Rethinking equine gastric ulcer syndrome: Part 2 – Equine squamous gastric ulcer syndrome (ESGUS)

It has recently been highlighted that significant differences in prevalence, risk factors and the response to treatment exist between ulceration of the squamous gastric mucosa and ulceration of the glandular gastric mucosa in the horse. In the first article in the series, the term equine squamous gastric ulcer syndrome (ESGUS) was used to describe disease of the squamous gastric mucosa with clinical signs and diagnosis discussed. The purpose of this article is to review the pathophysiology, risk factors, prevalence, treatment and prevention of ESGUS.     

Rethinking equine gastric ulcer syndrome: Part 1 – Terminology,clinical signs and diagnosis

Equine gastric ulcer syndrome (EGUS) is a common condition in the horse. A series of recent articles highlighting differences in healing of squamous and glandular ulceration have reinvigorated interest in the condition. The purpose of this series of articles is to review the current thinking on EGUS with particular emphasis on the differences between diseases of the squamous and glandular mucosae. This article, the first will review the terminology, clinical signs and diagnosis of EGUS in the horse.     

The prevalence and distribution of gastric ulceration in 345 racehorses

OBJECTIVE: To report the prevalence and distribution of gastric ulceration within a group of racehorses and to describe the endoscopic appearance of gastric antrum and pyloric ulceration. DESIGN: Retrospective clinical study. PROCEDURE: Medical records from gastroscopic examinations of 345 racehorses (331 Thoroughbreds and 14 Standardbreds) were reviewed. Prevalence, distribution and severity of gastric ulcers were recorded. Lesions involving the squamous mucosa and the glandular mucosa of the antrum and pylorus were graded and compared. RESULTS: Gastric ulceration was found in 86% of racehorses. The squamous mucosa around the margo plicatus was most commonly affected. The pylorus was examined in 175 horses and 47% were ulcerated. No association was found between presence of lesions of the squamous mucosa and those of the pylorus. Low correlation was found between grade and location of lesions, with the pyloric lesion score being significantly less than the squamous mucosal lesion score. CONCLUSION: Gastric ulceration was present in a large proportion of racehorses. The pylorus was also an important site of ulceration. There was no association between presence of lesion at one site and the other, although there was a low correlation between grade of lesion and location, with the pyloric ulcer grade being lower.     

Prevalence of gastric ulcers in endurance horses--a preliminary report

Gastric endoscopy was performed at the end of a 50 or 80 km endurance ride. Gastric ulceration was evident in 67% of the horses with ulcers on the squamous region of the stomach found in 57% of the horses and active bleeding of the glandular mucosa in 27%. Three horses (10%) had lesions only on the glandular mucosa. Values of albumin, creatinine and glucose were higher in horses without gastric lesions. We conclude that horses from endurance competitions have a high prevalence of gastric ulceration that is similar to that observed in performance horses. However the severity of ulceration is less severe than has been reported in Thoroughbred race horses in active training. Owners should be aware of the high prevalence of gastric ulceration in horses that perform in endurance competitions. The high incidence of active bleeding from the glandular mucosa of the stomach in these horses requires further investigation.     

Comparative endoscopic evaluation of normal and ulcerated gastric mucosae in Thoroughbred foals

To contribute to early diagnosis and treatment of gastric ulcer of foals, we examined the gastric mucosa of healthy and affected foals using an endoscope. In healthy foals, the characteristic changes in the development of the squamous mucosa were seen mainly in the squamous mucosa, and maturation of the squamous mucosa in the greater curvature (GC-S) occurred more slowly than that of the squamous mucosa in the lesser curvature (LC-S). Epithelial desquamation in the LC-S and GC-S was observed between 6 and 90 days but was not observed in the LC-S at about 60 days, whereas it was observed in the GC-S until 90 days old. These findings suggest that there is a difference in the development of the gastric mucosa by region and that desquamation continues over a term longer than studies have reported in the past. In the affected foals, the minimum age at which gastric ulcer was observed was 4 days old. Gastric ulcers formed predominantly in the squamous mucosa (LC-S and GC-S) of foals with an immature mucosa before the weaning period, and the peak incidence occurred between 61 and 90 days old. The differences in the ulceration sites were considered to depend on the difference in the development (maturation) stage of the squamous mucosa. The grading score of the gastric ulcer increased with the growth of the affected foals. The gastric ulcer might be enhanced greatly by stress in the weaning period.     

