Albert's odd ailment

What seemed like a simple case of gastric ulcers turned out to be a rare condition that required risky surgery.
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Something was wrong with Albert. The 10-year-old Hanoverian was normally amiable and outgoing. “I’d bought him when he was 4, and I’ve known him his entire life,” says his owner Jennifer Pifer. “He had always been the kind of horse who would come right up to you, with his ears up and a perky ‘happy to see you’ attitude.” The 17.2 hand gelding had also been very willing in his work as an eventing and dressage mount.

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Over the course of a few months in the summer of 2014, however, all that changed. Albert became increasingly sullen. He was reluctant to work, indifferent toward Pifer and had frequent skirmishes with pasturemates. “I remember looking at him and thinking, ‘He seems depressed,’” says Pifer.

Albert was also developing some unusual physical problems. He had always had periodic bouts of runny manure, says Pifer, but now they were becoming more frequent. “We had moved from Colorado to Seattle, and I thought maybe the new environment was contributing to it. I had multiple veterinarians out to look at him, and nobody was too concerned. With a gray horse that becomes a real issue, though. I was constantly washing his back end.”

Pifer was even more worried that fall when Albert started having bouts of mild colic. “The first time he colicked, I had the veterinarian out right away,” says Pifer. “He found that Albert was a bit dehydrated, so he tubed him with fluids and that seemed to get everything going again. The veterinarian advised me to monitor his fluid intake, so I started making mashes to make sure he was getting plenty of water.”

By the new year, Albert hadn’t improved---he still seemed out of sorts and had periods of discomfort. Pifer called her veterinarian out again, and he suggested trying a course of omeprazole in case gastric ulcers were the source of the gelding’s troubles. Low-level colics and a sour attitude are common signs of gastric ulcers in horses. “She said we could use a gastroscope to look for ulcers, or we could just try a month of medication to see if he improved,” says Pifer. “That seemed to make the most sense at the time.”

Albert seemed to improve slightly after a month on omeprazole, Pifer says, but a move back to Colorado in late spring limited her riding time and made it difficult to discern exactly how much change there had been, if any. “When we got back to Colorado, I called my old veterinarian again,” she says. “She knew Albert well, and I brought her up to speed on what we’d been dealing with for the past six months.”

The veterinarian suggested it was time for a gastroscopic examination to see exactly what might be going on, and she referred Albert to Colorado State University (CSU). “It wasn’t a difficult decision to take him in,” says Pifer, “and honestly, I wasn’t too worried about what they’d find. At that point, I was pretty sure it was ulcers. That’s what I’d been told by so many people, and it seemed to fit the signs. He had never lost his appetite or dropped weight, and he hadn’t had a significant colic since I’d been so diligent about his mashes. He still had really loose manure, though.”

A good look around

Yvette Nout-Lomas, DVM, PhD, met Albert shortly after he arrived at the CSU clinic on June 18, 2015. “I knew he was here for suspected ulcers,” she says, “but from what I was hearing, I didn’t think that’s what he actually had.”

For starters, says Nout-Lomas, Albert’s lifestyle and diet did not fit the ulcer profile. “He wasn’t on a high-grain diet, he got plenty of turnout and didn’t have a very stressful training schedule,” she says. The fact he had been treated for ulcers once also led her to believe that perhaps they weren’t to blame. “And, generally speaking,” she adds, “I think that gastric ulcers are overdiagnosed in horses.”

With Albert sedated, Nout-Lomas began the gastroscopic exam, threading a long, flexible tube with a light source and camera at the end through his nose, down his esophagus and into his stomach. “We’d asked for him to be fasted the night before so his stomach would be empty,” she says. “That allows us to get a good look around.”

