Gastric Ulcers: What the Research Says
Evidence from 22 peer-reviewed studies
What Professionals Should Know
- •Current veterinary evidence for honey is weak—mostly case reports in dogs and horses; before adopting honey protocols, seek controlled trial data specific to your species and condition
- •Wound healing is the most researched application, but veterinary-specific evidence remains limited; medical-grade honey may differ from non-medical products, so clarify formulation in any studies you review
- •This scoping review identifies a major evidence gap: the field needs rigorous controlled trials in equine and cattle practice to move beyond anecdotal use
- •Equine Omega Complete cannot be relied upon as a preventive measure for gastric ulcers in horses; omeprazole remains the evidence-supported option for ulcer prevention in at-risk animals
- •While EOC does raise serum alpha-tocopherol levels, the variable individual response and lack of ulcer prevention benefit suggests it may not be justified as a standalone supplement for horses with ulcer risk factors
- •This study provides important negative evidence that may help practitioners counsel clients on supplement efficacy and guide treatment decisions toward evidence-based options
- •When prescribing phenylbutazone to horses, consider concurrent use of evidence-based nutritional therapeutics to minimize gastric ulcer development and intestinal barrier dysfunction
- •Monitor horses on NSAIDs for signs of GI compromise; microbiota changes and increased permeability may precede clinical disease
- •Prophylactic nutritional support appears beneficial during phenylbutazone therapy, potentially reducing need for additional gastroprotective medications
- •Reconsider the frequency and concentration of electrolyte supplementation during endurance competitions; hourly dosing of hypertonic solutions appears to worsen gastric ulcers in horses
- •Alternative electrolyte supplementation schedules (lower frequency, lower concentration) should be investigated and considered for endurance horses
- •Horses receiving electrolyte supplements, particularly those with existing gastric ulcers, should be monitored and may benefit from gastroprotective strategies
- •Assess signalment, paddock management, hay quality/quantity, and activity type when evaluating horses with suspected gastric ulcers, as these factors are modifiable risk factors for ESGD in pleasure and breeding horses.
- •EGGD appears less management-dependent than ESGD; consider breed and individual predisposition when evaluating glandular lesions.
- •Time spent with current owner and consistency of management transitions warrant attention as risk factors for squamous gastric disease development.
- •Gastric ulcers are highly prevalent in working horses; implement routine monitoring and preventive management strategies for horses in your care, particularly those in intensive work
- •Work intensity and type appear to be stronger risk factors than age or breed; prioritize horses performing demanding tasks (performances, pulling) for closer observation and prophylactic treatment
- •Older horses warrant attention to both glandular and squamous regions during assessment; breed-specific ulcer patterns may inform targeted prevention protocols
- •EGGD is highly prevalent (46%) in Icelandic horses in training; screen for glandular ulcers even in absence of clinical signs, as this differs from lower ESGD prevalence
- •Allow ≥5 weeks transition when bringing horses from pasture into training to reduce ESGD risk; the first 4 weeks represents a critical vulnerability window
- •Provide >2 hours daily paddock access combined with stabling, plus low-NSC complementary feed (<1g NSC/kg/BW/meal), to protect against gastric ulceration during training
- •Investigate and manage lower airway inflammation in underperforming trotters, as it has both immediate and career-long impacts on racing success.
- •Upper airway problems and gastric ulcers may temporarily limit racing but don't necessarily predict permanent career damage if managed appropriately.
- •The role of exercise-induced pulmonary hemorrhage and cardiac arrhythmias in poor performance remains uncertain; assess these findings alongside other clinical signs rather than assuming causation.
