Gastric Ulceration - Horse

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This article is still under construction.


Also known as: Gastroduodenal ulceration

Gastrointestinal ulceration
 Equine Gastric Ulcer Syndrome
 Peptic ulcer disease
 Equine Gastric Ulcer

See also: Gastric Ulceration - all species


Description

The term 'Equine gastric ulcer syndrome (EGUS)' is used to describe the disease complex associated with ulceration of the oesophageal, gastric or duodenal mucosa[1] in horses. When such damage is caused by acidic gastric juice, the defect is described as a 'peptic ulcer'.[1] Ulceration of either or both[2] regions of the gastric mucosa is one of the most important conditions of the equine stomach as it may limit performance[3] and compromise welfare.[4] The non-glandular (proximal or orad) region of the equine stomach is lined by stratified squamous mucosa and a glandular mucosa lines the distal (aborad) portion. The two regions meet abruptly at the margo plicatus[5], adjacent to where most ulcers occur.[1] Damage to these regions occurs via differing pathophysiological routes and varies in severity from inflammation, to cellular death and sloughing causing disruption of the superficial mucosa (erosion), penetration of the submucosa down to the level of the lamina propria[1](ulceration), full thickness ulceration (perforation)[5] and potentially duodenal stricture.[6] The occult nature of the disease typically precludes the observation of clinical signs until severe ulceration has developed.[1]

Prevalence

The prevalence of equine gastric ulceration has increased over the last century.[7] In a retrospective study of 3715 Swedish horses, ulcers were most often found in the squamous mucosa along the margo plicatus, then the glandular body, proximal squamous mucosa and antrum.[7] For the squamous region, reported prevalences are:

  • Racehorses 70-100%[8][9][10]
  • Racehorses in active race training 80-90% (incidence 100%)[11][12]
  • Show horses 58%[13]
  • Ponies 78%[14]
  • Endurance 67%[15]
  • Western performance horses 40%[16]
  • Thoroughbred broodmares (67-77%)[17]
  • Nonracing performance horses (17% pre-competition, 56% post-competition)[18]
  • Pleasure horses in full work ~ 60%[3]
  • Pleasure, riding lessons, showing 37%[19]
  • Foals ~25-57%[20][21][22], the incidence increases dramatically in foals with clinical signs, especially gastrointestinal signs.[1]

The prevalence and severity of ulcers increases with work intensity[6] and duration[23][24], thus racehorses in active training are more often affected[8] and in half of these, the lesions are moderate to severe.[6] In one study, all horses developed gastric ulcers within 2 weeks of entering simulated race training.[11] Lesions are thought to be chronically progressive during race training, but to regress during retirement.[8] Horses with signs of gastrointestinal distress also demonstrate an increased frequency and severity of ulcerative lesions.[1]EGUS prevalence is high in horses with bowel, liver and oesophageal lesions.[7] Among show horses, 82% of those with signs of abdominal discomfort had gastric ulcers[25] Around 30% of adult horses and about 50% of foals have mild gastric erosions which heal without treatment or clinical signs.[6] In 201 clinically normal horses in Denmark, 53% had EGUS with severity score >2 and older horses were more likely to have lesions in both regions of the stomach[26]

Signalment

EGUS develops in horses of all ages[5] but is most common in young horses in training and foals. Gastric ulceration is considered to be rare in horses at pasture.[27]

Pathophysiology

NOT associated with Helicobacter pylori and not typically associated with Gasterophilus

Risk Factors

Clinical syndrome

The clinical signs associated with gastric ulcers are often very non-sepcific, difficult to document and at times only subjective.(Orsini) In addition, there appears to be a poor correlation between the severity of endoscopic lesions and the clinical presentation.(Murray et al 1989 in Orsini) The significance of gastric ulceration in horses thus remains questionable. However, there have been instances in which ulcer treatment has preceded an improvement in clinical status and/or racing perfomance, suggesting that in some horses, ulcers are a considerable burden.(Orsini) Cases gastric ulceration are often asymptomatic, but signs that have been attributed to these lesions in mature horses include:

