New to the forum

[Olesia711]

SO glad to hear that VOS is doing much better... gaining weight and more active!

The problem with EPI dogs and vet advice is that the diagnose, give a recommendation and send you on your way.... BUT.... with EPI dogs.... that doesn't always work cause much of the suggestions for EPI need to be "tweaked"" to best suit the individual dog's system.... and vets don't have the time to work with you 24/7.

This is where we come in. After working with EPI pets for 15 years, 24/7... we have seen more EPI cases than anyone else.... and because of this, we have observed which of the many adjustments "Tweaks" that just might yield better results for the EPI patient. Of course there is never any guarantee..... but we are here 24/7 to walk you thru these many adjustments step-by-step. HOWEVER... always, Always, ALWAYS still share everything we suggest to you with your vet.

[Vossiesmom]

SO glad to hear that VOS is doing much better... gaining weight and more active!

The problem with EPI dogs and vet advice is that the diagnose, give a recommendation and send you on your way.... BUT.... with EPI dogs.... that doesn't always work cause much of the suggestions for EPI need to be "tweaked"" to best suit the individual dog's system.... and vets don't have the time to work with you 24/7.

This is where we come in. After working with EPI pets for 15 years, 24/7... we have seen more EPI cases than anyone else.... and because of this, we have observed which of the many adjustments "Tweaks" that just might yield better results for the EPI patient. Of course there is never any guarantee..... but we are here 24/7 to walk you thru these many adjustments step-by-step. HOWEVER... always, Always, ALWAYS still share everything we suggest to you with your vet.

It's such a relief to see our sweet girl doing so well. We had to adjust her harness twice in the last two weeks and she's the heaviest she's ever been! And it even seems like she's growing taller too. With all the extra energy she can finally be taken to the park again to run around and play with other doggies.

We also transferred Vos again, this time to a raw meat mix that has beef pancreas in it too. It's from a Dutch brand (Carnibest) that made this mix specifically for EPI dogs. We took a lot of time to transfer her from kibble + enzymes, first putting some boiling water over the raw meat (and after letting that cool adding enzymes, because the water most likely killed the enzymes in the raw pancreas). Since a week she's fully transferred to the raw diet.
Vos' poop now is most of the time very solid and in the morning they are crumbly. The past week she would have solid logs (with moist surface) in the afternoon followed by soft poop. But all still small amounts, nothing like the huge soft piles she used to have.
Dogs that are used to eating kibble can start 'detoxing' when they transfer to raw, so they start shedding (that's definitely happening) and you can also see a reaction in their stool for a couple of weeks. With that in mind we just kept doing what we were doing and yesterday was the first day since this transfer that all her poops were good! If it stays that way she wouldn't need enzymes on her meals anymore!

It's been so nice to have this forum and the website for all the adjustments after the diagnosis. The log is also a great, insightful tool.
It would have been so much more of a struggle if we wouldn't have all this wonderful information. We are very grateful for EPI4dogs!

[Vossiesmom]

And some photos to show Vos' weight gain so far:

A month before the diagnosis/starting with enzymes (late January):

WhatsApp Image 2023-04-13 at 11.48.32.jpeg (285.22 KiB) Viewed 69349 times

Yesterday:

WhatsApp Image 2023-04-13 at 12.08.06.jpeg (293.87 KiB) Viewed 69349 times

[jilbert57]

Marie,
What a great update on Vossie! She is beautiful, and the no rib picture is just right. What a cutie. It sure is nice when everything comes together with the food also. Great job.

Jill

[Olesia711]

Hi Marie,

So good to hear how well Vos is doing and i appreciate you sharing with us her journey from kibble to raw... and YES... it does take time, but overall it is amazing the difference feeding "real" food can make vs. over baked/nutrient depleted kibble.

The raw food has natural enzymes in it PLUS it sounds like this company includes raw pancreas in the mix... but if you are putting boiling water over it, as you said, i am sure much of the natural enzymes might be killed, so i think you are doing the right thing by adding enzymes. However.... i wouldn't stop using enzymes all together... we have had others try this over the years, when feeding raw... and all seems fine for a little while and then things go all wrong again. If anything.... when you feel Vos is very stable and has been for a while on this regimen, at that point try reducing the enzymes... little by little. I am guessing you will discover that in the end you probably do not need to use as much enzymes as you are using now.

