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Equine Nutrition with Dengie: Equine Gastric Ulcers with Katie Williams | Podcast #6

Podcast show notes episode #6

Today we're talking about Equine Gastric Ulcers in our podcast with Katie Williams, MSc (dist)  Equine Nutritionalist from Dengie horse feeds.

Katie tells us "it's certainly a hot topic at the moment. A lot of people worried about gastric ulcers and suspecting that their horses have got them. So it's really good timing to be discussing it today."

We started the podcast with Katie giving us an overview of what ulcers actually are...

In simple terms, ulcers are damage to the lining of the stomach, and can be caused by a number of factors that break down horses natural defences. You've got a very acidic environment in the stomach, so as soon as that protection system is compromised, the acid can erode the stomach tissue.  We know there are two distinct types of ulcers affecting different regions of the stomach. Each with different risks factors, which we will cover throughout the discussion, because those two distinct areas are key.

There's lots of acronyms and letters and words to digest with this one, We have ESGD -  Equine Squamous Gastric Disease, and they are the ones that we more typically associate with low fibre diets and high exercise intensity. We also then have EGGD - Glandular Gastric Disease, in which the bottom half of the horse's stomach, where all the gastric juices and the acids that break down the food are produced, and we need a real breakdown in horses defence mechanism in the stomach for those to occur. That, at the moment seems to be associated with stress and pain in particular. So, that's the one that's relatively recently being investigated and diagnosed more frequently.

So has it been a bit of an eye opener having the, the new, recent definition of these two different types of ulcers in terms of management and, and helping the horses?

Yes, very much so. And I think if you went back 20 years, the ulcers in the EGGD type would have been more typically thought to be associated with longterm use of non-steroidal anti-inflammatories, so Bute. It's a bit like a human taking aspirin, for some other issue and ending up with an ulcer as a result of doing that. So we extrapolated from the human experience and attributed it to the horse. What we've shown and the researchers that have been investigating it, also the vets that do a lot of work on this is that that is actually quite a low risk factor.  But ulcers occurring in horses, doesn't seem to have the same impact as it can do in humans. But in actual fact, it's stress that really is compromising the built in protection systems in the glandular region of the stomach.

Now that might be through pain, or it might just be through the very nature of what we are wanting to do, i.e. if they are a performance or competition horse, then stress is inevitable. You've got to travel and go to very stressful places for those horses.  So, it's how we manage them as much as the medicinal treatments and that is going to determine  how likely they are to have the ulcer, but also their long term prognosis. We've spoken to vets, and in some cases, if horses don't respond to treatment and you can't change their function, you're not going to solve the problem and you might have to consider retiring your elite performance horse as a result, so it's a serious issue. And those with EGDD are tending to be a lot less common than the squamous version.

So could you tell to us a little bit more about the risk factors and causes and give us a little bit more information about the two different types of ulcers...

So the squamous ulcers tend to be the ones that we are more familiar with and over the last 20 - 25 years  we've really determined a lot more about them. We would attribute them to a low fibre diet and to exercising at speed. When you haven't got forage or something fibrous in the stomach, the acidic contents can splash around and the faster and harder work, the more likely there is for this acid splash effect, so you've literally got nothing suppressing the acid.

Historically, when I first started as a nutritionist, you could quite often go into a racing yard and they'd be feeding one section of hay, so two kilos or whatever, in the 24 hour period which is way, way below what we should feed. So, it's no surprise that it was commonly seen in racehorses because they were typically fed the lowest fibre diets. And as a result, I think we've increased the amount of forage that we feed to all horses and understood the importance of doing so and racing trainers in particular have improved their feeding strategies with this kind of problem in mind. So it's good management, that's required, explains Katie.

And again, one of the fundamental changes is that we now advocate feeding a double handful of chopped fibre or forage about 20 minutes before exercise to act as a suppressant. So it's kind of a mat or sponge to absorb the acid and just stop it splashing around in the horses stomach. If you go back 20 years, there's no way we would have thought that - you need an hour, you want the horse to exercise on an empty stomach. It's been a really fundamental shift in the way we've advised and do things.

