Chronic enteropathy vs Exocrine pancreatic insufficiency in Dogs: How to Tell Them Apart

References

1. Chronic enteropathyvetlexicon.com
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   - Chronic enteropathy (CE) is currently the preferred umbrella term to describe a group of chronic gastrointestinal (GI) conditions seen in dogs and cats. These conditions present as chronic (greater than 3 weeks’ duration) GI signs including diarrhea, vomiting, weight loss and change in appetite. - CE is further subdivided based on the region(s) of the GI tract affected, and the main inflammatory cell type present and, most useful clinically, based on the response to treatment into the following categories: - Food-responsive enteropathy (FRE) - Antibiotic-responsive enteropathy - Immunosuppressant-responsive enteropathy (IRE).

2. Canine and Feline Exocrine Pancreatic Insufficiencytodaysveterinarypractice.com · by PGC Vet
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   EPI is an important diagnostic differential for dogs with poor stool quality and weight loss despite a good appetite. Unlike dogs, cats with EPI present with nonspecific signs, including weight loss alone. June 20, 2025 | Issue: July/August 2025 To take the CE quiz, click here. This quiz is open until June 2027.

   Exocrine pancreatic insufficiency (EPI) is an important diagnostic differential for dogs with poor stool quality and weight loss despite a good appetite. Unlike dogs, cats with EPI present with nonspecific signs, including weight loss alone. In both species, the diagnostic test of choice is the trypsin-like immunoreactivity (TLI) test, with a low TLI concentration being consistent with EPI. Treatment consists of high-quality pancreatic enzyme replacement in conjunction with an easily digestible low-residue diet and cobalamin supplementation as needed. Most animals respond well to therapy. Suboptimal responses may be due to inadequate timeline to allow for a clinical response, an enzyme dose or formulation issue, an inadequate diet, concurrent chronic enteropathy, or persistent dysbiosis. **Take-Home Points**

   A poorly responsive case of EPI demonstrates persistent clinical signs despite treatment. These cases are often frustrating for veterinarians, but a logical approach to identifying the underlying cause and treating it accordingly can improve clinical response. First, it is reasonable to evaluate the validity of the original diagnosis. If the measured TLI concentration was low, the clinician can be confident in the diagnosis. However, if the original diagnosis was made based on an overall clinical assessment and response to enzyme supplementation, without TLI measurement, then TLI should be measured on a fasted sample. Pancreatic enzyme supplementation does not interfere with the results of the TLI assay.11 Once the original diagnosis is validated, the clinician should consider the following potential differentials:

   EPI is an important diagnostic differential for dogs with poor stool quality and weight loss despite a good appetite. Unlike dogs, cats with EPI present with nonspecific signs, including weight loss alone. In both species, the diagnostic test of choice is the TLI test, with a low TLI concentration being consistent with EPI. Treatment consists of high-quality pancreatic enzyme replacement in conjunction with an easily digestible low-residue diet and cobalamin supplementation as needed. Most animals respond well to therapy. Suboptimal responses may be due to inadequate timeline to allow for a clinical response, an enzyme dose or formulation issue, an inadequate diet, concurrent chronic enteropathy, or persistent dysbiosis.

3. A review: Pancreatic enzymes in the treatment of chronic ...pmc.ncbi.nlm.nih.gov
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   The purpose of this review was to analyze the scientific literature on exocrine pancreatic insufficiency (EPI) in dogs and cats and our own research on porcine model to compare animal‐ and microbial‐derived enzymes in the treatment of animals with this disease. Clinical signs of EPI occur when more than 85% of the pancreatic parenchyma is non‐functional. EPI can be a consequence of various diseases. The insufficient activity or deficiency of pancreatic enzymes leads to impaired digestion and absorption, and consequently, to malnutrition. The primary treatment for enzyme insufficiency is pancreatic enzyme replacement therapy (PERT). PERT in animals with EPI is a lifetime therapy. Most commercially available products are of animal origin (processed pancreata obtained from a slaughter house) and contain…

   Insufficiency of the exocrine pancreas can be a consequence of various diseases, such as atrophy of pancreatic acinar cells, chronic pancreatitis, pancreatic cancer, cystic fibrosis, severe acute necrotizing pancreatitis or gastrointestinal and pancreatic surgical resections. 1 They all share a common pathophysiological result: insufficient activity or deficiency of pancreatic enzymes, which causes digestive and absorption disorders. The primary treatment for enzymatic insufficiency is pancreatic enzyme replacement therapy (PERT). This is lifelong therapy. Both, human and veterinary products contain enzymes of animal origin (pancreatin from porcine pancreas). In recent years, there has been increasing interest in the use of enzymes of microbial origin, for many reasons, including production and their action. Enzymes of microbial and plant origin appear to be a…

