Possible EPI diagnose? Please Help

[lylzzf3841]

Hi all, I'm Uto and new to the forum. I have a beautiful male Germen Shepherd who will be 8 year old in February. I wanted to apologize in advance for this lengthy post.

About 3 months ago he had a really bad diarrhea (mostly large bowel because of the urgency and frequency) out of nowhere and were put on bland diet immediately. The diarrhea resolved after a day, but came back even worse (with fresh blood streaks) when we tried to switch him back to his normal diet. We ran a fecal tests for parasites and it was all negative. He was sent home with Hills i/d and probiotics which worked well. His poop returned to normal when he's on bland diet + hill's i/d.

This is where all things began. Ever since the initial diarrhea episode he could no longer eat his normal diet, no matter how slowly we tried to switch him back. The soft stool will always return at certain point. It seems he couldn't handle even a little bit of fat content. The only thing was working for him was lean chicken breast/fish, boiled rice and Hill's i/d. He's lost about 5lbs in the past 3 month.

About a week ago, he had another really bad diarrhea which was completely liquid and bloody and won't resolve with bland diet. We rushed him to emergency where they ran all sorts of tests, xrays, ultrasound and also IDEXX GI and pancreas tests. We were sent home with Metronidazole and Panacur. The antibiotics worked really well for him. The diarrhea immediately stopped even when he has higher content fat intake. But after we finished a 5 days of antibiotics and Panacur course, the soft stool came back.

His IDEXX result were in 2 days ago, it turned out his TLI was 6.7, and he's also got a really low B12 number. He received a B12 shot immediately and doctor prescribed Tylan powder because I was so worried about long term side effect with Metronidazole. The doctor doesn't seem to think he's got EPI because according to IDEXX, his number was in the normal range. But I read about the updated interval from TAMU and know that this is considered subnormal and EPI is highly possible.

I've been reading through the EPI4dogs website and am really overwhelmed by all the info. So I got some questions that I'd really appreciate if someone can help me out here -

• Based on his TLI number, should I start enzyme treatment immediately? If he doesn't have EPI, would enzyme do any harm to him? e.g. make the enzyme produced by pancreas reduce further?

• The doctor seems to believe that it's more like SIBO or IBD because his diarrhea was very responsive to antibiotics. But as I understand SID/SIBO don't normally show up as a primary condition. So what should I try first, Tylan or enzyme? The dosage doctor prescribed was 1/8 tsp per 24 hours, which also doesn't seem to align with what I read about treating SID/SIBO

• Currently he has not been on any medication for about 5 days. His stool is usually very solid and normal in the morning, but very soft/formless in the evening. Is this a typical sign of EPI?

• He's now scheduled for weekly B12 shot for 6 week. Should I also do oral supplements at the same time, will that help?

I'm really at lost here what should I be doing first. But thanks so much reading the post. Looking forward to your replies

[Eddiespaghetti]

Hello Uto,
Let me start by saying the blood is probably from straining and/or the amount they were going potty. That shouldn't be an issue long term.
TLI of 6.7, with the new numbers, it is suggested to do a trial of enzymes. Were they fasted for at least 12 hours prior to the test? If not that can skew the results. As far as I am aware it will make the results higher than they actually are.
It is possible and probable it's both EPI and SIDs. Short intestine dybiosis is the newer name for SIBO. The problem is if you do just the Tylan and they have EPI the poop won't improve and if you do just the enzymes, the SIDs won't improve. You will have to start both to notice any real difference.
1/8th of a teaspoon seems low, but I do not know their weight. Plus, it's usually done every 12 hours. Your vet might have him on a low dose because they don't know for sure what is going on. You could also try slippery elm instead of Tylan, if you want to go that route.
The B12 shots should be sufficient for the next 6 weeks but it won't do any harm in also doing oral supplements. That is a personal preference, and if you are able to give them.
Pooping schedule is weird with untreated EPI and sometimes it can be super firm while other times it's just a waterfall. Color seems to matter more, and will typically be yellow or grey.
Metronidazole is really good at masking symptoms while not fixing anything. It is really a terrible drug. Luckily, more and more vets are moving away from it as the first choice. Studies are starting to show that is can actually slow down recovery.

[lylzzf3841]

Were they fasted for at least 12 hours prior to the test? If not that can skew the results. As far as I am aware it will make the results higher than they actually are.
It is possible and probable it's both EPI and SIDs. Short intestine dybiosis is the newer name for SIBO. The problem is if you do just the Tylan and they have EPI the poop won't improve and if you do just the enzymes, the SIDs won't improve. You will have to start both to notice any real difference.
1/8th of a teaspoon seems low, but I do not know their weight. Plus, it's usually done every 12 hours. Your vet might have him on a low dose because they don't know for sure what is going on. You could also try slippery elm instead of Tylan, if you want to go that route.
The B12 shots should be sufficient for the next 6 weeks but it won't do any harm in also doing oral supplements. That is a personal preference, and if you are able to give them.

