Stomach and Colonic Ulcers: A pain in the Gut

1. Stomach and Colonic Ulcers: A pain in the Gut!!

Frank M. Andrews, DVM, MS
Diplomate ACVIM
Professor and Section Chief
Large Animal Medicine

2. Equine Gastric Ulcer Syndrome (EGUS)

Esophagus, Stomach and Duodenum
Prevalence: 40% to 93% in performance horses

3. Equine Gastric Ulcer Syndrome (EGUS)

Prevalence in Foals 25% to 51%
Prevalence in breeding Stock?
– Pregnant women (↑ progesterone)
– Less gastric acid
– more mucus
• Less gastric ulcers
• 66% develop heartburn
– Decrease LES tone
Stress??

4. Equine Gastric Ulcer Syndrome (EGUS)

Prevalence in breeding
Stock?
– Pregnant women at Risk
• Previous gastric ulcer
disease
• Smokers
Trans Global Chronicle™

5. Impact of EGUS on Horses

Results in poor body
condition
Poor performance?
Can cause colic
Can have severe
complications
– duodenal strictures

6. Impact of EGUS on Foals

• Gastric outflow
obstruction
• Esophagitis
• Chronic ulceration
• Perforation (rupture)
& peritonitis
Photos courtesy of MJ Murray.

7. The Stomach of the Horse

Nonglandular region
(squamous epithelium)
Esophagus
Duodenum
Margo plicatus
Pylorus
Glandular region
(glandular epithelium)

8. Cause of EGUS: Aggressive Factors Overpowering Defensive Factors

Gastric lining damage occurs when:
Aggressive (acid, pepsin, bile,
organic acids) factors overpower
Defenses (bicarbonate, mucus)
of gastric mucosa
Squamous mucosa lining lacks these
defenses
Murray, Equine Vet J Suppl, 1992; Sweeney, In Practice, 1992; Pagan,
World Equine Vet Rev, 1997; Murray and Schusser, Equine Vet J, 1993.
SM
MP
GM

9. Risk Factors for EGUS: Feeding

• Feeding management
– Low prevalence of ulcers in horses at
pasture
– Decreased acid when roughage available
Murray et al, Equine Vet J, 1996.

10. 24-Hr Gastric pH: No Feed

7
6
5
Good
4
pH
Bad
3
2
1
0
0
6
12
Hours
Murray and Schusser, Equine Vet J, 1993.
18
24

11. 24-Hr Gastric pH: Free Choice Grass Hay

8
7
6
5
pH
Good
4
Bad
3
2
1
0
0
6
12
Hours
Murray and Schusser, Equine Vet J, 1993.
18
2
4

12. Hydrochloric Acid

• Gastric acidity is high in empty stomach
• Intermittent feed deprivation
– Lesions form in squamous mucosa
– No lesions form in glandular mucosa
– Lesions prevented by ranitidine (Zantac®)
Day 0
48 hours
96 hours
Murray and Schusser, Equine Vet J, 1993; Murray and Eichorn, Am J Vet Res, 1996.

13. Effect of Alfalfa Hay

Rebound Hyperacidity
Buffering effect
6
a
pH
5
b
a
a
a
4
3
a
b
2
b
b
b
Alf/gra
1
Brome
0
0
1
2
3
4
5
6
7
8
10
12
Time (hrs)
Nadeau JA, Andrews FM, Mathew AG, et al. AJVR 61(7): 784-790, 2000.
24

14. Results: Gastric ulcer Number and Severity Score

1.5
1
b
Change in score
0.5
b
0
-0.5
NG Lesion#
G Lesion#
NG Severity
G Severity
-1
a
-1.5
-2
a
-2.5
Nadeau JA, Andrews FM, Mathew AG, et al. AJVR 61(7): 784-790, 2000.
Alfalfa/grain
Bromegrass

15. Feed Analysis

Feed
(mg/g)
% DM
% CP
*Ca (mg/g) *P
Grain
99.8
14.81
3.2**
Alfalfa
94.52
20.85 14.1***
Brome
95.51
7.55
*on a dry matter basis
7.4**
0.56**
***2.1
6.22**
** estimated from later feed analysis
*** estimated from NRC
Nadeau JA, Andrews FM, Mathew AG, et al. AJVR 61(7): 784-790, 2000.

