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Year: 2022
Homemade diet as nutritional support for a dog suffering from chronic
pancreatitis and inflammatory bowel disease
Opsomer, Han ; Wichert, Brigitta ; Liesegang, Annette
Abstract: A spayed Boston terrier was referred for nutritional advice after failing to respond to long-
term medical and dietary treatment for chronic pancreatitis. Based on clinical appearance, consecutive
bloodwork and ultrasound examination, the concomitant occurrence of inflammatory bowel disease was
likely. An exclusion diet (novel protein approach) and a stepwise balancing schedule were formulated to
address combined nutritional recommendations, as well as the possibility for hypersensitivity to play a
role. After initiation of the exclusion diet, the patient relapsed twice. Once due to noncompliance of the
owner, once due to reaction to an added supplement. After correction, no major relapses were noted for
at least 1 year. To the authors’ knowledge, this report is the first to describe the successful supportive
care of chronic pancreatitis and concurrent inflammatory bowel disease by prescribing a homemade diet.
DOI: https://doi.org/10.1002/vrc2.355
Posted at the Zurich Open Repository and Archive, University of Zurich
ZORAURL:https://doi.org/10.5167/uzh-217857
Journal Article
Published Version
The following work is licensed under a Creative Commons: Attribution-NonCommercial-NoDerivatives
4.0 International (CC BY-NC-ND 4.0) License.
Originally published at:
Opsomer, Han; Wichert, Brigitta; Liesegang, Annette (2022). Homemade diet as nutritional support
for a dog suffering from chronic pancreatitis and inflammatory bowel disease. Veterinary Record Case
Reports, 10(2):e355.
DOI: https://doi.org/10.1002/vrc2.355
Received: 21 December 2021 Revised: 15 February 2022 Accepted:23February2022
DOI:10.1002/vrc2.355
CASEREPORT
Wildlife
Homemadedietasnutritionalsupportforadogsufferingfrom
chronicpancreatitisandinflammatoryboweldisease
HanOpsomer Brigitta Wichert AnnetteLiesegang
Institute of Animal Nutrition and Dietetics, Abstract
VetsuisseFaculty,UniversityofZurich,Zurich, A spayed Boston terrier was referred for nutritional advice after failing to respond
Switzerland
to long-term medical and dietary treatment for chronic pancreatitis. Based on clini-
Correspondence cal appearance, consecutive bloodwork and ultrasound examination, the concomitant
AnnetteLiesegang, Institute of Animal Nutrition occurrence of inflammatory bowel disease was likely. An exclusion diet (novel pro-
andDietetics,VetsuisseFaculty,Universityof tein approach)andastepwisebalancingschedulewereformulatedtoaddresscombined
Zurich, Winterthurerstrasse 270, 8057 Zurich, nutritionalrecommendations,aswellasthepossibilityforhypersensitivitytoplayarole.
Switzerland.
Email: aliese@nutrivet.uzh.ch After initiation of the exclusion diet, the patient relapsed twice. Once due to noncom-
pliance of the owner, once due to reaction to an added supplement. After correction, no
majorrelapseswerenotedforatleast1year.Totheauthors’knowledge,thisreportisthe
first to describe the successful supportive care of chronic pancreatitis and concurrent
inflammatoryboweldiseasebyprescribingahomemadediet.
