Equine Ulcers – You Really Need To Know More!

Kerry J. Ridgway, DVM
Institute for Equine Therapeutic Options


Ulcers in the digestive track are more than just the latest “disease du jour.” Thus far, for a problem that has been recognized for about 20 years, we are still seeing and understanding only the tip of a metaphorical iceberg. More than two thirds of the iceberg is still not visible and much is still being discovered about this ulcer “iceberg.” We do know that there are, basically, only two kinds of horses – those who have ulcers and those who will have ulcers!

We should all recognize that gastric and intestinal ulcers are literally a slow or non-healing acid burn - a burn such as if hydrochloric acid was splashed on your face. The horse’s ulcers are a combination of this hydrochloric acid, as well as volatile fatty acids and bile acids. In horses, the acid burns holes into the lining of the stomach, small or large bowel. The acids may burn a crater deeply enough to cause bleeding or even burn through and penetrate the gut. When the acid burn craters do heal they can create scar tissue and strictures, especially in the small intestine that may lead to colic.

Therefore, the real purpose of this paper is three fold.

  1. The first purpose is to provide a short synopsis regarding the dangers and sometimes-dire consequences of ulcers.
  2. The second is to alert you to the signs and symptoms pointing to the presence of ulcers.
  3. The third, and a very important purpose:  Empower you to use a simple examination technique that can give a very strong presumptive diagnosis of GI ulcers. This technique can, in many cases, bypass the need for endoscopic examination if, for example, this procedure is not readily available or is not affordable. Confirmation by administration of appropriate medications is often used as a diagnostic tool and confirmation of a “presumptive” diagnosis.

 

Twelve Good Reasons to Understand GI Ulcers in Horses:

  1. Ulcers increase the risk to the horse’s health, safety and welfare
  2. Ulcers increase the risk to the rider’s safety and welfare
  3. Ulcers cause loss of performance and competitive edge
  4. Ulcers can upset or interrupt an entire competition schedule
  5. Ulcers are very expensive to treat and to resolve – recurrence is common
  6. Ulcers cause many “behavioral” problems
  7. Ulcers set up many muscle, myofascial and chiropractic issues
  8. Ulcers increase risk of injury and lameness as a result of number seven (Musculo-skeletal problems
  9. Ulcers increase the risk of colic and diarrhea problems
  10. Ulcer stress may deplete the immune system and make a horse more susceptible to disease
  11. Ulcers often create “hard keepers” and cause weight loss. The result – an unthrifty horse. (However, some horses with excellent weight also have ulcers)
  12. Toxins released from altered gut flora increase a risk of laminitis/founder

When horses develop painful and restricted movement associated with excess muscle tension, and poor ability to use the spine – resulting in pain - they cannot perform at the desired level. They are, thus, more prone to injury if pushed to jump higher, run faster, suddenly change direction, etc. In the case of cross country eventing, show jumping, racing, cutting, gymkhana, marathon competitive driving and other high performance demands, the risk of injury is greatly increased.  A body in pain is always at risk and increases the likelihood of a fall. Needless to say a fall is always potentially dangerous for both horse and rider.

Next, it is appropriate to review the signs and symptoms associated with ulcers. Many of these the reader may already be familiar with. Others are less well known, but may serve even better to make one aware that a horse may be experiencing ulcer pain.

Changes in behavioral patterns:

The horse may respond by becoming more resistant to going forward and responding to the normal aids. It may kick out, rear or buck when asked to go forward. It may respond by becoming more irritable in general, but specifically to being groomed or handled. Some progress to the point of being aggressive. Particularly in chronic cases some “turn inward” and appear dull and disinterested – sort of “the light is on, but nobody is at home.”

Performance Issues and Body Pain Issues in Ulcer Cases:

Very importantly but not as commonly realized, as it should be, body pain goes hand in with ulcers. Whether arising from muscles, chiropractic problems or from joints, pain is inextricably associated with impaired performance. The form that the issue takes is, of course, variable, but may include reluctance to jump in good form, running out, bucking or refusals. It is not uncommon for the horse to buck after a jump. Similarly horses may be reluctant to go down hill. In such cases (including the horse landing after a jump), when the stomach has been compressed by the viscera (abdominal contents) the acids in the stomach are splashed up and onto the non-glandular portion. This portion of the stomach is more susceptible to acid damage than the glandular portion (that portion secreting the acid.) Performance horses, for example may refuse to take a specific lead or to perform a rollback or pirouette, slide, etc.

Due to the consistent muscle pain patterns found in ulcer cases, the horse will cross canter or refuse to pick up a specific lead. Often these horses do not come through in the hindquarters (especially the right hind). They are often restricted in the shoulders due to a consistently found neuromuscular pattern that tightens the fascia over the muscles of the shoulder and wither pocket area. This myofascial contracture limits the ability of the muscles to lengthen and shorten appropriately. The result is pain and develops into a consistent pattern of vertebral dysfunction (chiropractic problem) in the wither vertebrae. Other consistent findings include chiropractic issues in the thoraco-lumbar area (the transition zone from chest vertebrae to the loin vertebrae). There is also a consistent pattern of pain and dysfunction where the lumbar vertebra joints articulate with the sacrum. Vertebral joint dysfunction is defined, basically, as an inability of joints to move through their full range of motion. Loss of joint motion results in pain and inability to use the back well.

One very important muscle that is frequently dysfunctional in ulcer cases is the Psoas (pronounced “SO-as and is actually a group of 3 muscles). Taken together, this group represents one of the largest and strongest muscles in the body. Its function is to stabilize and protect the pelvic girdle from damage. This is the group of muscles that prevents a racehorse from literally fracturing its pelvis when it bolts from the starting gate. The Psoas muscles are usually intimately involved in chronic sore backs in both horses and people. When there is Psoas muscle pain the pelvis and croup muscles cannot function well. The croup muscles then go into spasm and are painful to palpation (touch). Understanding this, it is easy to visualize significant loss of performance ability.

What can you observe when you look at a horse with ulcer problems?

1. Weight Loss: That, of course, depends on the severity and duration of the ulcers. However, even in somewhat less severe cases horses are moderately down in weight. Recent history often indicates that it is hard to keep weight on them. Hand in hand the horse may show some loss of muscle mass and top line.

