Canine Chronic Enteropathy: Diagnosis, Treatments and Outcomes

Understanding Chronic Enteropathies in Dogs

Table of Contents

1. Introduction
2. What is Canine Chronic Enteropathy?
3. Types of Chronic Enteropathy in Dogs
4. Food-Responsive Enteropathy FRE
5. Antibiotic-Responsive Enteropathy ARE
6. Immunosuppressant-Responsive Enteropathy IRE
7. Non-Responsive Enteropathy NRE
8. FAQ Canine Chronic Enteropathy
9. Conclusion

Introduction

Chronic enteropathy (CE) in dogs encompasses a range of gastrointestinal disorders marked by inflammation and persistent or recurrent symptoms. This complex condition demands a thorough approach to diagnosis and management, with an emphasis on nutritional strategies. This article delves deep into the types, symptoms, causes, breed predispositions, prevalence, diagnostic methods, treatment options, and prognoses associated with canine chronic enteropathy.

What is Canine Chronic Enteropathy?

Canine chronic enteropathy refers to a spectrum of inflammatory gastrointestinal diseases that persist for more than three weeks, diagnosed after excluding other potential causes like infections, cancer, or systemic illnesses. It involves various pathologies within the gut that cause similar symptoms but may have different underlying mechanisms and treatments.

Canine chronic enteropathy is characterised by persistent (>3 weeks) or recurring gastrointestinal signs, such as diarrhoea, vomiting, loss of appetite, and weight loss. Depending on treatment response, chronic enteropathy is classified as food-responsive-, antibiotic-responsive-, immunosuppressant-responsive-, or non-responsive enteropathy. 

Types of Chronic Enteropathy in Dogs

Food-responsive enteropathy (FRE)

Food-responsive enteropathy (FRE) in dogs is a type of chronic enteropathy that specifically responds to modifications in the dog’s diet. This condition is characterised by chronic gastrointestinal symptoms such as diarrhoea, vomiting, and weight loss, which improve or resolve when a problematic food ingredient is eliminated from the diet. (1)

Characteristics of Food-Responsive Enteropathy

1. Symptoms: The typical signs include persistent diarrhoea, possibly with mucus or blood, intermittent vomiting, flatulence, abdominal discomfort, and weight loss. These symptoms can vary in intensity and may be chronic or intermittent.
2. Diagnosis: FRE is diagnosed by exclusion, meaning other potential causes for the symptoms, such as infectious diseases, parasites, or non-gastrointestinal disorders, must first be ruled out. The diagnosis is confirmed when there is a marked improvement in symptoms following dietary changes.
3. Dietary Trials: The cornerstone of diagnosing and managing FRE involves conducting dietary elimination trials. This involves switching the dog to a diet with novel protein sources that the dog has never consumed before, a plant-based protein food or to a hydrolysed diet where the proteins are broken down into small components that are less likely to trigger an immune response. If symptoms resolve with the new diet and recur when the original diet is reintroduced, a diagnosis of FRE is supported.

Management Strategies

The management of FRE focuses on identifying and avoiding the specific dietary components that trigger symptoms. Here are some key aspects:

• Elimination Diets: This is the initial step where a dog is fed a restricted diet containing ingredients that the dog has not been exposed to previously. Common novel proteins might include venison, duck, or kangaroo, while carbohydrate sources might be sweet potato or tapioca. The most effective, and final strategy employed is usually transitioning dogs to a plant-based dog food that does not include the known allergens – corn, soy, wheat and rice.
• Hydrolysed Diets: For dogs that do not respond to novel protein diets, hydrolysed diets are used. In these diets, proteins are enzymatically broken down to small peptides that are unlikely to provoke an immune response.
• Reintroduction Phase: After symptoms improve on the elimination or hydrolysed diet, individual ingredients may be gradually reintroduced to determine which ones cause a reaction. This helps to identify specific food allergies or intolerances.
• Long-term Diet Management: Once the offending ingredients are identified, they must be permanently excluded from the dog’s diet. The long-term diet should be nutritionally balanced to support overall health.

Prognosis

The prognosis for dogs with food-responsive enteropathy is generally excellent, as long as the offending dietary components can be successfully identified and avoided. With appropriate dietary management, most dogs can maintain a good quality of life without recurring gastrointestinal symptoms.

