EPI * Exocrine Pancreatic Insufficiency

If you are interested in a free tri-fold EPI brochure or EPI Log or My EPI Dog (in case something ever happens ) or in the article about EPI "Starving, but not Starved", please feel free to download any of the following PDFs or article on this page.  If you have any difficulty downloading anything, just email me at olesia@insightbb.com  and I will personally email it to you.

Please help us educate the public and bring awareness to EPI - - and you just might save a dog's life.

EPI in ALL BREEDS Brochures 7-28-09.pdf

Please feel free to print this tri-fold EPI Brochure on your computer and hand out at dog events, to your vet, other dog owners, pet stores, shelters, etc. These brochures may be mass-produced. You may also share this PDF brochure with other websites, message boards. etc.  It's purpose is to share EPI awareness.

After printing one side of the brochure- -reinsert the paper back into your printer to print on the other side. Various printers are set up differently, so you may have to play around with how you insert the page back in your printer (reversed or reversed & upside down, etc).

Once side one and side two are printed on the front and back of a piece of paper, tri-fold the paper so that "Minky" is on the front flap of the brochure. Hint: When printing, you can achieve a finished professional looking brochure if printed on a little thicker paper rather than just plain copy paper.

The EPI brochure PDF will always be the most current brochure with the latest information. (Any change will prompt an update)

If you would like a "personalized" EPI brochure with a picture of your dog on it or a picture of a specific breed for a breed club or dog event, etc. along with your organization's contact information, just email me a photo and the information to: olesia@insightbb.com

Please feel free to down load the following EPI LOG, created by Lanie in honor of her EPI dog, "Milo"
Keeping an EPI journal or log will help you determine what does and does not work for your dog.  It will also help you better identify the cause or trigger of possible future EPI flare-ups. EPI Dog Log2.pdf

~ Information to mention in your EPI FORUM post ~

Some information to mention to us.... if you can or want to... this is not required.... that may help us better help you and your dog:

• Name, breed and age of your dog ?
• Did the dog have a cTLI blood test done… was the dog fasted for 12 hours first?
• Was a B12 Deficiency blood test done … was the dog fasted for 12 hours first?
• What were the cTLI score and B12 / Folate scores?
• Was the test sent to Texas A&M Univ (TAMU) ?
• Does you vet suspect your dog has SIBO (small intestinal bacterial overgrowth)
• Was your dog given any antibiotics if so, what brand and for how long?
• Are you giving your dog pancreatic replacement enzymes… if so, brand name, how much, and what is your preparation with the enzymes?
• What brand name of food are you feeding your dog, amount and how often?
• How are you preparing the food (warm, cold, with or without water, enzymes mixed in, letting it sit for 20 minutes or not)?
• Has your vet given your dog a B12 shot…are they being continued?
• Are you giving your dog treats in-between meals... What kind?
• What does the dog’s elimination look like?
• How often does the dog eliminate daily?
• Does the dog have a lot of gas or tummy gurgling?
• Does the dog seem hungry all the time and/or eats things it should not?
• Does the dog not want to eat?
• Has the dog’s mood changed… cranky or fearful?
• Has the dog’s energy level changed?
• Has the dog lost weight… if so how much and in what period of time?

"Starving, Not Starved" EPI article by Olesia Kenendy

*** Please note that since this article was printed..... EPI Genetic Research being conducted by Drs. Leigh Anne Clark and Keith E. Murphy has moved from Texas A&M University to now being performed at Clemson University ***

Exocrine Pancreatic Insufficiency (EPI) prevents absorption of food.

Janis Fitzhugh, a member of the Almost Home Organization, knew she had to rescue Pandy, an extremely thin and seeminly vicious four-year-old Dachshund. Pandy had been relinquished to a shelter in Orange County (California), who turned her over to Southern California Dachshund Rescue. Deemed people- and animal-aggressive, Pandy appeared to have been starved, and weighed just 13 pounds. Fitzhugh thought the dog deserved a break, and brought Pandy home in May 2007.

During the first couple of weeks in her new home, Pandy managed to pull a chicken down from the counter and proceeded to eat the entire bird, including bones, plastic tray and grocery bag, in less than the 10 minutes that Fitzhugh was out of the room. Pandy was rushed to the vet and emergency surgery was performed, as the bones had ruptured her stomach lining in three places. Luckily she survived.

