Pancreatic Insufficiency

Pancreatic insufficiency - continued

Question: Dr. Richards-

Since I initially wrote to you all the lab results came back on the dog and there is no sign of anything wrong with her kidneys. Blood test were done and I also got a more concentrated urine sample first thing in the morning.

I'm having a hard time remembering what my vet said about the blood work...something about the kidneys and protein levels. Anyway, he suggested slowly switching her to a low-protein/fat diet. She still drinks alot periodically, but hasn't gotten sick or developed any other symptoms. I took her to a different vet who prescribed metronidazole, but after a few days her diarrhea got worse so the vet told me to stop giving it to her. About a week later, my original vet insisted I give her tetracycline, 500 mg., three times per day. I thought this was a little extreme, but went ahead and starting giving her that medication. About this same time I started mixing a low-fat dry food with her other food in an effort to start switching her over to that. I was also giving her about a teaspoon of yogurt with her food. She started getting worse diarrhea again almost immediately. I thought it might be the yogurt, so I started giving her benebac instead. I also increased the Viokase (per my vet's instructions) to almost three teaspoons per meal (1 1/2 cups of dry food am and pm). Last night I called my vet because my dog was having extremely bad diarrhea about one hour after I gave her 500 mg. of the tetracycline. (She had been on the tetracycline for five days.) He told me to stop the antibiotics. Throughout the last week of extremely bad diarrhea her energy level seems better than ever! She has been charging around our property, playing with the neighbor's dog, terrorizing the cats and the horses, playing with her toys in the house.... Tomorrow I am leaving for Montana for a week. The instructions I will leave my house/horse/dog sitter are: 1 1/2 cups of dry food, 2 teaspoons of Viokase with water mixed in and that's it. Currently her dry food is three different kinds mixed in equal parts: regular lamb and rice, sensitive stomach, and low-fat. When I get home I plan to switch her to low-fat exclusively.

So here's my current question: Why do the antibiotics make her diarrhea worse? Is the dosage too high? They don't seem to bother her when I give them to her immediately after she eats. Should I give her just two doses a day after meals? My original vet wanted to give her tetracycline vs. metronidazole because it was a "broader spectrum". Do you agree with this? Oh, also, I almost forgot. I read on your website to try giving her tegamet 1/2 hour before she eats. I broke the tablets in half so she was getting about 100 mg. This seemed to work really well initially, but two days after I started the tegamet, I started the antibiotics. Should I continue this when I get back.

Thanks, Gail

Answer: Gail-

The break from antibiotics may be very helpful in sorting through the possible causes and contributing factors for the diarrhea.

The recommended starting dosage for Viokase (tm) is 1 to 2 teaspoonfuls per 20kg of body weight. Adjustments are then made based on what it takes to control diarrhea. There are dogs who require higher dosages of Viokase than normal, although I can't quite understand why. The usual dosage is 1 to 2 teaspoonfuls per meal but I have seen case reports of dogs requiring higher dosages. So increasing the dosage of the Viokase is a reasonable option.

Many dogs with pancreatic insufficiency also have small intestinal bacterial overgrowth (SIBO). The most commonly recommended antibiotics for this condition are tylosin (Tylan Rx), metronidazole (Flagyl Rx) and tetracycline, although there are reports of a number of other antibiotics helping. Tetracycline is usually dosed at 10 to 25mg/kg of body weight and given every 8 to 12 hours. At the low end of the spectrum, 500mg will treat a 100 lbs. dog but most of the time the higher dosages work better. Metronidazole and tylosin are both usually given at 10 to 20mg/kg every 12 hours. In some patients these antibiotics will either cause other gastrointestinal problems, such as vomiting, or will make a particular patient worse. The prevalence of SIBO in association with exocrine pancreatic insufficiency is very high, though. So it is worth trying these antibiotics, and trying more than one of them, if necessary, to rule out this problem.

I do think that there is a chance the low fat diet will be helpful and is also worth trying. It is best to avoid low fat/high fiber combinations, though. The fiber may interfere with the action of the pancreatic enzymes. It may be worthwhile to try this prior to starting the antibiotic therapy again, just so that you can tell which of the things that you are doing is having a beneficial or detrimental effect, since this is hard to do when you change more than one thing at a time.

Exocrine pancreatic insufficiency is a frustrating problem in some dogs. It is usually possible to at least make them feel better, even if you can't control the diarrhea fully. This is a worthwhile goal and it does sound like you are at least helping your dog feel better.