KEYWORDS
dogs, inflammatory bowel disease, nutrition, pancreatitis
BACKGROUND the use of foodstuffs (e.g., rice, muscle meat and extracted
oils as carbohydrate, protein and fat source, respectively).18–20
Pancreatitis remains a challenge for the veterinarian. Its To avoid exceeding the patient’s digestive capacity, frequent
nonspecific presentation1,2 and the lack of sensitive, non- 21,22
small meals (individual tolerance) are warranted. Pan-
invasive tests (although markedly improved) often pro- creatitis as well as IBD also warrant a moderate to reduced
3–6
hibit straightforward diagnosis. This is even more true fat content in the diet (dry matter basis [DMB]: ≤10%–15%
for chronic pancreatitis.7 Its occurrence is therefore likely for pancreatitis, 8%–15% for IBD; metabolisable energy [ME]
underestimated.8–10 In addition, it is suspected that (chronic) basis: ≤20%–30% for pancreatitis, ≤15% for IBD in case of
pancreatitis is caused by an interplay of multiple risk fac- lymphangiectasia).21–26 Amoderateproteincontentofthediet
tors rather than one trigger, which in human medicine have (15%–30% DMB) has been advised in case of pancreatitis,
beensummarisedintheToxic-metabolic,Idiopathic,Genetic, whereasinIBDbothanincreaseanddecreaseoftheprotein
Autoimmune, Recurrent and severe acute pancreatitis and content can be argued.22,23,27 The necessity of supplementa-
6
Obstructive Pancreatitis Risk (TIGAR-O) system. This cat- tion with vitamins is dependent on the type of illness. For
egorises the predisposing factors as (a) toxic metabolic, (b) pancreatitis and IBD, special focus goes to cobalamin and fat-
idiopathic, (c) genetic, (d) autoimmune, (e) recurrent and solublevitamins.ForIBD,folateandthiaminewarrantatten-
severe acute pancreatitis or (f) obstructive. The importance 28,29
tion as well. Hypersensitivity should always be suspected
of each category in the pathogenesis of chronic pancreati- in case of IBD. The implementation of an exclusion diet is
tis may be species-dependent. In dogs, hereditary, nutritional 21,30
therefore advised. Due to the partly contradicting nutri-
and metabolic triggers (e.g., hyperlipidaemia, obesity, high tional recommendationswithsuchcomorbidities,anindivid-
fat foods, etc.) are recognised,3,7,11–15 whereas in cats this is ualapproachismandatorytoimplementthebest-fittingcom-
4,9,16
far less obvious. As an inciting cause is rarely deter- promise. Often, a homemade diet is the best option to meet
mined, treatment and subsequent management often remain the specific nutritional profile of the patient.30
nonspecific,6,7,17 with nutritional support playing a key role
in the successful approach. However, concurrent conditions,
like inflammatory bowel disease (IBD), can add to the com- CASEPRESENTATION
plexity thereof.17 For both pancreatitis and IBD, dietary prin-
ciples base on a highly digestible diet (digestibility of protein A spayed Boston terrier (6.5 years old at the time of pre-
≥87%,fatanddigestiblecarbohydrates≥90%),whichdictates sentation), weighing 7.4 kg (estimated to be ideal), with a
ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttribution-NonCommercial-NoDerivsLicense,whichpermitsuseanddistributioninanymedium,provided
the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
©2022TheAuthors.VeterinaryRecordCaseReportsPublishedbyJohnWiley&SonsLtdonBehalfofBritishVeterinaryAssociation
Vet Rec Case Rep. 2022;e355. wileyonlinelibrary.com/journal/vrc2 of
https://doi.org/10.1002/vrc2.355
of VeterinaryRecordCaseReports
knownheartmurmur(2/6,frequentlymonitored,nomedical
treatment) was referred to the Institute of Animal Nutri- LEARNINGPOINTS/TAKE-HOMEMESSAGES
tion and Dietetics of the Vetsuisse Faculty, University of
Zürich, due to the patient’s failure to respond adequately ∙ Nonresponsivechronicpancreatitispatientstoini-
to long-term treatment for pancreatitis with a reduced fat tial treatment, should be examined for aetiological
diet (commercial therapeutic dry and wet food), initiated by factors or concurrent disease.
the Internal Medicine Department of the Vetsuisse Faculty, ∙ Concurrent gastrointestinal, infiltrative disease
University of Berne. Before referral, the patient suffered from shouldbeconsidered.
severe episodes of apathy, anorexia, vomiting and occasional ∙ Dietary support remains the basis for successful
diarrhoea. This resulted three times in hospitalisation at two- managementofthepatient.
monthly intervals whenever the patient deteriorated rapidly. ∙ Inflammatory bowel disease patients can respond
Despite its reduced appetite, the patient always retained well to the prescription of an exclusion diet.
an ideal to slightly increased body condition scores (BCS), ∙ Homemadedietsareeasytoadaptifnecessary.
ranging from 5/9 to 6/9 (estimated 10% overweight). A likely
reduced activity (and therefore energy expenditure) during
acute phases might explain this stable BCS. Muscle mass was
considered normal. Aside from slight abdominal discomfort NRC 2006, modified by Dobenecker and Kienzle, Munich,
andoccasionalmilddehydration,nootherabnormalitieswere Germany).