At first, nothing abnormal appeared on the screen. “I knew, though, that there was more to look at,” Nout-Lomas says. “Many people stop a gastroscopy exam when the camera enters the stomach, but to do a thorough exam, you really need to go further, around a slight bend and through some fluids to look at the pylorus, which is the sphincter where the stomach meets the small intestine. It’s around a corner and kind of hard to get to, but it’s important that you look. That’s what’s called a ‘complete gastroscopy’.”

It was there, just in front of the pylorus, that Nout-Lomas saw something abnormal. “It was a large growth, which we estimated to be about 10 centimeters in diameter,” she says. “I hadn’t seen anything like it before.”


Ominous possibilities

The growth Nout-Lomas found was likely one of two things. It could be a cancerous (neoplastic) tumor that, judging from its size, had likely already spread aggressively to invade local tissues. Such a tumor would be untreatable. Or, it could be something much less ominous---a simple polyp, an overgrowth of the normal epithelial cells that line the stomach. Nout-Lomas took a biopsy of the tissue cells and sent them to the pathology laboratory to find out what they were dealing with.

Still, even if the growth were benign, Nout-Lomas had to wonder, could this polyp be the cause of Albert’s sour attitude and digestive troubles? Or was there still another problem lurking somewhere? It was impossible to know.

“You wouldn’t necessarily expect a growth in that location to cause those problems,” says Nout-Lomas, “and that was a difficult part of this case. We had to stretch a bit to link the two in our minds. For instance, one of Jennifer’s concerns was that Albert was reluctant to exercise. We know that with exercise stomach contents move around quite a bit. Maybe this mass was affecting the stomach’s ability to empty, and that was causing him discomfort.”

The loose stools could also, possibly, be caused by the polyp. “Motility along the length of the digestive tract is all related, from the stomach through the colon,” says Nout-Lomas. “It was possible that all of it tied together. Or maybe it didn’t. It was really just speculation and theories.”

But even if the presumed polyp wasn’t causing Albert’s immediate problems, it was still a concern. Polyps are generally considered benign, but in humans they can become cancerous. “While we don’t have evidence that polyps can turn cancerous in horses,” says Nout-Lomas, “we do know that they can grow to be very large. In this location, just in front of the pylorus, it could potentially block the exit to Albert’s stomach entirely, and that could be catastrophic. There are reports in older literature of large polyps in this location found during necropsies, after the horse went through a period of weight loss for weeks and then died following a painful colic.”

Nout-Lomas relayed this information to Pifer, who struggled to process the idea that her horse had something much more rare and complex than gastric ulcers. She headed home with Albert to await the biopsy results, which would determine the next step. “I remember crying as I drove the trailer,” she says. “I probably shouldn’t have driven I was so upset.”

Making a plan

The call finally came a few days later. The biopsy results showed only normal epithelial tissues, meaning that the mass in Albert’s stomach was most likely a polyp, not a cancerous tumor. “We could only get surface cells in that first biopsy,” says Nout-Lomas, “so there was still the potential that there were cancerous cells deeper in the mass, but at this point we hadn’t seen them.”

This good news was tempered by the next set of looming questions: What should be done, if anything, about the polyp?

“Opening up his abdomen to remove the polyp wasn’t a good option,” says Nout-Lomas. “On a horse that size it would be a very difficult surgery, and because you can’t see the mass from the outside of the stomach, you’d have to reach in and blindly incise the stomach to remove the growth, and that would be virtually impossible.”

A better plan would be to remove the mass endoscopically, working with tools and a camera through the same sort of tube that had been used for the gastroscopy. Just seeing the mass, however, had required a three-meter-long scope. Nout-Lomas was unaware whether there even were endoscopic surgical tools that could reach that length. “I told Jennifer that I’d have to do some research and get back in touch with her when I had more information,” she says.

Nout-Lomas turned to her colleague Eileen Hackett, DVM, PhD, who is a respiratory surgery specialist, for advice. “Dr. Hackett does a lot of upper airway procedures endoscopically, and she indicated that there were certain surgical instruments that we could use through a three-meter endoscope to try to remove the polyp.” After several conversations, the pair decided that a surgical snare that could cauterize the mass as it cut might be the best option.

