Downloaded from http://veterinaryrecord.bmj.com/ on July 14, 2015 - Published by group.bmj.com
Research
Research EDITORIAL
Equine gastric ulceration syndrome: treatment and prevention David Sutton KNOWLEDGE of the clinical signs, incidence, aetiology, management, treatment and prevention of equine gastric squamous mucosal ulceration has developed since the original groundbreaking work performed by Murray and others over 20 years ago (Murray and others 1989). Equestrian disciplines in which horses have been found to have a high incidence of squamous ulceration include racing (Murray and others 1996), endurance (Tamzali and others 2011) and showing (McClure and others 1999), but significant proportions of horses used for less demanding pleasure pursuits may also have gastric ulceration (Luthersson and others 2009). Although omeprazole has been shown to be highly effective in suppressing gastric acid production and enhancing the rate of ulcer healing (Murray and others 1997), it is expensive and not permitted for use in many competitive events. There is therefore great demand for the production of alternatives, such as gastroprotective feed supplements, that are allowed according to competition rules. Many such products are available, but very few are supported by convincing clinical evidence regarding their efficacy in suppressing ulcer development.
David Sutton, MA, VetMB, CertEM(IntMed), DECEIM, PhD, MRCVS, Weipers Centre Equine Hospital, School of Veterinary Medicine, University of Glasgow, Bearsden Road, Glasgow, UK e-mail: [email protected]
On p 147 of this issue of Veterinary Record, Sanz and others (2014) report a prospective crossover study designed to assess the ability of an oral pectin-lecithin complex to prevent the development of ulcers in an experimental model. The evidence published previously regarding the efficacy of this complex in either preventing or treating equine gastric ulceration has been conflicting. In a prospective clinical study using 12 horses with naturally acquired ulceration, Venner and others (1999) found that those receiving the complex had significantly greater improvement in both squamous and glandular ulceration gastroscopic scores after just 11 days, compared to matched controls. Importantly, both case and control animals continued normal work patterns during the course of the study, and the ulcers occurred naturally. Ferrucci and others (2003) suggested that the same complex was also beneficial in improving both the clinical signs of gastric ulceration and squamous ulcer scores in a small group (n=10) of standardbred horses in training. In the latter study, the pectinlecithin complex was continued for 30 days with gastroscopic comparisons of ulceration at the start and finish of the study, but no control group was included. Both of these studies were performed in small groups of horses, but cumulatively provide some evidence that the product may enhance the rate of ulcer repair in horses in training. In contrast, Murray and Grady (2002) reported that the same product was not successful at preventing the development of squamous ulceration in a prospective
August 9, 2014 | Veterinary Record | 145
Downloaded from http://veterinaryrecord.bmj.com/ on July 14, 2015 - Published by group.bmj.com
Research this important topic. In crossover study in addition to this welcome eight ponies. In that initiative, further research experimental study, ponies tools are required to assist were given the complex in determining the clinical or an equivalent volume significance of specific of a pelleted control feed lesions in individual for seven days before the horses, and particularly induction of ulceration so with lesions of the using a feed deprivation glandular mucosa, protocol. Gastric ulceration where basic information scoring was performed regarding pathogenesis on the first and last days and progression is still of the trial period and the lacking. groups were compared. In order to induce ulceration, References ponies were fasted every ANDREWS, F., BERNARD, second day, resulting in W. & BYARS, D. (1999) a cumulative 72 hours of Recommendations for the diagnosis and treatment of equine gastric feed deprivation over a ulcer syndrome (EGUS). Equine seven-day