2. Eating Patterns: In observing the ulcer horse’s eating patterns, you may notice that it has become a slow or picky eater.  Some will literally walk away from their hay and/or grain. It is common that they may nibble hay, but refuse grain. (Some horses with ulcers will continue to eat like a proverbial pig)

3. Appearance: It is also commonly observed that the hair coat, especially, over the thorax (chest) is duller than on the neck or hindquarters. (not every horse will show this pattern)

4. Resistance to Grooming: Many horses with ulcers do not like to be brushed on the bottom of the chest and abdomen. They may even kick out if touched in the area of the sheath or mammary glands.

5. It is very important to note that some horses may be in good flesh, have good appetites and still have ulcers in their digestive tracts and have musculo/skeletal issues and performance related problems that are consistent with the ulcers.

6. Horses with chronic ulcers may show poor quality feet

Presumptive Diagnosis by Palpation: General Considerations:

In medicine, the term “presumptive” or, also called, “tentative diagnosis” is used until a diagnosis is actually confirmed by a medical professional. Having said that, a rider, trainer or body worker using the techniques that follow will be much more aware and can convey the need for examination by a veterinarian.

Palpation is the touching and feeling of tissues with the goal of identifying structures that are not normal. The only tools needed are your hands/or fingers or a not-so-sophisticated tool like the blunt end of a ballpoint pen or more ideally, the cap from a hypodermic needle. The goal is to identify small points or areas that are painful and see them be manifested by a flinch response. Hard or deep pressure is not necessary to elicit such responses in a horse with ulcers. Stick with a moderate pressure.

So, What Can Be Identified? The flinch response can be used to identify reactive “trigger” or “acupuncture” points. It can be used to identify painful muscles and even to identify chiropractic issues in an individual vertebra or identify the chiropractic pattern commonly in ulcer cases. The pressure applied with the needle cap in some locations is done with the point and on other locations with the side of the needle cap.

You should always touch any area on a horse first with the fingers, or stroke the area with the palm of the hand, so as not to surprise the horse and elicit a false response.
 
Places to palpate:

In Traditional Chinese Medicine (TCM), the Stomach Meridian runs down the bottom side of the so-called “strap muscles” at the base of the neck. The lower one third of this “strap” muscle (The Brachiocephalicus) is nearly always reactive in ulcer cases when pressure is applied using the side of the needle cap. Do not use the tip of the needle cap as a false response may be elicited. The horse, if not first surprised, should not flinch from the amount of pressure that you can comfortably tolerate on the palm your hand. For this to be indicative of ulcers, it should be equally reactive on both the left side and the right side.

Acupuncture Points:

In all cases of using these five points, the reactivity (flinch response) must be present on both the left and the right side of the horse. As described in this article you do not have need for an in-depth understanding of acupuncture or to know the exact anatomical point location.

Point 1. Using the tip of the needle cap (after first using finger tip pressure), examine an acupuncture point that refers to the Stomach in TCM (The point is BL 21). This point lies at the rear border of the last rib. If one follows the rib’s curve well, there is not a need for pinpoint accuracy in location of the acupuncture point. If the horse has ulcers, a marked flinch is noted when the tip of the cap is stroked downward from the spine along that rear border of the last rib. The flinch will occur as the needle cap passes over the point about a hands breath out from the spine.

Point 2. The next point to be examined lies at the same distance from the spine but at the border of the next rib forward. The palpation is repeated in exactly the same manner as above. This point refers to the TCM Spleen (BL 20). The TCM Spleen is associated with the pancreas. The pancreas secretes the enzymes necessary for digestion of fats, carbohydrates and proteins. Therefore, in TCM it is considered the key organ of digestion and works with its Chinese Medicine partner, the TCM Stomach.

Points 3.  The next two points to be examined for the Stomach and Spleen are called “Alarm Points.” The first is a secondary “alarm point” for the Stomach. (Use the tip of the needle cap after first stroking with the tip of the index finger.) This point is located on the bottom of the chest about four or five inches behind the elbow (ST 11). It is in a soft depression where the chest muscle (the Ascending Pectoral muscle - on each side) blends into the bottom of the chest wall. A mild to moderate pressured stroking motion from the bottom center rearward again makes it unnecessary to have the point accurately pinpointed.

Point 4. The Spleen “alarm point” is located where the next to last rib joins the cartilage that leads to the sternum (LIV 13). The sternum is analogous to that row of bones that is on the front of a human’s chest. The bone/cartilage junction is approximately where the abdomen starts to curve in toward the midline. This point can be quite reactive and palpating first with fingertip pressure is indicated for safety’s sake.

There are several other points with which to strengthen the presumptive diagnosis of ulcers and help distinguish foregut from hindgut ulcers (or both) that are better described by demonstration; but if the strap muscle and the points described are all equally reactive on both the left and right sides of the horse, the indications are very strong that ulcers are present somewhere in the digestive track.

I recognize that many persons do not learn well from the written word alone no matter how hard I try to put the descriptions into words, it may require the help of a veterinary acupuncturist/chiropractor to demonstrate and teach the location of the points.

As a veterinary acupuncturist and chiropractor, I then, after checking all the “test points” on the neck thorax and abdomen, use an acupuncture treatment protocol that is indicated for acute gastrointestinal distress.  The protocol I use treats only points on the limbs of the horse and none of the test points are needled. If all of the test points become non-reactive the presumptive diagnosis is very much strengthened.  This diagnostic treatment also provides a good base from which the healing effects of conventional ulcer medications are given a boost.

Myofascial/Neuromuscular Patterns:

There are patterns in the fascia (the fibrous covering over muscle) that can also be used as further evidence of ulcers. Testing is best performed by a person is trained in “neuromuscular release” and “myofascial release.” However, with instruction, the procedure for this specific use can be readily taught to a layman.

The Wither Pocket Muscles:

The other area readily evaluated with the needle cap is the “wither-pocket”. This is the pocket where the pommel points and panels/bars of the saddle rest behind the shoulder blade. Begin the stroking from the top of the “pocket” just behind the scapula (shoulder blade). Commence the exam with the fingertips and exert a light pressure then gradually stroke with more pressure. Continue stroking somewhat rearward to the bottom of the “wither pocket.” The exam can be better executed using the flat side of the needle cap (not using the point of the cap).