“The snare is essentially a wire loop that you can wrap around the mass and pull tight to slice through it,” explains Nout-Lomas. “As it tightens, it uses electrical current to become heated to a very high degree, cauterizing the tissue and limiting bleeding. It’s a device used often in respiratory surgery, but I hadn’t heard of it to remove anything from a stomach before.”

The procedure would carry some risks. “You run the risk of perforating the stomach if you cut it too close,” says Nout-Lomas. “If that happened, there would be nothing we could do to save Albert.” It was also possible that they could successfully remove the mass and the gelding wouldn’t feel any better because it was entirely unrelated to his clinical signs.

Nout-Lomas explained all of this to Pifer over the phone. “I was reluctant to say ‘yes,’ but I didn’t have long to decide---maybe a day or two,” she says. “I was running up against an insurance deadline, and any issue that we hadn’t addressed by the end of that month wouldn’t be covered by the new policy.”

Ultimately, Pifer decided to try the surgery. She and Albert headed back to CSU.

The night before the procedure, Albert stayed at CSU so he could be fasted and rested. Then, the next morning, he was sedated and Nout-Lomas and Hackett set to work. “We tried to go in with two scopes first, one just for viewing and one for cutting,” she says. “But that was very awkward, so we ended up using one for both.”

Once she could see the mass, the surgeon looped the snare around it and pulled. Albert felt nothing. “Sometimes in gastroscopic procedures the horse can get a distended stomach, so we watch for signs of colic,” says Nout-Lomas, “but otherwise they don’t feel what we are doing.”

The procedure produced a good amount of smoke in Albert’s stomach, but when it cleared, Hackett took several more cuts. A large section was removed and this was submitted as a biopsy to confirm the polyp diagnosis. They removed about 40 percent of the mass.

“We didn’t want to cut too close the stomach wall and, honestly, the area we had cut looked pretty awful,” says Nout-Lomas. “It was very red and angry looking. It was one of those moments when you wonder if you made things worse.” Albert recovered from his sedation well and returned to his stall, looking relaxed and unaffected by the procedure.

The gelding wasn’t ready to go home, though. The following morning, Nout-Lomas again threaded the gastroscope down to his stomach. “The initial idea was to go back in and see how bad things looked---to see what the damage was from the day before.” To her surprise, however, the area looked great. “It was remarkable; the area was flat and pink and not at all extremely irritated,” she says. “All it needed was some time.” The team was so encouraged that they decided to take an additional series of cauterized cuts, removing another 30 percent of the mass for a total removal of 70 percent. Albert, once again, came out of sedation uneventfully.

Meanwhile, the pathology results from the first procedure confirmed that the mass was, indeed, a benign polyp with no deeper tumor tissue. All of this was great news, but only in time would they know whether the procedure would resolve Albert’s digestive issues and general grumpiness.

Pifer loaded up her gelding and headed for home.

Pifer knew right away that the procedure had worked. “Albert was his old, cheerful self almost immediately,” she says. “And the first time I saw solid manure I was so excited. I was just blown away.” 

A few weeks later, she started riding the gelding again and found him to be as willing and forward as he had been before his troubles began. She would bring him back to CSU several times in the coming months for re-checks, and at each visit, the polyp area looked calm and healed, with no regrowth.

“The area actually contracted a bit so it looked like there was never a polyp there at all,” says Nout-Lomas. “It was an extremely satisfying result. The polyp could theoretically grow back, but right now we have no reason to think it will.”

More than a year later, Albert is in full work, being ridden four times a week and starting back over fences. “He’s my happy guy again,” says Pifer. “I go out to catch him in the field and he comes right up to me. He’s not running the other way. I feel bad that he felt so bad for so long, and that it took us a while to figure it out, but he’s Albert again, and it’s fantastic.”