A systematic review of the evidence of reduced allergenicity and clinical benefit of food hydrolysates in dogs with cutaneous adverse food reactions

Detection of chicken DNA in commercial dog foods

BACKGROUND

These days the number of potential food allergens is very large, but chicken is one of the most common allergens in dogs. Elimination diet is one of the clinical tools for the diagnosis of allergies and allergy tests are not very reliable. The restriction diet is most commonly carried out by feeding pet foods, relying on the ingredients on the label to select an elimination diet not containing previously eaten foods. Unfortunately, mislabeling of pet food is quite common. The purpose of this study was to determine the absence or presence of chicken DNA using both qualitative and quantitative polymerase chain reaction (PCR) analysis methods in dry and wet maintenance complete pet foods for adult dogs. Results were used to verify the declared composition on the labels.

RESULTS

Eleven out of fifteen (73%) dog foods were produced as declared by the manufacturer, two of which showed the presence of chicken protein as stated on the label. The remaining nine foods contained amounts of chicken DNA below 1%, consistent with declarations that no chicken was added in the composition. Four of tested dog foods (27%) were not produced consistently with the declaration on the packaging. Two dog foods (one dry and one wet) did not contain the claimed chicken protein. In two foods the addition of chicken DNA was detected at the level of over 2% and almost 6%, respectively.

CONCLUSIONS

In this study, we focused on one of the most commonly undeclared animal species on the label-chicken protein-and performed DNA analyzes to investigate possible contamination and mislabeling. The results showed some inaccuracies. However, most of them are trace amounts below 1%, which proves compliance with the label. Our results showed that undeclared animal species can be as common as missing an animal protein declared on the label. The conducted research indicates that both dry and wet analyzed foods should not be recommended as a diagnostic tool in elimination tests, because it may result in false negative results. Over-the-counter maintenance foods for dogs should not be recommended for the diagnosis and treatment of food hypersensitivity.

Identification of Allergic Epitopes of Soybean β-Conglycinin in Different Animal Species

Soybean can cause allergy in both humans and animals. The herein study aims to identify the antigenic determinants (epitopes) of β-conglycinin that lead to allergy in different animal species (swine, bovine, and rats). The epitopes of β-conglycinin were identified through co-immunoprecipitation and mass spectrometry. The binding abilities of seven identified epitope peptides to allergic sera of three animal species were compared by ELISA and dot-blot techniques. Some epitope peptides could be recognized by the three animal allergic sera, while most epitopes showed some differences in binding abilities to the different animal sera. The strongest reaction using swine sera was detected with peptides α2, β2, and β3, but the biggest sensitive regions for bovine and rats were peptides α2, β1, and β4. Most epitopes of β-conglycinin exhibited different binding abilities to the three animal sera, in which the biggest sensitive regions were peptides α2, β2, and β3 for swine, but peptides α2, β1, and β4 were detected for bovine and rats.

Treatment With Hydrolyzed Diet Supplemented With Prebiotics and Glycosaminoglycans Alters Lipid Metabolism in Canine Inflammatory Bowel Disease

Canine inflammatory bowel disease (IBD) is a chronic, immunologically mediated intestinal disorder, resulting from the complex interaction of genetic, environmental and immune factors. Hydrolyzed diets are used in dogs with food-responsive diarrhea (FRD) to reduce adverse responses to immunostimulatory proteins. Prebiotics (PRBs) and glycosaminoglycans (GAGs) have previously been demonstrated to show anti-inflammatory activity in the intestinal mucosa. Notably, hydrolyzed diets combined with the administration of PRBs and GAGs offer a promising approach for the treatment of canine IBD. Our aim was to investigate the effects of hydrolyzed diet and GAG+PRB co-treatment on the serum metabolomic profile of IBD dogs. Dogs with IBD randomly received either hydrolyzed diet supplemented with GAGs and PRBs (treatment 1) or hydrolyzed diet alone (treatment 2) for 10 weeks. A targeted metabolomics approach using mass spectrometry was performed to quantify changes in the serum metabolome before and after treatment and between treatment 1 and 2. Principal component analysis (PCA), partial least squares-discriminant analysis (PLS-DA), hierarchical cluster analysis (HCA) and univariate statistics were used to identify differences between the treatment groups. PCA, PLS-DA, and HCA showed a clear clustering of IBD dogs before and after hydrolyzed diet, indicating that the treatment impacted the serum metabolome. Univariate analysis revealed that most of the altered metabolites were involved in lipid metabolism. The most impacted lipid classes were components of cell membranes, including glycerophospholipids, sphingolipids, and di- and triglycerides. In addition, changes in serum metabolites after GAG+PRB co-treatment suggested a possible additional beneficial effect on the lipid metabolism in IBD dogs. In conclusion, the present study showed a significant increase in metabolites that protect gut cell membrane integrity in response to hydrolyzed diet alone or in combination with GAG+PRB co-treatment. Administration of such treatment over 70 days improved selected serum biomarkers of canine IBD, possibly indicating improved intestinal membrane integrity.