Hi @Eddiespaghetti Thank you so much for the reply! Yes he was fasted (not intentionally but he didn't eat at all on the we were at the emergency). The thing about starting the 2 together is I'm afraid that I won't be able to actually rule out the cause, and I definitely do not want to put him on something unless it's absolutely necessary. I guess I'll start with enzyme since I happen to have some Pancreatin by Solaray. I've also ordered Slippery elm and will also try that once it arrives. Right now he's on Proviable DC which also contains FOS.

Pooping schedule is weird with untreated EPI and sometimes it can be super firm while other times it's just a waterfall. Color seems to matter more, and will typically be yellow or grey.
Metronidazole is really good at masking symptoms while not fixing anything. It is really a terrible drug. Luckily, more and more vets are moving away from it as the first choice. Studies are starting to show that is can actually slow down recovery.

He's stool is usually dark/light brown, depends on how bland his diet was. I haven't really observed any pale/grey color, even when he was having soft stools, but I guess that's because his diet is very low in fat for that past 3 month. I did notice when he was on Metronidazole the color turned more yellow-ish.

I guess I just still can't wrap my head around why EPI would be responsive to antibiotics, even though it's effective for the underlying SID, shouldn't we still see the EPI stool? Part of me always think it was the diarrhea left untreated 3 month ago and things just went spiraling down from there . And he's now somehow suffering a long-term infection/inflammation in his small intestines. When the doctor did the ultrasounds there was severely decreased intestinal motility, but no mass was found.

[Eddiespaghetti]

SIDs is usually caused the soft/cow pie stools. The overgrowth of bacteria also makes them smell horrid. The metro can clear that up, but then the EPI stools are usually huge and are yellow or grey sometimes orange. It will have bits of food in it as well. I went through the same metronidazole cycle and that is what happened with my Eddie boi.
I get not wanting to give anything that is not needed. It's just tough since EPI and SIDs goes hand in hand. Without treating EPI the SIDs will never go away. The undigested food will keep creating more bacteria. Enzymes and slippery elm will hopefully take care of it. If not, you do have the Tylan. Both enzymes and tylan are incredibly safe for dogs and have a high margin of safety on them.

[Olesia711]

Hi Uto,

thanks for writing in! with a score of 6.7..... according to the new TLI scoring... it is highly suggestive of possible EPI.... and they recommend starting enzymes at this juncture... and watch to see if the response to the enzymes is positive.

IF this is EPI... or if your dog is developing EPI, the problem is that all dogs with EPI have SID (small intestinal dysbiosis). This is why you need to address both.

The iffy stools that you are describing often happens when a dog is segueing into EPI.... but your vet is also correct, as this could be something like IBD and may not evolve into EPI... however... with a 6.7 TLI test score... i personally would opt to lean towards possible EPI.

The good thing about giving the enzymes, even if your dog does not develop full blown EPI... is that the enzymes will not hurt. The only thing we do advise is to not keep a dog on enzymes for a long duration (like a year or more) if the dog has not been confirmed with EPI. IN the past some folks "guessed" that their dog had EPI and treated it with enzymes.... after a year or more, what then happened was that the dog developed loose stools because it did not need the enzymes... this was the only adverse affect from long term use.

I do like the fact that your vet is offering Tylan... like Jeremy alluded to, many vets are finally starting to thankfully shy away from using Metro if they do not have to. If you dog is around 60lbs i suspect that the Tylan dose is too low.... usually around 60lbs, they take 1/4 tsp twice a day for 45 days.....

Just a FYI.... many EPI dogs, before diagnosis, are placed on Hills i/d food and it works... temporarily... simply because Hills i/d is loaded with prebiotics... and this does help the dysbiosis. but over time, EPI rears it's ugly head and enzymes will be needed to maintain stability.
But the same can also be said for IBD.

With regards to the B12.... the shots should suffice for now, but, whatever is going on is chronic.... and when you have a chronic condition with low B12, you need to continue B12 supplementation and not stop the B12 supplementation even when the B12 levels are brought up to par. Instead, what you do at that point is continue the B12 supplementation, but at a reduced amount and or reduced frequency...but do not stop the B12. This is where the pills might come in handy

Going by just your post, i personally would add enzymes to the regimen for possible EPI along with Tylan for the dysbiosis ( SIBO / SID) .. and after a few months, assess if you think the dog is doing well all around on the enzymes. If you do not think the enzymes are helping... then stop them.... and try a prescription hydrolyzed food for possible IBD and see if that helps. In the meantime.... if you and your vet cannot confirm what is really going on with your dog... i would re-do the TLI test in 6 months to see if your dog is segueing into EPI or not.

