#94 Understanding Equine Gastric Ulcer Syndrome with Dr. Ben Skyes

[SPEAKER 1]
[00:00:01-00:00:12]
In this episode, we're talking with Dr. Ben Sykes, a veterinarian with over 28 years of clinical experience, as well as the world-leading expert on equine gastric ulcer syndrome.

[SPEAKER 2]
[00:00:13-00:00:30]
Glandular disease is really about treating the whole horse and focusing on the whole horse's medical conditions and the whole horse's environment. Squamous disease is much more focused on those big three factors of roughage, carbohydrates, and exercise duration.

[SPEAKER 1]
[00:00:32-00:02:34]
Welcome to the Equestrian Connection podcast from WeHorse. My name is Danielle Crowell and I'm your host. Dr. Ben Sykes is a world-leading expert on equine gastric ulcer syndrome and is actively changing the way we think, talk about, treat, prevent, and manage gastric ulcers in our horses. He has pioneered research on gastric ulcers with a focus on equine glandular gastric disease and is a well-recognized speaker at numerous conferences around the world on subjects relating to equine health and equine gastric ulcer syndrome. Dr. Sykes is also a veterinarian with over 28 years of clinical experience and is boarded with the American College of Veterinary and Internal Medicine. He graduated from Murdoch University in 1997 before completing an internship at Randwick Equine Center, followed by a residency in equine internal medicine in Virginia, gaining his diplomat registration in large animal internal medicine in 2004. He then spent seven years in Finland as the head of the equine hospital at Helsinki University in private practice and as a visiting professor in equine medicine and surgery in Estonia. He has a special interest in equine gastric ulcers with many peer-reviewed publications to his credit, including being the lead author on the 2015 European College of Equine Internal Medicine consensus statement on equine gastric ulcer syndrome in adult horses. Throughout his career, Dr. Sykes has worked with a wide range of horses, focusing on high-performance horses in racetrack, breeding, and sport horse settings. Today we'll be discussing, you guessed it, ulcers. There's a lot to cover, including what they are, signs to look for, treatment, prevention, and so much more. So let's get started. Ben, thank you so much for coming on the WeHorse podcast. I'm really excited to have this discussion, both for my own interest and as I mentioned before recording, I have a feeling that our audience will be really interested in this as well. So thanks so much for being here.

[SPEAKER 2]
[00:02:35-00:02:37]
Thank you, Danielle. It's a pleasure to be here. Looking forward to chatting.

[SPEAKER 1]
[00:02:38-00:02:45]
Awesome. So I want to get into it right away, and we're going to start at the very basic. First of all, what are ulcers?

[SPEAKER 2]
[00:02:47-00:06:04]
Yeah, so it's really important, actually, that we separate, that we get that from the get-go, because effectively, I mean, I guess we have three types of ulcers that people talk about. So When we talk about the stomach, it's a big single chamber. It's, you know, 15 to 20 litre chamber depending on the size of the horse. And it has, but it has two linings. The top half of the stomach is lined by a squamous mucosa and that's pretty much identical to our skin. And then the bottom half of the stomach is lined by a glandular mucosa and that's like our stomach. So it's quite unusual. Rats, rhinoceroses and horses are the three main species that have this sort of type of stomach where the split occurs and Whereas in humans, the split happens, the esophagus is squamous and the stomach is glandular. And that's important because what it means is that in the stomach, we have effectively two distinctly different disease conditions. So although we talk about, you know, equine gastric ulcer syndrome, EGUS, as a sort of an overarching term, there are actually two entirely separate diseases. And I think of them like the odd couple. They just happen to live in the same apartment. But they're very, very different. And so squamous disease is As I said, the squamous mucosa is basically like our skin, and it's an area that under normal conditions has very limited exposure to acid. But through a range of things that we'll get into today, we get disruption of those normal mechanisms that keep the acid down in the bottom part of the stomach where it belongs, and we get acid exposure to the squamous mucosa. In the same way as if we put acid on our skin, we're going to get a burn. And so effectively, squamous disease is a chemical burn. And I think of squamous disease as being 80% management and 20% horse. And it's really management factors that contribute to that risk of disease. Some horse level factors as well. Galangal disease is, which is the bottom half of the stomach, is much more like our stomach and much more like the types of ulcers that we get. In humans, it's Helicobacter as a particular bacterial species, and it's not that in horses. We've looked for that, and it's not that. In humans, it's non-steroidal drugs like ibuprofen, these types of drugs. It's not that primarily in horses. It's more similar to idiopathic, peptic ulcer disease in people, and idiopathic simply means we don't know what it is. We don't know what causes it. But it's a gastritis. It's an inflammatory response. And it's much more behaviorally and stress-related. So, again, we'll get into the details of what that is. But I think more about glandular disease being 80% horse and 20% management. There's much more of a horse-level experience of glandular disease and predisposition. There's some breed predisposition. So, for example, our warm-blood sports horses are kind of the poster children for glandular disease. And it's that much more horse centric. And then the last one we have is hindgut ulcers. And we'll put that to the side. But, you know, the hindgut of the horse is an important part. That's sort of a whole conversation in itself. Except to say they're not really ulcers per se, but hindgut disease is very relevant. But obviously today we're just going to focus on the stomach and that separation between squamous and glandular ulcers.

