Wendy Harless Mollat, DVM, DACVIM

Board Certified Large Animal Internal Medicine wmollat@pilchuckvet.org

Equine Gastric Ulcer Syndrome

Equine Stomach Anatomy and Physiology Clinical Signs How Ulcers Form Key Risk Factors Diagnosing and Classifying Ulcers Treatment Options Prevention Questions?

Equine Gastric Ulcer Syndrome

Very similar to Gastric Esophageal Reflux Disease in humans Very prevalent in performance horses of any discipline

Prevalence and Impact

At least 90% of race horses At least 60% of performance horses
Most all competitive horses will suffer from an ulcer sometime in their competitive career

25 57% of foals have ulcers

These are potentially fatal if clinical illness is present

Significantly affects condition and performance

Murray et al, Equine Vet J, 1989 &1996; Murray, JAVMA, 1989; Murray, AAEP, 1997.

Gastric Ulcers in Foals

Foals
Ulcers develop very quickly in foals and can be fatal Clinical Signs:
Poor appetite or intermittent nursing Colic Poor body condition Frequently lies on back Teeth grinding (bruxism) Excessive salivation (ptyalism) Diarrhea

Murray, Vet Med, 1991.

Stomach Anatomy
Healthy Stomach Ulcerated Stomach

Stomach Anatomy
Esophagus:
Squamous lining

Squamous Mucosa:
80% of ulcers occur here; highly susceptible to injury

Duodenum:
outflow to small intestine

Margo Plicatus:
area of fluid line in stomach; ulcers usually start in this region

Glandular Mucosa: well protected

from damage; 20% of ulcers occur here

Basic Stomach Physiology

Acid Secretion in the horse:
Occurs 24 hours a day/ 7 days a week Adult horses produce up to 4 gallons/day Even foals as young as 2 days of age have high levels of acid detected in stomach

Other factors that contribute to ulcers:

Hydrochloric Acid Pepsin Weak Organic Acids Bile Salts

How Ulcers Form

Protective Mechanisms

Erosive Mechanisms

Protective Mechanisms
Salivary flow Grass or continuous hay Cell turnover within stomach Mucosal blood flow Mucus/Bicarbonate barrier

Erosive Mechanisms
Gastric acid (hydrochloric acid) always there! Feed deprivation Pepsin Reduced blood flow to stomach lining Intense exercise High grain diets

Risk Factors
Eating and Feeding Patterns Exercise Transportation Stress

Eating and Feeding Patterns

Episodic feeding: feeding 1X, 2X or 3X/ day Withdrawal of feed prior to work Diet selection: Grain & concentrate vs. hay/grass Change in feeding routine, particular when traveling

Feed Deprivation Model

0 hours

48 hours

96 hours

Murray and Schusser, Equine Vet J, 1993; Murray and Eichorn, Am J Vet Res, 1996.

24 hour Gastric pH No Feed

7

GOOD
6 5 4

pH

2
1 0 0 6 12 18 24

Bad

Hours
Murray and Schusser, Equine Vet J, 1993

24 hour Gastric pH Free Choice Grass Hay

8 7 6 5

Good

pH

4 3 2 1 0 0 6 12 18 24

Bad

Hours
Murray and Schusser, Equine Vet J, 1993

Feed Types

Forage vs. Concentrates (grain)

Exercise

Gastric Volume with Exercise

Stress
Physical
Training/competition Illness Painful disorders Surgery Lameness Stall confinement Transport Unfamiliar environment Social regrouping

Behavioral

Stress & Transportation

5 Day Study:
Gastric ulcer development in horses in a simulated show or training environment

Study Protocol
20 ulcer-free APHA horses 10 trailered 4 hours

10 kept at home

Scoped before & after

Trailered back 4 days later

Fed oats + grass/alfalfa

Mild exercise 30 min 2x daily

McClure, et al, JAVMA, Vol 227, No. 5, Sept 1,2005; pp 775-777

Outcome of Study
10 kept at home Scoped at end of 5-day study 10 trailered horses

