New to EPI - advice on managing a flare-up

[zerothehero]

Hello! I'm so glad to have found your forum. First let me say that my dog has not been tested for EPI. He is currently having an episode and after doing some research, I now believe he has EPI. As soon as his episode is resolved I will be getting him the TLI and B12 tests, but for now, I need to get his episode under control and was hoping for some advice. A brief history on my dog...
Male, 50 pounds, Mixed breed (lab/BBM), DOB Dec 21 2013 (6.5 yrs) Neutered April 6 2016 (aged 2.5 yrs)
First episode March 2018. He had gotten into the garbage a few times, vet was just calling it "extreme gastrointestinal distress." Did ultrasounds, x-rays, fecal exams, etc., no answers. He has has a total of at least 5? episodes since then.

Episodes usually start with some light vomiting (bile) and then diarrhea, which quickly turns into a very watery, mucous-y type of diarrhea that smells AWFUL. If treatment is not immediate, it soon turns very bloody. During some of the worst episodes, even his vomit has had flecks of blood in it. Each time, it's been successfully treated with a steroid injection (Dexamethasone), subcutaneous fluids (first episode it was so bad he needed an IV), Ondansetron, Metronidazole, PancrePlus tablets, oral Vit B12, and a 24-hour fast. The first few times, I tried transitioning him back to normal food and off the meds. Each time, the issue recurred. For at LEAST the last year he has been on a prescription diet (Purina Pro Plan Gastroenteric Fiber Balance) and DAILY, even when feeling well, he gets 2 Pancreplus tablets with each meal, 1.5 Metro every 12 hours (375mg) and one Cobalequin tablet each night as a preventative. Despite this, he still had a flare-up over the winter, so I stopped even giving him peanut butter in his kongs and started using prescription wet food (same formula as above). I don't give him any people food (very occasionally I will give something that's safe for dogs, like a small bite of watermelon or 3 blueberries) and I try to limit treats, but I know my mom gives him some treats when I'm not home. She said she feels bad because the other dogs are getting something and my dog always acts like he's STARVING. (Sound familiar?) He's constantly eating grass, sticks, and even dirt. The fenced in yard is mulch and I have to go around and pull every single weed, even ones along the edge because he can reach them through the chainlink. But that doesn't even help because he'll dig under the mulch and literally eat dirt. When not in the midst of an episode, he gets 4 cups a day of the food. For comparison, my siberian husky doesn't even get 2 cups (different food though) and he maintains around 50-55 pounds. (Same weight as Zero.)

This current flare-up started with vomiting bile at 10am Saturday 8/22. I thought it was just because he usually eats every 12 hours, and he'd eaten at 8pm the night before, but I slept in. As I was getting ready to bring him downstairs for breakfast he vomited the bile in my room. We went down and had breakfast, all seemed normal until 8:30 pm. I was holding off until 9 for dinner so that I could feed him around 9 or 10 the net morning without him vomiting bile due to an empty stomach, but then at 8:30 he did a big poop, then strained for a bit and did a little pile of.. how do I describe it? Kind of looked like someone squeezed frosting out of the corner of a ziploc bag. So for dinner I only gave him a little more than half his usual meal, and his meds.

The next morning, Sunday, he vomited bile at 7am, so I immediately knew something was up. Gave him breakfast again, but still not his full meal, and meds. Did another similar poop to the night before... but the main poop was mushy, and then he jogged around a bit and did another little pile just like Saturday night. He pooped again, mushy but with shape, around 5:30pm, and vomited bile again shortly after. At 8pm I gave him only 1/2 his normal meal and his meds. Pooped again at 8:15, not a lot and mushy. I also gave him 1/4 can of wet food at 10pm with a PancrePlus pill.

Monday I called out of work and got him an appointment with the vet. Did not feed him breakfast. His poop was very mushy and he pooped at 2:30, 5:00, 7:30, and 9:30 that morning. Vomited some bile around 11am, right before we left for his appointment. Because of COVID, I couldn't go in with him and talked to the tech outside. I told her that I keep a log of his episodes and she asked me to email it to them. I did, and she took Zero inside. After the vet examined him, he called me to discuss. It was difficult to hear him, especially with traffic driving by the building, but he said he gave him the steroid injection and would send me home with Prednisone. I asked about the Ondansetron and he said he wasn't vomiting. I said he was and he said he didn't realize. So it seems to me he didn't even read the log I sent in... Anyway he wrote the Ondansetron and the tech came out and took my credit card. Then she brought out Zero, my invoice, and his meds. I realized they didn't give him subcutaneous fluids this time. The vet offered me no feeding instructions so I asked the tech and she had to go back and check. She came back and said to start the Ondansetron that night, but not to feed until the next morning (so that's a food fast from 10pm Sunday night to 8am Tuesday morning) and re-start the rest of his meds then. I wasn't offered any instructions but since we'd done this before, I had an idea. The vomiting and diarrhea stopped and he seemed to feel better, which is usual after he fasts and gets his steroid injection. So Tuesday morning I started with a few tablespoons every few hours, but I had to go to work, so my mom was taking care of him during the day. Everything seemed to be going well, but then on Wednesday morning my mom messaged me while I was at work to tell me he had diarrhea again. Only once though, and it wasn't a lot, at least not comparatively to how it usually is with him, but I called the vet at 10am to discuss because that's not usual. Once he's fasted and gets the steroids he doesn't poop again for about 2 days and when he does, it isn't diarrhea anymore. The tech answered and I asked to speak with the vet himself and she said she'd tell him to call me. She called later to confirm what meds he was taking. I told her... again... Then no follow-up until I called at 4:30pm to remind them I was still waiting on a call back. He himself answered and told me he had 2 more clients and then he would call me. It's now 11am the next day, 13 hours later, and I still haven't received a call back. I'm furious, to be honest, because at this point my vet should know how serious it can get with Zero and how quickly. Now this morning he finally pooped again (24 hours later) and it was a LOT of diarrhea.

