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Also known as: '''''Gastroduodenal ulceration — Gastrointestinal ulceration — Equine Gastric Ulcer Syndrome — EGUS — Peptic ulcer disease — Equine Gastric Ulcer

Also known as: '''''Gastroduodenal ulceration — Gastrointestinal ulceration — Equine Gastric Ulcer Syndrome — EGUS — Peptic ulcer disease — Equine Gastric Ulcer

'''Clinical signs in foals vary depending on age and severity:'''

'''Clinical signs in foals vary depending on age and severity:'''

*'''Neonatal foals''': many ulcers are silent, some foals only exhibit signs when ulceration has become severe.  Glandular ulcers are considered the most significant<ref name="Sanchez">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.</ref>

*'''Neonatal foals''': many ulcers are silent, some foals only exhibit signs when ulceration has become severe.  Glandular ulcers are considered the most significant<ref name="Sanchez">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.</ref>.

**Poor appetite

**Poor appetite

**Diarrhoea

**Diarrhoea

====Histamine 2 receptor antagonists====

====Histamine 2 receptor antagonists====

Parietal cells secrete HCl upon stimulation of histamine, acetylcholine or gastrin receptors.<ref name="EGUC">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.</ref>  Competitive H2 receptor antagonists have successfully elevated gastric pH and treated gastric ulcers in mature horses and foals.<ref name="Lester">Sanchez, L.C, Lester, G.D, Merritt, A.M (1998) Effect of ranitidine on intragastric pH in clinically normal neonatal foals.  ''J Am Vet Med Assoc'', 212:1407-1412.</ref><ref>Becht, J.L, Byars, T.D (1986) Gastroduodenal ulceration in foals.  ''Equine Vet J'', 18:307-312.</ref>  There appears to be a great variability among horses in their dose requirements for H2 antagonists which may be explained by individual bioavilability for these compounds.<ref name="EGUC">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.</ref>  Currently recommended doses proposed to be effective in the majority of horses<ref name="Sanchez">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.</ref> are:

Parietal cells secrete HCl upon stimulation of histamine, acetylcholine or gastrin receptors.<ref name="EGUC">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.</ref>  Competitive H2 receptor antagonists have successfully elevated gastric pH and treated gastric ulcers in mature horses and foals.<ref name="Lester">Sanchez, L.C, Lester, G.D, Merritt, A.M (1998) Effect of ranitidine on intragastric pH in clinically normal neonatal foals.  ''J Am Vet Med Assoc'', 212:1407-1412.</ref><ref>Becht, J.L, Byars, T.D (1986) Gastroduodenal ulceration in foals.  ''Equine Vet J'', 18:307-312.</ref>  There appears to be a great variability among horses in their dose requirements for H2 antagonists which may be explained by individual bioavailability for these compounds.<ref name="EGUC">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.</ref>  Currently recommended doses for cimetidine, ranitidine and f amotidine proposed to be effective in the majority of horses have been recommended by Sanchez.<ref name="Sanchez">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.</ref>

====Proton-pump inhibitors (PPIs)====

====Proton-pump inhibitors (PPIs)====

====Mucosal protectants====

====Mucosal protectants====

'''Sucralfate''' is a complex salt of sucrose and aluminium hydroxide.  It is thought to promote ulcer healing via several mechanisms: adherence to ulcerated mucosa, stimulation of mucus secretion, pepsin inibition, increasing PGE synthesis and enhancing the local production of epidermal growth factor.<ref name="Sanchez">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.</ref>  It has been used effectively to treat and prevent stress-induced ulcers in man and has been recommended at 10-20mg/kg three times daily for the treatment of glandular ulcers in horses.<ref>Murray, M.J (1994) Gastric ulcers in adult horses.  ''Comp Cont Educ Pract Vet'', 16:792-794,797.  In: Orsini, J (2000) Tutorial Article Gastric ulceration in the mature horse: a review. ''Equine Vet Educ'', 12(1):24-27.</ref>  However, the effect of sucralfate on equine squamous gastric ulcers remains inconclusive<ref name="EGUC">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.</ref> and the product may be ineffective in the alkaline conditions created by acid suppression agents.<ref>Danesh, J.Z, Duncan, A, Russell, R.I, Mitchell, G (1988) Effect of intragastric pH on mucosal protective action of sucralfate.  ''Gut'', 29:1379-1385.  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.</ref>