[SPEAKER 1]
[00:06:05-00:06:48]
Okay, that brought up so many different questions, but I'm going to see if this next question will kind of answer that. So I think back to like when I first started riding, you know, 25 or so years ago. And as, you know, as a kid, as a teen, you didn't really hear, or at least in my circle, I didn't really hear much about ulcers. It wasn't really anything that was ever discussed. And Maybe it was just simply a we didn't really know as much about them at the time, or perhaps it just seems like they're more prevalent nowadays. What is your thought there? Like, why does it seem like everybody's talking about ulcers now? Is it more like common or is it just more talked about?

[SPEAKER 2]
[00:06:49-00:09:25]
Yeah, so ulcers kind of burst onto the scenes in the late 90s. And really, actually, it's interesting because initially it was squamous disease. And that was because in the late 90s, we got access to gastroscopes where we could look inside the horse's stomachs. and so all these they'd obviously been in horses for years in post-mortem studies but no one had really paid too much attention and then once we got gastroscopes and we could look inside the horse's stomach we started getting this realization that you know just how common squamous disease was and our original gastroscopes were two or maybe two and a half meters and really all that allowed us to view was the squamous mucosa so Until sort of 2015-ish, around about that point. So sort of the first 10, 15 years of gastric ulcers, really what we talked about was squamous disease. And then we started using three-meter scopes or three-and-a-half-meter scopes a lot more routinely. And then there was a crossover where we started recognizing actually To see glandular, you've got to get all the way down to the very bottom part of the stomach. But once you get down there, we start seeing a lot of disease there. And now glandular disease has started to become very relevant as well. So I think they've always been there. I think it's an awareness and it's our improved diagnostic capacity to see them that has driven that. And obviously, we've had medications come available and medications bring with them research funding and research funding brings awareness. So, you know, all of those things tie together. But When we look at the drivers of disease, I think particularly squamous disease, squamous disease has been around as long as we've domesticated horses. If we go back to the old cart horses that lived in the city on pure grain diets and worked continuously all day, I guarantee you, you know, dollars to donuts that those horses had significant squamous disease. It's just that we weren't looking for it, therefore we weren't seeing it. Yeah. same can kind of be said of the hindgut you know no one's really looked so hard at the hindgut so there's a lot going on there that we don't know about um but yeah i think it's as much of its awareness i think glandular disease is probably more prevalent um because of the intensity of management that we're putting horses under um maybe it's been like that for you know for quite a while but it's definitely a reflection of environment and stresses and so um i think it's kind of a combination of both and We've done studies where we've looked at feral horses and feral horses do have ulceration to a certain rate, but that rate of ulceration, you know, dramatically increases both squamous and glandular when you bring those horses into domestication.

[SPEAKER 1]
[00:09:27-00:10:15]
Gotcha. You had mentioned one thing a little bit earlier that caught my attention, and that was, now I'm going to paraphrase here, of course. You had mentioned that things like ulcers in humans, for example, use of ibuprofen, things like that, isn't the same for horses. Is that correct? And immediately that brought to mind to me the overuse of certain medications in horses and how I've always heard that if you overuse things like Butte, you know, Banamine, et cetera, et cetera, et cetera, you'll cause ulcers in horses. Is that completely incorrect or is there like a little bit of a trickle of truth there?

[SPEAKER 2]
[00:10:17-00:12:08]
The difference between remedy and poison is dose. And so, you know, and probably – and dose and duration is probably the way, you know, we look at that. So, you know, drugs like Flinixin, drugs like phenylbutazone, they play a really important role in managing horses with acute conditions, you know, acute painful conditions. But they also play a really important role, especially if we have an aged horse population, in managing – low-grade disease, low-grade pain. We can't ignore that pain just because of concerns of what might happen if we give an appropriate medication. Nearly all the data we have that says that for the absolute vast majority of horses, we get the odd one that appears to be particularly susceptible, but for the absolute vast majority of horses, when used appropriately at appropriate therapeutic doses, these drugs are safe. It's when we use them excessively or in very rare but particular circumstances that we could potentially run into trouble with them. But I think it's not the major driver of disease. And I think it becomes a distractor that people say, oh, oh, it's this drug. It's like, no, that's not the main driver of disease. The main driver of disease is what's happening every day of the week in the backgrounds of those horses' lives. And it's really, it's a little bit like competition. Everyone wants to focus on competition and say, oh, the horse got the ulcers at competition. They don't. They get them at home. They might show them at competition. And so it's important. It's something that's relevant to talk to your veterinarian about in your particular horse's case. But it shouldn't distract us from what the main drivers of disease are and the day-to-day impact on disease risk and focusing on that to improve our horse welfare and well-being.

[SPEAKER 1]
[00:12:10-00:12:21]
Are there any specific, quote, causes of ulcers or are there just way too many variables to nail down specific causes? Yes.