Love the picture of Vos... Looking REALLY good and sure is a cutie!!!!

Please continue to keep us posted.

[Vossiesmom]

Hi Marie,

So good to hear how well Vos is doing and i appreciate you sharing with us her journey from kibble to raw... and YES... it does take time, but overall it is amazing the difference feeding "real" food can make vs. over baked/nutrient depleted kibble.

The raw food has natural enzymes in it PLUS it sounds like this company includes raw pancreas in the mix... but if you are putting boiling water over it, as you said, i am sure much of the natural enzymes might be killed, so i think you are doing the right thing by adding enzymes. However.... i wouldn't stop using enzymes all together... we have had others try this over the years, when feeding raw... and all seems fine for a little while and then things go all wrong again. If anything.... when you feel Vos is very stable and has been for a while on this regimen, at that point try reducing the enzymes... little by little. I am guessing you will discover that in the end you probably do not need to use as much enzymes as you are using now.

Love the picture of Vos... Looking REALLY good and sure is a cutie!!!!

Please continue to keep us posted.

Hi again!
Soooo I was thinking and hoping that Vos would do fine with just the raw food and guess what... The exact thing that you described happened...
Vos' morning poop has been good in the morning and later on in the day getting softer again, sometimes even diarrhea.

Vos' ALT level have gone up from 300 (March) to 1500 (now). So we were sent to the pet hospital to get an ultrasound of her liver, which happened last Monday. We spent 4(!) hours in the hospital, because they also did a biopsy of her spleen and a lymph node by her intestines, both looked enlarged. On the ultrasound they didn't see anything out of the ordinary with her liver. They also tested for a bunch of other stuff, but nothing came out of all tests and the biopsies show no signs of cancer. At the hospital they are suggesting doing another biopsy, but now of the liver (to see if there's copper building up), possibly through surgery. Not having unlimited money and being concerned for Vos' stress levels(she gets incredibly anxious, every time it's worse), we decided to talk to our own vet and tell them that we don't want to infinitely run tests on Vos. Right now it feels like trying to find a needle in a haystack, while I have the feeling that the high ALT (and her enlarged lymph node by her intestines) can very well be because Vos' digestion is messed up again. I also mentioned SIBO in the hospital, but they are skeptical of that because Vos' B12 is on the high side. From what I understand from this website is that SIBO is a condition that pretty much all EPI dogs have as a secondary condition and that the tests for SIBO are very flawed.
Our own vet is supporting us following the SIBO protocol on this website, which is what we want to try before poking around in Vos' belly some more. And instead of doing more (invasive) tests on Vos, we're going to keep an eye on Vos' ALT and her bile acid. The acid tells a lot about the liver condition. Until so far it has been good.

I have some questions about the next possible steps:
- This week we started again with adding enzymes (Zymoral) to her raw food (that contains pancreas) and it seems that her poop is darker and more solid again. Goal is to have to use as little added enzymes. How long should we wait/should Vos' poop be good before decreasing the amount of added enzymes?
- After the EPI diagnosis we already started with the first two steps of the SIBO protocol:
* Prebiotics: Vos is using slippery elm, twice a day 1/8 tsp. I think the daily recommended dose is 1/4 tsp, if necessary we can increase that.
* Probiotics: using Greenfield's probiotics now, but we can switch to one of the listed probiotics on this site.
I guess in general my question is, how long do we wait between the steps in the protocol?

Do we for example first try out the current amount of enzymes for a week, if Vos' poop stays good, we decrease, try that for another week. If that also goes well for a week, then we increase the slippery elm, try out for a week. If the poop is good, keep doing this, if not, change the probiotics.
Then with the probiotics the same question: how long do we try out a probiotic? And if it doesn't work, try out a different one?

And what happens if the poop gets worse after increasing slippery elm? Do we decrease it again or do we go to the next step (switching probiotics)?

I feel like I'm making this far more complicated, but I can't seem to figure this out


P.S.: to finish with some good news, Vos now weighs 14,2 kg, which means that she almost gained half of her weight!

