Why are gastric ulcers still a significant concern for horses in training?

With the advances in scoping and increased awareness of gastric ulcers, along with the high prevalence found in horses in training, one may wonder, Why is this condition still such a problem? Do we not know enough to prevent this condition from recurring? 

The short answer is that much is known, and for certain, there are effective medications and many feeds and supplements designed to manage the condition. The underlying problem is that the factors leading to ulceration, at least the most significant ones, are fundamental to the routine and management of a horse in training. Quite simply, the environment and exercise required are conducive to development of ulcers. Horses in training will always be at risk from this condition, and it is important to manage our expectation of how much influence we can have on ulcers developing, and our ability to prevent recurrence. 

Clarifying Gastric Ulceration

Before considering how and why ulcers are a recurrent problem, it is helpful to understand the different types of gastric ulceration as the term most commonly used, Equine Gastric Ulcer Syndrome (EGUS), is an umbrella term which represents two distinct conditions. 

The term EGUS came into use in 1999 and represented ulceration of the two separate locations in the stomach where ulcers are found: the squamous and glandular regions. The two regions are functionally different, and ulceration in either location has different causative factors. This is important when considering what can be managed from a risk point of view at a racing yard. The term EGUS is now split into two categories: Equine Squamous Gastric Disease (ESGD) and Equine Glandular Gastric Disease (EGGD). 

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ESGD is the most commonly occurring form and the focus of dietary and management interventions. The majority of horses in training have the primary form of ESGD where the stomach functions normally. There is a secondary form that relates to a physical abnormality which causes delayed emptying of the stomach.

The condition ESGD is influenced by the training environment and time spent in training as noted by researchers looking at prevalence of horses out of training compared to those within training. In this case, 37% of untrained thoroughbred racehorses had ESGD and this progressed to 80-100% of horses within two to three months of training. This effect is not unique to thoroughbreds and is seen in other breeds with an ‘active workload’; for example, standardbreds progress from an average of 44% ESGD in the population to 87% when in training. Such research is helpful in understanding two things: firstly, that ulcers in the squamous section can occur outside of training, and that the influence of exercise and dietary changes have a significant effect regardless of breed. Even horses in the leisure category, which are thought of as low risk or at almost no risk at all, can return surprising results in terms of prevalence.

There are multiple risk factors associated with development of ESGD, some of which are better evidenced than others, and some of which are more influential. These include:

  • Pasture turnout

  • Having a diet high in fibre/provision of ‘free choice’ fibre

  • Choice of alfalfa over other forages

  • Provision of straw as the only forage source

  • Restricted access to water

  • Exceeding 2g of starch per kilogram of body weight 

  • Greater than 6 hours between meals (forage/feed)

  • Frequency and intensity of exercise 

  • Duration of time spent in a stabled environment combined with exercise

Of these factors, the stabled environment—which influences feeding behaviour—and exercise are the most significant factors. The influence of diet in the unexercised horse can be significant, however once removed from pasture, and a training program is entered into, ulceration will occur as these factors are more dominant. An Australian study of horses in training noted the effect of time spent in training, with an increase in risk factor of 1.7 fold for every week spent in training. 

Once in training, there is some debate as to whether provision of pasture, either alone or in company, has a significant effect. Some studies report a lower risk of ESGD when pasture in company is provided for horses in training, whereas others have found no significant effect. The duration of access and quality of pasture involved may be part of the differences in results found. There is a distinct difference between turnout in a paddock that offers a pick of grass and a leg stretch and a paddock rich in well managed pasture. Ultimately a period of turnout whilst in a training program is not enough of a counter-balance to the risks of frequent and intense exercise, coupled with a need for stabled periods and higher rates of compound feeding.

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Ulcer medication: are the products different?

By Celia M. Marr

Stomach Ulcers Are Not All the Same

Racehorse trainers and their vets first began to be aware of stomach ulcers over 20 years ago. The reasons why we became aware of ulcers are related to technological advances, which produced endoscopes long enough to get into the equine stomach. At that time, scopes were typically about eight feet long and were most effective in examining the upper area of the stomach, which is called the squamous portion. Once this technology became available, it was quickly appreciated that it is very common for racehorses to have ulcers in the squamous portion of the stomach.

Figure 1

The equine stomach has two main areas: the squamous portion and the glandular portion. The stomach sits more or less in the middle of the horse, immediately behind the diaphragm and in front of and above the large colon. Imagine the stomach as a large balloon with the esophagus—the gullet—entering halfway up the front side and slightly to the left of the balloon-shaped stomach and the exit point also coming out the front side but slightly lower and to the right side. The tissue around the exit—the pylorus—and the lower one-third, the glandular portion, has a completely different lining to the top two-thirds, the squamous portion.

