Break the Cycle: Why Ulcers Keep Coming Back and What to Do About It

Dr. Rob Franklin, DVM, and Dr. Keith Latson, DVM, DACVS, Answer Your Most Common Ulcer Questions

• Gastric ulcers affect an estimated 40 to 90% of performance horses¹
• Treating ulcers without changing the environment is like patching a tire without pulling out the nail
• The horse's stomach is designed for constant grazing, not stall life, concentrated feeds, and haul schedules
• When omeprazole stops, acid-producing cells come back with force, surging acid onto newly healed tissue
• Both the foregut and hindgut are involved, and supplements that only address one side leave gaps
• The goal is not just to treat. It is to change the environment so ulcers do not have a reason to come back

Ulcers are not random. They are the predictable result of the world your horse lives in every day. Stall time, concentrated feed, hauling, training stress, pain relievers. Each one chips away at the stomach's ability to protect itself. Treating ulcers without addressing those root causes means you are going to be back at the same conversation a few months later. 

The Stomach Was Not Built for This

To understand why ulcers keep coming back, it helps to understand what the horse's stomach was actually designed for.

"The horse's stomach is smaller and designed to take on small amounts of food throughout the day," Dr. Franklin explains. A horse in the wild grazes 20 or more hours a day. The saliva produced during that constant chewing is high in bicarbonate, a natural acid buffer. The fiber from all that forage creates a mat in the lower stomach that keeps acid from sloshing upward into the unprotected upper region.

Now take that animal, put it in a stall, feed it two or three large grain meals a day, haul it to competitions, and ask it to perform under pressure. Every one of those changes works against the stomach's natural protective mechanisms.

As Dr. Keith Latson describes it, the foregut is the kitchen and the hindgut is the brewery. The needs of both are very different, and when one is suffering, the other is listening.

How Ulcers Actually Form

The horse's stomach has two distinct regions. The lower glandular region produces acid, digestive enzymes, mucus, and bicarbonate, giving it a built-in layer of protection. The upper squamous region has none of that. It is lined with the same type of cells that form calluses on your hands, tough but unprotected from acid.

When a horse exercises, acid splashes upward into that unprotected squamous region. Dr. Franklin describes it this way: "Think about taking a gallon milk jug and putting a half gallon of water in it and driving around. That is going to be sloshing all over. Now put a bunch of hay or grass in there first and it is not going to slosh near as much."

A horse with constant forage access has that fiber mat. A horse eating two grain meals a day in a stall does not.

Add concentrated feed that spills undigested starch into the hindgut, haul stress that raises cortisol and suppresses the prostaglandins that protect the stomach lining, and NSAID use that blocks those same prostaglandins, and the stage for ulcers is set from every direction.

"It is statistically 40 to 90 percent of show and race horses that are going to have ulcers," Dr. Franklin said. "Even if you are not recognizing it in your horse, there is better than a flip of a coin's chance that your horse has some degree of gastric ulcers going on."¹

Signs Your Horse May Have Ulcers

These signs rarely show up alone. It is the stack of them that tells the story.

• Girthiness or sensitivity when tacking up
• Eating hay normally but backing away from grain
• Dull coat or gradual weight loss
• Subtle change in attitude or performance
• Mild recurring colic
• Not recovering as quickly from training as before
• Loose or inconsistent manure

As Dr. Keith puts it: "If the gut is not functioning well, not absorbing well, not digesting well, everything else downstream is affected."

Why Ulcers Keep Coming Back

This is the question most horse owners eventually ask. You treated them. The horse felt better. A few months later, you are back at square one.

The answer is almost always that the treatment ended but the environment did not change. The stall is still the stall. The hauling schedule is still the hauling schedule. The grain meals are still the grain meals.

And when omeprazole stops, the situation can get worse before it gets better.

"Those acid-producing cells that were suppressed during treatment come back with force," Dr. Franklin explains. "The pH in the stomach drops. You get that whole cascade flaring up, but this time instead of maybe having a pH of three in their stomach, now they have got a pH of one and a half or two because they are just pouring acid out. It does not take long for that fire just to reignite in those horses."

