Articles about EPI Dogs
We are very pleased to announce that Liz Morfitt of the UK Hearing Dogs for People http://www.hearingdogs.org.uk/ contacted Epi4Dogs and asked to do a piece on one of our UK EPI dogs that they could use as an informational piece when pairing a hearing trained dog with a hearing impaired person. Liz selected to tell the story of our long-time EPI member, sweet, loving, funny but once very very sick, Mr. Dexter, who shares his life with Fiona!
If you would like to print the article in it’s entirety, please click on this PDF: Dexter-Dogs asstg Deaf.pdf
Dexter’s EPI Journey
Image 1, Dexter June 2012
17 week old Dexter, a lurcher cross, was rehomed by Fiona Buchanan in May 2011. He had suffered severe neglect along with his mother and siblings since birth and had been removed from that environment at 15 weeks old.
During the first year of owning Dexter, Fiona had tackled a few bouts of diarrhea that were treated with antibiotics. At his first yearly vaccination the vet noted Dexter weighed 17.4kgs, 3 kilos below his ideal body weight. The vet advised Fiona to increase Dexter’s food but this seemed to cause severe diarrhea so Fiona dropped it back to the original amount. In June 2012 Dexter developed dietary indiscretion that progressed into watery diarrhea.
Over the following weeks he was treated for parasites, given more antibiotics, probiotics and put on to a prescription Allergen-Free diet with novel proteins. During all this Dexter was put through several blood tests and regular stool samples were taken. The watery diarrhea stopped, but was replaced by soft yellowish stools.
By September Dexter’s weight loss was becoming quite drastic and his temperament was changing. He had gone from a boisterous, friendly, active dog to a subdued, quiet boy who was becoming aggressive towards Fiona’s cats.
Image 2, October 2012
By October Dexter’s weight had dropped to a dramatic 14.3kgs. He had a ravenous appetite and was regularly passing grey ‘cow pat’ stools. Dexter was puzzling the vets; they discussed full body scans, biopsies and referring him to specialists. Then the vet Fiona was working with came up with one last idea. To test Dexter for a condition called Exocrine Pancreatic Insufficiency (EPI).
What is Exocrine Pancreatic Insufficiency? (EPI)
EPI is the inability of the pancreas to produce and secrete the necessary enzymes needed to digest food.
These enzymes are:
• Amylase for digestion of carbohydrates (sugars & starches in grains, fruits & vegetables).
• Lipases for digestion of fat.
• Trypsin and Proteases for digestion of proteins.
(DiMagno EP, Go VL, Summerskill WH 1973).
Without a steady supply of these enzymes the body can’t break down and absorb nutrients, meaning the dog literally starves.
Incomplete digestion causes the continual presence of copious amounts of fermenting food in the small intestine (Williams. D.A. et al 1987). This can lead to a secondary condition, common in many EPI dogs, named Small Intestinal Bacterial Overgrowth (SIBO).
The condition occurs when bacteria that is feeding on the fermenting food overpopulates the tissue lining of the small intestine, further impairing the proper absorption of vital nutrients and depleting the body’s store of vitamin B12. This then causes the body to develop a B12 deficiency (Kennedy .O.C 2009).
Causes of EPI?
It’s believed that EPI has both an environmental and genetic origin; the exact mode of inheritance is not known (Kennedy .O.C 2009).
Prior research suggested that EPI was inherited in an “autosomal recessive” manner (i.e., both parents had to be carriers for a dog to get EPI); however, it’s no longer believed that both parents must be carriers in this manner. Latest research by Dr. Leigh Anne Clark and her Research Associate, Dr. Kate Tsai of Clemson University yielded new findings to help understand the causes of EPI. The study found that autoimmune reactions which can destroy digestion-related parts of the pancreas play a key role. These autoimmune reactions were found to have a relationship to a certain chromosome and a particular gene. The “alleles” associated with this particular gene appear to be significant. Dogs that had one particular allele associated with this gene had an increased EPI risk. Dogs that had other alleles associated with this gene appeared to have more protection from EPI (Kennedy 2009).
Certain illnesses, such as chronic pancreatitis, can lead to EPI. Although pancreatic tumors (such as insulinoma) are not common, pancreatic surgery related to a tumor can lead to EPI symptoms. Each time a dog gets pancreatitis, small portions of the pancreas can become permanently damaged from scarring or necrosis (tissue death). The more damage done, the greater the risk of EPI occurring (GlobalSpan 2008).
Symptoms of EPI
• Runny “Cowpie” stools
This is one of the most common symptoms of EPI & may be the first sign the owner sees yellow, orange, grey, or pale-coloured stools.
Image 3, EPI stool
• Much greater quantity of stools than normal and may occur several times a day
• Food is passing through the dog’s body without being used
Rapid weight loss
• Normally occurs since the dog is literally starving to death
• It’s not unusual for a 100 lb dog to lose 1/2 lb a day
Ravenous appetite (polyphagia)
• Loss of appetite is associated with SIBO and/or B12 deficiency (both often accompany EPI)
Gas (burping, flatulence, etc.)
• Very common early symptom of SIBO
• Higher risk of Bloat due to gas
Dry, dull, or brittle coat
• Possibly excessive shedding too
Vomiting, regurgitation, throwing up, or wet burps
• May be mostly liquid (often brown)
Eating stools / feces (coprophagia)
• Quite a few EPI dogs do this
• May accompany SIBO due to malabsorption
Temperament changes showing fear and/or aggression
• Some EPI dogs understandably become temporarily aggressive because they’re starving to death
• B12 deficiencies can affect cognitive functions
• SIBO creates on-going abdominal discomfort which may aggravate behaviour issues
How to test for EPI
• A trypsin-like immunoreactivity (TLI) determination is primarily used for the diagnosis of exocrine pancreatic insufficiency. This disease involves the portion of the pancreas that produces digestive enzymes. Insufficient enzyme production results in improper digestion of fats, carbohydrates, and proteins (Williams.D.A & Batt.R.M 1986).
The TLI test is highly sensitive and specific for the diagnosis of canine exocrine pancreatic insufficiency (EPI). This test measures the concentration of trypsin-like proteins in a blood sample by radioimmunoassay (Williams.D.A & Batt.R.M 1986).
• In normal dogs the TLI concentrations are greater than 5.5µg/L
• In dogs with exocrine pancreatic insufficiency TLI concentrations are less than 2.5µg/L
• On October 18, 2012 Dexter’s results came back showing a shocking TLI level of only 1.5 µg/L. This was evidence that Dexter’s body was not following a normal digestive process and proof that he was confirmed with EPI.
Management of EPI
There is no quick fix or simple solution for EPI. It is all about finding what is right for the individual dog. Dexter was prescribed Pancreatic Enzymes for cats and dogs to promote better digestion. Within a few days Dexter’s stools were becoming more solid. Over time he slowly began to gain small amounts of weight and his aggression towards the cats had stopped.
Enzyme supplementation is the first step in managing EPI. The best results are usually obtained with freeze-dried, powdered porcine enzymes rather than plant enzymes or enzyme pills. Plant enzymes and enzymes in a pill form do work for some, though with enzyme supplements, as with diet, much is dependent on the individual EPI dog (Kennedy.O.C 2009). Some of the most widely used prescription enzyme supplements are Viokase, Epizyme, Panakare Plus, Pancrease-V, and Pancrezyme. Enzyme Diane is a non-prescription generic equivalent (Kennedy.O.C. 2009).
Some EPI dogs have allergies and cannot tolerate the ingredients in the most common enzyme supplements. Those owners learn to develop alternative methods such as using plant enzymes, or a different source of pancreatic enzymes such as beef-based (rather than porcine-based) (Tom 2011). Raw beef, pork, or lamb pancreas can also be used. One to three ounces of raw chopped pancreas can replace one teaspoon of pancreatic extract (Kennedy.O.C 2009).
The starting dosage of prescription enzymes is usually one level teaspoon of powdered enzymes per cup of food. As time goes on and a dog stabilizes, many owners find that they can reduce the amount of enzymes administered with each meal, sometimes to just ½ teaspoon per cup, although some EPI dogs require an increased dosage of enzymes in their senior years (Kennedy.O.C 2009).
Supplements for an EPI diet
Whether the dog is fed dry, canned, home-cooked, raw, or any combination, there are many supplements that may be added to provide additional benefits for EPI dogs (Estermarck.E & Wilberg.M 2006). Wild Salmon Oil is used by many EPI dog owners who alternate between that and cold pressed, unrefined coconut oil. Coconut oil consists of approximately 90% saturated fats and most of those fats are Medium Chain Triglycerides (MCTs). The main component of the MCTs in coconut oil is lauric acid, which is antiviral, antifungal, antibacterial and helps to balance the immune system. MCTs are an excellent source of energy and are extremely easy to digest, as they do not require lipase or gall bladder bile to digest, making it easily processed in the body (Westermarck.E. et al 1995).
Probiotics are another important addition to the EPI diet, especially since most EPI dogs are, or have been, treated with antibiotics because of SIBO. Antibiotics wipe out not only bad bacteria, but also good bacteria. Probiotics help maintain good gut flora. One popular brand of probiotics that has been successfully used by EPI owners is Primal Defense, but there are many quality probiotics available.
Other natural nutrient sources that are often included in an EPI diet are kelp, green tripe, slippery elm, and alfalfa (Kennedy.O.C 2009).
A common saying among those whose dogs have EPI is, “If you’ve met one EPI dog, then you have met just one EPI dog.” Even with pancreatic enzyme supplements, much of the health and well-being of each EPI dog depends on his diet. Sometimes all that is needed are supplemental enzymes and the standard recommended dietary modifications: no more that 4% fibre and no more than 12% fat (Kennedy.O.C 2009).
