CASE RE­PORT

EQUUS - - Equus -

Al­bert’s odd ail­ment: What seemed like a sim­ple case of gas­tric ul­cers turned out to be a rare con­di­tion that re­quired risky surgery.

Some­thing was wrong with Al­bert. The 10-year-old Hanove­rian was nor­mally ami­able and out­go­ing. “I’d bought him when he was 4, and I’ve known him his en­tire life,” says his owner Jen­nifer Pifer. “He had al­ways been the kind of horse who would come right up to you, with his ears up and a perky ‘happy to see you’ at­ti­tude.” The 17.2 hand geld­ing had also been very will­ing in his work as an event­ing and dres­sage mount.

Over the course of a few months in the sum­mer of 2014, how­ever, all that changed. Al­bert be­came in­creas­ingly sullen. He was re­luc­tant to work, in­dif­fer­ent to­ward Pifer and had fre­quent skir­mishes with pas­ture­mates. “I re­mem­ber look­ing at him and think­ing, ‘He seems de­pressed,’” says Pifer.

Al­bert was also de­vel­op­ing some un­usual phys­i­cal prob­lems. He had al­ways had pe­ri­odic bouts of runny ma­nure, says Pifer, but now they were be­com­ing more fre­quent. “We had moved from Colorado to Seat­tle, and I thought maybe the new en­vi­ron­ment was con­tribut­ing to it. I had mul­ti­ple ve­teri­nar­i­ans out to look at him, and no­body was too con­cerned. With a gray horse that be­comes a real is­sue, though. I was con­stantly wash­ing his back end.”

Pifer was even more wor­ried that fall when Al­bert started hav­ing bouts of mild colic. “The first

What seemed like a sim­ple case of gas­tric ul­cers turned out to be a rare con­di­tion that re­quired risky surgery. By Chris­tine Barakat

time he col­icked, I had the ve­teri­nar­ian out right away,” says Pifer. “He found that Al­bert was a bit de­hy­drated, so he tubed him with flu­ids and that seemed to get ev­ery­thing go­ing again. The ve­teri­nar­ian ad­vised me to mon­i­tor his fluid in­take, so I started mak­ing mashes to make sure he was get­ting plenty of wa­ter.”

By the new year, Al­bert hadn’t im­proved---he still seemed out of sorts and had pe­ri­ods of dis­com­fort. Pifer called her ve­teri­nar­ian out again, and he sug­gested try­ing a course of omepra­zole in case gas­tric ul­cers were the source of the geld­ing’s trou­bles. Low-level col­ics and a sour at­ti­tude are com­mon signs of gas­tric ul­cers in horses. “She said we could use a gas­tro­scope to look for ul­cers, or we could just try a month of med­i­ca­tion to see if he im­proved,” says Pifer. “That seemed to make the most sense at the time.”

Al­bert seemed to im­prove slightly after a month on omepra­zole, Pifer says, but a move back to Colorado in late spring lim­ited her rid­ing time and made it dif­fi­cult to dis­cern ex­actly how much change there had been, if any. “When we got back to Colorado, I called my old ve­teri­nar­ian again,” she says. “She knew Al­bert well, and I brought her up to speed on what we’d been deal­ing with for the past six months.”

The ve­teri­nar­ian sug­gested it was time for a gas­tro­scopic ex­am­i­na­tion to see ex­actly what might be go­ing on, and she re­ferred Al­bert to Colorado State Univer­sity (CSU). “It wasn’t a dif­fi­cult de­ci­sion to take him in,” says Pifer, “and hon­estly, I wasn’t too wor­ried about what they’d find. At that point, I was pretty sure it was ul­cers. That’s what I’d been told by so many peo­ple, and it seemed to fit the signs. He had never lost his ap­petite or dropped weight, and he hadn’t had a sig­nif­i­cant colic since I’d been so dili­gent about his mashes. He still had re­ally loose ma­nure, though.”

A good look around

Yvette Nout-Lo­mas, DVM, PhD, met Al­bert shortly after he ar­rived at the CSU clinic on June 18, 2015. “I knew he was here for sus­pected ul­cers,” she says, “but from what I was hear­ing, I didn’t think that’s what he ac­tu­ally had.”

