An In­tro­duc­tion to Gas­tric Ul­cers

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Although gas­tric ul­cers and colonic ul­cers are sim­i­lar in the sense that they are both a thin­ning of the lin­ing of the gas­troin­testi­nal tract, they are very dif­fer­ent. They oc­cur in dif­fer­ent parts of the horse’s di­ges­tive tract, present dif­fer­ently, are di­ag­nosed dif­fer­ently and in some in­stances, re­quire al­most op­po­site treat­ments.

Gas­tric ul­cers, or stom­ach ul­cers, oc­cur in the horse’s foregut and are a re­sult of a break or ero­sion in the lin­ing of the esoph­a­gus, stom­ach or small in­tes­tine. Cricket Rus­sillo, DVM, a se­nior as­so­ciate at Vir­ginia Equine Imag­ing in The Plains, Vir­ginia, ex­plains that stom­ach ul­cers typ­i­cally oc­cur in ei­ther the nong­lan­du­lar re­gion, the up­per por­tion of the stom­ach, or the glan­du­lar re­gion—the lower por­tion of the stom­ach.

Clin­i­cal Signs and Di­ag­no­sis

Clin­i­cal signs of gas­tric ul­cers can in­clude changes in at­ti­tude, poor ap­petite, colic, de­creased per­for­mance, de­cline in body con­di­tion, weight loss and lack of en­ergy.

To di­ag­nose stom­ach ul­cers, vet­eri­nar­i­ans use an en­do­scope. In order to per­form the pro­ce­dure, re­ferred to as a gas­troscopy, the horse must have fasted for 12 hours, with an ex­cep­tion given to wa­ter. Us­ing a fiberop­tic cam­era, the vet­eri­nar­ian in­serts the en­do­scope through the horse’s nos­tril, into the back of the throat, un­til the horse swal­lows it. Then the cam­era is di­rected down the esoph­a­gus un­til it reaches the stom­ach.

Ac­cord­ing to Rus­sillo, it is vi­tal that all ar­eas of the stom­ach be looked at for any in­di­ca­tion of ul­cers, in­flam­ma­tion or other ir­ri­ta­tion. A com­plete eval­u­a­tion is cru­cial since horses can have ul­cers in mul­ti­ple ar­eas of the stom­ach.

In the case of a stom­ach ul­cer, there is a grad­ing scale from 0 to 4; 0 in­di­cates a healthy, non-ir­ri­tated stom­ach, whereas 4 in­di­cates the stom­ach is suf­fer­ing from se­vere ul­cers and ul­cer­a­tions. The max­i­mum grade es­sen­tially, in­di­cates a com­plete loss of the ep­ithe­lium. Grade 4 ul­cers are large, co­a­lesc­ing and full thick­ness (with com­plete loss of the ep­ithe­lial lin­ing of the stom­ach), of­ten with as­so­ci­ated hem­or­rhage. This is called Equine Gas­tric Ul­cer Syn­drome (EGUS).

Treat­ment and Preven­tion

Rus­sillo sug­gests feed­ing a low-starch/low-sugar diet; as in ex­cess, it causes more acid in the horse’s di­ges­tive sys­tem. Op­po­site from colonic ul­cers, stom­ach ul­cers, in order to heal, re­quire that the horse be eat­ing and di­gest­ing at all times. This means hav­ing free-choice ac­cess to pas­ture and hay. A pop­u­lar prod­uct, the Nib­bleNet, a slow-feeder hay net, has been found quite effective in these cases, as it pre­vents the horse from get­ting fat but still en­cour­ages him to con­tin­u­ously eat. Rus­sillo also en­cour­ages mul­ti­ple grain meals through­out the day, as op­posed to the con­ven­tional morn­ing and evening feed­ings.

She also en­cour­ages own­ers to make en­vi­ron­men­tal changes for their horses. This means pro­vid­ing as much free pas­ture time as pos­si­ble. She ex­plains that horses are nat­u­rally de­signed to eat and graze all through­out the day and be­cause of their nat­u­ral bod­ily func­tion and de­sign, they need to have some­thing in their sys­tem to buf­fer their con­stant acid pro­duc­tion.

Ac­cord­ing to Rus­sillo, there is cur­rent think­ing that sug­gests that gas­tric ul­cers that oc­cur in the py­loric re­gion of the stom­ach may re­spond bet­ter to miso­pros­tol and su­cral­fate, but the ul­cers in the squa­mous por­tion of the stom­ach seem to still re­spond well to omepra­zole. Omepra­zole is a med­i­ca­tion that in­hibits the pro­ton pump in a horse’s stom­ach.