Based on the information you provided in your post.... your observations with the poo, antibiotics, etc. does not IMHO rule out EPI.... but rather l think EPI is still a possibility and it is something you and your vet are going to have to watch for.

What might help is if you kept a journal, or what we call, an EPI log. Record EVERYTHING you give your dog and record with response (poo condition, etc, farting, tummy noises, regurgitation, vomiting, etc).... make only one-change-at-a-time... even take poo pics to show a "response" . BY keeping a journal, this might really help you and your vet more easily figure out what is really going on, whether this is EPI or IBD or something else. Here is a link to the EPI log page. Check it out and see if this is something you can do.
https://epi4dogs.com/epi-log/

[lylzzf3841]

Hi Uto,

thanks for writing in! with a score of 6.7.....

@Olesia711 Thanks so much for taking the time and providing so much details. I agree that at this point we can't rule out EPI at all and it's the best to start enzyme and Tylan together to try to get my boy to a more stable phase. I'm relieved to read that even if he doesn't have EPI the extra enzyme wouldn't hurt. I'm still waiting on the purchase from ENZYME DIANE and capsules for Tylan powder (my dog won't touch it when mixed in his food).

My dog is currently around 75lbs. I actually double checked with my vet on the Tylan dosage - it seems that she didn't really know if Tylan would work and actually wanted to start another Metro course. I insisted to try Tylan and she probably thought 1/8 tsp per 24 hours is enough for maintenance.

I'm also look into delayed released capsules for enzyme since it seems to be a bit easier to administer (I don't really trust myself with the whole incubation process), do you have any recommendations for that?

[lylzzf3841]

SIDs is usually caused the soft/cow pie stools. The overgrowth of bacteria also makes them smell horrid. The metro can clear that up, but then the EPI stools are usually huge and are yellow or grey sometimes orange. It will have bits of food in it as well. I went through the same metronidazole cycle and that is what happened with my Eddie boi.
I get not wanting to give anything that is not needed. It's just tough since EPI and SIDs goes hand in hand. Without treating EPI the SIDs will never go away. The undigested food will keep creating more bacteria. Enzymes and slippery elm will hopefully take care of it. If not, you do have the Tylan. Both enzymes and tylan are incredibly safe for dogs and have a high margin of safety on them.

Great to know that they're both safe. That was the only concern I have regarding the enzyme + Tylan trial. I added some solaray enzymes to his food today since I happen to have some. Did the conversion based on the info proved on Enzyme Diane website. Not sure if I'll notice any difference tomorrow, but keep my fingers crossed.

[Eddiespaghetti]

I'm also look into delayed released capsules for enzyme since it seems to be a bit easier to administer (I don't really trust myself with the whole incubation process), do you have any recommendations

Are you looking for recommendations for the incubation process, or for the capsules?

Tylan is so safe, it was something like 11 grams a day dosage for 2 years before they saw any effects. 22 grams is considered the lethal dose. About a 4th of the entire 100 gram tub. Obviously, I don't recommend giving more than the required amount.
If it is EPI, I noticed a difference the very first time I gave him enzymes. He went from pooping 2-3 hours after a meal to pooping every 12 hours. His stomach made a lot less noise and he just seemed more energetic. I don't know how other dogs reacted immediately, but Eddie responded quickly.

[Olesia711]

If this is EPI.... results can be varied (but i will also explain why here ..

for example:
1. Jeremy saw an immediate improvement once his dog was started on enzymes.
2. i saw zero improvement after 2 weeks on the enzymes.... after the 2nd week, the vet prescribed Tylan and within 24 hrs, i saw 100% improvement.

In both cases the enzymes WERE working on EPI.... but what folks do not realize is that BOTH the (1) EPI poo and the (2) SID/SIBO (Dysbiosis) poo looks the same.

SO, while the enzymes were working on my dog, the dysbiosis was so out of control, that i was still seeing loose, light colored poo... until we started the Tylan which got the dysbiosis under good control.

I'd like to also comment on some points you made in your post. With Tylan, it is very forgiving (you do not have to be exact in the dose) but very often, it is better to give a pinch more (in the beginning) then less. If your dog turns out to need to be on Tylan for life..... once you get the dysbiosis under good control.... THEN and only then... do you try to give the lowest dose of Tylan possible but that will still maintain your dog's dysbiosis. It does not work to start off with a "less than" dose of Tylan in the beginning....

