Good evening everyone and welcome to this month's equine webinar. My name is Ofi. I'm from the University of Edinburgh.
So before we get started, with the webinar, just a few, housekeeping rules. So we, you all have a Q&A box, on your screens. So if you want to ask any questions, from the speaker.
Then feel free to put those questions in there, and then I can ask them at the end. And also if you have any technical difficulties, you can put it in the Q&A box as well. And then we have Dawn, as backup on the webinar vet who have.
To address any technical issues that you may have. So moving now onto the webinar for tonight. So I'm pleased to introduce Sarah Smith.
So Sarah is an equine medicine clinician at Wangford Eine centre at the University of Bristol. Sarah has a strong interest in the investigation of the poorly performing . Sports horse or racehorse, in particular, neurological and cardiovascular investigations, and as well as the care of equine neonates and the peripotter man.
So I'm very pleased to introduce the talk that you been today, which will be what do you do if there are no gastric ulcers. And so over to you, Sarah. Thank you very much.
So, I thought briefly, I'll just run through our aim for today. We're gonna look at assessment of pain as the cause of poor performance, how we can use analgesia trials to assess pain, discuss whether this can be due to orthopaedic pain. We'll talk for a little while about the significance of hindgut disease, which has become increasingly fashionable, and receiving the blade for equine poor performance, and then we'll assess, the involvement of hormonal and reative problems.
So briefly we'll just talk about being sure there are no ulcers, what to do next, and the different types of pain, and then we'll go through some interesting case examples at the end. So, the title of the talk is what to do if there are no Gastric Ulcers. So firstly, you've got to be sure there are no gastric ulcers.
And from my point of view, really, that does mean gastroscopy. An oral omeprazole trial without gastroscopy is a very poor, diagnostic test, mostly because the response to oral omeprazole, although generally pretty good, can be variable and varies hugely in terms of owner compliance and things like, whether the omeprazole's given on an empty stomach. So, really, you need, gastroscopy.
And then either it's very simple, if the images look like those on the top here, if there's dreadful gastric ulceration, you have your answer for now. And if they look like the ones at the bottom and the stomach is pristine, that's also pretty easy. But what do you do if it's somewhere in between?
What if there's some mild to moderate ulceration and the clinical signs are also quite, quite mild to moderate? Well, generally, then you're gonna need a treatment trial. Conventionally, oral omeprazolepas these days, there are some other options, certainly for glandular ulceration.
And the best thing to do is, if possible, to keep a daily diary of the reported clinical signs. Ideally, this would start before you start treatment, although that's not always practical. And then certainly during and after the treatment, get the client to keep a diary of the clinical signs.
Because it can be extremely difficult if you, you know, particularly if you're out in the yard when you see them, and at the end of the treatment trial, you're trying to establish whether or not there's, you think there's been a difference. If you just ask them, has the changed, often they'll say yes. And then actually, if you grill them a little bit more about, well, what was the problem?
And has it really stopped, sometimes you find the answer is no. So the diary really is one of the best ways of being sure about what's going on. And then the last thing you really need to do is show on gastroscopy, you've got resolution of those ulcers.
And then at that point, if the horse is still showing the clinical signs and you know that they either never were any ulcers or you've got rid of them, then we can move on to this idea of what do we do next. So, For most of these horses, and particularly I think, low-level sports horses and pleasure horses, gastroscopy is extremely common as a sort of first port of call for any kind of poor performance or behavioural abnormality. .
So there was normally a reason the client wanted these horses gastroscopy. And the key then is to sort of think, well, what was it? And for me, one key question is, was there a change in behaviour?
So, the hardest cases in this situation are those where the client maybe bought the horse 23 months ago, and they didn't do very much with the horse when they first got it, and now it's not performing in the way that. They want. In those cases, it's very hard to establish whether there was ever a baseline in which the horse performed in the way that they wanted.