Assessment of the clinical accuracy of serum and saliva assays for identification of adverse food reaction in dogs without clinical signs of disease

OBJECTIVE

To assess the clinical accuracy of 2 serum-based assays and 1 saliva-based assay for detection of adverse food reaction (AFR) in dogs without clinical signs of disease.

ANIMALS

30 healthy client-owned dogs.

PROCEDURES

Dog owners completed an online survey to collect comprehensive information about their pets' diet history. From each dog, serum and saliva samples were obtained and submitted for AFR testing by means of 3 assays that assessed the immunoglobulin response to 24 foods. Assays A and B measured food allergen-specific IgE concentrations in serum, whereas assay C measured food allergen-specific IgA and IgM concentrations in saliva. Descriptive data were generated, and Fisher exact tests were used to assess the respective associations between positive test results and specific food ingredients to which dogs were exposed.

RESULTS

Assays A, B, and C yielded positive results for 26, 18, and 30 dogs, respectively. All dogs had positive results for at least 1 assay. The median (range) number of foods or ingredients to which dogs tested positive was 10.5 (0 to 24) for assay A, 1 (0 to 13) for assay B, and 12.5 (4 to 22; IgM) and 3 (0 to 24; IgA) for assay C. Positive test results were not significantly associated with prior food exposure.

CONCLUSIONS AND CLINICAL RELEVANCE

Saliva and serum assays for AFR often yielded positive results for apparently healthy dogs and are not recommended for clinical use. Elimination diet trials remain the gold standard for diagnosis of AFR in dogs.

Cross-contamination in canine and feline dietetic limited-antigen wet diets

Background

Adverse food reactions (AFRs) are defined as abnormal responses to an ingested food or food additive. Diagnosis and treatment of AFRs consist of the complete elimination of these ingredients in the dietary trial. Previous studies have demonstrated the presence of undeclared ingredients in commercial limited-antigen dry food diets that can compromise the results and efficacy of dietary elimination trails. The aim of this study was to assess a selection of commercial canine and feline dietetic limited-antigen wet foods for the potential cross-contamination of animal proteins from origins not mentioned on the label.

Results

Eleven canine and feline dietetic limited-antigen wet foods (9 novel animal protein foods, 1 vegetarian and 1 hydrolyzed) were analyzed by polymerase chain reaction (PCR) to detect the presence DNA of animal and vegetal origins. PCR analysis confirmed the contamination of 6 of the 11 (54.5%) limited-antigen wet diets with undeclared animal protein. One of these 6 diets was solely composed of animal protein sources completely unrelated to those declared on the label. None of the foods containing horse meat or fish were contaminated, and neither were the vegetarian or the hydrolyzed food products. Moreover, the results show that had zoological class primers only been used to check for cross-class contaminations, as are generally used in the pet food industry for in-house checks, the apparent contamination rate would have been significantly underestimated: less than 20% (3/11), instead of the actual rate of 54.7% using species-specific primers.

Conclusion

This study reveals a high rate of cross-contamination in dietetic limited-antigen wet canine and feline foods, as previously described for dietetic dry limited-antigen foods (reported to be more than 80%). These results add new fuel to the discussion about the potential causes underlying the failure of elimination diets, since animal protein contaminants may actually be present in the commercial dietetic limited-antigen diets. AFRs may therefore occur as a result of inadequate practices in the pet food industry.

An open label clinical trial to evaluate the utility of a hydrolysed fish and rice starch elimination diet for the diagnosis of adverse food reactions in dogs

BACKGROUND

The diagnosis of adverse food reaction (AFR) is based on an eight week elimination diet (ED) and is confirmed by relapse upon re-challenge with the previously fed diet. Hydrolysed EDs are commonly used for this purpose.