Recommendations keep evolving and changing with new research, as well as the feedback from networks of owners of EPI dogs. A recent change in feeding recommendations concerns dietary fat. Multiple studies from the past decade indicated that a fat-restricted diet is of no benefit whatsoever to the EPI dog. A 2003 paper by Edward J. Hall, of the University of Bristol in England, states that there is experimental evidence to show that the percentage fat absorption increases with the percentage of fat that is fed. This may explain why some EPI dogs can tolerate higher concentrations of fat. Veterinarians usually recommend an initial diet of a prescription or veterinary food, such as Hill’s Prescription Diet w/d, i/d, or z/d Ultra Allergen-Free; Royal Canin’s Veterinary Diet Canine Hypoallergenic Diet or Digestive Low Fat Diet. Prescription diets that are made with hydrolyzed ingredients (carbohydrates and proteins that have been chemically broken down into minute particles for better absorption in the small intestine, leading to more complete digestion, better/faster weight gain, and firmer stools) appear to work for some EPI dogs but not the majority. Unless there is a concurrent condition requiring this food, a prescription diet is not necessary. A grain free diet with 4% or less fiber is what works for the majority.
Dexter’s EPI Management
By January Dexter’s stools were becoming soft and his aggression was resurfacing. Fiona had been researching EPI and had found Epi4Dogs Foundation where she was advised to look into his vitamin B12 levels and also advised that he was showing many of the symptoms linked with SIBO. Fiona approached her vet and Dexter was put on a course of B12 injections and Metronidazole for the SIBO.
Those animals who are not properly treated for B12 deficiency will have a very poor prognosis and will not show improvement when only treated for EPI. Because animals with EPI are unable to absorb certain nutrients and have a diminished capacity to produce intrinsic factor, giving them oral B12 supplementation without intrinsic factor will not help. Thus, the most effective method of vitamin B12 supplementation is by injection (PetMD 2013).
The dog will continue to receive injections of B12 until levels are high enough and any secondary intestinal problems are improved. Once an animal has a normal level of B12 in the bloodstream, it should begin to gain weight and improve considerably, even in the face of EPI (PetMD 2013).
Once again Dexter’s temperament began to improve but the SIBO persisted. The vet changed Dexter’s antibiotics to Oxytetracycline and the SIBO began to clear up. As before though, when the antibiotic course was finished the SIBO kept returning.
Fiona and the vet decided that a grain free diet may be easier to digest and help Dexter overcome these bouts of SIBO. However, changing an EPI dog’s food is not a simple task. With each new food they tried, Dexter would suffer with severe acid reflux which meant that changing his food was a lengthy process. Eventually Dexter was able to be settled on Millies Wolfheart Gundog Mix. Dexter seemed to settle and seemed to be suffering less with SIBO flare ups.
In June 2013 Fiona changed Dexter’s enzyme medication to Panzym; Dexter had been emitting a smell of sour milk whilst on Pancreatic Enzymes for cats and dogs. The Panzym was successful and Dexter’s smell of sour milk reduced.
Over the next few months, although he suffered with SIBO flare ups, Fiona was treating Dexter at home with the antibiotic Oxytetracycline when necessary. Dexter was slowly gaining weight and by August 2013 his weight had reached 17.5kg. He seemed back to the healthy, energetic dog he had been before his illness. In October the antibiotics were changed to Tylan and in November Fiona introduced coconut oil to his food.
Dexter began to pile on the weight and reached an excellent 19.7kg. He is now living a full and happy life with the careful management of Fiona.
Figure 4, Dexter 2014
What if Dexter had been a hearing Dog?
With Dexter’s illness it was not clear until he was 21 months old that he was suffering with EPI. Although he had displayed some symptoms in puppyhood, they had only been minor incidents.
At this stage Dexter would likely be in placement, working with a recipient. Due to the nature of the condition it would have to be discussed as to whether the recipient could cope with the long term commitment of maintaining Dexter’s health.
With this condition, it is not only the dog that suffers, the owners can too. When considering a dog, the recipient is, of course, also taken into account. Could this condition cause the recipient to become anxious? Is their lifestyle suited to the dog’s condition? Would they cope with the condition when it was flaring up badly? Is it fair for the charity to ask them to? The charity would need to provide a strong network of support for the recipient and be in direct contact with the vets to ensure all information was being communicated well.
Financial matters would also have to be considered. Should the charity help with payments? Can the recipient afford to pay for the treatments/management needs?
What if Dexter was in the advanced stages of training?
If Dexter was in training when not stable, the following areas would have to be considered:
• Frequency of diarrhea and vomiting – This, for example, would need to be taken into consideration when looking for a match for the dog. If the recipient worked, it may be unsuitable to place this particular dog with them. A quieter match would most likely be more suited to a dog with EPI simply due to the common symptoms of the condition.
• Triggers for flare ups.
• Extent of weight loss – It would need to be taken into consideration how often the dog may need to visit the vet to monitor its weight. A less experienced recipient may not notice the weight loss, whereas a more experienced recipient is more likely to notice.
• Type of food rewards used – What food would be the most suited to the dogs health?
• Triggers for the condition to flare up such as stress – If stress is a contributing factor, the charity would have to evaluate if the dog copes with changes in its life or if it becomes stressed. For example, if the condition flares up when the dogs goes to a new B&B socialiser, then it is likely to flare up when it is placed with a recipient.
• Behavior – EPI dogs can display aggressive behaviors due to the fact that they are literally starving to death. They may begin stealing food and eating inappropriate items. The pain that can be caused by this condition may also have an effect on their behaviour; they can become more sensitive to touch, even fearful of certain areas being handled. Finally, B12 can affect cognitive functions which will affect a dog’s behavior. The dog would have to be matched to a very specific recipient. They would have to be able to understand and cope with the condition and, of course, be happy to take on a dog that will need lifelong careful management.
• EPI is becoming more prevalent and appearing in more breeds of doga. It is not a condition that can be cured, but it can be managed. Many dogs that suffer with EPI can live long and fruitful lives. With the correct care and attention, an EPI dog could become a hearing dog but it would require extra support from the charity.
• Each EPI dog is different and the severity of the illness can vary widely. Dexter suffered badly in the beginning but with care, attention and support he is now living a full and happy life. Fiona has his EPI at a manageable level and through trial and error she has found what is right for him.
DiMagno EP, Go VL, Summerskill WH. Relations between pancreatic enzyme outputs and malabsorption in severe pancreatic insufficiency. N Engl J Med. Apr 19 1973;288(16):813-5.
Global Span.net (2008) EPI in Dogs Available: http://www.globalspan.net/epi.htm. Last accessed 08/12/2014
Kennedy, O C. (2009). Exocrine Pancreatic Insufficiency in Dogs. Available: http://www.whole-dog-journal.com/issues/12_3/features/Exocrine-Pancreatic-Insuffinciency-in-Dogs_16109-1.html. Last accessed 14/11/2014.
PetMD (2014) Small Intestinal Bacterial Overgrowth (SIBO) and Pancreatic Insufficiency. Accessible: http://www.petmd.com/dog/care/evr_multi_sibo_and_epi?page=show. Last Accessed 08/01/2015
PetMD (2013) VitaminB12SupplementationinPetswithEPI.http://www.petmd.com/dog/wellness/evr_multi_vitamin_b12_therapy_for_epi. Last Accessed 10/1/2015
Tom(2011)GreenTripeandEPI.Accessible:http://www.greencuisine4pets.com/greentripe_4_epi.htm. Last Accessed 10/01/2015
Williard M.D., Simpson R.B., Fossum T.W., Cohen N.D., Delles E.K., Kolp D.L., Carey
D.P., Reinhart G.A. Characterization of naturally developing small intestinal bacterial overgrowth in 16 German shepherd dogs. J. Am. Vet. Med. Assoc. 1994; 204: 1201-1206.
Williams D.A., Batt R.M., Mclean L. Bacterial overgrowth in the duodenum of dogs with exocrine pancreatic insufficiency. J. Am. Vet. Med. Assoc. 1987; 191: 201-206.
Williams D.A., Batt R.M. Exocrine pancreatic insufficiency diagnosed by radioimmunoassay of serum trypsin-like immunoreactivity in a dog with normal BT-PABA test result. J. Amer.
Anim. Hosp. Assoc. 1986; 22: 671-674.
Westermarck E., Junttila J., Wiberg M. The role of low dietary fat in the treatment of dogs with exocrine pancreatic insufficiency. Am. J. Vet. Res. 1995; 56: 600-605.
Image 1, Dexter 2012. Personal photograph by Fiona Buchanan
Image 2, October 2012. Personal Photograph by Fiona Buchanan
Image 3, EPI Stool. Kennedy, O C. (2009). Exocrine Pancreatic Insufficiency in Dogs. Available: http://www.whole-dog-journal.com/issues/12_3/features/Exocrine-Pancreatic-Insuffinciency-in-Dogs_16109-1.html. Last accessed 14/11/2014.
Image 4, Dexter 2014. Personal photograph by Fiona Buchanan
Please feel free to see the entire article on TUFT”S UNIV website:
Exocrine Pancreatic Insufficiency In Dogs
A dog with this condition can starve to death no matter how much she eats — unless the disease is diagnosed and managed correctly.
“Three years ago, Maya started having an ‘iffy’ stomach,” says Paula Gatens of Waynesville, North Carolina. But it didn’t appear to be anything serious. “She would eat something and get diarrhea, but then it would go away,” Ms. Gatens relates. “Like other German shepherds, she had a sensitive stomach, but she was a normal dog.”