But for the horses where the owner has had the horse for 5, 10 years, and the horses perform perfectly well. And now it's not, whether that's snapping, bucking, not going forward, resenting being tacked up, resenting their own mounting, all of those things, if it's a change in behaviour from the previous acceptable performance. Then for me, you've got a tangible problem there, you need to investigate further.
And particularly, I think it's worth just considering also the horse's age and experience, you know, for example, a 14 year old, low-level event horse that's performed perfectly well. Up until now, that horse is very unlikely to suddenly develop a behavioural problem, so, I think we need to be careful not to ascribe a lot of these problems to behaviour and to investigate further what's really going on. So, if we're gonna look into what's going on in these horses, pain has got to be top of your list, really.
The majority of these horses have got some kind of painful component. They, if they're mares, they may, it's perfectly possible it's a hormonal thing. And then the last category is behavioural.
And from my point of view, behavioural problems in a horse that's shown a distinct change in behaviour, is a diagnosis of exclusion. I want to be sure of it. I've excluded everything else first.
That comes with an important caveat from the point of view of the insurance company. It is worth noting that lots of insurance companies don't cover the cost of investigation of behavioural complaints, . But the client needs to be informed of that, and there's not no real way around that.
But it's fairly a problem as apart from anything else, most of these cases are not religion. So, if we're going to talk first about pain, horses are flight animals, and they're really programmed to mask signs of pain. So I think for me, that's a very important thing.
People often say, Oh, that low grade lameness can't really be causing all these problems, can it? But we don't know how much those kind of things bother these horses because they're very good at masking signs of pain. So I think if you identify a lesion that might be causing pain, it warrants further investigation.
And the other thing to consider is whether it's possible to use their response to pain to localise the signs and localise the disease further. So there's a really nice paper that's just come from the group at the Animal Health Trust, looking at the expressions of ridden horses as a mechanism of determining the presence of musculoskeletal pain. But I'd go a bit further than that and say actually you can probably use the facial expressions to even help you, localise other sources of pain, and also to consider whether their, pain is recurring and occurring in response to a particular event.
If the horse isn't giving you very many clues, and if you're not even really sure whether the horse is in pain, then an analgesia trial can be a pretty neat. Trick. I think at this point, it's worth saying that I think it's quite important to sort of commit to your analgesia trial.
You know, a couple of sachets of you's not gonna do the job. You need to, as we said before, actually, with the, the same with the gastroscopy, you firstly need to get the client to keep a diary before you start. Then your analgesia trial is gonna need to be at least 2 to 3 weeks in duration.
That allows for any. Tips in the client's schedule. You know, if it rains a lot and they don't ride for a week or it's half term and they ride less than normal or whatever, you know, you need a good period of time to iron out any oddities in their scheduling.
And also any variation in the horse's response. And then the more, the most conventional thing to do is 2.2 makes the gigabute twice a day.
If you need to use a different non-steroidal for another reason, that's fine. But be sure that you're using it at a dose that you think will provide adequate analgesia, and also with an appropriate frequency. So, SID dosing will be tricky, in a drug that needs to, that doesn't have a 24 hour.
Efficacy because obviously, if you then exercise the horse in a period where they're in the trough of that medication, you're pretty unlikely to see a positive response. And then you need to, have a diligent assessment of your response to the trial. So we talked about this diary.
He only needs to make regular assessments, keep a diary. And actually, one of the things that can be really useful is if they're technologically, minded to just get them to make repeated videos, of what's going on with the horse. What we do do sometimes, actually in the hospital is, if the clinical signs are really marked or very predictable, if they occur occur in response to a particular event every time, then possibly a one-off analgesia trial actually might be sufficient.
So, in a horse with a very predictable response to a certain stimulus, you can try giving a higher dose of but, so 4.4 mg per gig, IV but or and or so, a reasonable dose of morphine. And then assess the horse somewhere between half an hour and 2 hours later, and see how your patient responds.