Squamous gastric ulceration complicated by gastric stenosis in a foal

A 2-month-old Warmblood colt presented with recurrent colic and regurgitation. Gastroscopy, performed on several occasions, and barium-contrast radiography revealed severe squamous gastric ulceration and stenosis at the level of the margo plicatus. Treatment with omeprazole reduced the extent and severity of the gastric ulcers but did not affect the stenosis. The foal was euthanised because of a poor prognosis, and post-mortem examination confirmed the clinical diagnosis. Severe squamous gastric ulceration, granulation tissue formation and cicatrisation of deep gastric lesions were considered to have caused the stenosis. Gastroduodenal outflow obstruction is a recognised disorder in foals, but stenosis at the level of the margo plicatus has not been reported in foals or adult horses. To the authors' knowledge, this is the first case of severe squamous gastric ulceration, complicated by stenosis at the level of the margo plicatus, in a foal. Although rare, gastric stenosis should be considered in foals suffering recurrent colic and regurgitation.     

Equine gastric ulcer syndrome in adult horses: a review

In recent years, gastric ulceration has been recognised as a common, possibly performance-limiting disease of adult horses. Here, we aim to provide the reader with a useful review of recent literature covering all aspects of equine gastric ulcer syndrome (EGUS) in adult horses. The anatomy and physiology of the stomach, with particular reference to secretion of acid and mucosal protective mechanisms, are reviewed, as are the differing theories relating to the aetiopathogenesis of gastric ulceration. We also explore the possible influence of various management factors on development of the disease. The prevalence of the disease in racehorses has been reported to be as high as 100%. In general, horses that are in active training for racing tend to have a prevalence of around 90%, whereas pleasure horses in full work have a reported prevalence of approximately 60%. Emerging diagnostic tests which could obviate the need for gastroscopy are introduced and current recommendations for treatment are summarised, focussing on proton pump inhibitors, in particular omeprazole, administered orally. The oral administration of omeprazole has been shown to be effective in both treating horses with gastric ulceration and at preventing re-occurrence whilst the horses are in training, provided that daily dosing is maintained.     

Effects of short-term light to heavy exercise on gastric ulcer development in horses and efficacy of omeprazole paste in preventing gastric ulceration

OBJECTIVE: To determine the effects of 8 days of light to heavy exercise on gastric ulcer development in horses and determine the efficacy of omeprazole paste in preventing gastric ulceration. DESIGN: Randomized, controlled, multicenter clinical trial. ANIMALS: 102 horses with normal-appearing gastric mucosa on endoscopic examination that were in light to heavy training. PROCEDURES: Horses at 4 trial locations were allocated into replicates and sham dosed orally (empty syringe) or treated with a paste formulation of omeprazole (1 mg/kg [0.45 mg/ lb], PO) once daily for 8 days. Training regimens varied among locations and included early training for western performance events; walking, trotting, and cantering in a mechanical exerciser; and race training (2 locations). Prevalences of gastric ulceration at the completion of the 8-day treatment period were compared between groups. RESULTS: At the end of the 8-day treatment period, the proportion of omeprazole-treated horses free from gastric ulceration (88%) was significantly higher than the proportion of sham-dosed horses free from gastric ulceration (27%). CONCLUSIONS AND CLINICAL RELEVANCE: Results showed that horses in light to heavy training for as short as 8 days were at risk of developing gastric ulcers and that administration of omeprazole paste decreased the incidence of gastric ulcers.     