[SPEAKER 2]
[00:12:23-00:16:50]
Yeah, so when we think about squamous disease, I mean, if you Google it, there's a thousand different potential causes. There's a thousand different, you know, clinical signs. And we'll come back to those clinical signs or symptoms later. But, you know, for squamous disease, I think of three main things. I think about roughage. I think about carbohydrates. And I think about exercise. And so roughage, when I say roughage, what I really mean is hay or haylage. And so long stem, stalky roughage. Interestingly, grass is not necessarily protective against ulcers. It's quite dependent on specific conditions. So, you know, horses are actually evolved to eat stalky long stem type fiber, not lush green grass. That's been something that we've imposed upon them with management. They like it because it's tasty, but it's not what they evolved to eat. And so, you know, I think about the type, the timing and the amount of roughage. And so they should be eating, you know, a hay or a haylage. They should be getting that ad libitum 24-7. They should be getting it pre-exercise. And they should be consuming about at least 2% of their body weight per day on an ad-fed basis. So, you know, that starts being quite a lot of hay. That's 10 kilograms of hay for an average-sized horse. And that really is the cornerstone of squamous disease risk and the cornerstone of squamous disease prevention because what that hay does is it forms basically the size of a basketball, a ball of food in the stomach, and that ball of food in the stomach stops acid from splashing up from where it belongs down on the glandular part of the stomach where there's normal defensive mechanisms up onto the squamous mucosa where there's limited defensive mechanisms and we're going to get that chemical burn. I think, you know, if we want to keep it as simple as possible, the first thing we always focus on is roughage and roughage intake. And I think it's really important to recognise that eating is a behaviour for horses and to eat, horses have to feel safe and secure. And just because we give a horse free choice hay doesn't necessarily mean it's going to consume it, doesn't necessarily mean it's going to consume it in an appropriate amount to protect its stomach. So One of the first things I always do with owners who are concerned is tell them to go and measure the hay intake. How much is your horse actually eating? And it's remarkable how many horses don't eat what they should be eating. They'll have free choice, but they're not eating their 2% per day. They're eating less than that. And that's a behavioral impact. That's because eating is a behavior. And there's things we can do to play with that. carbohydrates are important, but it's a little bit like it's the same thing. It's that I think of carbohydrates like red wine, you know, a small amount, a glass a day is probably not going to cause you any harm. Up to bottles a day is bad for you. And carbohydrates are the same. So a moderate amount of carbohydrates in horses diets are fine. We don't need to go carb free. We don't need to go grain free. But it's about a gram per kilogram per meal. We need to stay below that. Otherwise, we start seeing an increased risk of squamous disease. And then it's exercise. We start seeing exercise. And exercise really is because exercise splashes around the acid and pushes it up on the stomach. So it's the amount of exercise. When we think about glandular disease... It's more horse-based, but there are environmental drivers. Exercise plays a role, but it's the number of days we exercise per week. So we know that horses exercising five to seven days a week are more likely to get glandular disease than horses exercising four or five days a week or less. And so making sure we've got rest days. And then it's really about I think the three Fs, friends, forage and freedom and well-being and management of the total horse and the horse's environment and stress reduction that are the critical players. And then the last one is managing concurrent disease like musculoskeletal disease, lameness, sore backs, other potential causes of pain because we know they're drivers of glandular disease. And so, you know, glandular disease is about really about treating the whole horse and and focusing on the whole horse's medical conditions and the whole horse's environment. Squamous disease is much more focused on those big three factors of roughage, carbohydrates, and exercise duration.

[SPEAKER 1]
[00:16:52-00:17:06]
I love how almost everything with horses always comes back to friends, forage, and freedom. It's keeping that in mind will keep a very happy, healthy horse healthy.

[SPEAKER 2]
[00:17:07-00:18:09]
Yeah, look, I think the stomach is a great proxy for horse well-being, and it's almost impossible to get really good gastric health unless the horse has good well-being. It's hard to get good squamous health because eating is a behavior, and they won't consume their roughage intake unless they've got good well-being. It's hard to get good glandular health. We'll segue a little bit, but I was down doing some gastroscopy the other day, and I was in a four-star elite Olympic-level event in Stable. And we scoped – I scoped 10 of their horses, and not a single one of them had ulcers. And, you know, this is Olympic-level horses, four-star eventers, and not a single one of them had ulcers. But when you looked around, they're out with Friends Forage and Freedom. And so, you know, it really does show – the data says that they should all have ulcers, or at least 70% of them should have ulcers, but it really does show that impact of lifestyle on potential gastric disease and then gastric disease being a proxy for lifestyle.

[SPEAKER 1]
[00:18:10-00:18:35]
Absolutely. I want to keep with this segue for a brief moment before we go on to to some of the other things. When you mentioned, you know, you went and you scoped those horses and that I would love to know what drew you to specifically researching and becoming an expert in ulcers of all of the, you know, the topics within veterinary medicine. Why ulcers?