[Olesia711]

Hi Marie,

Thanks for writing in with an update on Vos Very glad to hear about the weight gain!
Now... about everything else. I will try to answer as best i can.

Regarding the high ALT....and the enlarged lymph node/spleen/intestines they noticed from the ultrasound. If they didn't find cancer, etc. i have to agree with you and your vet to not do anymore "exploratory" surgeries at this time. In short, sometimes an enlarged spleen doesn't even require treatment, unless deemed necessary. WIth regards to the enlarged lymph, and i am guessing enlarged intestines? This can be simply all from SID along with the high B12. Just because the B12 is high does not eliminate SID... And you are correct. ALL dogs with EPI have SID to one degree or another. Our objective is to keep it under good control. When it is not under good control, the ALT can get quite high. Especially when their digestion is all messed up like you mentioned.

My take is that you did the right thing, you had an ultrasound done and you had Vos tested. SInce nothing showed... for now, if your vet agrees, i would focus on getting the SID under better control and then retest the blood to see if the ALT levels are coming down. If not... THEN i would proceed with more testing.

And yes, you are correct, there are NO reliable tests for SIBO. the reasons are (straight from Texas A&M Gastro Lab/ Dr. Joerg Steiner, Dir of the TMU lab)" Folate test results such as Culturing, Counting bacterial numbers, and Duodenal juice collection all have majors flaws in their technique rendering them inaccurate indications of SID/SIBO, but rather “the type of flora and/or
how the host and flora interact is most important.” Recent studies have revealed that all dogs with EPI have SID. "

SO.... getting the ALT down if this is SID (previously called SIBO)down.. which sounds like a good possibility... IMHO sounds like the best next step.

Also.... dogs with EPI also have dysregulated bile acid functionality.... sometimes we see physical evidence of this (regurg) and if so, treat... but if no physical evidence... leave as is.

Please read and share with your vet the latest on bile acids in EPI dogs which ties in with SID/dysbiosis:
https://epi4dogs.com/epi-research/
there is multiple research about this since 2017 on this page.

SO...... how to get SID back under better control.
first we try SLippery Elm powder.... as a prebiotic. many times it helps, but sometimes it just doesn't
Over all, prebiotics can and do work on SID, but sometimes you have to try different prebiotics.... the problem with prebiotics is that too little does nothing but too much trigger loose stools....so if Slippery Elm doesn't work then try a probiotic with prebiotics in it. I see that you are using a probiotic with prebiotic in it... but i am not sure if this product is helping or not..... so...

In your situation, go ahead and increase the SE (Slippery Elm)to the 1/4 tsp and watch the stools for a few days...(2 or 3) to ascertain if the increased SE appears to be helping or not.

The Greenfield probiotic you are using may or may not be helping..... might want to try PROVIABLE-FORTE... i am assuming you can get this in the UK. if not, let me know and i can do more research.

I looked up the Zymoral (again) and it looks low in USP Lipase units at 20,000
Composition
Lactose 47.5%, pancreatic powder (from pigs). Contains per gram of powder: 20,000 USP units of lipase, 100,000 USP units of protease and 100,000 USP units of amylase.

https://www.vetsend.co.uk/zymoral-pancreas-powder#:~:text=Zymoral%20pancreas%20powder%20is%20a%20nutritional%20supplement%20that,and%20cats.%20The%20nutritional%20supplement%20is%20vanilla%20scented.

(typically with dry food we give 71,000USP units of Lipase per 1 cup food)....
so, since you are doing raw, this can be decreased and on top of this i am guessing Vos still doesn't need so much, but maybe needs more than what she has been getting.......... so.... what i would try is 2 scopes of this per 1 cup of "minced/finely chopped" raw food.... watch the poos and ascertain after 3 to 5 days, if this increase in enzymes appears to be helping or hurting. My premise is that If not enough enzymes are given, the SID will get worse and worse.....

SO.... on to the decreasing enzyme bit.... IMHO i actually think you should up the enzymes for now... UNLESS her poos are perfectly firm right now on the enzyme dose you are giving her....

