Another Mina update

[DocX]

I last checked in about a month ago because Mina was getting progressively less well-formed since January, and took your advice to increase enzymes a little and go back to a lower-fiber dog food that she'd had very good luck with for several years. At first it seemed to be working and I thought it was just a matter of figuring out the correct enzyme multiplier (e.g. 125% 150%?) However, things got worse again; more puking, and lower GI bleeding progressed to upper GI bleeding. She will see the internal medicine vet tomorrow. Testing has ruled out parasites and any sort of other kidney / liver dysfunction. The only ones we are still waiting on are B12 levels and folate. She's on a short course of metronidazole and some carafate to settle the bleeding down. The combination of carafate 4x per day, feeding a lot of small-portion chicken and rice around that so the enzymes work, and keeping her full of cerenia so she feels OK has worked well as we wait to see the GI.

I suspect either she stopped absorbing B12 and it's gotten low, or the SIBO got so bad that she's worn down the villi in her small intestine and they'll take a while to grow back. I'll know what her GI thinks tomorrow. A couple of other observations about this:

1) The general vet has been incredibly pushy about switching to a much higher fiber prescription dog food and has been obviously displeased with me when I tell her I will not do this (it's more than 7.5% fiber, which seems unwise given that the difference between 4% fiber and 5% fiber seems to be what got us into this mess).

2) I am surprised at how well carafate is working for slowing down diarrhea - from about seven poops per day to "no BMS for 36 hours". Even after 36 hours inside the dog, poop is about the consistency of heavier canned cake frosting, so absorbing is not going very well even when slowed way down.

3) She's lost about seven pounds since December without us trying, and our second dog got obsessed with eating her poop around the same time, It is revolting but he's probably a very useful barometer of how well her enzymes are working.

4) Chewing up twelve pancreatin tablets every day has given Mina lovely, clean teeth for a dog her age.

I feel like I need to have a conversation with my vet about how we are communicating currently. It may be because she is still young, but I think she does not realize how much time I have spent thinking about EPI (and asking for help to learn more) and defaults to treating me like a crayon-eating preschooler whenever she wants to rigidly follow the generic "dog with gut issues" protocol for Mina instead of staying EPI-specific, so we clash whenever she wants to do a test that's very unlikely to be the problem or try a treatment inappropriate for an EPI dog. Has anybody ever had to have that conversation, and if so, how did you approach it? If I could turn it into a teachable moment that would help us work better together as a team, I would like that.

[Olesia711]

Hi Doc,

So sorry the Mina is back-sliding at the moment..... typically i would say that this is most likely SID/SIBO the issue.... BUT..... the fact that she did well on a new food and then back-slid.... reminds me of another dog i had....did the same thing.... by the time i got to the end of the bag of food, she no longer wanted to eat and her stools were no longer good..... Turns out her problem was low B12................. SO.............. you might be correct and that this is the problem.

BUT... on the flip side, it still can be uncontrolled SID/SIBO... which of course will NOT show up in any tests... BUT.... as you probably know, we strongly push not using Metronidazole but if you are going to use an antibiotic, request Tylan instead; https://www.chewy.com/tylan-tylosin-tar ... /dp/173768
You can order Tylan from Chewy, but your vet will have to approve it. Metro kills EVERYTHING Tylan simply inhibits the reproduction of more bacteria .... unless you give it for very long term of course.

Ahh.... i have had MANY conversations with vets... most were open to listening and reading the materials (research that i showed them) but there was 1 vet that was so set on he knew best that he wasn't interested in acknowledging anything i suggested...,,, in the end though, he ended up apologizing to me in two different instances because what i was touting finally reached his ears via other professionals.... SO.... it really does depend on the individual vet... the best thing is to print veterinarian research (we have lots here under each tab) that supports what you are asking your vet to do. Also.... sometimes you just have to go with, "my dog, my dollar" if you want a specific test run and they tell you its not necessary..... it's ultimately your choice to request a test and they should oblige

But usually it's more about the treatment.... and with EPI, you really want a vet that will work "with" you, not one that assumes that they have all the answers cuz the problem with EPI dogs is that even though there is an EPI recommended protocol... with these dogs, oftentimes the protocol needs to be tweaked to some degree to best suit the individual dog.... and for this you need a vet that is willing to think outside the box and work with you .

