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    Esophageal Obstruction and Equine Gastric Ulcer Syndrome

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    annelle0219
    This document discusses equine esophageal obstruction (choke) and equine gastric ulcer syndrome. It provides objectives, suggested readings, and a case study involving an old mare exhibiting choke symptoms. The document then covers the anatomy, common sites, treatment, and complications of choke. It also discusses the pathophysiology, diagnosis, and treatment of equine gastric ulcer syndrome, distinguishing between squamous and glandular forms. The case study involves a dressage horse ultimately found to have glandular ulcers. Key points covered include risk factors, grading systems, and the importance of gastroscopy for diagnosis.

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    Esophageal Obstruction and Equine Gastric Ulcer Syndrome

    Uploaded by

    annelle0219
    48 views30 pages
    This document discusses equine esophageal obstruction (choke) and equine gastric ulcer syndrome. It provides objectives, suggested readings, and a case study involving an old mare exhibiting choke symptoms. The document then covers the anatomy, common sites, treatment, and complications of choke. It also discusses the pathophysiology, diagnosis, and treatment of equine gastric ulcer syndrome, distinguishing between squamous and glandular forms. The case study involves a dressage horse ultimately found to have glandular ulcers. Key points covered include risk factors, grading systems, and the importance of gastroscopy for diagnosis.

    Original Title

    Lecture 6 EGUS

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    This document discusses equine esophageal obstruction (choke) and equine gastric ulcer syndrome. It provides objectives, suggested readings, and a case study involving an old mare exhibiting choke symptoms. The document then covers the anatomy, common sites, treatment, and complications of choke. It also discusses the pathophysiology, diagnosis, and treatment of equine gastric ulcer syndrome, distinguishing between squamous and glandular forms. The case study involves a dressage horse ultimately found to have glandular ulcers. Key points covered include risk factors, grading systems, and the importance of gastroscopy for diagnosis.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    48 views30 pages

    Esophageal Obstruction and Equine Gastric Ulcer Syndrome

    Uploaded by

    annelle0219
    This document discusses equine esophageal obstruction (choke) and equine gastric ulcer syndrome. It provides objectives, suggested readings, and a case study involving an old mare exhibiting choke symptoms. The document then covers the anatomy, common sites, treatment, and complications of choke. It also discusses the pathophysiology, diagnosis, and treatment of equine gastric ulcer syndrome, distinguishing between squamous and glandular forms. The case study involves a dressage horse ultimately found to have glandular ulcers. Key points covered include risk factors, grading systems, and the importance of gastroscopy for diagnosis.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 30

    Esophageal obstruction and

    Equine gastric ulcer


    syndrome
    Laura Waitt, DVM, DACVIM
    Cactus Wren 336-H, [email protected]
    Course Objectives

    Students will demonstrate competence in the etiology, pathophysiology,


    diagnosis, treatment and prognosis of choke and gastric ulcers in horses.
    Equine Glandular Gastric Disease (EGGD)
    Equine Squamous Gastric Disease (ESGD)
    Equine Gastric Ulcer Syndrome (EGUS)
    Compare and contrast the grading systems and treatment regimens for
    squamous versus glandular ulcerations
    Suggested readings

    Clinical Features and Prognostic Variables in 109 Horses with Esophageal Obstruction (1992 2009)
    L. Chiavaccini and D.M. Hassel
    J Vet Intern Med 2010;24:1147 1152
    European College of Equine Internal Medicine Consensus Statement Equine Gastric Ulcer Syndrome in
    Adult Horses
    Sykes et al
    J Vet Intern Med 2015;29:1288 1299
    Pharmacokinetics and bioeq i alence testing of e commercial form lations of omepra ole in the
    horse
    Sykes et al
    J. vet. Pharmacol. Therap. 39, 78--83. doi: 10.1111/jvp.12240.

    EGGD consensus statement Recommendations for the management of Equine Glandular Gastric
    Disease
    Rendal et al
    UK-Vet Equine | Volume 2 No 1 | January/February 2018
    Case in point

    You get a phone call from a client at 1am


    She just got home from work and fed her horses a snack (WHY?!)
    Her old mare is now coughing and gagging and has food and saliva pouring out
    her nose and mouth.
    She even threw herself to the ground once
    She is no longer eating
    You advise her to remove the food, massage the left side of her neck in the
    jugular furrow from throatlatch to chest and walk her.
    Esophageal obstr ction aka choke
    Common disease
    Typically caused by feed impaction of the esophagus
    *Inadequately soaked beet pulp*
    mostcommoncause
    Apples, carrots
    Rapid ingestion of fibrous feed
    Cubed feed stuff
    Foreign body ie: hedge apple
    Complicated by poor dentition unabletoproperlygrind
    Other causes
    inadequate water intake
    heavy sedation
    esophageal disease
    Neoplasia, stenosis, di ertic la, megaesophag s
    Anatomy and Physiology

