Need Help With Diagnosis

[Tyson]

Tyson is a little complicated. DX with Granulomatous Meningoencephalitis last December. On a ton of seizure meds and immunosuppressants. Has had mildly elevated liver enzymes in the past from steroid usage and intermittent loose stools I thought from Mycophenolate.

The beginning of August he developed severe diarrhea. Explosive and incontinent. Spent 2 days at the emergency specialty hospital and was discharged with diagnosis of diarrhea of unknown etiology. Was put on Flagyl and chicken and rice diet. He has never had a solid stool since that time (stool mushy to liquid) and every time Flagyl was stopped the diarrhea be came worse. Royal Canin GI LF canned food didn't help. Probiotics didn't do the trick. Flatulence was over abundant and deadly. Last weekend it dawned on me that he was smelling like a pancreatitis dog although I was told the pancreas was normal. So I started doing some research. It appears that he has a chronic pancreatitis and drug induced PAA. Many of the same symptoms, stool qualities. Started him on enzymes on Friday. Had 2 meals with enzymes and his stool Saturday morning are perfect solid doggy poo. They have remained that way even with starting a slow transition to a homemade liver detox diet (low fat) beginning yesterday (25% new, 75% old)

Tysons TLI beginning of August was 13.2. I read that TLI can be normal with Chronic pancreatitis. Is that true? Perhaps it might have been on the way down at time as well. I have a dilemna with repeating it because the vet wants a complete 12 hour fast and Tyson would miss too many does of his seizure medications (he's on enough of them to treat 4 adult humans!!) He would probably have to stay at the emergency hospital and that would be another $1000 bill. on topof paying >$500 a month in medications and $35 every 2 days to feed him.

Blood work-changes from end of June to beginning of August when he started horrible diarrhea
Alk Phos - 6237 (up from 433)
ALT 487 (up from 121)
GGT 258 (up from 4)
Cholesterol 449 (up from 219)
Amylase 375 (down from 969)
Lipase 547 (down from 1285)
B12 380
Folate 3.69
I read a post on here about someone who had a dog who assumed diagnosis with solid stools after enzymes but didn't have low TLI. The dog apparently died of some other treatable illness. What was that illness?
I have no doubt we also have an SIBO going on which is either due to the Mycophenolate or pancreatitis.
I am a nurse so I am not completely clueless but Ty doesn't have a lot of time left due to his primary diagnosis (although I am on a mission to change that) so I want to make him as good as possible for the time he does have left and I need to get this right. All of this is a bit difficult to digest (pun intended lol)

I would appreciate any advice!
Deb

[Olesia711]

Hi Deb... welcome to our EPI family.

Heavens, Tyson (and you) are dealing with an awful lot.... not sure if i have answers to all your questions, but i think i can help with a few.

The deal with Chronic Pancreatitis and if it is segueing into EPI (end stage chronic pancreatitis) and if you run the TLI test during this transition period the TLI test will not give an accurate reading- -it will be skewed. By how much is anyone's guess depending on the dog. How long is this transition window... a year maybe? Dr. Penny Watson did a lot of research with this, if you want, you can contact her directly, she is great to talk to about this sticky/unsure situation. You can read about her research here: https://epi4dogs.com/pancreatitis-to-epi/

SO... since the enzymes helped, my guess is that one of two things are happening....

1. Either Tyson is segueing into EPI- -so a TLI test is not going to be accurate at this particular time, but when given pancreatic replacement enzymes... they do MUCH better, like what you are describing.
2. Or, as with many Chronic Pancreatits dogs, when given pancreatic replacement enzymes-even if not segueing into EPI.... they do MUCH better, like what you are describing.

As you can see, either or can be happening. You cannot go by the CBC Lipase blood test values because that is only a snapshot in time.... that is why they don't use this to assess Lipase values to diagnose EPI.. but the fact that the Foalte level is so low..... that points to small distal proximal disease-HOWEVER- with all the meds Tyson is receiving i have no idea if this is even accurate or if the meds skewed this blood results too- - which is a good possibility.

Regarding what other condition happened where the pet owner treated for EPI , never tested the dog, and then the dog died - -it was untreated tick disease!

How old is Tyson?

If you just want to keep him comfortable... i would continue giving the enzymes- -they will not hurt short term... but you don't want t keep him on enzymes for a year or more assuming this is EPI without a proper diagnosis.... so you do have decisions to make.

I understand about him needing his meds and how difficult it is for him to go without his meds because of the TLI pre-test fast.....BUT...... i am wondering. In order to run the TLI blood test, it is recommended to be food fasted for 12/+ hr. If he can take his meds without food, then that should not be a problem.
Also.. what we always recommend is to run the TLI test first thing in the morning before breakfast.... this way at least 8-10 food fasting was done during sleep time.


Not sure if this helps, but i hope so.... please feel free to ask additional questions and keep us posted too!

[jilbert57]

Olesia answered your questions for sure. I have a couple additions to your question concerning Tli and pancreatitis. At diagnosis of pancreatitis Mickey's Tli was >50, and cPL was >1000. After 6mos of lower fat diet and enzymes Tli came down to 25 but cPL was over 800 till he passed away 3 yrs later. He never went on to develop EPI.
Just passing this link on for your information:

https://www.fda.gov/newsevents/newsroom ... 611046.htm

[Tyson]

Thank you so much for your replies!!
Tyson is just 3 1/2 years old. We are definitely not a tick borne disease as we have tested negative twice. I feel bad that she lost her pup.
He has not had any weight loss which seems to be key with EPI but he doesn't seem to be digesting food...at least not regular food. Last weekend I gave him meal of boiled chicken, white potato and oatmeal. Again thinking low fat for pancreatitis. I did not gradually switch him, I just gave the new meal...yep mistake on my part. Obviously not thinking right but it happened. He vomited 10 1/2 hours later. I had given him 1/2 cup finely shredded chicken, 1/2 boiled and smashed potatoes and half a cup of cooked rolled oats. When it came up it was perfect. No digestion at all. Didn't even smell like vomit. How can that be after 10 1/2 hours in the stomach? When he moved his bowels a little later, there was noticeable little pieces of potato in the liquid.