OBJECTIVE

To evaluate a commercially available hydrolysed fish protein and rice starch ED for the diagnosis of AFR.

ANIMALS

Fifty nonseasonally pruritic dogs.

METHODS AND MATERIALS

Pruritus was assessed with a Visual Analog Scale, lesions with the Canine Atopic Dermatitis Lesions Index and quality of life with a validated questionnaire on days 0 and 56. Antimicrobial treatments were permitted during the first four weeks, and corticosteroids and oclacitinib during the first six weeks. Dogs showing at least 50% pruritus improvement were separately challenged with their prior diet, fish and rice.

RESULTS

Thirty eight dogs completed the ED, four were dropped out due to worsening clinical signs, three to low palatability and five were lost to follow-up. In 24 dogs, pruritus improved by >50% and 22 underwent dietary challenges. Of these, 15 reacted to their prior diets and were diagnosed with AFR, whereas seven did not relapse (and a diagnosis of AFR was considered to be doubtful). Five dogs reacted to fish and four to rice. Of the 14 dogs in which pruritus did not improve, some underwent a second ED and others were successfully treated for atopic dermatitis.

CONCLUSION AND CLINICAL IMPORTANCE

The hydrolysed fish and rice diet seemed to be a useful ED for the diagnosis of AFR, even in dogs allergic to fish or rice.

DNA and Protein Analyses to Confirm the Absence of Cross-Contamination and Support the Clinical Reliability of Extensively Hydrolysed Diets for Adverse Food Reaction-Pets

Adverse food reactions (AFR) are a common cause of skin diseases in cats and dogs. The correct diagnosis and management of AFR relies upon clinical nutrition. The reliability of commercial hypoallergenic diets commonly used in AFR has been questioned because studies have shown the presence of proteins not declared on the label ingredients. It is proposed that extensively hydrolysed protein-based diets constitute a reliable nutritional solution. Royal Canin Anallergenic™ Canine and Feline diets are formulated with very low molecular weight feather protein and purified corn starch. Protein gel electrophoresis and thin layer paper chromatography were used to characterize protein hydrolysis in these diets and their hydrolysed raw materials; protein species were identified by mass spectrometry. To detect cross-contaminating protein, species-specific DNA was measured and correlated with ancillary protein content using calibration curves. The only protein components detected in the extensively hydrolysed feather protein raw material were amino acids and small oligopeptides. GBSS-I (Granule-bound starch synthase 1) was detected in the finished diets; this has not been reported as a clinically apparent allergen in dogs or cats. The DNA threshold corresponding to the maximum acceptable level of ancillary protein was not exceeded in 99.9% of more than 2150 product batches tested and no products were released to the market with cross-contaminating proteins. These results demonstrate the extensive level of protein hydrolysis in Royal Canin Anallergenic™ Canine and Feline diets and the absence of cross-contaminating protein, both key requirements for a diet to be used during diagnosis and for management of pets with AFR.

PCR analysis of a prescription vegetarian diet and use in three dogs with cutaneous adverse food reactions

BACKGROUND

Cutaneous adverse food reaction (CAFR) is diagnosed by performing an elimination diet trial utilizing prescription or home-cooked diets followed by provocative challenge.

OBJECTIVES

To report findings of PCR analysis of a prescription vegetarian diet (RCV) for undeclared proteins of animal origin, as well as to describe its utilization for diagnosis and management of dogs suspected of having CAFR.

ANIMALS

Three client-owned dogs.

METHODS

PCR analysis of RCV for 11 mammalian species and poultry. In three dogs, clinical examination, cytology, aerobic culture (if indicated) and at least one elimination diet trial with RCV.

RESULTS

In our case series, all dogs had a history of pruritus and recurrent pyoderma that resolved with infection control and an elimination diet trial. In cases 1 and 2, a diagnosis of CAFR was made following an elimination trial with RCV and provocative challenge. Case 3 had a previously confirmed diagnosis of CAFR and RCV was successfully used to maintain remission of CAFR-related signs. PCR testing of RCV was negative for 11 mammalian species and poultry.