When cimetidine (Tagamet tm) it is worth continuing with it. I am not sure that it is always beneficial. It is supposed to help most if it is given about 1/2 hour prior to feeding. In tough cases of EPI, it can also be helpful to add vitamins, especially Vitamin E and cobalamin (B12). Medium chain tryglyceride oil given at 1 to 2ml/kg/day is supposed to help some patients and in really resistant cases it may help to use corticosteroids such as prednisone, but I think this should be a last resort when it seems like nothing else is going to help.

If you keep working at this and keep working with your vet, the odds are in your favor that you can reach a point where you have good control of the diarrhea and can find a maintenance program that will allow you to maintain control.

Mike Richards, DVM 9/9/2001

Pancreatic insufficiency with small intestinal bacterial overgrowth (SIBO).

Question: I have a 3-year-old female dog of questionable breeding that has been diagnosed with "insufficient pancreas". Initially her symptoms were chronic diarrhea. My vet had trouble diagnosing the problem and was treating her for parasites and other intestinal problems for about three weeks before I started her on Viokase. Her energy level was still good and she was otherwise OK at first. She didn't get lethargic or act sick until she had gone from 53 pounds to about 46 pounds. With the Viokase, she improved immediately, but has still had bouts of diarrhea since April.

Recently, I noticed that she is drinking alot (I mean, alot! She goes to her bowl and drinks until it's empty) so I started thinking that now she's developing kidney problems. I took her to the vet on Saturday and he told me that any possible kidney problem is unrelated to the pancreas problem.

In doing some research, I read that "chronic renal failure" is commonly caused by (among other things) "inflammatory bowel disease, gastroenteritis, pancreatitis." So, it seems to me that I should have been doing something to try and prevent kidney problems through diet or supplements.

In addition, although the dog improved with the Viokase treatment, I have never felt like she has truly gotten better. She never has normal bowel movements--always somewhat runny and she still has periods where she'll have a few days of diarrhea. She has started losing weight again recently, seemingly in conjunction with the possible kidney problem. On Saturday, my vet tested her urine and her glucose level appeared normal, but her urine is diluted because she drinks so much. Blood work results are pending. I am unhappy with the vet (I've spent close to $1500 and my dog hasn't gotten better and is developing additional problems) so I am going to pick up her chart today and take her to a different vet.

My questions to you are: Is the kidney problem related to the pancreas problem? Is there anything I can do re: diet or anything else that would do more than just the Viokase? Is the pancreas problem chronic? If she starts having kidney problems will this be chronic? Is there anything at all you can suggest to help? This has been going on for five months. The dog is only three and she doesn't seem to be in any pain so it's hard to think about putting her down at this point.

Please help. Thanks. Gail

Answer: Gail-

Many dogs who have pancreatic enzyme insufficiency, or exocrine pancreatic insufficiency (EPI), also have small intestinal bacterial overgrowth (SIBO). When this happens, it is sometimes necessary to use antibiotic therapy for several months to try to get the bacterial population back to normal. The most commonly recommended antibiotics for dogs with pancreatic insufficiency and SIBO appear to be metronidazole (Flagyl Rx), tylosin (Tylan Rx) and tetracycline. In addition to this, there are studies that show that dogs with EPI do better on low fat diets, such as Purina's EN (tm) diet, Hills w/d (tm) diet or Waltham's Low Fat (tm) diet. Finally, some dogs with EPI are cobalamin deficient (Vitamin B12) and it may be necessary to supplement this vitamin before they really start to feel better.

Exocrine pancreatic insufficiency is usually a life long problem. It may be a good idea to try to confirm that it is present, although the response to treatment is certainly very suggestive.

I can not find a strong link between exocrine pancreatic insufficiency and kidney disease. Pancreatitis does cause acute kidney failure at times, so this link is important but doesn't really relate to EPI, which is a separate condition. It is conceivable that inflammatory bowel disease could lead to kidney problems due to the production of antigen/antibody complexes but I suspect that it isn't a major problem. It was a good idea to check for problems like kidney failure and diabetes with the increase in drinking, though. It is good that you didn't find diabetes. Hopefully, the lab work did not support kidney disease, either. The decrease in concentration of the urine is not a specific enough sign to say that kidney disease is present, especially based on the results of one urine sample. If blood work also supports the presence of kidney disease then it may be necessary to consider some form of treatment, such as phophate binders, fluid therapy or enalapril administration.