4. Laboratory Tests for Diagnosis of Gastrointestinal and ... - PMCpmc.ncbi.nlm.nih.gov
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   Decreased serum trypsin-like immunoreactivity is a very sensitive and specific test for the diagnosis of exocrine pancreatic insufficiency in dogs and cats. Serum pancreatic lipase is currently the most sensitive and specific test to identify pancreatic cell damage and acute pancreatitis. However, serum canine pancreas-specific lipase is less sensitive in canine chronic pancreatitis. Increased serum trypsin-like immunoreactivity is also specific for pancreatic damage but is less sensitive. It is very likely that further studies will help to better specify the role of these new tests in the diagnosis of canine and feline pancreatic diseases.

   Dysbiosis is a general term that covers quantitative and/or qualitative changes in intestinal microbes. Dysbiosis might cause GI disease such as IBD, but it can also be a consequence of GI diseases such as EPI. SIBO, that is, an increase in the quantity of small intestinal bacteria, has been considered as a possible cause of chronic GI signs in dogs and cats. More recently, the term antibiotic responsive diarrhea (ARD) has been proposed to replace SIBO, which describes a syndrome in which animals with chronic diarrhea improve with antibiotic treatment, relapse after cessation of treatment, and have no other possible cause to explain the clinical disease.36 However, there is no complete overlap with SIBO. Some dogs may have a diagnosis…

   Animals with a TLI measurement in this gray zone may or may not progress to having TLI results diagnostic of EPI, and it is recommended to retest them within 1 to 3 months. In one study that followed up on 44 dogs with inconclusive TLI results, 20/44 dogs had a normal TLI on the second sample.78 TLI became diagnostic of EPI in 11/44 dogs and remained in the gray zone for 13/44 dogs. These latter dogs underwent gross examination and biopsy of the pancreas, which showed a remarkable reduction in the amount of normal exocrine pancreatic tissue, but 8 dogs had no GI signs and 5 dogs had intermittent GI signs atypical for EPI.78 These dogs were diagnosed with subclinical…

   Histopathological lesions consistent with pancreatitis can be very localized and easily missed if systematic assessment of the entire organ is not performed.81 This is obviously impossible in field conditions except for postmortem studies. Furthermore, histopathological evidence of acute and chronic pancreatic inflammation does not always correlate with clinical signs of pancreatitis.81, 82 Also, other, less common pancreatic diseases, such as cysts or neoplasms, may induce pancreatic acinar cell damage and an increase in blood concentration of pancreatic enzymes. Because of lack of a practical gold standard, clinical research often relies on the combination of clinical presentation and results of a myriad of diagnostic tests, with or without histopathology, for the ultimate diagnosis of pancreatitis in dogs and cats.

5. Managing chronic enteropathies in dogs (Sponsored by ...dvm360.com · May 1, 2009
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   Dogs with intestinal disease typically present with clinical signs such as diarrhea, weight loss, or vomiting. Diarrhea that has lasted three weeks or more is usually considered chronic. The initial diagnostic approach to chronic diarrhea is based on determining the nature and severity of the diarrhea and the presence of specific or localizing clinical findings. The presence of additional clinical signs often points to the underlying cause (see Table 1). This information is integrated to determine whether diarrhea is most likely due to large bowel disease (dyschezia, tenesmus, increased frequency of defecation, small volume of feces with mucus and blood) or a consequence of small intestinal disease or exocrine pancreatic insufficiency (large volume of diarrhea, weight loss, possible vomiting). In…

   Table 1. Potential underlying causes of chronic diarrhea and commonly associated clinical signs

   The initial diagnostic approach to patients with chronic small bowel diarrhea is summarized in Table 2. Table 2. Initial diagnostic approach to chronic small bowel diarrhea After the exclusion of infectious and parasitic agents, non-GI disorders, exocrine pancreatic insufficiency, and intestinal structural abnormalities requiring surgery, the most common group of intestinal conditions associated with chronic small bowel diarrhea are idiopathic inflammatory bowel disease (IBD), diet-responsive enteropathy, antibiotic-responsive enteropathy, and lymphangiectasia.