DO NOT reduce the enzyme dose until after she has been delivering perfect solid poos for about a month... if/when this happens... then we typically say to try reducing the amount of enzymes by 1/8 of a tsp at a time. HOWEVER.... if the Zymoral product you are using only has 20,000 USP units of Lipase and you are only giving one scoop with one cup of food, i personally don't think i would try to reduce this any further simply because this is a low dose and if it is working, don't mess with it.

Please check the Zymoral package you have to make sure that my analysis of Zymoral only having 20,000 USP units of Lipase is the same on the product you are using.

your questions:
Prebiotics: Vos is using slippery elm, twice a day 1/8 tsp. I think the daily recommended dose is 1/4 tsp, if necessary we can increase that. Yes, try increasing and watch to see if this helps., if it makes it worse, reduce, if it doesn't help stop the slippery elm
* Probiotics: using Greenfield's probiotics now, but we can switch to one of the listed probiotics on this site. IMHO... i think i'd switch, try PROVIABLE and watch for 3 to 5 days to see if you see ANY improvement or not.
I guess in general my question is, how long do we wait between the steps in the protocol? Slippery Elm 2 to 3 days, probiotics, usually a week or two, BUT you should notice a tiny change one way or another within a few days....

Do we for example first try out the current amount of enzymes for a week, if Vos' poop stays good, we decrease, try that for another week. If that also goes well for a week, then we increase the slippery elm, try out for a week. If the poop is good, keep doing this, if not, change the probiotics.
Then with the probiotics the same question: how long do we try out a probiotic? And if it doesn't work, try out a different one? For all of the above, questions are answered in more detail above

And what happens if the poop gets worse after increasing slippery elm? REduce the Slippery elm and if poos are still sloppy then just stop the SLippery Elm and focus on pre+probiotics:) Do we decrease it again or do we go to the next step (switching probiotics)? Go to the next steps

If pre+probiotics fail (and this too happens) then talk to your vet about trying Tylan (Tylosin Tartrate soluble powder antibiotic) DO NOT give Metronidazole/flagyl! The Tylan is given twice a day with meals for 45 days... and then we think slowly withdrawing works better than stopping cold turkey. Sometimes this needs to be repeated once more time. If the SID is still raging out-of-control... then the next step is a fecal transplant. this sounds gross but it is like giving a new lease on "gut flora" life. It is a cheap procedure AND it is done by pill or enema (the enema technique is touted as better).

What you DO need to do with all the above is try one thing at a time. for example:
#1 try increasing the enzymes and see what happens after a few days (ascertain if it is helping or not)
#2 try increasing the Slippery Elm and determine if the change with SE is helping or hindering after 2 or 3 days
#3 if the above fails then try changing the probiotic+prebiotic
#4 if the probiotic +prebiotic change also fails after say a wee or two at the most, then try Tylan
#5 if the Tylan fails and loose stools etc returns, re-do the Tylan procedure one more time and if that fails, thenhave a chat about Fecal Transplant.

And... if it helps any, Epi4Dogs is getting ready to work on supporting research to better understand SID and maybe how to get rid of it! I swear, managing EPI alone is easy, but managing SID (the dysbiosis) can be a real challenge

Sorry for such a very long post- -i like to give as much details/information as possible, but i hope it helps somewhat and please feel free to ask any further questions you may have.

[Vossiesmom]

Hi Marie,

Thanks for writing in with an update on Vos Very glad to hear about the weight gain!
Now... about everything else. I will try to answer as best i can.

Regarding the high ALT....and the enlarged lymph node/spleen/intestines they noticed from the ultrasound. If they didn't find cancer, etc. i have to agree with you and your vet to not do anymore "exploratory" surgeries at this time. In short, sometimes an enlarged spleen doesn't even require treatment, unless deemed necessary. WIth regards to the enlarged lymph, and i am guessing enlarged intestines? This can be simply all from SID along with the high B12. Just because the B12 is high does not eliminate SID... And you are correct. ALL dogs with EPI have SID to one degree or another. Our objective is to keep it under good control. When it is not under good control, the ALT can get quite high. Especially when their digestion is all messed up like you mentioned.

My take is that you did the right thing, you had an ultrasound done and you had Vos tested. SInce nothing showed... for now, if your vet agrees, i would focus on getting the SID under better control and then retest the blood to see if the ALT levels are coming down. If not... THEN i would proceed with more testing.