CONCLUSIONS AND CLINICAL IMPORTANCE

The RCV diet was found not to contain any undeclared mammalian or avian proteins. In this case series, the RCV was successfully used to diagnose and maintain three dogs with CAFR.

Comparing immediate-type food allergy in humans and companion animals-revealing unmet needs

Adverse food reactions occur in human as well as veterinary patients. Systematic comparison may lead to improved recommendations for prevention and treatment in both. In this position paper, we summarize the current knowledge on immediate-type food allergy vs other food adverse reactions in companion animals, and compare this to the human situation. While the prevalence of food allergy in humans has been well studied for some allergens, this remains to be investigated for animal patients, where owner-reported as well as veterinarian-diagnosed food adverse reactions are on the increase. The characteristics of the disease in humans vs dogs, cats, and horses are most often caused by similar, but sometimes species-dependent different pathophysiological mechanisms, prompting the specific clinical symptoms, diagnoses, and treatments. Furthermore, little is known about the allergen molecules causative for type I food allergy in animals, which, like in human patients, could represent predictive biomarkers for risk evaluation. The definite diagnosis of food allergy relies-as in humans-on elimination diet and provocation tests. Besides allergen avoidance in daily practice, novel treatment options and tolerization strategies are underway. Taken together, numerous knowledge gaps were identified in veterinary food allergy, which need to be filled by systematic comparative studies.

Extensive protein hydrolyzation is indispensable to prevent IgE-mediated poultry allergen recognition in dogs and cats

Background

The central premise for the commercialization of diets with hydrolyzed ingredients is that the small-sized digested peptides would be unable to crosslink allergen-specific IgE at the surface of tissue mast cells and induce their degranulation. Evidence for the validity of this concept to diagnose food allergies in dogs and cats is limited, however. Our objectives were to study the recognition of standard and variably hydrolyzed poultry extracts by sera from dogs and cats with elevated chicken-specific serum IgE.

Results

Forty sera from dogs and 40 from cats with undetectable, low, medium or high serum levels of chicken-specific IgE were tested by ELISA on plates coated with the positive controls chicken, duck and turkey meat extracts and the negative controls beef meat (dogs) or wheat (cats). Plates were also coated with a non-hydrolyzed chicken meal, and mildly- or extensively-hydrolyzed poultry feather extracts. The frequencies of dogs with positive IgE against the various extracts were: chicken meat: 100%, duck and turkey meats: 97%, beef meat: 3%, non-hydrolyzed chicken meal: 73%, mildly-hydrolyzed poultry feathers: 37% and extensively-hydrolyzed poultry feathers: 0%. For cats, these respective percentages were (with wheat replacing beef as a negative control): 100, 84, 97, 7, 7, 0 and 0%. To detect any allergenic cross-reactivity between poultry meat-based and feather hydrolysate-derived extracts, an IgE ELISA inhibition was also done. Ten canine sera with the highest level of anti-poultry IgE in the previous experiment were incubated overnight with a previously optimized 50 μg amount of each of the extracts used above. We performed ELISA on plates coated with chicken, duck or turkey meats with or without inhibitors. The median inhibition percentages after incubation with the non-hydrolyzed chicken meal were ~22%, with the mildly-hydrolyzed poultry feathers: 14–22%, and those with the extensively-hydrolyzed poultry feathers: 5 to 10%; the last inhibition level was similar to that of the beef meat negative control.

Conclusions

Altogether, these results suggest that an extensive—but not partial—hydrolyzation of the poultry feather extract is necessary to prevent the recognition of allergenic epitopes by poultry-specific IgE.

Electronic supplementary material

The online version of this article (doi:10.1186/s12917-017-1183-4) contains supplementary material, which is available to authorized users.

Detection of IgE-reactive proteins in hydrolysed dog foods

BACKGROUND

Commercial hydrolysed diets are used for the diagnosis of food allergy in dogs. The cleaved parent proteins are presumed to be too small to elicit an allergic response by reacting with allergen-specific immunoglobin E (IgE).

OBJECTIVES

To evaluate three commercial hydrolysed dog diets for proteins.

ANIMALS

Sera were collected from dogs with suspected food allergy.

METHODS

Two batches of each hydrolysed diet were examined by electrophoresis and visualized by Coomassie blue, silver nitrate staining and IgE immunoblotting.