I'm at a loss here. Do you think I need to get him in today for fluids? Do they flush the system? Could that be why he isn't getting better this time? I've been watching him like a hawk to make sure he isn't eating sticks or dirt and to make sure I catch every waste elimination act that he does. But my mom let him out in the yard "for 10 minutes" yesterday without watching him (explicitly against my instructions), so for all I know he ate dirt while she wasn't watching. Temporarily living with my mother and having her assist with my dog's care has been a nightmare, but I don't have a choice and that's a story that's unrelated anyway. I've asked her to just leave them crated while I'm gone but she refuses because she doesn't like crates.

From browsing this forum, I've already learned that he wasn't getting enough PancrePlus tabets (he was getting 2 per meal, each meal being 2 cups of the prescription kibble), and that they need to be ground up and incubated on the food for 20-30 minutes first. I started doing that last night. Any other advice on how to help him through this episode, and get him back to normal so I can begin having tests done and figure out the root of the problem? Especially because if he really does have EPI, obviously a food with Fiber Balance probably isn't the best, based on what I've been reading. Does this sound like EPI to you all?

I apologize for the giant wall of text. Any and all advice is so, so appreciated. Thank you

[Olesia711]

Hi and thanks for contacting us.... BTW... Zero is a real cutie! Hopefully we can help.
First, when you finally do get to talk to your vet INSIST on a prescription for an antibiotic called Tylosin Tartrate soluble powder (this would replace the Metronidazole antibiotic- -with SID often, although not always.... Metro does NOT work well on SID... whereas Tylosin often works much better, this is why i am suggesting it).... I am not sure if all of this could possibly be EPI .... because of the sometimes bloody stools and even a touch of blood in the vomit.... he very well may have something like an HGE infection .... but he also may (or may not) have EPI, so yes, PLEASE do get him tested as soon as you can. Anyway, with or without EPI, dogs can have SID (small intestinal dysbiosis) when they have some kind of gastro issue going on... and it sounds like he does.

Next YES.... crush those pills into a powder, add more pills .. also, they only have 9,000 USP units of Lipase in them... you need at least 4 pills crushed.... but maybe more like 6 pills crushed if this is EPI.... so maybe start with crushing 4 pills into a powder per 1 cup of food, add a little water to moisten the powder to the food, let sit for 20 minutes and then serve the food.

More can be done... but.. since we don't know if this is or is not EPI.... and also, so as to see what helps.. try jsut one change at a time... start with either the Tylosin or the increased enzymes.

PLEASE keep us updated so we can do our best to help you.

[Madelon]

Hi and welcome to our group. Olesia and I were typing at the same time and she addressed the proper dosage/administration of the tablets so no need to repeat. Have the vets run any tests over the last year? If so, it would help if you could let us know the tests run and results. Whether or not it's EPI, keep a journal of everything you give, when you give it and the results - it can help you figure out what works and what doesn't.

I highly recommend getting the EPI test done as soon as possible. It's okay to treat as if it's EPI for a short time but we don't recommend treating as if EPI for a long time without the test to confirm if it's EPI or not as EPI mimics many other dog conditions, which if left untreated could have dire results.

I am of the opinion you know your dog best, so if you feel your dog is dehydrated, etc I would definitely get him in as soon as possible and put on fluids.

Hoping things improve soon and you get some definite answers.

[zerothehero]

Thank you both for your responses! The blood in the feces and vomit had only happened during like 2 of his episodes, after he didn't get better right away, so I'm thinking maybe it was just from the extreme irritation, and not an actual accompanying symptom of the initial diarrhea? (If that makes sense.) Has anyone else's dogs had this issue if they couldn't get the diarrhea under control right away? Thankfully right now, he hasn't had any blood in stool or vomit yet during this episode. I don't believe he's dehydrated at the moment and my mom said he hasn't had any diarrhea again since the large amount he had this morning.

One of you had mentioned something about the enzymes not being the right type? This is what he's on currently.
https://www.chewy.com/pancreplus-tablet ... /dp/173683
Should I get something different? I see a lot of you talking about Diane's enzymes. Would those be good to switch to regardless, even if it ends up not being EPI? And how fast can they be delivered if I ordered today? lol. I'm in New York.

