How to manage chronic inflammatory enteropathies for young canines, in general practice

Chronic inflammatory enteropathies (CIE) in dogs are defined as persistent gastrointestinal (GI) signs lasting more than 3 weeks after other systemic and extra-GI causes have been ruled out.¹ As a small-animal internist practicing in a major metropolitan referral center, one of the most frequent presentations I encounter is the young dog—typically under 5 years of age—with chronic GI signs. These dogs have often already undergone baseline diagnostics with their primary veterinarian, including normal blood work and fecal screening, before being referred for advanced evaluation.

While many of these patients are referred for abdominal ultrasound or endoscopy, it is worth emphasizing that most young dogs with CIE do not require these advanced diagnostics initially. In my experience, ultrasound findings in these cases rarely change the initial treatment plan, which nearly always begins with a diet trial. For most young dogs with chronic GI signs, the disease is ultimately food-responsive enteropathy (FRE).¹

Dietary management: The first and most crucial step

The cornerstone of management for CIE in young dogs is dietary therapy. The goal is to minimize antigenic stimulation of the intestinal mucosa. Several studies have shown that hydrolyzed or novel-protein diets can induce clinical remission in approximately 60–88% of dogs with CIE and normal serum albumin.^2,3 In one randomized controlled trial evaluating hydrolyzed fish-protein diets, 83% of dogs with non-protein-losing enteropathy (non-PLE) responded to their first diet, and all remaining non-responders achieved remission after switching to a second hydrolyzed diet.³

When initiating a diet trial, client education is essential. Owners must understand that strict adherence is non-negotiable: the prescribed diet must be the only source of nutrition. No other animal-protein treats, supplements, chews, or table scraps should be allowed. Approved hydrolyzed protein treats or small amounts of specific non-animal foods, such as certain vegetables or fruits, are acceptable but should remain limited.

A meaningful dietary trial typically lasts about 4 weeks. However, in my experience, some dogs require up to 8 weeks to show full improvement. If a dog fails to respond to one hydrolyzed or novel-protein diet, it is not appropriate to give up and proceed immediately to advanced diagnostics. Instead, trialing a second hydrolyzed or novel-protein diet is warranted. Because our current understanding of the canine intestinal microbiome and its dietary interactions is still evolving, no single diet is universally effective for all dogs. The long-term evaluation of 60 dogs with CIE demonstrated that many patients initially classified as immunomodulator-responsive enteropathy (IRE) were later reclassified as FRE after additional dietary trials.¹

Prebiotics, probiotics, and fiber: Targeting the microbiome

For dogs that improve clinically but continue to have loose stools or large-bowel signs, adjunctive therapy with prebiotics, probiotics, and fiber can be highly beneficial. Soluble fibers serve as fermentable substrates for colonocytes, generating short-chain fatty acids that enhance colonic health. A study evaluating a diet rich in mixed fiber sources showed significant improvement in stool quality and frequency in dogs with large-bowel diarrhea.⁴

Similarly, probiotics have an important role. One randomized, controlled trial demonstrated that dogs with idiopathic inflammatory bowel disease experienced improved mucosal microbiota balance when given a multi-strain probiotic.⁵ Particularly, the probiotic Visbiome, formerly VSL#3, has been shown to promote microbiota diversity and mucosal homeostasis in dogs with CIE.⁵

In my experience, adding a high-quality probiotic and soluble fiber to a hydrolyzed diet frequently resolves residual stool-quality issues and helps stabilize chronic large-bowel diarrhea. A diet combining hydrolyzed protein and pre-/probiotics can often maintain long-term remission without escalation of therapy. A main goal should be to avoid chronically medicating young dogs unless necessary.

The role of GI panels and cobalamin/folate testing

Even when routine laboratory results are normal, assessing for functional GI changes is crucial. A gastrointestinal panel (measuring serum cobalamin, folate, trypsin-like immunoreactivity (TLI), and pancreatic lipase immunoreactivity (PLI) can help identify malabsorption or concurrent pancreatic disease.