Pandy’s voracious appetite, large voluminous stools, and aggressive disposition were all caused by a medical condition called exocrine pancreatic insufficiency (EPI). With Fitzhugh’s loving care, including enzyme supplements and a change of diet, Pandy stabilized. Within a year, Pandy had transformed into a beautiful, funny, 26-pound Dachshund who gets along great with all the human and animal members in the Fitzhugh household.

What is EPI?

There are two primary functions of the pancreas:

1. Endocrine cells produce and secrete hormones, insulin, and glucagon.
2. Exocrine cells produce and secrete digestive enzymes.

Incomplete digestion causes the continual presence of copious amounts of fermenting food in the small intestine. This can lead to a secondary condition that is common in many EPI dogs, called SIBO (small intestinal bacterial overgrowth). If an EPI dog has a lot of belly grumbling/noises, gas, diarrhea, and sometimes vomiting, she most likely has SIBO.

The condition occurs when the "bad" bacteria that is feeding on the fermenting food overpopulates the tissue lining of the small intestine, further impairing the proper absorption of vital nutrients and depleting the body's store of vitamin B12. Treatment of SIBO includes a course of antibiotics to eliminate the bad bacteria. Treatment may also include supplemental cobalamin (B12) injections that help reestablish friendly bacteria colonies, which in turn helps inhibit the malabsorption.

Severity of the disease may vary, making it even more difficult to diagnose. EPI can be subclinical (no recognizable symptoms) for many months, sometimes even years, before it worsens and becomes noticeable. The symptoms can be exacerbated by physical or emotional stress, change of food or routine, and/or environmental factors. The most common symptoms include:

• Gradual wasting away despite a voracious appetite.
• Eliminating more frequently with voluminous yellowish or grayish soft “cow patty” stools.
• Coprophagia (dog eats his own stools), and/or pica (dog eats other inappropriate substances).
• Increased rumbling sounds from the abdomen, and passing increased amounts of gas.
• Intermittent watery diarrhea or vomiting

With hunger as an overwhelming force, many dogs act almost feral. Desperately seeking vital nutrition, many ingest inappropriate items, but nothing gets absorbed. As the disease progresses, the deterioration becomes quite rapid. Some dogs lose interest in any activities, preferring to just lie down or hide somewhere. Many owners of EPD dogs become increasingly frustrated, as they feed more than normal amounts and yet the dog continues to waste away before their eyes.

Since chronic loose stools are usually the first visible symptom in an EPI dog, most vets will prescribe an antibiotic to destroy what they suspect to be harmful intestinal bacteria. Owners are happy, because the problem appears to go away, at least for a while. No one has any reason to investigate further, until the loose stools return or the dog starts losing weight, and then the merry-go-round cycle begins. Vet  visits become numerous and costly, and one possible diagnosis after another is suggested. Expenses may include testing (and retesting) for giardia, coccidiosis, and other parasitic diseases; x-rays; ultrasound; MRI; antibiotics; and even surgery.

EPI Testing

Although other laboratories can run the TLI test, most blood samples are analyzed at Texas A&M University. The lab recently revised its reference ranges: values below 2.5 are now considered diagnostic for EPI. Results between 3.5 and 5.7 may reflect subclinical pancreatic disease that may ultimately lead to EPI. When values are between 2.5 and 3.5 µg/L, Texas A&M recommends repeating the TLI test after one month, paying particular attention to the fast before the blood sample is collected.

Even when a dog tests positive for EPI, it is important to retest TLI after the dog stablizes following treatment. For example, chronic inflammation can put such a strain on the pancreas that the production of digestive enzymes ceases or is greatly reduced. Consequently, when the TLI blood test is analyzed, it accurately depicts lack of enzyme production, even though the dog may not actually have EPI. In this case, it is important for the dog to be treated with pancreatic enzymes until his condition is stable. Enzyme treatment breaks down the food, allowing the stressed albeit non-EPI pancreas to recuperate and, in time, start producing the enzymes needed to digest foods.