Also, I just called the vet again and said that I think he's got EPI and asked if he'd ever heard of it. He actually said that's the treatment protocol he's been using. So I don't understand why EPI wasn't mentioned to me? Maybe he did, every time I go in I'm so stressed about this and he talks kind of quiet and really fast... I asked why he's on a Fiber Balance food if he thinks it's EPI as supposedly EPI dogs don't do well on fiber-rich foods. He said this is the protocol he's always had success with. I also asked about switching to the Tylosin and he said it's an "older" antibiotic not used much anymore. I think it may be time to switch vets... What do you all think about that? (Also I just realized I made a typo in my original post... it was 23 hours I was waiting for the vet to call me back... not 13. I made other typos as well but they seem inconsequential. I just can't figure out how to edit my post lol.)

Regardless... I asked him to email me all the results of all the tests we've run since this started in early 2018... So I will review and post those one I receive them. As for now, I'm going to stop by there after work and pick up some probiotics, and bring him in tomorrow for a fecal test and subcutaneous fluids.

[zerothehero]

Just got all the bloodwork from the vet. It's 8 documents, so I thought it would be easier to just link to a google drive folder. Hope that's okay!

https://drive.google.com/drive/folders/ ... sp=sharing

[Olesia711]

the current protocol for EPI is not Metro.... actually it is to try a prebiotic first, then a prebiotic with a probiotic and THEN of no results, try Tylosin Tartrate... if that doesn't work then the bacterial strains may be more loarge intestinal vs. small intestinal in which case Metro would help... but if i had to guess, well over 50% of EPI dogs respond MUCH better to Tylan/Tylosin Tartrate vs. Metronidazole.

Short personal example. WHen my dog was diagnosed with EPI, the gave her the right enzymes, low fiber food and treated with Metronidazole. Two weeks later i saw absolutely NO improvement!!!!!! I thought the enzymes weren't working at all. The vet switched us from Metronidazole to Tylan/Tylosin Tartrate... and within 24 hours she was doing great. No more loose stools, no fart, gas, tummy grumbling and she was happy!

Also... is is splattered all over EPI informational protocol is that fiber can inhibit enzyme activity. In reality it can hamper the enzymatic activity from anywhere between 0% to 50%... we just never know from one dog to the next. This is why we strongly suggest, at least when starting out and treating EPI to give a very low fiber content food. We "suggest" giving foods with 4% or less fiber content. Some dog actually do better with fiber in their food composition,.... but usually,, the less fiber in commercial food the better. THe food your vet has your dog on is 10% fiber content... OMG..... that is way too much fiber! Most (but not all) of our EPI dogs cannot even handle 5% fiber content in their food................

The enzymes your vet prescribed are right kind (pig enzymes) just the very wrong strength. Typically we give 71,000 USP units of Lipase in 1 tsp of powdered enzymes per 1 cup of food vs. the 9,000 USP units of Lipase that is in the pills your vet prescribed.... See the difference????????????????? Not to mention the Amylase and Protease enzyme units are also too low.

Sure, you can order enzymes from EnzymeDiane.... HOWEVER... i would just order a half a kilo or 250 grams until you have the test run to confirm that this is even EPI to begin with. I'd order the 6x powder. I am guessing a few days delivery. EnzymeDiane is in Ohio. Best to contact her and just ask about estimated delivery time.

[zerothehero]

Thank you so much. My vet is young, so I had hoped being a more recent veterinary school graduate, he would be more up-to-date on stuff like this. Do you think it's time I switched vets? Also, is it possible to have him tested for EPI in the midst of an episode like this, or should I wait until he's settled? If I can test during an episode I'd like to do it ASAP, like maybe tomorrow when he goes in for fluids.

[Olesia711]

i just looked at the test results..... there wasn't a TLI test ever done, so NONE of these blood tests could suggest EPI.
HOWEVER.... the globulin is low and that can be IGA related.... and tp me that translates into possible food sensitivities which to me means that this could possibly be IBD. Of course we do see MANY dogs with EPI that battle both EPI + IBD..... so this is not to say that EPI is not present.... Just that you really need to run the TLI test to confirm or not that your dog has EPI... and that will tell us how to proceed and then make adjustments as needed.

[zerothehero]

Thanks. I was trying to look at the results and have no idea what I'm even looking at, lol. So can I do the TLI test some time next week (I see on the test page it should be performed on certain days), or should I wait until he's settled? And what do you think about switching vets? Has any of the stuff I said raised any red flags to you?

PS. Thank you for creating this amazing website. May Izzy rest in peace.

[Olesia711]

switching vets is up to you..... what many of us have have come to realize though is that it is not so important that you have a vet with experience in EPI but rather you have a vet that listens to you, is willing to work WITH you, and is so excited about having an EPI case, that they also do their own research in addition to the knowledge they have or don't have about EPI. It seems that THOSE types of vets make the best vets for EPI pets

They suggest doing the TLI test in the morning (cause you have to fast the dog (from food) for 12 hours before having the blood drawn.
Next they suggest doing it on a Mon, Tue, or Wed... so that when the blood gets shipped it doesn't lay somewhere sitting over the weekend.....as it is time sensitive.