The nutritional management of canine chronic enteropathy is a challenge for even the most experienced practitioner.
Many owners have tried multiple diets, medications and supplements that are not useful or appropriate in attempts to find a solution. For example, an owner may try a recommended diet for only a few days or give a diet without eliminating the treats and extra foods they give their pet. They may try ingredients novel to the pet but in a form that does not eliminate exposure from other food sources.
As such, having a systematic approach to addressing this condition can help to find a dietary solution that is right for the individual pet.
A quick overview of canine chronic enteropathy
Chronic enteropathy can be defined as a presentation of gastrointestinal signs (most commonly diarrhoea or vomiting, but may also include constipation, hyporexia, flatulence, regurgitation and borborygmi) for a period of three or more weeks (Dandrieux, 2016).
While the nutritional management of acute diarrhoea can be accomplished with a highly digestible diet for a short period of time (Rudinsky et al., 2022), this may or may not be the case for chronic enteropathy. In these cases, medications may also be needed. However, when looking at chronic enteropathy subtypes, studies have shown that food-responsive enteropathy is the most common form, at an estimated 50 to 65 percent in dogs (Jergens and Heilmann, 2022). Immunosuppressant-responsive, antibiotic-responsive and non-responsive enteropathies make up the remaining types.
These studies consider food-responsive enteropathy to be based on the response to an elimination diet trial of novel protein and carbohydrate or hydrolysed protein sources. It does not take into account cases that may respond to other nutritional strategies (as detailed below).
Deciding on a strategy
Patient history
A detailed diet and medical history are the keys to selecting which nutritional management strategy to start treating canine chronic enteropathy with.
Diet history should include a list of all current and previous diets, including the brand name, exact flavour and texture (ie dry or wet). It should also list any treats or other foods given, including chews (both commercial and “natural”), dental treats, human foods, medications that contain flavours (such as heartworm preventatives), supplements and even toothpaste. Owners should detail approximately how long their pet was on each diet.
A detailed diet and medical history are the keys to selecting which nutritional management strategy to start treating canine chronic enteropathy with
Medical history should tackle the clinical signs and include their duration, description and any other details the owner can provide.
Tools such as faecal score charts, the canine inflammatory bowel disease activity index (CIBDAI) and a canine chronic enteropathy activity score index (CCECAI) can be especially useful for describing diarrhoea (Jergens et al., 2003; Allenspach et al., 2007). Charts that can discern whether the main complaint is small, large or mixed bowel diarrhoea (Table 1) are also effective.
| Diarrhoea characteristic | Small intestine | Large intestine |
|---|---|---|
| Volume | Increased | Decreased to normal |
| Mucus | Unlikely | Common |
| Melaena | Possible | Absent |
| Haematochezia | Unlikely | Common |
| Steatorrhoea | Possible | Absent |
| Undigested food | Possible | Absent |
| Urgency | Unlikely | Common |
| Tenesmus | Absent | Common |
| Frequency | Somewhat increased | Much increased |
| Completely soft | Usually | Can start out normal then soften |
| Weight loss | Possible | Unlikely |
| Borborygmi | Possible | Absent |
| Decreased appetite | Possible | Unlikely |
Weight changes should be described, and calorie counts verified to ensure any weight loss is due to malabsorption and not caloric deficits. Diagnostic testing results such as chemistry panels, complete blood counts (CBC), cobalamin and folate levels, faecal alpha-1 protease inhibitor tests, dysbiosis index, imaging (particularly ultrasound) and histopathology from biopsies can help localise and define the specific problem.
Next steps: owner compliance and considerations
Once you have obtained the patient’s history, deciding which strategy to start with is the next step.
Owners should always be informed that this will be a trial-and-error process and finding the best diet for the pet may not always happen on the first attempt. This is often because the owner has tried many different tactics, so it is not always clear what the most effective diet will be. Owners should also be warned that although food-responsive enteropathy is the most common subtype, nutritional management alone may not be the answer.
As treats are often very important to owners, you should incorporate them appropriately when creating the nutritional plan, so suitable extras can be given if desired
Minimising the number of dietary components during this process is always required. As treats are often very important to owners, you should incorporate them appropriately when creating the nutritional plan, so suitable extras can be given if desired.