16. Risk of Grain Feeding

• Fermentation of
grain by resident
bacteria and
production of byproducts
– VFAs, Lactic Acid,
and Alcohols?
• Lactobacillus spp.
Isolated
• HCl!!
Yuki N, et al. Appl. Env. Micro. 2000;66:5030-5034.
Scott PT et al. Recent Adv. An. Nut. Au. 2003;14:24A.

17. Risk Factors for EGUS: Training/Racing

• Intensive exercise
– Reduced blood flow to the stomach lining?
– Increased gastric acidity?
– Altered eating behavior?
March 25
June 3

18. Acids forced into the proximal stomach

Increased intra-abdominal pressure during intense exercise causes
gastric compression, pushing acid contents into proximal stomach
Pregnancy??
HCl,VFAs
Bile acids
Lorenzo-Figueras and Merritt, AJVR 2002;63:1481-1487

19. Risk Factors for EGUS: Stress

1.
Physical stress
–
–
–
2.
Illness
Painful musculoskeletal disorder
Endometritis?
Behavioral stress
–
–
–
Stall confinement
Transport
Unfamiliar environment,
social regrouping

20. Risk Factors for EGUS: Non-Steroidal Anti-Inflammatory Drugs

Phenylbutazone & Flunixin Meglumine
and other NSAIDs
Associated with ulcers throughout the
intestinal tract (Cecum & Colon)
Inhibit prostaglandins, interrupting
mucosal blood flow
and mucus
Local toxicity
Murray, Vet Med, 1991.

21. Clinical Signs of EGUS in Horses

• Poor appetite
• Poor body condition
• Attitude changes
• Decrease in performance
• Mild to moderate colic
Murray, AAEP, 1997.

22. Clinical Signs of EGUS in Foals

Poor appetite or intermittent nursing
Colic
Poor body condition
Frequently lies on back
Bruxism (grinding of teeth)
Excessive salivation (Ptylism)
Diarrhea
Murray, Vet Med, 1991.

23.

24. How can you tell that a horse has EGUS? (Diagnosis)

Clinical signs are
suggestive of, but not
specific for, EGUS
Lab: Mild anemia
Response to treatment
can be useful
Gastric endoscopy is
only definitive
diagnostic tool

25. Fecal Occult Blood Test (Pellegrini et al, JEVS, 2005.)

• Guaiac Test
Negative test
Positive test

26. Treatment of EGUS

• Eliminate clinical signs
• Promote healing
• Prevent complications
• Prevent recurrences
MacAllister, Vet Med, 1995.

27. Two Approaches to Treatment

• Management modifications
• Medical therapy-approaches that have
been used
– Control gastric acid
– Mucosal protectants
Murray, AAEP, 1997;
MacAllister, Vet Med, 1995.

28. Traditional Management Modifications

• Reduce level of Breeding?

29. Traditional Management Modifications

• Diet modifications
– Limit periods of fasting
– Increase roughage
• pasture turnout (green grass)
• free choice hay
• Alfalfa hay-dietary antacid
• Calcium Carbonate supplements
– Reduce grain/concentrates
Seahorn, LSU Equine Vet Res Program Newsletter, 1998; Pagan, World Equine Vet Rev, 1997.

30. Conclusions: Recommendations

• Roughage should be provided throughout
day and night
– Alfalfa hay/mixed alfalfa hay may help buffer
stomach contents
• Concentrates should be fed in small
amounts, distributed in at least 3 feedings
throughout day (base on requirements?)
• Concentrates should not exceed 0.5 kg of
grain per 100 kg body weight
Coenen M. Schweizer-Archiv-fur-Tierheilkunde, 1990, 132:121-126.