  • Poor appetite (particularly decreased consumption of concentrates)(Sanchez)
  • Poor condition
  • Rough hair coat
  • Weight loss
  • Excessive recumbency (EGUC)
  • Mild to severe colic
    • Mild, recurrent colic signs post-prandially[28]
    • In one study, 49% of horses that presented for colic had gastric ulceration and those with duodenitis-proximal jejunitis had a trend towards a higher prevalence of gastric ulceration compared to those with other GI lesions.(Dukti et al. 2006) (Nadeau 2009)
  • Changes in attitude (dullness or depression)
  • Poor racing performance and reluctance to train (Murray 1988, 1992; Murray et al. 1989) (Table 2).(Orsini)
    • Performance improved in 4 Thoroughbred racehorses after antiulcer treatment(Franklin et al.2008)(Nadeau 2009)
    • Gastric ulcers have adversely affected physiological indices of performance in horses.[29]

(Murray 1992, 1994b; Vatistas et al. 1999a; Sandin e t al. 2000).(Jonssen 2006)

Foals

Neonatal foals Many are asymptomatic and some only exhibit signs when ulceration has become severe. Glandular ulcers are considered the most significant(Sanchez)

  • Poor appetite
  • Diarrhoea
  • Intermittent colic
  • Frequent dorsal recumbency

Sucklings and weanlings (Sanchez) Diarrhoea Poor appetite (off suck or partially off suck) Poor growth, failure to thrive Poor body condition Rough hair coat Potbelly appearance Bruxism (almost pathognomonic) Colic after feeding or tubing Chewing straw Dorsal recumbency

Signs of gastroduodenal ulcer disease (GDUD)(Sanchez): Bruxism Colic Ptyalism (top DDx, secondary to gastric outflow obstruction and gastroesophageal reflux, DDx esophageal obstruction and Candida infection (Merck)) Diarrhoea Gastrooesophageal reflux after suckling (in foals with outflow obstruction, marked reflux may be seen even with limited to no suckling if the duodenal obstruction is distal to the common bile duct.) (Sanchez)

5 syndromes in foals: silent, active with clinical signs, perforated, gastric and duodenal stenosis, general malaise and low grade colic Sudden gastric perforation without prior signs occurs sporadically in foals.(Merck)

Complications related to gastric ulcers are most frequent and severe in foals and include perforation, delayed gastric emptying, gastroesophageal reflux and esophagitis, and megaesophagus secondary to chronic gastroesophageal reflux. Ulcers in the proximal duodenum or at the pylorus can cause fibrosis and stricture. The latter complication is seen in both foals and adult horses. In rare cases, severe gastric ulceration causes fibrosis and contracture of the stomach. (Merck)

Diagnosis

Presumptive on clinical signs and response to treatment (Sanchez) Definitive diagnosis requires endoscopy (cannot do in foals as need to starve prior to exam)

Endoscopy

Performed under mild sedation in standing horse or foal (Sanchez) Duodenoscopy is most specific diagnostic method but is technically me chanllenegng than gastrocopy EGUS Lesion Scoring System publsihed based on consens by Equine Gastric Ulcer Council(2 in Sanchez)

Lesion Grade Description
Grade 0 Intact epithelium with no appearance of hyperaemia or hyperkeratosis
Grade 1 Intact mucosa with areas of reddening or hyperkeratosis (squamous)
Grade 2 Small single of multifocal lesions
Grade 3 Large single or multifocal lesions or extensive superficial lesions
Grade 4 Extensive lesions with areas of deep ulceration

Diffuse reddeing or inflammation may be only lesion seen in cases of early duodenal disease In older foals with GDUD, detection ofgastrci outflow obsturction is critical to therapeutic plan and appropriate prognosis (Sanchez)

Minimum endoscope length of two metres and 2.8-3.0 metre instruments are required for duodenoscopy A 3 mtre endoscope allows visualization of stomach, pyrlorus and proximal duodenum (Sanchez) Shorter scopes permit investigation fo gastric body and fundus only (Sanchez) Maximum external diameter of 9mm for neonates (Sanchez) Foals - lesions mainly in glandular epithelium Adults - margo plicatus and squamous epithelium

Abdominal radiography without contrast in foals with outflow obsturction typically rveeals very disticnt enlarged, gas-filled stomach. Liquid barium contrast will either have markedly delayed (with incomplete obstruction) oir no (complete onsbtruction) outflow. (Sanchez)

Biopsy

A transendoscopic gastric biopsy technique was recently validated for obtaining samples from the gastric glandular mucosa in the live horse.[30]Unfortunately this technique failed to produce samples of squamous mucosa that would be suitable for histopathological analysis.