Prevalence of gastric ulceration in Swedish Standardbreds in race training

REASONS FOR PERFORMING STUDY: There is little information about the prevalence of gastric ulcers in Standardbred trotters and potential correlations between ulcers and various traits, e.g. age, sex, performance, temperament and feeding regimens, need further elucidation. OBJECTIVES: The prevalence of ulcers in the gastric squamous mucosa of Swedish Standardbreds was estimated and the associations between ulcer score and age, sex, performance, temperament and feeding regimens were determined. METHODS: Eighty Swedish Standardbreds in active race training, trained by 9 different trainers, underwent gastroscopy. Information on age, gender, status of training, performance over the last 4 months compared with the trainer's expectations before that period, behaviour, eating habits, feed type, bedding type, time spent outdoors per day and medical treatment during the last month was collected. Gastroscopy was performed and lesions in the squamous gastric mucosa were scored from 0 to 4 (0 = no lesions; 4 = > 5 lesions with haemorrhage, > 10 lesions with no haemorrhage, or a large area of diffuse loss of surface epithelium). RESULTS: Twenty-four (30%) of the horses had no lesions in the squamous mucosa, 22 (27.5%) had a score of 1; 21 (26.2%) score 2; 9 (11.2%) score 3; and 4 (5%) score 4. Horses that were in preparatory training and those that had raced during the last month were significantly more affected than horses that were fit for racing but had not raced during the last month, using a logistic regression model with trainer incorporated as a random effect. CONCLUSIONS: The study confirmed a high prevalence of ulcers in the gastric squamous mucosa of Standardbreds in race training. Of the studied parameters only status of training showed a significant association with gastric ulcers of the squamous mucosa. POTENTIAL RELEVANCE: Gastric ulceration is a common disease and diagnosis should be made by endoscopic examination of the gastric mucosa, since parameters such as age, gender, performance, behaviour, eating habits provide only weak clues as to which horses might be affected. Further studies are needed to determine the aetiology of the syndrome and to find ways to reduce, if possible, the frequency of gastric ulcers.     

Perforated gastric ulcer v associated with pyloroplasty for chronic hypertrophic pyloric gastropathy in a dog

A six-year-old male silkie terrier presented with a history of chronic vomiting. A diagnosis of gastric outflow obstruction was made using contrast radiography of the upper gastrointestinal tract. Surgical examination of the stomach revealed thickened pyloric antral mucosa. A Heineke-Mikulicz pyloroplasty combined with resection of the hypertrophic pyloric mucosa were performed to increase the patency of the pyloric lumen. The dog recovered well from surgery and his condition remained stable until the sixth day postoperatively when his condition deteriorated rapidly resulting in his death that night. At autopsy a perforated gastric ulcer was found in the cardiac region of the pylorus with evidence for a generalised peritonitis. An association between gastric outflow obstruction and gastric ulceration has been reported in human clinical literature and in canine experimental models. No such association has been previously documented in the veterinary clinical literature.     

Porcine gastric ulcer.

Ulceration of the pars esophagea in swine develops from a complex interaction of dietary particle size, gastric fluidity, dietary carbohydrate content, and presence of certain species of commensal gastric organisms capable of fermenting dietary carbohydrates. Unlike in humans, the significance of the role of Helicobacter sp. in development of porcine gastric ulcers is yet undefined. Management practices that limit the incidence and severity of gastric ulceration without interfering with growth performance appear to be the best option for control.     

A study of gastric mucosal pH and its correlation with gastric ulcers in adult horses

In a sample of twenty adult horses' stomachs, the mucosal surface pH was measured at 14 different loci, immediately post mortem, using a pH probe. The squamous epithelium of the pars oesophagea was observed to show a lower pH than the glandular mucosa. The pH of the glandular mucosa was generally uniform whereas within the pars oesophagea the different loci were observed to show variation, the lowest readings being found where the squamous epithelium adjoins the margo plicatus, the same area where ulceration initially tends to occur.

Ten horses in the sample showed moderate to severe ulceration and these horses had significantly lower pH readings compared to the group with mild to no ulceration.     