RESULTS

From two to five proteins, ranging from 21 to 67 kDa, were detected in all three diets evaluated. Circulating IgE antibodies targeting these proteins were detected by immunoblotting of dog sera. Six different carbohydrate proteins were identified by mass spectrometry; maize/potato granule-bound starch synthase-1, soybean glycinin, soybean β-conglycinin α chain, potato aspartic protease inhibitor, rice glutelin type B1 and soybean sucrose-binding protein. Four of these proteins have been described as allergens in humans.

CONCLUSIONS

Some commercial hydrolysed diets contain carbohydrate proteins. Some dogs have circulating IgE antibodies targeting these proteins. The clinical significance of these findings is unknown.

A randomized, double-blinded crossover trial testing the benefit of two hydrolysed poultry-based commercial diets for dogs with spontaneous pruritic chicken allergy

BACKGROUND

Hydrolysed protein diets are used to diagnose and treat dogs with cutaneous adverse food reactions (CAFR). Little is known about what proportion of dogs hypersensitive to the native protein would react to its hydrolysed form.

OBJECTIVES

To determine the clinical allergenicity of hydrolysed poultry feather (RCU) and chicken liver diets (HZD) in dogs with chicken induced CAFR.

METHODS

In this randomized, double-blinded, crossover trial, ten dogs with chicken induced CAFR were selected after a positive oral challenge to chicken meat and a negative one to corn. Test diets were fed for 14 days separated by a 14 day wash-out period. Owners rated pruritus daily with a Visual Analog Scale (PVAS). The challenge was ended if a flare in pruritus occurred (i.e. PVAS ≥5/10).

RESULTS

The median PVAS scores before feeding RCU and HZD were 0.9 and 1.7, respectively (Wilcoxon signed rank test, P = 0.46). Pruritus scores increased significantly after feeding HZD (Friedman's test, P < 0.001) but not after feeding RCU (P = 0.895). None of the dogs fed RCU, but four dogs fed HZD (40%), were withdrawn after a flare in pruritus developed (Fisher's test, P = 0.04). The maximal PVAS score was significantly higher after HZD (median: 4.7) compared to RCU (2.5) (Wilcoxon signed rank test, P = 0.01). One dog in each group was withdrawn due to diarrhoea.

CONCLUSIONS

The hydrolysed poultry feather diet did not induce pruritus flares in dogs allergic to chicken in contrast to the hydrolysed chicken liver diet that led to pruritus flares in 40% of these dogs.

Canine atopic dermatitis: detailed guidelines for diagnosis and allergen identification

BACKGROUND

Canine atopic dermatitis (AD) is a common, genetically predisposed, inflammatory and pruritic skin disease. The variation in clinical presentations, due to genetic factors, extent of the lesions, stage of the disease, secondary infections, as well as resemblance to other non-atopic related skin diseases, can complicate a diagnosis of canine AD. A sub-group of the International Committee for Allergic Diseases in Animals (ICADA) was tasked with the development of a set of practical guidelines that can be used to assist practitioners and researchers in the diagnosis of canine AD. Online citation databases and abstracts from international meetings were searched for publications related to the topic, and combined with expert opinion where necessary. The final set of guidelines was approved by the entire ICADA committee.

RESULTS

A total of 81 publications relevant for this review were identified. The guidelines generated focus on three aspects of the diagnostic approach: 1. Ruling out of other skin conditions with clinical signs resembling, or overlapping with canine AD. 2. Detailed interpretation of the historical and clinical features of patients affected by canine AD. 3. Allergy testing by intradermal versus allergen-specific IgE serum testing.

CONCLUSIONS

The diagnosis of canine AD is based on meeting clinical criteria and ruling out other possible causes with similar clinical signs. Flea combing, skin scraping and cytology should be performed, where necessary, as part of a thorough work-up. Elimination diet trials are required for patients with perennial pruritus and/or concurrent gastrointestinal signs. Once a clinical diagnosis of canine AD is made, allergy testing can be performed to identify potential causative allergens for allergen-specific immunotherapy.

Identification of epitopes of the β subunit of soybean β-conglycinin that are antigenic in pigs, dogs, rabbits and fish

BACKGROUND

β-Conglycinin (conglycinin) is one of the major seed storage proteins of soybean. Conglycinin is a 7S trimer composed of different combinations of β, α and α' subunits. All subunits of conglycinin have been reported to be allergenic in humans. The goal of this research is to identify epitopes of the β subunit of conglycinin that are antigenic in multiple animal species.

