116 | Have we got IBD wrong for years? Here’s what you ACTUALLY need to know about chronic inflammatory enteropathy as a veterinary nurse
It’s been a long time since we covered gastrointestinal disease on the podcast, and in 2 years and almost 100 episodes, things have changed.
Across the next few weeks, we’ll look at some of the GI conditions that we see the most - and the new direction we need to take when managing these patients.
And today, I’m bringing you the updated need-to-know information on one of the most common gastrointestinal diseases we see - chronic inflammatory enteropathy, or what we used to call inflammatory bowel disease.
There are brand new guidelines out on managing this condition, and we’ll use these to refresh and update our knowledge, and look at where veterinary nursing fits in in the management of this often complex disease.
So what actually is chronic enteropathy, and what impact does it have on our patients?
Chronic enteropathy was previously referred to as inflammatory bowel disease, or IBD. We borrowed the term from human medicine, firstly because it was easier for caregivers to understand the disease as they had a condition to compare it to, and secondly, because we saw inflammation within the gastrointestinal tract (assuming biopsies had been taken for histology).
In previous guidelines (the last ones before this year were published in 2010), this terminology changed to chronic enteropathy. And now it’s evolved again, to chronic inflammatory enteropathy, or CIE.
Chronic inflammatory enteropathies are a group of complex diseases causing gastrointestinal signs persisting for at least 3 weeks. They occur due to an exaggerated immune response, and the pathophysiology is multifactorial.
Affected patients are thought to have a combination of genetic predisposition, a dysregulated immune response, and environmental factors such as dietary or microbiome-related factors contributing to their disease.
We previously subclassified these patients mostly based on treatment response. If they responded to a diet trial, they were referred to as ‘food-responsive enteropathy’. If they responded to antibiotics (and we’ll talk a LOT more about antibiotics throughout the next few episodes), it was ‘antibiotic-responsive’. If it responded to immunosuppressants, it was ‘immunosuppressant-responsive’ and so on. There’s also a ‘non-responsive’ category, which pretty much does what it says on the tin.
Of these conditions, food-responsive enteropathy is most prevalent (50-65% of cases). Patients are classified as food-responsive if their signs resolve or significantly improve within 2-4 weeks of starting an elimination diet. FRE patients are usually younger, and less severely affected.
Where does protein-losing enteropathy fit in small animal chronic enteropathy?
A ‘branch’ subcategory of PLE could be added to each of these classifications. Protein-losing enteropathy is not a primary disease in itself, but a consequence of the underlying gastrointestinal disease. In PLE, serum proteins leak from the bloodstream and are lost via the diseased gastrointestinal tract. Affected patients have hypoalbuminaemia +/- panhypoproteinaemia, and often associated clinical signs such as oedema or ascites.
All of this works as a framework, but the problem is that this classification is retrospective - we only really know where our patient fits after trialling treatment. And the other - perhaps bigger - problem was antibiotics.
Have we been using antibiotics in small animal gastrointestinal disease wrong this whole time?
For a long time, antibiotics have been overused in gastrointestinal diarrhoea. In fact, we hosted a webinar in the medical nursing academy on this just a couple of months ago, where we looked at studies showing metronidazole is still the most commonly prescribed of all antibiotics, and it's currently prescribed the most in… you guessed it… GI disease.
Drugs like metronidazole and tylosin have been used in the management of diarrhoea for a long time. You could even argue that calling a form of chronic enteropathy ‘antibiotic-responsive’ may subconsciously reinforce their early use. And while they may still have a place in certain cases, what we know about the GI tract, and in particular the microbiome, is changing - and so too are the recommendations about antibiotic use.
What has changed in the management of chronic enteropathy in 2026?
Firstly, the term itself - IBD is most definitely out (it kind of already was, but you still do hear it thrown around in practice) and CIE is in.
And alongside this, the way we classify these patients has also changed. We now have a two-tier system based on clinical assessment - patients are described as either being CIE-I or CIE-II.