Dorsie Kovacs, DVM, of Monson Small Animal Clinic in Monson, Massachusetts, has seen some young dogs with false-positive EPI readings. Even when they display the lighter-colored “cow patty” stools, something other than EPI may be the cause. Sometimes a food allergy or an overabundance of bad bacteria has irritated or inflamed the pancreas, temporarily inhibiting enzyme production. In these situations, says Dr. Kovacs, it's important to put the dog on a pancreatic enzyme supplement for two months, allowing the stressed pancreas to heal. The dog should then be retested to confirm or rule out EPI.

In addition, Dr. Kovacs says, “It is also important to introduce good gut flora (bacteria) by adding yogurt, green tripe, or supplements such as Digest-All Plus (a blend of plant enzymes and probiotics). Good gut flora should continue to be maintained with supplements even after the inflamed or irritated pancreas has healed.” Dr. Kovacs has also noticed that some dogs with food allergies (especially dogs fed dry kibble) show rapid improvement when their diets are switched to raw or canned food. Raw meats contain natural enzymes, and fresh vegetables support the growth of good bacteria in the dog's gut..

Managing EPI

Enzyme supplementation is the first step in managing EPI. The dog will need pancreatic enzymes incubated on every piece of food ingested for the remainder of his or her life. The best results are usually obtained with freeze-dried, powdered porcine enzymes rather than plant enzymes or enzyme pills. Plant enzymes and enzymes in pill form do work for some, though with enzyme supplements, as with diet, much is dependent on the individual EPI dog.  Some of the most widely used prescription enzyme supplements are Viokase, Epizyme, Panakare Plus, Pancrease-V, and Pancrezyme. Bio Case V is a non-prescription generic equivalent.

Enzyme potency is measured in USP units. Prescription enzyme powders range from 56,800 to 71,400 units of lipase, 280,000 to 434,000 units of protease, and 280,000 to 495,000 units of amylase per teaspoon.

Pancreatic enzymes are also available as generic pancreatin. Strengths of 6x, 8x, etc. indicate that the dosage is concentrated. A level teaspoon of powdered porcine pancreatin 6x might contain 33,600 units lipase and 420,000 units protease and amylase, comparable to prescription enzyme products.

Some EPI dogs have allergies and cannot tolerate the ingredients in the most common enzyme supplements. Those owners learn to develop alternative methods such as using plant enzymes, or a different source of pancreatic enzymes such as beef-based (rather than porcine-based). Raw beef, pork or lamb pancreas can also be used. One to three ounces of raw chopped pancreas can replace one teaspoon of pancreatic extract.

The starting dosage of prescription enzymes is usually one level teaspoon of powdered enzymes per cup of food. As time goes on and a dog stablizes, many owners find that they can reduce the amount of enzymes administered with each meal, sometimes to just ½ teaspoon, although some EPI dogs require an increased dosage of enzymes in their senior years.

Enzymes need to be incubated, meaning that you add them to moistened food prior to feeding, letting them sit on the food at room temperature for at least 20 minutes. Some find incubation up to one or two hours works even better. Too often, EPI owners are instructed that enzyme incubation is not necessary; however, some dogs will develop blisters or sores in their mouth from the enzymes when they are not first incubated on the food.

How do you judge what works best for your dog? When dealing with EPI, everything is gauged by the dog's stool quality. EPI dog owners are always on “poop-patrol”. The goal is to obtain normal looking, chocolate brown, well-formed stools. When your dog produces something other than normal poop, it indicates she is not properly digesting her food. Sometimes longer enzyme incubation helps. Other times using more or less enzymes (since too little or too much enzymes can both cause diarrhea), changing the diet, treating a flare-up of SIBO, or starting a regimen of B12 shots solves the problem. Make only one change at a time. It is advisable to keep a daily journal as it may help you to identify the cause of a flare up or setback.

Prescription enzyme supplements can be very expensive. A $5,000 per year price tag for enzymes is not uncommon for a large dog -- but don't panic! There are several ways to reduce this cost. My 40-pound Spanish Water Dog has the dubious honor of being the first of her breed ever to be positively diagnosed with EPI. When the TLI results came in, I felt like my world came crashing down. Izzy is my once-in-a-lifetime best companion, and was very sick. Using information my vet gave me, I estimated that the enzymes alone were going to cost me $1,200 a year. She was only a year and a half old at the time, with an expected life span of 13 to 15 years. Eeek!

