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My take on Ulcers

- foregut ulcers, 'alleged' hindgut ulcers, and ... the detrimental use of PPIs (seriously)

PS - if you missed the video on how to diagnose ulcers, see the main Gut page and scroll to the bottom.

"As important as what you eat is how you digest it and what you absorb.”

- when we refer to ulcers, we're talking foregut ulcers. Hindgut 'ulcers' is a completely different thing; for starters they're a myth as there are no acid-secreting cells in the hindgut, so if you've been given a 'hindgut ulcers' diagnosis or suspicion, see our separate 'Hindgut Ulcers???' page, a Blog post we did in May 2020. (link also at the bottom of the page).

Here’s a thing – ulcers (foregut only) are there because the gut environment is already altered, usually due to either some form of stress, inappropriate feed, or stress caused by inappropriate feed. Both these factors are the cause of why our horses – and us humans – get ulcers. Stress and/or the wrong food/food management destroy the gut environment, literally, which means that without a strong, healthy protective mucosal gut lining, the foregut (stomach) acid will leak and create a wound, aka an ulcer, because it’s almighty strong hydrochloric acid, same as a car battery.

Some quick stomach acid facts:

  • Stomach acid is a prerequisite to healthy digestion – it’s there because it’s meant to be there. Without it, digestion would simply not occur.
  • The breakdown and absorption of nutrients occurs within only a narrow range of acidity in the stomach.
  • If there isn’t enough acid, the normal chemical reactions required to absorb nutrients is impaired.

Sounds simple enough, doesn’t it. Yet most of us have no idea how many vital roles stomach acid plays in the body, whether horse or human, and the drug companies know it. You can’t watch TV without seeing an advert for some chalky tablet to ‘calm’ the acid burn, especially after we've eaten a red hot, spicy curry.

The claim that the acid is causing the ulcers is a myth. The acid splash/leak is merely a side-effect of the stress/poor-quality feed which has caused the damaged gut. Remove the stressors or change the feed to a biologically species-appropriate, repopulate the beneficial gut bacteria, make sure there’s continuous ad-lib forage, and let a horse be a horse, and we’ll very likely witness a remarkably quick, not to mention safe, natural recovery, without shovelling damaging symptom-blocking chemicals into our horses already damaged digestive systems.

No horse is born ulcerogenic

It's true – something triggers this digestive disturbances in horses, i.e. sudden changes, moving, competition, psychological stress of travel and training, breeding and pregnancy, worming, parasites, medications, vaccines, viruses, injury ... you name it. We’re also talking unusual/unseasonable weather conditions, alterations in environment, and as said earlier, lesser quality feeds and unclean water. Trouble is, to fix a problem, we usually need to put medical stuff into the body to fix it, via the mouth and into the gut system for it to work its magic.

However, when we have an ulcerogenic state, the fix becomes an even Bigger Picture, because the gut’s not in a fit enough state to benefit from any medicine or improved diet. Whatever the cause, it’s irritated the digestive system as a whole. And when you get long-term irritation, you get inflammation at cellular level, along with red-raw pain which spreads a whole lot further than just the injurious site, thanks to the nerves in the body which are everywhere.

If the fire isn’t put out, the continuing inflammation of a system, especially the digestive system - the system upon which health completely relies on to fuel the very survival of the organism - triggers a cascade of further stressful cellular disruption on the immune system as a whole, because it’s already trying to work overtime in an attempt to maintain homeostasis, which is the ability to maintain a relatively stable internal state despite changes in the world outside - aka, balance. All living organisms, from plants to puppies to people, and our horses, need to keep their internal environment regulated to process energy and ultimately survive.

So, while the immune system and other organs are trying to pick up the slack from the non-functioning gut, they themselves become overburdened and sluggish, and eventually the whole organism starts to crash. For a healthy balanced body to be firing on all cylinders, we need that gut to be functioning properly - quite simply, life-force depends on it. Food nutrients are the body’s building blocks, and the gut is there to digest, assimilate and absorb those nutrients in the fuel (feed) that we give it. If good health isn’t happening, it’s because there’s something going wrong in the gut, so we need to clean up the gut function and sustain a healthy microbiome environment. Here’s why.