FRE underscores the importance of diet in managing chronic gastrointestinal conditions in dogs. Effective management relies on careful dietary manipulation and ongoing monitoring to ensure that the dietary needs of the dog are met while avoiding allergenic ingredients.

Antibiotic-responsive enteropathy (ARE)

Antibiotic-responsive enteropathy (ARE) in dogs is a condition within the spectrum of chronic enteropathies where the gastrointestinal symptoms primarily improve or resolve with antibiotic treatment. This type of enteropathy is characterized by persistent or recurrent gastrointestinal disturbances that are not caused by the most common pathogens but respond well to specific antibiotics. (2)

Characteristics of Antibiotic-Responsive Enteropathy

1. Symptoms: Dogs with ARE typically experience chronic diarrhoea, which may be watery or fatty (steatorrhea), and can include flatulence, borborygmi (gut rumbling sounds), and occasionally vomiting. Weight loss and poor body condition can also be observed if the condition persists.
2. Diagnosis: Like other chronic enteropathies, ARE is diagnosed after excluding other potential causes of gastrointestinal symptoms, such as parasites, viral and bacterial infections, or systemic diseases. The diagnosis is generally confirmed when a significant improvement in symptoms is seen following antibiotic therapy.
3. Response to Antibiotics: The improvement of symptoms with antibiotics suggests a bacterial component to the disorder, possibly due to an imbalance in the normal gut flora or overgrowth of pathogenic bacteria.

Management Strategies

The treatment approach for ARE primarily involves the use of specific antibiotics that are effective against intestinal bacteria. Here’s a closer look at the treatment protocol:

• Antibiotic Therapy: The most commonly used antibiotics for ARE include metronidazole or tylosin. These antibiotics are chosen for their effectiveness against anaerobic bacteria and certain aerobic bacteria that are often implicated in gastrointestinal disturbances. Treatment duration can vary, typically lasting from 1 to 4 weeks, depending on the dog’s response. (3)
• Monitoring and Adjustment: The response to antibiotics is closely monitored, and adjustments to the therapy may be made based on the dog’s improvement. In some cases, long-term or intermittent antibiotic therapy may be necessary to manage symptoms.
• Supportive Care: Along with antibiotics, other supportive treatments such as probiotics might be recommended to help restore and maintain a healthy balance of gut flora. Dietary modifications might also be beneficial, especially if the dog has concurrent food sensitivities.

Prognosis

The prognosis for dogs with antibiotic-responsive enteropathy is generally good, especially when the underlying bacterial imbalance is effectively managed with antibiotics. However, some dogs may require longer-term management strategies to prevent recurrence of symptoms, including ongoing intermittent antibiotic therapy.

ARE highlights the importance of a balanced intestinal microbiota and the role of antibiotics in managing specific gastrointestinal conditions in dogs. Effective management relies on a precise diagnosis, appropriate antibiotic selection, and careful monitoring of the dog’s response to treatment.

Immunosuppressant-responsive enteropathy (IRE)

Immunosuppressant-responsive enteropathy (IRE) in dogs, also known as immune-mediated enteropathy or steroid-responsive enteropathy, is a category of chronic enteropathies where the gastrointestinal symptoms primarily improve with immunosuppressive medications. This condition is believed to arise from an inappropriate immune response against the intestinal lining or its normal flora, leading to persistent inflammation and gastrointestinal disturbances. (4)

Characteristics of Immunosuppressant-Responsive Enteropathy

1. Symptoms: Dogs with IRE typically experience severe, chronic diarrhoea which may include the presence of blood, persistent vomiting, significant weight loss, and general malaise. The symptoms are more intense compared to other types of enteropathies and can significantly impact the dog’s quality of life.
2. Diagnosis: IRE is diagnosed after other causes of gastrointestinal symptoms are ruled out (e.g., infections, cancer, dietary sensitivities). The diagnosis is supported by the presence of chronic gastrointestinal inflammation noted on biopsies and a positive response to immunosuppressive therapy.
3. Immune Response: The condition is thought to be driven by an abnormal immune response to the dog’s own gastrointestinal flora or dietary antigens, which leads to ongoing inflammation.