Today those enzymes cost me a mere $200 a year. How? I joined an EPI support group and learned what others do to better manage the ongoing care of their EPI dogs. I buy enzymes from an EPI enzyme co-op that purchase enzymes in bulk and passes the savings on to owners who have a veteriniarian-confirmed EPI dog. The savings from these bulk purchases can be quite substantial. (For both groups, see Resources for Products mentioned in the Article below). Today, Izzy is a plump, active, happy dog who gives me more joy than any other dog I have had in my 55 years. I would have paid whatever it cost to help her, but not everyone has this option.

Another solution that can dramatically save money is to obtain raw beef, pork or lamb pancreas. Ask your butcher if he can get fresh pancreas, or check with meat inspectors in your state to find out if and where you can obtain fresh pancreas. A letter from your vet explaining why you need fresh pancreas may allow you to purchase it from a slaughterhouse. Fresh beef pancreas can also be ordered from suppliers such as Hare Today and Greentripe.com.

The suggested dosage of raw pancreas is 3 to 4 ounces per 44 lbs of the dog’s weight daily. The pancreas can be blended or finely chopped, then frozen into either cubes in an ice tray or “calculated by the dog’s weight” single meal amounts in Ziploc bags. Raw pancreas can be frozen for several months without losing potency. When ready to use, thaw naturally and serve the raw pancreas with the dog’s food.

A very important factor about enzymes -- whether using raw pancreas, powdered pancreatic enzymes, or pills -- is that all digestive enzymes work best at body temperature. Cold inhibits the enzymatic action while heat destroys it. Never cook, mix with very hot water, or microwave either raw pancreas or supplemental enzymes.

Antibiotics are the next line of defense, in order to combat SIBO (bad bacteria growth overtaking growth of good bacteria), the secondary condition that frequently accompanies EPI. Tylosin (Tylan) or metronidazole (Flagyl) are the commonly prescribed antibiotics, usually given for a 30 days. Some dogs have trouble with metronidazole due to possible side effects; in that case, Tylan  is given. Be warned: Tylan is bitter- tasting, and many dogs refuse to eat their meals when it's added. There are tricks to deal with this. Some put the Tylan powder in gelatin capsules; I camouflage it for my dog by inserting the required dose in a small chunk of cream cheese. Not all EPI dogs can tolerate dairy, so the camouflage method should depend on the individual dog’s tolerance.

B12 (cobalamin) injections are needed if the dog has very low serum cobalamin. A blood test is required to determine this, costs about $31, and is best done simultaneously with the TLI test. Many EPI dogs cannot replenish B12 levels on their own, so B12 injections are used. B12-complex formulas are not recommended since they contain much lower concentrations of cobalamin and appear to cause pain at the injection sites. Generic formulations of cobalamin (B12) are acceptable.

The recommended cobalamin dosage is calculated according to the dog’s weight and may be found on Texas A&M University website (see Resources below). Your vet can show you how to give your dog subcutandous (beneath the skin) B12 injection. What seems to work best are weekly injections for the first six weeks, then biweekly (every other week) injections for the next six weeks, and finally monthly B12 injections .

Feeding dogs with EPI

Sometimes it is much more complicated! Some dogs can tolerate much more fat. My dog, Izzy, for example, does extremely well on grain-free kibble with 22 percent fat content, well above the 12 percent range. Other dogs cannot tolerate even as little as 12 percent fat. The same applies to the fiber content. Some EPI dogs have unrelated food allergies, further limiting their diet.

Many dogs with EPI thrive on raw diets and some owners find a raw diet is the only one that works for their dogs. Conversely, other EPI dogs cannot tolerate raw diets. Some owners successfully feed grain-free kibble, some make home-cooked meals for their dog, while others feed a combination of commercial and homemade.

When adding to ar adjust a diet, feed the dog tiny chunks of raw carrot with the diet. These carrot pieces will present themselves in the stools (for better or worse) of that meal's elimination. This helps you to understand which foods/vitamins, etc., work well together and which don't.

Recommendations keep evolving and changing with new research, as well as the feedback from networks of owners of EPI dogs. A recent change in feeding recommendations concerns dietary fat. Multiple studies from the past decade indicated that a fat-restricted diet is of no benefit whatsoever to the EPI dog. A 2003 EPI paper by Edward J. Hall, of the University of Bristol in England, states that there is experimental evidence to show that the percentage fat absorption increases with the percentage of fat that is fed.  This may explain why some EPI dogs can tolerate higher concentrations of fat. For those dogs who cannot tolerate more than 12 percent fat, this may mean that the fat content needs to be increased very gradually, or perhaps that certain types of fat may be tolerated better than others.  Much more research is needed to answer these questions.

