Equine ulcers are a significant concern for many horse owners. Ulcers can affect all types of horses and have a variety of causes and clinical signs. Performance horses are especially prone to developing ulcers due to their lifestyle and exercise programs.

As a horse owner, it’s important to understand the types of equine ulcers, symptoms, causes, and treatments, as well as how best to prevent reoccurrence.

Peter Heidmann, DVM, a board-certified internal medicine specialist, and Bryan Dubynsky, DVM, a sport horse medicine specialist, of Palm Beach Equine Clinic in Wellington, Fla., are both experienced in identifying, treating, and helping owners prevent equine ulcers.

According to Heidmann and Dubynsky, equine ulcers can be grouped into two categories: gastric ulcers and hindgut ulcers. The horse can develop one or the other, or both in combination. Gastric ulcers, which are the most common, develop in the stomach, while hindgut ulcers are found in the colon.

Clinical Signs

Signs of gastric and hindgut ulcers can range in type and severity. A common indicator of ulcers in many sport horses is poor performance in the arena. Horses may also present symptoms of abdominal discomfort, such as girthiness or even colic. Other more subtle behaviors can also be warning signs.

“A symptom that people do not always realize is that sometimes horses will act like they are sore over their withers,” says Heidmann. “Horses with gastric ulcers will be reluctant to drop down if you pinch their withers because it shifts where the stomach is in their body, and it feels uncomfortable.

“Another classic sign that sometimes goes under the radar is eating slowly or suddenly becoming a picky eater,” he continues. “The horse may look hungry, walk up to food, take a bite or two, and then walk away from it with a sour look on his face. If I see that while I’m walking through a barn, it’s usually a trigger for me to consider looking into ulcers.”

Causes of Ulcers in Horses

One of the most common causes of gastric ulcers is stress. Some horses internalize their stress more than others, which can make them more prone to developing ulcers.

“Horses who are more worried or are in an environment that doesn’t suit them are at a higher risk for developing ulcers,” says Heidmann. “It’s not as much about breed as it is job, temperament, and environment. Something as simple as stall placement could affect the horse. The lead mare in the big barn might want to be in the middle of everything, whereas another horse may want a quieter stall. Apparently even small things like that are at play.”

Since performance horses are often traveling and put under stress for their job, the risk for gastric ulcers is higher.

“Gastric ulcers can be a significant health concern in sport horses,” says Dubynsky. “Studies show that 50 to 90 percent of all competing horses have gastric ulcers. Intense exercise, dietary changes, stress, and confinement can all contribute to the development of ulcers in these horses.”

In addition to the horse’s stress level, job, and environment, medication can also lead to gastric and hindgut ulcers. For example, chronic administration of non-steroidal anti-inflammatory drugs (NSAIDs) can result in both types of equine ulcers.

Diagnosing Ulcers in a Horse

Once symptoms have been acknowledged, proper diagnosis is the next step. For gastric ulcers, a gastroscopic examination of the stomach in a fasting horse is critical to the process.

“A gastroscopic exam not only tells you if the horse has ulcers or not, but the procedure helps you determine the severity and location,” explains Heidmann. “This information helps dictate the best treatment plan and what medication we prescribe, for how long, and a plan for prevention in the future.”

A gastroscopic exam is often repeated at the end of a treatment cycle to determine whether it was successful and if the horse needs to remain on medication. The procedure is very safe and can be performed easily.

Hindgut ulcers are more challenging to diagnose. The ideal strategy is a combination of an ultrasound and a fecal blood test.

“Ultrasound allows us to look at the colon, see wall thickness, and then by putting a lot of pieces together, we can infer if there is inflammation or not,” says Heidmann. “You can only see about 60 percent of the colon on an ultrasound because part of it points to the center of the abdomen that you can’t see. This means you can miss things, even with the best technology.”

Since an ultrasound doesn’t always provide a definitive diagnosis, the fecal blood test can be used as well. This test can have a high instance of false positives, so it is best to use it in combination with the ultrasound to determine if the horse has hindgut ulcers.

Treatment Options

Once equine ulcers have been diagnosed, a treatment plan is developed based on the information that has been gathered. Depending on the type and area of the ulcers, different medications may be given.

Omeprazole paste has been shown to be effective for treating gastric ulcers. However, misoprostol can also be added to the treatment regimen, especially for hindgut ulcers.

“There is some research comparing the efficacy of omeprazole products versus misoprostol for treating gastric ulcers in the lower stomach,” says Heidmann. “Depending on where the ulcers are in the stomach, we may do a combination of both medications. If the ulcers are up high in the stomach, then the omeprazole product does very well. If there are ulcers in the glandular and pyloric region of the lower stomach, then we often recommend a combination of both omeprazole and misoprostol.”

Prevention of Ulcers

Once ulcers have been treated, understanding how best to prevent them from reoccurring is critical. This is especially important for performance horses who are more susceptible to developing ulcers as a result of their lifestyle.