I think at this point, it is also worth mentioning, depending on the source of pain, you may not get a complete response to your analgesia trial. So, A partial improvement may be enough, and a report of no improvement to the Butte trial necessarily put me off pursuing pain as a source because as we've said already, the reporting may be a bit variable. The last thing whilst we're talking about analgesia trials to consider, is just the safety of your analgesia trial.
So, is it safe to be asking the client to continue to ride this horse, or is there another way you can reproduce the signs? Could you lunge the horse? Could you use side reins?
So this was it. Sorry, we'll see the horse here being ridden by the client. So that horse, you can see a pretty pronounced response to the rider just mounting.
So we were fairly unhappy to ask her to keep riding this horse repeatedly. We were worried about the severity of the response. But, however, you can see happily for us, what happens when we just lunge the horse with the tackle.
So with that horse, we we were pretty happy we didn't need to ask the owner to ride the horse. So, if we've had a positive response to our analgesia trial, or we're fairly convinced there's a source of pain in this horse. The next thing is to consider, well, where is this pain coming from?
Sorry. And in terms of considering sources of pain. The first thing generally is just because it's the most common, is to consider musculoskeletal pain.
It's the horse lane. If the answer on your initial trot up is no. The next things to consider are, could it be a bilateral lameness which makes the sizes more subtle, is there a response to tacking up?
Have you checked the horse's dentition, and as we've said already, does it occur when the horses lunge, lunch with ras, those kinds of things. It's important to the neck and back in your evaluation of musculoskeletal pain. Evaluation of neck and back pain can be quite challenging.
It's important to consider the horse's previous life, how much handling and training it's had, that often, influences your response to evaluation. And also, these days, it makes me laugh during my examinations. Familiarity with carrot stretches is important.
So, Your apparent neck collection will vary hugely depending on whether this horse is doing daily carrot stretches or really has absolutely no idea what you're asking of it. If we think we possibly may have some musculoskeletal pain, the next thing we often consider is diagnostic imaging. And for these horses with poor performance issues and particularly, apparent behavioural response to poor performance.
So, bucking and evasive kinds of behaviour, nuclear integraphy is quite often in our armoury. And aside from conventional. Limb pathology, we do see some fairly interesting things.
I'm sure that kissing spines is quite high up on your list. rib fractures is something I find quite interesting and surprisingly common by the time we get to the point of nucleus integraphy, of course, is with performance issues. Neo ligament bursitis is something we see quite commonly, and it's sometimes a little bit challenging to know how much, weight to assign to that.
Syric, region pathology is also pretty common. And, If there's any suggestion the signs may originate from the head, or certainly any response to being tacked up or that it's more common with sideways, those kinds of things, it's worth bone scanning the head as well to look for dental pathology. And once we're talking about pain originating from the head, again, if there's been a marked response to, The bridle a bit, pressure on the mouth, side drains when landing, or the horse exhibits abnormal head motion, .
Then computer tomography of the head, can be very helpful. The things we most commonly see would be dental pathology, syr hired osteoarthropathy, like you could see in this image on the right there, . This is really rather dramatic one.
Temporomandibular joint pain, and not quite as commonly but always, interesting find, things like sublingual foreign bodies. The reason that I put this slide up really is only because. I find particularly interesting, and I think, we have an increasing awareness of equine muscle disorders, and certainly when we consider musculoskeletal pain, actually, although we use that terminology, a lot of the time, most of what we're looking at is skeletal pain.
And we don't give the muscles quite as much air time as we probably should. I think our diagnostic capabilities are much improved with equine muscle disease these days, . The, neuromuscular laboratory of the IBC does an excellent job, helping with interpretation of biopsies and, our understanding of what might be going on with these horses is massively improved these days.
So, some interesting studies in the last few years have certainly found, that the glycogen synthase mutation, associated with, polysaccharide storage myopathy has been found in a number of different breeds outside of those originally reported, and breeds that are present in the UK so. A group quite a while ago so identified the mutation in a Welsh cross and Arab, and more recently they've seen it in cobs, Connemararo, Arab Red Cross, and polar bonny. So it's not something that's confined to warm bloods and draught horses.
