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Gastric Ulcers

Gastric ulceration refers to a scale of disease from inflammation to erosions of the lining of the stomach. The disease can also be called Equine Gastric Ulcer Syndrome (EGUS) or stomach ulcers. There are two types of ulcerative disease in the equine stomach which depends on where in the stomach they occur.

Squamous ulceration refers to ulceration of the squamous portion or top half of the stomach. This portion of the stomach is not designed to tolerate high acid levels as under normal circumstances the pool of acid should not sit this high up and with a natural diet there should be a matt of fibre sat on top of the acid keeping it low down and neutralised at this level. These ulcers can be considered acid splash ulcers and may be predisposed to by low fibre intake, exercise without a fibre matt or insufficient acid suppression caused by stress or a malfunction of this mechanism.

Glandular ulceration refers to a condition affecting the glandular portion or bottom half and exit of the stomach. This portion of the stomach is designed to tolerate high acid levels as this is where the acid pool sits, therefore the mechanism of disease in these cases is thought to be different. The barrier to acid must be breached to allow the acid to then cause ulceration, this is most likely due to a reduction in the mucosal blood flow which may be caused by stress, certain medications, or a malfunction of this mechanism.

Symptoms

There is a wide range of symptoms associated with gastric ulceration including any individual or combination of the following:

• Weight loss
• ‘Girthy’ or ‘saddle shy’ behaviour or resenting rugs being done up
• Resistance to the leg when ridden including tail swish or high head carriage
• Loss of performance in the absence of or alongside an orthopaedic cause
• Grumpy stable behaviour particularly around food
• Signs of discomfort after eating a hard feed which self resolves or preferring grass and hay to hard feeds
• Loss of condition of coat or just not looking as well as usual
• Colic
• Windsucking or weaving may have a relationship with ulcers
• Stressy or nervous behaviour or over-reacting to stimuli

Diagnosis

The only way to know whether a horse has gastric ulcers is via gastroscopy. This is a diagnostic test where a camera is passed up the nose, down the throat and into the stomach to visualise the inside of the stomach. The horse has to be starved overnight and is sedated for the procedure.

Treatment

There are a few different treatments available and the decision of which to use will depend on the location, type and severity of the ulcers as well as some practical considerations around the individual case and will be discussed between the vet and the owner in each case.

The potential treatments include:

Omeprazole

This suppresses acid which quickly improves comfort and allows the ulcers to heal. There are options to use oral paste syringes or injections.

Sucralfate

This also suppresses acid and also binds to the surface of the ulcers providing a barrier whilst they heal. This is a powder which can be mixed with water and syringed orally or mixed with food.

Misoprostal

This increases mucosal blood flow to promote healing and function of the mucosal barrier. This is a tablet given in food. There are human safety considerations with this medication so careful consideration must be given to its use.

Steroids

These are potent anti-inflammatory medications and may be used in some cases of severe glandular disease. These are tablets given in food.

A high specification supplement is often used alongside or immediately after medical treatment. These contain ingredients shown to keep acid levels suppressed, improve mucus production and improve the mucosal barrier to help treat and prevent recurrence of ulcers.

Identify and address any predisposing factors such as orthopaedic pain, feed issues or environmental stress. Without dealing with these the success of treatment is limited.

Treatment is required for a prolonged period of time and may range from 4 to 12 weeks in most cases.

Monitoring

A repeat gastroscope at the end of treatment is required to assess the response to treatment. Often the treatments will make the horse feel better so the outward signs improve but the healing may not be complete so stopping too soon could cause relapse.

Prognosis

In the majority of cases a good outcome is expected with full resolution of ulcers seen and a management strategy in place prevents recurrence. However, in some cases the ulcers do not fully respond to treatment, these are most likely to be glandular ulcers. It is thought that some horses have a fundamental issue with their stomach lining and it will need ongoing low doses or treatment or repeat course of treatment over time to manage but not cure the condition. Likewise if a horse has an underlying predisposition such as stress, orthopaedic pain or management factors which don’t suit him/her then the ulcers will not resolve. In the most part treating ulcers is straightforward but it can be complex and drawn out at times, as well as financially expensive.

Prevention

Some horses appear to get gastric ulcers regardless of what we do however there are some things well associated with ulcers that we can learn from. Prevention strategies include:

Ad lib forage

A constant source of good quality fibre forage is important to keep the acid levels normal in the stomach. This looks like ad-lib hay/haylage and turnout to grass.

Turnout

There is good evidence that being turned out is both mentally beneficial reducing environmental stress and provides ad lib forage. Ideally the horse should be able to interact with other horses too to promote natural behaviour and release happy hormones.

Hard feed

High fibre, low in sugar and starch is the aim. Most horses which are fed grass and hay are completely fine with this based diet. If a horse is underweight and therefore requires more calories it is advised that this is achieved via increased fat and protein levels as opposed to sugar and starch. For example, use linseed or oils in the feed to increase fat and replace a plain chaff with an alfalfa based chaff for increased protein. There is a range of mainstream feeds which do this for you which advertise that they are ulcer friendly and advice can always be sought by a nutritionist.

Corn Oil

There is evidence that 1ml corn oil per kg of horse’s bodyweight can support a healthy mucosal lining and help prevent stomach ulcers.

Shavings vs straw

You may come across advice regarding this. There is a study showing that horses which ate their straw bedding had higher rates of stomach ulcers and this is though to be due to the physical abrasiveness of the straw. This could be something to consider if your horse is on straw and has a stomach ulcer issue.

Alfalfa

There is conflicting advice regarding alfalfa. One study showed that it made ulcers worse and one showed that it makes them better. It turns out that it depends on the abrasiveness of the chop itself – the study where they got worse was using a harsh firm alfalfa chop and where it was seen to help stomach health used a soft alfalfa chop. So similar to the straw study this harshness of the chaff seems to make a difference and it may be worth using a soft alfalfa chop in an ulcer prone horse particularly if you want some extra calories.

Dentistry

If the teeth are ineffective or painful then food will be swallowed before it has been chewed properly, this may have an impact on stomach health. Routine dental checks are recommended every 6-12 months with a vet or BAEDT.

Comfort

It is well recognised that horses in physical discomfort are predisposed to gastric ulcers. Routine physiotherapy checks, farriery and saddle/bridle/bit fit checks are essential if you are riding your horse to prevent ridden discomfort.

Routine

Horses thrive on routine and this is thought the help prevent low grade stress.

Feeding before travel and exercise

Contrary to historic belief we now know that riding or travelling on an empty stomach is a big risk factor for stomach ulcers. It is recommended that a horse is fed a small chaff feed 20 mins prior to ridden work. This chaff forms a matt on top of the acid pool and prevents splashing and over-acidified stomachs during the exercise or travel session. Consider this also when at a show all day and may be riding multiple times, always offer the horse grass, hay or feed and water between rides and before and/or during travel home.

Supplements

There may be some merit in feeding a good quality gastric ulcer supplement including antacids and pro-barrier components if your horse has had ulcers before or is predisposed.