'''Sucralfate''' is a complex salt of sucrose and aluminium hydroxide.  It is thought to promote ulcer healing via several mechanisms: adherence to ulcerated mucosa, stimulation of mucus secretion, pepsin inibition, increasing PGE synthesis and enhancing the local production of epidermal growth factor.<ref name="Sanchez">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.</ref>  It has been used effectively to treat and prevent stress-induced ulcers in man and has been recommended for the treatment of glandular ulcers in horses.<ref>Murray, M.J (1994) Gastric ulcers in adult horses.  ''Comp Cont Educ Pract Vet'', 16:792-794,797.  In: Orsini, J (2000) Tutorial Article Gastric ulceration in the mature horse: a review. ''Equine Vet Educ'', 12(1):24-27.</ref>  However, the effect of sucralfate on equine squamous gastric ulcers remains inconclusive<ref name="EGUC">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.</ref> and the product may be ineffective in the alkaline conditions created by acid suppression agents.<ref>Danesh, J.Z, Duncan, A, Russell, R.I, Mitchell, G (1988) Effect of intragastric pH on mucosal protective action of sucralfate.  ''Gut'', 29:1379-1385.  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.</ref>

====Prostaglandin analogues====

====Prostaglandin analogues====

   

   

Synthetic PGE1 analogues are believed to inihibit gastric acid secretion and enhance mucosal cytoprotection.<ref>Leandro, G, Pilotto, A, Franceschi, M ''et al.'' (2001) Prevention of acute NSAID-related gastroduodenal damage: a meta-analysis of controlled clinical trials.  ''Dig Dis Sci'', 46:1924-1936.  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.</ref>  '''Misoprostol''' has been an effective agent in the treatment of human gastric and duodenal ulcers and at 5µg/kg has been shown to increase gastric pH in horses.<ref>Sangiah, S, MacAllister, C.C, Amouzadeh, H.R (1989) Effects of misoprostol and omeprazole on basal gastric pH and free acid content in horses.  ''Res Vet Sci'', 47:350-354.  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.</ref> Although contraindicated in pregnant mares, Misoprostol may be beneficial for mucosal recovery in the face of flunixin treatment.<ref>Tomlinson, J.E, Blikslager, A.T (2005) Effects of cyclooxygenase inhibitors flunixin and deracoxib on permeability of ischaemic-injured equine jejunum.  ''Equine Vet J'', 37:75-80.  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.</ref>

Synthetic PGE1 analogues are believed to inihibit gastric acid secretion and enhance mucosal cytoprotection.<ref>Leandro, G, Pilotto, A, Franceschi, M ''et al.'' (2001) Prevention of acute NSAID-related gastroduodenal damage: a meta-analysis of controlled clinical trials.  ''Dig Dis Sci'', 46:1924-1936.  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.</ref>  '''Misoprostol''' has been an effective agent in the treatment of human gastric and duodenal ulcers and has been shown to increase gastric pH in horses.<ref>Sangiah, S, MacAllister, C.C, Amouzadeh, H.R (1989) Effects of misoprostol and omeprazole on basal gastric pH and free acid content in horses.  ''Res Vet Sci'', 47:350-354.  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.</ref> Although contraindicated in pregnant mares, Misoprostol may be beneficial for mucosal recovery in the face of flunixin treatment.<ref>Tomlinson, J.E, Blikslager, A.T (2005) Effects of cyclooxygenase inhibitors flunixin and deracoxib on permeability of ischaemic-injured equine jejunum.  ''Equine Vet J'', 37:75-80.  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.</ref>