And alongside that, . I think we will probably in the next few years become aware of other types of muscle disorders, . And I think certainly interesting at the moment we know that hyperglycin A, the toxin that causes atypical myopathy, can be found in the blood of cow grazers on the pasture, .
And, these animals also have increased muscle enzyme activity, so it's imaginable that those, those horses, excuse me, . Which suffer from muscular pain at that time and potentially exhibit signs of poor performance. If we feel that we've, done a good, investigation of musculoskeletal pain, or sometimes it's necessary to combine these two things, abdominal pain is the next thing to investigate, so.
Without seeming too wacky, you've already gastroscoped this horse, so you must have thought it was feasible this horse did have abdominal pain. So then it's worth just ruling out other causes of abdominal pain. Excuse me, I'm just gonna pause for one second.
Sorry everyone, Sarah's got a bit of a cough, so I think she's having a just trying to catch her breath and get herself a drink. Hi there, sorry about that. So, we were talking about abdominal pain.
We've already ruled out gastric pain, really we're talking about the liver and kidneys, the rest of the intestinal system, and potentially infection, most likely peritonitis. So, if we're gonna look at the liver and kidneys, particularly and also the intestinal tract, biochemistry profile does you a lot of favours there. You'll rule out changes in liver enzyme activity, urine crechinine for the kidneys, and also look at your albumin for the intestine.
At the same time, I would probably just check inflammatory markers. It's gonna be very useful screening test, these days, SAA frinoin or zero Mahe concentration. So whilst we're talking about the intestinal tract, I think it's worth spending a little bit of time just thinking about the hindgut, .
So, hindgut disease has become a very fashionable condition, and certainly the tagline of succeed, equine girthiness may be a reflection of discomfort in the hindgut, . I think one of the key things that I can just consider is maybe. And hindgut disease these days seems to be being attributed to all sorts of clinical signs.
And it's really, really common. I find these days that after gastroscopy, if I tell the clients, so there's no gastric ulcers, almost invariably the next question is, well, is it the hindgut? So I think we need to try our best to answer that question.
If we're gonna talk about hindgut disease, well, what is that? It's low grade colitis. And if we think actually about low grade colitis, what are the normal clinical signs of low grade colitis?
In appetence. The horse appearing slightly dull, increased recumbency, we might see ventral edoema and reduced performance. But I suppose by reduced performance, we generally mean lethargy and underperformance rather than .
Bad behaviour. And alongside that, potentially we might see fever, colic, or diarrhoea, but I think we're, we're probably moving out of the realms of low grade at that stage. So, if we come to think of causes of low grade colitis, diet and dietary indiscretion have got to be quite high on the list, either as a single one-off, event, or, we know that dietary content can have a big impact on the, microbiota of the large colon and the production of volatile fatty acids, which can then in themselves cause, an inflammatory response.
We know that non-steroidal administration can be associated with colitis, either as an idiopathic, or sort of idiosyncratic response of an individual force to a normal, dose of. Or do a higher dose of you or just sometimes it's seen in horses after a very long exposure to non-steroidals. Depending on geographic location, sand can certainly be a cause of low grade colitis.
And the other thing not to forget is horses that are turned out in a sand paddock or starvation paddock, or even in the school, if they're eating their forage off a sandy, surface, they can develop sand accumulation. Parasites, I think sometimes these are sometimes sort of for some reason, put in a separate category. But cystines can certainly be a significant cause of colitis, so we need to not forget about them.
And then less commonly, inflammatory bowel disease, and neoplasia can be involved. So, one of the questions I certainly was curious about was, does this so-called time gut disease even exist? Do we see colonic inflammation or ulceration in these, in just the general equine population without signs of clinical disease.
So Nicky Gerbison and others from the University of Glasgow did a really nice study that was published last year, looking at the prevalence of colonic ulceration. So, they looked for postmortem examination of 56 horses. And these were 56 horses, euthanized, for a variety of reasons, and they found gross colonic ulceration in 12 out of 56 of these horses.