I don't really think of EPI as being painful. It is expensive to treat due to the cost of Viokase (tm) and it does have to be managed over the life of the dog, but most dogs do pretty well, with occasional setbacks that require more intensive management efforts, such as the use of antibiotics to combat SIBO.

If the lab work did support a diagnosis of kidney failure I would be happy to try to go into more detail about treatment of that disorder.

Mike Richards, DVM 9/4/2001

Exocrine pancreatic insufficiency or EPI and Colitis in German Shepherd

Question: I haven't had a lot of time to cruise your site, that's why I'm glad I get your newsletters. Today, however, I do!! Laundry can wait. I like to keep on top of information on EPI and Colitis as I have a dog that has both!!

Why are more vets not suggesting supplementing a dog's diet with pancrease meat for EPI? Fresh pancrease has worked great for both of my dogs that were diagnosed with it. The weight came back up, Robbie from 67 lbs to 90 lbs and the diahrea also disappeared. Mutz, was diagnosed at 6 months, he's up to 75 lbs at 2 years of age. It was my vet's idea when Robbie was diagnosed. He said it would be cheaper than the powder, and much better for him as the pancrease has lots of other things in it that were good for him. It worked great for Robbie (he's gone now) and it works great for my new guy, Mutz, shep number 4 (time to change breeders). I have to admit, though, that cutting it up and bagging it for freezing isn't one of my favourite past times. However, it keeps him healthy and at $1.00 a pound (Canadian dollars) it's worth it. Here's my second question. Mutz contracted colitis when he was a pup (whipworm was the cause). It was at our vet's suggestion that we put him on Hills W/D. It's the only one with such a high fibre content. So far, so good. I still have to be very careful what I feed him. Even his treats have to be high fibre. Luckily my vet carries both. Do you know of a more natural dog food that has the same fibre content as W/D? I've had comments from 'canine nutritional experts' that perscription dog food is made with leftovers of everything and is extremly bad for the dog long term. Which doesn't make sense. You'd think it would be better because it is perscription food!! W/D has 20% fibre and most dog foods I see have a maximum of 4.5 to 5%. I tried switching him and supplementing with oat fibre, but the diahrea came back - big time!! It's a good job I don't have carpets in my house!! I'd like to try and find a more natural dog food, but I can't take the chance of taking him off the W/D. Any information you can provide would be great.

I'd also like to say that it has been, and will continue to be, extremely enlightening to visit your site. Your thoroughness and sensitivity to people is to be commended. Keep up the good work.

Answer: Judy- I think that most veterinarians do not recommend using pancreas organ meat is the treatment for exocrine pancreatic insufficiency (EPI) because it is not consistently available in many areas. In places where it is available on a regular basis it is an acceptable treatment for pancreatic enzyme deficiency. It is good that your vet thought of it, since the pancreatic enzyme supplements are more costly.

I am not aware of a higher fiber natural diet, but you can use a natural diet and add fiber sources to it until you find one that works well. Psyllium fiber sources like Metamucil (tm) are acceptable and bran will work for many dogs, although that doesn't seem to be a good idea in your dog's case. There are two things that make w/d work well for colitis, though. The fiber is part of the reason it works well and the low fat content is the other. So you have to find a diet that is also low in fat. This can be just as hard as finding one that it is higher in fiber. It is possible that the lower fat content is the most beneficial part of the diet for Mutz.

The other option that you have is to make a diet at home. If you do this, it is best to have the diet reviewed by a veterinary nutritionist. There is a service online, run by a board certified veterinary nutritionist, Dr. Remillard, called petdiets.com (we have a link from our linkpage). There is also a link to Ohio State University's pet nutrition pages http://www.ag.ohio-state.edu/~ansci/ which contain comparisons of lots of dog foods.

I am not sure why people who claim to be nutritional experts talk about fillers and empty calories and things like that when discussing by-products. There is no supporting evidence that I have seen for claims that these products cause nutritional problems. I am not aware of any board certified nutritionists who have produced studies showing ill effects of by products in dog foods. These are usually organ meats that people find unattractive and things of this nature. The life span of dogs has increased in the last thirty or forty years while the use of commercial diets has become standard. While individual dogs may have nutritional needs that are different enough from average not to do well on commercial diets, the vast majority of dogs are doing fine with them.

I really think I'd stick with w/d for Mutz if it is working well, but if you wish to find a substitute remember that you need similar fat content as well as fiber content.