31. Dietary Management: Corn oil

• Decreases stomach acid
• Increases
(Cargile et al, JVIM 2004)
protective factors (PG)
• Provides Omega
3 & 6 fatty acids
• 8 oz once to
twice daily

32. Dietary Management: Rice Bran or Rice Bran Oil

• Contains protective factors for
stomach lining (phospholipids)
• Rancidity can be a problem
– Produces ketoaldehydes which are
ulcerogenic
• Steam pasteurization can help
decrease potential for rancidity
– Storage in refrigerator

33. Management Modifications

Limit stressful events
Long-term stall
confinement
Trailering
Overcrowding
Semen collection and
natural breeding?

34. Medical Management of EGUS

Neutralizing agents
– Antacids
Antisecretory agents
– Histamine H2 receptor
antagonists (Zantac™)
– Acid pump inhibitors
(GastroGard™)
Others (antibiotics,
neutriceuticals)
MacAllister, Vet Med, 1995.

35. UlcerGard (Prevention)

UlcerGard (Prevention)
• Prevention of ulcers 1 mg/kg
• Non-prescription strength
of GastroGard
• Sold through veterinarians

36. Misoprostol (Cytotec™)

• Synthetic prostaglandin E1
• Decreased free acid and
increased pH in stomach of
horses
Sangiah et al. Res. Vet. Sci, 1989
• Do not administer to pregnant
mares!!!
• 5 µg/kg, orally, Q8h

37. Antibiotic Treatment

Primarily used in humans with
Helicobacter pylori
Colonization of ulcer bed (rat)
– Bacteria rapidly colonize ulcer
bed and decrease ulcer healing
Elliott et al. Am. J. Physiol. 1998;275:G425-32
H. pylori has been associated with
the stomach of horses, but not
EGUSScott DR, Marcus EA, Shirazi-Beechey SSP, et al. Evidence of
Helicobacter infection in the horse. Proc Am Soc Microbiology 2001.
Antimicrobials may be used in horses
with resistant EGUS (TMS, Metronidazole,
Bismuth compounds)

38. Feed Supplements (Neutriceuticals)

NeighLox® (Kentucky Performance Products)
Antacid and Coating Agents:
– Aluminum Phosphate, Calcium Carbonate
– Dihydroxy-Aluminium
Sodium Carbonate
Labeled for prevention
of heartburn
No studies in horses
to prove or disprove
Probably does not
cause any harm

39. Other Feed Supplements (Neutriceuticals)

• G.U.T (Uckele Health &
Nutrition)
• TractGard (Foxden Equine)
• No studies proving efficacy

40. Conclusions

• EGUS is a major cause of illness in
performance horses and foals
Pregnant mares and breeding stallions??
Impacts health, performance, economics
Effective treatment entails both
environmental and dietary management
and medical interventions

41. Conclusions- Treatment

• Treatment may be needed to
decrease clinical signs and heal
ulcers
• Dietary supplements-not tested
• Consult your veterinarian before
treating pregnant mares and
breeding stallions!!

42. Colonic Ulcers and Right Dorsal Colitis (General)

Ulceration in the Large
Intestine
– (Right Dorsal Colon)
Cause
– Parasites
– Infectious agents (Salmonella)
– Inflammation of the Intestine
• IBD, Cancer?
– NSAIDs
– Stress
Pellegrini FL. JEVS 25(3), 2005

43. Colonic Ulcers and Right Dorsal Colitis (Diagnosis)

• History:
– Recurrent episodes of loss of appetite, lethargy,
colic, weight loss, and diarrhea
– Chronic administration of NSAIDs (especially
phenylbutazone)
– Intensive breeding or pregnancy
– Painful musculoskeletal problems or uterine
infection

44. Colonic Ulcers and Right Dorsal Colitis (Diagnosis)

• Physical Exam and Clinical Signs:
– Normal between episodes
– May present with acute abdominal pain
– Lethargy, partial anorexia (icteric MM),
intermittent fever, colic, diarrhea,
dehydration, congested mucus membranes,
edema, vaginal discharge
– Rectal examination: thick edematous colon
– Weight loss, thin body condition with chronic
disease