About three weeks before Maya’s fourth birthday, however, she began to experience diarrhea that wouldn’t go away. “We put her on a high-fiber diet, and that seemed to help a bit,” Ms. Gatens says. “But then all of a sudden she lost about 15 pounds in two to three weeks. Her stools were enormous — and soft.”
Ironically, Maya was one of the lucky ones. The clinical signs of the disease that was ravaging her body were so clear that she was easy to diagnose. Her condition is called exocrine pancreatic insufficiency, or EPI. In a nutshell, it’s an inability to digest food. The dog is ravenous and eats copious amounts, but the food and the calories it contains go right through her system without being broken down and absorbed, so she starves because her body can’t use the nutrients she takes in. “Maya was eating acorns, grass, six cups of food a day,” Ms. Gatens says, but she couldn’t relieve her hunger or keep on weight.
Other symptoms, besides wasting away despite a voracious appetite:
- Eliminating more frequently, sometimes every hour or two.
- Greasy, voluminous, unformed stools, often yellowish but sometimes grayish.
- Eating substances a dog wouldn’t normally eat.
- Increased rumbling sounds from the stomach.
- Personality changes, veering either toward fearfulness or sudden crankiness/aggression.
The disease can strike any dog from a young puppy to an elderly “dowager,” but German shepherds have a predisposition. That, along with Maya’s symptoms, helped her veterinarian pinpoint her disease relatively easily.
It’s not always a slam dunk. Some dogs don’t display symptoms, or don’t have all of them, or display them only to a certain degree. “There are variable degrees of expression of this disease trait, from a mild form to the most severe form, where patients are ravenous, losing weight, and passing large volumes of stool that are essentially undigested food,” says Tufts veterinarian Mary Labato, DVM, DACVIM, a specialist in small animal internal medicine. If the disease is mild, and if the dog is not a German shepherd, it can be harder for a vet to do quick sleuthing.
Exocrine Pancreatic Insufficiency Causes
Exocrine pancreatic insufficiency develops when the exocrine pancreas fails to produce and secrete the enzymes required for digesting food. In the main, the pancreas is an endocrine organ, meaning it secretes substances — often hormones —directly into the bloodstream (such as the hormone insulin, which is necessary for metabolizing the blood sugar glucose). But it does have some exocrine functions, which is to say that is it secretes certain substances to a “far-away” environment via ducts.
Among those substances: enzymes essential for food digestion, which normally get sent from the pancreas to the intestine to help break down food for absorption by the body. These enzymes include amylase, which is involved in the digestion of carbohydrates found in grains, fruits, and vegetables; lipase, essential for the digestion of fat; and trypsin and proteases, needed to digest protein. (Carbs, fat, and protein are the three calorie-containing nutrients.)
In dogs with exocrine pancreatic insufficiency, the enzymes are neither manufactured nor secreted. The pancreas, literally, becomes insufficient in that regard. Its exocrine cells are atrophied. Unfortunately, symptoms do not appear until some 80 to 95 percent of the cells at issue are destroyed; it is detected late in the game.
While in German shepherds the condition is usually hereditary, in other breeds, it often is the result of some other problem. For instance, says Dr. Labato, it can be “an acquired problem after severe pancreatitis [inflammation of the pancreas].”
In fact, Dr. Labato says, these days, with breeders aware of the disease and screening for the trait in German shepherds, veterinarians are more likely to see the condition as a complication of some other disease in a dog of any breed than in a German shepherd genetically primed to develop the problem. And since the hereditary form that afflicts some German shepherds produces the most pronounced symptoms, like the kind Maya had, more often veterinarians will see dogs with milder symptoms that are less obviously suggestive of EPI.
Diagnosing Dogs with EPI
If a dog is suspected of having exocrine pancreatic insufficiency, the only way to confirm the diagnosis is to administer a trypsin-like immunoreactivity (cTLI) test. As we said above, trypsin is one of the enzymes needed to digest food — protein, specifically. And trypsinogen is a prohormone that is also produced by the exocrine pancreas, and needed to create trypsin. The test, a blood test before which the dog must have been fasted for at least 12 hours, checks how much of that substance is in the bloodstream. The normal range is along the lines of 5 to 35 micrograms per liter of blood. A level lower than that is generally definitive for a diagnosis.
Often, a blood test for the presence of vitamin B12, known as cobalamin, will be administered as well. A cobalamin deficiency occurs in four out of five dogs with exocrine pancreatic insufficiency, and some research suggests it can be at least partly responsible for the personality changes seen in dogs with the condition, making them perhaps more fearful and timid or more aggressive with, say, other dogs — or at least somewhat confused or disoriented, impairing cognitive function. Paula Gatens’s dog, Maya, was found not to have very low levels when she was first diagnosed with the disease, so Ms. Gatens didn’t think any personality changes would come into play.
Treatment for Exocrine Pancreatic Insufficiency
Managing exocrine pancreatic insufficiency involves a five-pronged approach that includes supplementation with digestive enzymes missing from the dog’s pancreas, feeding the dog 150 percent of her usual rations, treatment for bacterial overgrowth in the gut that results from the disease, cobalamin supplementation, and a low-fiber diet.
Supplementation of digestive enzymes: Enzymes to take the place of those not produced by the pancreas are needed at every single meal. Ideally, there are no between-meal treats, but if there are, the dog must be supplied with enzymes at those eating occasions also. The enzymes of choice are porcine (pig) enzymes that have been ground to a powder or are given as tablets, granules, or other formulations. “The amino acid sequence of the enzymes are a closer match between pigs and dogs than between, say, cows and dogs,” Dr. Labato says. “Also,” she adds, “it is inexpensive for enzyme manufacturers to obtain pig pancreas from a slaughter house.” Furthermore, “with all of the bovine viral disease that people are now concerned about, it is harder to get cow by-products for medical use these days.”
It used to be thought that mixing powdered enzymes in the dog’s food and then pre-soaking it in lukewarm water allowed for some pre-digestion before the dog actually consumed the victuals. But there have now been “a couple of studies to support the notion that this is not necessarily needed,” Dr. Labato comments. Thus, if for whatever reason your dog takes the enzymes more easily in another form that is not powdered, your vet can advise you on whether that form is okay for your pet. For some dogs, softening the food-powder mixture in water helps avoid mouth sores that can possibly occur because of the caustic attributes of the powdered enzymes. Every dog reacts differently.
Note: If the food and enzymes have been heated to too high a temperature prior to serving, the enzymes will be destroyed. If it’s too chilled, they’ll be inactivated. At room temperature or very close to that is best.
150 percent of usual rations: Dogs who have experienced significant wasting because of the disease need to catch up. Until a dog’s body is back to itself, 150 percent of the amount of food she’s supposed to get should be given daily in small meals, at least 2 hours apart.
Low-fiber diet: Most, but not all, dogs with exocrine pancreatic insufficiency fare better on a diet that is very low in fiber, less than 4 percent. Fiber interferes with the function of the replacement enzymes, and it can inhibit absorption of certain nutrients, to boot.
That said, different dogs do better on different kinds of diets. For some, a very high-protein, grain-free food is the right choice, while other dogs with exocrine pancreatic insufficiency actually need some grain, with its attendant fiber. Complicating the issue further is that there are two kinds of dietary fiber, soluble and insoluble. Soluble fiber slows digestion (a good thing if you want to absorb the most nutrients), while insoluble fiber tends to speed the transit time of food through the digestive system. And very often, both kinds of fiber are contained in a single food. A veterinarian, particularly a board-certified veterinary nutritionist, can help you experiment safely until you come up with the fiber level and the fiber quality that is right for your dog. You’ll know because her stool volume, color, and quantity will be normal, or at least close to normal.
Treatment for SIBO: SIBO stands for “small intestinal bacterial overgrowth,” meaning that lack of ability to properly digest food in the small intestine (where the lion’s share of digestion takes place once food leaves the stomach) creates an environment that allows “bad” bacteria to overtake “good” bacteria, worsening the gastrointestinal signs of the disease. Today, veterinarians are starting to replace the term SIBO with SID, which is short for small intestinal dysbiosis. It’s a little more precise because “dysbiosis” refers to a bacterial imbalance rather than a bacterial overgrowth per se.
Whichever term your vet’s office uses, the doctor will often not lose time after diagnosis of exocrine pancreatic insufficiency taking a cell culture and growing it in the lab to see whether bad bacteria are present. She will go straight to prescribing an antibiotic to kill any offending bacteria that may be lurking — not an unreasonable approach since virtually all dogs diagnosed with exocrine pancreatic sufficiency also have SIBO. That was the approach with Maya. In fact, with the porcine enzymes her “soft stools went away right away,” says Ms. Gatens. “But they [still] gave her antibiotics.”
Some vets wait a week or two after starting the dog on porcine enzyme supplementation to see if that corrects the bacterial imbalance. If the dog’s stools continue to have yellowish coloring or remain loose and “ploppy” even with the administration of porcine enzymes, then antibiotic treatment will begin. The antibiotics most commonly used are metronidazole (Flagyl), amoxicillin/clavulanic acid (Clavamox), and tylosin (Tylan). Sometimes enrofloxacin (Baytril) will be prescribed if it is suspected — or learned upon further examination — that the offending bacteria are of the E. coli variety. Usually the dog receives a two- to four-week course of antibiotics, although “some patients require more long-term administration,” says Dr. Labato. If SIBO, or SID, is indeed present, a positive response should be observed in about a week to 10 days. (Don’t stop giving the antibiotic after just a few days if you don’t see any improvement right away in the dog’s stools.) If a positive response is not seen in that time period, the vet will often change the antibiotic. For instance, that’s when she might switch from, say, metronidazole to enrofloxacin on the suspicion that a different type of bacteria has taken hold.