And yes, you are correct, there are NO reliable tests for SIBO. the reasons are (straight from Texas A&M Gastro Lab/ Dr. Joerg Steiner, Dir of the TMU lab)" Folate test results such as Culturing, Counting bacterial numbers, and Duodenal juice collection all have majors flaws in their technique rendering them inaccurate indications of SID/SIBO, but rather “the type of flora and/or
how the host and flora interact is most important.” Recent studies have revealed that all dogs with EPI have SID. "

SO.... getting the ALT down if this is SID (previously called SIBO)down.. which sounds like a good possibility... IMHO sounds like the best next step.

Also.... dogs with EPI also have dysregulated bile acid functionality.... sometimes we see physical evidence of this (regurg) and if so, treat... but if no physical evidence... leave as is.

Please read and share with your vet the latest on bile acids in EPI dogs which ties in with SID/dysbiosis:
https://epi4dogs.com/epi-research/
there is multiple research about this since 2017 on this page.

SO...... how to get SID back under better control.
first we try SLippery Elm powder.... as a prebiotic. many times it helps, but sometimes it just doesn't
Over all, prebiotics can and do work on SID, but sometimes you have to try different prebiotics.... the problem with prebiotics is that too little does nothing but too much trigger loose stools....so if Slippery Elm doesn't work then try a probiotic with prebiotics in it. I see that you are using a probiotic with prebiotic in it... but i am not sure if this product is helping or not..... so...

In your situation, go ahead and increase the SE (Slippery Elm)to the 1/4 tsp and watch the stools for a few days...(2 or 3) to ascertain if the increased SE appears to be helping or not.

The Greenfield probiotic you are using may or may not be helping..... might want to try PROVIABLE-FORTE... i am assuming you can get this in the UK. if not, let me know and i can do more research.

I looked up the Zymoral (again) and it looks low in USP Lipase units at 20,000
Composition
Lactose 47.5%, pancreatic powder (from pigs). Contains per gram of powder: 20,000 USP units of lipase, 100,000 USP units of protease and 100,000 USP units of amylase.

https://www.vetsend.co.uk/zymoral-pancreas-powder#:~:text=Zymoral%20pancreas%20powder%20is%20a%20nutritional%20supplement%20that,and%20cats.%20The%20nutritional%20supplement%20is%20vanilla%20scented.

(typically with dry food we give 71,000USP units of Lipase per 1 cup food)....
so, since you are doing raw, this can be decreased and on top of this i am guessing Vos still doesn't need so much, but maybe needs more than what she has been getting.......... so.... what i would try is 2 scopes of this per 1 cup of "minced/finely chopped" raw food.... watch the poos and ascertain after 3 to 5 days, if this increase in enzymes appears to be helping or hurting. My premise is that If not enough enzymes are given, the SID will get worse and worse.....

SO.... on to the decreasing enzyme bit.... IMHO i actually think you should up the enzymes for now... UNLESS her poos are perfectly firm right now on the enzyme dose you are giving her....

DO NOT reduce the enzyme dose until after she has been delivering perfect solid poos for about a month... if/when this happens... then we typically say to try reducing the amount of enzymes by 1/8 of a tsp at a time. HOWEVER.... if the Zymoral product you are using only has 20,000 USP units of Lipase and you are only giving one scoop with one cup of food, i personally don't think i would try to reduce this any further simply because this is a low dose and if it is working, don't mess with it.

Please check the Zymoral package you have to make sure that my analysis of Zymoral only having 20,000 USP units of Lipase is the same on the product you are using.

your questions:
Prebiotics: Vos is using slippery elm, twice a day 1/8 tsp. I think the daily recommended dose is 1/4 tsp, if necessary we can increase that. Yes, try increasing and watch to see if this helps., if it makes it worse, reduce, if it doesn't help stop the slippery elm
* Probiotics: using Greenfield's probiotics now, but we can switch to one of the listed probiotics on this site. IMHO... i think i'd switch, try PROVIABLE and watch for 3 to 5 days to see if you see ANY improvement or not.
I guess in general my question is, how long do we wait between the steps in the protocol? Slippery Elm 2 to 3 days, probiotics, usually a week or two, BUT you should notice a tiny change one way or another within a few days....