I think we pretty much understand the ESGD. The EGGD, it was only last year, or maybe 2018 that we had the first real consensus statement from the European College of Internal Equine Medicine. So, in other words, the researchers and vets that are investigating this all the time. And it was really the sort of development in the understanding of it not to being relating to the drug and much more to do with the stress which may be caused by pain, etc. What I find really fascinating about the EGGD, is that actually the risk factor is the trainer themselves. You can see that certain people have yards that are much more stressful environments than others, and so it's not the trainer per se, but it's the way perhaps that they manage. And that's just where you get a correlation and not necessarily a causation.

But also, this is when stress relates to it. It has been shown that actually two days off a week, as opposed to one is actually a preventative benefit. So you can reduce the risk in your performance horse by actually giving them two days off rather than one. So it clearly shows that the stress and the expectations of what we do with our horses in, in a normal or what we perceived to be a normal, environment of a competition horse are actually causing them to have some stress that is compromising the defence mechanisms in the glandular region of the stomach. Therefore you get that breakdown and the acid can then start to erode the stomach tissue.

If you think about the horses kind of natural day to day life and their natural environment as they would be without interference from humans, Then all that we expect from horses is pretty stressful by comparison.

Yeah, definitely. I mean, they would be in herd groups, roaming around sort of eating for 16, 18 hours a day, maybe. Especially in the performance horse world, you put them in a stable, they might only have an hour or so exercise a day. They can be quite sedentary for a long period of time and potentially very little, if any, contact with other horses.  You can understand, there's a lot of reasons why you wouldn't want to risk them getting kicked if they're valuable performance horse. And that's where the ethical considerations come in, of horse ownership. Quite frankly, you have to balance the welfare of the animal, versus obviously its commercial value and its role. It's not an easy decision to make.

I think we've been talking a lot about the performance horse, but equally, if you have a good doer or Laminitic and you have to bring them off the grass because you've got to control their weight. Obviously it's the right thing to do to reduce their risk of laminitis, which is also a potentially fatal disease, that can be another consideration even at that end of the spectrum. So we do tend to find that kind of overweight pony or native type can be as vulnerable to some form of ulcer. Just as much as the elite performance horse, its an interesting disease. That's for sure.

It's quite a balancing act, really, because if you're trying to avoid laminitis, then you're trying to do the best for your horse and it would be irresponsible to do otherwise. But at the same time, then you're changing that natural environment and the natural routine and obviously risking other disorders and illnesses. Yeah. It's a difficult one. 

 

So how would ulcers be diagnosed? What are the typical signs?

So most people, if they come to us, maybe they've called a feed line with  concerned their horse might have ulcers, they tend to describe things like, 'girth-iness' - so they're very sensitive when they're being girthed up. So it might be when you're literally getting on or just tightening your girth and they become uncomfortable or they might try to turn around and sort of bite you. Also more general conditions that you would suspect something wasn't right. So, things like poor condition or performance, just general poor health, you get the instinct that something's wrong. But, can't quite put your finger on it. There's no other obvious cause. You can sometimes have intermittent colic, because obviously the horse has pain in its stomach. So colic is a generic term really for discomfort and showing signs of discomfort in the digestive tract.

Another kind of fairly unique symptom or sign in a horses when they start to eat and then stop eating. So they perhaps find the eating, or the presence of food in their stomach uncomfortable. That can also be a sign that narrows it down a little bit more to ulcers. But it's so difficult to diagnose because you can have a Grade 4 ulcer, which is the most serious and you can have a horse that shows no sign of it whatsoever. They could be racing at top level and good condition, performing really well and have a really bad ulcer. And then on the opposite side, they could have just like a Grade 1 or 2, something fairly mild and actually get a lot of pain from it. So it's, it's not a guarantee, if you like, or a direct relationship, that if they're showing signs, they've got really bad ulcers or vice versa.