Regarding your comment "delayed released capsules for enzyme since it seems to be a bit easier to administer ".....do not do this unless you HAVE to .... unless your dog cannot take powdered enzymes or for folks who do not have access to the powdered enyzmes.

Powdered porcine enzymes are the best for EPI dogs and the most easy to administer and get right for the dog. Sometimes we have to give our dogs CREON (enteric coated capsules) and although do-able....it is much more expensive (in the USA) and you have to play around with the capsules to find what administration technique works best for your individual dog. CREON is designed for human consumption with a pH of around 5.... where as a dog's digestive pH is around 1... SO we have to try different methods of administering the CREON until we find a technique that works best for the individual dog. Some folks will buy CREON to give when they are travelling, for ease... but use powdered enzyme for the main-stay of giving enzymes. Also.... the minute size of the powdered particles are better utilized by the dog's digestive system vs. the CREON pellets (which are larger).... but...CREON will and does work if this is the only EPI medication you can get or if you have a situation like a diabetic dog that HAS to eat, and your dog 100% refuses to eat anything with the powdered enzymes on it. It is crucial for a diabetic dog to eat, so if they don't and also have EPI, this is another situation where we recommend CREON, a enteric coated enzyme. CREON 12 comes as a delayed release capsule. Although the delayed release works.... the non-delayed release capsules appear to work better.. in short, we all do the best we can with what we have to work with

SO......... my understanding is that your dog will not touch the food with the powdered enzymes in it??? Before resorting to a different method, what we first strongly suggest (unless your dog is a diabetic and you don't have choice of trying these options).... is to
1. put a topper on top of the food with the enzymes mixed in with moist food for 20 minutes ... for toppers, you can try BB sauce, parmesan cheese, stinky canned cat food, canned kippers/sardines ... any of this sprinkled on top of the food.
2. if the above doesn't work... try giving you dog 1/4 of the food you normally would feed... kind of reverse psychology.... when they see so much less of their meal, they freak out and decide to eat it.
3. If they refuse to eat the food within 10 minutes.... take the dish away and DO NOT offer them any food again until next meal time. Usually they will go no more then 2 days without really eating and then they decide, enzymes be damned, they are now hungry and will eat it even with enzymes.

ONLY when all of the above fails (usually by #3 the problem is solved).... but if not.... THEN the next step is just purchase empty gel caps... stuff the powdered enzymes into the empty gel caps equivalent to the amount of enzymes needed to cover that meal plus add 1 more capsule of enzymes (due to the fact that this technique will work but is not as effective as directly mixing the powdered enzymes into the actual meal itself.

And last but not least..... if you have to resort to pouring the designated powdered enzymes into empty gel caps.... then... once done with the powder you have on hand.... then you might as well just go ahead and order CREON. However.... if you are in the USA and need CREON, we strongly advise getting a script from your vet and we will give you the link to an online Canadian source to get the CREON for about $75.00 for 100 capsules of CREON 10.... vs. paying some outrageous price at USA walmart, or any USA drugstore etc....

hopefully this info helps you with some of your decision making.

[lylzzf3841]

Are you looking for recommendations for the incubation process, or for the capsules?

@Eddiespaghetti mostly I was looking for recommendation for the capsules, but could also use some help with incubation process. I sometimes feed my dog frozen raw patties. So even adding warm water to it the temperatures will still be way below that for enzyme activation. Do I need to wait longer for it? or if I just add the enzyme into warm water and wait for 20 mins, then mix it into the food, would it make any difference?

CREON is designed for human consumption with a pH of around 5.... where as a dog's digestive pH is around 1...

I was under the impression that enteric coated capsules will only dissolve in more alkaline environment, i.e small intestines with ph > 5.5. Doesn't it make it even more suitable for dogs since the chances of having ph>5.5 in dogs' stomach are extremely low? I always somehow thought making the enzyme survive through the stomach acid is the key (I have a family member who used to rely on enzymes).

My dog doesn't seem to mind the enzyme powder or the smell in his meal, it was mainly me trying to figure out what's the best process to bring out the full potency of the enzymes. But he hates Tylan powder, no matter how hard I tried he won't touch his food with Tylan in it.

So a little update on my dog, he received some low potency enzyme yesterday (I did my best, still waiting for enzyme Diane) with lunch and dinner, but not Tylan yet since I'm still waiting on the gelatin capsule. His poop this morning is actually much worse than yesterday I guess it's part of SID getting out of control since he hasn't been on any antibiotics for past 5 days. I'll give him some Tylan this evening and see how it goes tomorrow.