Management Strategies

Management of IRE involves the use of immunosuppressive drugs to reduce the immune system’s activity and alleviate the gastrointestinal inflammation. Here are some specifics of the treatment approach:

• Immunosuppressive Therapy: The primary treatment involves corticosteroids, such as prednisone or prednisolone, which are effective in reducing inflammation. In cases where steroids are not sufficient or cause unacceptable side effects, other immunosuppressive agents like cyclosporine, azathioprine, or mycophenolate mofetil may be used.
• Dosage and Monitoring: The initial dosage of immunosuppressive medication is usually high, and once improvement is noted, the dosage is gradually tapered to the lowest effective dose. Continuous monitoring is essential to adjust the therapy as needed and to manage any side effects of long-term immunosuppressant use.
• Supportive Care and Diet: Supportive treatments, including dietary modifications, can be beneficial. Diets that are easy to digest and low in fat might be recommended to improve nutrient absorption and reduce intestinal workload. Probiotics may also be used to help maintain a healthy gut microbiota.

Prognosis

The prognosis for dogs with immunosuppressant-responsive enteropathy varies. While many dogs respond well to immunosuppressive medications and can maintain a good quality of life with management, the need for ongoing medication can lead to complications, such as increased susceptibility to infections and potential side effects from the drugs themselves.

Long-term management may be necessary, and regular follow-ups with a veterinarian are crucial to monitor the dog’s health status and adjust treatment as needed. The success of treatment largely depends on the individual dog’s response to the immunosuppressive therapy and the ability to manage any associated complications effectively.

Non-Responsive Enteropathy (NRE)

Non-responsive enteropathy in dogs refers to a form of chronic enteropathy that does not adequately respond to standard treatments such as dietary changes, antibiotics, or immunosuppressive therapies. This condition is particularly challenging to manage because the usual therapeutic approaches—targeting food sensitivities, bacterial imbalances, or immune system abnormalities—fail to alleviate the clinical signs. (5)

Characteristics of Non-Responsive Enteropathy

1. Persistent Symptoms: Despite comprehensive treatment strategies, symptoms like chronic diarrhoea, weight loss, vomiting, and poor appetite continue unabated.
2. Diagnosis of Exclusion: Non-responsive enteropathy is often diagnosed after all other potential causes of the symptoms (like infections, cancer, or other systemic diseases) have been ruled out and after the failure of treatments for other types of chronic enteropathies.
3. Intensive Diagnostic Work-Up: Typically requires a more extensive diagnostic approach, including repeated tests such as advanced imaging (ultrasound, MRI), extensive blood work, and multiple intestinal biopsies to understand the underlying pathology.
4. Complex Management: Management of non-responsive enteropathy may involve experimenting with various combinations of therapies, including novel therapeutic diets, more potent immunosuppressive agents, and possibly experimental treatments.

Management Strategies

Managing non-responsive enteropathy often necessitates a multifaceted and highly individualized approach, including:

• Advanced Dietary Management: This may involve trying several different types of hypoallergenic diets, including those made from novel or hydrolysed proteins and, in some cases, home-cooked diets under veterinary supervision to ensure nutritional adequacy.
• Immunosuppressive Therapy: In cases where immunosuppressive therapy has not been effective, veterinarians might escalate the dose or switch to a more potent immunosuppressive drug, such as cyclosporine or azathioprine.
• Supportive Care: Supportive treatments such as vitamin supplementation, probiotics, and anti-inflammatory medications can also be part of the management to improve overall gut health and condition.
• Experimental Treatments: For some cases, veterinarians might consider experimental or emerging therapies. This could include faecal microbiota transplantation (FMT) or the use of novel biologic drugs.

Prognosis

The prognosis for non-responsive enteropathy in dogs can be variable and often more guarded than for other types of chronic enteropathies, primarily due to its resistance to standard treatments. The success of managing this condition depends on the underlying cause, the extent of intestinal damage, the dog’s overall health, and the response to more intensive therapies.

Non-responsive enteropathy represents a significant challenge in veterinary medicine, requiring ongoing research and innovative treatment approaches to improve outcomes for affected dogs.

FAQ Canine Chronic Enteropathy

What are the Different Types of Chronic Inflammatory Enteropathies?