- •Feeding larger meals may paradoxically increase absolute gastric emptying rate, but smaller, lower-starch meals empty proportionally faster—consider meal composition alongside size when designing feeding strategies to reduce colic risk
- •High-starch meals delay proportional gastric emptying compared to low-starch alternatives; feeding practices emphasizing smaller, more frequent, lower-starch meals may help mitigate gastric dysfunction and associated colic
- •Individual meal composition (starch content) has measurable effects on gastric function; practitioners should consider this when advising on feeding management for colic-prone horses
- •Gastric ulceration is a longstanding condition in horse populations with breed predisposition; Thoroughbreds and Standardbreds warrant closer monitoring for ulcer-related clinical signs
- •Colic presentation may indicate concurrent gastric ulceration; investigation and preventative management should be considered in susceptible breeds
- •Multiple ulcers and concurrent lesions in other organs are common findings, suggesting gastric ulceration should prompt assessment for systemic or multifocal disease
- •Saliva testing could eventually replace or reduce the need for gastroscopy as a screening tool for EGUS in horses with suspected ulcers, reducing cost and invasiveness
- •These biomarkers may help identify horses with subclinical EGUS (no obvious clinical signs), allowing earlier intervention before performance issues develop
- •Non-invasive saliva sampling could facilitate regular monitoring of EGUS status during treatment and management changes without repeated gastroscopic procedures
- •Nasogastric tube fragmentation is a potential complication that can cause delayed colic; account for tube integrity when removing tubes and consider this differential in recurrent colic cases
- •Exploratory surgery can effectively resolve impaction caused by nasogastric tube fragments when medical management fails
- •Ensure proper nasogastric tube handling and removal protocols to minimize fragmentation risk in horses with recurrent colic or gastric ulcers
- •Equipment choices must prioritize comfort and natural head/neck position—harsh bits, tight nosebands, and hyperflexion should be avoided; if uncertain about a practice's safety, assume it may be harmful until proven otherwise
- •Saddle fit is non-negotiable; invest in proper fitting to both horse and rider to prevent back pain and force distribution problems that compound over time
- •Develop your riding skills in balance, body control, and understanding equine behavior; poor horsemanship creates stress and discomfort that equipment alone cannot fix, and always screen for lameness and gastric ulcers before or concurrent with ridden work
- •Senior horses competing successfully into their late teens/early twenties commonly present with osteoarthritis and gastric ulcers; practitioners should anticipate managing these concurrent conditions in aging athletes
- •Nearly half of competing seniors show no diagnosed medical conditions, suggesting selective breeding/management practices or that many aging horses remain athletically viable with appropriate care strategies
- •Stiffness and joint flexibility loss are the most frequently reported clinical signs by owners, indicating this should be a key focus area for preventive management, conditioning, and therapeutic interventions in senior competitors
- •HGS shows promise as a pain detection tool in equine practice but cannot yet be relied upon as a standalone indicator of gastric ulcer presence
- •Current evidence suggests clinical assessment of gastric ulcers requires additional diagnostic methods beyond facial expression evaluation
- •Consider HGS as a complementary pain monitoring tool alongside other clinical and behavioral parameters rather than a definitive gastric ulcer indicator
- •Veterinarians should tailor client education on condition severity and management to address knowledge gaps, particularly for metabolic and respiratory conditions where owner understanding is lowest
- •Recognize that owners' emotional responses to equine illness directly correlate with their perception of disease impact; counseling should address both horse welfare and owner wellbeing
- •Discussions about quality of life, pain management, and end-of-life care are critical touch points for owners making health decisions—prioritize these conversations in clinical practice
- •In tropical regions where mangoes are available, restrict or eliminate free access to fallen ripe mangoes to prevent gastric ulceration in pastured horses
- •Monitor horses with signs of gastric distress (behavioral changes, reduced appetite) during mango season using gastroscopy if clinical signs persist
- •Natural recovery occurs within 2-3 weeks once mango intake ceases and regular hay/pasture diet is resumed; medical intervention may not be necessary if dietary management is corrected promptly
- •Gastroscopy is essential to differentiate ESGD from EGGD, as treatment protocols and prognosis differ significantly between the two conditions