[SPEAKER 2]
[00:18:37-00:19:33]
So my background is I'm equine veterinarian first and equine internal medicine specialist second. And then working in that, it's gastroenterology, lots of emergency, lots of colic. And I then went to Europe and spent some time in Finland. And it was a huge part of our caseload were horses with gastric disease. Now, they might potentially come in initially for colic, but when we started looking for underlying causes, we would see gastric disease. And then at the time, we had this great frustration, particularly we were just starting to recognize the importance of glandular disease. And with this great frustration that glandular disease wasn't responding to treatment the same way squamous disease responds. It's a general rule that squamous disease responds very well and glandular disease just wasn't responding. And so it was really out of that frustration as a clinician that I started looking to say, well, you know, how can I...

[SPEAKER 1]
[00:19:34-00:20:22]
unpack all of this and see if i can figure out some of the key factors that are contributing to why our glandular disease isn't healing to to try and improve healing rates for you know initially primarily for my patients and then that became as i've drifted more into research a bigger picture of being you know a real focus of what i've been doing now for for well over 10 years yeah Yeah, it's one of those things where I feel like every barn you go into, it's a huge topic of discussion. It's, yeah, it's one of those main things that is affecting, you know, whether it's a sport horse, whether it's a pleasure horse, you know, it's affecting so many horses. So, yeah, I think it's an important place to be.

[SPEAKER 2]
[00:20:23-00:21:46]
Yeah, yeah, and I think affecting is a great word because – For years, we sort of said, oh, look, all of these horses, we know all these horses have ulcers. We know the prevalence is 50%, 70%, but they're fine. The horses aren't showing, they're not showing any symptoms. So if a tree falls in the forest, does it really matter? But what we're recognising a lot more now is that the horses, they are great communicators and And that language of pain that's coming from the ridden horse pain ethogram, the work that Sue Dyson has done with the lameness stuff has really changed the way we're looking at these horses and going, well, actually, they're not fine. A lot of these horses do have discomfort, particularly exercise associated discomfort associated with their gastric disease or with other causes of pain. We just need to be better listeners. And I think when we start listening better to these horses, we start realising just how impactful and how affected these horses are. And I think we're hopefully at a tipping point where we start to... That becomes the impetus for some real industry-wide change to address some of these underlying factors that we've known about for 25 years but really haven't made much impact on in terms of improving... from the horse's perspective, improving their well-being, which then hopefully will be reflected in improved gastric health.

[SPEAKER 1]
[00:21:46-00:22:20]
Yeah, yeah. I'm absolutely loving these conversations with so many experts like yourself that is shifting the narrative away from the behavioral, quote, bad horse and how it's just a training issue into looking at, you know, the holistic aspect, whether it's environmental, whether it's pain, you know, all of the different aspects of the horse that leads to what we see as the behavioral issues. So I'm loving the shift in the narrative.

[SPEAKER 2]
[00:22:21-00:24:02]
Yeah, and I think it's also a shift in perspective. And I'm lucky that I get to travel a lot and talk to a lot of veterinarians. But one of the slides I present them with is, you know, we know that when we talk about these behavioral changes, it can be musculoskeletal pain. It can be back pain. It can be poor saddle fit. It can be poor bridle fit. It can be gastric ulcers. It can be sand. It can be dental disease. You know, the list goes on. And we as veterinarians, inherently the way we're trained, we'll look at the horse and go, hey, we've fixed all of these things, the problem's solved, but we're not really trained to look at it from the horse's perspective. And I think a lot of the time, and people coming into horses, you know, I didn't grow up with a horsey background. We're sort of trained quite technically, and that's not just veterinarians. I think that's a lot of riders and stuff as well are trained very technically and And what I think we need to do is take that step back and look at it more from the horse's perspective. What is the impact? So what do we see, but what is also the impact from the horse's perspective? And what I really like about that, many things I like about the Ridden Horse Pain Ethogram is it's given us a common language. It's given us a common language to talk about this now. And Dr. Dyson also refers to it as the ridden horse performance checklist because she's got some really cool data out prediction of performance and outcome. But it's given us a common language to say, when we identify these things, what do they mean? And then how do we intervene? But it's the common language from the horse's perspective. And I think that's the shift that's very, very different.

[SPEAKER 1]
[00:24:03-00:24:16]
Absolutely. Yeah. Sticking with this conversation about like the signs and the symptoms, the things to look for, what are some of the common signs that could indicate that a horse might have ulcers?

