Stomach and Colonic Ulcers: A pain in the Gut презентация

Содержание

Equine Gastric Ulcer Syndrome (EGUS) Esophagus, Stomach and Duodenum Prevalence: 40% to 93% in performance horses

Слайд 1 Stomach and Colonic Ulcers:

A pain in the Gut!!

Frank M. Andrews, DVM, MS
Diplomate ACVIM
Professor and Section Chief
Large Animal Medicine

Слайд 2Equine Gastric Ulcer Syndrome (EGUS)
Esophagus, Stomach and Duodenum
Prevalence: 40% to 93%

in performance horses


Слайд 3Equine Gastric Ulcer Syndrome (EGUS)
Prevalence in Foals 25% to 51%



Prevalence in

breeding Stock?
Pregnant women (↑ progesterone)
Less gastric acid
more mucus
Less gastric ulcers
66% develop heartburn
Decrease LES tone

Stress??

Слайд 4Equine Gastric Ulcer Syndrome (EGUS)
Prevalence in breeding Stock?

Pregnant women at Risk
Previous

gastric ulcer disease

Smokers

Trans Global Chronicle™

Слайд 5Impact of EGUS on Horses
Results in poor body condition
Poor performance?


Can cause colic
Can have severe complications
duodenal strictures


Слайд 6Impact of EGUS on Foals
Gastric outflow obstruction
Esophagitis
Chronic ulceration
Perforation (rupture) & peritonitis
Photos

courtesy of MJ Murray.


Слайд 7


The Stomach of the Horse
Margo plicatus
Glandular region
(glandular epithelium)
Pylorus
Esophagus
Duodenum

Nonglandular region
(squamous epithelium)

Слайд 8Cause of EGUS: Aggressive Factors Overpowering Defensive Factors
Gastric lining damage occurs

when:
Aggressive (acid, pepsin, bile, organic acids) factors overpower
Defenses (bicarbonate, mucus) of gastric mucosa
Squamous mucosa lining lacks these defenses

Murray, Equine Vet J Suppl, 1992; Sweeney, In Practice, 1992; Pagan, World Equine Vet Rev, 1997; Murray and Schusser, Equine Vet J, 1993.

SM

GM

MP


Слайд 9Risk Factors for EGUS: Feeding
Feeding management
Low prevalence of ulcers in horses

at pasture
Decreased acid when roughage available

Murray et al, Equine Vet J, 1996.

Слайд 1024-Hr Gastric pH: No Feed
Murray and Schusser, Equine Vet J, 1993.

Слайд 1124-Hr Gastric pH: Free Choice Grass Hay
Murray and Schusser, Equine Vet

J, 1993.

Слайд 12
Hydrochloric Acid
Gastric acidity is high in empty stomach
Intermittent feed deprivation
Lesions form

in squamous mucosa
No lesions form in glandular mucosa
Lesions prevented by ranitidine (Zantac®)

Murray and Schusser, Equine Vet J, 1993; Murray and Eichorn, Am J Vet Res, 1996.

Слайд 13Effect of Alfalfa Hay


Buffering effect
Rebound Hyperacidity
Nadeau JA, Andrews FM, Mathew AG,

et al. AJVR 61(7): 784-790, 2000.

Слайд 14Results: Gastric ulcer Number and Severity Score


Nadeau JA, Andrews FM, Mathew

AG, et al. AJVR 61(7): 784-790, 2000.

Слайд 15Feed Analysis
Feed % DM % CP *Ca (mg/g)

*P (mg/g)
Grain 99.8 14.81 3.2** 0.56**
Alfalfa 94.52 20.85 14.1*** ***2.1
Brome 95.51 7.55 7.4** 6.22**
*on a dry matter basis
** estimated from later feed analysis
*** estimated from NRC




Nadeau JA, Andrews FM, Mathew AG, et al. AJVR 61(7): 784-790, 2000.

Слайд 16Risk of Grain Feeding
Fermentation of grain by resident bacteria and production

of by-products
VFAs, Lactic Acid, and Alcohols?
Lactobacillus spp. Isolated
HCl!!

Yuki N, et al. Appl. Env. Micro. 2000;66:5030-5034.
Scott PT et al. Recent Adv. An. Nut. Au. 2003;14:24A.

Слайд 17Risk Factors for EGUS: Training/Racing
Intensive exercise
Reduced blood flow to the stomach

lining?
Increased gastric acidity?
Altered eating behavior?


Слайд 18Acids forced into the proximal stomach
Increased intra-abdominal pressure during intense exercise

causes
gastric compression, pushing acid contents into proximal stomach

Lorenzo-Figueras and Merritt, AJVR 2002;63:1481-1487


HCl,VFAs
Bile acids

Pregnancy??

Слайд 19Risk Factors for EGUS: Stress
Physical stress
Illness
Painful musculoskeletal disorder
Endometritis?
Behavioral stress
Stall confinement


Transport
Unfamiliar environment, social regrouping


Слайд 20Risk Factors for EGUS: Non-Steroidal Anti-Inflammatory Drugs
Phenylbutazone & Flunixin Meglumine and other

NSAIDs
Associated with ulcers throughout the intestinal tract (Cecum & Colon)
Inhibit prostaglandins, interrupting mucosal blood flow and mucus
Local toxicity

Murray, Vet Med, 1991.