In simple terms, nearly all dis-ease (with dis-ease meaning the body is ill at ease) is traceable back to a damaged or abnormal gut environment and gut flora (microbiome), with the typical causes being anything mentioned above and more … the list is endless, and let’s not forget the dreaded green stuff - grass, which we all know about.

Here's what actually happens down there. Cue the pH value dropping. Cue acidosis. Cue destruction of the healthy fibre-digesting bacteria which lowers the gut pH value even further into acidity. Cue the release of endotoxins (a toxin kept within the gut microbe cell which is released only after destruction); cue these same toxins leaking through the damaged gut wall into the bloodstream; and Boom! - cue the cascade of pain, inflammation and unbalanced homeostasis. Everything is connected, and it all relates to silent inflammation in the body at cellular level. This ultimately tracks its way through the tissues to the organs, leading to an overburdened toxic state, which ultimately impacts immunity.

Pulling this all together

To summarise, a stressed system is a poorly functioning one. It destroys gut health first and foremost, upon which immunity relies. It also means that the feed nutrients won’t be getting to the body’s cells to maintain optimum health and movement, so the physiological self – the functioning self – is exhausted. What we need to do is ensure that the diet is absolutely appropriate, as clean and uncontaminated as possible, along the lines that the equine digestive system is evolved to eat, alongside forage-balanced minerals to support the physical frame and the vitality of the central nervous system. See our Feeding our Horses section for the full story, and especially the chapter Why What We Feed Has To Be Right.

Back to the drug companies

So, we think we've got foregut ulcers, with (allegedly) too much acid going on (but hopefully we've already dispelled that myth), and we need it fixed. Behind the scenes the drug companies are preying upon our GPs and vets, insisting that stomach acid isn’t essential, and that they should write expensive prescriptions for their wonder-drugs for us mortals to either swallow, or something to give to our horses, to quell the acid burn.

Never is there a mention that there might be an actual reason for why there’s acid burn or ulcers; never a suggestion that the curry we ate might have been a bit much, or for our horses, no mention that it's likely to be the haylage, alfalfa, soya and many other poor-quality ingredients found in processed feedbags, that are known to cause gut sensitivities and damage the gut environment, and therefore Should Be Avoided.

Truth is, those wonder-drugs not only fail to address the actual causes of acidity and/or ulcers (stressors and/or inappropriate feed) but put us or our horses at further health risks.

If I was to say to you that by feeding acid-stopping drugs to our horses, it might cause ...

  1. Increased negative bacterial overgrowth
  2. Impaired digestion causing colic risk
  3. Significant nutrient malabsorption
  4. Decreased resistance to infection
  5. Kidney disease

... what would you say?

I had originally intended to cover all of these issues here, but as I started to write I realised it would take way too long. So I’ll just go with what I feel is the most important for us horse owners, specifically impaired digestion, impaired gut flora syndrome, and impaired nutrient absorption.

With so much new research coming out about the negative side-effects of acid-stopping drugs, let's just dive straight in and talk Omeprazole, aka a PPI (Proton Pump Inhibitor), the vet's go-to drug of choice for an equine ulcerogenic/acid state.

Proton Pump Inhibitors

When it comes to our horses, the acid-stopping drug of choice is generically known as a PPI, aka a Proton Pump Inhibitor, i.e. Omeprazole (and plenty of others ending in ‘zole’). It's also probably useful to understand what a proton pump is, so here we go with a quick explanation. A proton pump is a natural part of every body out there, an integral membrane protein, essential for cellular energy production, and their vital function is literally to pump an electrical instruction to trigger an essential function across a biological membrane, for balanced homeostasis to exist. Hope that wasn't too science-y.

In the equine foregut, the proton pump's instruction is to produce digestive acid, which means an inhibitor of the proton pump reduces the production of acid - it does this by blocking the enzyme in the wall of the stomach that produces acid. Hence the name, Proton Pump Inhibitor, aka PPI.