====Gastric prokinetics====

====Gastric prokinetics====

====Treatment problems====

====Treatment problems====

The prevalence of gastric ulcers in horses remains high regardless of the common use of antiulcer treatments.  This has been attributed to the expense of recommended products encouraging subtherapeutic and curtailed dosing schedules.<ref>Orsini, J.A, Haddock, M, Stine, L, Sullivan, E.K, Rabuffo, T.S, Smith, G (2003) Odds of moderate or severe gastric ulceration in racehorses receiving antiulcer medications.  ''J Am Vet Med Ass'', 223:336-339.  In: Nadeau, J.A, Andrews, F.M (2009) ''Science: Overviews'' Equine gastric ulcer syndrome: The continuing conundrum. ''Equine Vet J'', 41(7):611-615.</ref>  Omeprazole and ranitidine must be administered for at least 28 days for adequate ulcer healing.<ref name="Nadeau">Nadeau, J.A, Andrews, F.M (2009) ''Science: Overviews'' Equine gastric ulcer syndrome: The continuing conundrum.  ''Equine Vet J'', 41(7):611-615.</ref>  In the USA, compounded omeprazole from bulk powders are used as a cheaper substitute for the FDA approved products. However, these formulations lack efficacy and are not regulated<ref>Nieto, J.E, Spier, S, Pipers, F.S, Stanley, S, Aleman, M.R, Smith, D.C, Snyder, J.R (2002) Comparison of paste and suspension formulations of omeprazole in the healing of gastric ulcers in racehorses in active training.  ''J Am Vet Med Ass'', 221: 1139-1143.  In: Nadeau, J.A, Andrews, F.M (2009) ''Science: Overviews'' Equine gastric ulcer syndrome: The continuing conundrum.  ''Equine Vet J'', 41(7):611-615.</ref>  A considerable challenge lies in the management of abdominal pain associated with EGUS, since the commonly used NSAIDs for pain control may worsen and even induce further ulcerative lesions.<ref>Videla, R, Andrews, F.M (2009) New perspectives in equine gastric ulcer syndrome.''Vet Clin North Am Equine Pract'', 25(2):283-301.</ref>  Another challenge is the horse in which oral medication is prohibited.  However, Andrews and colleagues (2006) have demonstrated the efficacy of an omeprazole powder, adminstered IV in sterile water, which signifcantly increases the pH of equine gastric contents and may be useful in problem horses.<ref name="Andrews 2006">Andrews, F.M, Frank, N, Sommardahl, C.S, Buchanan, B.R, Elliott, S.B, Allen, V.A (2006) Effects of intravenously administrated omeprazole on gastric juice pH and gastric ulcer scores in adult horses.  ''J Vet Intern Med'', 20(5):1202-6.</ref>  An ongoing point of debate is the use of antiulcer medication in competition horses.  In 2000, the Bureau of '''The Fèdèration Equestre Internationale (FEI)''' permitted the use of cimetidine, ranitidine and omeprazole to prevent and treat gastric ulcers.  This decision was based on evidence that the compounds were not performance enhancing and that EGUS was such a widespread concern. However, these drugs are still listed under prohibited substances in the '''2009 Appendices of the American Endurance Ride Conference (AERC) Rules and Regulations'''.  The argument is that a horse requiring such treatment is not suffciently well to compete and should be withdrawn from competition if it needs preventative medication.  A related concern is that the AERC permits the use of hyperosmolar oral electrolyte pastes which may cause gastric ulcers.<ref>Holbrook, T.C, Simmons, R.D, Payton, M.E, MacAllister, C.G (2005) Effect of repeated oral administration of hypertonic electrolyte solution on equine gastric mucosa.  ''Equine Vet J'', 37: 501-504.</ref>  Without the protection afforded by antiulcer agents, these horses may be at considerable risk for EGUS.<ref name="Nadeau">Nadeau, J.A, Andrews, F.M (2009) ''Science: Overviews'' Equine gastric ulcer syndrome: The continuing conundrum.  ''Equine Vet J'', 41(7):611-615.</ref>