“It is crucial for horse owners and trainers to be vigilant in monitoring their animals’ well-being,” says Dubynsky. “If ulcers are suspected—the first symptom usually being behavior change—it’s important to seek veterinary advice. Proper management practices, such as providing a consistent feeding schedule, reducing stress, and using medications or supplements to support gastric health, can help prevent and manage ulcers in sport horses, ensuring their overall [health] and performance.”

In addition to reducing stress, one of the most important ways to help prevent ulcers is allowing horses to have free-choice access to pasture grazing or hay. This increases the buffering effect of constant saliva production, meaning the high pH of equine saliva helps neutralize the low pH of stomach acid. Additionally, a soft hay such as orchard grass may help to relieve discomfort with hindgut ulcers.

“Horses evolved to be grazing 16 to 19 hours of the day,” says Heidmann. “When we domesticate horses, put them in a barn, and feed them a few flakes three times a day, the risk for ulcers goes way up. When horses can continuously graze, it also allows saliva—produced by grazing—to be a buffering agent. Saliva is very protective of the stomach.”

Some feed adjustments may help prevent ulcers. Try to avoid high-sugar feeds that make the stomach more acidic as a result of the feedstuff being digested.

Adding alfalfa hay or pellets to a horse’s feeding program may reduce the incidence of gastric ulcers as well. Alfalfa has less sugar than grass, is energy-dense, and contains high levels of calcium and magnesium—think “Tums for horses.”

If you suspect ulcers, it’s important to discuss diagnostic and treatment options with your veterinarian immediately. The best approach for horse owners is to be aware of the clinical signs of equine ulcers in order to prevent this debilitating disease.

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Equine Gastric Ulcer Syndrome

Equine gastric ulcer syndrome (EGUS) is more common in horses than you might think. The majority of horses with gastric ulcers don’t always show symptoms. For those horses that do exhibit clinical signs, here are some to look for:

• Poor performance.
• Poor hair coat and/or body condition.
• Poor appetite or a picky eater.
• Unexplained weight loss.
• Abdominal discomfort or colic.
• Behavioral changes (aggressive or nervous).
• Cribbing or other stereotypic vices, like weaving, pawing and stall-walking.

A diagnosis of EGUS is confirmed only by gastroscopy, where your vet views the stomach with an endoscope, and not just based on clinical signs and suspicion.

A horse’s stomach has two distinct areas. The lower half is referred to as glandular, where glands produce acid. This portion has a protective lining. The upper half has no glands and no protective lining, and is called the squamous region.

Each has its own form of ulcer disease: the non-glandular portion can get equine squamous gastric disease (ESGD); and the glandular region can have equine glandular gastric disease (EGGD).

Equine Squamous Gastric Disease

The most common form of gastric ulcers, ESGD, is well-known to affect 80 to 100 percent of racehorses, but it’s also prevalent in many other disciplines:

• Show and sport horses: 17-58 percent
• Pleasure horses: 37-59 percent
• Endurance horses: 48 percent when not in competition, rising to 66-93 percent during a competition season.

The greater the intensity of exercise, the greater the likelihood a horse will develop ESGD. At gallop speeds such as racing or other intense activities, the stomach is squeezed between the chest and the abdomen. This pushes stomach acid onto the lining of the upper portion of the stomach that normally isn’t exposed to stomach acid.

Horses ridden mostly at home and not involved in competition may be the least affected, at around 11 percent. However, a variety of management and lifestyle factors increase the incidence.

Equine Glandular Gastric Disease

The glandular portion sits low in the stomach near where food exits into the small intestine. Experts are still defining the prevalence of EGGD, since it was just recently recognized through the use of longer endoscopes that are able to reach to the very bottom of the stomach. Reports estimate approximately 57 percent of horses are affected with EGGD. Unexplained weight loss is a common complaint.

Interestingly, EGGD is seen in horses that are managed well with good lifestyles and low starch/high forage diets. The glandular lining of the stomach normally is bathed in a very acidic pH, so dietary measures don’t play a significant role in managing EGGD.

Read more about nutrition and ulcer management here.

Normal defense mechanisms protect the glandular lining from excess acid exposure. Breakdown of these defenses may contribute to development of EGGD, such as can result from high or long-term doses of non-steroidal anti-inflammatory drugs (NSAIDs) like phenylbutazone, ketoprofen, flunixin meglumine, and firocoxib (Equioxx).

Another important element in the development of EGGD relates to the number of days a horse is exercised per week. A horse ridden six to seven days a week is three and a half times more likely to have EGGD compared to a horse ridden five or fewer days per week. At least two rest days per week are important in minimizing the risk of EGGD.

Interestingly, EGGD is seen in horses that are managed well with good lifestyles and low starch/high forage diets. The glandular lining of the stomach normally is bathed in a very acidic pH, so dietary measures don’t play a significant role in managing EGGD.

