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

Comparison of oral esomeprazole and oral omeprazole in the treatment of equine squamous gastric disease

BACKGROUND

Oral omeprazole is the accepted treatment for equine squamous gastric disease (ESGD); however, it is not universally effective. Esomeprazole results in more consistent and pronounced acid suppression in men and is more effective than omeprazole in the treatment of oesophageal and gastric disease. Pharmacodynamic and pilot clinical studies have indicated esomeprazole might also be more effective than omeprazole in horses.

OBJECTIVES

To compare the efficacy and safety of oral esomeprazole and omeprazole pastes in the treatment of ESGD and, where present, concurrent equine glandular gastric disease (EGGD).

STUDY DESIGN

Randomised, single-blinded controlled trial.

METHODS

Horses presenting with grade ≥2 ESGD lesions were randomly allocated to receive 4 mg/kg of either a buffered esomeprazole or omeprazole paste orally once daily for 28 days before gastroscopy being repeated within a further 3 days. Videos and images were anonymised and subsequently graded blind by one researcher. The severity of ESGD (and EGGD) lesions before and after treatment, and thereby treatment responses, were compared using univariable logistic regression.

RESULTS

A higher proportion of horses had ESGD healing in response to esomeprazole treatment (63/74, 85%) than with omeprazole treatment (43/73, 59%) (odds ratio [OR]: 4.00, 95% confidence interval [CI]: 1.81, 8.82, p = 0.001). In a subset of horses that had concurrent EGGD, a greater proportion of the horses treated with esomeprazole had lesions ≤grade 1 (esomeprazole 28/51, 55%; omeprazole 6/24, 25%; OR: 3.65, 95% CI: 1.25, 10.71, p = 0.02) Using grade 0 as the benchmark for EGGD healing, the difference remained significant (OR: 4.44, 95% CI: 1.33, 14.85, p = 0.02).

MAIN LIMITATIONS

It may not be possible to extrapolate these results to other populations with different signalment or management.

CONCLUSIONS

Oral-buffered esomeprazole was a more effective treatment for ESGD (and concurrent EGGD) than oral-buffered omeprazole.

Recurrent Colic: Diagnosis, Management, and Expectations

Most recurrent episodes of non-specific colic are self-limiting, and the results of clinical examinations are unremarkable. Differentiating these cases from serious diseases can be difficult, but repeated evaluations are warranted. Horses presenting with very frequent bouts of colic are more likely to have serious diseases and a higher mortality rate compared to horses presenting with less frequent bouts of transient colic. Horses with recurrent bouts of prolonged colic are more likely to have motility issues or partial intestinal obstruction. Non-gastrointestinal diseases can also cause recurrent bouts of pain ("false colic"). Adhesions are common causes of colic following abdominal surgery.

Effects of the Ingestion of Ripe Mangoes on the Squamous Gastric Region in the Horse

Erosions and gastric ulcers may be present in horses at any age and under different conditions of rearing and handling. In tropical regions, horses can feed on fruits rich in soluble carbohydrates, such as mangoes, but little is known about how these foods interact with their digestive systems. To test the hypothesis that the ingestion of ripe mangoes with peels could cause disturbances in the digestive processes of horses, an experiment was developed to monitor animals that had free access to ripe mangoes in their pasture areas. Horses (purebred Arabians, n = 5; ~340 kg, ~13 years) were evaluated by video gastroscopy and blood analysis. A controlled postprandial glucose curve for mango intake was also performed. Gastroscopies were performed at intervals of 15 days, starting in December, just before the beginning of the harvest, until the beginning of February, and days after the end of the harvest. Blood collection was performed on the same day between November and February for blood analysis. The results were submitted to ANOVA and Tukey’s test, with a significance level of p < 0.05. Gastroscopies indicated that four out of five horses had erosions and ulcers in the squamous region between 15 and 30 days after the start of the season. Biochemical tests indicated a reduction in plasma proteins during the harvest period, and the postprandial glucose curve showed concentrations above 200 mg/dL between 30 and 180 min after ingestion of 5.37 kg mangoes. The animals were not treated and recovered after 15 days of harvest and without ripe mangoes on the ground. It is concluded that the indiscriminate ingestion of mangoes favors the appearance of lesions in the gastric squamous region, to varying degrees, and that animals recover naturally after an average of 15 days from the end of the season when the animals return to their regular feeding with hay and grass pasture.