Laboratory tests

The detection of occult blood in faeces has proven unreliable in the horse and currently, useful laboratory markers for EGUS are lacking.[1] Tests that require further analysis for sensitivity and specificity[5] include:

  • Urine[31] and blood[32] sucrose absorption as an assay of gastric mucosal permeability
  • Serum alpha1-antitrypsin which has been detected more frequently in foals with gastric ulceration[33]

Pathology

Treatment

Proton pump inhibitors: only omeprazole (Gastroguard) is licensed for horses. Given PO once daily (4mg/kg) for 3-4 wks, most effective drug at controlling HCl secretion (decreases basal and stimulated release). Expensive and not absorbed in foas with diarrhoea Histamine H2 receptor antagonists:

  • ranitidine 7mg/kg TID for 3-4wks
  • cimetidine 25mg/kg QID for 3-4wks (cheaper but less effective so must be given more frequently)

Gastric protectants: sucralfate 10-20mg/kg TID for 2-4wks Antacids: magnesium and aluminium hydroxides (NOT recommended as have massive rebound effect)

Foals: Omeprazole 4mg/kg PO SID (preferred) Ranitidine (Zantac, Zeneca, UK) 6mg/kg TID PO, 1-2mg/kg IV BID (second choice) Sucralfate (Antepsin, Wyeth Labs, Maidenhead, UK)(intestinal mucosal protective), 2-4g total dose or 50kg per foal QID PO (in theory best effect of this compound is in acid medium so should not be given at the same time or after H2 blockers btu latest research shows it appears to work just as well if given at the same time and this reduces stress of handling), NB nto a good prophylactic Antacids not good - rebound effect Metocloprmade, gastrci decompression (foals with severe gastor0duodenal stenosis), analgesia (butorphenol or pethidine or morphine NOT NSAIDs) Supportive nursing by reducing stressors, milk and saliva have preventative effects so good feeding habits should be encouraged Corn oil (50ml q6h) reportedly anti-ulcerogenic (increases PG production) PG analogues (Misoprostenol) 5microgram/kg PO q8h

Prognosis

Complications:

  • Recurrence if management not altered
  • Perforation and peritonitis (rare - foals)
  • Pyloric stenosis (rare - foals)

Prevention

Gastroguard at lower dose (1-2mg/kg) daily for 3-4wks (100, 107-109 in Sanchez) Prophylaxis in foals controversial as gastric acidity may be protective against bacterial translocation (Sanchez). It may be beneficial in foals receiving substantial doses of NSAIDs for orthopaedic pain (Sanchez) Management: diet, training, exercise, stress (company, toys) Pasture turnout and continuous access to high quality forage especially alfalfa (Sanchez)