B12 supplementation: Since more than four out of five dogs with exocrine pancreatic insufficiency are estimated to have insufficient levels of vitamin B12, it’s a good idea for the vet to test blood levels of that nutrient at the same time she orders a trypsin-like immunoreactivity blood test. It will save money because only one blood draw is needed, and the price is lower when it’s packaged with the TLI test. And it’s critical. If B12 levels are low and not corrected, the dog will not bounce back sufficiently.
Maya’s B12 levels were tested right up front and found to be in the 600s (meaning 600+ nanograms of B12 per liter of blood). Too low is generally considered to be less than 300, so B12 supplementation was not ordered. But, says Ms. Gatens, she did have SIBO, which “just ate away at her B12 stores.” It’s a vicious cycle. Inadequate B12 levels will set the stage for SIBO, and then the presence of SIBO can keep the B12 stores even lower.
Within 3 months, Maya’s B12 levels had fallen from the 600s to the 100s. “That made her dog reactive,” Ms. Gatens says. “Some dogs get really lethargic, but some can get nasty,” she adds. Maya became harder to have around others of her species — enough so that Ms. Gatens even took her to a behaviorist, who regretfully announced, finally, that she couldn’t work with Maya. It was because the problem was medical rather than truly behavioral. Once she was put on B12 supplementation, the problem largely cleared up. The supplement of choice is a schedule of B12 injections rather than pills that contain the nutrient. With most pills, the B12 never makes it to the bloodstream. The vet will look for B12 levels to be in the normal-to-upper range once B12 supplementation has begun. Levels in the normal range are usually not sufficient.
“Maya is much better now that she’s on B12,” Ms. Gatens remarks — “still a bit reactive” but in general not impossible to keep calm when other dogs are around.
In fact, says Ms. Gatens, today — three years after her diagnosis and the start of treatment — Maya is “great. She’s a good dog. Still intense. She was intense even before this started, so I think she will always be.” But the two are great pals, and Ms. Gatens is thrilled that her companion is “thriving now” when she was once so sick.
Fortunately, exocrine pancreatic insufficiency is relatively rare. “We see some variant of it three to four times a year,” say Tufts veterinarian Mary Labato, DVM. But if your pet is one of those affected, it can be a nightmare. Your dog might literally begin to waste away in front of you.
Olesia Kennedy knows the disease well because of her experience with her own dog. It led her to create a website devoted to understanding and treatment of the disease, including updates, called epi4dogs.com. The site has been recommended as an online EPI resource in the Journal of the American Veterinary Medical Association and has also been recommended in Topics in Companion Animal Medicine. For those whose dogs have been diagnosed with the condition, it will prove a great adjunct to the information you get from your pet’s doctor, and will also provide you with guidance on important questions to ask.
TCAM 2012 Topics in Companion Animal Medicine – EPI Online Support
By: Olesia C. Kennedy & Dr. David A. Williams
Geralda Aubrey, one of our EPI FORUM members, wrote a wonderful article on EPI that was published in the Schutzhund USA (Feb 2012) magazine titled “EPI: A Tale of Poop” by Geralda Aubry. CONGRATULATIONS GERALDA!!!!!!!!!!
In the article, not only does Geralda showcase her EPI dog, “Sirius”, but she also writes about some of our other EPI FORUM members EPI dogs such as Donna’s “Onza”, Tom’s “Yo-E” and Troy’s “Jade”. Please check out the article: (it is in 3 pages)
Thank You Geralda and Sirius
For those of you who don’t know, I’m a writer, and one of the messages I’m trying to spread is about EPI—specifically what it is and how dogs can thrive in spite of it. Today on Writers and Other Animals, I share EPI success stories. Please check it out, and those of you who are struggling right now please have hope!
As Dogs Waste Away, Owners Seek Answers
By EMMA G. FITZSIMMONS and JENNIFER CONTOGEORGOS
DECEMBER 20, 2012 10:18 AMDecember 24, 2012 2:35 pm
Michele Daniels of Point Pleasant, N.J., with her dog, Jackie, now recovered from E.P.I., a digestive illness that researchers are seeking to better understand.
A few years ago, Michele Daniels’s puppy, Jackie, suddenly became sick with constant, messy stomach problems. As Jackie, a 9-month-old German shepherd, rapidly lost 20 pounds, Ms. Daniels, who lives in Point Pleasant, N.J., spent many sleepless nights caring for her dog and worrying.
“The lowest point was getting up during the night probably five or six times and taking her out with diarrhea,” said Ms. Daniels, 51, a client services representative at a veterinarian’s office. “We were watching her fade away in front of us, and we couldn’t do anything about it.”
After visiting several veterinarians, Jackie finally received a diagnosis of exocrine pancreatic insufficiency, or E.P.I., a disorder in which the pancreas does not produce enough enzymes to properly digest food and absorb nutrients. A similar disorder occurs in people, including those with cystic fibrosis, celiac disease or chronic pancreatitis, and both people and pets often take the same enzyme-rich dried pork pancreas in powder or capsule form to treat it.
Ms. Daniels, who initially feared that her dog would have to be put down, added pancreatic enzymes to her pet’s diet, along with vitamin B12 injections, then watched as her dog improved after several months of treatment. “I feel like she has been given the life she was meant to have,” she said, fighting off tears.
Researchers are currently trying to determine the genetic cause behind exocrine pancreatic insufficiency in dogs and searching for better treatment options. The fact that it is most common among German shepherds indicates that there is a hereditary component to the disease, said Dr. Leigh Anne Clark, an assistant professor of genetics at Clemson University, where researchers are working to identify a genetic marker that could be used by breeders to identify dogs at risk. About half of all cases occur in other breeds, including Chihuahuas, terriers and beagles, and it occurs less frequently in cats.
Genetic testing has become more common for pets in recent years. There are already at least 80 DNA tests available to detect disease-related genes in dogs, from narcolepsy in Labrador retrievers to early-onset, hereditary cataracts in Boston terriers. Breeders are now using the information to identify dogs that carry the faulty genes and make sure they do not pass them on to future generations by eliminating them from the breeding pool.
There are quite likely multiple genetic and environmental factors that contribute to E.P.I., Dr. Clark said. While the disease was first observed in dogs 150 years ago, she has noticed an increased awareness of the illness in recent years. At a recent dinner with friends who are veterinarians, she asked whether any of them had been treating the condition.
“I had them go around the table, and every one of them had an E.P.I. case – 10 years ago that wasn’t the case,” she said.
There are no official statistics on the number of pets with the disorder. But Dr. Jorg Steiner, director of the gastrointestinal laboratory at the College of Veterinary Medicine at Texas A&M University, estimates that E.P.I. is diagnosed in 8,000 dogs in the United States each year, and says that the number of cases will most likely rise as awareness of the disease grows.
Dr. Steiner is conducting clinical trials on a new enzyme that would be easier for dogs with the disease to digest — and less costly for pet owners. The current options for owners who have dogs with E.P.I. can be expensive. A 12-ounce bottle of powdered enzymes can cost about $200 and often lasts less than two months, depending on a dog’s size and the dosage.
The main online resource about the disease — www.epi4dogs.com — gets about 15,000 page views a month, according to Olesia Kennedy, who created the Web site after her own dog struggled with the illness. A simple blood test by a veterinarian can determine whether a dog has the disease, she said, and treatments can be tailored to the individual pet, usually some combination of pancreatic enzymes, a low-fiber diet, antibiotics and vitamin B12 shots that must be given on a continuing basis.
Some pet owners report improvements after feeding their dogs a completely raw diet of unprocessed food that includes antibiotic-free meat and organic produce.
Dr. Sandy Willis, a veterinary internal medicine specialist who works with the American Veterinary Medical Association, said the E.P.I. Web site was a good resource for pet owners. Although most veterinarians know about the disease, she said, it might not be the first one they test for, and pet owners who suspect their animal might have the disease might speed the diagnostic process by mentioning it to their veterinarians.
Last year, Kelli Grant, who works at a molecular diagnostic company and lives in San Antonio, became alarmed when her 3-year-old Shetland sheepdog, Addie, developed bad diarrhea and lethargy and quickly dropped from a healthy 38 pounds to a skeletal 26. When Ms. Grant called the dog’s breeder, she was “devastated” to learn that Addie’s mother had been put down because of a similar problem.
After a veterinarian diagnosed E.P.I., Ms. Grant started Addie on pancreatic enzymes and B12 shots at home. Since then, she has learned that it is possible to manage the disease without spending a fortune. A year later, the dog has “put the weight back on,” Ms. Grant said. “She’s super happy and plays Frisbee.”
Epi4Dogs was respectfully featured in an article in the
October 2015 AUSTRLIAN SHEPHERD NEWS … an article “Joy’s Story- -a Journey with EPI”
October 2015 Joy’s Story—a journey with EPI Joy is a female German Shepherd that I bred. She was diagnosed with EPI (Exocrine Pancreatic Insufficiency) last year. Joy’s owners contacted me to let me know that they were at their wits end how to deal with this. They had contacted several Vets, but other than putting her on Creon and grain free kibble, the vets did not know what to do next, short of euthanising her. They wanted that to be a last resort. The final straw was that someone reported them to the RSPCA for neglect. Their case was far from that. They had all the invoices from all the Vets they had consulted, to prove that they were doing everything possible. I suggested that they bring her back to me, and let me try and bring her back to health. She was 19.5kg. Just skin and bone. I signed onto a website specifically for EPI dogs. I cannot speak more highly of the people that gave me advice.
