Practice Scenario

Say hello to Duffy, a young adult dog with chronic small bowel diarrhea

Meet DUFFY

A 2-year-old, neutered male Bernese Mountain Dog

  • Duffy is presented today for intermittent chronic small bowel diarrhea. Although the owner reports he only defecates 2 to 3 times per day and has no urgency, he does have voluminous soft stools. The owner also reports the diarrhea and flatulence have occurred consistently over the past 6 months. What the owner finds concerning today is Duffy’s lethargy, which started 2 days ago.
  • Duffy currently eats a high-protein dry dog food formulated for all life stages that is purchased at a pet specialty store. The owner reports that the dog’s appetite has been good. Year-round, Duffy is given once-monthly medication to protect against heartworm disease, ticks, fleas, roundworms, and hookworms.
  • Physical exam findings are unremarkable. However, a comparison of Duffy’s weight today with previous body weights in the medical record reveals he has lost weight. His body condition score today is 4/9, compared to 5/9 at previous visits.
  • Blood, urine, and fecal samples are obtained and submitted to a reference laboratory for overnight evaluation. No evidence of intestinal parasites or ova are observed. However, the results of the serum chemistry profile reveal a mild panhypoproteinemia.

Gastrointestinal Disorders

Canine Immunosuppressant-Responsive Enteropathy (Inflammatory Bowel Disease)

Steroid- or immunosuppressant-responsive enteropathy, also known as idiopathic inflammatory bowel disease (IBD), is one category of chronic enteropathy in dogs. Immunosuppressant-responsive enteropathy is characterized by persistent or intermittent gastrointestinal (GI) clinical signs lasting 3 weeks or longer in the absence of other intestinal conditions (e.g., dietary indiscretion, parasitism, identified enteropathogens, or neoplasia) and non-GI diseases.1─4 Any combination and severity of clinical signs may be present, including diarrhea, vomiting, weight loss, changes in appetite, borborygmus, nausea and abdominal pain.1,5,6 

canine intestines icon

A diagnosis of immunosuppressant-responsive enteropathy is made by exclusion and therefore implies:1,5,7─9 

  • anthelmintic, dietary, and/or antibiotic treatments failed to produce satisfactory clinical responses
  • intestinal biopsies and histopathology confirmed the presence of inflammation
  • glucocorticoid or other immune-modulating therapy resulted in a positive response

Many dogs with chronic GI disorders, including immunosuppressant-responsive enteropathy, present with intestinal inflammation and changes in the gut microbiome, a condition known as intestinal dysbiosis.10─15 However, it is unclear whether dysbiosis is a cause of the enteropathy or is a symptom of it.16,17 

Although diet change by itself may produce an inadequate response, nutritional modifications should still be considered as adjunctive therapy for dogs with immunosuppressant-responsive enteropathy. A change in diet may be beneficial because intestinal inflammation is thought to be triggered by interactions between food components, the mucosal immune system, and the microbiota in genetically susceptible dogs.18,19 Furthermore, malnutrition is common in dogs with chronic enteropathy due to dysrexia, malabsorption, and increased nutrient losses.20 

The goals of nutritional intervention are to provide a complete and balanced diet that meets the dog’s nutrient requirements, minimizes mucosal inflammation, compensates for maldigestion and/or malabsorption, and helps control clinical signs.