- •High concentrate diets, intense exercise, and stress should be minimized or avoided to prevent ulcer recurrence in treated horses
- •Treatment duration and medication selection must be tailored to ulcer type; EGGD cases typically require longer therapy and may need combination or alternative treatments beyond standard omeprazole
- •This nutraceutical may help reduce gastric hypermotility in performance horses, a risk factor for gastric ulcers, though in vivo equine studies are still needed to confirm efficacy
- •Consider this as a potential adjunctive strategy for horses at high risk of gastric ulceration, pending further clinical validation
- •Results are preliminary and based on porcine tissue; direct equine studies are required before recommending for clinical use
- •This long-acting injectable omeprazole formulation may offer a practical alternative to daily oral dosing for managing gastric ulcers in horses, with evidence of efficacy comparable to conventional oral therapy
- •Two injections spaced 7 days apart appear effective for squamous gastric disease (100% healing rate) and show promise for glandular disease (75% healing rate)
- •The formulation's ability to maintain therapeutic pH for several days per injection could improve compliance and reduce handling stress associated with daily oral medication
- •Intravenous pantoprazole could expand treatment options for neonatal foals with gastric ulceration when oral medication administration is not feasible
- •This research supports the development of parenteral PPI formulations to improve clinical flexibility in managing acid-related disease in young horses
- •Feed deprivation protocols significantly increase gastric acidity and peptic injury risk in horses; maintain consistent feeding schedules to prevent ulcer development
- •Gastric ulcers demonstrate intrinsic healing mechanisms that begin immediately after injury; acid-reducing medications facilitate rather than initiate healing by optimizing the healing microenvironment
- •Understanding that ulcers heal naturally even with repeated injury may help prioritize management approaches focused on reducing gastric acidity and feed management over aggressive medical intervention alone
Key Research Findings
397 articles reporting 436 primary research studies on medicinal honey in animals were identified, with biomedical research (n=350) vastly outnumbering veterinary studies (n=47)
Veterinary literature consisted primarily of low-evidence case reports/series (n=23) rather than controlled trials (n=8), limiting clinical applicability
Wound healing was the most commonly examined indication across all studies, with honey derivatives and medical-grade formulations representing only 8% of interventions studied
High-quality controlled trials in veterinary species are substantially lacking, preventing evidence-based assessment of honey efficacy in equine and other clinical practice
Equine Omega Complete supplementation for 28 days did not prevent gastric ulcer formation during induced ulcer protocol (ulcer grades increased from median 1 to 2.5, P=0.54 vs control)
Omeprazole effectively prevented ulcer formation during the same induction protocol, with no grade increase (P=0.02 vs control and EOC)
EOC supplementation did increase serum alpha-tocopherol concentrations from 2.2 to 2.96 μg/mL (P<0.001), but this increase was not significantly different from control or omeprazole groups
High individual variation in serum alpha-tocopherol response to EOC supplementation was observed among treated horses
Phenylbutazone alters gastrointestinal barrier function in vivo in horses, consistent with previous in vitro and ex vivo findings
Nutritional therapeutic interventions may prevent or mitigate phenylbutazone-induced changes to GI barrier function
NSAID use is associated with measurable effects on intestinal permeability and fecal microbiota composition in horses
Combined phenylbutazone and nutritional therapeutic approach shows potential for reducing GI adverse events
Hypertonic electrolyte solution administered orally once hourly for 8 hours significantly increased mean gastric ulcer number (P = 0.0174) in the nonglandular stomach
Mean ulcer severity score increased significantly (P = 0.0006) with hypertonic electrolyte treatment, reaching a mean severity score of 2.7
Mean ulcer number score after treatment was 3.6, indicating exacerbation of existing gastric lesions
Evidence Base
A Scoping Review of the Evidence for the Medicinal Use of Natural Honey in Animals.
Vogt Nadine A, Vriezen Ellen, Nwosu Andrea et al. (2020) — Frontiers in veterinary science
Efficacy of the oral supplement, Equine Omega Complete, for the prevention of gastric ulcers and alpha-tocopherol supplementation in horses.
Williams Louie Elizabeth, Nieto Jorge, Wensley Fiona et al. (2023) — Journal of veterinary internal medicine
Effects of phenylbutazone alone or in combination with a nutritional therapeutic on gastric ulcers, intestinal permeability, and fecal microbiota in horses.
