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Pancreatic insufficiecncy - continued
Pancreatic insufficiency with small intestinal bacterial overgrowth (SIBO)
Pancreatic enzyme insufficiency
Exocrine pancreatic insufficiency or EPI
Pancreatic Insufficiency
Chronic Diarrhea in German Shepherd
also see Diarrhea
also see Digestive Problems
also see Medication
also see Pancreatitis
Pancreatic insufficiency - continued
Question: Dr. Richards-
Since I initially wrote to you all the lab results came back on the
dog and there is no sign of anything wrong with her kidneys. Blood test were
done and I also got a more concentrated urine sample first thing in the
morning.I'm having a hard time remembering what my vet said about the blood
work...something about the kidneys and protein levels. Anyway, he
suggested slowly switching her to a low-protein/fat diet. She still
drinks alot periodically, but hasn't gotten sick or developed any
other symptoms. I took her to a different vet who prescribed
metronidazole, but after a few days her diarrhea got worse so
the vet told me to stop giving it to her. About a week later, my original vet
insisted I give her tetracycline, 500 mg., three times per day.
I thought this was a little extreme, but went ahead and starting giving her
that medication. About this same time I started mixing a low-fat dry food
with her other food in an effort to start switching her over to that. I was also giving her
about a teaspoon of yogurt with her food. She started getting worse
diarrhea again almost immediately. I thought it might be the yogurt, so I
started giving her benebac instead. I also increased the Viokase (per my
vet's instructions) to almost three teaspoons per meal (1 1/2 cups of dry
food am and pm). Last night I called my vet because my dog was having
extremely bad diarrhea about one hour after I gave her 500 mg. of the
tetracycline. (She had been on the tetracycline for five days.) He told me to stop
the antibiotics. Throughout the last week of extremely bad diarrhea her
energy level seems better than ever! She has been charging around our
property, playing with the neighbor's dog, terrorizing the cats and
the horses, playing with her toys in the house.... Tomorrow I am leaving
for Montana for a week. The instructions I will leave my house/horse/dog
sitter are: 1 1/2 cups of dry food, 2 teaspoons of Viokase with water
mixed in and that's it. Currently her dry food is three different
kinds mixed in equal parts: regular lamb and rice, sensitive stomach, and
low-fat. When I get home I plan to switch her to low-fat exclusively.So here's my current question: Why do the antibiotics make her
diarrhea worse? Is the dosage too high? They don't seem to bother her when I
give them to her immediately after she eats. Should I give her just two
doses a day after meals? My original vet wanted to give her tetracycline vs.
metronidazole because it was a "broader spectrum". Do you agree with
this?
Oh, also, I almost forgot. I read on your website to try giving her
tegamet 1/2 hour before she eats. I broke the tablets in half so she
was getting about 100 mg. This seemed to work really well initially, but
two days after I started the tegamet, I started the antibiotics. Should I
continue this when I get back.Thanks, Gail
Answer: Gail-
The break from antibiotics may be very helpful in sorting through the
possible causes and contributing factors for the diarrhea.The recommended starting dosage for Viokase (tm) is 1 to 2 teaspoonfuls
per 20kg of body weight. Adjustments are then made based on what it takes
to control diarrhea. There are dogs who require higher dosages of Viokase
than normal, although I can't quite understand why. The usual dosage is 1 to
2 teaspoonfuls per meal but I have seen case reports of dogs requiring
higher dosages. So increasing the dosage of the Viokase is a reasonable
option.Many dogs with pancreatic insufficiency also have small intestinal
bacterial overgrowth (SIBO). The most commonly recommended antibiotics
for this condition are tylosin (Tylan Rx), metronidazole (Flagyl Rx) and
tetracycline, although there are reports of a number of other
antibiotics helping. Tetracycline is usually dosed at 10 to 25mg/kg of body weight
and given every 8 to 12 hours. At the low end of the spectrum, 500mg will
treat a 100 lbs. dog but most of the time the higher dosages work better.
Metronidazole and tylosin are both usually given at 10 to 20mg/kg every
12 hours. In some patients these antibiotics will either cause other
gastrointestinal problems, such as vomiting, or will make a particular
patient worse. The prevalence of SIBO in association with exocrine
pancreatic insufficiency is very high, though. So it is worth trying
these antibiotics, and trying more than one of them, if necessary, to rule
out this problem.I do think that there is a chance the low fat diet will be helpful and
is also worth trying. It is best to avoid low fat/high fiber combinations,
though. The fiber may interfere with the action of the pancreatic
enzymes. It may be worthwhile to try this prior to starting the antibiotic
therapy again, just so that you can tell which of the things that you are doing
is having a beneficial or detrimental effect, since this is hard to do
when you change more than one thing at a time.Exocrine pancreatic insufficiency is a frustrating problem in some
dogs. It is usually possible to at least make them feel better, even if you
can't control the diarrhea fully. This is a worthwhile goal and it does sound
like you are at least helping your dog feel better.When cimetidine (Tagamet tm) it is worth continuing with it. I am not
sure that it is always beneficial. It is supposed to help most if it is
given about 1/2 hour prior to feeding. In tough cases of EPI, it can also be
helpful to add vitamins, especially Vitamin E and cobalamin (B12).