period. Murray Veterinary Education 11, 262-272 and Grady (2002) found An example of glandular mucosal ulceration, showing an inflamed pylorus with A N D R E WS , F. M., REINEMEYER, C. R., a deep ulcer in the final stages of healing, following four months of medication. that all ponies undergoing MCCRACKEN, M. D., Chronic weight loss was the major presenting problem in this horse this protocol developed BLACKFORD, J. T., NADEAU, significant squamous J. A., SAABYE, L., SÖTELL, M. & SAXTON, A. in gastric acidity (Husted and others 2009). ulceration, and that administration of the (2002) Comparison of endoscopic, necropsy and histology scoring of equine gastric ulcers. Equine Veterinary In the clinical setting, the development pectin-lecithin complex was not effective in Journal 34, 475-478 of significant squamous ulceration is ulcer prevention. FERRUCCI, F., ZUCCA, E., CROCI, C., DI FABIO, V. multifactorial. Risk factors in athletic horses The study design used by Sanz and & FERRO, E. (2003) Treatment of gastric ulceration in 10 standardbred horses with a pectin-lecithin complex. include decreased gastric mucosal blood others (2014) is similar to that of Murray and Veterinary Record 152, 679-681 flow and increased intra-abdominal pressure/ Grady (2002), and the authors’ aim was to HUSTED, L., SANCHEZ, L. C., BAPTISTE, K. E. & gastric compression at high work intensity provide further evidence as to the value of OLSEN, S. N. (2009) Effect of a feed/fast protocol on (Lorenzo-Figueras and Merritt 2002). As the pH in the proximal equine stomach. Equine Veterinary pectin-lecithin complex supplementation in Journal 41, 658-662 equine athlete is also unlikely to experience equine ulcer prophylaxis. The research was LORENZO-FIGUERAS, M. & MERRITT, A. M. (2002) such extreme fluctuations in gastric acidity performed in 10 stabled horses, allocated Effects of exercise on gastric volume and pH in the as induced by the feed/fast model it is not randomly to intervention or control groups, proximal portion of the stomach of horses. American Journal of Veterinary Research 63, 1481-1487 possible from the results of Sanz and others before crossover for the second half of the LUTHERSSON, N., HOU NIELSEN, K., HARRIS, P. & to exclude a prophylactic role for the pectinstudy. Sanz and others (2014) implemented PARKIN, T. D. H. (2009) The prevalence and anatomilecithin complex in the clinical setting. a 28-day treatment period for the complex cal distribution of equine gastric ulceration syndrome The ideal means of proving efficacy of (EGUS) in 201 horses in Denmark. Equine Veterinary in accordance with manufacturer Journal 41, 619-624 any potential product for gastric ulceration recommendations, before induction of MCCLURE, S. R., GLICKMAN, L. T. & GLICKMAN, would be a large, prospective clinical trial, ulceration by a similar feed deprivation N. W. (1999) Prevalence of gastric ulcers in show in which the product is tested under field protocol (96 hours cumulative deprivation horses. Journal of the American Veterinary Medical Association 215, 1130-1133 conditions in a case-controlled cohort over seven days). The authors gastroscoped MURRAY, M. J. & GRADY, T. C. (2002) The effect of horses with blinded comparison of each horse at days 1 and 28 of the trial, and of a pectin-lecithin complex on prevention of gastric gastroscopic information by a specialist. The then again after feed deprivation (day 35). mucosal lesions induced by feed deprivation in ponies. Equine Veterinary Journal 34, 195-198 initial evaluation of the complex by Venner Ulceration was restricted to the squamous MURRAY, M. J., HAVEN, M. L., EICHORN, E. S., and others (1999) followed this study mucosa, and was scored using three different ZHANG, D., EAGLESON, J. & HICKEY, G. J. (1997) design, albeit in a relatively small number ordinal systems, including the widely used Effects of omeprazole on healing of naturally-occurof horses. The further problem in gastric ring gastric ulcers in Thoroughbred racehorses. Equine equine gastric ulceration score (EGUS) Veterinary Journal 29, 425-429 ulceration studies lies in the interpretation system (Andrews and others 1999) in which MURRAY, M. J., GRODINSKY, C., ANDERSON, C. of gastroscopic