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Managing Gastric Ulcers

Are you or your horse an antacid junkie? Stomach or gastric ulcers are a common condition impacting horses, people and even pets sometimes.  We see commercials regarding antacids and ‘acid blockers’ all of the time and horse owners are exposed to these medication way too often, being an unfortunate part of many horse’s daily routines.  For some people, it is no different and many of the commercials seen make it seem like it is the ‘in’ thing to do to take or give these medications.  If it is as prevalent in today’s horse world and for people as we are made to believe, then we have a problem.  If we have a problem, then we need to understand the problem in order to remedy it or at least improve it.

Many horse owners and people with stomach ulcers have heard the same old rhetoric time after time, regarding the details of stomach anatomy and influence of stomach acids on the development of ulcers.  Maybe some even realize that there are different grades to stomach ulcers, some being worse than others, but yet still stomach ulcers none the less.  I won’t bore you with these details as the facts are the facts.  In plain language, we have a situation in which there is too much stomach acid being produced which then erodes a certain section of the stomach, causing pain, bleeding and potentially perforation or rupture if untreated.  In people, synonymous conditions include hearburn and acid reflux as they are both tied in with stomach ulcers.

Clinical signs:

In most people and animals, the clinical signs are the same, just expressed differently as people can talk and animals express more through behavior than direct verbal language.  In people, we have typical signs including stomach burning, belching, a sensation of heat in the chest, bad breathe and even vomiting of blood in progressed cases.  All of these signs vary with food intake, sometimes better, sometimes worse, but all of these signs impact one’s behavior often resulting in irritability.

In horses, the signs are not much different, just expressed in a different manner.  Horses do likely experience a burning sensation, sometimes belching and even foul breathe in some instances, but more often we see negative changes in behavior, resistance to girth tightening, resistance to various gaits or movements, irritability, head shaking and even signs of frequent colic or being off their feed.  

Diagnosis:

In more cases than not, the diagnosis is tentative and based on clinical signs mentioned above as well as response to traditional medications such as antacids and acid blockers.  In other cases, if we really want to know what is going on or if we have a persistent problem, gastroscopy is performed in order to view the inside of the stomach and visualize the ulcer itself. If the ulcer is bad enough with significant bleeding, we may also be able to detect digested blood, not fresh blood, in the feces of both humans and horses, which helps us as well with diagnosis.

Causes:

The causes of stomach ulcers are many but often attributed mainly to:

  • Dietary Causes
  • Stress Induced
  • Overuse of Non-Steroidal Pain Medications

In some cases, we have other health conditions that predispose to ulcers, but primarily, diet and stress are to blame.  Stress is a huge factor in both humans, horses and pets; being a physical response to an emotional event with far reaching health implications.  On a simple level, stress causes a higher than normal release of cortisol from our adrenal glands, which impacts us and our horses negatively on many levels.  The other impact of stress is an excess release of acid within the stomach.  Now, we have to understand that acid production is a normal part of physiology and is necessary for digestion of foods for nutrient assimilation.  In the case of stress, often we secrete too much acid, which when compounded with no food being present in the stomach, leads to stomach lining irritation.  

When we couple a bad diet on top of things, the matters get worse.  Now, what do we mean by a poor diet?  It could be a human diet that is too high in ‘hot’ spices that results in further irritation or it could also be a diet that is too deficient in the necessary nutrients to maintain adequate levels of health in light of elevated stress.  In horses, diets that are too high in carbohydrates, such as grains, especially with high sugar content, can further add to problems.  This is one of the reasons that horses with stomach ulcers tend to go off of their grains, but still consume hay or pasture.  The grains or concentrates require higher levels of acid secretion for digestion, thus if an ulcer is present, burning is increased and uncomfortable. Sometimes, just seeing the grain or having a person see hot peppers is enough to trigger acid secretion and ulcer irritation.

The stomach is designed to resist the impacts of acid for the most part, however, some parts of the stomach are more vulnerable than others.  The lining of the stomach is dependent on chemical signalers called prostaglandins to maintain overall health and integrity.  There are several different types of prostaglandins in the body, some tied directly with inflammation, while others have a more ‘protective’ effect.  In those horses and people in which there is long term use of various pain medications called non-steroidal anti-inflammatories, we can potentially open up the door for ulcer development due to prostaglandin inhibition.  By themselves, it is rarely a problem, but when coupled with diet problems and stress, the risk is more pronounced.

We have to understand that with increased demands on our body, physical or emotional, the likewise demand for nutrients is increased.  We can’t believe that a person or horse under stress and pressure requires the same diet as a horse on pasture or a person that is in a different lifestyle.  Those under stress need higher levels of protein, certain vitamins, minerals and antioxidants to protect against inflicted damage and restore cellular health on all levels.  In some cases, we can see based on research that even some amino acids such as L-glutamine are vital and important to restoring gut function.  