The prevalence of gastric ulcers in horses remains high regardless of the common use of antiulcer treatments.  This has been attributed to the expense of recommended products encouraging subtherapeutic and curtailed dosing schedules.<ref>Orsini, J.A, Haddock, M, Stine, L, Sullivan, E.K, Rabuffo, T.S, Smith, G (2003) Odds of moderate or severe gastric ulceration in racehorses receiving antiulcer medications.  ''J Am Vet Med Ass'', 223:336-339.  In: Nadeau, J.A, Andrews, F.M (2009) ''Science: Overviews'' Equine gastric ulcer syndrome: The continuing conundrum. ''Equine Vet J'', 41(7):611-615.</ref>  Omeprazole and ranitidine must be administered for at least 28 days for adequate ulcer healing.<ref name="Nadeau">Nadeau, J.A, Andrews, F.M (2009) ''Science: Overviews'' Equine gastric ulcer syndrome: The continuing conundrum.  ''Equine Vet J'', 41(7):611-615.</ref>  In the USA, compounded omeprazole from bulk powders are used as a cheaper substitute for the FDA approved products. However, these formulations lack efficacy and are not regulated.<ref>Nieto, J.E, Spier, S, Pipers, F.S, Stanley, S, Aleman, M.R, Smith, D.C, Snyder, J.R (2002) Comparison of paste and suspension formulations of omeprazole in the healing of gastric ulcers in racehorses in active training.  ''J Am Vet Med Ass'', 221: 1139-1143.  In: Nadeau, J.A, Andrews, F.M (2009) ''Science: Overviews'' Equine gastric ulcer syndrome: The continuing conundrum.  ''Equine Vet J'', 41(7):611-615.</ref>  A considerable challenge lies in the management of abdominal pain associated with EGUS, since the commonly used NSAIDs for pain control may worsen and even induce further ulcerative lesions.<ref>Videla, R, Andrews, F.M (2009) New perspectives in equine gastric ulcer syndrome.''Vet Clin North Am Equine Pract'', 25(2):283-301.</ref>  Another challenge is the horse in which oral medication is prohibited.  However, Andrews and colleagues (2006) have demonstrated the efficacy of an omeprazole powder, adminstered IV in sterile water, which signifcantly increases the pH of equine gastric contents and may be useful in problem horses.<ref name="Andrews 2006">Andrews, F.M, Frank, N, Sommardahl, C.S, Buchanan, B.R, Elliott, S.B, Allen, V.A (2006) Effects of intravenously administrated omeprazole on gastric juice pH and gastric ulcer scores in adult horses.  ''J Vet Intern Med'', 20(5):1202-6.</ref>  An ongoing point of debate is the use of antiulcer medication in competition horses.  In 2000, the Bureau of '''The Fèdèration Equestre Internationale (FEI)''' permitted the use of cimetidine, ranitidine and omeprazole to prevent and treat gastric ulcers.  This decision was based on evidence that the compounds were not performance enhancing and that EGUS was such a widespread concern. However, these drugs are still listed under prohibited substances in the '''2009 Appendices of the American Endurance Ride Conference (AERC) Rules and Regulations'''.  The argument is that a horse requiring such treatment is not suffciently well to compete and should be withdrawn from competition if it needs preventative medication.  A related concern is that the AERC permits the use of hyperosmolar oral electrolyte pastes which may cause gastric ulcers.<ref>Holbrook, T.C, Simmons, R.D, Payton, M.E, MacAllister, C.G (2005) Effect of repeated oral administration of hypertonic electrolyte solution on equine gastric mucosa.  ''Equine Vet J'', 37: 501-504.</ref>  Without the protection afforded by antiulcer agents, these horses may be at considerable risk for EGUS.<ref name="Nadeau">Nadeau, J.A, Andrews, F.M (2009) ''Science: Overviews'' Equine gastric ulcer syndrome: The continuing conundrum.  ''Equine Vet J'', 41(7):611-615.</ref>