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 The Equine Gastric Ulcer Council (1999) Tutorial Article: Recommendations for the diagnosis and treatment of equine gastric ulcer syndrome (EGUS). Equine Vet Educ, 11(5):262-272.
  2. ↑ Andrews, F.M, Bernard, W.V, Byars, T.D et al. (1999) Recommendations for the diagnosis and treatment of equine gastric ulcer syndrome (EGUS). Equine Vet Educ, 1:122-134. In: Sanchez, L.C (2010) 'Diseases Of The Stomach' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.
  3. ↑ 3.0 3.1 Bell, R.J, Mogg, T, Kingston, J.K (2007) Equine gastric ulcer syndrome in adult horses: a review. N Z Vet J, 55(1):1-12).
  4. ↑ Martineau, H, Thompson, H, Taylor, D (2009) Pathology of gastritis and gastric ulceration in the horse. Part 1: Range of lesions present in 21 mature individuals. Equine Vet J, 41(7):638-644.
  5. ↑ 5.0 5.1 5.2 5.3 Sanchez, L.C (2010) 'Diseases Of The Stomach' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.
  6. ↑ 6.0 6.1 6.2 6.3 Merck & Co (2008) The Merck Veterinary Manual (Eighth Edition), Merial
  7. ↑ 7.0 7.1 7.2 Sandin, A, Skidell, J, Haggstrom, J, Nilsson, G (2000) Postmortem findings of gastric ulcers in Swedish horses older than age one year: a retrospective study of 3715 horses (1924–1996). Equine Vet J, 32(1):36-42.
  8. ↑ 8.0 8.1 8.2 Hammond, C.J, Mason, D.K, Watkins, K.L (1986) Gastric ulceration in mature Thoroughbred horses. Equine Vet J, 18(4):284-287.
  9. ↑ Vatistas, N.J, Snyder, J.R, Carlson, G, et al (1994) Epidemiological study of gastric ulceration in the thoroughbred racehorse:202 horses 1992-1993. Proc Am Assoc Equine Pract, 40:125-126
  10. ↑ Murray, M.J, Schusser, G.F, Pipers, F.S, Gross, S.J (1996) Factors associated with gastric lesions in thoroughbred racehorses. Equine Vet J, 28:368-374.
  11. ↑ 11.0 11.1 Vatistas, N.J, Sifferman, R.L, Holste, J, Cox, J.L, Pinalto, G, Schultz, K.T (1999) Induction and maintenance of gastric ulceration in horses in simulated race training. Equine Vet J Suppl, 29:40-44
  12. ↑ Vatistas, N.J, Snyder, J.R, Carlson, G, Johnson, B, Arthruy, R.M, Thurmond, M, Zhou, H, Lloyd, K.L.K (1999) Cross-sectional study of gastric ulcers of the squamous mucosa in Thoroughbred racehorses. Equine Vet J, Suppl 29:34-39.
  13. ↑ McClure, S.R, Glickman, L.T, Glickman, N.W (1999) Prevalence of gastric ulcers in show horses. J Am Vet Med Assoc, 215:1130-1133.
  14. ↑ MacAllister, C.G, Sangiah, S, Mauromoustakos, A (1992) Effect of a histamine H, type receptor antagonist (WY 45, 727) on the healing of gastric ulcers in ponies. J Vet Int Med, 6:271-275.
  15. ↑ Nieto, J.E, Snyder, J.R, Beldomenico, P et al. (2004) Prevalence of gastric ulcers in endurance horses: a preliminary report. Vet J, 167:33-37.
  16. ↑ Bertone, J (2000) Prevalence of gastric ulcers in elite, heavy use western performance horses. Proc Am Assoc Equine Pract, 46:256-259.
  17. ↑ LeJeune, S.S, Nieto, J.E, Dechant, J.E, Snyder, J.R (2009) Prevalence of gastric ulcers in Thoroughbred broodmares in pasture: a preliminary report. Vet J, 181(3):251-5.
  18. ↑ Hartmann, A.M, Frankeny, R.L (2003) A preliminary investigation into the association between competition and gastric ulcer formation in non-racing performance horses. J Equine Vet Sci, 23:560-561. In:Sanchez, L.C (2010) 'Diseases Of The Stomach' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.
  19. ↑ Murray, M.J, Grodinsky, C, Anderson, C.W, Radue, P.F, Schmidt, G.R (1989) Gastric ulcers in horses: a comparison of endoscopic findings in horses with and without clinical signs. Equine Vet J Suppl, 7:68-72.
  20. ↑ Wilson, J.H (1986) Gastric and duodenal ulcers in foals: a retrospective study. Proc Equine Colic Res Symp 2nd:126-128.