[SPEAKER 2]
[00:24:18-00:27:09]
Yeah, I mean, if you believe the marketing material, it's just about anything. You know, it's just about anything, right? And, I mean, that's, I think, I say that somewhat cynically because if you're going to sell something, then you just make it, you know, you attribute everything to it. And then when something's common, the association is naturally formed. And, you know, correlation doesn't equal causation. So I think we have to, you know, we have to be careful of that. Squamous disease, historically, we've associated most commonly with loss of appetite and unexplained weight loss. And certainly, we still see that. So certainly, especially in our high-performance populations like our racehorses, our endurance horses, they have the main risk factors for squamous disease. And if they lose appetite or they have unexplained weight loss because of decreased voluntary consumption, then, you know, squamous disease is going to be very high on our list. Glandular disease, we don't see that eating behavior change. In fact, there's one paper that had horses with glandular disease eating more voraciously than horses without disease. So they don't have to have a poor appetite to have ulcers. They don't have to be skinny to have ulcers. And that's really important because... the poster child for our glandular disease is the well-conditioned shiny warm blood show horse um and outwardly they look amazing and so it's then what do those horses show as their as their main symptoms and that's where we come into this behavioral piece in this behavioral conversation so 85 percent of horses in the us presenting for gastroscopy have behavior as one of their primary complaints or undesirable behavior as one of their primary complaints so I think it's really recognising that it goes back to what we were just talking about, about that language of pain and that sort of the things in the ridden horse pain ethogram. But it's the owners recognising a change in their behaviour of their horse. And I think listening to that change is the most important thing. And listening to that change should trigger a conversation with the veterinarian about my horse's behaviour has changed. Why has it changed? And then what, you know, what can we do about it? Rather than my horse's behavior has changed, I'm going to try and change it back, which is the traditional approach that, you know, everyone's been trained to do. We're all outcomes of our training. Everyone's been trained. Well, if the horse does something, you just correct it. We use words like correction, not punishment, but effectively that's what we're talking about. So I think when we see those behavioral changes, it's asking why did the behavior change? Why is the horse doing this rather than what do I need to do to stop that from happening? And that's a conversation with your vet and that's a conversation around potentially different causes of pain, including ulcers.

[SPEAKER 1]
[00:27:11-00:27:38]
Let's say... somebody listening is thinking, I'm just getting the feeling, I'm seeing, you know, some signs and symptoms. I know that my horse hasn't had, you know, consistent access to forage, whatever it may be, I would like to bring my vet in and, you know, diagnose for ulcers or check for ulcers. In your opinion, what is the ideal way to diagnose ulcers?

[SPEAKER 2]
[00:27:39-00:30:34]
Yeah, the ideal way to diagnose is gastroscopy. Some people are sort of resistant to gastroscopy because you have to starve the horse overnight, and that's true. But the information we gain is really, really valuable. The first piece of information we gain is, is it ulcers or not? Because we know from that huge body of work done with the ridden horse pain ethogram that all of these symptoms that we want to blame on ulcers, because that's what marketing tells us to do, can also be caused by lameness, can also be caused by poor saddle fit. And so before we go and spend a lot of money on treatment, we need to make sure we've got the right diagnosis. We need to make sure it's actually gastric disease and that we're not actually potentially should be looking at something else like lameness. The other is, is that it separates squamous and glandular disease. So we started our conversation saying, you know, we've got the odd couple and they're two distinctly different diseases. Horses can have one or the other. They can have both or they can have none. There's four possible outcomes. But what's important is the management, the long-term preventative management varies depending on whether you've got squamous or glandular disease. I mean, yes, you can do it all, but doing it all can be really quite challenging from a pure management perspective. And so we're not just talking about what's going to happen in the next month while we treat this horse. We're talking about how do we set this horse up for success for the rest of its life in a stable, in whatever environment it's in. And knowing whether we've got a horse with squamous or glandular disease, I think, is really relevant there. Because the squamous disease, we're going to focus very much on those forage-carbohydrate exercise interactions, and that's going to be something that's really related to the horse. And if we can change those, we can really change the disease risk. I think if glandular disease is more of a continuum, once a horse has glandular disease, I tend to think of them as being predisposed to continuing to have problems with glandular disease. And so that's going to set me up a different way, and that's going to set me up Every horse should have friends, forage and freedom, but it's going to really place greater emphasis on that. It's also going to place emphasis on the potential use of appropriate supplements and those types of things, recognising that this may be a chronic condition that even after that initial period of treatment and we get improvement, we don't necessarily get complete resolution and we need to manage that horse. So gastroscopy gives us all of that information to set up a plan, not just for the next one or two months of treatment, but for really the rest of that horse's performance career. Can we diagnose without gastroscopy? Can we treat and see? We can. There are limitations to that and there are benefits to that. And so that's always, again, a conversation to going back to your veterinarian and saying, what's the pros and cons of each? But me personally, I'm always going to, prefer gastroscopy because of the absoluteness of the information we get.

[SPEAKER 1]
[00:30:36-00:30:57]
And you mentioned the predisposing of the glandular disease could be something that ends up being a chronic condition so what you're saying with that is that a horse may be more susceptible to like repeated glandular disease once they've had it in the first place is that correct?