Do we for example first try out the current amount of enzymes for a week, if Vos' poop stays good, we decrease, try that for another week. If that also goes well for a week, then we increase the slippery elm, try out for a week. If the poop is good, keep doing this, if not, change the probiotics.
Then with the probiotics the same question: how long do we try out a probiotic? And if it doesn't work, try out a different one? For all of the above, questions are answered in more detail above

And what happens if the poop gets worse after increasing slippery elm? REduce the Slippery elm and if poos are still sloppy then just stop the SLippery Elm and focus on pre+probiotics:) Do we decrease it again or do we go to the next step (switching probiotics)? Go to the next steps

If pre+probiotics fail (and this too happens) then talk to your vet about trying Tylan (Tylosin Tartrate soluble powder antibiotic) DO NOT give Metronidazole/flagyl! The Tylan is given twice a day with meals for 45 days... and then we think slowly withdrawing works better than stopping cold turkey. Sometimes this needs to be repeated once more time. If the SID is still raging out-of-control... then the next step is a fecal transplant. this sounds gross but it is like giving a new lease on "gut flora" life. It is a cheap procedure AND it is done by pill or enema (the enema technique is touted as better).

What you DO need to do with all the above is try one thing at a time. for example:
#1 try increasing the enzymes and see what happens after a few days (ascertain if it is helping or not)
#2 try increasing the Slippery Elm and determine if the change with SE is helping or hindering after 2 or 3 days
#3 if the above fails then try changing the probiotic+prebiotic
#4 if the probiotic +prebiotic change also fails after say a wee or two at the most, then try Tylan
#5 if the Tylan fails and loose stools etc returns, re-do the Tylan procedure one more time and if that fails, thenhave a chat about Fecal Transplant.

And... if it helps any, Epi4Dogs is getting ready to work on supporting research to better understand SID and maybe how to get rid of it! I swear, managing EPI alone is easy, but managing SID (the dysbiosis) can be a real challenge

Sorry for such a very long post- -i like to give as much details/information as possible, but i hope it helps somewhat and please feel free to ask any further questions you may have.

Thank you so much again for this great information!!! And all the details are very helpful!
Also good to hear your perspective on what if probably happening and I'm happy that you agree with our decision of focusing on SID for now rather than more surgical testing.

Oof, so the bile acid test (next to ALT test) wouldn't be very reliable in showing the condition of the liver? Good to know that! I will also read the research you linked and I added it to what I sent the vet.
Since starting the enzymes again (last week) Vos does sometimes have regurgitation, that happened before too when she was on enzymes. So I'm thinking this is more linked to that than to dysregulated bile acid functionality.
Are there things we can do about acid reflux/regurg caused by enzymes? I'm hoping increasing the slippery elm helps, but from what I understand we first need to settle on the right dose of enzymes. Is that right?

The Zymoral package we have here:
Composition is the same as what you looked up
Contains per gram of powder is different: 22.800 USP units of lipase, 95.000 USP units of protease and 95.000 USP units of amylase
But still on the low side of if 71.000 USP units of lipase is the standard to go with 1 cup of food.

We are now on 1/8 tsp of Zymoral per meal (3x a day), I think I'll have to measure how much grams that is to figure out how much UPS lipase that is and how much more Vos needs to get to 71.000 USP lipase. (We don't have the original scoop anymore, just a tsp set.) Or I can try increasing to 1/4 tsp and see what happens for a few days. Once on a good dose I don't think I'll bother decreasing the enzymes again, knowing now that Zymoral is such a low dose.
The poops have been getting better since starting again with the enzymes, they are not pale anymore, but mid brown, and even dry and sometimes crumbly in the morning. But later on in the day the 'ending' of the poop gets soft again. Yesterday they were good all day, today softer poop again(the whole thing, not just the last bit), but Vos also found a lot of 'snacks' on the street(considering a muzzle at this point)...

Am I right that the poops will probably not be completely good from 'just' the right amount of enzymes? If enzymes were enough there wouldn't be a need for the SID protocol, I assume.
I guess my question about this is: what do the poops need to look like to go to step 2 (increasing slippery elm)?
Maybe I'm overthinking this...