Key Messages

  • Nutritional intervention is used as an adjunct to immunosuppressive therapy in dogs with chronic GI signs that fail to respond to dietary management alone or in combination with antibiotic treatment. Common dietary types include:8,16,21,23,24 
    • hydrolyzed protein diets
    • amino acid-based (i.e., elemental) diets
    • novel protein diets
  • Diet characteristics and nutrients of concern include digestibility, energy density, fat, protein, cobalamin (vitamin B12), potassium, and water consumption.20,25 
    • Not every nutrient of concern is relevant for every patient.
    • Nutrients of concern for a particular dog will vary, depending on which clinical signs are present, their duration and severity, and a nutritional assessment.
  • Dogs with immunosuppressant-responsive enteropathy should be fed a highly digestible, palatable, moderate- to low-fat, hydrolyzed or novel protein diet that provides sufficient calories to manage impaired digestion and/or absorption of macronutrients (e.g., protein, fat, or carbohydrate), address dysbiosis, and minimize lean body mass loss.26
    • An amino acid-based, or elemental, diet can be fed instead of a hydrolyzed or novel protein diet to provide readily available amino acids and small peptides for protein synthesis.
    • The chosen diet should be fed exclusively for as long as needed.
  • Dehydration is a frequent problem in dogs with immunosuppressant-responsive enteropathy, and may be accompanied by electrolyte imbalances, particularly potassium and possibly sodium.20 Dogs with mild fluid deficits can be managed with oral water intake or subcutaneous fluid administration. However, dogs with moderate to severe dehydration should receive intravenous fluid and electrolyte replacement as appropriate.
  • GI malabsorption may result in cobalamin (vitamin B12) deficiency in dogs with chronic enteropathies, despite its abundance in canine diets. If testing reveals a deficiency, vitamin B12 should be supplemented, either parenterally or orally.25,27 
  • Increased levels of omega-3 fatty acids, which have anti-inflammatory and immune response-modulating effects, may benefit dogs with immunosuppressant-responsive enteropathy.26,27 
  • Prebiotics, probiotics, or synbiotics may help dogs with immunosuppressant-responsive enteropathy by influencing the composition of the GI microbiome which, in turn, changes the bacterial antigens presented to the intestinal mucosa and modulates the inflammatory response.25,26 
    • Prebiotic fiber (e.g., soluble or mixed fiber) in the diet may benefit some dogs through increased production of short-chain fatty acids by the microbiota.
  • Many dogs with immunosuppressant-responsive enteropathy experience dysrexia and may benefit initially from eating small, frequent meals (e.g., 3 to 6 meals per day). This can help improve nutrient absorption and minimize adverse responses such as vomiting or diarrhea.25,28 
    • If clinical signs of the enteropathy resolve, a very gradual transition to the dog’s usual diet can be attempted over a 7-day period. 
    • Depending on the suspected underlying cause, some dogs may need to remain on a therapeutic diet.
conversation starter

“Based on the lack of response to our previous dietary and medical interventions, I suspect [dog’s name] may have a chronic gastrointestinal disease known as immunosuppressant-responsive enteropathy. I think [dog’s name] will benefit from an amino acid-based therapeutic diet and a medication called [insert drug or brand name]. We should see improvement within the next 2 to 4 weeks and, if not, we can discuss what steps to take next.”

Related Tools and Content:

Chronic Enteropathy in Dogs

Nutrition can play an important role in diagnosis and management of dogs with chronic enteropathy.

View Brief 1 min to 5 min

Intestinal Dysbiosis in Dogs and Cats

Diet modification is a key component of therapeutic plans for managing dogs and cats with intestinal dysbiosis.

View Brief 1 min to 5 min

Nutritional Assessment Is an Iterative Process: Extended Evaluation

An extended nutritional evaluation is important for pets at risk for nutrition-related problems.

View Brief 1 min to 5 min

Amino Acid-Based Enteral Diets For Canine Adverse Food Reactions and Gastrointestinal Disease

Learn about the history, uses, and benefits of amino acid-based enteral diets.

View Monograph 20+ minutes

To Share With Pet Owner:

Screening Diet History Form

This short, screening diet history form is a practical, easy-to-use document that can help clients provide important information about their pets’ diets.

View Tool 1 min to 5 min

Evaluating Your Dog’s Body Condition

Assess your dog's Body Condition in just 3 simple steps.​

View Video 1 min to 5 min

Prebiotics

Purina was the first to use prebiotics in pet food and is a leader in the field. What are the benefits of prebiotics to pets?

View Hot Topic 6 min to 10 min

Probiotics

Probiotics offer many benefits, but with so many options available, pet owners may not know how to select the best quality and most appropriate one for their pet's needs