They could see reasons in a lot of the horses. So out of their 12, 2, they were caused by tapeworm. 6 by cystomans, 1 due to sound accumulation, and 3 appeared to be idiopathic.
There was no apparent reason for them. What I think is quite interesting is that in these 3 out of the 12 horses. With the idiopathic ulceration, the ulceration seemed to cover a larger area of the colon, and also very interestingly, 2 out of 3 of those horses had been euthanized for behavioural reasons.
It's closing quite a lot of links to immediately join that back in a circle that the colonic ulceration in those two horses had been the cause of the behavioural reasons, but it's certainly interesting. I think the other thing to just highlight is Those idiopathic cases had larger areas of alteration. So that makes me feel more strongly that we should be able to identify the ulceration in these horses.
The other interesting conclusion from this study, as we've just said, is that although colo incarceration was there, in most cases, it was a direct result of parasitism. So, if we're gonna go looking, the client said to us, Is it the hindgut? Well, you could just try some spurious treatments, but if you don't know the disease is present, and we're even less confident that the treatments of hindgut disease work, then you're probably onto a bit of a loser there.
So I think it's well worth investing in some diagnostics of these horses before you invest in expensive therapeutics for hindgut disease. So, firstly, if we think this horse has got low grade colitis, it's not inconceivable that there will be hyperalbnemia from a protein losing enteropathy. So, a blood sample is an excellent way to start.
In some of these sources, particularly if they've got parasites, you may well see a hypoglobular anaemia alongside it. Anaemia of chronic disease, if it's been going on for a long time. Increased inflammatory markers are sometimes present, and In some of these sources, you'll also see, also see a low to moderate level of increased liver enzyme activity, which we assume is because there's an increased burden on the liver draining the blood from the inflamed colon.
The other test that's available, these days it's, you can do an equine faecal blood test or, faecal albumin test. I was really interested to look a little bit more into this test, and I'm afraid to admit I'd always been rather cynical about it. But actually, these days, I would say there's some benefit to doing this test.
It has a very high positive predictive value. So this means if the test is positive, and there's haemoglobin present in the poo, then this horse does have gastric or colonic disease. If there's albumin present, then there is some form of colonic disease, or they will come back to exactly what that means in a second.
But what it's really, really important to note is this test has a really, really rubbish, negative predictive value. So if the test is negative, it doesn't mean very much. So by all means go ahead and do the test.
If it's positive, that gives you some answers, but if it's negative, you're no further on. I think the other thing just to consider is the albumin part of that test. Again, Nicky Caberson and others at the University of Glasgow looked further at the faecal albumin test.
And what they showed in this very neat little study is that if you did a faecal albumin test before giving the animals anantmentic, most of them were positive. A few weeks later, after anthelmintic treatment, most of them were negative. So, possibly the faecal albumin test is really just a test of whether your horse needs worming or not.
Ultrasonography is the next test in our armoury, when we're looking at low grade colitis or hindgut disease. So ultrasonography is routine in equine hospitals for the diagnosis of colitis, but as scanners get better and better, it's increasingly available in the field. So, the very, very basic things, normal wall thickness of a large colon, less than 3 millimetres, and in general, mostly what you're looking for is the presence of edoema in the wall.
The colon takes up a vast quantity of the abdomen, and in terms of imaging, interpretation depends a little bit on operator experience, but not hugely, the colon is everywhere and it's pretty easy to image, . Image quality, however, is a different subject, and that depends hugely on the quality of the ultrasound machine, but also particularly on the patient's obesity and hair coat, which can really limit image quality. So, moving on from abdominal pain, we talked about orthopaedic pain, the next big thing to consider is could this horse have a hormonal problem?
Generally, this is restricted to mares, the first. Thing we'll talk about is ere behaviour, we'll talk a little about transitional follicles and then about granulosa cell tumours. So, if we're gonna blame Ere for this, we need to ask ourselves a few questions.
