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

SM
MP
GM
Murray, Equine Vet J Suppl, 1992 Sweeney, In
Practice, 1992 Pagan, World Equine Vet Rev,
1997 Murray and Schusser, Equine Vet J, 1993.
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
Murray and Schusser, Equine Vet J, 1993.
11
24-Hr Gastric pH Free Choice Grass Hay
Murray and Schusser, Equine Vet J, 1993.
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)

Murray and Schusser, Equine Vet J, 1993 Murray
and Eichorn, Am J Vet Res, 1996.
13
Effect of Alfalfa Hay
Rebound Hyperacidity
Buffering effect
Nadeau JA, Andrews FM, Mathew AG, et al. AJVR
61(7) 784-790, 2000.
14
Results Gastric ulcer Number and Severity Score
Nadeau JA, Andrews FM, Mathew AG, et al. AJVR
61(7) 784-790, 2000.
15
Feed Analysis

• Feed DM CP Ca (mg/g) P (mg/g)
• Grain 99.8 14.81 3.2 0.56
• Alfalfa 94.52 20.85 14.1 2.1
• Brome 95.51 7.55 7.4 6.22
• on a dry matter basis
• 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 by-products
• VFAs, Lactic Acid, and Alcohols?
• Lactobacillus spp. Isolated
• HCl!!

Yuki N, et al. Appl. Env. Micro.
2000665030-5034. Scott PT et al. Recent Adv.
An. Nut. Au. 20031424A.
17
Risk Factors for EGUS Training/Racing

• Intensive exercise
• Reduced blood flow to the stomach lining?
• Increased gastric acidity?
• Altered eating behavior?

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
2002631481-1487
19
Risk Factors for EGUS Stress

• Physical stress
• Illness
• Painful musculoskeletal disorder
• Endometritis?
• Behavioral stress
• Stall confinement
• Transport
• Unfamiliar environment,social regrouping

20
Risk Factors for EGUSNon-Steroidal
Anti-Inflammatory Drugs

• Phenylbutazone Flunixin Meglumineand other
  NSAIDs
• Associated with ulcers throughout the intestinal
  tract (Cecum Colon)
• Inhibit prostaglandins, interrupting mucosal
  blood flowand 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
(No Transcript)
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

Positive test
Negative 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
ConclusionsRecommendations

• 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, 132121-126.
31
Dietary Management Corn oil

• Decreases stomach acid
• Increases protective factors
  (PG)
• Provides Omega 3 6 fatty
  acids
• 8 oz once to twice daily

(Cargile et al, JVIM 2004)
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)

35
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
• Do not administer to pregnant mares!!!
• 5 µg/kg, orally, Q8h

Sangiah et al. Res. Vet. Sci, 1989
37
Antibiotic Treatment

• Primarily used in humans with Helicobacter
  pylori
• Colonization of ulcer bed (rat)
• Bacteria rapidly colonize ulcer
  bed and decrease ulcer healing
• H. pylori has been associated withthe stomach of
  horses, but not EGUS
• Antimicrobials may be used in horses with
  resistant EGUS (TMS, Metronidazole, Bismuth
  compounds)

Elliott et al. Am. J. Physiol. 1998275G425-32
Scott DR, Marcus EA, Shirazi-Beechey SSP, et al.
Evidence of Helicobacter infection in the horse.
Proc Am Soc Microbiology 2001.
38
Feed Supplements (Neutriceuticals)

• NeighLox (Kentucky Performance Products)
• Antacid and Coating Agents
• Aluminum Phosphate, Calcium Carbonate
• Dihydroxy-AluminiumSodium Carbonate
• Labeled for preventionof heartburn
• No studies in horsesto 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 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.

Succeed
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

59
(No Transcript)