For starters, says Nout-Lo­mas, Al­bert’s life­style and diet did not fit the ul­cer pro­file. “He wasn’t on a high-grain diet, he got plenty of turnout and didn’t have a very stress­ful train­ing sched­ule,” she says. The fact he had been treated for ul­cers once also led her to be­lieve that per­haps they weren’t to blame. “And, gen­er­ally speak­ing,” she adds, “I think that gas­tric ul­cers are over­diag­nosed in horses.”

With Al­bert se­dated, Nout-Lo­mas be­gan the gas­tro­scopic exam, threading a long, flex­i­ble tube with a light source and cam­era at the end through his nose, down his esoph­a­gus and into his stom­ach. “We’d asked for him to be fasted the night be­fore so his stom­ach would be empty,” she says. “That al­lows us to get a good look around.”

At first, noth­ing ab­nor­mal ap­peared on the screen. “I knew, though, that there was more to look at,” Nout-Lo­mas says. “Many peo­ple stop a gas­troscopy exam when the cam­era en­ters the stom­ach, but to do a thor­ough exam, you re­ally need to go fur­ther, around a slight bend and through some flu­ids to look at the py­lorus, which is the sphinc­ter where the stom­ach meets the small in­tes­tine. It’s around a cor­ner and kind of hard to get to, but it’s im­por­tant that you look. That’s what’s called a ‘com­plete gas­troscopy’.”

It was there, just in front of the

py­lorus, that Nout-Lo­mas saw some­thing ab­nor­mal. “It was a large growth, which we es­ti­mated to be about 10 cen­time­ters in di­am­e­ter,” she says. “I hadn’t seen any­thing like it be­fore.”

Omi­nous pos­si­bil­i­ties

The growth Nout-Lo­mas found was likely one of two things. It could be a can­cer­ous (neo­plas­tic) tu­mor that, judg­ing from its size, had likely al­ready spread ag­gres­sively to in­vade lo­cal tis­sues. Such a tu­mor would be un­treat­able. Or, it could be some­thing much less omi­nous---a sim­ple polyp, an over­growth of the nor­mal ep­ithe­lial cells that line the stom­ach. Nout-Lo­mas took a biopsy of the tis­sue cells and sent them to the pathol­ogy lab­o­ra­tory to find out what they were deal­ing with.

Still, even if the growth were be­nign, Nout-Lo­mas had to won­der, could this polyp be the cause of Al­bert’s sour at­ti­tude and di­ges­tive trou­bles? Or was there still an­other prob­lem lurk­ing some­where? It was im­pos­si­ble to know.

“You wouldn’t nec­es­sar­ily ex­pect a growth in that lo­ca­tion to cause those prob­lems,” says Nout-Lo­mas, “and that was a dif­fi­cult part of this case. We had to stretch a bit to link the two in our minds. For in­stance, one of Jen­nifer’s con­cerns was that Al­bert was re­luc­tant to ex­er­cise. We know that with ex­er­cise stom­ach con­tents move around quite a bit. Maybe this mass was af­fect­ing the stom­ach’s abil­ity to empty, and that was caus­ing him dis­com­fort.”

The loose stools could also, pos­si­bly, be caused by the polyp. “Motil­ity along the length of the di­ges­tive tract is all related, from the stom­ach through the colon,” says Nout-Lo­mas. “It was pos­si­ble that all of it tied to­gether. Or maybe it didn’t. It was re­ally just spec­u­la­tion and the­o­ries.”

But even if the pre­sumed polyp wasn’t caus­ing Al­bert’s im­me­di­ate prob­lems, it was still a con­cern. Polyps are gen­er­ally con­sid­ered be­nign, but in hu­mans they can be­come can­cer­ous. “While we don’t have ev­i­dence that polyps can turn can­cer­ous in horses,” says Nout-Lo­mas, “we do know that they can grow to be very large. In this lo­ca­tion, just in front of the py­lorus, it could po­ten­tially block the exit to Al­bert’s stom­ach en­tirely, and that could be cat­a­strophic. There are re­ports in older lit­er­a­ture of large polyps in this lo­ca­tion found dur­ing necrop­sies, after the horse went through a pe­riod of weight loss for weeks and then died fol­low­ing a painful colic.”