Let's delve a little deeper into PPIs, and what they do to the body. PPIs are a group of drugs whose main action is a significant, and long-lasting, reduction of stomach acid production; they are the most potent inhibitors of acid secretion available. Vets prescribe them for equine ulcers because on the surface, they provide fairly quick relief and you can't argue with that. Your horse has ulcers, and half a ton of p****d-off horse in pain is no joke. So the powerful chemicals in the ‘zoles’ switch off the proton pump which secretes the stomach acid. Hence, in theory, by turning the acid off, there’s no more burn, and ultimately that's the goal, to stop the pain, and make your horse safe to be around again.

Sounds simple enough, so what's not to love? Here's the reality - behind the scenes PPIs drastically mess with the biochemisty, which I’ll get to further on. (I'll quickly confess now that I'm not a fan of PPIs, in case you hadn't guessed. At all.)

Although generally assumed to be safe, studies as far back as 2010 have shown that they have numerous side effects, including causing a further altered gut environment and impaired nutrient absorption, to an increased risk for kidney disease and neurological impairment, to name just a few. And here’s the irony – this is a biggie so it deserves bold type remember, those ulcers are there because the gut environment is already altered. As I said above, usually due to either some form of stress or inappropriate feeding, or inappropriate feeding which causes stress, which destroys the beneficial gut bacteria, etc etc.

These clever little proton pumps in the body are a highly complex part of the mammalian physiology, and ... they’re not just limited to the stomach - they’re present in just about every cell in the whole body, so let's quickly talk cells for a moment. Other than red blood cells, all of the body’s cells have a mitochondria (probably my favourite M-word which I use a lot on this website), an energy-producing furnace in the middle of every cell. Imagine the coal fire on a steam train being constantly fed coal to create the heat to generate steam, which produces the energy that makes the train move. That coal fire is the train’s ‘mitochondria’.

The body’s cellullar mitochondria metabolise (burn) carbs, fat, chemicals, minerals – you name it, the mitochondria burn them, to produce specific energies to make the body’s various systems operate. And how do they do this? They trigger this thing called a proton - a source of electric instruction which is pumped across a membrane that’s specifically harnessed to form ATP, the body’s main storage form of energy.

Now here’s the rub - without an efficiently functioning proton-pumping system pumping their message, the body must rely on anaerobic systems for energy production, which will lead to rapid fatigue.

So, back to the proton pump in the stomach, the pump to make the acid-secreting cells, aka the parietal cells. The chewed food mixed with saliva (bolus), travels down the oesophagus towards the stomach, collecting beneficial bacteria - and a few digestive enzymes - on the way. This very action triggers the foregut’s proton pump to stand by, ready to release the stomach acid to start the digestion process.

When the bolus arrives in the stomach, it’s immediately mixed with the stomach acid and pepsinase, the precursor to pepsin, the first protein-digesting enzyme the bolus will meet. I say precursor, because pepsinase needs to be converted to pepsin in order to work, and the converter is ... you’ve guessed it - stomach acid!

This next bit's really important. Without the acid, pepsinase doesn’t become pepsin - depressed acid levels means depressed pepsin levels, so this means that proteins won’t get broken down into their crucial-building-blocks-for-the-body amino acids and peptides. Which means a deficiency of those essential amino acids, which creates its own significant side-effects, i.e. depressive stress, anxiety and exhaustion. Already we can see the first negative side-effect of giving our horses a PPI; inhibiting the release of stomach acid from the parietal cells impairs the onset of protein digestion.

Let's move on to further effects of PPIs (and we haven’t even got to what else happens in the digestion process). Research shows that – more bold type needed - PPI’s also bind to the many other proton pumps in the body (https://www.ncbi.nlm.nih.gov/pubmed/1647821). This really is significant. This binding to the body's other proton pumps is essentially irreversible - PPIs continue to inhibit all the other proton pumps until the body’s own master antioxidant, glutathione, which can only be made by the body, has to step in to facilitate disassociation. This means that stopping feeding PPIs won’t stop their damaging effects immediately, meaning that weaning the body off PPIs is much more complex than we think.

However, getting back to digestion, the Big Issue for me with the PPIs/Omeprazoles of the world is that the foregut needs its acid to perform digestion, and feeding PPIs stops this essential function.