Whitfield-Cargile Canaan M, Coleman Michelle C, Cohen Noah D et al. (2021) — Journal of veterinary internal medicine
Effect of repeated oral administration of hypertonic electrolyte solution on equine gastric mucosa.
Holbrook T C, Simmons R D, Payton M E et al. (2005) — Equine veterinary journal
Prevalence and Risk Factors for the Presence of Gastric Ulcers in Pleasure and Breeding Horses in Italy.
Busechian Sara, Bindi Francesca, Orvieto Simona et al. (2024) — Animals : an open access journal from MDPI
The Prevalence of Gastric Ulcer Syndrome in 395 Horses in Jiangyin City, China, Jiangsu Province.
Zhou Kairen, Dong Zhen, Zhou Xuzheng et al. (2024) — Animals : an open access journal from MDPI
Risk Factors for Equine Gastric Ulcer Syndrome Incidence in Adult Icelandic Riding Horses.
Luthersson Nanna, Þorgrímsdóttir Úndína Ýr, Harris Patricia A et al. (2023) — Animals : an open access journal from MDPI
Associations between Medical Disorders and Racing Outcomes in Poorly Performing Standardbred Trotter Racehorses: A Retrospective Study.
Lo Feudo Chiara Maria, Stucchi Luca, Stancari Giovanni et al. (2023) — Animals : an open access journal from MDPI
Meal size and starch content affect gastric emptying in horses.
Métayer N, Lhôte M, Bahr A et al. (2004) — Equine veterinary journal
Postmortem findings of gastric ulcers in Swedish horses older than age one year: a retrospective study of 3715 horses (1924-1996).
Sandin A, Skidell J, Häggström J et al. (2000) — Equine veterinary journal
Assessment of Salivary Biomarkers of Gastric Ulcer in Horses from a Clinical Perspective
M. Matas-Quintanilla, L. Whitacre, I. R. Ipharraguerre et al. (2025) — Animals : an Open Access Journal from MDPI
Removal of a fragmented nasogastric tube from the transverse colon of a horse undergoing exploratory celiotomy for colic
Guerra M., Kilcoyne I. (2021) — Equine Veterinary Education
Riding With Care: A review of factors that influence the welfare of the ridden horse and a case for the application of the precautionary principle in equestrian pursuits.
Caleigh Copelin, K. Merkies (2026) — Journal of equine veterinary science
Demographics and health of U.S. senior horses used in competitions.
Herbst Alisa C, Coleman Michelle C, Macon Erica L et al. (2025) — Equine veterinary journal
Focus sur: Intérêt de la <i>Horse Grimace Scale</i> dans l’évaluation de la douleur lors d’ulcère gastrique ?
Schambourg Morgane (2024) — Le Nouveau Praticien Vétérinaire équine
Survey of the knowledge and perceptions of horse owners in Ireland of common clinical conditions and their impact.
Golding Emma, Neavyn Neita Aoife, Walshe Nicola et al. (2023) — Equine veterinary journal
Effects of the Ingestion of Ripe Mangoes on the Squamous Gastric Region in the Horse.
Silva Carolina J F L, Trindade Keity L G, Cruz Raíssa K S et al. (2022) — Animals : an open access journal from MDPI
Equine gastric ulcer syndrome in adult horses.
van den Boom Robin (2022) — Veterinary journal (London, England : 1997)
A Botanical-Based Equine Nutraceutical Reduces Gastric Smooth Muscle Contractile Force In Vitro.
Reed Lexie, MacNicol Jennifer L, Charchoglyan Armen et al. (2020) — Journal of equine veterinary science
Preliminary investigations into a novel, long-acting, injectable, intramuscular formulation of omeprazole in the horse.
Sykes B W, Kathawala K, Song Y et al. (2017) — Equine veterinary journal
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Pharmacokinetics and pharmacodynamics of pantoprazole in clinically normal neonatal foals.
Ryan C A, Sanchez L C, Giguère S et al. (2005) — Equine veterinary journal
Histological characteristics of induced acute peptic injury in equine gastric squamous epithelium.
Murray M J, Eichorn E S, Jeffrey S C (2001) — Equine veterinary journal