Gastric Ulcers Articles

Equine Gastric Ulcers: Special Care and Nutrition

Equine Gastric Ulcer Syndrome

Equine Gastric Ulcers: Special Care and Nutrition
by Scott McClure, DVM
Why do horses get ulcers?
Equine gastric ulcers affect up to 90 percent of racehorses and 0 percent of sho! horses" Ulcers
are the result of the erosion of the lining of the stomach due to a prolonged e#posure to the
normal acid in the stomach" Unli$e ulcers in humans% &acteria do not cause equine gastric ulcers"
' horse(s stomach continually secretes acid% !hich can result in e#cess !hen the horse is not
eating regularly due to there &eing no feed to neutrali)e the acid" *orses are designed to &e
gra)ers !ith regular inta$e of roughage"
+he horse(s stomach is di,ided into t!o parts" +he &ottom part is glandular that secretes acid and
has a protecti,e coating to $eep it from &eing damaged &y acid" +he top portion of the stomach is
designed for mi#ing of the contents of the stomach and does not ha,e as much protection from
the acid" +his is the most common place to find ulcers"
*orses at -is$
Ulcers are a man.made disease" Stall confinement alone can lead to the de,elopment of ulcers"
When horses are fed t!o times per day% the stomach is su&/ected to a prolonged period !ithout
feed to neutrali)e the acid" 0urthermore% high.grain diets produce ,olatile fatty acids that can
contri&ute to the de,elopment of ulcers"
Stress 1&oth en,ironmental and physical2 can also increase the li$elihood of ulcers" *auling%
mi#ing groups of horses and training can lead to ulcers" Strenuous e#ercise can decrease &oth
the emptying function of the stomach and &lood flo! to the stomach% thus contri&uting to the
pro&lem"
0inally% chronic administration of non.steroidal anti.inflammatory drugs such as phenyl&uta)one
can decrease the production of the protecti,e mucus layer% ma$ing the stomach more suscepti&le
to ulcers"
Symptoms
+he ma/ority of horses !ith gastric ulcers do not sho! out!ard symptoms" +hey ha,e more su&tle
symptoms% such as a poor appetite% decreased performance and a poor hair coat" 3ore serious
cases !ill sho! a&dominal pain 1colic2"
4iagnosis
+he only !ay to definiti,ely diagnose ulcers is through gastroscopy% !hich in,ol,es placing an
endoscope into the stomach and loo$ing at its surface" +o allo! this% the stomach must &e empty%
so most horses are held off feed for si# to 56 hours and not allo!ed to drin$ !ater for t!o to three
hours" With light sedation% the endoscope is passed through the nostril and do!n the esophagus
into the stomach" +he light and camera on the end of the endoscope allo!s the ,eterinarian to
o&ser,e the lining of the stomach"
+reatment and 7re,ention
+reatment is aimed at remo,ing predisposing factors and decreasing acid production" When
possi&le% horses should &e allo!ed free.choice access to grass or hay" En,ironmental factors
should &e addressed" *orses that must &e stalled should &e arranged so they can see and
sociali)e !ith other horses" Some horses appear to en/oy ha,ing a &all or other o&/ect in the stall
to occupy their time"
3ore frequent feedings !ill help &uffer the acid in the stomach" 4ecreasing types of grain that
form the ,olatile fatty acids may help some horses" +he energy from the grain can &e replaced &y
using a feed higher in fat" 8n horses !ith lo!er caloric needs% free.choice grass hay !ith the
appropriate ,itamin and mineral supplements !ill help"
3edication to decrease acid production is only necessary in horses sho!ing clinical disease or
!hen the predisposing factors cannot &e remo,ed% such as !ith some horses in race training"
While antacids sound li$e a good idea% to &e effecti,e% they !ould need to &e administered si# to
56 times a day" 'ntacids in feeds are relati,ely ineffecti,e since they are ingested at the same
time as the feed% !hich !ill &uffer the acid" 3ultiple medications are a,aila&le to decrease acid
production" +he most effecti,e treatment is 9mepra)ole% !hich decreases acid production for up
to 6: hours"
7re,ention of ulcers is $ey" ;imiting stressful situations% frequent feedings and free.choice access
to grass or hay is imperati,e" +his pro,ides a constant supply of feed to neutrali)e the acid and
stimulate sali,a production% !hich is nature(s &est antacid" When this is not adequate or possi&le%
horses at greatest ris$ !ill &enefit from medication to decrease acid production"
posted: :<5<600:" ;ast updated: =<5><600?"