Nout-Lo­mas re­layed this in­for­ma­tion to Pifer, who strug­gled to process the idea that her horse had some­thing much more rare and com­plex than gas­tric ul­cers. She headed home with Al­bert to await the biopsy re­sults, which would de­ter­mine the next step. “I re­mem­ber cry­ing as I drove the trailer,” she says. “I prob­a­bly shouldn’t have driven I was so up­set.”

Mak­ing a plan

The call fi­nally came a few days later. The biopsy re­sults showed only nor­mal ep­ithe­lial tis­sues, mean­ing that the mass in Al­bert’s stom­ach was most likely a polyp, not a can­cer­ous tu­mor. “We could only get sur­face cells in that first biopsy,” says Nout-Lo­mas, “so there was still the po­ten­tial that there were can­cer­ous cells deeper in the mass, but at this point we hadn’t seen them.”

This good news was tem­pered by the next set of loom­ing ques­tions: What should be done, if any­thing, about the polyp?

“Open­ing up his ab­domen to re­move the polyp wasn’t a good op­tion,” says Nout-Lo­mas. “On a horse that size it would be a very dif­fi­cult surgery, and be­cause you can’t see the mass from the out­side of the stom­ach, you’d have to reach in and blindly in­cise the stom­ach to re­move the growth, and that would be vir­tu­ally im­pos­si­ble.”

A bet­ter plan would be to re­move the mass en­do­scop­i­cally, work­ing with tools and a cam­era through the same sort of tube that had been used for the gas­troscopy. Just see­ing the mass, how­ever, had re­quired a three-me­ter-long scope. Nout-Lo­mas was un­aware whether there even were en­do­scopic sur­gi­cal tools that could reach that length. “I told Jen­nifer that I’d have to do some re­search and get back in touch with her when I had more in­for­ma­tion,” she says.

Nout-Lo­mas turned to her col­league Eileen Hack­ett, DVM, PhD, who is a res­pi­ra­tory surgery spe­cial­ist, for ad­vice. “Dr. Hack­ett does a lot of up­per air­way pro­ce­dures en­do­scop­i­cally, and she in­di­cated that there were cer­tain sur­gi­cal in­stru­ments that we could use through a three-me­ter en­do­scope to try to re­move the polyp.” After sev­eral con­ver­sa­tions, the pair de­cided that a sur­gi­cal

snare that could cau­ter­ize the mass as it cut might be the best op­tion.

“The snare is es­sen­tially a wire loop that you can wrap around the mass and pull tight to slice through it,” ex­plains Nout-Lo­mas. “As it tight­ens, it uses elec­tri­cal cur­rent to be­come heated to a very high de­gree, cau­ter­iz­ing the tis­sue and lim­it­ing bleed­ing. It’s a de­vice used of­ten in res­pi­ra­tory surgery, but I hadn’t heard of it to re­move any­thing from a stom­ach be­fore.”

The pro­ce­dure would carry some risks. “You run the risk of per­fo­rat­ing the stom­ach if you cut it too close,” says Nout-Lo­mas. “If that hap­pened, there would be noth­ing we could do to save Al­bert.” It was also pos­si­ble that they could suc­cess­fully re­move the mass and the geld­ing wouldn’t feel any bet­ter be­cause it was en­tirely un­re­lated to his clin­i­cal signs.

Nout-Lo­mas ex­plained all of this to Pifer over the phone. “I was re­luc­tant to say ‘yes,’ but I didn’t have long to de­cide---maybe a day or two,” she says. “I was run­ning up against an in­sur­ance dead­line, and any is­sue that we hadn’t ad­dressed by the end of that month wouldn’t be cov­ered by the new pol­icy.”

Ul­ti­mately, Pifer de­cided to try the surgery. She and Al­bert headed back to CSU.

The night be­fore the pro­ce­dure, Al­bert stayed at CSU so he could be fasted and rested. Then, the next morn­ing, he was se­dated and Nout-Lo­mas and Hack­ett set to work. “We tried to go in with two scopes first, one just for view­ing and one for cut­ting,” she says. “But that was very awk­ward, so we ended up us­ing one for both.”

