Ulcers in the digestive track are more than just the latest “disease du jour.” Thus far, for a problem that has been recognized for about 20 years, we are still seeing and understanding only the tip of a metaphorical iceberg. More than two thirds of the iceberg is still not visible and much is still being discovered about this ulcer “iceberg.” We do know that there are, basically, only two kinds of horses – those who have ulcers and those who will have ulcers!
We should all recognize that gastric and intestinal ulcers are literally a slow or non-healing acid burn – a burn such as if hydrochloric acid was splashed on your face. The horse’s ulcers are a combination of this hydrochloric acid, as well as volatile fatty acids and bile acids. In horses, the acid burns holes into the lining of the stomach, small or large bowel. The acids may burn a crater deeply enough to cause bleeding or even burn through and penetrate the gut. When the acid burn craters do heal they can create scar tissue and strictures, especially in the small intestine that may lead to colic.
Therefore, the real purpose of this paper is three fold.
- The first purpose is to provide a short synopsis regarding the dangers and sometimes-dire consequences of ulcers.
- The second is to alert you to the signs and symptoms pointing to the presence of ulcers.
- The third, and a very important purpose: Empower you to use a simple examination technique that can give a very strong presumptive diagnosis of GI ulcers. This technique can, in many cases, bypass the need for endoscopic examination if, for example, this procedure is not readily available or is not affordable. Confirmation by administration of appropriate medications is often used as a diagnostic tool and confirmation of a “presumptive” diagnosis.
Twelve Good Reasons to Understand GI Ulcers in Horses:
- Ulcers increase the risk to the horse’s health, safety and welfare
- Ulcers increase the risk to the rider’s safety and welfare
- Ulcers cause loss of performance and competitive edge
- Ulcers can upset or interrupt an entire competition schedule
- Ulcers are very expensive to treat and to resolve – recurrence is common
- Ulcers cause many “behavioral” problems
- Ulcers set up many muscle, myofascial and chiropractic issues
- Ulcers increase risk of injury and lameness as a result of number seven (Musculo-skeletal problems
- Ulcers increase the risk of colic and diarrhea problems
- Ulcer stress may deplete the immune system and make a horse more susceptible to disease
- Ulcers often create “hard keepers” and cause weight loss. The result – an unthrifty horse. (However, some horses with excellent weight also have ulcers)
- Toxins released from altered gut flora increase a risk of laminitis/founder
When horses develop painful and restricted movement associated with excess muscle tension, and poor ability to use the spine – resulting in pain – they cannot perform at the desired level. They are, thus, more prone to injury if pushed to jump higher, run faster, suddenly change direction, etc. In the case of cross country eventing, show jumping, racing, cutting, gymkhana, marathon competitive driving and other high performance demands, the risk of injury is greatly increased. A body in pain is always at risk and increases the likelihood of a fall. Needless to say a fall is always potentially dangerous for both horse and rider.
Next, it is appropriate to review the signs and symptoms associated with ulcers. Many of these the reader may already be familiar with. Others are less well known, but may serve even better to make one aware that a horse may be experiencing ulcer pain.
Changes in behavioral patterns:
The horse may respond by becoming more resistant to going forward and responding to the normal aids. It may kick out, rear or buck when asked to go forward. It may respond by becoming more irritable in general, but specifically to being groomed or handled. Some progress to the point of being aggressive. Particularly in chronic cases some “turn inward” and appear dull and disinterested – sort of “the light is on, but nobody is at home.”
Performance Issues and Body Pain Issues in Ulcer Cases:
Very importantly but not as commonly realized, as it should be, body pain goes hand in with ulcers. Whether arising from muscles, chiropractic problems or from joints, pain is inextricably associated with impaired performance. The form that the issue takes is, of course, variable, but may include reluctance to jump in good form, running out, bucking or refusals. It is not uncommon for the horse to buck after a jump. Similarly horses may be reluctant to go down hill. In such cases (including the horse landing after a jump), when the stomach has been compressed by the viscera (abdominal contents) the acids in the stomach are splashed up and onto the non-glandular portion. This portion of the stomach is more susceptible to acid damage than the glandular portion (that portion secreting the acid.) Performance horses, for example may refuse to take a specific lead or to perform a rollback or pirouette, slide, etc.
Due to the consistent muscle pain patterns found in ulcer cases, the horse will cross canter or refuse to pick up a specific lead. Often these horses do not come through in the hindquarters (especially the right hind). They are often restricted in the shoulders due to a consistently found neuromuscular pattern that tightens the fascia over the muscles of the shoulder and wither pocket area. This myofascial contracture limits the ability of the muscles to lengthen and shorten appropriately. The result is pain and develops into a consistent pattern of vertebral dysfunction (chiropractic problem) in the wither vertebrae. Other consistent findings include chiropractic issues in the thoraco-lumbar area (the transition zone from chest vertebrae to the loin vertebrae). There is also a consistent pattern of pain and dysfunction where the lumbar vertebra joints articulate with the sacrum. Vertebral joint dysfunction is defined, basically, as an inability of joints to move through their full range of motion. Loss of joint motion results in pain and inability to use the back well.