Endoscopic findings of the gastric antrum and pylorus in horses: 162 cases (1996-2000)

Medical records and endoscopy images were examined for 209 horses that had gastroscopic examinations performed with a 2.5- or 3-m-long endoscope by one of the authors (MJM) during a 4-year period (1996-2000). The antrum and pylorus were viewed in 162 horses, and the duodenum was viewed in 94 horses. Of these 162 horses, the gastric squamous mucosa was seen in 157 horses and 50% or more of the glandular mucosa of the body of the stomach was seen in 156 horses. Erosions or ulcers were seen in the gastric squamous mucosa in 91 (58%) horses. Erosions or ulcers were seen in the glandular mucosa of the body of the stomach in only 8% of the horses. Lesions consisting of erosion or ulceration were seen in the antrum or pylorus in 94 (58%) horses. Lesions consisting of hyperemia and a rough or "bumpy" appearance were seen in the mucosa of the duodenum of 16 horses. An association between the presence of lesions in the squamous mucosa and the presence of lesions in the mucosa of the antrum/pylorus was examined by Fisher's exact test, and the linear association of lesion severity scores between the squamous mucosa and the mucosa of the antrum/pylorus was tested using a Monte Carlo estimate for linear-by-linear association. There was no association (P = .88) between these sites for presence of lesions or lesion severity scores. Similarly, there was no association between scores for the glandular mucosa in the gastric body and those in the antrum/pylorus. Because of the high prevalence of lesions in the antrum and pylorus of the stomachs of adult horses examined in a hospital setting, the entire stomach should be viewed during a gastroscopic examination.     

A comparison of the prevalence of gastric ulceration in feral and domesticated horses in the UK

Equine gastric ulcer syndrome is common in domesticated horses, especially those performing in athletic endeavours. However, the prevalence of equine gastric ulcer syndrome in feral populations of horses is not documented. This study investigated the prevalence and severity of squamous and glandular gastric ulceration in an abattoir population of horses in the UK. Both squamous and glandular ulceration were more prevalent in domesticated horses when compared to the feral horses studied.     

Prevalence of gastric ulcer syndrome in high-level endurance horses

Reasons for performing the study: Equine gastric ulcers syndrome (EGUS) prevalence studies are rare in the endurance horse and none has been carried out to date in horses competing at high level. Objectives: To determine the prevalence of EGUS in high‐level endurance horses. Methods: Thirty endurance horses competing at high level were selected and submitted to 2 gastroscopic examinations. The first gastroscopy was performed during the interseason period, and the second during the competition season within 2–3 days following a ride of 90–160 km. Data related to housing, feeding, training system as well as age, breed and gender were recorded for each horse. Results: The prevalence of squamous gastric ulcers was 48% during the interseason period (mean score 0.85 ± 0.13 on a scale from 0–4) and 93% during the competition season (mean score 1.60 ± 1.15) with a highly significant difference between the seasons (P = 0.001). Most of the lesions were situated in the squamous portion of the stomach but 33.3% of horses showed also glandular lesions. Significant influence of training and performance level on the gastric score (according to the distance of the ride preceding the second gastroscopy) was shown (P = 0.038). There was also a significant influence of housing on the gastric score (P = 0.002) showing higher scores in the horses kept totally on pasture (mean score: 2.14 ± 0.14) vs. horses housed in a mixed environment (stable + pasture, mean score: 1.43 ± 0.17). Both the pastured and (stabled + pastured) groups were receiving a grain supplement but the pastured group received a higher daily starch intake, which might explain the higher ulcer prevalence. There was no influence of age, breed or gender on the gastric scores. Conclusions: The high prevalence of gastric lesions observed in this study is probably related to the high level of training and performance of the horses examined compared to the population of horses included in the prior study. Potential relevance: This prevalence of EGUS in high‐level endurance horses is comparable to the prevalence established in racing horses. The equine veterinarians may take into consideration EGUS as a potential cause of poor performance.     

Courses for horses: Rethinking the use of proton pump inhibitors in the treatment of equine gastric ulcer syndrome

Oral omeprazole has been the cornerstone of equine gastric ulcer syndrome (EGUS) treatment for nearly 20 years. However, approximately 15–30% of equine squamous gastric disease (ESGD) cases and 75% of equine glandular gastric disease (EGGD) cases fail to heal within current treatment guidelines. Recently, a number of factors that may affect the efficacy of oral omeprazole have been highlighted and the pharmacodynamics of a number of novel proton pump inhibitors (PPIs) have been described in the horse. The purpose of this article is to review the factors that affect oral omeprazole efficacy, with the goal of maximising therapeutic response, and the novel PPIs recently described.     