I made a translation of the steps for the vet and added most of the info you shared, thanks a lot!!!!

[Olesia711]

thank you for sharing with your vet what we are suggesting ... and the research . Epi dogs do best when everybody works together to help the dog get better.

In regards to "Oof, so the bile acid test (next to ALT test) wouldn't be very reliable in showing the condition of the liver? " the bile acid test is good to do to check on the liver..... BUT.... what i meant is that because of EPI, there already is a dysregulation of bile acid functionality.... so, if you are looking to rule out any liver damage, a bile acid test is very good to do, just be aware that with the EPI condition, there already is a dysregulation with the bile acids. And hopefully the liver, in reality, is just fine and that all these "off" values are SID (small intestinal dysbiosis) related..

In regards to "Since starting the enzymes again (last week) Vos does sometimes have regurgitation, that happened before too when she was on enzymes. So I'm thinking this is more linked to that than to dysregulated bile acid functionality." this happens to lots of dogs on enzymes....... to alleviate this regurg, we suggest talking to your vet about acid reflux meds (like Omeprazole) or even trying a bile acid sequestrant (i think i mentioned Cholestyramine earlier)..... but what is really crazy is that another way to sometimes alleviate this regurg is to slightly reduce the amount of enzymes... but this can be tricky and in Vos's case, she wasn't getting enough enzymes........ SO... yes, you are correct the enzymes are triggering it, but it really is from the very typical bile acid dysregulation that happens with EPI dogs. You and your vet might want to try different things that i suggested and see which one you think best helps Vos.

Regarding how much Zymoral to give Vos.... the 71,400 USP units of Lipase is a "general guideline" per 1 cup of kibble moistened. If using real food, or moist food, you start with less enzymes, maybe 1/2 tsp to 3/4 tsp... HOWEVER.... this is a guideline. SOme dogs need more enzymes, some dogs need less. WHat we use to judge is how the poop looks. the perfect poop is a #2 on the Purina Poop chart..
..
However, with EPI dogs, sometimes you will never get perfect poo, so a #3 is good and even #4 is almost acceptable... but the goal is #2

SO with regards to "The poops have been getting better since starting again with the enzymes, they are not pale anymore, but mid brown, and even dry and sometimes crumbly in the morning. But later on in the day the 'ending' of the poop gets soft again." This could be one of two things:

1. SID (and this "could be" that Vos's digestive system needs more time to get better now that she is back on enzymes and to get SID under better control).... and sometimes this is accomplished by food. SOmetimes certain ingredients just don't optimally agree with an EPI dog, so there might be a lot of trial and error with food.... as you are already discovering by how much improved Vos is doing since you changed the diet. SO this "could" be that the diet still needs a little more "tweaking".
2. OR.....sometimes, with any kind of excitement (good or bad excitement) the poo gets a little softer. This is why some dogs have great poos in the morning, but then as the day goes on, with walking, playing and just being active, the poos get a little softer.

To figure this out, keep good notes, even take poop pictures to include with your notes... and when you try making a change, remember do only 1 change at a time and by including poop pictures, this is a great way to tell if some change/food/medicine dose is helping or hindering. And share with your vet, as this will also help your vet see what is going on.

[Vossiesmom]

thank you for sharing with your vet what we are suggesting ... and the research . Epi dogs do best when everybody works together to help the dog get better.

In regards to "Oof, so the bile acid test (next to ALT test) wouldn't be very reliable in showing the condition of the liver? " the bile acid test is good to do to check on the liver..... BUT.... what i meant is that because of EPI, there already is a dysregulation of bile acid functionality.... so, if you are looking to rule out any liver damage, a bile acid test is very good to do, just be aware that with the EPI condition, there already is a dysregulation with the bile acids. And hopefully the liver, in reality, is just fine and that all these "off" values are SID (small intestinal dysbiosis) related..