RESULTS

Sera from pigs, dogs, rabbits and hybrid striped bass that had antibodies against soybean conglycinin were identified by ELISA. Most of these sera recognized peptides that represent the β subunit of conglycinin. One antigenic region of the β subunit of conglycinin had considerable overlap among all species tested. One region that was similar to a peanut allergenic epitope in humans overlapped with a region that binds IgE from dogs. One region was antigenic in multiple rabbits and pigs, suggesting it may play a role in the response of pigs to soybean in the diet.

CONCLUSION

One region of the β subunit of conglycinin is an important antigen across species and abuts a region similar to the peanut allergen ARA h 1. A second region is particularly antigenic in pigs and rabbits. Variants of these antigenic regions of the β subunit of conglycinin may be useful in determining the role these regions play in the health of animals fed soybean. Published 2014. This article is a U.S. Government work and is in the public domain in the USA.

Identification of undeclared sources of animal origin in canine dry foods used in dietary elimination trials

Failure to respond to commercial limited antigen diets can occur in dogs kept on a dietary trial for the diagnosis of adverse food reaction (AFR). The aim of this study was to assess twelve canine dry limited antigen diets (eleven novel protein diets and one hydrolysed diet) for potential contamination by ingredients of animal origin not mentioned on the label. The validity of the two methods adopted for the detection of such food antigens was also evaluated. Each dietary product was analysed by microscopy analysis using the official method described in Commission Regulation EC 152/2009 with the aim of identifying bone fragments of different zoological classes (mammalian, avian and fish) and by polymerase chain reaction (PCR) for the identification of DNA of animal origin. Discrepancies between the results obtained by PCR and/or microscopy analysis and the ingredients listed on pet food packages were found. Only in two pet foods did the results of both analyses match the ingredients listed on the label. In the remaining ten samples, microscopy detected bone fragments from one or two unpredicted zoological classes, revealing avian fragments in six of ten samples followed by those of fish in five of ten and mammalian fragments in four of ten. In two samples, microscopy analysis identified a contamination that would have otherwise passed unobserved if only PCR had been used. However, PCR confirmed the presence of all the zoological classes detected by microscopy and also identified the DNA of an additional unexpected zoological class in two samples. Dogs might fail to respond to commercial limited antigen diets because such diets are contaminated with potential allergens. Both PCR and microscopy analysis are required to guarantee the absence of undeclared animal sources in pet foods. Before ruling out AFR, a novel protein home-made diet should be considered if the dog is unresponsive to a commercial regimen.

A randomized, open-label, positively-controlled field trial of a hydrolyzed protein diet in dogs with chronic small bowel enteropathy

BACKGROUND

Hydrolyzed protein diets are commonly used to manage canine chronic enteropathies (CE), but their efficacy has not yet been critically evaluated.

HYPOTHESIS

A hydrolyzed protein diet is superior to that of a highly digestible (control) diet in the management of CE in dogs.

ANIMALS

Twenty-six dogs (18 test diet, 8 control diet) referred for investigation and management of naturally occurring chronic small intestinal disease.

METHODS

Randomized, open-label, positively controlled trial. After a full diagnostic investigation, which included endoscopy, dogs were assigned either to the test diet or control diet on a 2:1 basis (test:control). Cases were re-evaluated 3 times (at approximately 3, 6-12 months, and 3 years). Outcome measures included response of clinical signs (complete, partial, none), change in severity of signs (based upon clinical disease activity index; canine inflammatory bowel disease activity index [CIBDAI]), change in body weight, and need for other therapy.

RESULTS

There were no significant differences in baseline characteristics (eg, signalment, body weight, and duration of clinical signs), and histopathologic severity between test and control diet groups. However, despite randomization, CIBDAI was significantly higher in the test diet group (P=.013). Most dogs had responded by first evaluation, with no difference between groups (P=.87). However, significantly more dogs on the test diet remained asymptomatic at both the second (P=.0012) and third (P<.001) re-evaluation, and the decrease in CIBDAI was significantly greater (P=.010).

CONCLUSIONS AND CLINICAL IMPORTANCE

A hydrolyzed protein diet can be highly effective for long-term management of canine chronic small bowel enteropathy.