A horse that does not have ulcers (or saddle fitting problems) should be able to tolerate the degree of pressure that you can readily tolerate when stroking the side of the needle cap against the open palm of your hand. The reaction in an ulcer case may be present on both the left and right wither pockets. Remember, even though the “pocket” is almost always reactive in ulcer cases this procedure as an only test is not adequate to say that the horse has ulcers, since it may also indicate poor saddle fit. It has more significance when viewed along with e.g. “ulcer point” sensitivity

Conclusions:

Gastro-Intestinal ulcers are a serious, difficult and expensive disease problem. Early diagnosis and prompt treatment are extremely important. The good news is that with the information provided in this article you, the reader, can be much more aware and pick up on the evidence much earlier.

Regarding the value and validity of this method of diagnosing ulcers, I have experienced a greater than 95% accurate positive diagnosis response. This is based on horses that have been confirmed ulcer positive by diagnostic ultrasound or confirmed by a positive response to Omeprazole (GastroGard) therapy. Endoscopic diagnosis is limited to diagnosis in only the stomach and a small portion of the small intestine. In a retrospective university autopsy study of 565 horses, 45% of non-performance horses and 65% if performance horses were found to have ulcers in the hind-gut (specifically in the Right Dorsal Colon). These cannot be picked up by endoscopic examination. This explains why one may find the points and patterns described in this article reactive in spite of a negative endoscopy.

Another very interesting and surprising fact has surfaced over and over with the author’s ulcer cases. When the horses are treated with acupuncture as part of the diagnosis, not only do the “test” points become non-reactive, much of the body pain (muscle and chiropractic) issues resolve or are significantly mitigated.

When this is found to be the case, my protocol is to perform additional acupuncture and chiropractic therapy prior to starting an ulcer medication. This type of Integrative Medicine approach has done a remarkable job of returning ulcer horses to full performance and competition capabilities usually within six to ten days. Some cases do require a follow up with acupuncture and chiropractic to resolve remaining or recurrent chiropractic and muscle issues.

Ulcer occurrence can be greatly reduced with management and feeding. As a veterinary practitioner, I am very interested in prevention of recurrent ulcers as well as prevention of first time cases. In this series, I will provide articles on prevention (and therapy) based on environmental aspects such as stress minimization. Such stress mechanisms are encountered with transportation, competition, weaning, separation anxiety, and housing. A follow up article titled “Feeding Horses With Gastro-intestinal Ulcers” will address the concepts of feeding for prevention and feeding as part of treatment. Also an article de-mystifying and/or debunking various medication therapies will follolw.

 

Gastro-Intestinal Ulcers Part 2 – How Can We Deal With Them?

In Part 1 of we discussed the incredible preponderance of horses that have ulcers in their digestive tract. We also discussed the largely unrecognized but extensive performance limiting body/muscular-skeletal problems and “behavioral” problems that go hand in hand when horses have ulcers.

Since we have only some fifteen years ago, started recognizing that ulcers are a significant a problem, our knowledge is still limited. We are still learning and seeing the problem in more depth. What I, as a rider and clinician am now recognizing is that through the years we have unknowingly condemned hundreds of thousands of horses to the “trash heap. We simply had not known that so many “hard keeping hoses,” “bad disposition horses”, “poor performing horses” were suffering from gastrointestinal tract ulcers. Looking back, some dispositional issues were so severe that afflicted horses could be dangerous to handle and show severe aggression. Many of these horses could have been top horses if we had simply known how diagnose and how to deal with ulcers.

The sad truth is that with what we do know at this point is that many - many horses are still being condemned for these very same reasons. Because of a lack of knowledge about ulcers they are being relegated as failures as performance horses or just too difficult to work with. In my practice, I, daily, see horses that were normally mellow and easy to work with become nervous or agitated or even become downright aggressive.

So now let us talk about dealing with GI ulcers. (In all of the following discussion, I am going to refer to the horse as “he” or “him” with the readers understanding that I am referring to both genders in all instances.)

 The first thing that must be acknowledged, like it or not, is that equine ulcers are a man made disease. We have taken a nomadic herbivore evolved to graze as much 20 hours a day (often on low quality forage) and placed him in confinement and bulked him up with “high quality” hay and massive quantities of grain that he would never have seen in his more natural state.

The “high quality forage” that we feed is really designed to fatten cattle or increase milk production and not the “lower quality” of forage that nature designed the horse to eat. This so-called “lower quality” may in fact be of more quality for equids needs! Perhaps we should answer the question, “Are we feeding the horse to eat or produce more milk?” Adding insult to injury, we don’t even allow the horse to eat and cover some distance over the 18 - 20 hour grazing period for which nature designed him. Instead we add to his stress by confining him to a stall or small area and feed him twice, or if he is lucky and we are good managers, we feed three times a day. Often he is alone, or out of sight of his companions – totally against his nature as a herd animal.

But we are not through yet. We transport him to strange locations, often over long distances, often without the companionship of horses that he knows, change the water that he is used to, perhaps change the forage he has at home and again confine him in a very small box stall, or tie him to a trailer for long hours at a time.

I am not so naïve as to suggest that we are going to suddenly change everything in our management and use of the horse. That is a fact of life and so are the consequent ulcers. However, it is possible with common sense to find ways to mitigate the environmental stresses, feeding, and many management aspects.

So, our next need is to understand a bit of anatomy with regard to the horse’s digestive tract and a bit of the physiology of how horses digest food. This will help us with common sense answers to what we have stated above. It will also help us to understand what types of medicines and nutritional factors we can use to treat ulcers and prevent recurrences.

Lets start with the horse’s digestive tract. If it were to be stretched out to its full length, it would be a full city block long. The stomach portion is one of the smallest aspects and can only hold two or three gallons of material at a given time. This means that with the large amount of food a horse consumes in a day, the stomach must pretty rapidly process the food and move it on into the small intestine and from there into the large bowels. So – in relationship to stomach ulcers - the key point is that the stomach is geared to eating small amounts on a nearly continuous basis and not large amounts two or three times a day. The horse evolved as a grazing animal, right?