Medium chain tryglyceride oil given at 1 to 2ml/kg/day is supposed to help
some patients and in really resistant cases it may help to use
corticosteroids such as prednisone, but I think this should be a last resort when it
seems like nothing else is going to help.If you keep working at this and keep working with your vet, the odds
are in your favor that you can reach a point where you have good control of
the diarrhea and can find a maintenance program that will allow you to
maintain control.Mike Richards, DVM
9/9/2001
Pancreatic insufficiency with small intestinal bacterial overgrowth (SIBO).
Question: I have a 3-year-old female dog of questionable breeding that has
been diagnosed with "insufficient pancreas". Initially her symptoms were
chronic diarrhea. My vet had trouble diagnosing the problem and was
treating her for parasites and other intestinal problems for about
three weeks before I started her on Viokase. Her energy level was still
good and she was otherwise OK at first. She didn't get lethargic or act sick
until she had gone from 53 pounds to about 46 pounds. With the Viokase,
she improved immediately, but has still had bouts of diarrhea since
April.Recently, I noticed that she is drinking alot (I mean, alot! She
goes to her bowl and drinks until it's empty) so I started thinking that now
she's developing kidney problems. I took her to the vet on Saturday and
he told me that any possible kidney problem is unrelated to the pancreas
problem.In doing some research, I read that "chronic renal failure" is
commonly caused by (among other things) "inflammatory bowel disease,
gastroenteritis, pancreatitis." So, it seems to me that I should
have been doing something to try and prevent kidney problems through diet or
supplements.In addition, although the dog improved with the Viokase treatment, I
have never felt like she has truly gotten better. She never has normal
bowel movements--always somewhat runny and she still has periods where
she'll have a few days of diarrhea. She has started losing weight again
recently, seemingly in conjunction with the possible kidney problem. On
Saturday, my vet tested her urine and her glucose level appeared normal, but her
urine is diluted because she drinks so much. Blood work results are
pending. I am unhappy with the vet (I've spent close to $1500 and my dog hasn't
gotten better and is developing additional problems) so I am going to pick
up her chart today and take her to a different vet.My questions to you are: Is the kidney problem related to the
pancreas problem? Is there anything I can do re: diet or anything else that
would do more than just the Viokase? Is the pancreas problem chronic? If
she starts having kidney problems will this be chronic? Is there
anything at all you can suggest to help? This has been going on for five
months. The dog is only three and she doesn't seem to be in any pain so it's
hard to think about putting her down at this point.Please help. Thanks. Gail
Answer: Gail-
Many dogs who have pancreatic enzyme insufficiency, or exocrine
pancreatic insufficiency (EPI), also have small intestinal bacterial overgrowth
(SIBO). When this happens, it is sometimes necessary to use antibiotic
therapy for several months to try to get the bacterial population back
to normal. The most commonly recommended antibiotics for dogs with
pancreatic insufficiency and SIBO appear to be metronidazole (Flagyl Rx), tylosin
(Tylan Rx) and tetracycline. In addition to this, there are studies
that show that dogs with EPI do better on low fat diets, such as Purina's
EN (tm) diet, Hills w/d (tm) diet or Waltham's Low Fat (tm) diet.