Is the behaviour really seasonal? Although some horses cycle all the year round, it's not very common. And is it cyclical approximately every 3 weeks.
Ultrasonography will help us out here if we're gonna assign it. It's just then there should be a big follicle when the mares drink whatever behaviours ascribed to this. And the other thing worth considering is some people describe as a phenomenon.
Of ovulatory pain, is it worth doing an analgesia trial in these meds to see whether that helps? The other things we can try also altranogest, everyone's very familiar with Regumate, given at a standard dose, it should stop the air from cycling. The other thing that's interesting to note though is that, progestins have been shown to have a sedative effect, particularly when used at higher doses.
These days there's also a GNRH vaccine available. You'll get a longer lasting suppression of stress in these kind of animals, . And I'm sure they appreciate some analgesia at the time of vaccination.
The other thing to consider while thinking about seasonal hormonal problems is, that during the transitional period, the re-like behaviour may follow an erratic pattern. And people often ascribe as behavioural problems to transitional and obviously to follicles. Whilst there may be some behavioural abnormalities if follicles are developing.
It's fairly unlikely to have problems if there's an unalulatory follicle long term because the oestrogen concentration, which is what we think causes the behavioural problems, is likely to be sub subnormal. And so your a treated follicle is relatively unlikely to cause excitable or re-like behaviour. In terms of non-seasonal hormonal problems, The last thing to consider is a granulosa cell tumour.
So, I'm sure everyone's pretty familiar with the diagnosis of granulosa cell tumours. Ultrasonography is an easy way to start because if they're large, they have a very characteristic, loculated appearance. However, if they're caught early on, they can be quite small and harder to detect with ultrasound, but anti-malarian hormone, concentration is a pretty good test these days.
It's very easy to get run and it's got good sensitivity and specificity. So we've done a very thorough evaluation of our horse for pain and also for hormonal problems. So that really probably at this stage, leads us with behavioural problems.
So obviously, obviously at this stage, a professional rider or trainer can be of great help, . It can firstly be used actually as a diagnostic test. If it's really behavioural, it may be that the professional rider or trainer can make the signs go away.
But also, I think it's worth noting that some professional riders will be able to mask any potential problems, and particularly signs of pain, and they may appear less severe. With a professional on board. And then the other thing to consider obviously is behavioural training, .
Which is readily available these days. So, if we just have a little recap, what do we do if there are no gastric ulcers? Firstly, we consider was the problem due to a change in behaviour?
And if we think there's been a substantial change in this animal's behaviour, we need to consider whether there's a problem there. And most of the time, this will be looking for a source of pain. However, this investigation of pain will require patience and persistence, and the outcome in some cases might surprise you.
So I thought we'd go through some of the more interesting cases that I've seen recently. So, Little Snowy was a children's riding pony, with a recent history of bucking when ridden, which is particularly suboptimal if you're a children's pony. Sorry, the referring vet, had found no abnormalities on physical examination and orthopaedic evaluation, and Sn originally was seen by us for a gastroscopy.
No gastric ulcer ulceration was seen, and Snowyonor had bought us some videos, . Which we found very useful because, given that Snowy's primary clinical sign was bucking, when written by a child, we were fairly nervous about how we were going to achieve an analgesia trial. So this is snowy loose loose schooling at home.
So he looks pretty happy to me. Maybe an unconventional, technique here, but he's pretty happy. Oh here he is being ridden, I think at this stage he was no longer being ridden by his child, and it's being written by an older professional writer, .
And he doesn't look so happy. The video he's in in Trot, and he does look pretty cranky about life. If he was pushed harder, he then he started showing the fucking behaviour described.
So, as I said, We want to do an analteser trial with snow, but we were pretty worried about the safety. So, we got snowy, rigged up here. With a Zing and just as they went to tight and the side reins, we found that it might be going to be quite easy to do our analgesia trial with the snowy.
Oh, sorry about the sound. So Snowy was pretty happy, unhappy, even being lunged in sideways. So again, like our previous friend, made our be trial an awful lot easier and we didn't need to put any, children at risk.