Add to this the fact that the glandular portion (in the lower part) of the stomach secretes well over a quart and a half of hydrochloric acid every hour on a 24/7 basis whether food is present or not. If no food is present for long periods, the acid can literally start digesting the lining of the stomach itself. This phenomenon is even more likely to occur with exercise. During exercise, the tightening abdominal muscles compress the stomach and move acid up where it does not belong.  Especially during a canter or gallop, the viscera are propelled forward, essentially slamming into the stomach and compressing it against the diaphragm. The result is “splashing” of the acids (hydrochloric, volatile fatty acids and bile acids) up and onto the upper part of the stomach.

 

 stomach
(courtesy: Lorenzo-Figueras and Merritt)

The lower part of the stomach, in addition to producing the acid, receives protection by also producing mucous. The upper or non-glandular part has no protection and thus is more susceptible to damage by the acids. The upper portion has squamous epithelium – not dissimilar in a way to our skin and you are aware of the effect of acid on our skin.

Add grain to the horse’s diet and we compound the acid load problem because grain digestion, as it starts in the stomach, is broken down into “volatile fatty acids” and adds to the hydrochloric acid and bile acids already present. Grains empty from the stomach more quickly than forage materials and progress into the small intestine. The larger the grain portion, the quicker the emptying. Here the digestion is aided by enzymes that break down the starch and complex carbohydrates into simple forms that can be absorbed through the gut wall. However, if there are large amounts of grain consumed, it is not adequately processed in the small intestine. The transit time in the small bowel, like the stomach, at one and a half to two hours is relatively short.

That means that food; especially grain that is not fully digested between stomach and small intestine ends up in the huge vat called the cecum. The cecum is the first part of what is referred to as the hindgut. The balance of the hindgut is the large (ascending) colon, the small colon and the rectum and the anus. The cecum is where all the tough fibrous forage material is processed and is not well adapted to processing carbohydrates (grain). Digestion here is accomplished by trillions of “good” bacteria that break the tough fibers into useable volatile fatty acids that are then absorbed through the gut wall.

When grain gets to the hindgut the breakdown, (besides volatile fatty acids) produces gas and lactic acid. Lactic acid makes the hindgut more acid and creates and environment where the “good” bacteria die off and release endotoxins in the process. Endotoxins are poisons generated by the death of the bacteria. The good bacteria are then replaced by “bad” bacteria that can thrive in the more acid environment created by the lactic acid.  The “bad” bacteria damage the intestinal mucosa (lining) allowing the toxins to enter the bloodstream. It is common to see picky eating, leaving food, becoming agitated or grouchy. The discomfort can also start horses to cribbing, weaving or stall walking. Other signs and consequences are bouts of mild diarrhea and/or colic that can, of course, progress to more dire consequences.

Besides giving medications (I will address the use of ulcer medications in the third part of this series), what can we do to help? We obviously cannot take our performance horses and duplicate their natural environment. But, we can make valuable changes via our management procedures.

The more time the stomach has food within it, the more it will properly stimulate the gut and use that amazing amount of acid production for the digestive process. With that in mind, whether at home or on the road, keep him eating small amounts of food as frequently as possible. Hay bags with small openings such as the “Nibblnet” (see www.nibblenet.com), or a device that will dispense small amounts at preset intervals are available (google “slow feeders for horses”). At home the ideal, of course, is free access to pasture or forage. For those horses who “pig out” one can always use a grazing muzzle that makes them work for every blade. Also instead of feeding a bunch of hay in one pile, scatter it allover the paddock so that he moves and picks and moves and picks.

For horses that are on timothy, orchard grass or other grass hays, consider feeding about 20 to 25 percent of the hay in the form of alfalfa. It is postulated from studies showing lower ulcer rates when on alfalfa, that the higher calcium content and higher protein can serve to help buffer acids. Alfalfa may also induce more saliva production that helps buffer acids and protects the squamous portion of the stomach. Grazing also produces more saliva that has a protective effect. Acid buffering bicarbonate is released in the saliva by the act of chewing. Adding beet pulp (soaked and not containing molasses and preferably not genetically modified beet pulp) can be very helpful to at risk horses. It will slow the emptying of the gut and that is a good thing. It goes without saying, whether hay or grain, make any feed changes gradually. Gut flora (bacteria) need time to adapt.

If you are feeding grain with beet pulp, the pulp/grain mix will slow the passage out of the stomach and to the small bowel. More complete conversion to volatile fatty acids will take place and allow better absorption of those volatile fatty acids from the small intestine. (Remember, you don’t want them to get to the cecum.) You can also slow the intake of grain by feeding it in a pan that contains a number of smooth rocks that makes the horse work for every little particle. Remember that grains that contain quite a bit of fiber are good. Oats, for example, with about 50% fiber via the hulls are a safer and less carbohydrate rich but still good energy rich source for the horse (80 - 90% percent pre-cecal starch digestibility).

You can replace some of the grain/concentrate needs by adding fats to the diet. An athletic fit horse can handle up to 10% of his energy intake with fats/oils such as corn oil, peanut oil, or the rice bran supplements that are rich in fat.

Turnout, even when not a lot of forage is available, creates significantly less risk of ulcers and colic than occurs in stalled horses. Stalls, though often a necessary evil, are still one of the worst concepts that we have forced upon our horses. Turnout – turnout – turnout as much as possible, and yes, – even with dressage horses! In turnout it is always best for the horse to at least be in sight of other horses. Avoid any turnout with horses that your horse doesn’t know.

When exercising horses it is good for food some roughage to be present in the stomach to help blunt the effects of acid getting pushed up and onto the unprotected squamous porting of the stomach. It cannot be emphasized enough times to do your best to feed small amounts frequently.

It is a fact that many show, competition and racehorses live on the “go” and are in the “fast lane.” So what else can we do? Think about it – some horses handle stress better than others. We tend to ride what we have, but given a choice we can select horses that are not afflicted with anxiety separation. We can try to select horses that handle many stressors better than others - such as being around new horses, horses that are less anxious in a stall, horses that trailer well. Regarding all of these factors, talent, of course, may of necessity govern our choice, so what else can we do to mitigate the ulcer risk. We can keep a partner around whether it’s another horse, a small pony, donkey or a goat. Some horses are happy with a cat, a dog, or even a chicken in their stall or trailer.