==Prognosis==

==Prognosis==

====Prophylaxis====

====Prophylaxis====

'''Omeprazole paste''' at a lower dose (1-2mg/kg) daily for 3-4 weeks.<ref name="McClure">McClure, S.R, White, G.W, Sifferman, R.L, ''et al.'' (2005) Efficacy of omeprazole paste for prevention of recurrence of gastric ulcers in horses in race training.  ''J Am Vet Med Assoc'', 226:1685-1688.</ref>

'''Omeprazole paste''' at a lower dose daily for 3-4 weeks.<ref name="McClure">McClure, S.R, White, G.W, Sifferman, R.L, ''et al.'' (2005) Efficacy of omeprazole paste for prevention of recurrence of gastric ulcers in horses in race training.  ''J Am Vet Med Assoc'', 226:1685-1688.</ref>

*Prevented ulcers in horses maintained under ulcerogenic conditions.<ref name="McClure">McClure, S.R, White, G.W, Sifferman, R.L, ''et al.'' (2005) Efficacy of omeprazole paste for prevention of recurrence of gastric ulcers in horses in race training.  ''J Am Vet Med Assoc'', 226:1685-1688.</ref><ref>McClure, S.R, White, G.W, Sifferman, R.L, ''et al.'' (2005) Efficacy of omeprazole paste for prevention of gastric ulcers in horses in race training.  ''J Am Vet Med Assoc'', 226:1681-1684.</ref><ref>White, G.W, McClure, S.R, Sifferman, R.L, Bernard, W, Doucet, M, Vrins, A, Hughes, F, Holste, J.E, ALva, R, Fleishman, C, Cramer, L (2003) Prevention of occurrence and recurrence of gastric ulcers in horses by treatment with omeprazole at 1mg/kg/day.  ''Proc Am Ass Equine Practnrs'', 49: 220-221.</ref><ref>White, G.W, McClure, S.R, Sifferman, R.L, Holste, J.E, Fleishman, C, Murray, M.J, Cramer, L.G (2007) Effects of short-term light to heavy exercise on gastric ulcer development in horses and efficacy of omeprazole paste in preventing gastric ulceration.  ''J Am Vet Med Ass'', 230:1680-1682.</ref>

*Prevented ulcers in horses maintained under ulcerogenic conditions.<ref name="McClure">McClure, S.R, White, G.W, Sifferman, R.L, ''et al.'' (2005) Efficacy of omeprazole paste for prevention of recurrence of gastric ulcers in horses in race training.  ''J Am Vet Med Assoc'', 226:1685-1688.</ref><ref>McClure, S.R, White, G.W, Sifferman, R.L, ''et al.'' (2005) Efficacy of omeprazole paste for prevention of gastric ulcers in horses in race training.  ''J Am Vet Med Assoc'', 226:1681-1684.</ref><ref>White, G.W, McClure, S.R, Sifferman, R.L, Bernard, W, Doucet, M, Vrins, A, Hughes, F, Holste, J.E, ALva, R, Fleishman, C, Cramer, L (2003) Prevention of occurrence and recurrence of gastric ulcers in horses by treatment with omeprazole at 1mg/kg/day.  ''Proc Am Ass Equine Practnrs'', 49: 220-221.</ref><ref>White, G.W, McClure, S.R, Sifferman, R.L, Holste, J.E, Fleishman, C, Murray, M.J, Cramer, L.G (2007) Effects of short-term light to heavy exercise on gastric ulcer development in horses and efficacy of omeprazole paste in preventing gastric ulceration.  ''J Am Vet Med Ass'', 230:1680-1682.</ref>

*May benefit foals receiving substantial doses of NSAIDs for orthopaedic pain.<ref name="Sanchez">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.</ref>

*May benefit foals receiving substantial doses of NSAIDs for orthopaedic pain.<ref name="Sanchez">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.</ref>

==Literature Search==

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