I do believe that diet is very important but stress is more often to blame, especially in the equine world.  Stress implications are huge and we fail to realize this all too often.  As a veterinarian, I too failed to realize the implications and was quick to reach for the medications to control symptoms.  Things changed for me, perspective wise, when we started to rehabilitate horses on a more full time basis.  The majority of horses that we acquire are ‘burned out’ from prior overtraining or racing careers.  Many of those horses come to us with the owners stating that they just quit working, were developing bad attitudes, behavioral problems and even persistent lameness conditions.  When we would dig into their past, training and housing, we realize the high level of stress that the animal was undergoing.  In many instances, upon presentation, these horses are difficult to deal with due to deep rooted problems.  The good news is that with a few changes, many of these guys are more content physically and mentally within a few days, despite having histories of being on stomach ulcer therapies with no evident results.  In many of those cases, we also have marked improvement in other lameness conditions and even joint problems as a result of managing the stomach problems, likely due to nutrient deficiency as a secondary problem tied in with the ulcer.

Management:

I think the key to managing many health conditions lies in understanding their causes, but there 3 things that we do with our patients.

  • Improve Diet
  • Reduce Stress as much as possible, Improve lifestyle
  • Use protective herbs including Marshmallow & Aloe in proper doses (critical)

If we build a porch on our house, but it rots after a year due to weather, we realize the cause and hopefully take precautions to protect our investment on the next go round.  The same thing comes with stomach conditions.

If we understand that high levels of stress and possibly nutrient deficient diets or certain excessive diets are to blame, then we have something to work with.  As a veterinarian, I do realize that stress is a component to many horse’s lives that we cannot eliminate.  This stands true for people as well, myself included.  If we can’t eliminate it, then we need to protect against the negative implications and manage it better.  We can do this in many simple ways.

First, realize that stress is a factor, then we need to realize what part of that day for us or that animal makes matters worse?  For us, maybe it is a specific part of work, maybe meetings that get us in knots.  Okay, so change it, alter it to make it more acceptable.  For horses, many are stalled a high percentage of time, with little exposure to the real world.  All they know is 4 walls to a stall, training and competition.  Many get no real turnout time on pasture or a nice sized lot so that they can run and stretch their legs, releasing pent up energy.  Some horses have never been turned out with other horses due to fear of confrontation and injury.  This I do understand, but here we have to realize the true nature of the horse and that they are social animals, running in herds. Some trainers complain that they have a hard time controlling a horse around other horses and the reason is obvious, but rarely realized.  I do understand the concerns regarding potential injury with turnout or exposure to other horses, but even in our own program with our injured horses, I feel that turnout and socialization is vital to mental well being.  Yes, sometimes I cringe as a new horse is introduced to others, but the fact is most of the time, it is all talk with no injury and the horse is better emotionally for doing it.  After all, the saying goes, “all work and all play, make Johnny a dull boy”.  This could never be truer when it comes to horses or people and something that I have to remind myself of often.

The sad thing is that we, as people and horse owners, tend to feel that we must continue to push forward to get results.  Many horse owners I have talked to mention problems with stomach ulcers but when we talk about stress, they respond by saying that they need a hyper or over-stressed acting horse in order to compete.  The reality here, in my opinion, is that this is not true as many of our rehab horses are now quieter and more easily managed, but still very willing to work and actually doing better, being more focused.  In the racing industry, many trainers over use concentrated feeds to pump up the energy and make the horses hotter, feeling that they have to be this way to perform.  Well, in the end, that opinion is in the eye of the beholder but if we chose this route, we must also accept the consequences.

One of the main courses of therapy with both humans and horses is the overuse of antacids and acid blockers.  We see commercials for the “purple pill” and in horses, the terms omeprazole, Gastroguard® or Ulcergard® are all too common place.  These medications are not only used for treatment, but many horses are on them daily as part of a regimen.  In some people, this is true as well, popping a pill before the nightly meal or cookout.  Commercials fantasize this and make it seem like the norm.

Often, these medications do provide relief through their ability to neutralize or buffer the excessive acid.  In other cases, the medications provide relief by reducing the amount of acid that is produced, which seems logical but the long term results could potentially prove problematic.  Here again, we have to understand that a certain level of stomach acid is needed to digest food and aid in nutrient assimilation.  If we block the acid production, then digestion could be impaired and nutrient absorption reduced.  This is becoming apparent in human studies with evidence that proton pump inhibitors (PPIs) such as omeprazole may not only increase the risk of bone fractures, but reduce the absorption of some vitamins, minerals especially calcium and magnesium. The FDA has a warning letter out regarding the long term effects which can seen here.  These drawbacks apply to human and equine ulcer medications that inhibit acid production.