Other factors associated with EGGD include situations that add to behavioral stress, such as the number of riders and/or handlers a horse experiences, or isolation of a horse from the herd and social interaction. For example, horses stabled apart from direct contact with others show a high incidence of EGGD.

It isn’t always possible to identify when a horse is stressed. It’s not unusual for an anxious and nervous horse with stall vices to be ulcer-free, while a seemingly calm horse that stands quietly in his stall has stomach ulcers.

Prevention and Treatment of Ulcers

Prevention of ESGD relies to some degree on dietary measures (see Nutritional Management for Equine Ulcer Prevention) along with lifestyle adjustments that minimize a horse’s stress. The more owners do with their horses, the greater the horse’s chance of developing gastric ulcers, especially with transport and changes in routine while away from home. Some horses adapt well to changing routines, active training, competition, and being around strange horses, while others do not.

Treatment of ESGD is based on the principle of “no acid, no ulcer.” Acid suppression is achieved with medication, namely omeprazole (GastroGard). The goal is to raise the pH of the stomach for at least 16 hours in a 24-hour period.

Timing of feeding significantly impacts effectiveness of oral omeprazole treatment. The amount that enters the bloodstream to exert an active effect may decrease by as much as 66 percent when a horse has access to free choice hay.

A better strategy is to fast the horse overnight and then administer omeprazole 60 to 90 minutes prior to the morning feeding. This achieves a greater amount and duration of acid suppression than horses fed free-choice hay day and night.

Even with this strategy, once-a-day treatment with oral omeprazole doesn’t maintain acid suppression for a full 24 hours, or even the desired 16 or more hours. As it turns out, stomach pH is raised for only a four to six hour period. This is especially true when the horse has access to free-choice hay, which stimulates stomach acid secretion whenever he eats. Still, omeprazole is the drug of choice to use for EGUS treatment and it does help.

Currently an intramuscular (IM) formulation of omeprazole is in development, although it’s not yet available in the U.S. The IM form of omeprazole gives results within 24 hours. It is injected weekly to suppress acid, increasing pH for 80 percent of the time between doses. Longer durations of acid suppression translate to better healing.

This article originally appeared in the May 2019 issue of Horse Illustrated magazine. Click here to subscribe!

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Free-Choice Forage Management

Since the horse industry became aware of how common equine gastric ulcers are decades ago, prevention focused on a need for horses to graze intermittently to keep their intestinal tract filled with forage, just as they would in the wild. The commonplace feeding of two large meals a day with long periods of fasting in between was thought to contribute to the development of gastric ulcers, especially in the face of other stressors like training, competition, and herd dynamics.

While current thinking has changed somewhat, fasting a horse for more than six hours is still recognized as a risk for development of ESGD. Studies demonstrate that horses with at least some amount of turnout or the ability to eat hay at will are less likely to develop ESGD.

That said, the effect of pasture turnout or free-choice hay might be overstated. In a notable study, nearly 71 percent of broodmares at pasture had equine gastric ulcer syndrome (EGUS), suggesting that there is more to this story, and other risk factors must also be minimized in order to control the development of gastric ulcers. Ben Sykes, an Australian equine veterinarian at the forefront of EGUS research states, “ESGD is unusual in well-managed performance horses on appropriate diets despite limited turnout.”

Feeding Hay for Equine Ulcer Prevention

Horses need at least 1 percent of their body weight per day in the form of forage (hay or pasture) to decrease stomach acidity (this equates to a minimum of 10 pounds dry weight for a 1,000-pound horse). Weigh the amount of hay a horse will actually consume, as some is generally trampled and wasted or discarded with stall cleaning.

If hay is not available free-choice, ideally a horse is fed four to six hay meals per day. If your schedule doesn’t allow that, use a slow feeder system or small-hole hay net to extend your horse’s eating time. Alfalfa hay, even in small amounts, helps to increase stomach pH, and this protective effect may last four to five hours.

Grain Products for Equine Ulcer Prevention

Another tip for dietary management for equine ulcers are grain products. Grain products (corn, oats, barley, sweet feed) should be fed in minimal amounts, as their digestion produces large quantities of volatile fatty acids (VFAs). Exposure for three to four hours to VFAs decreases stomach tissue resistance to acid. Food usually moves quickly from the stomach into the small intestine, but there are instances where it can take up to four and a half hours to empty one pound of grain from the stomach, with digestive acid present during that time.

Recommendations call for limiting grain meals to less than 5 pounds per feeding, although it’s better still to feed no more than 1 to 2 pounds for a 1,000-pound horse, and to separate grain meals by at least six hours.

Another important point for EGUS management is that horses with limited or no access to water are more than two and a half times as likely to develop EGUS. Fresh, clean water should be available at all times.

This article originally appeared in the May 2019 issue of Horse Illustrated magazine. Click here to subscribe!

The post Nutritional Management for Equine Ulcer Prevention appeared first on Horse Illustrated Magazine.