Ahhh... high fiber. Many EPI dogs do NOT do well with high fiber because fiber can reduce the efficacy of the pancreatic enzymes from anywhere between 0% to 50%. The problem is that we don't know which dog is affected by this and if they are affected... by what %.
BUT i am guessing the reason why your vet wants Mina on high fiber is because the fiber actually helps improve bad gut flora (SID).... so... if you are willing (but maybe not since 5% fiber put her in a tailspin) what you might want to do is tell the vet you will only try high fiber for 2 to 3 days ONLY (so have the vet give you a sample as those prescription high fiber foods are EXPENSIVE!!!) .... if Mina develops loose stools you will KNOW she definitively cannot have high fiber... but if she doesn't develop loose stools then the positive part is that it should help her with SID. It's just that way too many EPI dogs cannot handle fiber hence why we tell everyone to "start" with a low fiber food and once poos are normal.... THEN try some grain, like rice and see if it is tolerable with that individual dog.

TIDBIT: if CARAFATE helps.... just for future reference know that you can also use slippery elms instead... does the same thing. Carafate raises blood sugar, slippery elm doesn't. might want to keep some slippery elm powder on hand just because.... it also helps with SID. Usually EPI dogs respond really well with SLippery Elm, but sometimes some just don't.

BTW... under the SID/SIBO tab... we have research that talks about how fiber can reduce the efficiacy of the enzymes and hence why we are always mentioning this.

[DocX]

Thanks so much Olesia. I will put slippery elm on my list of things to try in the near future if GI vet doesn't object. I used to use psyllium for that but I really want to avoid anything that lowers enzyme efficiency right now.

I appreciate the resources you posted a lot, and I referred to them at the last appointment so I could feel quite confident in saying that foods with > 4% fiber were contraindicated!

In regard to the B12 - it may be the problem. I started feeding her drug store B12 tablets daily from the time of diagnosis, and when we checked serum levels about six months later, they were fine (above reference range even). From this I assumed that she was absorbing B12 fine without addition of intrinsic factor, but if a little bit more of her pancreas has stopped working since then, maybe I will need to switch to injections or intrinsic factor formulation. I'll update when I know the test result.

[Olesia711]

there simply aren't enough studies (hardly at all!) with B12 and EPI dogs....we just don't have all the answers.

TAMU and i went round and round about why some dogs just don't respond as expected to Cyanocobalamin B12 and yet their B12 levels all of a sudden sky-rocketed when placed on Methylcobalamin with Intrinsic factor. Neither TAMU nor I could explain this..... and neither of us had any prove proof why it Intrinsic factor worked. All we know for certain is that if Cyanocobalmin fails, then try Hydroxycobalamin or Methylcobalamin.

Many, MANY years ago there was a study that was done that showed some animals could use other species intrinsic factor with success while yet others needed to be species specific. Dogs supposedly needed to be species specific.

However, a (company) that we were working with producing oral B12 observed via multiple individual B12 blood tests on EPI dogs (no control clinical trial that when some of these dogs were placed on oral Methylcobalamin B12 their B12 levels dd not come up, but once the company was able to finally source porcine intrinsic factor, these same dogs B12 levels with both Methylcobalamin + Intrinsic factor skyrocketed. Epi4Dogs wanted to do a controlled clinical trial with this, but we did not have enough $$$ to fund such a research.... so the best we can do is suggest trying Methylcobalamin B12 with Intrinsic Factor if/when Cyanocobalamin doesn't yield the expected results... or if the pet owner just wants to go with an oral B12 from the beginning.

The other B12 observation we noticed, although again, no clinical trial, just an observation.... is that it if there is going to be an issue with Cyanocobalamin B12 it is usually with small dogs vs. large dogs. Again.... i have no idea why.

[Eddiespaghetti]

Eddie kind of had this problem. Not the exact same symptoms but pretty close. We eventually broke down and started doing B12 shots instead of capsules. It has helped him quite a bit. Now whenever he starts to have diarrhea, we give him a B12 shot and it clears up quickly. I don't know if it's the B12 or not helping him

[DocX]

Test results came back: folate 8.2 (ref range 7.7 - 24.4) and B12 760 (ref range 251-908). From this I assume that she's still doing a reasonable job absorbing the B12 as cyanocobalamin. My understanding is that if her small bowel was massively overgrown, folate would probably be quite high?

Olesia, that's so interesting about the B12. Apparently exocrine pancreas cells are the main source of dog intrinsic factor, but parietal cells in the stomach can also produce a little. Perhaps this process has a lot of within-dog variation and Mina's stomach has picked up the slack better than usual. It would be neat if intrinsic factor in stool could be measured and used to predict whether alternative B12 supplementation was needed.

[Olesia711]

yeah... i have a LOT of unanswered questions about B12.... but until we can do a controlled study, i have to go with a combo of what we do know from research combined with repeated anecdotal evidence.

so 760 B12 is okay.