View Hot Topic 6 min to 10 min

References

  1. Dandrieux, J. R. S. (2016). Inflammatory bowel disease versus chronic enteropathy in dogs: Are they one and the same? Journal of Small Animal Practice, 57(11), 589─599. doi: 10.1111/jsap.12588
  2. Dandrieux, J. R. S., & Mansfield, C. S. (2019). Chronic enteropathy in canines: Prevalence, impact and management strategies. Veterinary Medicine: Research and Reports, 10, 203─214. doi: 10.2147/VMRR.S162774
  3. Hall, E. J., & Day, M. J. (2017). Diseases of the small intestine. In S. J. Ettinger, E. C. Feldman & E. Côté (Eds.), Textbook of veterinary internal medicine: Diseases of the dog and the cat (8th ed., pp. 3643─3820). Elsevier.
  4. Jergens, A. E., & Simpson, K. W. (2012). Inflammatory bowel disease in veterinary medicine. Frontiers in Bioscience-Elite, 4(4), 1404─1419. doi: 10.2741/470
  5. Procoli, F. (2020). Inflammatory bowel disease, food-responsive, antibiotic-responsive diarrhoea, protein losing enteropathy: Acronyms, clinical staging, and treatment of chronic inflammatory enteropathy in dogs. Advances in Small Animal Care, 1, 127─141. doi: 10.1016/j.yasa.2020.07.010
  6. Schmitz, S., Glanemann, B., Garden, O. A., Brooks, H., Chang, Y. M., Werling, D., & Allenspach, K. (2015). A prospective, randomized, blinded, placebo-controlled pilot study on the effect of Enterococcus faecium on clinical activity and intestinal gene expression in canine food-responsive chronic enteropathy. Journal of Veterinary Internal Medicine, 29(2), 533─543. doi: 10.1111/jvim.12563
  7. Simpson, K. W., & Jergens, A. E. (2011). Pitfalls and progress in the diagnosis and management of canine inflammatory bowel disease. Veterinary Clinics of North America: Small Animal Practice, 41(2), 381─398. doi: 10.1016/j.cvsm.2011.02.003
  8. Makielski, K., Cullen, J., O’Connor, A., & Jergens, A. E. (2019). Narrative review of therapies for chronic enteropathies in dogs and cats. Journal of Veterinary Internal Medicine, 33(1), 11─22. doi: 10.1111/jvim.15345
  9. Washabau, R. J., Day, M. J., Willard, M. D., Hall, E. J., Jergens, A. E., Mansell, J., Minami, T., & Bilzer, T. W. (2010). Endoscopic, biopsy, and histopathologic guidelines for the evaluation of gastrointestinal inflammation in companion animals. Journal of Veterinary Internal Medicine, 24(1), 10─26. doi: 10.1111/j.1939-1676.2009.0443.x
  10. Honneffer, J. B., Minamoto, Y., & Suchodolski, J. S. (2014). Microbiota alterations in acute and chronic gastrointestinal inflammation of cats and dogs. World Journal of Gastroenterology, 20(44), 16489─16497. doi: 10.3748/wjg.v20.i44.16489
  11. Minamoto, Y., Otoni, C. C., Steelman, S. M., Büyükleblebici, O., Steiner, J. M., Jergens, A. E., & Suchodolski, J. S. (2015). Alteration of the fecal microbiota and serum metabolite profiles in dogs with idiopathic inflammatory bowel disease. Gut Microbes, 6(1), 33─47. doi: 10.1080/19490976.2014.997612
  12. Suchodolski, J. S., Xenoulis, P. G., Paddock, C. G., Steiner, J. M., & Jergens, A. E. (2010). Molecular analysis of the bacterial microbiota in duodenal biopsies from dogs with idiopathic inflammatory bowel disease. Veterinary Microbiology, 142(3─4), 394─400. doi: 10.1016/j.vetmic.2009.11.002
  13. Suchodolski, J. S., Dowd, S. E., Wilke, V., Steiner, J. M., & Jergens, A. E. (2012). 16S rRNA gene pyrosequencing reveals bacterial dysbiosis in the duodenum of dogs with idiopathic inflammatory bowel disease. PLoS ONE, 7(6), e39333. doi: 10.1371/journal.pone.0039333
