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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
Thursday, November 1, 2012
EGUSGastric ulcers
Thursday, November 1, 2012
EGUS
Widely known
Widely studied
Widely diagnosed
Poorly understood
Thursday, November 1, 2012
EGUS
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?
Thursday, November 1, 2012
EGUS
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
Thursday, November 1, 2012
EGUS
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
Thursday, November 1, 2012
EGUS
• 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…
Thursday, November 1, 2012
ESGUS
100% Improving
70% Healing
EGGUS
57% Improving
41% Healing
Omeprazole Effects at 4mg/Kg
EGUS
Thursday, November 1, 2012
ESGUS
62% Improving
50% Healing
EGGUS
26% Improving
9% Healing
Omeprazole Effects at 1.6mg/Kg
EGUS
Thursday, November 1, 2012
EGUS
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).
Thursday, November 1, 2012
EGUS
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)
Thursday, November 1, 2012
EGUS
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
Thursday, November 1, 2012
COLONIC ULCER SYNDROME
Thursday, November 1, 2012
Colonic Ulcer Syndrome (ColiKs)
Not widely known
Not widely studied
Not widely diagnosed
Poorly understood
Thursday, November 1, 2012
Colonic Ulcer Syndrome (ColiKs)
Summary of possible causes:
NSAIDs (anB prostaglandins)
CorBsol level (stress)
Acidity (intermiient feeding)(i)
Bacteria
Parasites
Thursday, November 1, 2012
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)
Thursday, November 1, 2012
BacteriologyAnalysis of Tissue Samples (via necropsy)Each column is a bacterial species
MulB colored
Thursday, November 1, 2012
Colonic Fingerprint by Grade
Thursday, November 1, 2012
Bacteriology
A correlaBon was found between ulcerated and un-‐ulcerated Bssue, disBnguished by both quality and quanBty.
Thursday, November 1, 2012
DIFFERENTIAL DIAGNOSISGastric and colonic ulcers
Thursday, November 1, 2012
Gastric and Colonic Ulcers
Necropsy results, 2003 – 180 performance horses:
Journal of Equine Veterinary Science, March 2005
Thursday, November 1, 2012
DifferenKal Diagnosis
DifferenBaBng foregut vs. hindgut allows for a more targeted treatment.
Treatment protocols are different.
Thursday, November 1, 2012
DifferenKal Diagnosis
S.O.A.P.Subjec+ve Objec+veAssessmentPlan
Thursday, November 1, 2012
S.O.A.P.
SubjecKve
Clinical Signs?
Thursday, November 1, 2012
S.O.A.P.
Subjec*ve: Poor body condiBon
ParBal anorexia/poor appeBte
Girthiness
Altude changes
Poor performance/poor training
Altered fecal consistency (diarrhea)
Thursday, November 1, 2012
S.O.A.P.
Subjec4ve:
Clinical Signs
Poor body condiBon
Thursday, November 1, 2012
S.O.A.P.
Subjec4ve:
Clinical Signs
ParBal anorexia/poor appeBte
Thursday, November 1, 2012
S.O.A.P.
Subjec4ve:
Clinical Signs
Girthiness
Thursday, November 1, 2012
S.O.A.P.
Subjec4ve:
Clinical Signs
Girthiness
Thursday, November 1, 2012
S.O.A.P.
Subjec4ve:
Clinical Signs
Altude changes
Thursday, November 1, 2012
S.O.A.P.
Subjec4ve:
Clinical Signs
Poor performance/poor training
Thursday, November 1, 2012
S.O.A.P.
Subjec4ve:
Clinical Signs
Altered fecal consistency (diarrhea)
Thursday, November 1, 2012
S.O.A.P.
Objec+ve
Measurable Data
Thursday, November 1, 2012
S.O.A.P.
Objec4ve:
1. 3-‐meter endoscopy
2. Rapid anBbody test (lateral flow immunoassay)
3. pH Meter
Thursday, November 1, 2012
S.O.A.P.