We can train horses from an early age to handle short and then progressively longer separations. They can learn to trailer quietly and to get used to the presence of strange horses, crowds and the hubbub of shows and events before actually competing. Take them to the bank, the grocery store or dry cleaners! Getting used to stress inducing conditions early is certainly easier than dealing with them once emotional patterns are set. Exposure, exposure, exposure! We can help by keeping food available via hay bags or nets even when trailering. Fill with relatively small amounts and frequently replenish the bag or net.

In my opinion, ulcers of the digestive tract are an extremely important factor that has deleterious effects on their health, wellbeing and ability to compete at their best. We can do much to mitigate the risks. For all we do, we must still recognize that ulcers in our horses will be a part of life and must be treated. The final part in this series on GI tract ulcers will look at what the pharmaceutical industry has to offer in ulcer meds, as well as their pros and cons. We will also look at nutriceuticals that help maintain a healthy gut. The vast array that is out there can be pretty confusing. I hope this next section can make it less confusing for you.

 

Part Three: Treating Equine Ulcers – A Gordian Knot

In the first three parts, we discussed the high number of horses that have ulcers in their digestive tracts and the signs and symptoms of an ulcer. Part two addressed feeding and management practices that can help keep our horses from getting ulcers. Once a horse does have an ulcer, however, it needs to be treated. There are many different medications and supplements on the market. Some work; some don’t. Most are relatively expensive. In this, the third part of this series, we will examine some of the treatment options, discussing their benefits, their drawbacks, and their costs.

So what does work to treat equine ulcers? For starters, it’s important to realize that no program or medication will work without good consumer compliance. It requires good management of nutrition, of the environment, and of stress-producing situations such as training, showing, and transportation. As a veterinarian, I try to help owners design management programs that are reasonable in terms of the owner’s time and capabilities. The administration of medications and supplements also has to be convenient enough to fit into busy days.

Ulcer treatments for horses come in many varieties. Some work by blocking acid production, while others neutralize acids. Some attempt to buffer acids so there is less harm done, and yet others try to condition or coat the surface of the digestive tract so that it is less susceptible to damage by the acid or that will form a “bandage” over the ulcer.

Some of the products work best on ulcers in the stomach and small bowel while others work on hindgut ulcers. Some horses may need to be treated with more than one product. It is no secret that ulcer treatments can be expensive. In this article, I have sorted the products by daily cost – you don’t have to be ultra rich to afford ulcer treatment.

My next caveat is that it is wise to do everything you can to prevent ulcers. These nasty little acid burns are just plain expensive to treat!

Treatment Options and Considerations
There are many different medications and supplements on the market. Some work, some don’t. Most are relatively expensive. Let’s examine some of the treatment options, discuss their benefits, drawbacks, and costs. Cost projection is a problem, because even as this chapter is being written, more new products have been introduced, some are no longer available, and prices are always subject to change. Keep that in mind as you read on. My purpose in including prices of products is, simply, to provide a sense of comparison of costs for therapy and give you some idea of what is out there. It is, unfortunately, also a fact that almost every book written about medicine, therapy, etc., is at least partially out-of-date from the moment it is published. That is not, however, a reason to skip this part. Much, if not most of it, will remain viable and important for the foreseeable future.

Owner Compliance
So what does work to treat equine ulcers? For starters, it’s important to realize that no program or medication will work without good consumer compliance. Success depends on more than just administering medicine and hoping for the best. There must be good management of nutrition, of the environment, and of stress-producing situations that we have discussed. Knowledgeable veterinarians can design medication and other management programs that are reasonable in terms of the owner’s time and capabilities. The administration of medications and supplements has to be convenient enough to fit into an owner’s busy days.

Ulcer Medications
Ulcer medications for horses come in many varieties. Some work by blocking acid production, while others neutralize acids. Some attempt to buffer acids so there is less harm done, and yet others try to condition or coat the surface of the digestive tract so that ulcers damage it less, while others work better for hindgut ulcers. Some horses may need to be treated with more than one product. It is no secret that ulcer treatments can be expensive. In this chapter I have attempted to sort products by their actions and by an approximate daily cost — you don’t have to be ultra rich to afford ulcer treatment (but it would help).

Omeprazole Treatment Products
Let’s start with the gold standard for treatment for horses, Omeprazole®, which is the active ingredient of the human ulcer medication, “Prilosec®.” It is produced by Merial Pharmaceuticals and in the horse world goes by the names GastroGard® and UlcerGard®. They are identical products and each tube contains the same amount of Omeprazole. GastroGard® requires a prescription whereas UlcerGard® is available over the counter (OTC) without a prescription. The cost for both products is the same. Merial justifies marketing this dual product by stating that they sell the UlcerGard® as an ulcer preventive with its directions to use one-fourth of a tube daily, while GastroGard® (as a primary treatment) calls for the prescription strength of a full tube per day. Weird, but true! Most horsemen are certainly capable of figuring out that they don’t need to go to the trouble of getting a prescription when they can buy an identical product OTC and often less expensively. Having said that, the dose of 1/4 to 1/2 of the syringe contents, given daily for an advised period, is helpful in terms of follow-up to the more intense therapy. It is also often recommended for use as a preventative once the ulcers have healed. It is not the least expensive way to do follow-up or for further prevention.

Omeprazole is a “proton pump inhibitor” which basically means that it blocks the glandular (parietal) cells in the stomach from producing hydrochloric acid. It is so effective that it can block acid production for up to 27 hours. Moreover, it can block up to 90% of acid production. This is great and important from the standpoint of convenience for owners and for effectiveness. However, the question that has to be asked is how long should the horse be deprived of 90% of its acid production? After adequately chewing forage, acid production is the next step in digestion. In order to break down forage material, a fair amount is required. The acid is also the first line of defense against pathogenic bacteria such as Salmonella. A bacterial infection with this organism is likely to cause a life-threatening diarrhea.

The Merial program suggests a full dose (one tube) of GastroGard® every day for 28 days, then going to a half-dose per day and then suggesting a one-quarter tube dose for prevention. Many veterinarians, myself included, feel that long-term Omeprazole therapy may be setting up another problem. If feed (especially grain) passes quickly through the stomach without adequate breakdown from hydrochloric acid, it can create problems when it reaches the hindgut by making the environment there more acidic. As we previously discussed, but important to reiterate, this results in the death of the normal flora (bacteria). This is setting the stage for ulcer development in the large bowel as well as all the problems associated with the release of endotoxins released by the dead bacteria.