   Clinical findings: The clinical findings are essentially a consequence of the intestinal loss of protein and can include weight loss, chronic diarrhea, ascites, edema, and chylothorax. Diagnosis: Lymphangiectasia usually presents with clinical signs of a protein-losing enteropathy. It appears endoscopically as white blebs on the mucosa (dilated lymphatics). Endoscopic biopsies are often adequate. Surgical biopsy should be undertaken carefully with appropriate precautionary measures to avoid dehiscence. Treatment: The underlying cause of lymphangiectasia is not usually determined. Treatment is supportive and symptomatic. 1. Dietary recommendations are similar to those for the other causes of chronic small bowel diarrhea listed, but fat restriction may have to be more severe.

6. Practical Approach to Chronic Diarrhea in Dogswww.vin.com
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   Chronic or chronic-intermittent diarrhea of more than 3 weeks duration. Mild CE may cause intermittent clinical signs, whereas progressive and severe clinical signs are common in severe IBD. Poor body condition with poor hair coat is frequent with severe disease. Dehydration is possible. Thickened small intestinal loops may occasionally be palpated. Animals may show pain or discomfort on abdominal palpation. Ascites, hydrothorax, and peripheral edema may occur in case of significant protein loss (protein-losing enteropathy or PLE). Diagnosis

   Diagnosis of CE consists of an elimination process to rule out other diseases of known etiology that may cause similar clinical signs: fecal flotation and Giardia antigen test should be performed in all dogs. Alternately, empiric parasiticide treatment can be administered (e.g., fenbendazole 50 mg/kg q 24 h for 3–5 days). Subsequently, the diagnostic process is different for dogs with mild clinical signs and no evidence of systemic complication such as hypoproteinemia, and for dogs that are more severely affected.

   Differential Diagnoses General differentials include chronic intestinal foreign body, intestinal parasitosis, bacterial enteritis, fungal enteritis, and diseases originating outside the GI tract such as chronic kidney disease, chronic liver disease, chronic pancreatitis, exocrine pancreatic insufficiency, and atypical hypoadrenocorticism. Management In most instances, the goal of treatment is to manage the clinical signs. Full recovery is possible in mild cases.

   1.  Treatment trials: The standard approach for a dog with mild to moderate chronic recurrent diarrhea of unknown origin without systemic repercussions is to initiate a food trial with a novel protein or hydrolyzed peptide diet. A majority of dogs presented with chronic diarrhea of unknown origin respond at least partially within 10 to 14 days. For those who don't, the next step may consist of another treatment trial with another novel protein or hydrolyzed peptide diet, and/or antimicrobials. Dysbiosis (change in the composition of the intestinal microbiota) occurs in most dogs with IBD. Young large breed dogs with CE (particularly but not exclusively German Shepherd Dogs) respond to prolonged treatment with antimicrobials such as tylosin (20 mg/kg PO BID) or…

7. Updated guidance on canine chronic inflammatory enteropathy ...www.avma.org · Feb 23, 2026
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   **Published on** February 23, 2026 **By** Christine Won As research has advanced understanding of chronic gastrointestinal (GI) inflammation in dogs, the American College of Veterinary Internal Medicine (ACVIM) has endorsed a new consensus statement on the diagnosis and treatment of chronic inflammatory enteropathy (CIE) in dogs. The consensus statement, published on January 21, outlines a stepwise diagnostic approach, that includes patient history, clinical signs, physical examination findings, sequential diagnostic tests, and imaging. It also covers practical treatment strategies for managing CIE that tailor care based on a patient's underlying disease subtype and response to therapy.

   Chronic inflammatory enteropathy (CIE) in dogs remains a diagnosis of exclusion. The American College of Veterinary Internal Medicine's (ACVIM) newly endorsed consensus statement incorporates more than a decade's worth of research into advanced diagnostic and treatment strategies for canine CIE since the 2010 ACVIM consensus statement. "CIE can be frustrating for both clinicians and pet owners due to its variable presentation and response to treatment," said Dr. Romy Heilmann, lead author of the statement, in a January 27 press release. "This consensus guidance brings together the latest evidence to help veterinarians make informed decisions, optimize treatment plans, and ultimately improve quality of life for affected dogs."