  21. ↑ Murray, M.J, Grodinsky, C, Cowles, R.R, et al.(1990) Endoscopic evaluation of changes in gastric lesions of Thoroughbred foals. J Am Vet Med Assoc, 196:1623-1627.
  22. ↑ Murray, M.J (1989) Endoscopic appearance of gastric lesions in foals: 94 cases (1987-1988). J Am Vet Med Assoc, 195:1135-1141.
  23. ↑ Orsini, J.A, Pipers, F.S (1997) Endoscopic evaluation of the relationship between training, racing, and gastric ulcers. Vet Surg, 26:424. In: Orsini, J (2000) Tutorial Article Gastric ulceration in the mature horse: a review. Equine Vet Educ, 12(1):24-27.
  24. ↑ Murray, M.J (1994) Gastric ulcers in adult horses. Comp Cont Educ Pract Vet, 16:792-794. In:Orsini, J (2000) Tutorial Article Gastric ulceration in the mature horse: a review. Equine Vet Educ, 12(1):24-27.
  25. ↑ Murray, M. (1992) Gastric ulceration in horses: 91 cases (1987-1990). J Am Vet Med Assoc, 201:117-120. In: Martineau, H, Thompson, H, Taylor, D (2009) Pathology of gastritis and gastric ulceration in the horse. Part 1: Range of lesions present in 21 mature individuals. Equine Vet J, 41(7):638-644.
  26. ↑ Luthersson, N, Nielsen, K.H, Harris, P, Parkin, T.D (2009) The prevalence and anatomical distribution of equine gastric ulcer syndrome (EGUS) in 201 horses in Denmark. Equine Vet J, 41(7):619-24.
  27. ↑ Murray, M.J (1994) Characteristics of gastric ulcer pathophysiology. Proc Am Coll Vet Intern Med, 12:610-612. In: Sandin, A, Skidell, J, Haggstrom, J, Nilsson, G (2000) Postmortem findings of gastric ulcers in Swedish horses older than age one year: a retrospective study of 3715 horses (1924–1996). Equine Vet J, 32(1):36-42.
  28. ↑ Videla, R, Andrews, F.M (2009) New perspectives in equine gastric ulcer syndrome. Vet Clin North Am Equine Pract, 25(2):283-301.
  29. ↑ Nieto, J.E, Snyder, J.R, Vatistas, N.J, Jones, J.H (2009) Effect of gastric ulceration on physiologic responses to exercise in horses. Am J Vet Res, 70(6):787-95.
  30. ↑ Rodrigues, N.L, Dore, M, Doucet, M.Y (2009) Validation of a transendoscopic glandular and nonglandular gastric biopsy technique in horses. Equine Vet J, 41(7):631-5.
  31. ↑ O'Connor, M.S, Steiner, J.M, Roussel, A.J, et al. (2004) Evaluation of urine sucrose concentration for detection of gastric ucleration in horses. Am J Vet Res, 65:31-39. In: Sanchez, L.C (2010) 'Diseases Of The Stomach' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.
  32. ↑ Hewetson, M, Cohen, N.D, Love, S, et al. (2006) Sucrose concentration in bood: a new method for assessment of gastric permeability in horses with gastric ulceration. J Vet Intern Med, 20:388-394. In: Sanchez, L.C (2010) 'Diseases Of The Stomach' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.
  33. ↑ Taharaguchi, S, Nagano, A, Okai, K, et al. (2007) Detection of an isoform of alpha(1)-antitrypsin in serum samples from foals with gastric ulcers. Vet Rec, 161:338-342. In: Sanchez, L.C (2010) 'Diseases Of The Stomach' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.


Gastric Ulceration - all species

  • Affects the pars oesophagea (margo plicatus) in adults and foals.
  • Due to parasites - Gasterophilus (Bots).
  • Bots are not as common as they once were.
  • Look like big pink maggots.
  • Killed by Ivermectin.
  • Gasterophilus leave large ulcers in glandular regions of the stomach.
    • Ulcers / erosions are quite deep.
  • The parasites are believed to be non-pathogenic, but in large numbers they probably produce some discomfort and poor growth.
  • Carcinoma can also produce ulceration in the stomach of the horse as, in other species.
  • In foals, the glandular area may sometimes be affected.
    • This may be e.g. stress-related, or due to used of NSAIDs.
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