Campylobacter-like organisms isolated from gastric mucosa of ferrets

Campylobacter-like organisms (CLO) were isolated from gastric lesions in 1 ferret and gastric mucosa of 2 healthy ferrets. The organism was not isolated from biopsies of gastric mucosa of 14 other healthy ferrets, 1 of which had small gastric lesions located at the pylorus. Lesions from which CLO were isolated were located in the antrum of 1 ferret and were classified as inflammation with repair. Affected gastric tissue was highly vascularized with fibrous connective tissue surrounding irregularly shaped glands. Necrosis and ulceration of adjacent mucosa also were observed. Using Warthin-Starry stain, Campylobacter-like organisms were seen on and in the glandular epithelium of the ferret with gastric lesions from which CLO were isolated.     

Pathomorphological study on gastroduodenal ulceration in horses: localisation of lesions

Gastroduodenal ulceration is a prevalent disease in foals and adult horses. Decreased performance as well as fatal complications relate to this syndrome. The objective of our study was to determine the prevalence of gastric ulceration in a mixed population of horses by postmortem examination and to evaluate a possible association between equine gastric ulcer syndrome (EGUS) and sex or age of the examined horses, to evaluate the localisation of lesions in the proximal part of the gastrointestinal tract and to determine the occurrence of gastric parasites. Postmortem examinations were performed on 71 horses over a period of 24 months. Gastric ulcers were found in 52 horses (73.2%). There was no significant association between age or sex and occurrence of gastric ulcers. In all horses the squamous mucosa lesions were localised near the margo plicatus (100% of the cases), whereas in 23 horses the lesions were near the margo plicatus and lesser curvature and in 7 horses at the greater curvature. In 18 horses the mucosa was affected in the whole extent of the margo plicatus and in 1 horse diffuse lesions of the squamous mucosa were noted. Lesions of the glandular mucosa were localised in 11 horses at the fundic area, in 1 horse they occurred in the pylorus, and in 10 horses diffuse lesions of the glandular mucosa were recorded. A low prevalence of Gasterophilus intestinalis infection was detected (1 horse, 1.4%). We have confirmed that gastric ulcers are a common problem in horses and duodenal or oesophageal ulceration is rare (not a single case of the latter was found in this study). Lesions in the glandular mucosa of the stomach are more frequent in suckling foals than in older animals. Lesions of the glandular mucosa are also common in adult horses, and a complete gastroscopic examination including examination of the pylorus is advisable to evaluate this syndrome.     

Megaloesophagus and associated gastric heterotopia in the cat.

Two young adult male Siamese cats had heterotopic gastric mucosa in the dilated and inflamed oesophagi. Normally differentiated gastric mucosal glands were present and there was severe ulceration in one cat. It is uncertain whether the gastric heterotopia was a reparative change after oesophagitis or whether it represented a coincidental anatomical anomaly.     

Prevalence of gastric ulcers in Thoroughbred broodmares in pasture: a preliminary report

Gastroscopic examinations were performed in 62 Thoroughbred broodmares (33 pregnant, 29 non-pregnant) at one breeding farm to investigate the prevalence of gastric ulceration. Age, pregnancy status, race earnings, last race start, herd size, medical history, number of live foals, breeding years, feed type and number of feedings were recorded, plus coat condition and body condition score were determined. Twenty-one mares were re-evaluated after foaling, and the foaling date, foal weight at birth and placenta weight were recorded.The overall prevalence of gastric ulcers was 70.9%, with a median ulcer score of 3.0 (range: 2–5). Most ulcers were present on the squamous portion of the stomach, while two mares had glandular ulcers. There were no differences in the presence, location and severity of gastric ulcers between pregnant and non-pregnant mares. Furthermore, there were no significant associations between the variables measured and the presence of gastric ulceration. The prevalence of gastric ulceration in this specific population of horses was higher than expected and further investigation is warranted to determine the factors that contributed to this finding.