So we had a positive response to ourburi and Snowy went for a nuclear cytigraphy, and at which point he passed safely into the care of my orthopaedic colleagues who identified, abnormalities in the bone scan. In the region of the state. So Snowy had the region medicated with corticosteroids, showed a positive response, and that was 6 months ago, and he's still going strong.
So he probably represents a fairly classic. Continuation of a horse we'd be presented with for gastroscopy on a day to day basis. I think this is probably the other case that I would see quite often.
Sorry. Avanti was a very handsome, seven year old and a Lucian, who had been imported from Spain for dressage, with a relatively novice owner. He'd recently begun resenting countertransitions and bucking.
On physical examination, he appeared to have slightly poor dorso and ventral flexion of the back on palpation and to resent it. There were no other abnormalities. He was in good body condition, stable 24/7, and gastroscopy didn't seem like a bad plan, but there was nothing to see there.
So, as is quite often the case, I had asked my orthopaedic colleagues to have a look at him. Did he have some back pain? I was reasonably convinced by my palpation findings, and we got the owner to ride him.
He displayed the clinical signs that she described and really looked up a little bit like she might deposit her on the floor shortly. My orthopaedic colleague spotted something I didn't really, which was that the horse was barking every time it got to the doorway of the indoor arena. I asked one of our maybe slightly more forceful hospital grooms to ride the horse.
Lo and behold, the behaviour disappeared entirely. So I think in that course, we were relatively happy to concede that it was probably behavioural, and the owner actually, was perfectly happy with that outcome and went away to get some professional help. But at the back of all of our minds, and we did say to the owner as well, it's possible that the pain could have been being masked by the firm rider riding of our room, and not to completely rule that out from the back of our minds if the problem was to recur.
Bobby was a particularly interesting case, and I must say that he was seen by my colleague Veronica Roberts, who I think did an excellent job here. He was an eight year old Friesian Gig, used for high-level dressage, . And he had a 2 week history of presenting girthing and application of the leg.
Again, completely reasonably referred for gastroscopy. And again, nothing at all to see. But what Ronnie spotted was that when he was asked to move over during the physical examination, he grunted.
So Ronnie submitted some bloods and his serum amyloid A concentration was really significantly high. Following the grunting, she went on a little, ultrasonography safari of the abdomen and thorax. And, there was nothing at all in the thorax to see, and a little bit of increased free fluid in the abdomen led her to do an abdominocentesis, which had a significantly increased, total nucleated cell count, consistent with peritonitis.
And the fluid culture Dynobacillus eli, which is commonly seen in cases of peritonitis of unknown origin. Bobby was given 2 weeks of antimicrobial treatment, peritonitis resolved, the serum amyloid A concentration returned to normal, and very pleasingly, Bobby's performance returned shortly afterwards. Again, another case I found particularly interesting, Charlie was a 14 year old, very successful children's jumping ponies, one of those ponies it could be relied on to always perform, and suddenly he was refusing to jump.
He had had a pretty thorough lay evaluation before we saw him, had shown no response to a butte trial and performed in a very thorough way. And gastroscopy didn't identify any abnormalities when we saw him. So following on from all of that, we ran a haematology and biochemistry profile just to be thorough.
And interestingly, he had a moderately increased GGT activity, bile acid concentrations were within normal limits, and at that point we ultrasounded his abdomen as well and didn't identify any abnormalities. He was given supportive treatment for his presumed hepatopathy, milk thistle, and Sammy. And his CDT activity gradually returned to normal over the following 8 weeks.
He was given a holiday during this time, and at the end of those eight weeks, his performance had returned. He's only one case, so it's hard to be sure, but it is interesting that it appears the hepatic inflammation was causing abdominal pain and affecting his jumping performance. I think this is my last case and probably one of my favourites.
This chap was a very sweet, great be show jumper, . Who had begun to show mild to moderate signs of colic after exercise, these became more severe and more intense the exercise. There were no abnormalities on physical examination and bloods and quite reasonably, he underwent gastroscopy, which didn't identify any abnormalities.
