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Professional Version

Inflammatory Bowel Disease in Horses


Allison J. Stewart

, BVSc (Hons), PhD, DACVIM-LAIM, DACVECC, School of Veterinary Science, University of Queensland

Reviewed/Revised Oct 2022

Inflammatory bowel disease in horses includes granulomatous enteritis (GE), lymphocytic-plasmacytic enterocolitis (LPE), multisystemic eosinophilic epitheliotropic disease (MEED), and idiopathic focal eosinophilic enterocolitis (IFEE). Disease is characterized by infiltration of the small and large intestine with inflammatory cells, including lymphocytes, plasma cells, macrophages, and eosinophils.

Inflammatory bowel disease in horses may be limited to only a short segment of the bowel or may be more diffuse. Malabsorption and a protein-losing enteropathy result. Diarrhea may or may not be a clinical feature. Inflammatory bowel disease should be considered a differential diagnosis of horses with weight loss, recurrent colic, or hypoproteinemia, as well as in some horses with generalized skin disease.

Pathogenesis of Inflammatory Bowel Disease in Horses

The pathophysiology of the various syndromes comprising inflammatory bowel disease is not well understood. An altered immune response to a common intestinal factor (eg, feed, parasites, bacteria) has been suggested. Histopathologic similarities exist between GE in horses, Johne's disease in cattle, and Crohn's disease in humans. Standardbreds seem to be predisposed to GE and MEED, which suggests possible genetic predisposition.

Diagnosis of Inflammatory Bowel Disease in Horses

Diagnosis of inflammatory bowel disease is based on clinical signs, low serum protein concentration, possible thickened bowel, evidence of malabsorption, and intestinal or rectal biopsy. Malabsorption of carbohydrates occurs secondary to severe villous atrophy throughout the small intestine. Failure to absorb oral glucose or d-xylose verifies malabsorption from the small intestine.

Ultrasonography is the best diagnostic for detection of bowel wall thickening (if the affected area of bowel can be imaged) or mesenteric lymphadenopathy. Rarely, rectal palpation may help detect bowel thickening and mesenteric lymphadenopathy or abdominal fluid cytology may reveal neoplastic cells. GI biopsy may be undertaken by endoscopy, laparoscopy or laparotomy. Full-thickness intestinal biopsies can be obtained by using a laparoscopic procedure via a flank incision or by ventral midline celiotomy. Because most of the horses have severe hypoproteinemia at the time of diagnosis, incisional healing can be problematic.

Histologic diagnosis is subjective and should be performed by a pathologist experienced in reading equine intestinal biopsies. Rectal mucosal biopsy is useful in the diagnosis of ~50% of cases of GE and MEED but is rarely helpful in the diagnosis of LPE and IFEE. High numbers of eosinophils and lymphocytes can be identified in the intestinal wall of normal horses; however, overinterpretation should be avoided. The presence of eosinophilic granulomas, vasculitis, and fibrinoid necrosis of intramural vessels is diagnostic of MEED. Horses with MEED may have severe dermatitis, eosinophilic infiltrations in the liver or pancreas, and sometimes marked eosinophilia. Horses with IFEE have eosinophilic infiltration restricted to the intestine and have a better prognosis for survival.

Treatment of Inflammatory Bowel Disease in Horses

Various medical treatments for inflammatory bowel disease have been tried with limited success. Corticosteroids, dietary alterations, metronidazole, and the antimetabolite azathioprine have been used. Hypereosinophilic syndrome in humans often responds to hydroxyurea or vincristine, and sometimes interferon alpha and cyclosporine are used. Supportive nutritional care should involve frequent feeding of good-quality, high-energy feeds. The prognosis is grave.

If only a limited and accessible section of the bowel is affected, surgical removal may be successful. This is more common in IFEE, in which horses commonly present with colic rather than weight loss. Focal thickening, sometimes restricted to circumferential mural bands, is detected via exploratory laparotomy or necropsy; a diagnosis can be made by subsequent histopathology. Horses with IFEE respond to surgical resection of the diseased segment of intestine. Medical treatment with corticosteroids and feeding small frequent meals has also led to resolution of clinical signs after small-intestinal decompression without resection.

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