Veterinarians usually recommend an initial diet of a prescription or veterinary food, such as Hill's Prescription Diet w/d, i/d, or z/d Ultra Allergen-Free; Royal Canin's Veterinary Diet Canine Hypoallergenic Diet or Digestive Low Fat Diet; or Purina's EN. Prescription diets that are made with hydrolyzed ingredients (carbohydrates and proteins that have been chemically broken down into minute particles for better absorption in the small intestine, leading to more complete digestion, better/faster weight gain, and firmer stools) appear to work for many EPI dogs. However, these diets are usually starch-based (often almost 60 percent carbohydrates on a dry matter basis); the digestive system of a dog is designed more for fats and protein than for starches, which may be why many EPI dog owners achieve better results by reserving prescription diets for short-term use and feeding other diets over the long haul.

The best results for managing EPI requires combining veterinarian advice with the experience of actual EPI dog owners. Too many times, managing EPI can be a real roller coaster ride! For example, initial research studies showed that supplemental enzyme powders needed to incubate on the food. Additional research studies then suggested that food incubation with enzymes was no longer necessary. Consequently, some EPI dogs developed mouth sores, so owners are again being advised to let the enzymes incubate to prevent this side effect. Until the causes and effects of this disease are better understood, it will continue to be managed via trial and error.

General Feeding Guidelines

Once an EPI dog is stable, some owners find that they can ”cheat” and give their dog a smidgeon of a treat without any enzymes on it. Others find the least little crumb ingested without enzymes will cause a flare-up.

If possible, feed two to four meals a day, taking into consideration whether the dog’s condition has stabilized and whether the family’s schedule can accommodate multiple feedings. Feeding smaller, more frequent meals puts less stress on the EPI dog’s digestive system.

At first calculation, many owners of EPI dogs wonder if they can sustain the added expense of all these “special foods” in addition to the enzymes. It may take many attempts to find just the right diet for a dog with EPI that is also affordable by the owner, but it can be done. Following are some suggestions and techniques that owners of dogs with EPI have successfully used.

* Kibble or Canned: Many EPI owners who feed commercial kibble or canned dog food have found more success when feeding a grain-free product. Much depends on the individual dog.

When feeding kibble, many owners let the food and enzymes incubate until the food has an oatmeal-like consistency. Some even grind the kibble to allow for more surface contact with the enzymes. Some also add a teaspoon of pumpkin or sweet potato, which may help firm stools and reduce coprophagia; plus, both ingredients are packed with vitamins C and D. Sweet potato is also an excellent source of vitamin B6.

* Combination Kibble and Homemade: Many owners feed a combination of commercial food and raw or home-cooked. EPI owners mix foods at a ratio of 20 to 80 percent. An example would be 20 percent raw meat mixed with 80 percent dry food, or 20 percent kibble with 80 percent raw meat. As always with an EPI dog, enzyme supplements should be mixed in with the wet portion of the food at room temperature and allowed to incubate.

Depending on each individual dog’s tolerance, any variety of meats and fish may be used. Sources of proteins can include beef, chicken, turkey, pork, venison, rabbit, lamb, canned or cooked salmon, and jack mackerel, as well as eggs, yogurt and cottage cheese. Organ meats, such as liver, kidney, and heart should also be included in the diet. Green tripe is another good option. Variety is key! Again, incubate the food with the enzymes and feed 2 to 4 times daily, depending on your individual dog’s needs and your own schedule.

* Raw and home-cooked: Over the last few years, many owners have been able to stabilize their EPI dogs by feeding a raw diet. Raw food has the innate advantage of maintaining natural food enzyme activity that aids digestion. Many vets disapprove of feeding a raw food diet, especially to compromised dogs (possibly exposing them to further complications), while other vets suggest that raw is best for an EPI dog. There have been many anecdotal cases of dramatic improvement when the owners feed their EPI dog a raw diet, especially when all else fails.