Once she could see the mass, the sur­geon looped the snare around it and pulled. Al­bert felt noth­ing. “Some­times in gas­tro­scopic pro­ce­dures the horse can get a dis­tended stom­ach, so we watch for signs of colic,” says NoutLo­mas, “but oth­er­wise they don’t feel what we are do­ing.”

The pro­ce­dure pro­duced a good amount of smoke in Al­bert’s stom­ach, but when it cleared, Hack­ett took sev­eral more cuts. A large sec­tion was re­moved and this was sub­mit­ted as a biopsy to con­firm the polyp di­ag­no­sis. They re­moved about 40 per­cent of the mass.

“We didn’t want to cut too close the stom­ach wall and, hon­estly, the area we had cut looked pretty aw­ful,” says Nout-Lo­mas. “It was very red and an­gry look­ing. It was one of those mo­ments when you won­der if you made things worse.” Al­bert re­cov­ered from his se­da­tion well and re­turned to his stall, look­ing re­laxed and un­af­fected by the pro­ce­dure.

The geld­ing wasn’t ready to go home, though. The fol­low­ing morn­ing, NoutLo­mas again threaded the gas­tro­scope down to his stom­ach. “The ini­tial idea was to go back in and see how bad things looked---to see what the dam­age was from the day be­fore.” To her sur­prise, how­ever, the area looked great. “It was re­mark­able; the area was flat and pink and not at all ex­tremely ir­ri­tated,” she says. “All it needed was some time.” The team was so en­cour­aged that they de­cided to take an ad­di­tional se­ries of cau­ter­ized cuts, re­mov­ing an­other 30 per­cent of the mass for a to­tal re­moval of 70 per­cent. Al­bert, once again, came out of se­da­tion un­event­fully.

Mean­while, the pathol­ogy re­sults from the first pro­ce­dure con­firmed that the mass was, in­deed, a be­nign polyp with no deeper tu­mor tis­sue. All of this was great news, but only in time would they know whether the pro­ce­dure would re­solve Al­bert’s di­ges­tive is­sues and gen­eral grumpi­ness.

Pifer loaded up her geld­ing and headed for home.

Pifer knew right away that the pro­ce­dure had worked. “Al­bert was his old, cheer­ful self al­most im­me­di­ately,” she says. “And the first time I saw solid ma­nure I was so ex­cited. I was just blown away.”

A few weeks later, she started rid­ing the geld­ing again and found him to be as will­ing and for­ward as he had been be­fore his trou­bles be­gan. She would bring him back to CSU sev­eral times in the com­ing months for re-checks, and at each visit, the polyp area looked calm and healed, with no re­growth.

“The area ac­tu­ally con­tracted a bit so it looked like there was never a polyp there at all,” says Nout-Lo­mas. “It was an ex­tremely sat­is­fy­ing re­sult. The polyp could the­o­ret­i­cally grow back, but right now we have no rea­son to think it will.”

More than a year later, Al­bert is in full work, be­ing rid­den four times a week and start­ing back over fences. “He’s my happy guy again,” says Pifer. “I go out to catch him in the field and he comes right up to me. He’s not run­ning the other way. I feel bad that he felt so bad for so long, and that it took us a while to fig­ure it out, but he’s Al­bert again, and it’s fan­tas­tic.”

The pathol­ogy re­sults con­firmed that the mass was in­deed a be­nign polyp. This was great news but only in time would the team know whether the pro­ce­dure would re­solve Al­bert’s di­ges­tive is­sues and gen­eral grumpi­ness.

GUNG HO: One sign of Al­bert’s dis­com­fort was an un­will­ing­ness to work, a sig­nif­i­cant de­vel­op­ment in a nor­mally game com­peti­tor.

RE­SOLVED: Dur­ing a com­plete gas­troscopy, ve­teri­nar­i­ans dis­cov­ered a polyp in the py­lorus, the area of the stom­ach just in front of the small in­tes­tine ( left). After a del­i­cate pro­ce­dure to re­move the growth ( right), Al­bert’s gas­tric dis­com­fort dis­ap­peared. out­flow to small in­tes­tine

body of stom­ach duo­de­num py­lorus

out­flow to small in­tes­tine

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