images, with ordinal scales lesions are graded from 0 (intact epithelium) W., RADUE, P. F. & SCHMIDT, G. R. (1989) Gastric of ulcer ‘severity’ being far from ideal. It to four (extensive, deep lesions). Sanz and ulcers in horses: a comparison of endoscopic findings in horses with and without clinical signs. Equine Veterinary is arguable whether fluctuations in EGUS others (2014) report that ulcer numbers, Journal supplement 7, 68-72 scores between 0 and two are clinically severity and EGUS scores were significantly MURRAY, M. J., SCHUSSER, G. F., PIPERS, F. S. & significant in individual horses, and higher at day 35 in all individuals, and that GROSS, S. J. (1996) Factors associated with gastric categorical distinction between ‘significant’ lesions in Thoroughbred horses. Equine Veterinary Journal treatment had no significant effect on these 28, 368-374 and ‘not significant’ may ultimately be more parameters, supporting the findings of SANZ, M. G., VILJOEN, A., SAULEZ, M. N., relevant. However, it has been demonstrated Murray and Grady (2002). OLORUNJU, S. & ANDREWS, F. M. (2014) Efficacy that gastroscopic estimation of ulcer When assimilating apparently of a pectin-lecithin complex for treatment and prevention of gastric ulcers in horses. Veterinary Record depth correlates poorly to subsequent conflicting pieces of evidence regarding drug doi: 10.1136/vr.102359. histopathological findings (Andrews or supplement efficacy, the clinician must TAMZALI, Y., MARGUET, C., PRIYMENKO, N. & and others 2002); estimates of EGUS consider several factors, including study LYAZRHI, F. (2011) Prevalence of gastric ulcer syndrome in high-level endurance horses. Equine Veterinary score, and indeed conclusions regarding design, group size and statistical power, and Journal 43, 141-144 significance, are therefore susceptible how closely the experimental model used VENNER, M., LAUFFS, S. & DEEGEN, E. (1999) to error. A consensus statement on the relates to the clinical scenario. The fast/ Treatment of gastric lesions in horses with pectinoptimum gastroscopic scoring system for lecithin complex. Equine Veterinary Journal supplement 29, feed protocol for equine gastric ulceration is 91-96 EGUS is to be published shortly, and may known to cause severe squamous mucosal standardise subsequent scientific reports on doi: 10.1136/vr.g4613 ulceration due to recurrent prolonged peaks 146 | Veterinary Record | August 9, 2014
Downloaded from http://veterinaryrecord.bmj.com/ on July 14, 2015 - Published by group.bmj.com
Equine gastric ulceration syndrome: treatment and prevention David Sutton Veterinary Record 2014 175: 145-146
doi: 10.1136/vr.g4613 Updated information and services can be found at: http://veterinaryrecord.bmj.com/content/175/6/145
These include:
References Email alerting service
This article cites 13 articles, 1 of which you can access for free at: http://veterinaryrecord.bmj.com/content/175/6/145#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Research
Research EDITORIAL
Equine gastric ulceration syndrome: treatment and prevention David Sutton KNOWLEDGE of the clinical signs, incidence, aetiology, management, treatment and prevention of equine gastric squamous mucosal ulceration has developed since the original groundbreaking work performed by Murray and others over 20 years ago (Murray and others 1989). Equestrian disciplines in which horses have been found to have a high incidence of squamous ulceration include racing (Murray and others 1996), endurance (Tamzali and others 2011) and showing (McClure and others 1999), but significant proportions of horses used for less demanding pleasure pursuits may also have gastric ulceration (Luthersson and others 2009). Although omeprazole has been shown to be highly effective in suppressing gastric acid production and enhancing the rate of ulcer healing (Murray and others 1997), it is expensive and not permitted for use in many competitive events. There is therefore great demand for the production of alternatives, such as gastroprotective feed supplements, that are allowed according to competition rules. Many such products are available, but very few are supported by convincing clinical evidence regarding their efficacy in suppressing ulcer development.