A bit about digestion

Contrary to popular belief, the foregut doesn’t actually do most of the digesting – it’s relatively small compared to the size of a horse and makes up only 10% of the capacity of the digestive system, around just 9-15 litres in volume.

No, the foregut is all about starting the digestion process off - it provides the environment, and the muscle, to churn that bolus from solid chunks to a soup-y liquid (chyme) of broken down food, saliva, acid and pepsin, to enable a smooth passing of the chyme digesta into the small intestine where it meets more digestive enzymes. A bit like a pre-wash programme on our washing machine before the main cycle kicks in. Without acid, this pre-wash won’t happen. A quick reminder - the stomach acid works with digestive enzymes at the very beginning of the digestive process to start the breakdown of the food. If the acid’s switched off at the beginning, the digestion process is impaired from the get-go.

The perfect world of digestion

Let’s break the foregut digestion down into easy stages – the full gory details of how a perfectly functioning digestive system works, from the second food goes into our horse’s mouth:

  1. Food is chewed, causing three pairs of salivary glands to release saliva. The acid-buffering agent in saliva, bicarbonate, buffers and protects the mix of chewed food and saliva (bolus). Saliva also contains small amounts of amylase, the first of many crucial digestive enzymes, which starts digesting carbs.
  2. Once the bolus is swallowed, it travels down the oesophagus where various beneficial flora reside, ready to jump into the mix to start their own important digestive role.
  3. The bolus arrives in the foregut, where it meets the all-important stomach acid and pepsinase, which the acid converts to pepsin, a protein-digesting enzyme, on entry.
  4. The muscular wall of the foregut now starts churning, where the digesta gets thoroughly mixed with the stomach acid and pepsin. Together they initiate the process of digestion and degradation of lipids (fats) and proteins (amino acids).
  5. Once the foregut has done what it needs to, the pepsin and acid digesta mix is now a soupy mix called chyme, and is pushed through the exit valve into the small intestine, where a team of other digestive organs get involved. First up, the duodenum, which signals the liver to release bile to break down the fats. Next, the pancreas, which secretes further digestive enzymes to continue the process of enzymatic breakdown of the proteins, fats, starches and sugars. The pancreatic juices also contain some alkali and further bicarbs to provide more buffering of the acid leaving the stomach, to help maintain an optimal environment in the intestines for those important digestive enzymes to function.
  6. It’s only now that the serious business of digestive processes starts taking place, as the small intestine also has its own digestive enzymes – as well as more beneficial bacteria - to continue the breakdown of those proteins, fats, starches and sugars.
  7. Finally, much further down the small intestine, when everything’s now broken down and assimilated, the nutrients are finally absorbed through the intestinal wall and carried off by the blood stream to whatever cells need the nutrients. This generally takes 3-4 hours, usually moving at a rate of approximately 30cm per minute. Imagine how much longer this will take with the PPI effect; worse, they amplify the burden by overloading the digestive tract with undigested digesta, which greatly increases the risk of colic, laminitis and acidosis.

Remember that this is The Perfect World of Digestion. But introduce PPIs and you can see how, by switching off the acid secretion:

- the acid level declines

- the pH of the stomach increases

- the structure of the digesta is impaired

- enzymatic digestion is limited

- nutrient absorption is impaired which drastically impairs health, wellness, and staying sound and active.

We might think we feed our horses well, but without the acid influence, they’ll end up under-nourished. We can feed the most nutritious diet imaginable, packed with vitamins, minerals and other essential nutrients, but if they’re not absorbing those nutrients that you’ve paid good money to provide, they won’t benefit from them.

As an example, let’s have a quick look at how this affects the important micronutrients. Decades of research have confirmed that low stomach acid reduces absorption of several key nutrients such as iron, B12, folate, calcium and zinc, with many reduced micronutrient levels also dependant on each other being absorbed.