CIE-I is the milder presentation. These are the dogs with a low clinical score, no lethargy, no weight loss, a normal appetite, and an unremarkable physical exam. These patients are bright, eating, and the signs are mild.
CIE-II is the more significant presentation. These patients have a higher clinical score, weight loss of 5% or more, a poor appetite, abnormal findings on physical exam, or a longer duration of signs. They may also be hypoalbuminaemic, but not always.
Our CIE-II patients are the ones we're more worried about, and the ones where a more extensive workup is typically indicated.
This categorisation doesn’t exist as another thing to remember, but instead highlights the importance of considering how severely the disease is impacting each individual patient before planning next steps. Not every patient is affected in the same way, and every patient needs to be approached with that in mind.
On top of CIE-I and CIE-II, we still retrospectively classify patients based on their treatment response - so food-responsive CIE, immunomodulatory-responsive CIE, and non-responsive CIE.
But one category is missing - we’ve got rid of antibiotic-responsive as a disease process, because with the benefit of evidence, we now know a lot more about how antibiotics really affect the gut.
This change reflects our better understanding of what's actually going on.
We know that CIE is multifactorial. It involves the immune system, genetic susceptibility, the gut microbiome, and environmental factors, including diet. Dysbiosis, which is the disruption of the normal gut bacterial population, is well documented in these patients, along with changes in things like how bile acids are handled. We’ll talk more about the microbiome in a separate episode - because it is a HUGE topic - but it plays an enormous role in how we manage these patients.
How do we approach chronic GI patients, and what role do we play in this process as veterinary nurses and technicians?
While we won’t be directly diagnosing as veterinary nurses and technicians, we still play an essential role in the process. From processing samples to supporting patients during imaging and endoscopy, our role cannot be overlooked.
This means we need to know how these patients are diagnosed, and the most important principle within this is that chronic inflammatory enteropathy is a diagnosis of exclusion.
This means we don’t have a test confirming our patient has CIE. Instead, we need to rule things out, step by step, and see how the patient responds to treatment trials. The good news about this is we can play a significant role in this process - probably a bigger one than many of us are currently in our clinics.
First, these patients need a physical assessment.
This should include a diet and medication history, comprehensive exam, BCS and MCS, and a clinical score. To do this, we use the canine chronic enteropathy activity index scoring system.
Alongside this, routine diagnostics are typically performed. These include comprehensive biochemistry and haematology, urine analysis and a faecal examination.
Now we need to consider further testing.
This testing includes malabsorption testing (TLI, B12 and folate), basal cortisol levels to screen for hypoadrenocorticism, +/- a pancreatic lipase and other diagnostics as required. Imaging, typically abdominal ultrasound +/- thoracic radiography, is also usually performed.
Then there’s the diet trial, which is where we really come into our own
In a stable patient who is eating, the dietary trial is the preferred first diagnostic step. This means we don’t rush them into endoscopy and biopsies - instead, we see how they respond to an appropriate elimination diet (or diets, plural).
This is important because between 38-89% of these dogs are food-responsive. Many stay in remission on diet alone, long term, with no other medication at all.
Diet trials are essential - and it’s also essential they’re done properly, because they’re easy to get wrong (and caregiver support is a key factor in this).
A true diet trial is where we feed a single therapeutic diet, exclusively, for at least two weeks. The diet is chosen based on the dog's history and signs. It might be highly digestible, a novel protein, a hydrolysed protein, low-fat, or fibre-enriched - it all depends on the individual, because different categories suit different patients.
Ideally we’d try at least 3 different diets if the first doesn’t work - which is why our role in supporting with this really cannot be overstated. Trying to get a client to feed only one diet - no table scraps, no treats, no nothing - for at least two weeks is hard enough, but the potential of them having to do that a further two times can easily be off-putting.