[SPEAKER 2]
[00:30:58-00:33:08]
Yeah, we have very little data on glandular disease recurrence. We've got really good data on squamous disease recurrence. If you don't change the environment, they come back within days. Oh, okay. Certainly within weeks. But we're showing squamous disease can come back within three days, back to the rate. So it's a very rapid change. Three days to a week is all it takes for squamous disease. And that's, you know, treatment... If we're not going to change management, treatment is not going to achieve anything in the long run for Swaymas disease. It's just a stopgap to reset the horse while we work on management in the background. And if we don't change management, they're coming back because it's a reflection of that management. The glandular disease, we don't have great data on recurrence. We've got one study from a paper I did where they recurred back to their baseline within four weeks with no management changes. But I tend to think of them more... As I said, it's more of a gastritis, and so it's more of that stress-based gastritis. So we can reduce the rate, probably reduce the rate of recurrence. We can reduce the impact. And I think one of the things that we separate out is the idea that we're trying to make the ulcer go away, to we're trying to make the ulcer go quiet, to we're trying to reduce the impact of the ulcer on the horse or the disease on the horse. And so... If we can improve environment, we can reduce, we expect to reduce disease risk, recurrence, but also the impact. Horses that are healthier and happier are less impacted by disease that's low grade and present. And that's true of lameness as well. And so, you know, I really, I think the glandular horses, that stress-based environment, when you is so central. The other one is that we see some of them have structural change in their stomach. So some of them, when we treat squamous disease, it goes away. It's gone away completely. Whereas some of the glandular horses actually have structural changes in their stomach. And that structural change means that the surface of the mucosa is not necessarily going to have the normal integrity and protective mechanisms that it would without the structural change.

[SPEAKER 1]
[00:33:08-00:33:38]
So there's a lot of information there about what we can see and, that potentially sets us up to say i think this one's going to settle down nicely this one's going to be one that's going to be at increased risk going forward because of the structural change in the stomach or the like and so once ulcers have been diagnosed regardless of the type what is your recommended treatment protocol and does that change based on the type Yeah, it does change based on the type.

[SPEAKER 2]
[00:33:38-00:35:19]
So the treatment for squamous is it's caused by acid and the treatment is to remove the acid. And the squamous mucosa has a great capacity to heal. So again, like our skin, unless it's a super deep burn, it's going to heal. And so a superficial burn is going to heal. And even these really severe, deep ulcers, it's amazing how quickly they heal. They'll heal within two to four weeks with acid suppression. So our meprazole, which is our cornerstone drug, removes acid production, and then the ulcers naturally heal by themselves. And as I said, the very high rate of healing, approximately 80% of healing over a two to four week period, typically three to four weeks for those guys to heal. The glandular disease... is more complicated. We know that omeprazole alone is less effective at healing glandular disease and so we look at using acid suppression to remove the ongoing damage but we also look at drugs like sacral fate as a patch as sort of a band-aid for one for better description and because it has benefits in terms of promoting healing in the environment. So And then mesoprostol is the other one. So glandular disease, there's no clear cut which is the best approach. There's a couple of different options. And there does seem to be variation between, you know, when you talk to different veterinarians, it's like, well, in my environment, this seems to work really well for me. In my environment, this seems to work really well for me. The data says there's not a huge difference between the main treatments that we use. And so, again, it goes back to that conversation with the veterinarian and what's suitable in your particular environment.

[SPEAKER 1]
[00:35:20-00:36:05]
And now, during the healing process, so let's say that it is – well, I'll just – you can – You can do an example of each here, but let's look at exercise. So let's say that a horse is diagnosed with ulcers, whether it's glandular disease or the squamous, and the owner wants to still ride. What happens there? Because I know that there's that stomach acid, right? It's like the heartburn that kind of flares up. It creates a discomfort. What is the recommended protocol during the healing process for exercise? Should it be stopped? Should it be limited? What do you recommend?

[SPEAKER 2]
[00:36:06-00:38:11]
Yeah, I guess it's not a black and white answer. What is my personal approach and how do I do it is probably the best way to answer that is I don't rest horses during treatment as a general rule. And there's a couple of reasons for that. So if we talk about squamous disease, if we remove that acid, that stomach is going to heal whether we're exercising or not, because it's not the exercise per se that causes the ulcers. It's the exercise pushing the acid around that causes the ulcers. And so if the acid's not there, the stuff sloshing around in the stomach doesn't matter. It's just a neutral fluid sloshing around in the stomach. So And we know from lots and lots and lots of studies with racehorses where they continue in high-intensity work that omeprazole works really well at treating squamous disease, regardless of whether we continue to exercise those horses or not. And whether there's any benefit over and above that, whether the 80% becomes higher if we rest those horses, it's less clear. I also... For glandular disease, it's not as clear. We do know that, for example, showing is a risk factor for glandular disease. So horses that are actively showing in one study were 10 times more likely to have glandular disease than horses that were doing the same work at home. And so you could make an argument for that. I don't initially rest them because really what I'm trying to do is establish, because I think of glandular disease as that sort of continuum, I'm trying to establish what's the new normal for the horse. I'm trying to establish the horse's new normal and its lifestyle. And that new normal has to reflect its lifestyle. We use these horses for competition or we use these horses for, you know, recreation and activities. they've got to find their new normal in that position. And so that's really what I'm trying to achieve the vast majority of time. If I have a really stubborn case, I might rest for a brief period, but not initially. But, you know, say my one month recheck, the horse is not responding. I might then go ahead and rest the horse.

[SPEAKER 1]
[00:38:12-00:38:56]
But as a general rule, the goal is to find a way to manage the horse with its current lifestyle and um with the different tools in the toolbox to make it healthy and happy and comfortable doing what we want it to do so we get the best of both worlds because it's one thing to rest the horse have it feel better but then bring it straight back and have it have issues again we've got to find that balance eventually so i try and find that from the start if that makes sense yeah absolutely We've been focusing a lot on glandular and squamous, and there was a brief mention in the very beginning about Heimgut. Now, I know we're not going to get into that one in depth because there is so much depth to it, but can you give us a brief overview of Heimgut?