Equine Gastric Ulcer Syndrome
by Fran M! Andre"s, DVM, MS, DACV#M
Gastric ulcer disease is common in foals and horses and the term Equine Gastric Ulcer
Syndrome 1EGUS2 has &een used to descri&e this disease &ecause of its many causes and
complicated nature" 7re,alence estimates ha,e &een reported to range from 6?@ to ?0@ in foals
and 0@ to 90@ in adult horses% depending on age% performance% and e,aluated populations"
Gastric ulcers ha,e &een identified in the non.glandular stratified squamous mucosa% margo
plicatus% glandular mucosa% and pyloric regions of the equine stomach" +!o age related clinical
syndromes ha,e &een descri&ed% one in foals 1A 9 months of age2 and the other in yearlings and
adult horses 1B 9 months of age2" 'lthough ulcers are similar in foals and horses% the syndromes
frequently ha,e different inciting causes and may produce different clinical signs" ' diagnosis of
these clinical syndromes relies on recognition of clinical signs and endoscopic e#amination of the
stomach"
+he *orse Stomach
+he horse stomach is di,ided into t!o distinct regions% the esophageal or non.glandular region
and the glandular region" +he esophageal region or squamous mucosa co,ers appro#imately
one.third of the equine stomach% is ,oid of glands% and is co,ered &y stratified squamous
epithelium similar to the esophagus" +he glandular region co,ers the remaining t!o.thirds of the
stomach and contains glands that secrete hydrochloric acid% pepsin% &icar&onate% and mucus" '
sharp demarcation or margo plicatus 1cuticular ridge2 separates the squamous mucosa from the
glandular mucosa" Gastric ulcers in foals 1less than ?0 days of age2 and adult horses are
commonly located in the non.glandular region of the stomach ad/acent to the margo plicatus
along the greater cur,ature and lesser cur,ature" *o!e,er% foals and adult horses !ith a
concurrent medical disorder or &eing gi,en non.steroidal anti.inflammatory drugs 1NS'84s2 1Cute
or Canamine2 may ha,e gastric ulcers located in the glandular region of the stomach near the
pylorus" 0oals% and to a lesser e#tent in adult horses% may ha,e duodenal ulcers% !hich may lead
to gastric and esophageal ulcer% secondary to delayed gastric emptying"
+he horse stomach continuously secretes ,aria&le amounts of hydrochloric acid throughout the
day and night and secretion of acid occurs !ithout the presence of feed material" 0oals secrete
gastric acid as early as 6.days.of.age and acidity of the gastric fluid is high" *igh acid in the
stomach may predispose foals to EGUS"
+he adult horses% the stomach secretes appro#imately 5"? liters of gastric /uice hourly and acid
output ranges from : to 0 mmoles hydrochloric acid per hour" +he p* of gastric contents ranges
from 5"? to ="0% depending on region measured" ' near neutral p* can &e found in the dorsal
portion of the esophageal region 1saccus cecus2 near the lo!er esophageal sphincter% !hereas%
more acidic p*s can &e found near the margo plicatus 1D"0."02 and in the glandular region near
the pylorus 15"?.:"02" Gastric emptying of a liquid meal occurs !ithin D0 minutes% !hereas
complete gastric emptying of a roughage hay meal occurs in 6: hours"
Causes of Clinical Syndromes of Gastric Ulceration in 0oals and *orses
Equine Gastric Ulcer Syndrome in foals and horses results from a disequili&rium &et!een
mucosal aggressi,e factors 1hydrochloric acid% pepsin% &ile acids% organic acids2 and mucosal
protecti,e factors 1mucus% &icar&onate2" Since mucosal protecti,e factors are more de,eloped in
the glandular mucosa of the equine stomach !hen compared to the squamous mucosa% different
causati,e mechanisms may lead to ulceration in these regions" Ulcers in the squamous mucosa
are primarily due to prolonged e#posure to hydrochloric acid% pepsin% &ile acids or organic acids"
Ulcers occurring in this region are similar to Gastroesophageal -eflu# 4isease Syndrome
1GE-4S2 in humans% since this region lac$s !ell.de,eloped protecti,e factors% similar to the
esophagus" +he se,erity of squamous ulcers is pro&a&ly related to length of time of acid
e#posure" +he squamous mucosa near the margo plicatus is constantly e#posed to these acid
and this region is !here gastric ulcers are frequently found in foals and horses"
Ulcers in the glandular mucosa are primarily due to disruption of &lood flo! and decreased mucus