Firstly they suggested that EPI dogs usually are deficient in Vitamin B12. After consultation with my Vet, I took that advice and started giving her B12 twice a week. My Vet put her on a 3 week course of Metronizole to make sure that any infections were cleared up. I elected to bypass all the so called “specific foods” and put her on VIP Grain Free Kibble, available from Woolworths (another recommendation from someone else who had used this kibble successfully). At this stage she was still on the Creon tablets twice daily. Very quickly there was a difference. After speaking with the EPI Website again, I decided to try and source Pig Pancreas for Joy. This was done with great difficulty. They are very hard to find. But I managed to find some and minced the fresh pancreas, froze it, and then cut it into 60gm measured pieces. I then cut the Creon out. The Creon is a replacement enzyme. She was given Pig Pancreas twice a day initially. Her motions almost immediately became firmer. I then increased the dose to three times daily. Her motions were completely normal. Yay, no more scrubbing the kennel twice a day! We kept up with the Vitamin B12 injections. And her weight started to creep up. Bit by bit we watched her improve. After a while we were able to go back to twice a day. She was still gaining weight. On the odd day, we would have a bit of a relapse, but these episodes lessened as time went on. When she weighed 29kg I decided that she could go back to her owners. They had been anxiously watching her progress, the full way. They would come and visit her regularly. Joy will continue on the B12 for the rest of her life. The grain free kibble will also remain. The Pig Pancreas is impossible to get. We have tried Australia wide to source it. We are now moving across to Beef Pancreas, as we have exhausted our supply of Pig Pancreas. My friends on the EPI website suggested the Beef as an alternative. Her coat is remaining good. And best of all she is a well loved member of their family. I am so glad that they contacted me about Joy. I have learnt so much, and we now have a dog that will live her life in pretty good condition. I found a lack of knowledge about this problem, was across most Vets. I am glad I have had the opportunity to research it, and am more than happy to share my knowledge. And once again so thankful to the people I met through www.epi4dogs.com
Joy’s original coat condition A happier and much more healthy Joy!
Editor’s Note— The pancreas is the organ in the body responsible for producing insulin (which regulates the body’s blood sugar levels) and digestive enzymes (which aid in the digestion of starches, fats, and proteins in an animal’s diet). If the pancreas fails to produce enough of these digestive enzymes, exocrine pancreatic insufficiency, or EPI, develops. EPI may affect a dog’s gastrointestinal system, as well as general nutrition, and can cause problems such as weight loss, muscle atrophy, poor coat and chronic diarrhea. The condition is thought to be hereditary in German Shepherds but can also appear due to other causes such as cancer and infection. A dog with EPI left untreated, will starve to death no matter how much he eats. Prior to that he will suffer from malnutrition. There are a number of tests used to diagnose EPI.
If you have any concerns about your dog due to him displaying the above symptoms, please see your vet without delay. With appropriate assistance and management, dogs with EPI can live a normal life with a normal life span.
Edmonton dog owners deal with pet’s pancreatic disease
EDMONTON – Bad dog, or sick dog? It’s not always easy to tell.
Katherine and Alan Hrynyk of Vegreville own three large shepherd breed dogs. One of them, Arvo — isn’t he a beautiful dog? — was diagnosed with exocrine pancreatic insufficiency, or EPI, a couple of years ago. Not before he lost a tremendous amount of weight, though, and not before presenting symptoms which the couple found puzzling, and initially wondered if were more behavioural than physical.
And therein lies part of the problem. Unfortunately, the disease often goes either undiagnosed or misdiagnosed, and dogs can end up as strays or in dog shelters. Some die a painful death from malnourishment, starvation or organ failure.
Dogs with EPI have a voracious appetite, yet gradually waste away because their pancreas does not produce the enzymes they need to digest food. A lack of nutrients often results in temperament changes, which can manifest in fear and/or aggression.
When food isn’t available, EPI dogs will eat whatever is. Bizarrely, Arvo ate everything from lawn mower pull cords, extension cords, door mats, fences, even the stuffing from his dog bed. Because he ate so much, he pooped constantly, both where he should and where he shouldn’t, and often ate his own feces.
The disease, while not curable, is manageable with treatment, and with a special diet. It’s not uncommon but often goes unrecognized and untreated, even by some breeders and veterinarians.
Katherine and her husband are longtime dog owners and always thought they were pretty knowledgeable about canine diseases — until this one came along.
“It hit us with a big jolt,” she says. “Educating ourselves has been one long learning curve.”
I asked Louis Kwantes, a veterinarian at Park Veterinary Centre in Sherwood Park, about EPI. He says that while it’s a relatively well-known syndrome, it is more difficult to diagnose in the early stages, or if there are other medical issues going on.
“When the condition presents in a classic or severe form, though, you can get a pretty good idea that a dog has EPI from history and physical exam alone,” says Kwantes, “although confirmatory testing is available and not cost-prohibitive.”
He says EPI is most commonly seen in German shepherds and collies but can be seen in other breeds of dogs, and less commonly in cats. He has never diagnosed EPI in a cat, in fact, but has treated a number of dogs at the clinic, and with good success.
Arvo, meanwhile, is thriving, according to Katherine. The couple has recently discovered that three of Arvo’s half siblings — same sire, different dam — also have EPI. She says the couple now belongs to some EPI groups online and one of them — www.epi4dogs.com — has started an international project called EPI Awareness, its goal to educate owners and thereby save dogs’ lives. There’s also a Yahoo forum — K9-epiglobal — which is open to pet owners whose dogs suffer from the disease. Sadly, says Katherine, membership is growing by the week, but it’s a very friendly and helpful site, especially for owners whose pets have just been diagnosed.
EPI Article in Purina Pro Club Newsletter – published May 2010
"Used with permission from the Purina Pro Club Update newsletter, Nestle Purina PetCare"
Exocrine Pancreatic Insufficiency May Have Complex Inheritance Pattern
“Izzy” had lost one-third of her body weight. Despite a voracious appetite, the 1-year-old Spanish Water Dog dropped to 27 pounds in four months. Owner Olesia Kennedy went from feeding two cups of food daily to eight cups.
A fecal test for bacterial infection came back negative, yet Izzy continued to decline, going from having a few loose stools to constant diarrhea. “I frantically called the veterinarian and said something is seriously wrong with my dog,” Kennedy recalls.
EPI is a disorder in which the pancreas fails to produce an adequate amount of digestive enzymes. Without those enzymes, food is not properly digested and absorbed. No matter how much food is ingested, a dog with EPI can literally starve to death.
Signs of Exocrine Pancreatic Insufficiency
• Weight loss
• Malnourished, thin or emaciated appearance
• Voracious appetite
• Chronic or intermittent diarrhea
• Eating feces or nonfood items
• Voluminous and frequent foul-smelling, yellowish, greasy stools with a watery to cow-pie consistency
• Gas (burping or flatulence)
• Rumbling digestive sounds
• Abdominal discomfort
• Dry, dull or brittle coat
There is no cure for EPI, but the disease can be successfully managed. Treatment, however, is lifelong.
The list of affected breeds is long, says David A. Williams, Vet.M.B., Ph.D., chairman of the Department of Veterinary Clinical Medicine at the University of Illinois College of Veterinary Medicine. “I stopped counting in the late 1980s when the breed count diagnosed through my laboratory went well past 100,” he says. “While certain breeds have an above-average occurrence, essentially all breeds are at risk. The disease is known to be prevalent in German Shepherd Dogs, Rough-Coated Collies and Chow Chows.”
The pancreas is a glandular organ located under the stomach that produces and secretes digestive enzymes. Acinar cells in the pancreatic tissue produce amylase to digest carbohydrates, lipase to digest fats, and trypsin and other proteases to digest proteins. These enzymes are secreted into the small intestine to help break down food into smaller parts so nutrients can be absorbed through the intestinal wall. An insufficiency of these enzymes causes nutrients to remain in the gastrointestinal tract undigested and pass in the feces.
The most common cause of EPI in dogs is pancreatic acinar atrophy (PAA) in which the acinar cells decrease in number and function. Though little is known about the cause of PAA, researchers believe the condition is genetically inherited. PAA usually develops between 6 months and 6 years of age. German Shepherd Dogs represent the majority of the cases identified in several studies.
In rare cases, EPI results from pancreatic cancer or pancreatic hypoplasia. Pancreatic hypoplasia is a congenital condition in which the exocrine pancreas does not fully develop.
“When the puppies were about 1 year old, I received a phone call from one of the buyers,” says Vose, of Paw Paw, Ill. “The woman’s male puppy had started losing weight inexplicably and was finally diagnosed with EPI. I was extremely shocked and heartsick.”
Vose was able to turn that tragedy into hope. When she learned that researchers at Texas A&M University were working to find a genetic link to pancreatic insufficiency in German Shepherd Dogs, she coordinated the donation of more than 80 blood samples from Dulcimer’s progeny.
Results from a study published in the Journal of Veterinary Internal Medicine in the March/April 2010 issue and performed at the University of Helsinki in Finland cast doubt on that theory. Researchers mated two German Shepherd Dogs with EPI and tracked the litter of six puppies throughout their lives. If EPI was indeed an autosomal recessive condition, all offspring of the two affected dogs would be affected with the disease. During the 12-year study, only two of the six puppies developed PAA.
EPI now is believed to have a more complex mode of inheritance, says Leigh Anne Clark, Ph.D., assistant professor of genetics and biochemistry at Clemson University. “EPI may result from mutations in multiple genes or from both genetic and environmental factors,” she says.