One very important muscle that is frequently dysfunctional in ulcer cases is the Psoas (pronounced “SO-as and is actually a group of 3 muscles). Taken together, this group represents one of the largest and strongest muscles in the body. Its function is to stabilize and protect the pelvic girdle from damage. This is the group of muscles that prevents a racehorse from literally fracturing its pelvis when it bolts from the starting gate. The Psoas muscles are usually intimately involved in chronic sore backs in both horses and people. When there is Psoas muscle pain the pelvis and croup muscles cannot function well. The croup muscles then go into spasm and are painful to palpation (touch). Understanding this, it is easy to visualize significant loss of performance ability.
What can you observe when you look at a horse with ulcer problems?
1. Weight Loss: That, of course, depends on the severity and duration of the ulcers. However, even in somewhat less severe cases horses are moderately down in weight. Recent history often indicates that it is hard to keep weight on them. Hand in hand the horse may show some loss of muscle mass and top line.
2. Eating Patterns: In observing the ulcer horse’s eating patterns, you may notice that it has become a slow or picky eater. Some will literally walk away from their hay and/or grain. It is common that they may nibble hay, but refuse grain. (Some horses with ulcers will continue to eat like a proverbial pig)
3. Appearance: It is also commonly observed that the hair coat, especially, over the thorax (chest) is duller than on the neck or hindquarters. (not every horse will show this pattern)
4. Resistance to Grooming: Many horses with ulcers do not like to be brushed on the bottom of the chest and abdomen. They may even kick out if touched in the area of the sheath or mammary glands.
5. It is very important to note that some horses may be in good flesh, have good appetites and still have ulcers in their digestive tracts and have musculo/skeletal issues and performance related problems that are consistent with the ulcers.
6. Horses with chronic ulcers may show poor quality feet
Presumptive Diagnosis by Palpation: General Considerations:
In medicine, the term “presumptive” or, also called, “tentative diagnosis” is used until a diagnosis is actually confirmed by a medical professional. Having said that, a rider, trainer or body worker using the techniques that follow will be much more aware and can convey the need for examination by a veterinarian.
Palpation is the touching and feeling of tissues with the goal of identifying structures that are not normal. The only tools needed are your hands/or fingers or a not-so-sophisticated tool like the blunt end of a ballpoint pen or more ideally, the cap from a hypodermic needle. The goal is to identify small points or areas that are painful and see them be manifested by a flinch response. Hard or deep pressure is not necessary to elicit such responses in a horse with ulcers. Stick with a moderate pressure.
So, What Can Be Identified? The flinch response can be used to identify reactive “trigger” or “acupuncture” points. It can be used to identify painful muscles and even to identify chiropractic issues in an individual vertebra or identify the chiropractic pattern commonly in ulcer cases. The pressure applied with the needle cap in some locations is done with the point and on other locations with the side of the needle cap.
You should always touch any area on a horse first with the fingers, or stroke the area with the palm of the hand, so as not to surprise the horse and elicit a false response.
Places to palpate:
In Traditional Chinese Medicine (TCM), the Stomach Meridian runs down the bottom side of the so-called “strap muscles” at the base of the neck. The lower one third of this “strap” muscle (The Brachiocephalicus) is nearly always reactive in ulcer cases when pressure is applied using the side of the needle cap. Do not use the tip of the needle cap as a false response may be elicited. The horse, if not first surprised, should not flinch from the amount of pressure that you can comfortably tolerate on the palm your hand. For this to be indicative of ulcers, it should be equally reactive on both the left side and the right side.
In all cases of using these five points, the reactivity (flinch response) must be present on both the left and the right side of the horse. As described in this article you do not have need for an in-depth understanding of acupuncture or to know the exact anatomical point location.
Point 1. Using the tip of the needle cap (after first using finger tip pressure), examine an acupuncture point that refers to the Stomach in TCM (The point is BL 21). This point lies at the rear border of the last rib. If one follows the rib’s curve well, there is not a need for pinpoint accuracy in location of the acupuncture point. If the horse has ulcers, a marked flinch is noted when the tip of the cap is stroked downward from the spine along that rear border of the last rib. The flinch will occur as the needle cap passes over the point about a hands breath out from the spine.
Point 2. The next point to be examined lies at the same distance from the spine but at the border of the next rib forward. The palpation is repeated in exactly the same manner as above. This point refers to the TCM Spleen (BL 20). The TCM Spleen is associated with the pancreas. The pancreas secretes the enzymes necessary for digestion of fats, carbohydrates and proteins. Therefore, in TCM it is considered the key organ of digestion and works with its Chinese Medicine partner, the TCM Stomach.