When we couple possible nutrient absorption issues with an already delicate situation, the problem can become enhanced with other health concerns soon arising in both people and horses. I do feel these medications are beneficial for acute condition management, but am more concerned with the manner in which they are currently used and being popped like candy.  They are drugs with real concern for side effects and they are not ‘fixing’ the cause of the ulcers, only managing the effects.

So What Do We Do?

In some cases, I feel that temporary administration of PPI type medications is beneficial, but we need to try to reduce stress as much as possible or if that is impossible, then I find that use of various herbs or foods can help minimize the impact.

Stress is a huge factor, as discussed above, but there are many herbs that can act as adaptogens, helping our body to cope with the stressors and improving our overall health. Increased stress leads to higher levels of acid production in the stomach but it also leads to higher levels of cortisol production.  Excess cortisol has its own negative effects on health, so really in these situations, it is not just the stomach acid that is the problem.  Herbs, including Ashwaghanda, for instance do exactly that by aiding in reduction of cortisol, reducing anxiety and even improving cardiac function on a certain level likely through antioxidant type activities.  There are many others including Bacopa, Rhodioloa, Cordyceps, Schisandra, Pomegranate and even Hawthorne.  In my equine patients, I mainly rely on Ashwaghanda (EQ Adapt) to help calm the nerves and settle the minds of our rehabiliation patients.  I find that if we can reduce that anxiety, then we reduce the fuel for the stomach ulcers.  The impact can be dramatic in some instances, despite no changes to work schedules.

The other approach is to use various herbs (foods) to help encourage ulcer healing.  Two of the main herbs that we use to accomplish this are Marshmallow and Aloe.  These two herbs actually help to ‘cool’ the stomach down, which reduces the burning, but both also have tremendous healing properties that I feel benefit the stomach and other areas of the digestive tract. In cases of acute gastric ulcers and discomfort, I will often combine our EQ Stomach formula with our EQ Adapt, providing a soothing effect to the stomach while settling anxiety, stress and cortisol levels.

Now, I am very well aware of the well held opinions about ‘alternative therapies’ and herbs.  Many will claim that they have tried these herbs with no results, but in my opinion they do work, but one has to use the correct dosage or level on a daily basis.  

We have to look at ulcers for what they are and that is an induced wound in the body.  The research data discusses how there is an inflammatory component to ulcers with upregulation of various enzymes and pro-inflammatory proteins, including MMP’s (matrix metalloproteinases).  Given this, we have to look for ways to combat or manage these pathways.  Now, Curcumin has shown tremendous benefit in managing ulcers in some human research data due to blocking MMP’s, thus allowing for ulcer healing, but we have to consider all variables that are present.

Aloe has been used for centuries for its ability to heal wounds, after all, we are most familiar with its use post sunburn but the concept crosses many borders. The scientific research world has been exploring the use of Aloe for many years in the treatment of skin wounds associated with diabetes, oral sores and ulcers associated with cancer therapy and stomach ulcers with good results noted in most cases.  The exact means by which Aloe provides benefits appears to be through inflammation reduction, mucous layer protection and even anti-bacterial/anti-fungal methods.

Marshmallow (Althaea officinalis) has also been used for centuries for wounds, gastrointestinal complaints and respiratory conditions.  Clinical research has also demonstrated benefits including inflammation reduction and gastric ulcer management.

Many will deny the benefits of these herbs and even food on overall health, noting that there are no changes for the positive or resolution to the clinical problem.  The fact is that even with various medications, we have to admit that the clinical problem is not resolved.  If it was, most people and horse owners would not be seeking other options.  The reason for this is that the problem is multi-factorial and the medications are only combating one small facet.  Thus, if we want better control, we have to look at all factors involved with the problem and address as many as possible to get those results or at least better manage the condition.

In the majority of horses presented into our program with stomach ulcer or behavioral issues, our standard approach is to use Ashwaghanda, Marshmallow and Aloe.  We don’t continue their medications, but change their environment, let them have good turnout and socialization.  The results are often very quick with positive improvement in a matter of days.  In some cases, we don’t need the anxiety relief but more so just stomach attention, but it varies from horse to horse dependent on the cause.  

I believe that the bottom line with stomach ulcers or ailments is the same as with anything else.  If we understand the cause, then we open the door for options.  The ultimate question comes as to what your approach is going to be.  Do you just rely on traditional approaches with medications daily, or do you truly want to seek other options.  They may not provide the complete answer to what you are looking for, but they will provide some much needed benefits not only to the stomach but overall health.  Wouldn’t it be better to have less pain, less burning and a horse that is willing to work and compete with less anxiety?  On top of that, how about a lower monthly overall expense and a healthier lifestyle?

You do have a choice and together we can find options.

All my best,

Tom Schell, D.V.M.

Nouvelle Research, Inc.

www.nouvelleresearch.com

 

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