So to definitively diagnose it a vet has to put a gastroscope in, it's a camera in a tube that they put into the horses stomach, you usually have to withhold feed for at least overnight. And we speak to vets quite a lot, who find that they stop feeds, say four or five o'clock the night before and still coming to try and scope in the morning and there's still food there. So it can be a challenge. Obviously, if the stomach is full of food, you can't see. So you have got to have an empty stomach, which again, some people find a bit counterintuitive potentially. How is that actually impacting on the ulcers themselves? Cause you've withheld feed, a period of time. And then you'll have horses that are really hungry, or so hungry, that start to eat their beds, so again, you haven't given them hay or food or whatever, it can be quite a challenge to get the gut empty enough to have a proper look. Effectively you need a three meter endoscope, and that's why probably 25 years ago it was really only to vet hospitals in places like Newmarket or maybe down in Lambourn, where the vets there had the long enough scopes to have look. Now we find that most of the regional, equine practices will have a gastroscope, and they often do specific days where they've got the gastroscope at the veterinary practice and you can take your horse in and have it scoped and get advice there.

That's really good, that technology is allowing that to be diagnosed so much more easy for people, that its so much more accessible.

Yeah, absolutely. You really do need a kind of a good skilled vet to use it and have a proper look around. So it's worth getting that person to do for you, and get a proper definitive diagnosis. Otherwise you're guessing a lot of the time, but some vets, you know, it's not cheap to have it done. So a lot of vets will try and help by making management changes and potentially almost trying some treatments. So in affect you diagnose by treatment and you're not going do any harm by sort of making the management changes that would be recommended, and using some of the medications. Because the actual gastroscoping isn't a cheap procedure, for some people it's just not viable. If they haven't got insurance, some vets will take the approach that they make the management changes, also do some medication on the basis that if the symptoms improve, that's given them the diagnosis in effect. So it's very much worth talking to your vet about the different options, it's quite simply sometimes just changing a few dietary and some management approaches can make difference, but definitely one to talk to your vet about.

So what can horse owners do to manage either type of ulcer?

I think obviously with the EGGD and it comes back to the ethical considerations and you need to make management changes. If your horse is stressed in some way, it can be on a yard situation, just who they're stabled next to, if they're being bullied by another horse, through railings, rather than a solid wall... some people will put mirrors up in the stables, so that they feel that they've got company. So they're not so socially isolated and, rest days, quite frankly.  Hopefully two days off a week is not going to compromise the fitness or the performance of the animal, but could actually make a huge difference in terms of the risk of that sort of glandular area disease.

I would imagine, for recovery as well, for the horse's physical recovery, and mentally very important...

Yeah, definitely. And then for the, for the squamous gastric disease or gastric ulcers it is really about trying to reduce the acidity levels by avoiding starch as much as possible. So, feeding fewer cereals if you need them at all. Making sure you've got as much fibre in the diet as you can. Trying to feed a double handful of chopped fibre is ideal, but if they've got access to forage about 20 minutes before exercise, so you're trying to form that fibre mat in the stomach that stops the acid splash. It's just making sure that you keep your horse as stress free as you can. And I do appreciate, that's not always easy, even for the average horse owner, when you've got a horse on a busy livery yard, they're busy environments, there's a lot going on, but certainly in terms of turning out with other horses and giving them as much time as natural an environment as possible is going to be helpful.

Yeah, absolutely. I think it's such a game changer thinking about that fibre mat and thinking 20 minutes before versus that hour, which it's just been around forever - an hour before and an hour after exercise and I suppose it's not really a case of saying to somebody to suddenly feed a big, massive feed and, and lots of concentrates 20 minutes before, but just that fibre, and I think to make it really clear that it's, that it is just fibrous food.

Yeah definitely cereals are still the sort of risk factor for a lot of diseases in the horse. So, whether it's, colic or ulcers or laminitis, for every horse it's good practice to have as a low amount of cereal starch, you can in the ration and certainly that's where the basic rules of feeding really apply. So allowing your hour before exercise, if you're using cereal base feeds, of course, that still applies. But as a principal, the fibre and the forage in the ration, unless you've got the most overweight horse or pony there's no reason to compromise or restrict the amount of forage they've got access to. And a lot of the time, if you're feeding good quality forage and plenty of it, you can use fibre in their bucket as well and a good quality fibre source. There's not many horses, unless they are elite athletes, and there's not many that really, actually, genuinely need cereals in their ration. We are almost conditioned to thinking, 'Oh, he's doing a bit of work. So I must use a mix or a cube.' And hopefully thats a step away, you know, we're seeing a definite shift away from cereal based feeds to using balancers, and fibre and oil with it. And hopefully that will continue. So, those cereal based feeds come with a lot of risks and you have to really weigh up whether they're worth it to be honest.