Finally, some dogs with EPI are cobalamin deficient (Vitamin B12) and it may be
necessary to supplement this vitamin before they really start to feel better.Exocrine pancreatic insufficiency is usually a life long problem. It
may be a good idea to try to confirm that it is present, although the
response to treatment is certainly very suggestive.I can not find a strong link between exocrine pancreatic insufficiency
and kidney disease. Pancreatitis does cause acute kidney failure at times,
so this link is important but doesn't really relate to EPI, which is a
separate condition. It is conceivable that inflammatory bowel disease
could lead to kidney problems due to the production of antigen/antibody
complexes but I suspect that it isn't a major problem. It was a good idea to
check for problems like kidney failure and diabetes with the increase in
drinking, though. It is good that you didn't find diabetes. Hopefully,
the lab work did not support kidney disease, either. The decrease in
concentration of the urine is not a specific enough sign to say that
kidney disease is present, especially based on the results of one urine
sample. If blood work also supports the presence of kidney disease then it may be
necessary to consider some form of treatment, such as phophate
binders, fluid therapy or enalapril administration.I don't really think of EPI as being painful. It is expensive to treat
due to the cost of Viokase (tm) and it does have to be managed over the
life of the dog, but most dogs do pretty well, with occasional setbacks that
require more intensive management efforts, such as the use of
antibiotics to combat SIBO.If the lab work did support a diagnosis of kidney failure I would be
happy to try to go into more detail about treatment of that disorder.Mike Richards, DVM
9/4/2001
Exocrine pancreatic insufficiency or EPI and Colitis in German Shepherd
Question: I haven't had a lot of time to cruise your site, that's why I'm glad I get
your newsletters. Today, however, I do!! Laundry can wait. I like to
keep on top of information on EPI and Colitis as I have a dog that has
both!!Why are more vets not suggesting supplementing a dog's diet with pancrease
meat for EPI? Fresh pancrease has worked great for both of my dogs that
were diagnosed with it. The weight came back up, Robbie from 67 lbs to 90
lbs and the diahrea also disappeared. Mutz, was diagnosed at 6 months, he's
up to 75 lbs at 2 years of age. It was my vet's idea when Robbie was
diagnosed. He said it would be cheaper than the powder, and much better
for him as the pancrease has lots of other things in it that were good for
him. It worked great for Robbie (he's gone now) and it works great for my
new guy, Mutz, shep number 4 (time to change breeders). I have to admit,
though, that cutting it up and bagging it for freezing isn't one of my
favourite past times. However, it keeps him healthy and at $1.00 a pound
(Canadian dollars) it's worth it.
Here's my second question. Mutz contracted colitis when he was a pup
(whipworm was the cause). It was at our vet's suggestion that we put him
on Hills W/D. It's the only one with such a high fibre content. So far,
so good. I still have to be very careful what I feed him. Even his treats
have to be high fibre. Luckily my vet carries both. Do you know of a more
natural dog food that has the same fibre content as W/D? I've had comments
from 'canine nutritional experts' that perscription dog food is made with
leftovers of everything and is extremly bad for the dog long term. Which
doesn't make sense. You'd think it would be better because it is
perscription food!! W/D has 20% fibre and most dog foods I see have a
maximum of 4.5 to 5%. I tried switching him and supplementing with oat
fibre, but the diahrea came back - big time!! It's a good job I don't have
carpets in my house!! I'd like to try and find a more natural dog food,
but I can't take the chance of taking him off the W/D. Any information you
can provide would be great.I'd also like to say that it has been, and will continue to be, extremely
enlightening to visit your site. Your thoroughness and sensitivity to
people is to be commended. Keep up the good work.
Answer: Judy-
I think that most veterinarians do not recommend using pancreas organ meat
is the treatment for exocrine pancreatic insufficiency (EPI) because it is
not consistently available in many areas. In places where it is available
on a regular basis it is an acceptable treatment for pancreatic enzyme
deficiency. It is good that your vet thought of it, since the pancreatic
enzyme supplements are more costly.I am not aware of a higher fiber natural diet, but you can use a natural
diet and add fiber sources to it until you find one that works
well. Psyllium fiber sources like Metamucil (tm) are acceptable and bran
will work for many dogs, although that doesn't seem to be a good idea in
your dog's case. There are two things that make w/d work well for colitis,
though. The fiber is part of the reason it works well and the low fat
content is the other. So you have to find a diet that is also low in fat.
This can be just as hard as finding one that it is higher in fiber. It is
possible that the lower fat content is the most beneficial part of the diet
for Mutz.The other option that you have is to make a diet at home. If you do this,
it is best to have the diet reviewed by a veterinary nutritionist. There is
a service online, run by a board certified veterinary nutritionist, Dr.
Remillard, called petdiets.com (we have a link from our linkpage).