Hypocobalaminemia has been shown to negatively affect prognosis in dogs with CIE.⁶ Fortunately, both oral and parenteral supplementation effectively correct deficiencies and improve clinical outcomes.⁷ Hypocobalaminemia, hypofolatemia, or hyperfolatemia support gastrointestinal inflammation and CIE is likely. I typically follow the dosing guidelines provided by the Texas A&M Gastrointestinal Laboratory. Testing should be performed on a fasted sample to avoid post-prandial variability and to allow concurrent evaluation for exocrine pancreatic insufficiency and pancreatitis.

Additionally, a baseline cortisol test is often worthwhile to screen for atypical hypoadrenocorticism, even when electrolytes are normal, particularly in dogs with chronic GI signs and unremarkable standard diagnostics.

When to refer for advanced diagnostics

If a dog has failed to respond to multiple diet trials (ideally 2 or more hydrolyzed/novel-protein diets), pre-/probiotic supplementation, and cobalamin support, referral for advanced diagnostics is appropriate. Abdominal ultrasound is particularly indicated when there are abnormalities such as hypoalbuminemia or hypocholesterolemia, which may suggest protein-losing enteropathy (PLE).

It is also important to remember that dogs over 5 years with new-onset GI signs are more likely to have neoplasia or severe inflammatory disease. In such cases, early imaging is appropriate to assess for focal disease, such as masses. If ultrasound imaging is normal, then treating for FRE would be the appropriate next step. However, for many young dogs, ultrasound findings rarely alter the initial management plan. Dietary therapy remains the foundation of treatment.

When dietary and adjunctive measures fail, abdominal ultrasound and, subsequently, endoscopic biopsies become necessary to reach a definitive diagnosis. Histopathology often reveals lymphoplasmacytic enteritis—the hallmark lesion of inflammatory bowel disease. Only at this stage should immunomodulatory therapy be considered. Empirical immunosuppressive treatment is discouraged unless anesthesia or cost constraints preclude endoscopy.

Reference

1. Hodel S, Brugger D, Kook PH. Long-term evaluation of the initial response to therapy in 60 dogs with chronic inflammatory enteropathy. J Vet Intern Med. 2024;38(5):2444-2453. doi:10.1111/jvim.17161
2. Mandigers PJ, Biourge V, van den Ingh TS, Ankringa N, German AJ. A randomized, open-label, positively-controlled field trial of a hydrolyzed protein diet in dogs with chronic small bowel enteropathy. J Vet Intern Med. 2010;24(6):1350-1357. doi:10.1111/j.1939-1676.2010.0632.x
3. Simpson KW, Miller ML, Loftus JP, Rishniw M, Frederick CE, Wakshlag JJ. Randomized controlled trial of hydrolyzed fish diets in dogs with chronic enteropathy. J Vet Intern Med. 2023;37(6):2334-2343. doi:10.1111/jvim.16844
4. Lappin MR, Zug A, Hovenga C, Gagne J, Cross E. Efficacy of feeding a diet containing a high concentration of mixed fiber sources for management of acute large bowel diarrhea in dogs in shelters. J Vet Intern Med. 2022;36(2):488-492. doi:10.1111/jvim.16360
5. White R, Atherly T, Guard B, et al. Randomized, controlled trial evaluating the effect of multi-strain probiotic on the mucosal microbiota in canine idiopathic inflammatory bowel disease. Gut Microbes. 2017;8(5):451-466. doi:10.1080/19490976.2017.1334754
6. Tamura Y. Chronic Enteropathy and Vitamins in Dogs. Animals (Basel). 2025;15(5):649. Published 2025 Feb 23. doi:10.3390/ani15050649
7. Chang CH, Lidbury JA, Suchodolski JS, Steiner JM. Effect of oral or injectable supplementation with cobalamin in dogs with hypocobalaminemia caused by chronic enteropathy or exocrine pancreatic insufficiency. J Vet Intern Med. 2022;36(5):1607-1621. doi:10.1111/jvim.16528