Mike Richards, DVM 1/13/2001

Pancreatic Insufficiency

Q: We have a 7 month German Shepherd puppy who the Vet feels has a genetic pancreatic disorder. She has had diarrhea for 3 weeks and has lost 15 lbs. Worms, parasites and inflammation of the bowels have all been ruled out. We will start her on a special enzyme supplement powder, which the Vet says will help her system digest the food it can't and get the nurtrition she needs. Can anyone tell us more about this disorder? And what the prognosis could be? The breeder has told us that this problem has been in the blood line. Some have said that there may be little we can do to save her. My wife, daughter and I love Liesl very much. Does anyone have suggestions? Thanks.

A: It is hard to be sure from your mail, but I am assuming that Liesl has pancreatic insufficiency - the inability to produce adequate digestive enzymes. It is possible to treat this by using Viokase or other products containing digestive enyzmes. . In most dogs, these will help enough that the dog can live a pretty normal life. If they are not successful alone, using cimetidine (Tagamet) to decrease stomach acids and allow the enzymes to work better is helpful. Some dogs can not be controlled through these measures and will die. In addition, some dogs are controlled well but suffer a twisting of the intestinal supporting structures for an unknown reason and die as a result of this. In one study, 10% of the dogs with pancreatic insufficiency studied had this problem. This is a serious problem but many dogs do live relatively normal lives with enzyme supplementation. I hope Liesl is one of these.

Mike Richards, DVM

Chronic Diarrhea in German Shepherd

Q: Dear Dr. Mike, My 2 1/2 year old German Shepherd, Simba, has had diarrhea for the last five weeks. He has lost twenty-two pounds (from ninety pounds). Initially, I didn't notice that he was eating outdated dog food from a pet store. It was manufactured in September 1995. In the last two weeks he has been eating new food, but the diarrhea has persisted. I took him to the vet, he tested his stool sample for parasites and pancreatitis. The vet said that pancreatitis was a possibility, but there were no parasites. I've done some research and don't believe that it is pancreatitis because his lower abdomen is not painful to palpations, has not had a loss of appetite and does not vomit. He was neutered and vaccinated just prior to the diarrhea. Could this have affected the situation being that his system was malnourished from the old dog food and then had to combat the antibodies from the vaccines? He also spent four days in a kennel a few days after the vaccinations at this point is when I noticed the diarrhea. Is it possible that there could be parasites that were not detected and can pancreatitis be determined by just taking a stool sample? These are the things that I have tried: fasting him, giving pepto-bismol and white rice. There was a slight improvement after the rice, but after eating regular food again, he resumed the diarrhea. Right now, I have fasted him and gave him charcoal tablets. I broke the fast slowly with vegetable broth, then cooked vegetables and now rice and oats. I don't have any more ideas, so any input would be greatly appreciated on my Simba's behalf. Thank-you in advance, Judy

A: Judy- In any German shepherd with chronic diarrhea my first instinct is to look for pancreatic insufficiency. In this case, insufficient digestive enzymes are being produced to allow proper digestion. This leads to persistent diarrhea. Pancreatic insufficiency is reasonably common in shepherds. There are pretty accurate tests for this condition now. Blood tests for trypsin like immunoreactivity (TLI) and serum folate levels are an improvement over older tests utilizing digestion of X-ray film. It is important not to overlook other possible causes, though. These tests are simple enough to include in the initial workup of a case, along with the more obvious things you mention, such as ruling out intestinal parasites, a general blood panel to make sure that there is not an obvious organ system problem (liver, kidney) and an attempt to make sure bacterial enteritis is not a problem.

Pancreatic insufficiency is NOT pancreatitis. It is an entirely different problem. Your vet may have been referring to this but phrased the concern badly or may be thinking that pancreatitis is possible. I would tend to agree that it isn't too likely as a continuing cause of diarrhea, though.

If no problem can be found with the labwork above, then the possibility of malabsorption disorders like lymphangectasia becomes more likely. Diagnosis of these conditions is best done by biopsy, usually utilizing an endoscope. We refer patients to an internal medicine specialist for this procedure.

The food can't be ruled out as a source of the initial problems but something else is probably keeping the problem going. Lots of times stressful situations bring on the clinical signs of problems such as pancreatic insufficiency and lymphangectasia or plasmacytic/lymphocytic enteritis -- and then these problems just keep on going.

Mike Richards, DVM