Question for you.... you mentioned that Mina is "Chewing up twelve pancreatin tablets every day has given Mina lovely, clean teeth for a dog her age." If we look at the possibility that this is not a B12 issue and maybe more likely a SID/SIBO/Dysbiosis issue... it's possible that Mina is not getting all the enzymes at the right time that she needs from these enzyme pills.... for one of two reasons:
1. as some of these dogs age, they often need a little more enzymes than what sustained them before.... and when not getting enough enzymes SID will unfortunately get out-of control. One symptom of SID, is going off their food (would explain the other dog eating her poo, and the poo that slowly got worse and the diarrhea that the Carafate is helping with, etc...)
2. usually, if taking enzyme pills, EPI dogs do better when the pills are crushed, added to the food, incubated and then served (unless you are giving enteric coated enzymes).

Maybe next step is to up the enzymes by another pill or two and then you might want to try crushing the pills, mixing in the food to see if this improves anything????

[waylonwesley]

Eddie experienced health issues similar to those you are observing, though not identical. After switching from B12 capsules to B12 shots he noticed a significant improvement in his condition. Whenever he began to experience diarrhea, a B12 shot would quickly alleviate the problem. While it is uncertain whether the B12 is solely responsible for this improvement, it has proven effective for him. This anecdote could provide valuable insight when discussing treatment options for Mina with your veterinarian

[DocX]

I want to thank you all for so many suggestions, especially Wesley, Eddie, and Olesia!

Mina's internal medicine specialist says she has no concerns about B12 (or folate), but she thinks EPI doesn't entirely explain Mina and that she will eventually end up with an IBD diagnosis as well. However, we agreed not to discuss endoscopy further unless diet and medication management is no longer working. She also wants me to try to get Mina off all antibiotics and we had a very reasonable discussion about how I'd love to but I'm not sure it will work.

The plan is: switch to low-residue diet (Hills I/d), add slippery elm (vet is a big fan), add visibiome probiotic, and call her when I'm at the point that I think that Mina needs tylosin again so she can try something else (probably short course of mesalamine). Mina is down about seven pounds from where she should be so I need to feed her 20 calories per pound of ideal body weight for a while and see if she gains.

[Olesia711]

Hi Doc,

So sorry i am just now reading your post about Mina's update from the internal med vet.

I do have some suggestions i'd like to share with you. First i really agree with your vet to try and take Mina off the antibiotics. We encourage everyone to try this if/when possible. Unfortunately, it's not always possible and some dogs have to stay on Tylan for life but at a tiny maintenance dose... BUT................When it comes to stopping Tylan...... over the years here on the forum, we have come up with a slow withdrawal technique that i discussed with Dr. Suchodolski over at TAMU and he said it made sense why this would work for some of those dogs that appear to go back to loose stools when stopping Tylan all at once.

here is the Tylan withdrawal technique:
1. After the 45 day/twice a day course of Tylan is completed.... do not stop the Tylan completely but rather:
2. give 1/2 dose of Tylan twice a day for the next week.
3. at the end of the above week, then give 1/2 dose of Tylan once a day for another week.
4. at the end of the above week, then give 1/2 dose of Tylan every other day for one more week.
Then stop. Fingers and Paws crossed that this works! (please share this with your vet)

Another suggestion that i did with my current dog who i too think may have been edging into possible IBD.
I tried multiple probiotics, none really had any positive effect.
High Fiber food helps but i can only use it until the poo straightens out and then i have to slowly segue out of the high fiber food .
Hills I/D helped and then it didn't.

A member here wrote me privately and suggested a single and specific strain of Lactobaccillus called L-Reuteri.

OMG... it worked and continues to work. ( i am forever thankful to this members for writing me about this ) The product that i use is " CaniOtic"
https://www.chewy.com/bluegrass-animal- ... VMQAvD_BwE
it only contains L-Reuteri ...BUT this Lacto strain L-reuteri is "live" (hence the short viable date) and "These tablets are packed with live cultured canine bacteria (in other words taken from healthy dogs/processed into a pill form). It is mfg in Kentucky. Since this is live bacteria, there is a very timely expiration date depending on when the batch you purchased was processed.... So far my purchases had expiration dates between 3 months and 6 months (6 mo was the longest.. )

My thought on this product is that it is almost like the 2nd part of an FMT (Fecal Microbiota Transplant) in a pill... (without the high cost)... with Live bacteria. Live and "viable" bacteria is one of the things Dr.Joerg Steiner/TAMU suggests in one of his dysbiosis reports with regards to giving your dog probiotics if they are going to work (as they don't always work).

It took 3 weeks before i noticed an complete turn-around with my dog's elimination.
SO.... just mentioning in case this is something you might want to talk to your vet about trying prior to getting off Tylan completely ????