[SPEAKER 2]
[00:38:58-00:41:22]
Yeah, so hindgut, I mean, the first thing to say is hindgut ulcers is a misnomer. They're not ulcers. They're very, very few of the changes we see in the hindgut are truly ulcerative. And so to call them hindgut ulcers is inaccurate. What we have, though, is we definitely see hindgut disease. And at the simplest level, I think of the hindgut as being basically a big fermentation vat. And so... It's effectively a big fermentation fat that horses generate between 50% and 70% of their energy from their hindgut and that fermentation. So it's really, really important. What the hindgut likes is good quality, a constant supply of good quality roughage. What it doesn't like is carbohydrates. And so as a starting point, everything we do for the stomach is good for the hindgut. Everything, particularly our dietary management for our squamous disease is exactly what we should be doing as our initial point for our hindgut, which is good quality, constant supply of good quality roughage and moderate amounts of carbohydrate. And again, that number, one gram per kilogram, is the number that's relevant to the hindgut because that's the amount where we get bypass of the small intestine and we start getting hindgut acidosis if we get too much carbohydrate into the hindgut. So that's where I start. And I think when we do the same things that we fix for the stomach, a lot of our horse's hindgut health is going to improve as well. I also really like the use of appropriate probiotics. And the one that I'm a particular fan of is the Saccharomyces cerevisiae, specific strains of Saccharomyces cerevisiae, because they've been well-researched to show that they have benefits in improving hindgut function and health and diversity and all those things that we use as markers for hindgut health and so that's going to be my basic approach and then from there if the horse continues to have issues it's to the veterinarian to make sure we don't have an underlying disease that we don't have inflammatory bowel disease or we don't have you know something else going on that's driving this before we keep going down the path of trial and error gotcha I might have to get the spelling of that for you later.

[SPEAKER 1]
[00:41:22-00:41:34]
I have a gelding that I cannot figure out his fecal water syndrome for the life of me. So I might get the spelling of that from you. What's that?

[SPEAKER 2]
[00:41:35-00:41:35]
It's bruises.

[SPEAKER 1]
[00:41:36-00:41:37]
Bruises.

[SPEAKER 2]
[00:41:37-00:41:50]
Oh. Yeah, but you can't just grab any brewer's yeast off the shelf. It's actually specific strains of brewer's yeast that have been looked at and investigated. But it's the same yeast that makes beer, so it's a fantastic yeast.

[SPEAKER 1]
[00:41:50-00:41:59]
Interesting. Very interesting. Okay. What do you wish more people knew about ulcers and equine health?

[SPEAKER 2]
[00:42:02-00:43:09]
I think it's that understanding of that intersection between ulcers being a proxy for well-being. And, you know, when we see a horse with ulcers, we need to deal with those ulcers, but we need to deal with those underlying factors. And we need to, not just for our benefit, not just because the ulcers are going to go away, the endoscope is going to look better, but because, A, removing the ulcers will hopefully make the horse feel better. But, B, to keep those ulcers away, we're going to have to make changes. significant improvements in that horse's overall well-being. So we get a win-win. So we can improve the horse's quality of life. When we see the gastric disease, it's an indicator to us that we've maybe got some work to do on well-being. And if we can then use that as our reason and our driver for improving well-being, then A, we can keep the ulcers away and stop them coming back, but B, we have a healthier, happier horse, and that's a win-win for everyone. And that goes to looking at it as much from the horse perspective as from our perspective of, well, we don't want ulcers. Well, the horse doesn't want ulcers either, but it also doesn't want the reason why it got ulcers in the first place.

[SPEAKER 1]
[00:43:11-00:43:33]
Absolutely. I have been asking all of our podcast guests this for the past couple of years because we've just seen such a shift in the industry for the better, in my opinion. And we kind of touched a little bit about this or on this earlier. But what is your hope for the future of the equestrian industry?

[SPEAKER 2]
[00:43:35-00:45:00]
I would like to see, I hope that the equestrian industry becomes more horse-centric. And I think that if we start looking at it from the horse's perspective. And so I would like to see a horse industry where the minimum standard is friends, forage, and freedom. And that, you know, what does that mean? There are ways that we can work through that. But one of my favorite things is when we talk about friends, it doesn't have to be turnout with two horses in the same yard. There's some really cool split stable designs that allow horses to reach over and groom and engage with a horse in a stable next to it. They're in their own space, but they've also got the opportunity to groom. And that gives the horse the opportunity to groom. That gives it friends. Forage is kind of a no-brainer, but forage isn't just about gastric health. Forage is a really important well-being tool. It's really important for horses' mental health and well-being. And freedom. And so freedom includes turnout, but freedom also includes freedom of choice. And so I would like to see the future of the horse industry being a minimum standard that those three things are met for every single horse. And that's going to require a big shift. Friends and forage are pretty easy to meet. Freedom becomes more challenging. But I think if we don't change, I think we're going to start having increased resistance to the viability of our future.