45. Colonic Ulcers and Right Dorsal Colitis (Diagnosis)

• Gastroscopy to rule out gastric ulcers
– May have concurrent disease

46. Colonic Ulcers and Right Dorsal Colitis (Diagnosis)

Pellegrini FL. JEVS 25(3), 2005

47. Colonic Ulcers and Right Dorsal Colitis (Diagnosis)

• Ultrasonographic
examination:
Jones et al. JAVMA 222(9), 2003

48. Colonic Ulcers and Right Dorsal Colitis (Diagnosis)

Changes on blood work:
– Anemia (usually mild)
– High WBC count
– Low blood protein
– Low blood calcium
• Fecal cultures
• Fecal floatation (parasites)

49. Fecal occult blood test

Fecal occult blood positive (guaiac-based)
Pellegrini FL. JEVS 25(3), 2005

50. Ruling out causes

• Large bowel colic, displacement
• EGUS
• Exploratory Abdominal Surgery
– Biopsy of intestine
• If Diarrhea present
– Salmonellosis, IBD, Cancer

51. Colonic Ulcers and Right Dorsal Colitis (Treatment)

• Principles:
– Treat the underlying cause
– Avoid NSAIDs (especially phenylbutazone)
– Decreasing the bulk (mechanical and
physiologic load on colon) in the GI tract
• Restricting or eliminating hay from the diet
• Frequent feedings
– Coating and repair of the colon
– Implement methods to decrease stress

52. Colonic Ulcers and Right Dorsal Colitis (Treatment)

– Frequent feedings (4 to 6 X
daily) of complete pelleted
diet with at least 30%
dietary fiber
– Reduction or elimination of
hay from diet
– Grazing should be limited
to 10 to 15 minutes 2 to 3
times daily??
16 to 19 lbs/horse/day
Light to Moderate Work

53. Right Dorsal Colitis (Treatment)

Sucralfate
Aluminum salt of sucrose
octasulfate
– Partially disassociates and
forms bridges with
aluminum hydroxide and
coats ulcer bed
– Fortifies the mucus coating
– Diminishes bacterial growth
– 22 mg/kg, PO, Q6h-Q12h
www.Gastrafate.com

54. Right Dorsal Colitis (Treatment)

Psyllium Mucilloids
– Shortens transit time of
ingesta
– Increases colonic
concentration of short
chain fatty acids and
promote healing
– 1 cup orally twice daily
Premium Psyllium Supplement
50 lbs/$129.00
Metamucil can be substituted!!

55. Right Dorsal Colitis (Treatment)

Corn or Flaxseed oil
– Supplies Omega-3
fatty acids to colon
– Improves healing??
– Increases energy for
weight gain
– 1 cup orally twice
daily

56. Colonic Ulcers and Right Dorsal Colitis (Treatment)

Probiotics and Digestive aids
Polar Lipids – components of oat oil,
help transport nutrients into the blood
stream and support a healthy gut lining.
Soluble Oat Fiber – supports a healthy
immune system while evening out the
Succeed™
rate of digestion and nutrient absorption
for even blood sugar levels and reliable energy.
Yeast Extracts – support normal levels of digestive
microbes in a healthy hindgut.
Amino Acids – building blocks of proteins, support a
healthy mucous lining throughout the digestive tract.

57. Right Dorsal Colitis (Treatment)

Reduce Stress and Dehydration
– Discontinue or decrease strenuous
exercise
– Decrease transport
– Provide good quality water
• Flavor or sweeten water to increase
palatability
• Add salt or electrolyte paste to grain or
pellets to increase water consumption

58. Right Dorsal Colitis (Treatment)

Length of Treatment and Prognosis
– Resolving clinical signs
– Monitor PCV and plasma proteins
(especially albumin) every week to 1-2
weeks or more frequent if needed
– Serial ultrasonographic examinations
(5 weeks after initiation of treatment)
– 3 to 4 months
– Good to Guarded depending on duration
and severity