2 with ulcers

7 with ulcers

McClure, et al, JAVMA, Vol 227, No. 5, Sept 1,2005; pp 775-777

Results
Healthy stomach
5 days

Ulcerated stomach

Photos courtesy of MJ Murray

Clinical Signs
How would a horse owner recognize ulcers?
Weight loss Change in attitude/behavior or work ethic Intermittent colic Dull coat Poor doer Change in eating patterns Reluctance to perform Stiffness Lack of response to leg Holding their body in this case leading to back pain

Horses react to pain in a variety of ways

Diagnosis
Clinical Signs
Suggestive but not specific

Response to treatment Definitive Diagnosis = Gastroscopy

Requires a 3 meter scope Patient preparation Experience
Murray, Vet Med, 1991.

Gastroscopy

Classifying Squamous Ulcers

Grade 0 = normal stomach

Classifying Squamous Ulcers

Grade1 = hyperkeratosis

Classifying Squamous Ulcers

Grade 2 = small single or multi-focal ulcers

Classifying Squamous Ulcers

Grade 3 = large; single or multi-focal ulcers

Classifying Squamous Ulcers

Grade 4 = severe ulcers; often coalescing with deep areas

Glandular Ulcers
No current grading scale

Normal Pylorus

Pyloric ulcers

Glandular Ulcers

Classifying Ulcers
Biggest take away = NO CORRELATION BETWEEN CLINICAL SIGNS AND SEVERITY OF ULCERS!

Current Therapy Options

What are people using to treat gastric ulcers?

Current Therapy Options

Manage Gastric Acid
Antacids Sucralfate Histamine H2 Blockers Omeprazole

Goal of treatment: Control pH of stomach

Maintain pH above 4.0

At least 22 of every 24 hours

4.0

pH Scale

14

Acid

Neutral
(Water)

Alkaline

Lambert, Aliment Pharmacol Ther, 1997

Current Therapy Options

Treatments act at different sites
Site of Action
H2 antagonists

H2 (+)

ACh (+)

Gastrin (+)

Prostaglandins (-)

GASTROGARD
H+ H+

ACID PUMP

PARIETAL CELL

Sucralfate H+ Antacids CIH+

H+

MUCUS/BICARBONATE BARRIER
CIH+ CISTOMACH LUMEN

H+CI-

Antacids
Neutralized gastric acid Aluminum or magnesium hydroxide Large volumes (250ml) Very short term effect

Sucralfate
Aluminum salt of sucrose Binds to ulcer crater with appropriate pH Good adjunct therapy, especially for pyloric ulcers

Histamine H2 Blockers
Ranitidine*, cimetidine Prevents histamine from binding to H2 receptor in stomach Reduces stomach acid Variable absorption Short acting = three times per day dosing

Omeprazole
Proton (acid) pump inhibitor Must be absorbed in the small intestine into blood stream Very effective, but long treatment

Current Therapy Options

Compounded omeprazole products Two trials:
1st trial looking at active ingredient (omeprazole) in compounded products
Poor results

2nd trial looking at their efficacy

Horses on compounded product or GASTROGARD for 28 days under ulceragenic conditions Each group switched at the end of 28 days

UlcerGard vs. GastroGard

GASTROGARD (Rx)
Treatment of diagnosed ulcers (4 mg/kg once a day=full tube) 28 days following treatment for healing process (2mg/kg once a day=1/2 tube)

ULCERGARD (Non-Rx)
For true prevention of ulcers during stressful events: training, competition, transport, weaning, surgery, stall confinement, etc. (1 mg/kg once a day=1/4 tube)

Implications
1. Ulcers can happen fast 2. Multiple factors can lead to development of ulcers 3. Ulcers are not exclusive to high-performance horses

Questions?

Thank you!