Increased bacterial overgrowth (SIBO)

Low stomach acid causes bad bacterial overgrowth in the stomach and other parts of the intestine. This in itself creates a knock-on effect:

  • Over population of bad bacteria v. good bacteria causes mal-digestion of carbohydrates.
  • This in turn produces gas.
  • This gas increases the pressure in the foregut, causing the lower esophageal sphincter (LES) to malfunction.
  • The malfunction of the LES allows acid from the stomach to enter the easophagus, thus producing the symptoms of acid burn. So when your vet says your horse has acid in the ‘upper digestive tract’ (easophagus), this is what’s going on.

Bacterial overgrowth has a number of other undesirable effects, including inflammation and as before, reducing nutrient absorption. Studies have confirmed that by suppressing stomach acid, PPIs profoundly alter the gastrointestinal bacterial population. Researchers in Italy have shown increased incidence of SIBO (small intestinal bacterial overgrowth) in 50% of patients using PPIs, compared to only 6% of healthy control subjects. https://www.ncbi.nlm.nih.gov/pubmed/20060064

To summarise the PPI effect

They drastically impair digestion and nutrient absorption. It’s a product I simply cannot endorse. There is another way, and it’s healthy, and natural – it’s all about lifestyle factors, removing stressors and/or tweaking the diet.

Top Tips

  • To promote healing of the gut, this is where the right kind of bacteria comes into play. The right kind of bacteria will break down fibre in the diet into molecules that are really easily used by the gut cells as energy sources. So, we have to make sure we have plenty of fibre and the right kind of bacteria in the gut to heal the gut, and then there are certain nutrients you can use to start to heal the gut. Two essential amino acids are: · N-Acetyl L-Cysteine (NAC), the precursor to glutathione, arguably the most powerful antioxidant in the body, which replenishes glutathione production, and Glutamine, a building block for proteins that maintain cellular health and tissue repair. During critical illness, trauma, intestinal disease, excessive loss of lean body mass, and extreme endurance exercise, Glutamine is shown to be beneficial. Glutamine also works in synergy with NAC to help promote glutathione. We've blended both these amino acids together as a gut support - see our GutAminos blend. And on a personal note, if there's one supplement I won't be without, it's my NAC+ from Viridian Nutrition.
  • Aloe Vera juice can help support the stomach and colon. It's high in digestible fibre which gives it the properties of lowering bowel transit time, absorbing toxins in the bowel, supporting colonic bacteria, and soothing the digestive tract. Aloe also contains a complex mixture of mucopolysaccharides (complex sugars) that nourish cells and supports them in replicating - this property is especially important for gut acid. The polysaccharides can also be helpful for horses who have been on buffering agents or similar that destroy healthy bacterial populations in the gut and allow pathogenic bacteria to multiply. Good quality Aloe juice can be found in most health food stores, and Aloe concentrate powder is also available (but almighty costly - I can supply it but believe me, no-one would buy it due to the £££). Add 50-100ml of Aloe juice to feed when your horse is displaying symptoms.
  • Slippery Elm v Marshmallow Slippery Elm is a renowned soothant herb with similar properties to Aloe. However, the native populations of the Slippery Elm tree are suffering due to its popularity and the tree is now considered extremely rare and as a result, a protected species, as well as pricey. The good news is that the herb Marshmallow can be suitably substituted for Slippery Elm because Marshmallow has almost identical properties and is so much more widely available - and cheaper. That said, we include both organic Slippery Elm and Marshmallow herb in our UlsaTonic herbal blend. If you want to feed separately, add 50ml Aloe juice and 1 desertspoon of Marshmallow to feed or syringed directly into the mouth. Always opt for Marshmallow Root as it has a higher mucilage % than the leaf.
  • Aloe and Marshmallow are not only beneficial for digestion in general but their soothing mucilge also supports the burn of gut acidity as well. They can both be fed long term with no negative effects.
  • Apple Cider Vinegar is also invaluable for gut health - not only is it a beneficial supporter of immunity, it's also rich in natural probiotics, beneficial enzymes and acids that help absorption of nutrients.

10.10.20 - Edited to add:

Acid production is needed to absorb magnesium, calcium and vitamin D, so feeding a PPI can impact this very important nutrient absorption function, a factor to consider if you're feeding a mineral balancer.