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DIFFERENTIAL DIAGNOSIS AND TREATMENT OF GASTRIC AND COLONIC ULCERS

Franklin L. Pellegrini, DVM

Wild West Veterinary Conference19 October, 2012

Thursday, November 1, 2012

Ulcers vs. Syndrome

• GI Ulcers = lesions of the GI mucosa

• Ulcers reflect a syndrome (collecBon of symptoms that occur as a result from an underlying condiBon)

• Gastric ulcers/lesions = EGUS = stage of gastriBs

• Colonic ulcers/lesions = colonic ulcer syndrome (ECUS?) = stage of coliBs

EGUSGastric ulcers

Widely known

Widely studied

Widely diagnosed

Poorly understood

Lots of informa,on, but many uncertain,es:

Do all the lesions have clinical importance/significance?

Has EGUS been over-‐diagnosed and/or over-‐treated?

Is the eBology certain?

And, most important:

is EGUS a single ulcera4ve pathologic gastric condi4on?

Severe gastric ulceraBon in the squamous (non-‐glandular) porBon of a horse’s stomach.

Glandular mucosa, near the pyloric opening, showing several linear ulcers.

ESGUS EGGUS

A new study shows that EGUS is not a single exis6ng gastric ulcera6ve condi6on.BEVA Congress 2012: new research reported that Gastric UlceraBon must be further differenBated in 2 syndromes.

• EGGUS (Equine glandular gastric ulcer syndrome)

• ESGUS (Equine squamous gastric ulcer syndrome)

A comparison of two doses of omeprazole in the treatment of gastric ulceraBon in Thoroughbred racehorses.

Sykes BW and Hallowell GD

• In a 24-‐plus horse study, horses were scoped and treated with convenBonal omeprazole at therapeuBc dosage for 30 days.

• Upon compleBon of this study the following findings were noted…

100% Improving

70% Healing

57% Improving

41% Healing

Omeprazole Effects at 4mg/Kg

62% Improving

50% Healing

26% Improving

9% Healing

Omeprazole Effects at 1.6mg/Kg

As a consequence, Glandular Gastric Ulcera4on and Squamous Gastric Ulcera4on cannot be represented as a single syndrome called EGUS.

• They may have completely different TREATMENT and ETIOLOGY.

• Further work is needed to determine whether the two syndromes share the same symptomology.

• It’s likely that all we know about EGUS refers only to ESGUS (squamous).

Summary of causes known for EGUS before the new differen4a4on and findings (published e4ology theories):

• NSAIDs (anB prostaglandins)

• CorBsol level (stress)

• Acidity (intermiient feeding)

• Hard feed (excessive carbohydrates)

• Bacteria (H Equorum) (i)

• Parasites (bots)

Consequences of Sykes’ work for the common equine prac4ce:

1. 50% of the horses treated convenBonally are not going to respond (omeprazole)

2. This helps to explain the large percentage of poor performing/training horses even aker an expensive complete course of omeprazole

COLONIC ULCER SYNDROME

Colonic Ulcer Syndrome (ColiKs)

Not widely known

Not widely studied

Not widely diagnosed

Poorly understood

Colonic Ulcer Syndrome (ColiKs)

Summary of possible causes:

NSAIDs (anB prostaglandins)

CorBsol level (stress)

Acidity (intermiient feeding)(i)

Bacteria

Parasites

Bacteriology

What is “normal flora” in a healthy horse?

It’s not the same in each horse

There are thousands of bacterial species, but each horse has typically only a hundred or so, and those populaBons are unique.

There are bacteria associated with colonic lesions (coliBs)

BacteriologyAnalysis of Tissue Samples (via necropsy)Each column is a bacterial species

MulB colored

Colonic Fingerprint by Grade

Bacteriology

A correlaBon was found between ulcerated and un-‐ulcerated Bssue, disBnguished by both quality and quanBty.

DIFFERENTIAL DIAGNOSISGastric and colonic ulcers

Gastric and Colonic Ulcers

Necropsy results, 2003 – 180 performance horses:

Journal of Equine Veterinary Science, March 2005

DifferenKal Diagnosis

DifferenBaBng foregut vs. hindgut allows for a more targeted treatment.

Treatment protocols are different.

DifferenKal Diagnosis

S.O.A.P.Subjec+ve Objec+veAssessmentPlan

S.O.A.P.

SubjecKve

Clinical Signs?

S.O.A.P.

Subjec*ve: Poor body condiBon

ParBal anorexia/poor appeBte

Girthiness

Altude changes

Poor performance/poor training

Altered fecal consistency (diarrhea)

S.O.A.P.

Subjec4ve:

Clinical Signs

Poor body condiBon

S.O.A.P.

Subjec4ve:

Clinical Signs

ParBal anorexia/poor appeBte

S.O.A.P.

Subjec4ve:

Clinical Signs

Girthiness

S.O.A.P.

Subjec4ve:

Clinical Signs

Girthiness

S.O.A.P.