Effect of a novel fermented soy product on gastric ulcer scores in horses

Non-pharmaceutical methods are desirable to treat or prevent gastric ulceration in horses. This two-period, randomised, double-blinded placebo-controlled study was designed to evaluate the efficacy of dietary supplementation (25 g once daily in feed for 30 days) with Fermaid®Ease 187 (FE, Lallemand Australia Pty Ltd, Maroochydore, Australia) on gastric squamous and glandular mucosal ulcer scores in horses. Gastroscopy of 120 horses presented to the Veterinary Clinical Centre at Charles Sturt University (CSU; Bathurst, Australia) or at local training establishments identified 60 horses with spontaneous gastric ulcer disease (50%). Of horses eligible for inclusion, 29 horses were recruited and randomised to receive either the FE or placebo for 30 days. Effects were assessed by repeat gastroscopy (Day 31), at which time horses started the reciprocal treatment. Eleven horses successfully completed both treatment periods. Treatment with FE showed a significant decrease in squamous ulcer scores in period 1 (P=0.008), with a similar effect observed in period 2. No change was observed in squamous ulcer scores for horses receiving placebo treatment in period 1, but increased squamous scores were observed in horses receiving placebo treatment in period 2 (P=0.062). Squamous ulcer scores on Day 31 were significantly lower (P=0.005) following FE treatment than for horses receiving the placebo treatment. No effects were observed on glandular ulcer scores. This study supported the use of FE in horses predisposed to ulceration of the squamous gastric mucosa.

Effects of transportation on gastric pH and gastric ulceration in mares

Background

Transportation has been suggested as a risk factor for gastric ulceration in horses, but limited evidence supports this assumption.

Animals

Twenty‐six Standardbred, Thoroughbred, and Warmblood mares from a university teaching herd.

Methods

Twelve mares were confined for 12 hours, overnight, in reproductive stocks with indwelling nasogastric tubes (NGTs) to assess pH of gastric fluid (GF). Gastric ulceration was assessed endoscopically before and after confinement. Subsequently, 26 horses were transported for 12 hours, overnight, in 2 consignments. During transportation, GF was aspirated from indwelling NGT placed in the same 12 mares used in the confinement study, and gastric ulceration was assessed endoscopically before and after transportation in all horses.

Results

The median pH of GF in confined horses was 1.70‐2.49 at each sampling point, and there was no apparent effect on gastric squamous ulcer scores. The median pH of GF from the same 12 horses at corresponding sampling times during transportation was 6.82‐7.22. Transportation was associated with increased gastric squamous ulcer scores, particularly in horses fasted for gastroscopy and NGT placement immediately before departure. Gastric emptying appeared delayed after transportation in horses fed before departure.

Conclusions and Clinical Importance

Transportation is associated with increased gastric squamous ulceration and with increased pH of GF. These findings may be a consequence of impaired gastric emptying and reflux of alkaline small intestinal content, with factors such as duodenal bile salts and short‐chain fatty acids mediating mucosal injury.

A Botanical-Based Equine Nutraceutical Reduces Gastric Smooth Muscle Contractile Force In Vitro

The objective of this study was to evaluate the effect of a botanical-based equine nutraceutical on contractility of gastric smooth muscle in vitro. Gastric ulcers are prevalent in performance horses and negatively impact horse welfare. Gastric hypermotility has been positively associated with the development of gastric ulceration in nonequine species, and reduction of hypermotility may be protective against their development. Stomachs from 12 pigs processed for food at a provincially inspected abattoir were collected within 1 hour of slaughter. Explants of nonglandular gastric tissue were prepared and suspended in a tissue bath, attached to a force transducer, in the presence or absence of a simulated digest extract of the nutraceutical. Tissue was stimulated to contract using increasing doses of acetylcholine. Peak and mean contractile force over 1 and 2 minutes after exposure to acetylcholine were measured. Exposure of gastric smooth muscle to the nutraceutical significantly reduced contractility of the tissue. These data provide support for the use of this nutraceutical to reduce contractility of nonglandular gastric smooth muscle and may indicate a protective effect of this nutraceutical in horses with mechanically induced gastric ulcers. Future studies are needed to clarify the role of gastric hypermotility on development of equine gastric ulcers and to determine the effect of this nutraceutical on equine gastric contractility and ulcerogenesis in vivo.