This may sound like a stupid question but I am not sure I am understanding this. So a dog with a low TLI is considered to have EPI. A dog with chronic pancreatitis whose TLI is normal is not considered EPI but essentially the treatment is the same because they both lack enzymes but the etiology is different??

The mean survival of a dog like Tyson with GME is 12-14 months from diagnosis. So while I am basically "short term" management I am not giving up and want to focus on long term. I don't want the treatment of the disease to be what kills him. I feel that I need to address the cause which I believe is both hepatic insufficiency and chronic pancreatitis induced by the type and dosages of his medication. And then again maybe not pancreatitis but SIBO instead....this is so confusing it's making my brain hurt.

So another question...SIBO, will the enxymes improve the symptoms with this condition as well?
It is quite possible that the Mycophenolate is causing SIBO or possibly its the pancreatitis......oh my...I need brain enzymes to help me digest all this!!

We see the Neurologist on Friday. I am going to run all this past her and see what she thinks. I would like to see about trying to decrease his seizure meds. If he is having malabsorption for whatever reason, could this impair the digestion of his meds requiring higher doses for seizure control?

Maybe we need a GI consult. I wish they had an endocrine specialist but they don't

CBD has been on my mind and I do have it. I was just going to start it for some help with seizure control when all this diarrhea stuff started. When they discharged him from the hospital they had decreased his prednisone from 60 a day to 30 and were concerned he may start seizing so they wanted to add a 4th seizure medication. I refused and told them if he started seizures again I would want to start the CBD before adding other meds. Thankfully we have been 6 weeks seizure free...Yay for Tyson!!

[Miss Maddie Moo]

Hello
I am noting from your test reults that the folate is low 3.69 this can indicate a problem with take up in the small intestine :
Folate: Absorbed in the proximal small intestine only. Values above the control range are consistent with bacterial overgrowth in the upper small intestine. Values below the control range are consistent with disease affecting the proximal small intestine.( 7.7is the control range base so if your results are correct this may be part of the problem ) it can often be an allergy problem and can mimic epi syptoms .
Just thought i would throw that out there.

Ann

[jilbert57]

" This may sound like a stupid question but I am not sure I am understanding this. So a dog with a low TLI is considered to have EPI. A dog with chronic pancreatitis whose TLI is normal is not considered EPI but essentially the treatment is the same because they both lack enzymes but the etiology is different??"

Diagnostic Tli for EPI is 2.5 or less

3.5 to 5.7 may be sub clinical

Mickey's pancreatitis was direct trauma induced

Upon testing, cPl was >800 and Tli was >50

After a month on enzymes cPl was>800, Tli 25

These last numbers remained same for 3 yrs until he passed.

Enzymes greatly improved his digestion resulting in great poops and reduced vomiting.

Sounds like the food sat that long then it was like a regurgitation, not a vomiting? Was this while using the porcine enzymes?

Sometimes the enzymes alone will resolve SID.

[Olesia711]

to answer your question about using enzymes for both EPI (atrophied pancreas/gone) and Chronic Pancreatitis (swollen pancreas).

In real simplified terms:

The reason why the replacement enzymes are needed for an EPI dog is because in EPI the body can no longer produce the necessary digestive enzymes do digest the nutrients from the food. The replacement enzymes do the job.....

With Chronic Pancreatitis.... sometimes enzymes are also used althou not forever/ just short term... because sometimes the pancreas is so inflamed that that in itself causes the pancreas not to be able to function or function efficiently. So again, The replacement enzymes do the job....

[Tyson]

Gotcha on the use of enzymes with EPI vs Pancreatitis and did manage a little smile on the not forever/short term. I am hoping for the later. I think more points in that direction than with EPI. Will keep my fingers crossed there.

Jibert you're probably right with the regurg instead of vomiting. No retching. He just jumped up on the couch to lay across the arm like he always does and bam there it was on the floor as he leaned over the arm. I had my back turned and didn't hear a thing. We were not on the enzymes at the time. That episode really made me think that we needed the enzymes.

[jilbert57]

Have they run the cPli test on your pup specifically?
I also know that dogs with hyperlipidemia are prone to pancreatitis, like schnauzers.

[Tyson]

No they haven't run the cPli. See the problem I am having is that my vet doesn't seem to be getting any of this. I seem to be the only one concerned about his liver enzymes and all this diarrhea. I told her I feel like we are missing something on him and she tells me (after a month of this) that she knows its frustrating but I need to be patient. In her closed mind she is simply treating a dog with diarrhea. She is not treating Tyson who has GME, hepatic issues due to meds and on enough drugs to kill a horse. So....I am in the process of a change for a home vet as the hospital our Neurologist is at is over an hour away. I am very anxious for our Neuro visit with her on Friday and I am feeling relieved that we at least have this diarrhea finally under control. Maybe she'll have some good idea of what is going on since I'm sure she frequently uses these same meds.