and &icar&onate secretion% !hich results in &ac$ diffusion of hydrogen ions and damage to the
underlying su&mucosa" 8nhi&ition of prostaglandins may play a ma/or role in the pathogenesis of
gastric ulcers in the glandular region of the equine stomach"
Gastric ulceration in the squamous mucosa is directly related to the degree and se,erity of gastric
acid e#posure" Se,eral factors ha,e &een implicated in causing ulceration and these include%
fasting% gastric acid clearance 1gastric motility and emptying2% aggressi,eness of the gastric /uice
1acid% pepsin% &ile acids% organic acids2 and the process of desquamation" 0asting is an important
factor in causing ulcers in the squamous mucosa in foals and adult horses" 8n foals% infrequent or
interrupted feeding and recum&ency has &een sho!n lead to lo!er gastric fluid p* in foals" +hese
findings suggest that mil$ may ha,e a &uffering effect on gastric acid and recum&ency may
increase e#posure of the squamous mucosa to acid" ;o! gastric p* from interrupted or
infrequent nursing may play a role in the cause of squamous ulceration in foals"
0eed depri,ation has &een sho!n to cause ulcers in the squamous mucosa of horses% !hich is
due to repeated e#posure of the squamous mucosa to high acidity" 8n yearling and adult horses%
hay and sali,a 1rich in sodium &icar&onate2% may help &uffer gastric hydrochloric acid" +he timing
of feeding and the type of roughage source may contri&ute to gastric ulceration in yearling and
adult horses" 8n a study% horses fed hay continuously had less acidity% !hen compared to horses
that !ere fasted" 8n another study% horses fed alfalfa hay had significantly less acidity and lo!er
gastric ulcer scores% than horses fed &romegrass hay" *igh protein 165@2 and calcium
concentration in alfalfa hay pro,ides &uffering of stomach acid up to ? hours after feeding" 'lso%
high roughage diets stimulate production of &icar&onate rich sali,a% !hich may contri&ute
&uffering of gastric acid"
Gastric motility and emptying may play a role in squamous mucosal ulcers in foals and horses" 8n
humans !ith GE-4S% acid clearance time and consequent e#posure of the esophageal mucosa
to potentially in/urious agents is in,ersely proportional to the rate of gastric esophageal and
gastric motility" 4elayed gastric emptying or decreased gastric motility could potentially increase
e#posure of the squamous mucosa to gastric /uice and other aggressi,e factors leading to
ulceration" 8n neonatal foals !ith concurrent disease or !ith a gastric outflo! o&struction%
decreased gastric motility and<or delayed gastric emptying may lead to prolonged acid e#posure
and ulceration% especially during periods of squamous cell desquamation"
8n adult horses% the pre,alence of gastric ulcers is high in the performance horse and may &e due
to prolonged e#posure of acid to the squamous mucosa" +he mechanical aspects of e#ercise and
the a&dominal pressure may &e sufficient to pro,ide prolonged e#posure of the non.glandular
mucosa to aggressi,e factors" 0urthermore% especially in racehorses that perform at near
ma#imal le,els% e#ercise may ha,e an inhi&itory effect on gastric emptying" 4ecreased gastric
and esophageal motility and delayed gastric emptying ha,e &een implicated in the cause of
GE-4S in humans during e#ercise and may lead to gastric ulceration in the performance horses%
especially the racehorse" 9ther organic acid may act synergistically !ith hydrochloric acid to play
a role in the pathogenesis of gastric ulcer disease in horses" -ecently% ,olatile fatty acids 1E0's2%
fermentation &yproducts of car&ohydrates% !ere found to induce acid in/ury to the
gastroesophageal 1squamous2 mucosa of horses" +he E0's easily penetrate the squamous
mucosa of the stomach !hen acid concentrations are high" +hese E0's enter the stomach tissue
causing cell damage% inflammation and ulceration" 8n a pre,ious report% E0's !ere found to &e
present in the stomach of horses in significant enough quantities to lead to acid in/ury" Since
performance horses are fed diets that are high in fermenta&le car&ohydrates% E0's% generated &y
resident &acteria% may cause acid in/ury and ulceration in the squamous mucosa"
9ther gastric aggressi,e factors such as% Cile salts% from duodenal reflu# and pepsin% ha,e &een