Слайд 21Clinical Signs of EGUS in Horses
Poor appetite
Poor body condition
Attitude changes
Decrease

in performance
Mild to moderate colic

Murray, AAEP, 1997.


Слайд 22Clinical Signs of EGUS in Foals
Poor appetite or intermittent nursing
Colic
Poor

body condition
Frequently lies on back
Bruxism (grinding of teeth)
Excessive salivation (Ptylism)
Diarrhea

Murray, Vet Med, 1991.


Слайд 24How can you tell that a horse has EGUS? (Diagnosis)
Clinical signs

are suggestive of, but not specific for, EGUS
Lab: Mild anemia
Response to treatment can be useful
Gastric endoscopy is only definitive diagnostic tool


Слайд 25Fecal Occult Blood Test (Pellegrini et al, JEVS, 2005.)
Guaiac Test
Positive test
Negative test

Слайд 26Treatment of EGUS
Eliminate clinical signs
Promote healing
Prevent complications
Prevent recurrences
MacAllister, Vet Med,

1995.


Слайд 27Two Approaches to Treatment
Management modifications
Medical therapy-approaches that have been used
Control gastric

acid
Mucosal protectants

Murray, AAEP, 1997; MacAllister, Vet Med, 1995.


Слайд 28Traditional Management Modifications
Reduce level of Breeding?

Слайд 29Diet modifications
Limit periods of fasting
Increase roughage
pasture turnout (green grass)
free choice hay
Alfalfa

hay-dietary antacid
Calcium Carbonate supplements
Reduce grain/concentrates

Seahorn, LSU Equine Vet Res Program Newsletter, 1998; Pagan, World Equine Vet Rev, 1997.

Traditional Management Modifications


Слайд 30Conclusions: Recommendations
Roughage should be provided throughout day and night
Alfalfa hay/mixed alfalfa hay

may help buffer stomach contents
Concentrates should be fed in small amounts, distributed in at least 3 feedings throughout day (base on requirements?)
Concentrates should not exceed 0.5 kg of grain per 100 kg body weight

Coenen M. Schweizer-Archiv-fur-Tierheilkunde, 1990, 132:121-126.

Слайд 31Dietary Management: Corn oil
Decreases stomach acid
Increases

protective factors (PG)
Provides Omega 3 & 6 fatty acids
8 oz once to twice daily

(Cargile et al, JVIM 2004)

Слайд 32Dietary Management: Rice Bran or Rice Bran Oil
Contains protective factors for

stomach lining (phospholipids)
Rancidity can be a problem
Produces ketoaldehydes which are ulcerogenic
Steam pasteurization can help decrease potential for rancidity
Storage in refrigerator


Слайд 33Management Modifications
Limit stressful events
Long-term stall confinement
Trailering
Overcrowding
Semen collection and

natural breeding?


Слайд 34Medical Management of EGUS
Neutralizing agents
Antacids
Antisecretory agents
Histamine H2 receptor antagonists (Zantac™)
Acid pump

inhibitors (GastroGard™)

Others (antibiotics, neutriceuticals)


Слайд 35UlcerGard™ (Prevention)
Prevention of ulcers 1 mg/kg
Non-prescription strength of GastroGard™
Sold through

veterinarians


Слайд 36Misoprostol (Cytotec™)
Synthetic prostaglandin E1
Decreased free acid and increased pH in stomach

of horses

Do not administer to pregnant mares!!!
5 µg/kg, orally, Q8h

Sangiah et al. Res. Vet. Sci, 1989

Слайд 37Antibiotic Treatment
Primarily used in humans with Helicobacter pylori
Colonization of ulcer bed

(rat)
Bacteria rapidly colonize ulcer bed and decrease ulcer healing

H. pylori has been associated with the stomach of horses, but not EGUS
Antimicrobials may be used in horses with resistant EGUS (TMS, Metronidazole, Bismuth compounds)


Scott DR, Marcus EA, Shirazi-Beechey SSP, et al. Evidence of Helicobacter infection in the horse. Proc Am Soc Microbiology 2001.

Elliott et al. Am. J. Physiol. 1998;275:G425-32

Слайд 38Feed Supplements (Neutriceuticals)

NeighLox® (Kentucky Performance Products)
Antacid and Coating Agents:
Aluminum Phosphate, Calcium

Carbonate
Dihydroxy-Aluminium Sodium Carbonate
Labeled for prevention of heartburn
No studies in horses to prove or disprove
Probably does not cause any harm

Слайд 39Other Feed Supplements (Neutriceuticals)
G.U.T (Uckele Health & Nutrition)

TractGard (Foxden Equine)

No studies

proving efficacy


Слайд 40Conclusions
EGUS is a major cause of illness in performance horses and

foals
Pregnant mares and breeding stallions??
Impacts health, performance, economics
Effective treatment entails both environmental and dietary management and medical interventions

Слайд 41Conclusions- Treatment
Treatment may be needed to decrease clinical signs and heal

ulcers
Dietary supplements-not tested
Consult your veterinarian before treating pregnant mares and breeding stallions!!