David Sutton, MA, VetMB, CertEM(IntMed), DECEIM, PhD, MRCVS, Weipers Centre Equine Hospital, School of Veterinary Medicine, University of Glasgow, Bearsden Road, Glasgow, UK e-mail: [email protected]
On p 147 of this issue of Veterinary Record, Sanz and others (2014) report a prospective crossover study designed to assess the ability of an oral pectin-lecithin complex to prevent the development of ulcers in an experimental model. The evidence published previously regarding the efficacy of this complex in either preventing or treating equine gastric ulceration has been conflicting. In a prospective clinical study using 12 horses with naturally acquired ulceration, Venner and others (1999) found that those receiving the complex had significantly greater improvement in both squamous and glandular ulceration gastroscopic scores after just 11 days, compared to matched controls. Importantly, both case and control animals continued normal work patterns during the course of the study, and the ulcers occurred naturally. Ferrucci and others (2003) suggested that the same complex was also beneficial in improving both the clinical signs of gastric ulceration and squamous ulcer scores in a small group (n=10) of standardbred horses in training. In the latter study, the pectinlecithin complex was continued for 30 days with gastroscopic comparisons of ulceration at the start and finish of the study, but no control group was included. Both of these studies were performed in small groups of horses, but cumulatively provide some evidence that the product may enhance the rate of ulcer repair in horses in training. In contrast, Murray and Grady (2002) reported that the same product was not successful at preventing the development of squamous ulceration in a prospective
August 9, 2014 | Veterinary Record | 145
Downloaded from http://veterinaryrecord.bmj.com/ on July 14, 2015 - Published by group.bmj.com
Research this important topic. In crossover study in addition to this welcome eight ponies. In that initiative, further research experimental study, ponies tools are required to assist were given the complex in determining the clinical or an equivalent volume significance of specific of a pelleted control feed lesions in individual for seven days before the horses, and particularly induction of ulceration so with lesions of the using a feed deprivation glandular mucosa, protocol. Gastric ulceration where basic information scoring was performed regarding pathogenesis on the first and last days and progression is still of the trial period and the lacking. groups were compared. In order to induce ulceration, References ponies were fasted every ANDREWS, F., BERNARD, second day, resulting in W. & BYARS, D. (1999) a cumulative 72 hours of Recommendations for the diagnosis and treatment of equine gastric feed deprivation over a ulcer syndrome (EGUS). Equine seven-day period. Murray Veterinary Education 11, 262-272 and Grady (2002) found An example of glandular mucosal ulceration, showing an inflamed pylorus with A N D R E WS , F. M., REINEMEYER, C. R., a deep ulcer in the final stages of healing, following four months of medication. that all ponies undergoing MCCRACKEN, M. D., Chronic weight loss was the major presenting problem in this horse this protocol developed BLACKFORD, J. T., NADEAU, significant squamous J. A., SAABYE, L., SÖTELL, M. & SAXTON, A. in gastric acidity (Husted and others 2009). ulceration, and that administration of the (2002) Comparison of endoscopic, necropsy and histology scoring of equine gastric ulcers. Equine Veterinary In the clinical setting, the development pectin-lecithin complex was not effective in Journal 34, 475-478 of significant squamous ulceration is ulcer prevention. FERRUCCI, F., ZUCCA, E., CROCI, C., DI FABIO, V. multifactorial. Risk factors in athletic horses The study design used by Sanz and & FERRO, E. (2003) Treatment of gastric ulceration in 10 standardbred horses with a pectin-lecithin complex. include decreased gastric mucosal blood others (2014) is similar to that of Murray and Veterinary Record 152, 679-681 flow and increased intra-abdominal pressure/ Grady (2002), and the authors’ aim was to HUSTED, L., SANCHEZ, L. C., BAPTISTE, K. E. & gastric compression at high work intensity provide further evidence as to the value of OLSEN, S. N. (2009) Effect of a feed/fast protocol on (Lorenzo-Figueras and Merritt 2002). As the pH in the proximal equine stomach. Equine Veterinary pectin-lecithin complex supplementation in Journal 41, 658-662 equine athlete is also unlikely to experience equine ulcer prophylaxis. The research was LORENZO-FIGUERAS, M. & MERRITT, A. M. (2002) such extreme fluctuations in gastric acidity performed in 10 stabled horses, allocated Effects of exercise on gastric volume and pH in the as induced by the feed/fast model it is not randomly to intervention or control groups, proximal portion of the stomach of horses. American Journal of Veterinary Research 63, 1481-1487 possible from the results of Sanz and others before crossover for