Until then, Clark, Steiner and Williams advise against breeding dogs with EPI or repeating matings that produced affected dogs. “The only way to decrease prevalence of the disease is by not breeding affected dogs,” Steiner says.
Veterinarians sometimes have difficulty diagnosing EPI because signs of the disease mirror those of other health issues. “The clinical signs are much more variable than most veterinarians realize, especially in the early stages of the disease before there is extreme weight loss,” Williams says. “The disease was formerly underdiagnosed in dogs with the disease and overdiagnosed in dogs without the disease.”
That situation improved considerably when a blood test for EPI was developed in England in the early 1980s. The canine trypsin-like immunoreactivity (cTLI) test was brought to the United States in 1985 when Williams made it available to veterinarians through university laboratories. Since the early 1990s, the test also has been available to veterinarians through commercial companies.
“With the advent of the serum cTLI test, there is simply no excuse for not testing suspect cases early, long before the classical signs of extreme weight loss and ravenous appetite become apparent,” Williams says.
This combination indicates small intestinal bacterial overgrowth (SIBO), a condition in which bad bacteria thrive on undigested food in the small intestine. SIBO can be treated with antibiotics. Cobalamin deficiency should be treated with injections of B12, a vitamin that is necessary for almost all cell functions, from normal neurological function to digestion and absorption of food.
Pancreatic enzyme supplements are available in tablet, capsule or powder form. Given before a meal or mixed with food, the supplements contain amylase, lipase, proteases and other pancreatic enzymes that replace the naturally occurring digestive enzymes depleted by EPI. The monthly cost of supplements is estimated at $60 to $100.
After their condition stabilizes, dogs still should be tested periodically, Williams says. “Cobalamin deficiency and other complications can occur years after the initial diagnosis of EPI even though classical signs of weight loss and diarrhea are well controlled by enzyme replacement,” he says.
“EPI is generally a manageable disease, but some cases require a little extra effort to get the best results,” Williams says. “With the right balance, most EPI dogs can live a full and wonderful life.”
Izzy’s condition stabilized in about three months, allowing her to return to pet therapy work at a local residence for senior citizens. She eventually gained back the weight she’d lost and then some, tipping the scale at 48 pounds and leading Kennedy to put her on a diet last summer.
A Web Site With a Mission
Olesia Kennedy bought her Spanish Water Dog “Izzy” to start a breeding program. Those plans changed when Izzy developed exocrine pancreatic insufficiency (EPI) at age 1.
Visitors can share their experiences with EPI, ask questions and find emotional support through the site’s discussion forum. “It is very helpful to talk with others also dealing with EPI,” Kennedy says. “This is why I created the EPI forum.”
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Starving, Not Starved
Exocrine Pancreatic Insufficiency (EPI) prevents absorption of food.
(reprinted with permission)
Janis Fitzhugh, a member of the Almost Home Organization, knew she had to rescue Pandy, an extremely thin and seeminly vicious four-year-old Dachshund. Pandy had been relinquished to a shelter in Orange County (California), who turned her over to Southern California Dachshund Rescue. Deemed people- and animal-aggressive, Pandy appeared to have been starved, and weighed just 13 pounds. Fitzhugh thought the dog deserved a break, and brought Pandy home in May 2007.
During the first couple of weeks in her new home, Pandy managed to pull a chicken down from the counter and proceeded to eat the entire bird, including bones, plastic tray and grocery bag, in less than the 10 minutes that Fitzhugh was out of the room. Pandy was rushed to the vet and emergency surgery was performed, as the bones had ruptured her stomach lining in three places. Luckily she survived.
Pandy’s voracious appetite, large voluminous stools, and aggressive disposition were all caused by a medical condition called exocrine pancreatic insufficiency (EPI). With Fitzhugh’s loving care, including enzyme supplements and a change of diet, Pandy stabilized. Within a year, Pandy had transformed into a beautiful, funny, 26-pound Dachshund who gets along great with all the human and animal members in the Fitzhugh household.
What is EPI?
Exocrine Pancreatic Insufficiency, or EPI, also referred to as Pancreatic Hypoplasia or Pancreatic Acinar Atrophy (PAA), is a disease of maldigestion and malabsorption, which when left untreated eventually leads to starvation. One of the major difficulties with this disease is in the prompt and accurate diagnosis. Astonishingly, visible symptoms may not appear until 80 to 95 percent of the pancreas has atrophied.
There are two primary functions of the pancreas:
- Endocrine cells produce and secrete hormones, insulin, and glucagon.
- Exocrine cells produce and secrete digestive enzymes.
EPI is the inability of the pancreas to secrete digestive enzymes: amylase to digest starches, lipases to digest fats, and proteases to digest protein. Without a steady supply of these enzymes to help break down and absorb nutrients, the body starves. When EPI is undiagnosed and left untreated, the entire body is deprived of the nutrients needed for growth, renewal, and maintenance. In time, the body becomes so compromised that the dog either starves to death or dies of inevitable organ failure.
Incomplete digestion causes the continual presence of copious amounts of fermenting food in the small intestine. This can lead to a secondary condition that is common in many EPI dogs, called SIBO (small intestinal bacterial overgrowth). If an EPI dog has a lot of belly grumbling/noises, gas, diarrhea, and sometimes vomiting, she most likely has SIBO.
The condition occurs when the “bad” bacteria that is feeding on the fermenting food overpopulates the tissue lining of the small intestine, further impairing the proper absorption of vital nutrients and depleting the body’s store of vitamin B12. Treatment of SIBO includes a course of antibiotics to eliminate the bad bacteria. Treatment may also include supplemental cobalamin (B12) injections that help reestablish friendly bacteria colonies, which in turn helps inhibit the malabsorption.
Severity of the disease may vary, making it even more difficult to diagnose. EPI can be subclinical (no recognizable symptoms) for many months, sometimes even years, before it worsens and becomes noticeable. The symptoms can be exacerbated by physical or emotional stress, change of food or routine, and/or environmental factors. The most common symptoms include:
- Gradual wasting away despite a voracious appetite.
- Eliminating more frequently with voluminous yellowish or grayish soft “cow patty” stools.
- Coprophagia (dog eats his own stools), and/or pica (dog eats other inappropriate substances).
- Increased rumbling sounds from the abdomen, and passing increased amounts of gas.
- Intermittent watery diarrhea or vomiting
Due to the lack of absorbed nutrients, the body starves: muscle mass wastes away, and bones may also be affected. An EPI dog’s teeth may be slightly smaller, and older EPI dogs appear to have a higher incident of hip dysplasia. Every part of the body is at risk, even the nervous system (including the brain), which in turn wreaks havoc with the dog’s temperament. Some EPI dogs exhibit increased anxiety, becoming fearful of other dogs, people, and strange objects.
With hunger as an overwhelming force, many dogs act almost feral. Desperately seeking vital nutrition, many ingest inappropriate items, but nothing gets absorbed. As the disease progresses, the deterioration becomes quite rapid. Some dogs lose interest in any activities, preferring to just lie down or hide somewhere. Many owners of EPD dogs become increasingly frustrated, as they feed more than normal amounts and yet the dog continues to waste away before their eyes.
Since chronic loose stools are usually the first visible symptom in an EPI dog, most vets will prescribe an antibiotic to destroy what they suspect to be harmful intestinal bacteria. Owners are happy, because the problem appears to go away, at least for a while. No one has any reason to investigate further, until the loose stools return or the dog starts losing weight, and then the merry-go-round cycle begins. Vet visits become numerous and costly, and one possible diagnosis after another is suggested. Expenses may include testing (and retesting) for giardia, coccidiosis, and other parasitic diseases; x-rays; ultrasound; MRI; antibiotics; and even surgery.
Until recently, EPI was most prevalent in German Shepherd Dogs. For this reason, a vet may fail to consider EPI as a possible diagnosis in other breeds and not pursue EPI testing: a trypsin-like immunoreactivity (TLI) blood test. TLI measures the dog’s ability to produce digestive enzymes. The test is done following a fast of 12 to 15 hours, and costs about $100.
Although other laboratories can run the TLI test, most blood samples are analyzed at Texas A&M University. The lab recently revised its reference ranges: values below 2.5 are now considered diagnostic for EPI. Results between 3.5 and 5.7 may reflect subclinical pancreatic disease that may ultimately lead to EPI. When values are between 2.5 and 3.5 µg/L, Texas A&M recommends repeating the TLI test after one month, paying particular attention to the fast before the blood sample is collected.
Even when a dog tests positive for EPI, it is important to retest TLI after the dog stablizes following treatment. For example, chronic inflammation can put such a strain on the pancreas that the production of digestive enzymes ceases or is greatly reduced. Consequently, when the TLI blood test is analyzed, it accurately depicts lack of enzyme production, even though the dog may not actually have EPI. In this case, it is important for the dog to be treated with pancreatic enzymes until his condition is stable. Enzyme treatment breaks down the food, allowing the stressed albeit non-EPI pancreas to recuperate and, in time, start producing the enzymes needed to digest foods.
Dorsie Kovacs, DVM, of Monson Small Animal Clinic in Monson, Massachusetts, has seen some young dogs with false-positive EPI readings. Even when they display the lighter-colored “cow patty” stools, something other than EPI may be the cause. Sometimes a food allergy or an overabundance of bad bacteria has irritated or inflamed the pancreas, temporarily inhibiting enzyme production. In these situations, says Dr. Kovacs, it’s important to put the dog on a pancreatic enzyme supplement for two months, allowing the stressed pancreas to heal. The dog should then be retested to confirm or rule out EPI.