  14. Suchodolski, J. S., Markel, M. E., Garcia-Mazcorro, J. F., Unterer, S., Heilmann, R. M., Dowd, S. E., Kachroo, P., Ivanov, I., Minamoto, Y., Dillman, E. M., Steiner, J. M., Cook, A. K., & Toresson, L. (2012). The fecal microbiome in dogs with acute diarrhea and idiopathic inflammatory bowel disease. PLoS ONE, 7(12), e51907. doi: 10.1371/journal.pone.0051907
  15. Xenoulis, P. G., Palculict, B., Allenspach, K., Steiner, J. M., Van House, A. M., & Suchodolski, J. S. (2008). Molecular-phylogenetic characterization of microbial communities imbalances in the small intestine of dogs with inflammatory bowel disease. FEMS Microbiology Ecology, 66(3), 579─589. doi: 10.1111/j.1574-6941.2008.00556.x
  16. Pilla, R., Guard, B. C., Blake, A. B., Ackermann, M., Webb, C., Hill, S., Lidbury, J. A., Steiner, J. M., Jergens, A. E., & Suchodolski, J. S. (2021). Long-term recovery of the fecal microbiome and metabolome of dogs with steroid-responsive enteropathy. Animals, 11(9), 2498. doi: 10.3390/ani11092498
  17. Ziese, A. L., & Suchodolski, J. S. (2021). Impact of changes in gastrointestinal microbiota in canine and feline digestive diseases. Veterinary Clinics of North America: Small Animal Practice, 51(1), 155─169. doi: 10.1016/j.cvsm.2020.09.004
  18. Allenspach, K. (2011). Clinical immunology and immunopathology of the canine and feline intestine. Veterinary Clinics of North America: Small Animal Practice, 41(2), 345─360. doi: 10.1016/j.cvsm.2011.01.004
  19. De Souza, H. S. P., & Fiocchi, C. (2016). Immunopathogenesis of IBD: Current state of the art. Nature Reviews: Gastroenterology & Hepatology, 13(1), 13─27. doi: 10.1038/nrgastro.2015.186
  20. Davenport, D. J., Jergens, A. E., & Remillard, R. L. (2010). Inflammatory bowel disease. In M. S. Hand, C. D. Thatcher, R. L. Remillard, P. Roudebush, & B. J. Novotny (Eds.), Small animal clinical nutrition (5th ed., pp. 1065─1076). Mark Morris Institute.
  21. Allenspach, K., Culverwell, C., & Chan, D. (2016). Long-term outcome in dogs with chronic enteropathies: 203 cases. Veterinary Record, 178(15), 368. doi: 10.1136/vr.103557
  22. Volkmann, M., Steiner, J. M., Fosgate, G. T., Zentek, J., Hartmann, S., & Kohn, B. (2017). Chronic diarrhea in dogsꟷRetrospective study in 136 cases. Journal of Veterinary Internal Medicine, 31(4), 1043─1055. doi: 10.1111/jvim.2017.31.issue-4
  23. Atherly, T., Rossi, G., White, R., Seo, Y.-J., Wang, C., Ackermann, M., Breuer, M., Allenspach, K., Mochel, J. P., & Jergens, A. E. (2019). Glucocorticoid and dietary effects on mucosal microbiota in canine inflammatory bowel disease. PLoS ONE, 14(12), e0226780. doi: 10.1371/journal.pone.0226780
  24. Mandigers, P. J. J., Biourge, V., van den Ingh, T. S. G. A. M., Nakringa, N., & German, A. J. (2010). A randomized, open-label, positively controlled field trial of a hydrolyzed protein diet in dogs with chronic small bowel enteropathy. Journal of Veterinary Internal Medicine, 24(6), 1350─1357. doi: 10.1111/j.1939-1676.2010.0632.x
  25. Lenox, C. E. (2021). Nutritional management of dogs and cats with gastrointestinal diseases. Veterinary Clinics of North America: Small Animal Practice, 51(3), 669─684. doi: 10.1016/j.cvsm.2021.01.006
  26. Gaschen, F. P., & Laflamme, D. (2010). Chronic enteropathies – canine. In Nestlé Purina PetCare handbook of canine and feline clinical nutrition (pp. 62─63). Nestlé Purina PetCare Company.
  27. Cave, N. (2012). Nutritional management of gastrointestinal diseases. In A. J. Fascetti & S. J. Delaney (Eds.), Applied veterinary clinical nutrition (pp. 175─220). John Wiley & Sons.
  28. Zoran, D. L. (2017). Nutritional management of gastrointestinal disease. In S. J. Ettinger, E. C. Feldman & E. Côté (Eds.), Textbook of veterinary internal medicine: Diseases of the dog and the cat (8th ed., pp. 1892─1899). Elsevier.