found during clinical examinations. Repeated blood exam- Diet A (diet fed before patient developing clinical signs)
inations showed hypoproteinaemia, hypoalbuminaemia, consisted of two commercial extruded dry foods supple-
hypocalcaemia, hypokalaemia and increased amylase, lipase mented daily with an estimated 100 g of varying fruits (e.g.,
andcanineC-reactiveprotein(CRP)values.Thebloodexam- apple, orange, banana, berries). As no data were available
ination before referral also showed a marked hyperglycaemia, on the mineral content of the commercial products, it was
hypocholesterolaemia and hypoglobulinaemia (Table 1). not possible to verify if all the patient’s requirements were
Unfortunately, it was not clear when this blood sample was met.DietB(dietprescribedbytheInternalMedicineDepart-
takeninrelationtothestartofthetherapy.Thisisimportant ment of the Vetsuisse Faculty Berne) consisted of mixture of
astheclinicaldatashowaglucoseboluswasadministereddue highlydigestiblelow-fatdryandwetfood,supplementeddaily
to hypoglycaemia, although no corresponding value thereof with 10 g of cottage cheese. This initial nutritional adjust-
could be traced in the records. Although unlikely, it was ment,asrecommendedbytheInternalMedicineDepartment
unknownwhethertheanimalhadeatenshortlybeforetaking of the Vetsuisse Faculty Berne (Diet B compared to Diet A),
thissample,whichcouldhaveinfluencedthebloodglucose markedly reduced the fat content (g) and concentration (%
as well. Neither a canine pancreatic lipase immunoreactivity of dry matter) of the diet, while increasing the protein and
(cPLI) test nor a check-up of the patient’s vitamin B status nitrogen-free extract (NfE) content (mainly digestible carbo-
wasconducted. hydrates like starch and soluble fibre from sugar beet pulp,
Abdominal ultrasound following the episode before refer- psyllium,etc.)tokeepthedailyrationisoenergetic.Asthis
ral excluded obstructive disorders (either partial or total) and generalapproachwasinsufficienttopreventsubsequentflare-
indicated acute pancreatic pathology, likely concurrent with ups, an alternative nutritional treatment (Diets C and C ;
1 2
chronicpancreatitis.Clearsignsoflymphangiectasiawerenot Tables 2 and 3) was initiated after referral to the Institute of
found. Parasitic infection was excluded (faecal examination, AnimalNutritionandDietetics.DietsC1 andC2 representthe
monthlydewormingwithmilbemycinoximeandpraziquan- exclusion diet and its adaption to the patient’s requirements,
tel). When hospitalised, the patient was treated with intra- respectively (completely homemade, Table 3), advised by the
venous(IV)fluidtherapy,anti-emetics(ondansetron:1.55mg Institute of Animal Nutrition and Dietetics of the Vetsuisse
IVevery8hours),antibiotics(metronidazole:76mgIVevery Faculty Zürich.
24 hours), analgesics (methadone: 0.8 mg IV every 4 hours) After 8 weeks, the original exclusion diet was balanced
and subsequently managed on a low-fat diet (see nutritional stepwise by adding further feedstuffs and supplements at
17 Duetotherecurringnature 2-week intervals to ensure the latest added ingredient was
approach)asguidelinesindicate.
of this case, the ultrasound examination, the consecutive tolerated. The protein content was reduced in addition to a
bloodwork and the patient’s clinical presentation, IBD was further decrease of the fat content in Diets C1 and C2 (com-
suspected to be a complicating factor. Biopsies for confirma- pared to Diets A and B). A vitamin B tablet (relatively high
tion were rejected by the owner. In dogs, IBD is more consid- in cobalamin) was added. When this supplement seemed to
ered as a differential or a concurrent condition with chronic cause symptoms to reoccur (see follow-up), it was replaced
17 by a water-based vitamin B solution. Furthermore, eicos-
pancreatitis, incontrasttohumansandcatswhereacorrela-
tionbetweeninfiltrativegastrointestinaldiseaseand(chronic) apentaenoic acid (EPA) and docosahexaenoic acid (DHA)
31,32 were supplemented (195 and 166 mg, respectively) as well.
pancreatitis has been noted.
The omega 6 to omega 3 polyunsaturated fatty acid ratio of
the complete diet was calculated as 2:1. With the exception
of mineral requirements in Diet A (could not be verified), all
NUTRITIONALSUPPORT diets (A, B, C2) covered the recommendations for a healthy
adult dog with an ideal bodyweight of 7.4 kg, as specified by
The nutritional constituents of the patient’s subsequent 19
the National Research Council. The patient maintained an
diets are specified in Table 2 andwerecalculatedwithDiet ideal body condition (5/9) before developing clinical signs.
Check Munich 2005 Version 3.0 (RV Software; based on Theenergycontentoftheoriginaldiet(DietA)wastherefore
VeterinaryRecordCaseReports of
TABLE Initial blood results in first opinion practice (D-124) and subsequent blood examinations conducted at the Internal Medicine Department of the
Vetsuisse Faculty, University of Berne
Reference D D D D D D D
Glucose(mmol/L) 4.16–6.69 4.78 . 4.5
Cholesterol (mmol/L) 3.47–10.03 . .
