how well blood sugars are controlled over time. However, pt's trigycerides shot back up to the 500's and his cholestoral held steady at 213.

Synopsis: Pt continues to have bouts of right flank discomfort and his fatty liver disease seems quite stubborn to treatment, indiacting that perhaps more emphasis now needs to be placed on lower jiao damp heat and coursing liver qi. I am in the process of re-evaluating his base herbal regimen. Overall pt's affect is much brighter, he is less angry and generally more optimistic about his future. He no longer has night sweats, sleeps better, and has more energy. His diabetes remains well controlled, but we still have to find some way to impact his dangerously elevated liver enzymes. Thankfully pt is very dedicated to his treatment goals and disciplined about taking his herbs and following his diet.