In humans, who for extended periods of time take Prilosec® (the human form of GastroGard®/Omeprazole), they are likely to create a serious vitamin B12 deficiency. Acid is a necessary step in B12 production to create a useable form. B12 is critical to nerve function as well as to energy levels. So far, it is not confirmed that this problem occurs in the equine, but it makes common sense not to use Omeprazole longer than necessary. Not infrequently, humans using Prilosec® for long periods of time experience a serious “rebound” effect when it is stopped. They may have intense gastric pain and GERD – (“gastric-esophageal-reflux disease”) that causes mucosal damage from stomach acid coming up from the stomach into the esophagus. This has not been thought to be a problem for horses, but I am finding that some horses on long-term use seem to quickly develop ulcers again when taken off the Omeprazole, so it is not unreasonable to suspect some type of a “rebound effect.”  If my follow-up exam says the case is going well, my preference is to go down to a half-tube dose after three weeks. It is also a good idea in many cases to put the horse on a gastrointestinal conditioner either at the same time as you start Omeprazole treatment or two weeks afterwards.

A major issue for many horse owners is the cost of GastroGard® at $35 to $50 per day. Thirty days of medication would cost from $1,050 to $1,500. Wow! So what about generic Omeprazole products? Merial has tested a number of generics and found the efficacy to run from a low of 35% to a high of 79%. It is always a consideration and a concern that such research reports done by the manufacturer may be biased. These reports should, however, still give us pause before shelling out our hard-earned money on generics. I have seen failures with a number of such generic Omeprazoles, especially in powder, pastes and pill forms. The problem is that Omeprazole that is not specially stabilized is acid labile. Acid labile means that the product is actually inactivated or destroyed in the presence of acid, and that obviously includes stomach acid. Merial has a proprietary means of stabilizing so that it gets beyond the stomach before being absorbed and that compounding pharmacies cannot duplicate.

Having said that, a number of veterinarians throughout the United States have found certain generic Omeprazole products have been clinically effective in treating ulcers. Personally, I have found one generic that has given consistently good results at a cost of $10 a day for the first three weeks and then $5 dollars a day (when I halve the dose) for the next two to three weeks. That is, at this time, about $300 for one month. Have I had any failures? Yes, rarely, but I also have had failures with the brand name products. Costs will likely come down for UlcerGard® and GastroGard® when Merial’s patents on these products expire. As an advocate for the client (as well as the horse), I feel it is my responsibility to point out both the pluses and minuses and help clients find effective therapy that fits their pocket book.

It is very important to realize that GastoGard and all omeprazole products only work on ulcers in the stomach. They will do nothing for the 45 to 65% of horses that have hind gut ulcers and will drain your pocketbook.

H2 Antagonists
Now let’s switch to an entirely different class of medications. These are called Histamine2 Antagonists. Histamines stimulate the stomach to produce acid. Regular antihistamines will not affect this acid production, but a group known, as Type 2 antihistamines will. Consequently there is a need for medications that will serve this purpose. Such a product is Ranitidine, better known as the human ulcer medication Zantac®. Ranitidine was first released in Australia for treatment of equine ulcers under the product name “Ulcer Guard®.” (Do not confuse this with UlcerGard, Merial’s Omeprazole  product.) For a 500 kg horse (1200 pounds) the dose is 6.3 grams per day divided into three doses per day.

Ranitidine is a useful and effective medication for both stomach and hindgut ulcers. Its drawback is that it should be administered three times a day for best effectiveness. It is possible, but less desirable, to increase the dose proportionately and give it twice a day. The cost per day (depending on the source) is approximately $5. Giving this dosage for 30 days, your cost would be $150. It is available on a number of veterinary product sites, but does require a prescription.

Another of the H2 antagonists is Cimetidine, known as Tagamet® in the human form. Unfortunately, well-documented research studies have failed to prove that Cimetidine is effective as a primary treatment for gastric ulcers in horses. Having said that, I have had reports from clients who say it has brought at least temporary relief if not a cure for their horses. Cimetidine might be helpful, say, at a show or other events in early cases of ulcers or stress.

Coating Agents

Sucralfate is one such interesting medication. It is a non-absorbed aluminum salt of sucrose. When in an acid environment like the stomach, it becomes a thick, viscous compound that adheres to an ulcer site and acts like a bandage. It will provide protection for about six hours at a time, so it needs to be given a minimum of three times a day. Now, to add a little more frustration to your horse management day, recommendations are that it is best given separately from any other medications that the horse is receiving. This is because it can interfere with the absorption of a number of medications.

Sucralfate is also a good product for use in both foregut and hindgut ulcers. Remember that hindgut ulcers may occur in as much of 60 to 65% of the horse population, particularly performance horses on high grain rations. Remember also that the percentage may be even higher as the only really accurate diagnosis is as a necropsy finding, and a very small percentage of horses are necropsied. Even those that are necropsied, for whatever reason, may have had episodes of hindgut ulcers, but happened to be “clean” at the time of the necropsy. Sucralfate is best used in combination with Ranitidine when hindgut ulcers are suspected. It is quite good in horses that exhibit colic pain with ulcers. Colicky signs are typically relatively mild, but chronic and recurring, but can occasionally be severe.

The dose range for Sucralfate is 20 to 40 milligrams per kilogram of weight, so the average horse would need 10 to 20 grams every eight hours. The medication typically comes in one-gram tablets that need to be crushed and fed with a little bit of grain. Some compounding pharmacies make it in a liquid form. Sucralfate costs approximately $6 per day ($180 for 30 days) at the lower dose, and $12 per day ($360 per month) at the upper dose level. (Add to this the $5 per day for the Ranitidine that you might use at the same time.) Prices for both Sucralfate and Ranitidine can vary widely.