Most EPI dogs cannot handle the 20 to 25 percent bone content in the diet that is commonly fed to normal dogs. With EPI dogs, it's smart to start with only 10 to 12 percent of bone. Some dogs still have difficulty digesting this amount of the bone and the ratio will need to be reduced even further, to 3 to 5 percent bone. Note we are talking about the amount of actual bone, not the amount of raw meaty bones, which are usually at least half meat.

Vegetables may be a large or small portion of the diet, or not included at all, depending on the individual dog’s tolerance. If included, they should always be mashed. Organ meats are usually recommended at 10 to 15 percent of the EPI diet, but once again, not all can tolerate this.

Supplements for an EPI diet

Most EPI dog owners add coconut oil and/or wild salmon oil to their dog’s diet. Many EPI dogs cannot digest other fats and develop dry, itchy skin or dry, brittle coats. Coconut oil contains medium-chain triglycerides (MCTs). Most vegetable oils have longer chain triglycerides, called LCTs. MCTs are utilized faster and burned more quickly for energy, raising the body’s metabolism, while LCTs are utilized more slowly. Also, coconut oil is one of the richest sources of lauric acid. Its benefits have recently been touted to aid in destroying various bacteria and viruses such as listeria, giardia, herpes simplex virus-1, and maybe even yeast infections such as candida.

Wild Alaskan salmon oil is an excellent source of omega-3 fatty acids, which help reduce inflammation.

Probiotics are another important addition to the EPI diet, especially since most EPI dogs are or have been treated with antibiotics because of SIBO. Antibiotics wipe out not only bad bacteria, but also good bacteria. Probiotics help maintain good gut flora. One popular brand of probiotics that has been successfully used by EPI owners is Primal Defense, but there are many quality probiotics available.

Zinc deficiency is another consideration with EPI dogs. It is difficult to accurately measure zinc absorption, Human EPI patients often develop a zinc deficiency, and though no studies have confirmed this to be true of dogs with EPI, many vets sugest a zinc supplement for EPI dogs.

Vitamin E (tocopherol) levels may also be low in an EPI dog due to malabsorption. Vitamin E is a fat-soluble vitamin that is an antioxidant and helps in the formation of cell membranes, cell respiration, and with the metabolism of fats. Vitamin E deficiency may cause cell damage in the skeletal muscle, heart, testes, liver and nerves; supplementation with vitamin E can help prevent these problems.

Other natural nutrient sources that are often included in an EPI diet are kelp, green tripe, slippery elm, and alfalfa.

Controlling EPI

If you own a purebred GSD, with or without EPI, and would like to contribute a blood sample, please contact Dr. Leigh Anne Clark at Clemson University (see Resources below).

 It is important that this research continues. EPI is rapidly spreading across all breeds. It is no longer just a GSD disease, or a working dog disease. Dogs of all breeds, including crossbreeds, are being diagnosed with EPI. It is happening in family lines too often to be coincidence without a genetic component. Yet, not every family member or generation in affected lines has EPI. For now, until we can actually test for the genetic markers, the best possible control is to remove positively-confirmed EPI dogs from breeding programs. Once genetic markers are identified in GSDs, the markers in other breeds will be more easily detechted.

Although there are many success stories, there are also heart-wrenching tales of dogs who cannot thrive, families who cannot afford the treatment, and throughout it all, the painful suffering the dog endures unless successfully treated. EPI can no longer be a “hush-hush” disease.  My hope is that this article will make a difference by helping raise awareness of EPI to the level of other major canine diseases.

Olesia Kennedy, a retired research analyst, and previously involved in Canine Search & Rescue, currently devotes her skills and time to EPI research. She resides with her husband and three Spanish Water Dogs in Georgetown, Indiana.
 

Please Support Research for EPI Hope, a Boxer, was adopted by Jodi Riddle, of NorCal Boxer Rescues in Texas. She was lovingly cared for and given enzyme replacements and a special diet. Hope completely recovered, becoming Jodi’s constant, gentle shadow. Hope has since passed on; Jodi wisher her photo inspires others to support finding EPI's cause.

To contact Dr. Clark, her office telephone number is: 1-864-656-4696; her email address is:  lclark4@clemson.edu 

Leigh Anne Clark, PhD.
Assistant Professor
Department of Genetics and Biochemistry
100 Jordan Hall
Clemson University
Clemson, South Carolina 29634