The stomach produces acid to start the digestive process. Ulceration of the squamous portion is caused by this acid. Like the human esophagus, the lining of the squamous portion has very limited defenses against acid.  But, the acid is actually produced in the lower, glandular portion. The position of the stomach is between the diaphragm, which moves backwards as the horse breathes in and the heavy large intestine which tends to push forwards as the horse moves. During exercise, liquid acid produced at the bottom of the stomach is squeezed upwards onto the vulnerable squamous lining. It makes sense then that the medications used to treat squamous ulcers are aimed at blocking acid production.

Lesions in the glandular portion of the stomach are less common than squamous ulcers. The acid-producing glandular portion has natural defenses against acid damage including a layer of mucus and local production of buffering compounds. At this point, we actually know relatively little about the causes of glandular disease, but it is becoming increasingly obvious that disease in the glandular portion is very different from squamous disease. Often, it is more difficult to treat.

Figure 2

Stomach ulcers can cause a wide range of clinical signs. Some horses seem relatively unaffected by fairly severe ulcers, but other horses will often been off their feed, lose weight, and have poor coat quality. Some will show signs of abdominal discomfort, particularly shortly after eating. Other horses may be irritable—they can grind their teeth or they may resent being girthed. Additional signs of pain include an anxious facial expression, with ears back and clenching of the jaw and facial muscles and a tendency to stand with their head carried a little low.




Assessing Ulcers

Ulcers can only be diagnosed with endoscopy. A grading system has been established for squamous ulcers, which is useful in making an initial assessment and in documenting response to treatment.

Grade 0 = normal intact squamous lining

Grade 1 = mild patches of reddening

Grade 2 = small single or multiple ulcers

Grade 3 = large single or multiple ulcers

Grade 4 = extensive, often merging with areas of deep ulceration

Although it is used for research purposes, this grading system does not translate very well to glandular ulcers where typically, lesions are described in terms of their severity (mild, moderate or severe), distribution (focal, multifocal or diffuse), thickness (flat, depressed, raised or nodular) and appearance (reddening, hemorrhagic or fibrinosuppurative). Fibrinosuppurative suggests that inflammatory cells or pus has formed in the area. Focal reddening can be quite common in the absence of any clinical signs. Nodular and fibrinosuppurative lesions may be more difficult to treat than flat or reddened lesions. Where the significance of lesions is questionable, it can be helpful to treat the ulcers and repeat the endoscopic examination to determine whether the clinical signs resolve along with the ulcers.

Medications for Squamous Ulcers

Because of the prevalence and importance of gastric ulcers, Equine Veterinary Journal publishes numerous research articles seeking to optimize treatment. The most commonly used drug for treatment of squamous ulcers is omeprazole. A key feature of products for horses is that the drug must be buffered in order to reach the small intestine, from where it is absorbed into the bloodstream in order to be effective. Until recently only one brand was available, but there are now several preparations on the market and researchers have been seeking to show whether new medicines are as effective as the original brand. There is limited information comparing the new products, and this information is essential to determine whether the new, and often cheaper, products should be used. A team of researchers formed from Charles Sturt University in Australia and Louisiana State University has compared two omeprazole products given orally. A study reported by Dr. Raidal and her colleagues, showed that not only were plasma concentrations of omeprazole similar with both products, but importantly, the research also showed that gastric pH was similar with both products, and both products reduced summed squamous ulcer scores. Both the products tested in this trial are available in Australia and, although products on the market in other regions have been shown to achieve similar plasma concentrations and it is therefore reasonable to assume that they will be beneficial, as yet, not all of them have been tested to show whether products are equally effective in reducing ulcer scores in large-scale clinical trials. Trainers should discuss this issue with their vets when deciding which specific ulcer product they plan to use in their horses.

Avoiding drugs altogether and replacing this with a natural remedy is appealing. There is a plethora of nutraceuticals around and anecdotally, horse owners believe they may be effective. One such option is aloe vera that has antioxidant, anti-inflammatory and mucus stimulatory effects, which might be beneficial in a horse’s stomach. Another research group from Australia, this time based in Adelaide, has looked at the effectiveness of aloe vera in treating squamous ulcers and found that, although 56% of horses treated with aloe vera improved and 17% resolved after 28 days, this is compared to 85% improvement and 75% resolution in horses given omeprazole. Therefore, Dr. Bush and her colleagues from Adelaide concluded treatment with aloe vera was inferior to treatment with omeprazole.

Medications for Glandular Ulcers….

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Calming Influence

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Catherine Dunnett BSc, PhD, R.Nutr - (Issue 24 - Triple Crown 2012)

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