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