    The muscle of the esophagus has


    two layers
    The muscularis mucosa is thin in the
    cranial esophagus but becomes
    more substantial as it approaches
    the cardia.
    It is composed of smooth muscle
    fibers with longitudinal orientation.
    The muscularis externa is present
    along the entire length of the
    esophagus.
    It is composed of striated muscle to
    the midthoracic region (i.e., the
    upper two-thirds).
    The caudal one-third of this muscle
    layer is composed of smooth muscle
    fibers.
    Most common sites

    The natural narrowing of


    esophagus
    Cervical esophagus
    Thoracic inlet

    3 Base of heart

    4 Cardia/terminal esophagus
    Treatment- most chokes resolve within 20 minutes on their
    own. Those that do not, typically need veterinary assistance to resolve.

    Physical examination is key


    Sedation
    Xylazine- alpha 2 agonist with sedative and pain relieving properties
    Butorphanol- partial kappa/sigma agonist opioid with pain relieving properties and with xylazine provide
    neuroleptic analgesia. Antitussive.
    Acepromazine- a phenothiazine sedative with muscle relaxant and anti-anxiety properties. No pain relief.
    Muscle relaxants
    Buscopan- N-butylscopolammonium which is an anticholinergic antispasmodic smooth muscle relaxant.
    Side effect is that it causes tachycardia for 30 minutes
    Acepromazine- see above
    NSAIDS
    Banamine
    Broad spectrum antibiotics
    aspiration
    blesalivagoesdowntrachea pneumonia
    Pass a nasogastric tube

    Sometimes can gently pass into the stomach


    Otherwise lavage while moving tube *gently* back and forth
    Pump warm water until it flows out and around the tube or the horse grunts
    and then siphon the fluid out.
    Some pass a nasotracheal tube with cuff to prevent aspiration
    Heavy sedation with head down is essential to prevent aspiration
    Once you are in the stomach I give water and electrolytes
    6-10 liters
    I hold them off feed for 12 hours and then restart on wet feed slowly.
    If ns ccessf l in relie ing the choke

    Supportive care: a night on IV fluids and muscle relaxants is not a bad thing
    if no other options.
    Sometimes they can resolve
    Refer to tertiary care facility for scoping to identify the blockage
    Sometimes just the trailer ride and time will do the trick
    Any horse that is choked for > 12 hrs or is difficult to relieve could benefit from
    endoscopy to identify damage to esophagus
    Potential general anesthesia for more aggressive manipulation
    Life threatening complications
    the longer the horse is choked the more likely it will have any or all of these

    Common Less common


    Dehydration Stricture formation
    Acid-base and electrolyte Esophageal perforation
    abnormalities
    Pleuritis
    Aspiration pneumonia
    Laminitis
    Esophageal mucosal irritation
    Laryngeal paralysis
    Horner s s ndrome
    Prevention
    properdentalcare
    Prognosis

    Depends on the development of


    complications
    No complications: excellent
    Complications can be fatal
    Case in point

    17yo Dutch Warmblood lesson horse at a fancy dressage place


    Grand prix but giving lessons at third level
    Intermittent poor appetite
    Thin body condition despite them feeding him for slaughter
    Chronic intermittent soft feces
    Poor coat condition
    Bruxism
    Behavioral changes associated with bridling or tacking
    A few super minor episodes of colic but not treated
    On lcer pre ention and scoped b referring that didn t find an thing
    Evaluation

    Lameness examination
    unremarkable
    Neurologic examination
    unremarkable
    glandular Bloodwork essentially
    unremarkable
    Repeated gastroscopy

    squamous normal
    ulcers on pylorus missed on previous
    scope
    A tin bit of histor

    Equine Gastric Ulcer Syndrome (EGUS) was first used in 1999


    Now used as an all encompassing term to describe erosive and ulcerative
    diseases in horses as PUD is in humans
    But now we refer separately to Equine Glandular Gastric Disease (EGGD)
    and Equine Squamous Gastric Disease (ESGD) because they are two
    different disease processes.
    Predispositions
    ESGD
    equinesquamousgastricdisease
    Racehorses more likely to have than cold blooded horses
    Intensity and duration of exercise are important to development of disease
    Decreased rate of ulcers if turn out available and even less if turned out with other
    horses
    High fiber may predispose/make worse
    > 6 hours between meals increases chance of ulceration
    Feeding grain at 1% of body weight increases disposition
    EGGD
    equineglandulargastricdisease
    Warmbloods
    Exercise more than 5 days a week
    Stressy Introverted thinkers
    Access to pasture may be protective
    Pathophysiology of ESGD