1. Food-responsive enteropathy (FRE): Primarily managed with dietary modifications.
2. Antibiotic-responsive enteropathy (ARE): Responds favourably to antibiotic treatment.
3. Immune-mediated enteropathy (IME): Also known as steroid-responsive enteropathy, this type requires immunosuppressive medications.
4. Non-responsive enteropathy (NRE): Refers to chronic gastrointestinal disorders that do not respond to conventional treatments such as dietary changes, antibiotics, or immunosuppressive therapies.

Breed Disposition to Different Chronic Enteropathies

• FRE: Common in Labrador Retrievers, Irish Setters (especially gluten sensitivity), and Cocker Spaniels.
• ARE: Frequently observed in German Shepherds and Rottweilers, likely due to their tendency towards gut dysbiosis.
• IME: Boxers and French Bulldogs show a higher predisposition, potentially related to genetic factors affecting immune regulation.

What is the Prevalence of Each of the Chronic Enteropathies?

The prevalence of each type of chronic enteropathy varies widely, influenced by geographical, breed-specific, and diagnostic criteria differences. FRE is generally the most commonly diagnosed, particularly in middle-aged dogs. ARE and IME are less common but not rare, often identified in specific breeds predisposed to these conditions.

How are These Chronic Enteropathies Diagnosed?

Diagnosis is achieved through:

• Detailed clinical history and physical examination.
• Comprehensive lab testing (blood tests, faecal exams) to rule out other conditions.
• Advanced imaging techniques such as ultrasound and X-rays.
• Gastrointestinal biopsies via endoscopy, essential for confirming the type of enteropathy.

What are the Recommended Treatment Strategies for Each of These Enteropathies?

FRE:

• Dietary management is key, involving an elimination diet to identify triggers, followed by a long-term diet excluding these allergens. Research has shown that diets based on novel proteins or hydrolysed proteins can be particularly effective. Some studies also suggest that a plant-based diet may help reduce symptoms in dogs with specific food allergies or intolerances.
• Incorporation of probiotics and prebiotics is recommended to support a healthy gut microbiome, potentially improving gastrointestinal health and function.

ARE:

• Treatment usually consists of a specific course of antibiotics like metronidazole or tylosin, based on culture and sensitivity results.
• Inclusion of probiotics and prebiotics during the course of antibiotics is recommended to support a healthy gut microbiome, potentially improving gastrointestinal health and function.

IME:

• Treatment involves immunosuppressive drugs such as prednisolone, with dietary adjustments to support immune health and manage symptoms.

What is the Prognosis for Dogs with Chronic Enteropathies?

• FRE: Generally excellent with dietary management.
• ARE: Good, though some dogs may need intermittent antibiotic therapy.
• IME: Guarded, as continuous immunosuppression is required, increasing the risk of secondary complications.

Conclusion

Managing canine chronic enteropathy demands a comprehensive and tailored approach, particularly in the realm of nutrition. With correct diagnosis, specific dietary management, and appropriate medical interventions, many dogs can maintain a good quality of life. Veterinarian collaboration is essential to optimise treatment outcomes, making veterinary gastroenterologists or nutritionists valuable partners in the care of affected dogs.

Bonza Superfoods and Ancient Grains, a 100% plant-based, vegan friendly, dog food contains none of the known allergens making it an ideal food for dogs suffering from food responsive enteropathy or those that would benefit from dietary management as part of the treatment of their condition.

In addition the formula contains a quality probiotic for dogs, Calsporin®, which helps to re-establish balance in the gut, particularly after the administration of medication including antibiotics.

Medium Chain Triglycerides (MCT) have also been shown to be a valuable source of fats for dogs suffering from food responsive enteropathy as they behave differently from other fat sources, they can be absorbed into the portal blood and are more easily digested, providing an easily metabolisable source of energy for dogs with enteropathy issues. (6) The coconut oil in Bonza Superfoods and Ancient Grains formula delivers MCT’s in the dog’s daily diet.

The inclusion of PhytoPlus®, a proprietary blend of natural plant-based phytonutrients formulated to provide dogs with the powerful benefits of anti-inflammatory and antioxidant nutrients, supports a reduction of inflammatory markers associated with chronic enteropathies.

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