In addition, Dr. Kovacs says, “It is also important to introduce good gut flora (bacteria) by adding yogurt, green tripe, or supplements such as Digest-All Plus (a blend of plant enzymes and probiotics). Good gut flora should continue to be maintained with supplements even after the inflamed or irritated pancreas has healed.” Dr. Kovacs has also noticed that some dogs with food allergies (especially dogs fed dry kibble) show rapid improvement when their diets are switched to raw or canned food. Raw meats contain natural enzymes, and fresh vegetables support the growth of good bacteria in the dog’s gut..
Most dogs with EPI can be successfully treated and regulated, although customizing the dog’s diet and supplements may involve much trial and error.
Enzyme supplementation is the first step in managing EPI. The dog will need pancreatic enzymes incubated on every piece of food ingested for the remainder of his or her life. The best results are usually obtained with freeze-dried, powdered porcine enzymes rather than plant enzymes or enzyme pills. Plant enzymes and enzymes in pill form do work for some, though with enzyme supplements, as with diet, much is dependent on the individual EPI dog. Some of the most widely used prescription enzyme supplements are Viokase, Epizyme, Panakare Plus, Pancrease-V, and Pancrezyme. Bio Case V is a non-prescription generic equivalent.
Enzyme potency is measured in USP units. Prescription enzyme powders range from 56,800 to 71,400 units of lipase, 280,000 to 434,000 units of protease, and 280,000 to 495,000 units of amylase per teaspoon.
Pancreatic enzymes are also available as generic pancreatin. Strengths of 6x, 8x, etc. indicate that the dosage is concentrated. A level teaspoon of powdered porcine pancreatin 6x might contain 33,600 units lipase and 420,000 units protease and amylase, comparable to prescription enzyme products.
Some EPI dogs have allergies and cannot tolerate the ingredients in the most common enzyme supplements. Those owners learn to develop alternative methods such as using plant enzymes, or a different source of pancreatic enzymes such as beef-based (rather than porcine-based). Raw beef, pork or lamb pancreas can also be used. One to three ounces of raw chopped pancreas can replace one teaspoon of pancreatic extract.
The starting dosage of prescription enzymes is usually one level teaspoon of powdered enzymes per cup of food. As time goes on and a dog stablizes, many owners find that they can reduce the amount of enzymes administered with each meal, sometimes to just ½ teaspoon, although some EPI dogs require an increased dosage of enzymes in their senior years.
Enzymes need to be incubated, meaning that you add them to moistened food prior to feeding, letting them sit on the food at room temperature for at least 20 minutes. Some find incubation up to one or two hours works even better. Too often, EPI owners are instructed that enzyme incubation is not necessary; however, some dogs will develop blisters or sores in their mouth from the enzymes when they are not first incubated on the food.
How do you judge what works best for your dog? When dealing with EPI, everything is gauged by the dog’s stool quality. EPI dog owners are always on “poop-patrol”. The goal is to obtain normal looking, chocolate brown, well-formed stools. When your dog produces something other than normal poop, it indicates she is not properly digesting her food. Sometimes longer enzyme incubation helps. Other times using more or less enzymes (since too little or too much enzymes can both cause diarrhea), changing the diet, treating a flare-up of SIBO, or starting a regimen of B12 shots solves the problem. Make only one change at a time. It is advisable to keep a daily journal as it may help you to identify the cause of a flare up or setback.
Prescription enzyme supplements can be very expensive. A $5,000 per year price tag for enzymes is not uncommon for a large dog — but don’t panic! There are several ways to reduce this cost. My 40-pound Spanish Water Dog has the dubious honor of being the first of her breed ever to be positively diagnosed with EPI. When the TLI results came in, I felt like my world came crashing down. Izzy is my once-in-a-lifetime best companion, and was very sick. Using information my vet gave me, I estimated that the enzymes alone were going to cost me $1,200 a year. She was only a year and a half old at the time, with an expected life span of 13 to 15 years. Eeek!
Today those enzymes cost me a mere $200 a year. How? I joined an EPI support group and learned what others do to better manage the ongoing care of their EPI dogs. I buy enzymes from an EPI enzyme co-op that purchase enzymes in bulk and passes the savings on to owners who have a veteriniarian-confirmed EPI dog. The savings from these bulk purchases can be quite substantial. (For both groups, see Resources for Products mentioned in the Article below). Today, Izzy is a plump, active, happy dog who gives me more joy than any other dog I have had in my 55 years. I would have paid whatever it cost to help her, but not everyone has this option.
Another solution that can dramatically save money is to obtain raw beef, pork or lamb pancreas. Ask your butcher if he can get fresh pancreas, or check with meat inspectors in your state to find out if and where you can obtain fresh pancreas. A letter from your vet explaining why you need fresh pancreas may allow you to purchase it from a slaughterhouse. Fresh beef pancreas can also be ordered from suppliers such as Hare Today and Greentripe.com.
The suggested dosage of raw pancreas is 3 to 4 ounces per 44 lbs of the dog’s weight daily. The pancreas can be blended or finely chopped, then frozen into either cubes in an ice tray or “calculated by the dog’s weight” single meal amounts in Ziploc bags. Raw pancreas can be frozen for several months without losing potency. When ready to use, thaw naturally and serve the raw pancreas with the dog’s food.
A very important factor about enzymes — whether using raw pancreas, powdered pancreatic enzymes, or pills — is that all digestive enzymes work best at body temperature. Cold inhibits the enzymatic action while heat destroys it. Never cook, mix with very hot water, or microwave either raw pancreas or supplemental enzymes.
Antibiotics are the next line of defense, in order to combat SIBO (bad bacteria growth overtaking growth of good bacteria), the secondary condition that frequently accompanies EPI. Tylosin (Tylan) or metronidazole (Flagyl) are the commonly prescribed antibiotics, usually given for a 30 days. Some dogs have trouble with metronidazole due to possible side effects; in that case, Tylan is given. Be warned: Tylan is bitter- tasting, and many dogs refuse to eat their meals when it’s added. There are tricks to deal with this. Some put the Tylan powder in gelatin capsules; I camouflage it for my dog by inserting the required dose in a small chunk of cream cheese. Not all EPI dogs can tolerate dairy, so the camouflage method should depend on the individual dog’s tolerance.
B12 (cobalamin) injections are needed if the dog has very low serum cobalamin. A blood test is required to determine this, costs about $31, and is best done simultaneously with the TLI test. Many EPI dogs cannot replenish B12 levels on their own, so B12 injections are used. B12-complex formulas are not recommended since they contain much lower concentrations of cobalamin and appear to cause pain at the injection sites. Generic formulations of cobalamin (B12) are acceptable.
The recommended cobalamin dosage is calculated according to the dog’s weight and may be found on Texas A&M University website (see Resources below). Your vet can show you how to give your dog subcutandous (beneath the skin) B12 injection. What seems to work best are weekly injections for the first six weeks, then biweekly (every other week) injections for the next six weeks, and finally monthly B12 injections .
Feeding dogs with EPI
A common saying among those whose dogs have EPI is, “If you’ve met one EPI dog, then you have met just one EPI dog.” Even with pancreatic enzyme supplements, much of the health and well-being of each EPI dog depends on his diet. Sometimes all that’s needed are supplemental enzymes and the standard recommended dietary modifications: no more that 4 percent fiber and no more than 12 percent fat (on a dry matter basis).
Sometimes it is much more complicated! Some dogs can tolerate much more fat. My dog, Izzy, for example, does extremely well on grain-free kibble with 22 percent fat content, well above the 12 percent range. Other dogs cannot tolerate even as little as 12 percent fat. The same applies to the fiber content. Some EPI dogs have unrelated food allergies, further limiting their diet.
Many dogs with EPI thrive on raw diets and some owners find a raw diet is the only one that works for their dogs. Conversely, other EPI dogs cannot tolerate raw diets. Some owners successfully feed grain-free kibble, some make home-cooked meals for their dog, while others feed a combination of commercial and homemade.
When adding to ar adjust a diet, feed the dog tiny chunks of raw carrot with the diet. These carrot pieces will present themselves in the stools (for better or worse) of that meal’s elimination. This helps you to understand which foods/vitamins, etc., work well together and which don’t.
Recommendations keep evolving and changing with new research, as well as the feedback from networks of owners of EPI dogs. A recent change in feeding recommendations concerns dietary fat. Multiple studies from the past decade indicated that a fat-restricted diet is of no benefit whatsoever to the EPI dog. A 2003 EPI paper by Edward J. Hall, of the University of Bristol in England, states that there is experimental evidence to show that the percentage fat absorption increases with the percentage of fat that is fed. This may explain why some EPI dogs can tolerate higher concentrations of fat. For those dogs who cannot tolerate more than 12 percent fat, this may mean that the fat content needs to be increased very gradually, or perhaps that certain types of fat may be tolerated better than others. Much more research is needed to answer these questions.
Veterinarians usually recommend an initial diet of a prescription or veterinary food, such as Hill’s Prescription Diet w/d, i/d, or z/d Ultra Allergen-Free; Royal Canin’s Veterinary Diet Canine Hypoallergenic Diet or Digestive Low Fat Diet; or Purina’s EN. Prescription diets that are made with hydrolyzed ingredients (carbohydrates and proteins that have been chemically broken down into minute particles for better absorption in the small intestine, leading to more complete digestion, better/faster weight gain, and firmer stools) appear to work for many EPI dogs. However, these diets are usually starch-based (often almost 60 percent carbohydrates on a dry matter basis); the digestive system of a dog is designed more for fats and protein than for starches, which may be why many EPI dog owners achieve better results by reserving prescription diets for short-term use and feeding other diets over the long haul.