In regards to "Since starting the enzymes again (last week) Vos does sometimes have regurgitation, that happened before too when she was on enzymes. So I'm thinking this is more linked to that than to dysregulated bile acid functionality." this happens to lots of dogs on enzymes....... to alleviate this regurg, we suggest talking to your vet about acid reflux meds (like Omeprazole) or even trying a bile acid sequestrant (i think i mentioned Cholestyramine earlier)..... but what is really crazy is that another way to sometimes alleviate this regurg is to slightly reduce the amount of enzymes... but this can be tricky and in Vos's case, she wasn't getting enough enzymes........ SO... yes, you are correct the enzymes are triggering it, but it really is from the very typical bile acid dysregulation that happens with EPI dogs. You and your vet might want to try different things that i suggested and see which one you think best helps Vos.

Regarding how much Zymoral to give Vos.... the 71,400 USP units of Lipase is a "general guideline" per 1 cup of kibble moistened. If using real food, or moist food, you start with less enzymes, maybe 1/2 tsp to 3/4 tsp... HOWEVER.... this is a guideline. SOme dogs need more enzymes, some dogs need less. WHat we use to judge is how the poop looks. the perfect poop is a #2 on the Purina Poop chart..
..
However, with EPI dogs, sometimes you will never get perfect poo, so a #3 is good and even #4 is almost acceptable... but the goal is #2

SO with regards to "The poops have been getting better since starting again with the enzymes, they are not pale anymore, but mid brown, and even dry and sometimes crumbly in the morning. But later on in the day the 'ending' of the poop gets soft again." This could be one of two things:

1. SID (and this "could be" that Vos's digestive system needs more time to get better now that she is back on enzymes and to get SID under better control).... and sometimes this is accomplished by food. SOmetimes certain ingredients just don't optimally agree with an EPI dog, so there might be a lot of trial and error with food.... as you are already discovering by how much improved Vos is doing since you changed the diet. SO this "could" be that the diet still needs a little more "tweaking".
2. OR.....sometimes, with any kind of excitement (good or bad excitement) the poo gets a little softer. This is why some dogs have great poos in the morning, but then as the day goes on, with walking, playing and just being active, the poos get a little softer.

To figure this out, keep good notes, even take poop pictures to include with your notes... and when you try making a change, remember do only 1 change at a time and by including poop pictures, this is a great way to tell if some change/food/medicine dose is helping or hindering. And share with your vet, as this will also help your vet see what is going on.

Thanks for clarifying!!
I'll talk to the vet about acid reflux meds.
Vos' poop is a 2 most part of the day and then then the last one on the afternoon walk is a 3 with 4 to 6 ending.
She does have a lot of anxiety on walks, I think this is probably part of the soft poop too.

Since yesterday Vos has been weird with her food, she didn't finish her breakfast both mornings (did finish lunch and dinner), but does seem very interested in any other food. Earlier in the week she also threw up. I didn't discover anything strange in the puke, it was just the raw meat that she got for lunch. So I'm starting to think that it might be an ingredient in her diet that she doesn't digest well. She is getting Carnibest Pancreas for all three meals (https://carnibest.nl/onze-producten/carnibest-hond/ site is in Dutch).
Composition :
fresh beef (including pancreas), fresh chicken, cold-pressed vegetable oil , natural vitamins and minerals.

Analysis :
Moisture: 61%, Protein: 15%, Fat: 14%, Fiber: 1%, Ash: 3%, Calcium: 0,48%, Phosphorus: 0.43%

The food is pre-mixed, so it's hard to discover what it is exactly that she doesn't digest. So I think our best option would be to change the food again, this time to home cooked.

To make sure Vos eats, yesterday we cooked coalfish for her. The coalfish is something that always goes well, we sometimes give her that as an extra.
Today I gave her half of a cooked sweet potatoe with half a boiled egg (all mashed and enzymed). She loved it, but hasn't pooped yet, so I don't know yet if her tummy likes it too. Added to all this she's getting Alphamix (https://dogchef.s3.eu-west-3.amazonaws.com/files/Alphamix_21_07_vecto.pdf) slippery elm and salmon oil.
She's getting the other half of the sweet potatoe and egg for lunch and for dinner maybe the coalfish again, with more sweet potatoe. Don't know yet, at this point I'm freestyling

I was reading this page https://epi4dogs.com/diet-raw-home-prepared-recipes/ and it seems like a lot of things to consider/think of when switching to home cooked. What would be good to first start with?