But the reality is that we are the ones who can explain why exclusive feeding is so important. We're the ones who sit down and problem-solve the multi-pet household, the kids who feed scraps under the table, the elderly neighbour who gives biscuits over the fence. We’re the ones who can help create feeding plans, do things like price comparisons to show that the diet we’re advising isn’t as expensive as they may think, and help create a nutritional plan that works for both them and their pet.
And this is important because if our diet trial fails because of poor compliance, it’s not just the time feeding that diet that has been wasted.
The worst-case scenario is our patient ends up having anaesthesia, endoscopy and other interventions and treatments that we could have avoided with a ‘proper’ diet trial. So supporting with this is a more important part of nursing these patients than it might intially seem.
If a diet does resolve the patients clinical signs, we need to feed this for at least twelve weeks before anyone tries to move away from it. Because managing expectations is an important part of improving treatment compliance, part of our job is ensuring our caregivers know this will be a long process, rather than a quick fix - but one that will ultimately be worth it.
Where do things like endoscopy and biopsies fit in?
If a dog has failed properly-run diet trials, or if they’re clinically unwell and it isn’t appropriate to wait, endoscopy and biopsies are indicated.
I’m actually going to be running an entire endoscopy series after this - because you guys have been asking for it! - so I’ll only touch on endoscopy briefly in this episode.
Put simply, we need to both visualise the gastrointestinal tract in a minimally-invasive way, and collect multiple good-quality diagnostic samples for histology.
We usually either scope the upper GI tract (oesophagus, stomach and duodenum), lower GI tract (ileum, colon) or both, depending on the individual patient and their clinical signs.
For us as veterinary nurses and technicians, our role involves:
Equipment preparation, assistance with use, and maintenance
Patient positioning, preparation and support
Anaesthetic planning, maintenance and monitoring
Handling, preparing and submitting samples for analysis
Many patients undergoing endoscopy are higher anaesthetic risk, with things like dehydration, hypoalbuminaemia and poor BCS - so careful anaesthetic planning and support is vital.
During the procedure, around 6-15 biopsies should be collected from each area, depending on the specific area itself. We need to be careful to avoid tissue damage or artefacts when handling and mounting these samples, as this can limit the diagnostic quality of the samples - and ultimately the information they give us.
And after diagnostics, we need to start thinking about treatment and management.
This treatment includes diet, microbiome management, and immunomodulatory drugs depending on the individual patient.
Selecting an appropriate therapeutic diet for a chronic enteropathy patient
The optimal diet will always depend on the individual patient. In general, we use limited-ingredient or hydrolysed protein diets in most chronic enteropathy patients. Patients with syndromes such as lymphangiectasia (dilation of the lymphatic vessels in the gut) or PLE need a low-fat diet. And some patients require manipulation of soluble dietary fibre - it all depends on their specific clinical signs and diagnostic results.
Even if we end up adding medication on top, we need to continue feeding the diet that helps improve clinical signs - because it often allows for lower drug doses, or may even enable us to discontinue some medications completely further down the line.
The role of the microbiome and antibiotics in chronic inflammatory enteropathy
First, the most important point to emphasise is that empirical antibiotics are not recommended for these patients.
The evidence shows that dogs tend to relapse soon after the antibiotics stop, and that antibiotics cause long-lasting disruption to the gut bacterial population so they can actually make the underlying problem worse.
Instead, antibiotics are reserved for cases that have failed everything else, unless the patient has one specific form of GI disease called granulomatous colitis.
Granulomatous colitis is a form of chronic, usually severe, large-intestinal disease linked to a specific invasive species of the bacteria E. coli.
This disease does need an antibiotic, usually a fluoroquinolone, and ideally guided by culture and sensitivity from biopsy samples because resistance is common. This is the only exception to early antibiotic use - in routine cases their use is contraindicated.
While we’re not making prescribing decisions as veterinary nurses and technicians, we may well find ourselves in situations where caregivers are asking us for them - or questioning why they haven’t been used.
It’s really helpful here to explain why this is - explaining that avoiding them is better for the gut, and not using them is a deliberate choice - often stops these client frustrations quickly.