Total protein (g/L) 55–73 . . .
Albumin(g/L) 30–41 . . . 32.5 .
Globulin (g/L) 19–39 . 19.7
AP(U/L) 9–132 35 62
ALT(U/L) 26–126 41 50
γGT(U/L) <743
Amylase(U/L) 500–1500 >
Lipase (DAG)(U/L) 200–1300
DGGR(U/L) 24–108 77 36
CanineCRP(mg/L) <10.0 6.1 . .
<10.7 7.9
Urea(mmol/L) 3.3–10.8 6.0
Creatinine (µmol/L) 52–117 70 58
Calcium(mmol/L) 2.42–2.85 . .
Potassium (mmol/L) 3.5–5.8 4.5
3.95–5.40 . 4.40
3.7–4.8 . 3.87
Chloride (mmol/L) 109–122 116
106–118 117 115
108–122
Note: Measurements using differing reference values are given per level. The day of implementation of the prescribed diet by the Institute of Animal Nutrition and Dietetics of the
Vetsuisse Faculty, University of Zurich is taken as Day (D) 0.
Theboldvalueinthetableindicatesoutsidereference value.
Abbreviations: DAG, 1-oleoyl-2,3-diacetylglycerol; DGGR, 1,2-o-dilauryl-rac-glycero-3-glutaric acid-(6′-methylresorufin).
considered appropriate and was maintained during fur- well. Even though for IBD, a moderate fat intake usually suf-
ther treatment under reservation of necessary amendments fices (if no malabsorption due to, e.g., lymphangiectasia is
depending on the further progress. This corresponds to 98% noted),thereducedfatintakeasadvisedforpancreatitiscanbe
and 118% of the metabolisable energy requirement according well accommodatedtoIBDrecommendations.Thefatsource
to FEDIAFandNRCcalculations,respectively19,33 (Table 4). (hemp oil) was however well considered for its high concen-
It was advised to feed the daily diet well mixed, as multi- tration of essential fatty acids, as well as its optimal omega 6
ple small meals (at least three) per day. No other ingredients to omega 3 fatty acid ratio. The latter ratio was further opti-
thanthoseprescribedintherecommendationateachspecific mised by the direct addition of EPA and DHA through cod
time point should be fed. In both the initial recommenda- liver oil and an additional supplement. Both a low omega 6 to
tions by the Internal Medicine Department(VetsuisseFaculty omega3ratio, as well as the direct addition of EPA and DHA
Berne),aswellastheonebytheInstituteofAnimalNutri- haveanti-inflammatoryeffects. Although clear recommenda-
tionandDietetics(VetsuisseFacultyZürich),thedietwasfor- tions on the effective quantities of EPA and DHA in diets for
mulated to be highly digestible and fat reduced in compli- 22), an
dogsarelacking(range50–300mg/kgbodyweight/day
21
ance with general recommendations for chronic pancreatitis. omega6toomega3ratioof<5canbeusedasaguideline.
This was done, as it would relieve the patient’s digestive tract The number of necessary portions per day is dependent
and would mitigate the pancreatic stimulation. The focus on ontherequiredenergyintakeofthepatientaswellas
multiplesmallmealsperdayaddressesthisaswell.23,24,28 The its individual tolerance (as larger portions can induce nau-
maindifference was the inclusion of IBD as a comorbidity in sea, maldigestion and in this case overstimulation of the
23,24,28
theapproachbytheInstituteofAnimalNutritionandDietet- pancreas ). Even though a gradual reduction of feeding
ics.Ashypersensitivityhadtobeexpectedtoplayarolein frequency for long-term management is advised, a minimum
its pathogenesis, an exclusion diet (novel protein approach, of three meals per day was recommended.21,22 The lacking
basedonthepatient’snutritionalhistory)wasdeemedmost examinationofthepatient’svitaminBstatusandtheunlikeli-
appropriate. Strict compliance to the plan described above ness of water-soluble vitamins to cause side effects when sup-
is mandatory to avoid a reaction to the suspected trigger- plemented, warranted the addition of three main vitamins:
21,22,30
ing antigens and therefore prolonging recovery. AsIBD cobalamin (vitamin B ), folate (vitamin B ) and thiamine
12 9
reducesthepatient’s digestive capacity as well, the implemen- (vitamin B ). Cobalamin is mentioned first as both pancre-
1
tation of a cooked highly digestible diet, fed as multiple small atitis as well as IBD can impair its absorption by either a
meals per day, complies with its recommended treatment as decreased pancreatic production of intrinsic factor (IF) and
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