There is another interesting product called Starting Gate® made by SBS Equine Products. This product straddles the area between ulcer treatment and ulcer prevention. My findings are that it is best used as a preventative. Starting Gate® contains a stabilized phospholipid called lecithin that forms a hydrophobic (water/acid hating) protective layer over the ulcerated area. Though Starting Gate® does have the potential to help ulcers heal by protecting the mucosal layer of the stomach from further aggravation by acid, its best use may be in a maintenance and prevention role — especially for horses that are routinely subjected to stress.It is also important to note that the pharmaceutical company Boeringher-Ingelheim researchers say that some lecithins must be stabilized with a hydrophilic polymer to prevent excess breakdown into another compound called lyso-lecithin. Lyso-lecithin is harmful to mucosal cells. For this reason pure lecithin, such as one can buy from the health store is, according to their research, contraindicated in the therapy of GI ulceration.

Starting Gate® comes in a pelleted form, so it can be used as a top dressing on feed, and is available in one-gallon or five-gallon containers. At the recommended dose of three-fourths to one cup of pellets daily for a 1000-pound horse, one gallon will last approximately three weeks. At current pricing this comes to approximately $2.50 per day. A five-gallon tub will last 15 weeks, costing approximately $2 per day. Contact www.sbsequine.com to find places where Starting Gate® can be purchased. 

There is another lecithin product, Equitop Pronutrin®, marketed in Europe and Asia by Boeringher-Ingelheim (not available in the USA or Canada) that also contains pectins along with lecithin. Pectins are found in fruits, tubers and the stems of plants. In the presence of a low pH (as is the case of acid in the stomach), pectins turn into a gel that binds bile acids in the stomach. Pectins also help stabilize the protective mucus in the glandular stomach and increase the buffering capacity of stomach acid. This results in a less acid environment after a meal.

Research test results indicate that the combination of lecithin and pectin is reasonably good at treating ulcers. A product combining the two, made available in the U.S., is something I could get excited about. It would be a good thing if pectins were to be incorporated in Starting Gate® or if Equitop Pronutrin® were to be made available in the USA. These two products may still find their best use as maintenance and preventive medications.

Gastrointestinal Conditioners
This is a rather broad group of products consisting of a myriad of mixed compounds containing such things as probiotics, herbs, vitamins, and the like. This group of products seems to be expanding exponentially. Their purpose is more geared to preventing ulcers than to treating them. Many producers of such products claim that they also are excellent treatments for acute ulcers. That has simply not been my experience. I see many horses on various products of this type that have a raging case of ulcers when examined.  Some claim to work more on stomach (foregut) ulcers, while others are aimed at the hindgut (right dorsal colitis). I will review a few that I think are worthy of consideration.

The products in this category are, perhaps, most important for horses that are prone to recurrent cases of ulcers, such as those in performance sports, horses on high grain rations, and those subjected to a number of stressors (shows, separation anxiety, transportation, irregular schedules and frequent changes of food and water).

Succeed®, a product made by Freedom Health LLC, is, at this time, probably the best-known product in the GI conditioner category. It works well on most (but not all) horses and seems to be most helpful for hindgut ulcers. The product contains oat oil, oat flour, irradiated dry yeast, glutamine and threonine. You can find out what each of these products does by going to the Succeed® website (http://www.suceedcp.com/formulation.asp). 

With once-a-day use, the convenience aspect of this product is good, and Succeed® is available as a paste or as top dressing granules. It is not, however, an inexpensive product. The 27-gram paste dose currently costs approximately $3.50 a day.  For one month that comes to about $105. The cost for the top dressing granules comes to approximately $3 per day or $90 dollars a month. The first week of therapy requires a double dose, so double the prices per day for the first week. I again want to remind the readers that these prices may rapidly change, so be sure to check current costs.

Ulc-Rid® is a proprietary compound with which I have had good success. It is sold by Equine Nutritional Consultants, LLC in Versailles, Kentucky. It is also, at the time of this writing, distributed by KV Equine Products (www.kvequine.com). Though most cases respond to Ulc-Rid® as a primary treatment, I still find its best use as a GI conditioner and it is definitely useful for maintenance-level therapy. It is an all-natural liquid containing herbs (echinacea, licorice root and slippery elm), live probiotics, potassium, naturally-occurring vitamins and trace minerals and accessory factors such as fatty acids and allantoin. It is an all-natural product and has no deleterious side effects. It does need to be kept refrigerated.

The Ulc-Rid® literature states that it is antibacterial, antiseptic, neutralizes stomach acid, improves circulation to the stomach and GI tract, helps stop internal hemorrhage and arrests inflammation. As such, it is indicated for hindgut ulcers as well as gastric ulcers. The recommended dose is 60 cc (two ounces) given twice daily. It is best given directly into the mouth. However, clients do report success with top-dressing onto a small amount of grain. Purchased in the gallon quantity, the cost per day is, at the time of this writing, about $5.50, or $165 dollars for a month’s supply.

Buffering Agents
EquiShure® is a time-released hindgut buffer manufactured by the highly reputable Kentucky Equine Research (KER) Company located in Versailles, Kentucky. A buffer is a solution that resists change in pH when acid is added to it, such as when the stomach secretes more acid, thus lowering the pH. This lowering of pH can be stopped by the use of buffers A buffering agent adjusts the pH — acid-base balance — of a solution). EquiShure® is aimed primarily at performance horses that are on high grain rations and subject to stressors such as environmental changes, transportation stressors, high exercise intensity and variability of food and water sources. The product requires administration three times a day (every 8 hours).

The dosage range is 50 grams per day for horses with low grain intake and 150 grams daily for horses on moderate- to high-grain rations. (Note the necessity of higher doses of any buffering agent with horses that are fed larger amounts of grain.) My findings and recommendations are to go with the higher dose if hindgut ulcers are at all suspected. The larger size (a 7.2 kilogram bucket) at the recommended current pricing (at the time of this writing) retails at a cost of approximately $200 for 48 doses. At the higher dose rate, the cost per day is about $4.15, or $125 per month. At the lower dose of 50 grams per day for horses on smaller grain rations, the daily cost would be approximately $1.40, or about $42 per month.

Nutrient Buffer® is another good buffering agent. Its principle ingredients are: calcium carbonate USP, magnesium oxide USP, and zinc oxide USP in an oil suspension. The company that makes this product, Vita Royal, is owned by biochemist, Linsey McLean. All Vita Royal products are made with USP (pharmaceutical grade) products. This product is interesting because it is also holds patents and approval for human use as well. It is the only product with a favorable 2:1 ratio of magnesium to calcium. Ranitidine, the H2 antihistamine inhibitor, has known side effects in the human. So Nutrient Buffer is marketed as a means of avoiding H2 inhibitor side effects in humans.