There is also a link to Ohio State University's pet nutrition pages
http://www.ag.ohio-state.edu/~ansci/ which contain comparisons of
lots of dog foods.I am not sure why people who claim to be nutritional experts talk about
fillers and empty calories and things like that when discussing
by-products. There is no supporting evidence that I have seen for claims
that these products cause nutritional problems. I am not aware of any board
certified nutritionists who have produced studies showing ill effects of by
products in dog foods. These are usually organ meats that people find
unattractive and things of this nature. The life span of dogs has increased
in the last thirty or forty years while the use of commercial diets has
become standard. While individual dogs may have nutritional needs that are
different enough from average not to do well on commercial diets, the vast
majority of dogs are doing fine with them.I really think I'd stick with w/d for Mutz if it is working well, but if
you wish to find a substitute remember that you need similar fat content as
well as fiber content.Mike Richards, DVM
1/13/2001
Q: We have a 7 month German Shepherd puppy who the Vet feels has a genetic pancreatic disorder. She has had diarrhea for 3 weeks and has lost 15 lbs. Worms, parasites and inflammation of the bowels have all been ruled out. We will start her on a special enzyme supplement powder, which the Vet says will help her system digest the food it can't and get the nurtrition she needs. Can anyone tell us more about this disorder? And what the prognosis could be? The breeder has told us that this problem has been in the blood line. Some have said that there may be little we can do to save her. My wife, daughter and I love Liesl very much. Does anyone have suggestions? Thanks.
A: It is hard to be sure from your mail, but I am assuming that Liesl has pancreatic insufficiency - the inability to produce adequate digestive enzymes. It is possible to treat this by using Viokase or other products containing digestive enyzmes. . In most dogs, these will help enough that the dog can live a pretty normal life. If they are not successful alone, using cimetidine (Tagamet) to decrease stomach acids and allow the enzymes to work better is helpful. Some dogs can not be controlled through these measures and will die. In addition, some dogs are controlled well but suffer a twisting of the intestinal supporting structures for an unknown reason and die as a result of this. In one study, 10% of the dogs with pancreatic insufficiency studied had this problem. This is a serious problem but many dogs do live relatively normal lives with enzyme supplementation. I hope Liesl is one of these.
Mike Richards, DVM
Chronic Diarrhea in German Shepherd
Q: Dear Dr. Mike, My 2 1/2 year old German Shepherd, Simba, has had diarrhea for the last five weeks. He has lost twenty-two pounds (from ninety pounds). Initially, I didn't notice that he was eating outdated dog food from a pet store. It was manufactured in September 1995. In the last two weeks he has been eating new food, but the diarrhea has persisted. I took him to the vet, he tested his stool sample for parasites and pancreatitis. The vet said that pancreatitis was a possibility, but there were no parasites. I've done some research and don't believe that it is pancreatitis because his lower abdomen is not painful to palpations, has not had a loss of appetite and does not vomit. He was neutered and vaccinated just prior to the diarrhea. Could this have affected the situation being that his system was malnourished from the old dog food and then had to combat the antibodies from the vaccines? He also spent four days in a kennel a few days after the vaccinations at this point is when I noticed the diarrhea. Is it possible that there could be parasites that were not detected and can pancreatitis be determined by just taking a stool sample? These are the things that I have tried: fasting him, giving pepto-bismol and white rice. There was a slight improvement after the rice, but after eating regular food again, he resumed the diarrhea. Right now, I have fasted him and gave him charcoal tablets. I broke the fast slowly with vegetable broth, then cooked vegetables and now rice and oats. I don't have any more ideas, so any input would be greatly appreciated on my Simba's behalf. Thank-you in advance, Judy
A: Judy- In any German shepherd with chronic diarrhea my first instinct is to look for pancreatic insufficiency. In this case, insufficient digestive enzymes are being produced to allow proper digestion. This leads to persistent diarrhea. Pancreatic insufficiency is reasonably common in shepherds. There are pretty accurate tests for this condition now. Blood tests for trypsin like immunoreactivity (TLI) and serum folate levels are an improvement over older tests utilizing digestion of X-ray film. It is important not to overlook other possible causes, though. These tests are simple enough to include in the initial workup of a case, along with the more obvious things you mention, such as ruling out intestinal parasites, a general blood panel to make sure that there is not an obvious organ system problem (liver, kidney) and an attempt to make sure bacterial enteritis is not a problem.
Pancreatic insufficiency is NOT pancreatitis. It is an entirely different problem. Your vet may have been referring to this but phrased the concern badly or may be thinking that pancreatitis is possible. I would tend to agree that it isn't too likely as a continuing cause of diarrhea, though.
If no problem can be found with the labwork above, then the possibility of malabsorption disorders like lymphangectasia becomes more likely. Diagnosis of these conditions is best done by biopsy, usually utilizing an endoscope. We refer patients to an internal medicine specialist for this procedure.
The food can't be ruled out as a source of the initial problems but something else is probably keeping the problem going. Lots of times stressful situations bring on the clinical signs of problems such as pancreatic insufficiency and lymphangectasia or plasmacytic/lymphocytic enteritis -- and then these problems just keep on going.
Mike Richards, DVM
Last edited 12/05/02