    Increased exposure of the squamous mucosa to acid


    Squamous mucosal cells are susceptible to HCL and VFA injury in a pH,
    dose, and time dependent manner
    Racehorses
    High grain, greater than 6 hours between meals

    Endurance horses
    As soon as the speed changes above a walk acid splashes onto the squamous portion
    Pathophysiology of EGGD

    Completely opposite to ESGD because during normal function the


    glandular stomach is exposed to high levels of acid (pH 1-3)continually.
    Believed to result from a breakdown of the normal defense mechanisms
    that protect the mucosa from acidic gastric contents
    In humans Helicobacter pylori and NSAIDS are the predominant cause
    No confirmation of this in horses in current research as of yet

    No direct causation has been identified


    Biopsies show inflammation: glandular gastritis with the majority being
    lymphocyticplasmacytic, some eosinophilic and neutrophilic.
    Diagnosis

    Gastroscopy is the only antemortem diagnostic for ulcers


    There is no relationship between EGGD and EGSD so you must perform a
    complete examination of the entire stomach
    Necropsy
    There is no other correct answer

    SOAPBOX *WARNING*
    This is a neb lo s and aried disease process that e don t kno eno gh abo t
    and response to treatment can be variable
    Clouding the process with no definitive diagnosis makes everything harder.
    ESGD
    4 stages
    hypericaratone
    normal

    smart target
    shallow shallow

    deep extensive
    ESGD treatment no acid, no lcer
    Acid suppression is key: goal is pH >4 for 16-18 hours daily
    Proton pump inhibitors:
    1-4mg/kg treatment for 21 days 70-80% of all lesions
    If not healed by day 28, you may consider if you are suppressing acid
    1mg/kg prevention
    Omeprazole is drug of choice but is acid labile and must be enterically coated or
    b ffered(can t use Costco tablets).
    About 25% of horses do not respond with adequate acid suppression
    Must be given on an empty stomach to improve absorption
    Followed 30 minutes later by feed to give true acid suppression
    If continual fasting (ie: colic, refluxing enteritis) this medication does not suppress acid well.

    GastroGard/UlcerGard is a buffered paste that is FDA approved


    Many generics are now available
    Enteric coated formulations in paste and granules

    Injectable omeprazole compounded is available last for 5-7 days following injection
    Recent research makes this sound very good
    Treatment

    H2 Receptor antagonists also effectively suppress acid


    Ranitidine 6.6mg/kg PO q 8hrs
    Multimodal therapy

    Nutritional management strategies


    Avoid high starch grain where possible
    Frequent feeding every 4-6 hours or free choice is ideal
    Slow feeder hay bag

    Vegetable oils decrease acid secretion


    Avoid electrolyte paste bolus, ok to mix with feed or water

    impt for endurance horses


    EGGD

    Grading system
    Anatomic location
    Pylorus, antrum

    Description
    Hyperemic, hemorrhagic, pseudomembranous

    Size
    % of area effected
    normal
    EGGD treatment
    Omeprazole 4-8mg/kg PO q12- 24hrs x 8 weeks
    Cannot use as monotherapy as in ESGD
    Fasting administration, in combination with sucralfate 80% healing
    Sucralfate 12mg/kg PO q 12hrs x 8 weeks
    Adheres to ulcerated mucosa, stimulates mucus secretion, prostaglandin E synthesis,
    and enhanced blood flow
    Administer 2 hours following the omeprazole
    Misoprostal 5ug/kg PO q 12hrs
    Prostaglandin E analogue reportedly had 73% healing as monotherapy
    Do not use with proton pump inhibitors since it interferes with their action
    Antimicrobials and steroids have not been shown to improve healing therefore
    use of them can not be recommended
    Reduce work to only 4 days weekly
    In frustrating cases I completely rest the horse
    Pre ention, let me co nt the a s .

    Provide a minimum of 2 rest days per week


    Turn out when possible
    Feed prior to exercise so no empty stomach while at speed
    Buffers for 4 hours
    ALL of the n trace ticals ..
    Purina Outlast
    Seabuckthorn berries
    Pectin-lecithin complexes combined with magnesium hydroxide and
    Saccharomyces cerivesiae
    SmartGut Ultra preventative effect
    ESGD EGGD

    Questions?
    Grades
    O normal
    I normal line someredness
    2 small shallowulcers
    3 large shallowulcers
    4 extensivedeepulcers

    Grade 3

    Scopeentire stomachthoroughly feed every 4 6 hrs or


    preferablycontinually put on Omeprazole giveon empty
    stomach feed 30min later

    EGGD

    omeprazole sucralfate rest tonly


    4days exercise
    1 anatomicallocation
    2 description
    3 size

    pass NG tube us Ultrasound1further diagnostics


    foodimpaction us Stricture

    dehydration
    acid base electrolyte abnormalities
    aspiration pneumonia
    esophageal mucosal irritation

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