implicated in causing gastric ulcer disease in other species and possi&ly the horse" Cile acids% in
com&ination !ith pepsin act to increase the permea&ility of the esophageal mucosa to hydrogen
ions" 0urthermore% &ile acids ha,e &een sho!n to act synergistically and in a dose.dependent
manner !ith hydrogen ions to cause damage to the squamous mucosa of pigs" +hese studies
suggest that pepsin and &ile acids may contri&ute to the production of squamous ulceration in
horses"
8n foals% gastric ulceration may &e related to desquamation or FsheddingG of the squamous
epithelium of the stomach" 4esquamation of the squamous mucosa% occurs in >0@ of foals up to
D? days of age" 8n a study of rats% it !as found that the loss of epithelial cells along the margo
plicatus resulted in the increased suscepti&ility of this region to acid in/ury" 'lso% acid in/ury to this
region resulted in a delay in reepitheliali)ation" 4elayed reepitheliali)ation could result in acid
in/ury of the deeper layers from hydrochloric acid and lead to gastric ulceration"
Glandular gastric ulcers occur most frequently in foals% &ut can occur in adult horses" +he cause
of glandular gastric ulcers is most li$ely due to decreased &lood flo! and decreased mucus and
&icar&onate secretion" 4ecreased prostaglandin synthesis 1primarily 7GE6% 8 and '2 has &een
implicated in the cause of glandular gastric ulcers in foals% since non.steroidal anti.inflammatory
drugs 1NS'84s2 administration caused gastric ulcers in foals" Cloc$ing prostaglandin synthesis
causes deceased mucosal &lood flo!% stimulates gastric acid secretion% and inhi&its &icar&onate
secretion &y the glandular mucosa" 7rostaglandins may also help maintain the integrity of the
squamous and glandular mucosa &y stimulating production of surface.acti,e protecti,e
phospholipid% stimulating mucosal repair% and pre,enting cell s!elling &y stimulating sodium
transport" 0uthermore% stress of parturition in foals and stress of training and confinement in
horses% may also lead to e#cess release of endogenous corticosteroid% !hich can inhi&it
prostaglandin synthesis" ' decrease in prostaglandins leads to a &rea$do!n in mucosal
protecti,e factors and may &e the primary cause of glandular gastric ulcers in foals and horses"
4iagnosis
+he diagnosis of EGUS is &ased on the presence of clinical signs and confirmation !ith
endoscopic e#amination" Clinical signs in foals include intermittent colic 1after suc$ling or eating2%
frequent dorsal recum&ency% intermittent nursing 1interrupted nursing due to discomfort2% diarrhea
or history of diarrhea% poor appetite% &ru#ism 1grinding of teeth2% and ptyalism 1e#cess sali,ation2"
+he later t!o signs are often signs of an outflo! o&struction% such as pyloric o&struction"
Clinical signs in other horses include poor appetite or failure to consume a meal% dullness%
attitude changes% poor appetite% decreased performance% reluctance to train% poor &ody condition%
rough hair coat% !eight loss% e#cessi,e recum&ency% and lo!.grade colic" ' presumpti,e
diagnosis of EGUS can &e made on these typical clinical signs and response to therapy"
' definiti,e can only &e made using a ,ideo or fi&reoptic endoscope" +he endoscope must &e at
least = feet long" ' longer endoscope 155 feet2 is necessary to o&ser,e the duodenum in adult
horses" ' shorter scope 1?. feet2 is sufficient to see the stomach of foals"
+reatment
8nhi&iting gastric acid secretion is the mainstay of gastric ulcer treatment in horses" ' num&er of
treatment modalities ha,e &een used for treatment and pre,ention of gastric ulcers in horses and
foals" Currently% there is only one 04' appro,ed treatment for gastric ulcers in horses%
GastroGard 19mepra)ole paste% 3erial ;imited% 'tlanta% G'2" *o!e,er% many treatment
modalities ha,e &een descri&ed in the literature"
GastroGard 19mepra)ole2 is one of the most studied medication in horses" 8t is an Facid pump
inhi&itorG and inhi&its gastric acid secretion regardless of the stimulus" GastroGard is a paste and
is gi,en to horses once daily for 6> days to treat EGUS" 8t is also la&eled for pre,ention of
recurrence of gastric ulcers at H dose" +he medication contained in GastroGard is the same
medication found in the F7urple 7illG 7rilosec that is currently sold to humans for treatment of
gastric ulcers"
posted: D<D5<600D" ;ast updated: D<D5<600D"