Objec4ve:
Measurable data sources
3-‐meter endoscopy
Thursday, November 1, 2012
S.O.A.P.
Objec4ve:
Measurable data sources
Rapid anBbody test (lateral flow immunoassay)
Thursday, November 1, 2012
S.O.A.P.
Objec4ve:
Measurable data sources
pH Meter
Thursday, November 1, 2012
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
Thursday, November 1, 2012
S.O.A.P.
Assessment:
DDX
Foregut or hindgut…or both?
Thursday, November 1, 2012
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).
Thursday, November 1, 2012
S.O.A.P.
Assessment:
DDX – Hindgut
Colonic ulcers
ColiBs
IntesBnal traumas (rectal tears, traumaBc events)
ParasiBsm
Neoplasia
Thursday, November 1, 2012
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.
Thursday, November 1, 2012
S.O.A.P.
Plan:
Further invesBgaBon, if needed
Treatment plan
Thursday, November 1, 2012
TREATMENTGastric and colonic ulcers
Thursday, November 1, 2012
EGUS Treatment
Prior to ESGUS and EGGUS differen4a4on:
1) PharmaceuBcal
2) Husbandry
3) Over-‐the-‐counter products (OTC)
Thursday, November 1, 2012
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?
Thursday, November 1, 2012
EGUS Treatment
Prior to ESGUS and EGGUS differen4a4on:PharmaceuBcals
Fenbendazole – Weak PPI (anthelmenBc)
Mucosal Protectant – Sucralfate
Thursday, November 1, 2012
EGUS Treatment
Prior to ESGUS and EGGUS differen4a4on:PharmaceuBcals
Thursday, November 1, 2012
EGUS Treatment
Prior to ESGUS and EGGUS differen4a4on:Husbandry
Turn out
MulBple feedings (4 daily, at least)
Dietary modificaBon
– Alfalfa (Brei Scoi 2007)
Thursday, November 1, 2012
EGUS (before ESGUS and EGGUS differenKaKon) Treatment
Husbandry
Thursday, November 1, 2012
EGUS Treatment
Prior to ESGUS and EGGUS differen4a4on:OTC Products
Antacids
Herbals
Patented products
“Gastric Aids” (supplements)
Thursday, November 1, 2012
EGUS Treatment
Prior to ESGUS and EGGUS differen4a4on:OTC Products
Antacids
– Neigh-‐Lox
– Mylanta extra strength
– Maalox
Temporary effect 30 to 90 minutes
Thursday, November 1, 2012
EGUS Treatment
Prior to ESGUS and EGGUS differen4a4on:OTC Products
Herbals
– Devil’s Claw
– Exacerbate ulceraBons?
Licorice
Anecdotal value
Thursday, November 1, 2012
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.”
Thursday, November 1, 2012
Colonic/ColiKs Treatment
May vary by diagnosis
– SymptomaBc vs. asymptomaBc
– InfecBous vs. non-‐infecBous
– Febrile vs. afebrile
– Immune-‐mediated
– ParasiBc
– NeoplasBc
Thursday, November 1, 2012
Colonic/ColiKs Treatment
1) PharmaceuBcal
2) Husbandry
3) Over-‐the-‐counter products (OTC)
Thursday, November 1, 2012
Colonic/ColiKs Treatment
Pharmaceu4cal
AnBbioBcs
Immuno-‐modulators
AnB-‐inflammatories
– Steroidal
– Non-‐steroidal
Mucosal protectant – Sucralfate
Psyllium
Thursday, November 1, 2012
Colonic/ColiKs Treatment
Husbandry
Turn out
MulBple feedings (4 daily, at least)
Dietary modificaBon
– Alfalfa (Brei Scoi 2007)
Thursday, November 1, 2012
Colonic/ColiKs Treatment
Over-‐the-‐Counter (OTC)
ProbioBcs
Patented products – SUCCEED
“DigesBve aids” (supplements)
Thursday, November 1, 2012
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)
Thursday, November 1, 2012