Слайд 42Colonic Ulcers and Right Dorsal Colitis (General)
Ulceration in the Large Intestine

(Right Dorsal Colon)
Cause
Parasites
Infectious agents (Salmonella)
Inflammation of the Intestine
IBD, Cancer?
NSAIDs
Stress

Pellegrini FL. JEVS 25(3), 2005

Слайд 43Colonic Ulcers and Right Dorsal Colitis (Diagnosis)
History:
Recurrent episodes of loss of

appetite, lethargy, colic, weight loss, and diarrhea

Chronic administration of NSAIDs (especially phenylbutazone)

Intensive breeding or pregnancy

Painful musculoskeletal problems or uterine infection

Слайд 44Colonic Ulcers and Right Dorsal Colitis (Diagnosis)
Physical Exam and Clinical Signs:
Normal

between episodes
May present with acute abdominal pain
Lethargy, partial anorexia (icteric MM), intermittent fever, colic, diarrhea, dehydration, congested mucus membranes, edema, vaginal discharge
Rectal examination: thick edematous colon
Weight loss, thin body condition with chronic disease

Слайд 45Colonic Ulcers and Right Dorsal Colitis (Diagnosis)
Gastroscopy to rule out gastric

ulcers
May have concurrent disease

Слайд 46Colonic Ulcers and Right Dorsal Colitis (Diagnosis)

Pellegrini FL. JEVS 25(3), 2005

Слайд 47Colonic Ulcers and Right Dorsal Colitis (Diagnosis)
Ultrasonographic examination:
Jones et al. JAVMA

222(9), 2003

Слайд 48Colonic Ulcers and Right Dorsal Colitis (Diagnosis)
Changes on blood work:
Anemia (usually

mild)
High WBC count
Low blood protein
Low blood calcium
Fecal cultures
Fecal floatation (parasites)

Слайд 49Fecal occult blood test
Pellegrini FL. JEVS 25(3), 2005
Fecal occult blood positive

(guaiac-based)

Слайд 50Ruling out causes
Large bowel colic, displacement
EGUS
Exploratory Abdominal Surgery
Biopsy of intestine
If Diarrhea

present
Salmonellosis, IBD, Cancer

Слайд 51Colonic Ulcers and Right Dorsal Colitis (Treatment)
Principles:
Treat the underlying cause
Avoid NSAIDs

(especially phenylbutazone)
Decreasing the bulk (mechanical and physiologic load on colon) in the GI tract
Restricting or eliminating hay from the diet
Frequent feedings
Coating and repair of the colon
Implement methods to decrease stress

Слайд 52Colonic Ulcers and Right Dorsal Colitis (Treatment)
Frequent feedings (4 to 6

X daily) of complete pelleted diet with at least 30% dietary fiber
Reduction or elimination of hay from diet
Grazing should be limited to 10 to 15 minutes 2 to 3 times daily??

16 to 19 lbs/horse/day
Light to Moderate Work

Слайд 53Right Dorsal Colitis (Treatment)
Sucralfate
Aluminum salt of sucrose octasulfate
Partially disassociates and forms

bridges with aluminum hydroxide and coats ulcer bed
Fortifies the mucus coating
Diminishes bacterial growth
22 mg/kg, PO, Q6h-Q12h

www.Gastrafate.com

Слайд 54Right Dorsal Colitis (Treatment)
Psyllium Mucilloids
Shortens transit time of ingesta
Increases colonic concentration

of short chain fatty acids and promote healing
1 cup orally twice daily

Premium Psyllium Supplement
50 lbs/$129.00

Metamucil can be substituted!!

Слайд 55Right Dorsal Colitis (Treatment)
Corn or Flaxseed oil
Supplies Omega-3 fatty acids to

colon
Improves healing??
Increases energy for weight gain
1 cup orally twice daily

Слайд 56Colonic Ulcers and Right Dorsal Colitis (Treatment)
Probiotics and Digestive aids
Polar

Lipids – components of oat oil, help transport nutrients into the blood stream and support a healthy gut lining. Soluble Oat Fiber – supports a healthy immune system while evening out the rate of digestion and nutrient absorption for even blood sugar levels and reliable energy. Yeast Extracts – support normal levels of digestive microbes in a healthy hindgut. Amino Acids – building blocks of proteins, support a healthy mucous lining throughout the digestive tract.

Succeed™

Слайд 57Right Dorsal Colitis (Treatment)
Reduce Stress and Dehydration
Discontinue or decrease strenuous exercise
Decrease

transport
Provide good quality water
Flavor or sweeten water to increase palatability
Add salt or electrolyte paste to grain or pellets to increase water consumption

Слайд 58Right Dorsal Colitis (Treatment)
Length of Treatment and Prognosis
Resolving clinical signs
Monitor PCV

and plasma proteins (especially albumin) every week to 1-2 weeks or more frequent if needed
Serial ultrasonographic examinations (5 weeks after initiation of treatment)
3 to 4 months
Good to Guarded depending on duration and severity

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