Points 3. The next two points to be examined for the Stomach and Spleen are called “Alarm Points.” The first is a secondary “alarm point” for the Stomach. (Use the tip of the needle cap after first stroking with the tip of the index finger.) This point is located on the bottom of the chest about four or five inches behind the elbow (ST 11). It is in a soft depression where the chest muscle (the Ascending Pectoral muscle – on each side) blends into the bottom of the chest wall. A mild to moderate pressured stroking motion from the bottom center rearward again makes it unnecessary to have the point accurately pinpointed.
Point 4. The Spleen “alarm point” is located where the next to last rib joins the cartilage that leads to the sternum (LIV 13). The sternum is analogous to that row of bones that is on the front of a human’s chest. The bone/cartilage junction is approximately where the abdomen starts to curve in toward the midline. This point can be quite reactive and palpating first with fingertip pressure is indicated for safety’s sake.
There are several other points with which to strengthen the presumptive diagnosis of ulcers and help distinguish foregut from hindgut ulcers (or both) that are better described by demonstration; but if the strap muscle and the points described are all equally reactive on both the left and right sides of the horse, the indications are very strong that ulcers are present somewhere in the digestive track.
I recognize that many persons do not learn well from the written word alone no matter how hard I try to put the descriptions into words, it may require the help of a veterinary acupuncturist/chiropractor to demonstrate and teach the location of the points.
As a veterinary acupuncturist and chiropractor, I then, after checking all the “test points” on the neck thorax and abdomen, use an acupuncture treatment protocol that is indicated for acute gastrointestinal distress. The protocol I use treats only points on the limbs of the horse and none of the test points are needled. If all of the test points become non-reactive the presumptive diagnosis is very much strengthened. This diagnostic treatment also provides a good base from which the healing effects of conventional ulcer medications are given a boost.
There are patterns in the fascia (the fibrous covering over muscle) that can also be used as further evidence of ulcers. Testing is best performed by a person is trained in “neuromuscular release” and “myofascial release.” However, with instruction, the procedure for this specific use can be readily taught to a layman.
The Wither Pocket Muscles:
The other area readily evaluated with the needle cap is the “wither-pocket”. This is the pocket where the pommel points and panels/bars of the saddle rest behind the shoulder blade. Begin the stroking from the top of the “pocket” just behind the scapula (shoulder blade). Commence the exam with the fingertips and exert a light pressure then gradually stroke with more pressure. Continue stroking somewhat rearward to the bottom of the “wither pocket.” The exam can be better executed using the flat side of the needle cap (not using the point of the cap).
A horse that does not have ulcers (or saddle fitting problems) should be able to tolerate the degree of pressure that you can readily tolerate when stroking the side of the needle cap against the open palm of your hand. The reaction in an ulcer case may be present on both the left and right wither pockets. Remember, even though the “pocket” is almost always reactive in ulcer cases this procedure as an only test is not adequate to say that the horse has ulcers, since it may also indicate poor saddle fit. It has more significance when viewed along with e.g. “ulcer point” sensitivity
Gastro-Intestinal ulcers are a serious, difficult and expensive disease problem. Early diagnosis and prompt treatment are extremely important. The good news is that with the information provided in this article you, the reader, can be much more aware and pick up on the evidence much earlier.
Regarding the value and validity of this method of diagnosing ulcers, I have experienced a greater than 95% accurate positive diagnosis response. This is based on horses that have been confirmed ulcer positive by diagnostic ultrasound or confirmed by a positive response to Omeprazole (GastroGard) therapy. Endoscopic diagnosis is limited to diagnosis in only the stomach and a small portion of the small intestine. In a retrospective university autopsy study of 565 horses, 45% of non-performance horses and 65% if performance horses were found to have ulcers in the hind-gut (specifically in the Right Dorsal Colon). These cannot be picked up by endoscopic examination. This explains why one may find the points and patterns described in this article reactive in spite of a negative endoscopy.
Another very interesting and surprising fact has surfaced over and over with the author’s ulcer cases. When the horses are treated with acupuncture as part of the diagnosis, not only do the “test” points become non-reactive, much of the body pain (muscle and chiropractic) issues resolve or are significantly mitigated.
When this is found to be the case, my protocol is to perform additional acupuncture and chiropractic therapy prior to starting an ulcer medication. This type of Integrative Medicine approach has done a remarkable job of returning ulcer horses to full performance and competition capabilities usually within six to ten days. Some cases do require a follow up with acupuncture and chiropractic to resolve remaining or recurrent chiropractic and muscle issues.
Ulcer occurrence can be greatly reduced with management and feeding. As a veterinary practitioner, I am very interested in prevention of recurrent ulcers as well as prevention of first time cases. In this series, I will provide articles on prevention (and therapy) based on environmental aspects such as stress minimization. Such stress mechanisms are encountered with transportation, competition, weaning, separation anxiety, and housing.