Abdominal ultrasonography, however, identified the presence of multiple large nephroliths in one kidney. Medical management was attempted for quite a long period of time, but the response to that was pretty poor. So eventually, he underwent unilateral nephrectomy, of a fairly dramatic kidney you can see here.
And I'm very pleased to say that once he made a recovery from his surgery, he was back jumping in no time at all. So, having had a little run through of those cases, we'll come back and summarise what do we consider if there's no gastric ulcers. For me, the first thing is to consider is was the original presenting complaint a change in behaviour.
If it was, then I think we need to go looking for musculoskeletal pain, starting off with an analgesia trial. And then also consider abdominal pain with blood tests and the question of the dreaded hindgut. We'll look at, we need to look at hormones in mares, and I think only lastly should we really consider it to be a behavioural problem.
Thank you very much. Does anyone have any questions? Oh, that's great.
Thank you very much, Sarah. So we've got one question regarding regu mate in stallions. So you mentioned, mentioned briefly that the, people can give remate to meres that may have a sedative effect.
Is that possibly why people are wanting to use it in stallions, even though not allowed for use is it? No, not installions. I think, absolutely, and I certainly had people talk about using double the dose you use in ama and stallions for its sedative effect.
And I think it probably, it's interesting in a way to consider actually, . That recent and very interesting work that's come out of UC Davis, looking at progestogens as the cause of Neonatal maladjustment syndrome, we know that they are causing a sedative effect in, falls in utero and causing, ongoing sedation in dummy falls. Although it's not, it's not quite the same progesterone, it's the same idea.
They can all have a sedative effect. OK, that's interesting. And also what was really interesting as well, is your, the case, cases that you saw, they, you know, all presented with poor performance, and actually, they all had quite very different reasons why they maybe weren't performing.
Quite as well as they should have. Yeah, I find the horse's response to pain absolutely fascinating. Like two horses can have the same problem, and the signs and their response to pain will be entirely different.
Yeah, yeah. And so moving on to the hindgut, so do you think that's something that we need to know more about? You know, is there potential there that, you know, there's something there that we don't fully understand that may be affecting how horses, work?
Yeah, absolutely. I think it's, it's a really interesting topic. And I think until very recently, we've known almost nothing about it.
The group at Glasgow have done some really interesting work and made a good start there, but it's, I think it's gonna be a long time before we really understand fully what's going on. But I think, probably as a group of clinicians, we rather owe it to the horses that we investigate this rather than just assigning, disease to the hindgut. And, I think what I didn't really discuss here is actually the treatment options for hindgut disease at the moment are Again, things we don't fully know whether they work or not, so it's, it's difficult to treat a condition you're not sure is there with the treatment you're not sure it works, without getting in a bit of a pickle.
Yeah. So what would you, just quickly, what would you do with that, what would you recommend for those cases if you were suspecting high gut low grade colitis, would it just be, things diet or? Yeah, I think there's all sorts of options, and it depends a little bit, if you can do anything to see if you can identify the cause, but if you can't, and it's truly idiopathic, then I think, dietary modification.
Really help if they're, if they're being fed a fairly starchy kind of diet, that's something to look at. Things like, if you think you've got a sort of acute onset problem, so ralfate, to help, the mucosal health, well, we've used quite a lot of misoprostol for the same reason. And then there's certainly longer term options in terms of, probiotics and things.
I think, Again, the whole probiotic, area is, is another contentious area for a lot of future work hopefully, but there's certainly some things that might help there. Brilliant. Well, thank you very much for, a really interesting, webinar.
It certainly makes you think, why that horse might not be working as well as it should. So yeah, so thank you very much for joining us tonight and thank you to everyone, for listening. And then before you close your browsers, there's a little questionnaire for you to fill in just to give us, give the web and our vet, some feedback, on tonight's webinar.
So thanks again, Sarah, and, good evening, everyone.