I think if you feed enough of it and you can get some good quality forage, it goes a huge way to making up the energy requirements and most of the other nutrients. And as long as you top up with a supplement or something like that, where you've got the vitamins, the minerals and the diet is balanced, and it can be as simple as that, We always say feeding, doesn't have to be complicated. For the vast majority of horses, good quality forage and a good quality vitamin mineral supplement or balancer and job's done really

So much less complicated than it was. I remember back a very long time ago... in the feed room, you had bins with all of the individual straight feeds and they all had to be mixed for each horse... and I always used to think, Oh my gosh, feeding is so complicated! ...it's so nice that it just is so much simpler these days.

I remember all the ratios,  60:40 and 50:50 forage and concentrates depending on workload, and all that's gone out the window. Now, the modern feeds are done according to body weight, so with the balancers. It's really simple. It's usually about a hundred grams, a hundred kilos bodyweight.  So, 500 grams for a 500 kilo horse. You can't get much simpler than that. I think it's much more like a building block system. Start with your foundation of plenty of forage, you top about with vitamins and minerals and then your next layer, if you need it, is some extra energy and there's lots of options that are much safer these days, whether it's things like micronised linseed or sugar beet, they're great sources of extra calories or energy for work if you need it. So, yeah, we do try to make it simple. I think the confusing thing now is just the sheer volume of different feeds that are available to someone, there's so much choice and trying to work out, which one you want to use is, is the challenge. But the principles are simple. It's just sometimes picking the right one. That's a bit more complicated!

 

At least it is much easier than having to work out ratios and also make your own balanced so-called mix out of all of the straight feeds. So glad to let somebody else do that for us!

Absolutely.

Going back to the ulcers, if you can manage it with feed and environment and looking after your horse and general management, that's brilliant. But what about if you do need something a little more to help your horse, are there medications or therapies that your vets use as well?

Yes, there are. And obviously you would need to discuss with your vet the right protocol for your horse, but the one that most people would be familiar with, I think is Omeprazole or Gastroguard as its marketing name.

Is it the same one humans have that as well?

Yeah. And that there are some pros and cons about the different options. But, the latest thinking with Omeprazole, actually for the oral administered, is that you should actually withhold feed or remove feed before using it. So basically, for quite a long time as well, eight hours prior to feeding the oral Omeprazole. Again, it always feels counterintuitive, a bit like the scoping when you have to withhold feed to see if you've got an ulcer.  If you've withheld feed all night, you might well have one by the time you actually scope anyway! But in theory, you shouldn't get ulcers forming just over one night. And then once you've given your Omeprazole, you would then withhold feed still for about another 30 minutes and maybe up to an hour or so, and that's really to allow the absorption of the drug. So again, a common misconception is that you feed it because it's going into the stomach, it works straight away on the stomach, but it doesn't, it has to go through and be absorbed into the bloodstream and then the blood takes it back to the stomach tissue. And that's when it has an impact. So obviously if you've got food present, it's going to block the absorption or reduce the absorption. So that is why they are saying to use or to withhold the feed before you use the Omeprazole, so it's really to maximise the absorption of the drug. So it's going to be at its most effective. With the sort of developments in that area, there are studies and research programs going on, looking at injectable Omeprazole. And obviously that would then negate the need for the withholding a feed. It's not licensed yet for the UK, but there are some vets doing research work with it. I believe now, if you talk to your vet and discuss the options, it is possible to have your horse treated with injectable, but that's newer special exemption. And you would need to talk to your vet about that. At the moment, the only licensed ones are the orally administered ones, and there are other versions of drugs, again, trying to suppress acid production in the stomach to give it time to heal effectively is the main mechanism. But different vets have different views on the effectiveness and I think there are some trials where they're using two different types of drugs together as well. So there are lots of options and that's really then the vet needs to see what problem your horse has, how it's responded to the management changes. And if you've tried any other treatments, then they might use a combined therapy as well. So there's lots of factors that come into play with that. But obviously the first step that most vets recommend would be to look at the management, change the diet, turn out more, try and reduce the stress, because they're the key things. Then obviously they tend to cost less to do too.