[SPEAKER 1]
[00:45:01-00:45:28]
Agreed. Absolutely agreed. I love it. Okay, we have four rapid fire questions that we ask every podcast guest. And I have to say, I'm just like absorbing all of this information. So if I seem a little like now, I'm like, okay, there's so much I'm taking from this. But our rapid fire questions, it's the first thing that pops into your head. The first one is, do you have a motto or favorite saying?

[SPEAKER 2]
[00:45:30-00:45:41]
Not really, but I'm old enough to still sort of like that old night, life short, play hard type scenario. So I think it fits the vet type personality. And, you know, there's a lot for us to achieve. So we should crack on.

[SPEAKER 1]
[00:45:44-00:45:46]
Who has been the most influential person in your equestrian journey?

[SPEAKER 2]
[00:45:48-00:46:18]
Uh, probably one of my lecturers back in vet school. So I didn't grow up with horses. My sister had horses, but that was her thing, not mine. And I didn't intend to be a horse vet. And then as I sort of got to the very end of my vet school journey, one of my lecturers tapped me on the shoulder and said, Hey, Ben, do you think you should be a horse vet? Do you want to be a horse vet? You know, you might enjoy it. And that's it. That's that sort of set the set the corner piece from there. And 28 years later, I'm still a horse vet and still enjoying it.

[SPEAKER 1]
[00:46:19-00:46:28]
It's so funny. I'm so interested in the fact that like it just it all shifted for you. That's so fascinating. I bet your sister thought it was pretty cool.

[SPEAKER 2]
[00:46:31-00:46:32]
Eventually. Yeah.

[SPEAKER 1]
[00:46:35-00:46:38]
If you could give equestrians one piece of advice, what would it be?

[SPEAKER 2]
[00:46:39-00:47:35]
listen listen listen to the horses horses are great communicators um and we haven't been great listeners and i think we're all having this uncomfortable period of reflection where we look back and just because we did something in the past um doesn't mean that we should keep doing it in the future and it's that list that understanding of listening to the horse and and making sure that the horse's voice in the conversation is at least as loud as all of the other voices in the conversation. You've got the trainer, you've got the barn staff, you've got the people in the, you know, your friends, you've got the vets, the horse's conversation, the horse's voice needs to be at least as loud as all of those other voices. And so I think that, and that's, that's uncomfortable because it means we've got to challenge a lot of the things that we've done historically, but I think it's necessary to, for the horses, for the horse well-being, and I think it's necessary for the future of our industry.

[SPEAKER 1]
[00:47:36-00:47:50]
Mm-hmm. I'm, like, keeping in my ear-to-ear smile here. I love when experts say this sort of thing because it's a trickle-down effect, right? When it starts at the top, it works its way down, and I just think it's so fantastic.

[SPEAKER 2]
[00:47:50-00:48:38]
I'll give you a perfect example is I don't ride with a whip anymore. So I used to ride with a whip because I was taught to ride with a whip, and if the horse did something, I would correct it. Yep. And, you know, I've sat there and I've thought about this and I thought I've got a good, kind, honest, tough horse. If I need to force him into doing something, then we're not doing it the right way. So, yeah, so I won't ride with a whip anymore. I've just decided that's an unnecessary correction slash punishment, whatever we want to call it, that doesn't, from the horse's perspective, achieve nothing. And, you know, it's those little incremental steps that with an overarching philosophy of saying, well, let's shift our perspective of what we're looking at, what we're looking from that I think is really, really important.

[SPEAKER 1]
[00:48:40-00:48:46]
Absolutely. And the last one here, please complete this sentence for me. Horses are.

[SPEAKER 2]
[00:48:48-00:50:00]
Horses are great teachers. And that's sort of, it's a follow on from that, um, If we listen, they force us to intraflect. That can be really uncomfortable. No one likes change. But if we listen, they are such a mirror of what's going on around them that we can learn from that. in so many different ways we can learn from that in terms of um you know making their life better which honestly makes our life better because if they're happier they're easier to be around and it's just this full circle so um it's that it's that teaching and as someone with you know had young kids growing up through horses um you know working with my young kids as they would you know come home in a bad mood and i'm like you can't go out to the horse like that you know it's not going it's going to mirror it back and we've had a couple of great horses that have really helped my kids understand and regulate their moods and behavior because the horses just won't let them near them. When the kid's in a bad mood, the horse won't engage. And when the kid changes that, so that ability for them to teach is so powerful if we're willing to listen and play along.

[SPEAKER 1]
[00:50:01-00:50:26]
Absolutely. Ben, it has been an absolute pleasure speaking with you here today. Like I said, I'm taking so much from this personally and from my own horses. And I don't just have a feeling. I very much know that our audience is going to take a lot from this as well. So thank you for speaking to us about this very important topic. And yeah, thank you.

[SPEAKER 2]
[00:50:26-00:50:28]
My absolute pleasure. Thank you for having me on.

[SPEAKER 1]
[00:50:31-00:51:04]
Thank you. Thank you. Until next time, be kind to yourself, your horses and others.

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