The best results for managing EPI requires combining veterinarian advice with the experience of actual EPI dog owners. Too many times, managing EPI can be a real roller coaster ride! For example, initial research studies showed that supplemental enzyme powders needed to incubate on the food. Additional research studies then suggested that food incubation with enzymes was no longer necessary. Consequently, some EPI dogs developed mouth sores, so owners are again being advised to let the enzymes incubate to prevent this side effect. Until the causes and effects of this disease are better understood, it will continue to be managed via trial and error.
General Feeding Guidelines
Enzymes should be mixed with about one to two ounces of room-temperature water per teaspoon of enzymes, then added to the food and allowed to incubate for 20 minutes or more. A couple of tablespoons of kefir or yogurt (or some other “sauce”) may be used instead of water to mix the enzymes.
Once an EPI dog is stable, some owners find that they can ”cheat” and give their dog a smidgeon of a treat without any enzymes on it. Others find the least little crumb ingested without enzymes will cause a flare-up.
If possible, feed two to four meals a day, taking into consideration whether the dog’s condition has stabilized and whether the family’s schedule can accommodate multiple feedings. Feeding smaller, more frequent meals puts less stress on the EPI dog’s digestive system.
At first calculation, many owners of EPI dogs wonder if they can sustain the added expense of all these “special foods” in addition to the enzymes. It may take many attempts to find just the right diet for a dog with EPI that is also affordable by the owner, but it can be done. Following are some suggestions and techniques that owners of dogs with EPI have successfully used.
* Kibble or Canned: Many EPI owners who feed commercial kibble or canned dog food have found more success when feeding a grain-free product. Much depends on the individual dog.
When feeding kibble, many owners let the food and enzymes incubate until the food has an oatmeal-like consistency. Some even grind the kibble to allow for more surface contact with the enzymes. Some also add a teaspoon of pumpkin or sweet potato, which may help firm stools and reduce coprophagia; plus, both ingredients are packed with vitamins C and D. Sweet potato is also an excellent source of vitamin B6.
* Combination Kibble and Homemade: Many owners feed a combination of commercial food and raw or home-cooked. EPI owners mix foods at a ratio of 20 to 80 percent. An example would be 20 percent raw meat mixed with 80 percent dry food, or 20 percent kibble with 80 percent raw meat. As always with an EPI dog, enzyme supplements should be mixed in with the wet portion of the food at room temperature and allowed to incubate.
Depending on each individual dog’s tolerance, any variety of meats and fish may be used. Sources of proteins can include beef, chicken, turkey, pork, venison, rabbit, lamb, canned or cooked salmon, and jack mackerel, as well as eggs, yogurt and cottage cheese. Organ meats, such as liver, kidney, and heart should also be included in the diet. Green tripe is another good option. Variety is key! Again, incubate the food with the enzymes and feed 2 to 4 times daily, depending on your individual dog’s needs and your own schedule.
* Raw and home-cooked: Over the last few years, many owners have been able to stabilize their EPI dogs by feeding a raw diet. Raw food has the innate advantage of maintaining natural food enzyme activity that aids digestion. Many vets disapprove of feeding a raw food diet, especially to compromised dogs (possibly exposing them to further complications), while other vets suggest that raw is best for an EPI dog. There have been many anecdotal cases of dramatic improvement when the owners feed their EPI dog a raw diet, especially when all else fails.
Most EPI dogs cannot handle the 20 to 25 percent bone content in the diet that is commonly fed to normal dogs. With EPI dogs, it’s smart to start with only 10 to 12 percent of bone. Some dogs still have difficulty digesting this amount of the bone and the ratio will need to be reduced even further, to 3 to 5 percent bone. Note we are talking about the amount of actual bone, not the amount of raw meaty bones, which are usually at least half meat.
Vegetables may be a large or small portion of the diet, or not included at all, depending on the individual dog’s tolerance. If included, they should always be mashed. Organ meats are usually recommended at 10 to 15 percent of the EPI diet, but once again, not all can tolerate this.
Supplements for an EPI diet
Whether you feed dry, canned, home-cooked, raw, or any combination, there are many other ingredients that may be added to provide additional benefits for EPI dogs.
Most EPI dog owners add coconut oil and/or wild salmon oil to their dog’s diet. Many EPI dogs cannot digest other fats and develop dry, itchy skin or dry, brittle coats. Coconut oil contains medium-chain triglycerides (MCTs). Most vegetable oils have longer chain triglycerides, called LCTs. MCTs are utilized faster and burned more quickly for energy, raising the body’s metabolism, while LCTs are utilized more slowly. Also, coconut oil is one of the richest sources of lauric acid. Its benefits have recently been touted to aid in destroying various bacteria and viruses such as listeria, giardia, herpes simplex virus-1, and maybe even yeast infections such as candida.
Wild Alaskan salmon oil is an excellent source of omega-3 fatty acids, which help reduce inflammation.
Probiotics are another important addition to the EPI diet, especially since most EPI dogs are or have been treated with antibiotics because of SIBO. Antibiotics wipe out not only bad bacteria, but also good bacteria. Probiotics help maintain good gut flora. One popular brand of probiotics that has been successfully used by EPI owners is Primal Defense, but there are many quality probiotics available.
Zinc deficiency is another consideration with EPI dogs. It is difficult to accurately measure zinc absorption, Human EPI patients often develop a zinc deficiency, and though no studies have confirmed this to be true of dogs with EPI, many vets sugest a zinc supplement for EPI dogs.
Vitamin E (tocopherol) levels may also be low in an EPI dog due to malabsorption. Vitamin E is a fat-soluble vitamin that is an antioxidant and helps in the formation of cell membranes, cell respiration, and with the metabolism of fats. Vitamin E deficiency may cause cell damage in the skeletal muscle, heart, testes, liver and nerves; supplementation with vitamin E can help prevent these problems.
Other natural nutrient sources that are often included in an EPI diet are kelp, green tripe, slippery elm, and alfalfa.
Texas A&M previously and now currently Clemson University is conducting an EPI genetic research project to try to identify the genetic markers for the disease. “This disease is characterized by a complex pattern of inheritance,” says Dr. Keith E. Murphy, Professor and Chair of Genetics and Biochemistry at Clemson University in South Carolina. “Thus, we have been limited in how we can attack this in order to identify the gene or genes, that contribute to this horrible disease. However, we are encouraged by the success that we and others have had using SNP technology [unique DNA tests] to identify genetic markers associated with various traits and we will be employing this approach to EPI.”
If you own a purebred GSD, with or without EPI, and would like to contribute a blood sample, please contact Dr. Leigh Anne Clark at Clemson University (see Resources below).
It is important that this research continues. EPI is rapidly spreading across all breeds. It is no longer just a GSD disease, or a working dog disease. Dogs of all breeds, including crossbreeds, are being diagnosed with EPI. It is happening in family lines too often to be coincidence without a genetic component. Yet, not every family member or generation in affected lines has EPI. For now, until we can actually test for the genetic markers, the best possible control is to remove positively-confirmed EPI dogs from breeding programs. Once genetic markers are identified in GSDs, the markers in other breeds will be more easily detechted.
Although there are many success stories, there are also heart-wrenching tales of dogs who cannot thrive, families who cannot afford the treatment, and throughout it all, the painful suffering the dog endures unless successfully treated. EPI can no longer be a “hush-hush” disease. My hope is that this article will make a difference by helping raise awareness of EPI to the level of other major canine diseases.
Olesia Kennedy, a retired research analyst, and previously involved in Canine Search & Rescue, currently devotes her skills and time to EPI research. She resides with her husband and three Spanish Water Dogs in Georgetown, Indiana.
Many EPI dogs flourish
Kara was lucky; she was diagnosed with EPI. While in foster care for four months, Audrey Blake met Kara twice during training classes and the frail little dog with the outgoing personality captured her heart. Although she understood that Kara would need pancreatic enzymes for every meal and a special diet, Blake took Kara home. Today, Kara is known as “U-CD Twenty-Four Karat Gold, UD, TDI, CGC (Kara), Rescue Sheltie,” and happily resides with Blake in Long Island, New York!
Sadly, Some Dogs Perish
Wayde was in the kennel for many months. Finally, a couple who was familiar with EPI, Pamela and Peter Burghardt from Wilmot, New Hampshire, decided to foster Wayde. In their home, his whole demeanor changed; he became happy and gained more than 2 pounds the first week. Wayde soon settled in with his foster family and became a sweet “Velcro” dog. He became best friends with his foster sister, another white GSD.
Sadly, Wayde was diagnosed with cancer a few weeks after going into foster care and passed away four months later. Despite the cancer, he had gained 14 pounds and was active and happy to the end.
Please Support Research for EPI
Hope, a Boxer, was adopted by Jodi Riddle, of NorCal Boxer Rescues in Texas. She was lovingly cared for and given enzyme replacements and a special diet. Hope completely recovered, becoming Jodi’s constant, gentle shadow. Hope has since passed on; Jodi wisher her photo inspires others to support finding EPI’s cause.
Texas A&M University website for recommended cobalamin dosage: http://www.cvm.tamu.edu/gilab/research/cobalamin.shtml
To participate in the EPI genetic research studies at please contact Dr. Leigh Anne Clark at Clemson University, SC, USA
To contact Dr. Clark, her office telephone number is: 1-864-656-4696; her email address is: email@example.com
Leigh Anne Clark, PhD. Assistant Professor Department of Genetics and Biochemistry 100 Jordan Hall Clemson University Clemson, South Carolina 29634
To support EPI research, send donations to: Keith E. Murphy, PhD., Professor and Chair, Department of Genetics and Biochemistry, 100 Jordan Hall, Clemson University, Clemson, SC 29634-0318
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