DESCRIPTION OF GASTRIC ULCERS AND OF THEIR SUSPECTED, ASSOCIATED RISK FACTORS IN DECEASED WILD EQUIDS AT THE RÉSERVE AFRICAINE DE SIGEAN, FRANCE (2010-2016)

Gastric ulcers are common in domestic horses and foals, affecting at least 90% of unmedicated racehorses in active training. Despite these high prevalences in domestic horses, literature about this condition in wild equids is almost nonexistent. The presence of gastric ulcers was evaluated at necropsy in six species of wild equids that died at the Réserve Africane de Sigean, a safari park in the south of France from 2010 to 2016. Among the 55 individuals that died during that period, a description of the gastric mucosa was available in 82% (45/55) of cases. Considering the cases for which a description of the gastric mucosa was available, the prevalence of gastric ulcers was 64% (29/45). The highest prevalences were noted in Grant's zebra (Equus quagga boehmi) and Hartmann's mountain zebra (Equus zebra hartmannae) at 83% and 100%, respectively. In contrast to what is reported in domestic foals, gastric ulcerations were only diagnosed in one foal (out of 11 foals necropsied). The higher prevalence was noted in young individuals (3-36 mo old) at 93% (14/15); the lesions observed consisted mainly of single to multiple, superficial lesions, of which, only the mucosa was missing; these superficial lesions are often considered not clinically significant. The prevalence was lower for adults (74%; 14/19), but lesions were deeper or with a hyperemic or inflammatory appearance. All the lesions observed were located in the gastric, nonglandular, stratified squamous mucosa, along the margo plicatus. No statistical correlation could be found between the development of gastric ulcers and an ongoing, chronic pathologic process or a digestive tract pathology. The detection of gastric ulcers was, therefore, significantly greater in wild equids isolated in smaller enclosures. Nevertheless, additional larger-scale research is needed to point out predisposing factors in equids under human care.

A pilot study comparing the effect of orally administered esomeprazole and omeprazole on gastric fluid pH in horses

AIMS To compare the efficacy of an enteric coated esomeprazole paste with an enteric coated omeprazole paste to increase gastric pH after oral administration in horses. METHODS Nine adult Standardbred horses were randomly assigned to three groups, each containing three horses, for a study comprising three phases of 10 days, with an 18-day washout period between each phase. In each phase, three horses received either 0.5 mg/kg esomeprazole, 1 mg/kg omeprazole or a placebo, as an oral paste, once daily for 10 days (Days 0-9). Over the course of study all horses received all three treatments. Gastric fluid samples were collected using a gastroscope on Days 1, 3, 5, 8 and 10, with food and water withheld for 16 hours prior to collection of samples. The pH of all samples was measured immediately after collection. RESULTS Mean pH (3.38; SD 1.75) of the gastric fluid samples in the horses that received the placebo was lower than in the horses that received esomeprazole (6.28; SD 1.75) or omeprazole (6.13; SD 1.75) (p<0.001). There was no difference in the mean pH between horses receiving esomeprazole and those receiving omeprazole (p=0.56). CONCLUSIONS AND CLINICAL RELEVANCE Under these study conditions, esomeprazole paste was equally as effective as omeprazole paste in increasing gastric pH in horses. Enteric coated esomeprazole, may be a therapeutic alternative to omeprazole for the prevention of gastric ulcers in horses.

Therapeutics for Equine Gastric Ulcer Syndrome

Equine gastric ulcer syndrome (EGUS) is an umbrella term used to describe ulcers in the nonglandular squamous and glandular mucosa, terminal esophagus, and proximal duodenum. Gastric ulcers in the squamous and glandular regions occur more often than esophageal or duodenal ulcers and likely have a different pathogenesis. At present, omeprazole is accepted globally as the best pharmacologic therapy for both regions of the stomach; however, the addition of coating agents and synthetic prostaglandins could add to its effectiveness in treatment of EGUS. Dietary and environmental management are necessary for prevention of recurrence.