There is some thoughts and again, there was one study published, I think, late 2019,  where the use of Omeprazole can actually compromise calcium absorption as well. So in the racing industry, because ulcers are so prevalent and they're using a lot of medication to try and keep the horses happy, healthy, and safe to run and everything, but they are starting to attribute some of the shattering bone issues to the lack of, or to the problems of calcium absorption. So again, there is always a balance. You're solving one problem with a drug, i.e the ulcers, you can be creating other ones. So if you can change management and improve the situation that way, it's obviously going to be a lot better in the long run.

 

Of course. That's really, really interesting. So what would be the take home message for people with regards to ulcers?

I think if you suspect your horse has ulcers you can make some changes yourself, it's well worth doing that straight away. But obviously if the symptoms persist and specifically that sort of 'girthiness' and perhaps reluctance to eat, then you need to get your vet involved and just have an open and honest conversation with your vet from the outset. If gastroscopes and medications are going to be problematic for you, or you can't afford them, then discuss the alternatives straight away. But definitely in terms of management, it's good practice, just turning your horse out as much as you can, giving them as much forage as you can, and reduce your reliance on cereals, if you use them. If you have a good doer, so on the Laminitic side of things, then again looking for those low calorie fibre sources. You don't want to feed ad-lib forage to a horse that's already overweight. You really need to find the low calorie option for them, so that you can give them enough fibre and reduce their risk of ulcers. It's forage, forage, forage really!

 

I think that's really good advice for any horse. That good management and lots of fibre, and as much as you can, allow them to be horses and to, and to be less stressed as well. I think it is difficult depending on what you want your horse to do, but so important to factor that into their overall plan and management.

Definitely, as we said earlier, it's that balance between having a horse that is healthy, but also one that is able to do what you want it to do. In the environment, consider changing yards, if your horse really isn't happy somewhere, it may be quite drastic, but it is worth moving to see if you can get them settled, maybe on a smaller yard with just one or two other horses present.

That can make such a difference. I've experienced it myself in the past and I've seen lots of different horses, that at one yard, nothing wrong with that yard, a lovely yard but a horse just does not settle for whatever reason. Then you change yards and they're a completely different horse, it's amazing how sensitive they are to their environment.

Definitely...lots of take home messages, also not to rule out pain somewhere else in the body. And we see that ulcers are secondary to some other issues. So if they've got a back problem or some sort of lameness or illness or something that's causing them stress in that way, because they're in pain. The ulcers may actually be secondary to another issue. So if you suspected they're a bit short, or lame or whatever, then get that investigated because there actually might be ulcers as well.

I suppose it's kind of like what comes first, the chicken or the egg?  If you've got a horse that has an ulcer, I suppose they may well move differently - that self protective mechanism because of the pain. You could see lameness or a change in movement if you've got an ulcer, but equally, it could be the other way round and they've got pain, but then ulcer follows because of the stress from it.

It's very difficult to ascertain, which comes first sometimes. Yeah. Sort both or one or the other and the other one might well fix itself. Sometimes the only way is to get the vet out. I know it's a big undertaking sometimes to have to get the vet to come and see, but sometimes it's essential really to get to the bottom of the problem.

If in doubt at all, it's always advisable to call your vet and find out what the cause is. 

Thank you so much, Katie. Another really informative podcast. So if anybody is worried about their horse potentially having an ulcer or think that that might be the cause, then look at the different management options, but if in doubt, call the vet and certainly get some advice from them. Thank you so much. Really, really good...and we'll look forward to speaking to you on the podcast again soon.

 For more information watch Dengie's video all about Gastric Ulcers: 

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