Subjec4ve:

Clinical Signs

Altude changes

S.O.A.P.

Subjec4ve:

Clinical Signs

Poor performance/poor training

S.O.A.P.

Subjec4ve:

Clinical Signs

Altered fecal consistency (diarrhea)

S.O.A.P.

Objec+ve

Measurable Data

S.O.A.P.

Objec4ve:

1. 3-‐meter endoscopy

2. Rapid anBbody test (lateral flow immunoassay)

3. pH Meter

S.O.A.P.

Objec4ve:

Measurable data sources

3-‐meter endoscopy

S.O.A.P.

Objec4ve:

Rapid anBbody test (lateral flow immunoassay)

S.O.A.P.

Objec4ve:

pH Meter

S.O.A.P.

Assessment:

DDX – Foregut

EGUS (ESGUS and/or EGGUS) – stomach ulcers (squamous, glandular or both).

Gastri+s

Neoplasia

Parasi+sm

Anterior enteri+s

S.O.A.P.

Assessment:

Foregut or hindgut…or both?

Problems with differenKaKon

• Clinical signs of RDC can be similar to the signs of gastric ulceraBon.

• They may occur concomitantly.

• Our studies have shown that 60% of gastric ulcers are accompanied by colonic ulceraBon (coliBs).

S.O.A.P.

Assessment:

DDX – Hindgut

Colonic ulcers

ColiBs

IntesBnal traumas (rectal tears, traumaBc events)

ParasiBsm

Neoplasia

S.O.A.P.

Assessment:

DDX – Hindgut

IntesBnal inflammatory disease

– Non-‐infec+ous

• Eosinophilia• Lymphocy+c

• Plasmacy+c

• Inflammatory bowel disease

• Etc.

– InfecBous

• Salmonellosis

• Clostridiosis• Lawsonia• Etc.

S.O.A.P.

Further invesBgaBon, if needed

Treatment plan

TREATMENTGastric and colonic ulcers

EGUS Treatment

Prior to ESGUS and EGGUS differen4a4on:

1) PharmaceuBcal

2) Husbandry

3) Over-‐the-‐counter products (OTC)

EGUS Treatment

Prior to ESGUS and EGGUS differen4a4on:PharmaceuBcals

Proton pump inhibitors -‐ omeprazole

– Gastrogard, FDA approved Rx

– Ulcergard (preventaBve?)

– Compounded

H2 Antagonist

– CimeBdine, RaniBdine, FamoBdine (all off label)

– Are these well absorbed?

EGUS Treatment

Fenbendazole – Weak PPI (anthelmenBc)

Mucosal Protectant – Sucralfate

EGUS Treatment

Prior to ESGUS and EGGUS differen4a4on:Husbandry

Turn out

MulBple feedings (4 daily, at least)

Dietary modificaBon

– Alfalfa (Brei Scoi 2007)

EGUS (before ESGUS and EGGUS differenKaKon) Treatment

Husbandry

EGUS Treatment

Prior to ESGUS and EGGUS differen4a4on:OTC Products

Antacids

Herbals

Patented products

“Gastric Aids” (supplements)

EGUS Treatment

Antacids

– Neigh-‐Lox

– Mylanta extra strength

– Maalox

Temporary effect 30 to 90 minutes

EGUS Treatment

Herbals

– Devil’s Claw

– Exacerbate ulceraBons?

Licorice

Anecdotal value

EGUS Treatment

Prior to ESGUS and EGGUS differen4a4on:Patented Products

SUCCEED DigesBve CondiBoning Program

“The only patented product for the treatment and prevenBon of gastric and colonic ulcers.”

Colonic/ColiKs Treatment

May vary by diagnosis

– SymptomaBc vs. asymptomaBc

– InfecBous vs. non-‐infecBous

– Febrile vs. afebrile

– Immune-‐mediated

– ParasiBc

– NeoplasBc

1) PharmaceuBcal

2) Husbandry

3) Over-‐the-‐counter products (OTC)

Pharmaceu4cal

AnBbioBcs

Immuno-‐modulators

AnB-‐inflammatories

– Steroidal

– Non-‐steroidal

Mucosal protectant – Sucralfate

Psyllium

Husbandry

Turn out

MulBple feedings (4 daily, at least)

Dietary modificaBon

– Alfalfa (Brei Scoi 2007)

Over-‐the-‐Counter (OTC)

ProbioBcs

Patented products – SUCCEED

“DigesBve aids” (supplements)

Conclusions

EGUS and Colonic Ulcera4on:

Lots of assumpBons on EGUS: may be over-‐diagnosed and over-‐treated.

In fact, EGUS is two separate syndromes – EGGUS and ESGUS

Symptomatology of EGUS overlaps other condiBons (i.e., hindgut)

Thus, hindgut (ulcers, coliBs) represents a third syndrome to consider in diagnosis of GI tract condiBons

Further studies needed for colonic pathologies and EGGUS (Equine Gastric Glandular UlceraBve Syndrome)

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