   Dr. Heilmann, a professor of small animal internal medicine at Leipzig University in Germany, said the new guidance, based on evidence from the past 16 years, places a stronger emphasis on well-designed dietary trials. The authors noted that dietary modification as a test of treatment is an adequate therapeutic point because 38%-89% of dogs with CIE are food-responsive, and many maintain long-term clinical remission of at least three months on dietary treatment alone. "Because CIE is a diagnosis of exclusion and is subclassified based on response to treatment … efficacy of treatment trials is also considered diagnostic," the authors wrote. "Dietary treatment trials are the preferred first-choice diagnostic recommendation in dogs suspected of having CIE before invasive diagnostic tests are…

   * Performing a thorough diagnostic evaluation that looks for signs of malnutrition such as body and muscle condition scores or indications of hypoalbuminemia. The authors note that dogs with CIE, especially protein-losing enteropathy, are susceptible to malnutrition. * Grading clinical disease severity according to disease activity scores on the Canine Inflammatory Bowel Disease Activity Index (CIBDAI) or Canine Chronic Enteropathy Clinical Activity Index (CCECAI), which are effective in distinguishing dogs suspected of CIE from healthy dogs, according to the authors. * Considering fecal culture exclusively for dogs with specific risk factors such as a raw meat-based diet. "Support for an infectious bacterial cause of CIE is lacking, but feeding a raw meat–based diet is a risk factor (e.g., for *Campylobacter*…

8. ACVIM–endorsed statement: consensus statement and systematic ...pmc.ncbi.nlm.nih.gov
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   . 2026 Jan 21;40(1):aalaf017. doi: 10.1093/jvimsj/aalaf017 ## ACVIM–endorsed statement: consensus statement and systematic review on guidelines for the diagnosis and treatment of chronic inflammatory enteropathy in dogs Romy M Heilmann

   Chronic gastrointestinal (GI) signs are a common reason for dogs to be presented in primary care and referral settings, and up to 20–30% of veterinary visits in companion animals are related to vomiting or diarrhea or both.1 Over the past decade, basic and clinical research has focused on advancing diagnostic and treatment strategies for chronic intestinal inflammation in dogs.2 The pathogenesis of chronic intestinal inflammation in dogs is complex and, based on current knowledge, driven by genetics, immunology, environmental factors, and GI luminal components, including diet and the microbiome. These aspects are summarized and reviewed elsewhere.2

   Recommendations: Diagnostic abdominal ultrasonography (evaluating intestinal walls, regional lymph nodes, other organs, and the presence of abdominal effusion) should be considered in any dog with suspected CIE to rule out diseases that mimic CIE, particularly in dogs with moderate or marked clinical signs (CIBDAI or CCECAI score ≥ 6), weight loss (≥5%), hypoalbuminemia, or no response to dietary trial (refer to Section ``Diagnostic treatment trials'') (SOR = strong). Thoracic imaging should be considered with possible thoracic involvement of CIE (eg, pleural effusion with PLE) or suspicion of other differential diagnoses or concurrent conditions (eg, cardiac disease, neoplasia, or infectious diseases such as histoplasmosis or blastomycosis) (SOR = conditional based on suspicion of thoracic involvement/concurrent disease).

   With CIE presenting as a diagnosis of exclusion, several patient characteristics are recommended for monitoring regardless of the stage of the sequential diagnostic evaluation or current form of treatment. These should include longitudinal assessment of BCS and MCS, body weight, severity of clinical disease (CIBDAI or CCECAI score), fecal score, any potential medication adverse effects, and overall quality of life every 1-2 weeks. Markers of intestinal function (including serum cobalamin concentration), inflammation, and protein loss might be monitored during treatment if baseline results at diagnosis were established. In patients with PLE, serum albumin concentrations should at least initially be reevaluated more frequently (every 1-2 weeks) and then at longer intervals (every 2-3 months) once the dog is normoalbuminemic and remains…

9. Nutritional Management of Chronic Enteropathies in Dogstodaysveterinarypractice.com
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   In cases of intestinal dysbiosis, where the animal’s immune system may be responding adversely to pathogenic intestinal flora, antibiotics may improve clinical signs either by specifically modifying the intestinal flora or by exerting other less easily defined immunomodulatory effects.There is likely a role for **probiotics** (live microorganisms that exert a beneficial effect in the intestinal tract, potentially by inhibiting pathogenic bacteria or other immunomodulatory mechanisms) in cases of chronic enteropathies; however, veterinary data are limited. One study evaluating dogs with IBD showed that treatment with a probiotic for 30 days was effective at reducing clinical signs of disease.3 However, caution must be exercised when recommending specific brands of probiotics because there is variable quality control among supplements.