the second half of the LUTHERSSON, N., HOU NIELSEN, K., HARRIS, P. & to exclude a prophylactic role for the pectinstudy. Sanz and others (2014) implemented PARKIN, T. D. H. (2009) The prevalence and anatomilecithin complex in the clinical setting. a 28-day treatment period for the complex cal distribution of equine gastric ulceration syndrome The ideal means of proving efficacy of (EGUS) in 201 horses in Denmark. Equine Veterinary in accordance with manufacturer Journal 41, 619-624 any potential product for gastric ulceration recommendations, before induction of MCCLURE, S. R., GLICKMAN, L. T. & GLICKMAN, would be a large, prospective clinical trial, ulceration by a similar feed deprivation N. W. (1999) Prevalence of gastric ulcers in show in which the product is tested under field protocol (96 hours cumulative deprivation horses. Journal of the American Veterinary Medical Association 215, 1130-1133 conditions in a case-controlled cohort over seven days). The authors gastroscoped MURRAY, M. J. & GRADY, T. C. (2002) The effect of horses with blinded comparison of each horse at days 1 and 28 of the trial, and of a pectin-lecithin complex on prevention of gastric gastroscopic information by a specialist. The then again after feed deprivation (day 35). mucosal lesions induced by feed deprivation in ponies. Equine Veterinary Journal 34, 195-198 initial evaluation of the complex by Venner Ulceration was restricted to the squamous MURRAY, M. J., HAVEN, M. L., EICHORN, E. S., and others (1999) followed this study mucosa, and was scored using three different ZHANG, D., EAGLESON, J. & HICKEY, G. J. (1997) design, albeit in a relatively small number ordinal systems, including the widely used Effects of omeprazole on healing of naturally-occurof horses. The further problem in gastric ring gastric ulcers in Thoroughbred racehorses. Equine equine gastric ulceration score (EGUS) Veterinary Journal 29, 425-429 ulceration studies lies in the interpretation system (Andrews and others 1999) in which MURRAY, M. J., GRODINSKY, C., ANDERSON, C. of gastroscopic images, with ordinal scales lesions are graded from 0 (intact epithelium) W., RADUE, P. F. & SCHMIDT, G. R. (1989) Gastric of ulcer ‘severity’ being far from ideal. It to four (extensive, deep lesions). Sanz and ulcers in horses: a comparison of endoscopic findings in horses with and without clinical signs. Equine Veterinary is arguable whether fluctuations in EGUS others (2014) report that ulcer numbers, Journal supplement 7, 68-72 scores between 0 and two are clinically severity and EGUS scores were significantly MURRAY, M. J., SCHUSSER, G. F., PIPERS, F. S. & significant in individual horses, and higher at day 35 in all individuals, and that GROSS, S. J. (1996) Factors associated with gastric categorical distinction between ‘significant’ lesions in Thoroughbred horses. Equine Veterinary Journal treatment had no significant effect on these 28, 368-374 and ‘not significant’ may ultimately be more parameters, supporting the findings of SANZ, M. G., VILJOEN, A., SAULEZ, M. N., relevant. However, it has been demonstrated Murray and Grady (2002). OLORUNJU, S. & ANDREWS, F. M. (2014) Efficacy that gastroscopic estimation of ulcer When assimilating apparently of a pectin-lecithin complex for treatment and prevention of gastric ulcers in horses. Veterinary Record depth correlates poorly to subsequent conflicting pieces of evidence regarding drug doi: 10.1136/vr.102359. histopathological findings (Andrews or supplement efficacy, the clinician must TAMZALI, Y., MARGUET, C., PRIYMENKO, N. & and others 2002); estimates of EGUS consider several factors, including study LYAZRHI, F. (2011) Prevalence of gastric ulcer syndrome in high-level endurance horses. Equine Veterinary score, and indeed conclusions regarding design, group size and statistical power, and Journal 43, 141-144 significance, are therefore susceptible how closely the experimental model used VENNER, M., LAUFFS, S. & DEEGEN, E. (1999) to error. A consensus statement on the relates to the clinical scenario. The fast/ Treatment of gastric lesions in horses with pectinoptimum gastroscopic scoring system for lecithin complex. Equine Veterinary Journal supplement 29, feed protocol for equine gastric ulceration is 91-96 EGUS is to be published shortly, and may known to cause severe squamous mucosal standardise subsequent scientific reports on doi: 10.1136/vr.g4613 ulceration due to recurrent prolonged peaks 146 | Veterinary Record | August 9, 2014
Downloaded from http://veterinaryrecord.bmj.com/ on July 14, 2015 - Published by group.bmj.com
Equine gastric ulceration syndrome: treatment and prevention David Sutton Veterinary Record 2014 175: 145-146
doi: 10.1136/vr.g4613 Updated information and services can be found at: http://veterinaryrecord.bmj.com/content/175/6/145
These include:
References Email alerting service
This article cites 13 articles, 1 of which you can access for free at: http://veterinaryrecord.bmj.com/content/175/6/145#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