 It does work well in horses. Nutrient Buffer®” is marketed as good for both foregut and hindgut ulcers and in dealing with “leaky gut syndrome.” Again, I feel its best use is as a maintenance and preventative for ulcers rather than as a primary medication for an active case of ulcers. Prices, of course, are always subject to change, but at the time of this writing, it is around $55.00 per gallon. At a dose of 1/3 cup fed twice daily, that would come to $5.80 per day or $174 per month. Vita Royal also offers comprehensive nutrition counseling. The website is www.vitaroyal.com.

Kombat Boots®, a strangely named and relatively inexpensive product, is a concentrated, pelleted form of brewers yeast. Originally developed to improve hoof growth (hence the strange name), the product is also useful in preventing ulcers. The website (www.kombatboots.com) states that adding yeast to equine rations helps stabilize hindgut bacterial populations, resulting in increased nutrient digestibility. It goes on to say that yeast helps “improve the percentages of useful microorganisms in the intestinal tract, boosts immune function and strengthens the structure of the gut wall,” at the same time lowering lactic acid levels. This means a higher pH in the hindgut. The higher pH results in a conducive environment for ‘good’ bacteria to thrive.  So far, this product has impressed me as a preventive gut conditioner and maintenance product. The cost per day for an individual horse is approximately $1.00 or less, thus making the cost per month about $30.00, making it one of the least expensive products. It also is all-natural and free of side effects. At the time of this writing, they have a toll free number and have maintained their policy of free shipping.

Natural Plan Stomach Soother® produced by Healthmate Products, Inc. is an all-natural liquid product that is made from papaya fruit. It is shelf-life stable, but does need to be refrigerated once the bottle is opened. This product has found a devoted following among eventing and endurance competitors, two sports that require significant amounts of training, transportation and other stressors such as frequent location changes. I have felt comfortable recommending it as a maintenance product. I feel is has preventive value in horses that have a stressful life. Quoting from Healthmate Products website:  “The active ingredient in papaya is papain, an enzyme found in indigestion remedies. Papain stimulates the production of mucous, which coats and soothes membranes of the esophagus and stomach, quiets inflammatory bowel syndrome, aids in protein digestion, and stimulates the appetite.” Papaya also contains vitamins A and C, niacin, riboflavin and thiamin as well as some calcium and iron.

Despite some glowing testimonials, I have not experienced good responses from Natural Plan Stomach Soother® as a primary treatment for confirmed ulcers, but am satisfied that it helps horses that do not have full-blown ulcers. It is available through many tack and feed stores or directly from the company. Information and ordering is available at www.stomachsoother.com. At a dose of 60 cc (2 ounces) given twice a day, one quart will provide eight days of treatment. At $13 a quart it will cost you about $1.62 cents per day or about $49 per month.

The Endless List of Manufacturers Vying for Market Share
There are myriad products out there claiming wonderful and sure-fire results. Most often they are combinations of antacids like bicarbonate, or buffers like calcium or magnesium, similar to baking soda, Tums or Rolaids. They may also contain probiotics to maintain healthy gut bacteria and herbs that treat ulcers. Others contain “protectants” that are supposed to coat over ulcers.

The sheer number of such products prevents me from covering them all in this article. Some have merit and many do not. For obvious reasons, I cannot be so foolhardy as to enumerate in writing the products that I feel are inadequate or not worthwhile. When providing consultation to an individual I am happy to discuss my experience and opinions regarding specific products.

With respect to products that contain primarily antacids, remember that acid is produced 24 hours a day every day, whether the horse is eating or not. Antacids can only neutralize acid that is currently there. So if you want to use antacids effectively, be prepared to administer them every two to four hours, day and night. Many of such products labels suggest that you use their products just twice a day!Such statements give the user a false sense of security, allowing them to think they are doing the right thing. Antacids and most buffering agents may be better used as part of a preventive program, or for horses that have more of a “heartburn-like” indigestion problem rather than true ulcers. 

It is also very difficult to comment on the many herbal and “natural”products that are talked about on the Internet. The problems lie in the lack of controls and lack of verification by any individual in a large number of cases. Other issues include: What is the dose (and how did that dose come to be); how many times a day should they be administered; are they better used for very mild cases or will they work on severe cases; and are they just better as a wellness and preventative (in which case, at what dose and what frequency of administration). In other words, there is just not enough information, nor enough proof, at this time for me to make any recommendations. For those of you interested in following this topic, I recommend the Yahoo chat group, www.wholehorsehealth.com. There is a very intense thread on this site, with extensive archived posts.

Ulcers in their earliest state may appear as nothing more than irritation and cell changes at the previously discussed border between the glandular portion and the epithelialized portion (the Margo Plicatum) of the stomach. The area first becomes hyperkeratinized (thickened) and inflamed before the tissue has deeper erosion (a true ulcer). Many horses will, at this point, show ulcer symptoms. It is my hypothesis that in this early stage, many products may create a soothing response and mitigate the problem. This irritated stomach syndrome I would liken to “heartburn” in people and for which they take antacids on an as-needed basis. I further suspect this is why so many products get glowing testimonials as “cures” for ulcers in the horse when the problem may actually be more of a gastric irritation and not a full-blown case of ulcers. These products or compounds usually don’t stand up to the challenge when confronted with true ulcers that have been confirmed by scoping. It is a caveat emptor (buyer beware) arena.

Enough of praise and condemnation of products; I am sure at this point that thoughtful readers of this chapter and caring horse persons, are now recognizing the importance of management and prevention. Above all, remember that ulcers are in large measure a man-made disease. Good feeding and management practices will go a long way towards keeping horses healthy and ulcer-free, saving our horses pain and saving us heartache, frustration, and money. Prevention is always better than having to cure any disease process.

For further information, contact Dr. Ridgway at 803-643-9188, or  800HorseDr@gmail.com.11Consultations or reprints of this series are available from the author for a nominal fee.

Dr. Ridgway has a strong background in equine sports medicine and is now an integrative medicine veterinarian specializing in equine acupuncture and chiropractic, saddles and tack evaluation as well as shoeing consultation for the performance horse. Our website and blog is at www.drkerryridgway.com

Ó 2011