Rus­sillo says that when own­ers uti­lize omepra­zole-based prod­ucts, they al­ways need to ask for FDA-ap­proved med­i­ca­tion. There are a myr­iad of omepra­zole-based prod­ucts on the mar­ket that claim to cure gas­tric ul­cers. How­ever, the FDA has is­sued warn­ings that these prod­ucts are un­safe and in­ef­fec­tive, as they con­tain vary­ing lev­els of omepra­zole, some at sub- or ex­cess ther­a­peu­tic lev­els. As of now, there is only one prod­uct of­fi­cially ap­proved to cure and pre­vent gas­tric ul­cers. If clin­i­cal signs haven’t re­solved af­ter diet and med­i­ca­tions have been ap­pro­pri­ately ad­justed, own­ers should also con­sider ad­just­ing the horse’s train­ing pro­gram.

Ac­cord­ing to Rus­sillo, in the case of a per­for­mance horse, although it may not be prac­ti­cal, re­mov­ing a horse com­pletely from his train­ing pro­gram may be nec­es­sary in order to give the body time to rest and heal.

ex­plains that this diet change is tem­po­rary. Any change in diet has the po­ten­tial to cause colic, but in hindgut ul­cers, this change is de­signed to de­crease colic, one of the clin­i­cal signs as­so­ci­ated with the con­di­tion. There­fore, by re­duc­ing the bulk in the diet, the colic episodes should ac­tu­ally re­solve. How­ever, if colic signs con­tinue, then hav­ing the horse eval­u­ated by a vet­eri­nar­ian is in­di­cated and it might be that the di­etary change needs to be more grad­ual and hay could be added back to the diet.

An­drews sug­gests the com­plete pel­let diet for three months in order to treat colonic ul­cers. Two com­plete pel­let grains in­clude an equine-se­nior and equinead­ult grain, which are al­falfa hay based. Es­sen­tially, a com­plete pel­let is grain and for­age wrapped in one feed source. It is de­signed to to­tally re­place hay and for­age in the horse’s diet and la­bel di­rec­tions should be fol­lowed care­fully so that the horse is fed the right amount.

An­drews also tends to pre­scribe corn oil or flaxseed oil. This coats the in­tes­tine and sup­plies omega fatty acids, which are anti-in­flam­ma­to­ries for the large in­tes­tine. Typ­i­cally, he sug­gests one cup of corn oil two times a day mixed with the se­nior or equine adult feed. The oil, he says, must be slowly in­tro­duced. If the horse is given too much at once, there is a chance the horse will refuse his grain.

An­drews also sug­gests twice-daily doses of psyl­lium, which is sim­i­lar to Me­ta­mu­cil for hu­mans. This com­po­nent coats the in­tes­tine and has anti-in­flam­ma­tory prop­er­ties. He men­tions other prod­ucts that con­tain psyl­lium along with pre­bi­otics and pro­bi­otics. It also acts as a lax­a­tive; An­drews has found that this lax­a­tive tends to lu­bri­cate the hindgut and help move feed through the colon and helps the di­ges­tive sys­tem heal.

In ad­di­tion to nu­tri­tional com­po­nents and changes, An­drews sug­gests that own­ers take their horses off any and all non­s­teroidal anti-in­flam­ma­to­ries (NSAIDs), such as phenylbu­ta­zone (bute) and Banamine. He rec­og­nizes that, in some cases, older horses who suf­fer from chronic arthri­tis may need these med­i­ca­tions on a pre­scribed main­te­nance dose. His warn­ing, how­ever, is that these med­i­ca­tions tend to ex­ac­er­bate hindgut ul­cers or may even cause the con­di­tion in the first place.

Af­ter re­mov­ing these med­i­ca­tions, he typ­i­cally pre­scribes su­cral­fate. This is a phar­ma­ceu­ti­cal coat­ing agent, ap­proved for treat­ing ul­cers in hu­mans. This prod­uct is not ap­proved for horses, so he uses the hu­man for­mula when ad­min­is­ter­ing. He ad­vises own­ers to avoid com­pounded prod­ucts, which he ad­mits, is hard to do. This is be­cause com­pounded prod­ucts are not ap­proved by the U.S. Food and Drug Ad­min­is­tra­tion (FDA) and the drug con­cen­tra­tion of the com­pound is not ver­i­fied or checked. An­drews typ­i­cally uses hu­man drugs (when an FDA-ap­proved prod­uct is not avail­able for horses) to treat horses with this con­di­tion be­cause these med­i­ca­tions are re­quired to un­dergo a very rig­or­ous FDA ap­proval process.

Es­sen­tially, Rus­sillo says that preven­tion comes down to at­tempt­ing to un­der­stand po­ten­tial trig­gers and manag­ing the horse’s life­style. In the case of the per­for­mance horse, these an­i­mals tend to live a very fast-paced, high-stress life­style. Although we can’t al­ways elim­i­nate stres­sors, we can try to bal­ance them as best we can. It is the owner’s re­spon­si­bil­ity to man­age stress lev­els and pro­vide the best main­te­nance rou­tine and, when needed, the best treat­ment and pre­ven­tive mea­sures.

Banamine and bute can cause or ex­ac­er­bate hindgut ul­cers.

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