So if antibiotics are out, what will we use instead?
We need to focus on supporting the microbiome - usually this is achieved using things like prebiotics, probiotics, and synbiotics. Faecal microbiota transplantation (FMT) is also an increasingly used treatment for these patients, since it’s easy and cheap to perform, well-tolerated, and has good results.
We’ll talk more on the microbiome and FMT in a future episode - but it plays a bigger role in GI disease than I think we’ve all previously appreciated.
And then we have immunomodulatory treatment.
Immunomodulatory drugs - drugs which regulate the immune system - are used when patients have not completely responded to a diet trial.
Usually, the first drug we try is a glucocorticoid steroid such as prednisolone. Budesonide can also be used; this can be useful where patients are displaying severe side-effects on pred.
Some patients will not respond to steroids alone, and need a second-line agent such as ciclosporin or chlorambucil. Many second-line agents are cytotoxic and require special handling and care; a big part of our role is advising and supporting clients with this at home.
Alongside this, wider education and support is a big part of nursing these patients. Our caregivers need to know what side effects to expect with treatment, and how to monitor for those. Tips on managing PUPD at home, for example, will be important for patients on high-dose steroids.
And throughout all of it, they need to continue feeding that diet.
Other treatments include B12 supplementation where levels are low. We used to use parenteral injections, but recent evidence shows that oral dosing works just as well - which is great, because weekly revisits for injection might seem like a hurdle impacting treatment for some clients.
In some cases, folate and vitamin D supplementation may be required - again, all depending on the individual patient.
And if you’re managing a PLE patient, they’ll also often be prescribed antithrombotics - because their protein loss puts them at a significantly higher risk for thromboembolism, meaning careful monitoring is an important part of their nursing.
Lastly, let’s look at the monitoring our chronic enteropathy patients need.
Interestingly, regular monitoring is highlighted in the new guidelines. In fact, their advice is that these patients are initially reassessed every 1-2 weeks.
And I think this presents a huge opportunity for veterinary nurses to do more in the long-term care of these patients.
This monitoring includes weight, BCS and MCS assessment, as well as quality of life assessment, clinical scoring, and medication side effects - all things we can assess in a nursing consultation. So if you’re not doing these in your GI patients, now’s the time to start.
So let’s recap everything we’ve discussed, and what it means for us as veterinary nurses and technicians.
The most important changes are in how we classify and manage it. We call it CIE now, not IBD. We classify it in two tiers, CIE-I and CIE-II, and then by what it responds to - food-responsive, immunomodulatory-responsive, and non-responsive.
Antibiotics have very much fallen out of favour, instead favouring protecting and supporting the microbiome, unless we have a specific case for antibiotic use.
And diet is essential - and something we need to use both for diagnostic and therapeutic purposes.
Above all, veterinary nurses have a much bigger role to play in the management of these patients.
Nutritional assessments, BCS and MCS assessment, dietary history collection, education and support, endoscopy assistance, I could go on… all of that is an essential part of our role.
Which means that we get to use our skills and our knowledge, all while making a significant difference to our patients and their families.
Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!
Thanks for learning with me this week, and I’ll see you next time!
References and Further Reading
Dupouy-Manescau N, Méric T, Sénécat O, et al. Updating the Classification of Chronic Inflammatory Enteropathies in Dogs. Animals (Basel). 2024;14(5):681. Published 2024 Feb 21. doi:10.3390/ani14050681
Heilmann RM, Jergens AE, Kathrani A, et al. ACVIM-endorsed statement: consensus statement and systematic review on guidelines for the diagnosis and treatment of chronic inflammatory enteropathy in dogs. J Vet Intern Med. 2026;40(1):aalaf017. doi:10.1093/jvimsj/aalaf017
Jergens AE, Heilmann RM. Canine chronic enteropathy-Current state-of-the-art and emerging concepts. Front Vet Sci. 2022;9:923013. Published 2022 Sep 21. doi:10.3389/fvets.2022.923013