Owners should be encouraged to journal responses and clinical signs using the above-noted resources. Complete compliance with the dietary strategy after dietary transition should be for at least two weeks, potentially up to eight weeks.
Nutritional management strategies for canine chronic enteropathy
Distilling the nutritional management of chronic enteropathy into four main strategies can help to home in on which strategy or strategies may be most effective in each case.
The four broad strategies to consider are as follows:
- Highly digestible diet
- Low-fat diet
- Elimination diet trial
- Fibre-inclusive diet
1) A highly digestible diet
Feeding a highly digestible diet alone (similar to those used in acute diarrhoea cases) can work for many pets with small bowel diarrhoea.
Digestibility is influenced by pet compliance (whether the pet eats the diet) and the diet itself in terms of formula (ingredients), process (such as grinding and cooking) or both.
Individual animals may have different digestive and absorptive capabilities. These cases can be animals with a history of small bowel diarrhoea that eat a variety of foods and treats with low digestibility. For example, dogs that regularly get rawhides or jerky treats may need their diet to be streamlined to only highly digestible items, such as a therapeutic diet and associated treats. This will often resolve the mild absorptive issues they were having with the interference of the poorly digestible treats.
2) A low-fat diet
A low-fat diet should be considered when vomiting is involved, as high-fat diets can delay gastric emptying.
Low fat is also important when there is evidence of protein-losing enteropathy or lymphangiectasia or when the pet has other conditions requiring decreased dietary fat, such as hyperlipidaemia or pancreatitis.
3) Dietary elimination
The goal of a dietary elimination trial is to reduce antigenicity exposure in the intestinal tract to reduce inflammation. Using a hydrolysed protein (dietary proteins broken down into small peptides or amino acids) or novel protein diet can accomplish this. However, it is critical that there is complete compliance with the elimination diet trial or it may be unsuccessful. Moreover, it may be the case that one dietary trial is unsuccessful, thus multiple trials will be needed to truly assess the situation.
The goal of a dietary elimination trial is to reduce antigenicity exposure in the intestinal tract to reduce inflammation
A complete dietary elimination trial for the nutritional management of canine chronic enteropathy includes the following six steps:
- Obtain a complete history
- Determine ingredient exposures: this includes reviewing all the animal’s previous diets for a period of longer than two weeks and noting all possible protein sources from both animal and plant sources
- Select an appropriate diet for use during the trial: this can be hydrolysed or truly novel proteins and can be a commercial or properly formulated home-cooked diet
- Feed the diet exclusively during the trial period. Clinical improvements can be seen in as little as two weeks, although some severe cases may take longer to show improvement. This means eliminating all items the pet ingests that may have protein flavours (such as treats, chews, medications and toothpastes)
- Observe the pet’s clinical response: charts and journaling clinical signs can be very helpful
- Rechallenge with original diet: many owners are reluctant to do this, but without this step, we cannot definitely know which protein the pet reacts to
4) Fibre-inclusive diet
The final strategy to consider in cases of canine chronic enteropathy is the use of dietary fibre. This is generally the go-to tactic when clinical signs point to large bowel or mixed bowel diarrhoea or chronic constipation (uncommonly seen in dogs).
With large bowel diarrhoea, fluid is not absorbed properly from the large intestine. Fibre can contribute to improved fluid absorption and is also seen as potentially exerting anti-inflammatory benefits by metabolising intestinal bacteria to short-chain fatty acids (SCFAs) and playing a role in maintaining intestinal barrier function (Gu and Feagins, 2020). Fibre can also serve as a prebiotic or source of nutrition to stimulate the growth of beneficial gut bacteria.
Conclusion
In conclusion, while controlling canine chronic enteropathy through nutritional management can be challenging, an initial strategy can be devised by carefully reviewing the diet and medical history as well as obtaining details about the clinical signs. From there, a tailored and specific plan can be created. Monitoring clinical signs closely and adjusting the strategy as needed can lead to at least partial or potentially complete resolution of clinical signs through diet alone.