   Diagnosing a true food allergy is more challenging than diagnosing food intolerance. There is no easy test to perform and, despite their appeal, serologic titers have been shown to have poor positive and negative predictive values.10 An elimination diet is required for diagnosis of a food allergy. After an elimination diet is fed for a minimum of 2 to 4 weeks, and response is noted, the animal should be challenged with one ingredient at a time to document the food(s) to which the animal reacts adversely with such signs as intense pruritus, vomiting, and diarrhea. This process can be time-consuming and challenging for an owner. Unless the owner wants to use those results to dictate how the animal will be fed in the…

   If there is no response to a diet trial, or only a partial response, a few factors must be considered: * Animal has skin disease caused by atopic dermatitis or other concurrent allergies * Lack of owner or pet compliance * Diet was *not* truly novel * Diet was contaminated. **Food Intolerance.** Food intolerances may be due to a number of factors, including food additives and the Maillard reaction (the chemical interaction between proteins and carbohydrates during cooking that releases various flavor compounds). Often no single, specific dietary component is identified. A definitive diagnosis requires: * Feeding an elimination diet (eg, novel ingredient diet, hydrolyzed diet; **Table 3**) for a minimum of 2 to 4 weeks * Observing good improvement…

10. Pancreatic Insufficiency Diagnosiswww.cliniciansbrief.com
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    Exocrine pancreatic insufficiency (EPI), a heritable condition, results from autoimmune destruction of pancreatic acinar cells and is most common in young-adult German shepherd dogs (GSDs) and rough-coated collies (RCCs). Signs include polyphagia, weight loss, and soft voluminous feces. Diagnosis is based on signs, serum trypsin-like immunoreactivity (TLI) below reference range, and resolution with pancreatic enzyme supplementation. This study documented 3 cases in which EPI signs were present but serum TLI was normal. Case 1 was an intact male GSD (6 months of age), case 2 was an intact male RCC (5 months of age), and case 3 was an intact male GSD (18 months of age). Each had chronic soft feces or diarrhea, polyphagia with marginal weight gain, and chronic…

11. Exocrine Pancreatic Insufficiency in Dogs and Catswww.merckvetmanual.com
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    Full Review: Sept 2025 ByJörg M. Steiner, Med Vet, Dr Med Vet, PhD, DACVIM-SAIM, DECVIM-CA, AGAF, Texas A&M University System | Peer reviewed byPatrick Carney, DVM, PhD, DACVIM, Cornell University College of Veterinary Medicine Last updated: Sept 2025 v3266874 View the Pet Owner Version Exocrine pancreatic insufficiency is caused by decreased synthesis and secretion of digestive enzymes by the pancreas. The most common clinical signs are weight loss and a large volume of loose stools. Dogs are also often polyphagic. Diagnosis is made by measurement of serum trypsin-like immunoreactivity. Treatment includes pancreatic enzyme replacement therapy and supplementation of cobalamin. - Etiology and Pathophysiology| - Epidemiology| - Clinical Findings| - Diagnosis| - Treatment| - Prognosis| - Key Points| - For More…

    - Measurement of serum trypsin-like immunoreactivity - Measurement of serum cobalamin and folate concentrations A low serum trypsin-like immunoreactivity (TLI) concentration (≤ 5.5 mcg/L in dogs or ≤ 8.0 mcg/L in cats) is diagnostic for exocrine pancreatic insufficiency. Because digestion of a macronutrient can often be accomplished by more than one enzyme, lack of exocrine pancreatic secretions does not necessarily lead to clinical signs. For example, subclinical EPI has been reported in several German Shepherd Dogs. These dogs had severely decreased serum TLI concentrations and a lack of exocrine pancreatic tissue but no or only intermittent clinical signs of EPI.

12. A quick review of canine exocrine pancreatic insufficiencywww.dvm360.com · Sep 1, 2009
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    Dogs with EPI should be evaluated regularly. After new treatments are initiated or altered, evaluate patients every two to four weeks for weight gain and improved body condition. The frequency of evaluation depends on the severity of clinical signs. Instruct owners to carefully monitor fecal consistency and volume and report any changes. After initial stabilization, patients with excellent response to therapy may be examined annually or biannually as recommended for healthy adult dogs. Follow-up monitoring of cTLI concentrations is not indicated since enzyme supplementation and other treatments are not expected to improve the secretory capacity of the exocrine pancreas. Figure 2. Percentage of dogs responding to pancreatic enzyme supplementation at recommended dosages. Source: Reference 9.