Nothing changed. The nail is still in the tire.

Ulcers are often thought of as a stomach problem. But the hindgut is always part of the story.

When concentrated feeds are not fully digested in the stomach and small intestine, they spill undigested starch into the hindgut. There, bacteria ferment that starch, producing acid, lowering the pH, and killing off the beneficial microbes that keep the environment stable.

"Those bad ones tend to expand," Dr. Franklin explains. "They lower the pH, so they make the environment more acidic, and that kills off the good ones. Many of those bad ones have endotoxins that they release. And that lower pH actually works to erode the lining of the intestinal tract, which allows those endotoxins to be absorbed."

This is leaky gut. And those toxins do not stay in the gut. They circulate through the bloodstream, lodging in joints, muscles, and soft tissue. As Dr. Franklin describes it: "There is a gut joint axis. These inflammatory molecules get absorbed, they lodge in the joint, they create joint inflammation. You could have a bad gut and it is going to create joint pain."

Signs of hindgut involvement can include stocking up in the legs, fetid-smelling manure, low blood protein on bloodwork, and horses that just seem off without a clear reason. As Dr. Keith put it: "Wherever the foregut is suffering, the hindgut is listening. And vice versa."

These are not quick fixes. They are the daily management decisions that change the environment.

1. Keep Forage in Front of Them Constantly

An empty stomach is an exposed one. The fiber mat that forage creates buffers acid and reduces the sloshing that tears up the squamous lining during exercise. "Never let your horse sit in a stall without something to eat," Dr. Franklin says. For metabolic horses that cannot have unrestricted access, low-quality hay or soaked coastal Bermuda hay keeps that fiber mat in place without the sugar load.

2. Split Grain Meals Up

"Instead of feeding one or two big grain meals, that is so much better done if you can do that three or four times a day," Dr. Franklin said. Large grain meals dump undigested starch into the hindgut, disrupt the microbiome, and drive acid production higher. Smaller, more frequent feedings let the gut handle the load.

3. Feed Alfalfa Before Exercise

Alfalfa contains calcium carbonate, a natural buffer. A small feeding before riding or hauling helps protect the squamous region from acid splash during the highest-risk period of the day. "Horses on alfalfa, it is good for their stomach," Dr. Franklin notes, pointing to both the calcium content and the fiber mat it provides.

4. Be Intentional With Pain Relievers

NSAIDs like bute and banamine block the same prostaglandins that protect the stomach lining. "They act very similar to the way that cortisol acts," Dr. Franklin explains. Use the lowest effective dose for the shortest time necessary and work with your veterinarian on newer generation anti-inflammatories with better gastrointestinal tolerability when long-term use is needed.

5. Manage Stress Where You Can

Cortisol suppresses prostaglandins that maintain blood flow and cellular turnover in the stomach lining. You cannot eliminate the stress of hauling and competing, but you can be intentional about how you stack it. Consistent feeding times on the road. Forage before and after hauling. Electrolytes to replace what travel and sweat take out. A day to settle before asking for maximum effort when the schedule allows.

6. Support Both Sides of the System Daily

"As soon as the horse goes in training, the horse needs to be on it and needs to stay on it," Dr. Franklin said. And that support needs to address the whole system, not just one side.

As Dr. Keith explains: "There are a lot of supplements that only address one or the other. Finding a supplement that addresses that entire foregut and hindgut supportively while making some of those management changes, that is where you start to get the layered effect of support that may counteract the likelihood of a recurrence of ulcers."

6666 Complete Gut Protection was designed to do exactly that. Beta-glucans and L-glutamine protect and nourish the stomach lining. Prebiotics, probiotics, and postbiotics at research-supported doses support the microbial balance and fermentation environment in the hindgut. The postbiotic has also been shown in research to reduce inflammatory markers measured directly in the joint, addressing that gut-joint axis Dr. Franklin describes. One scoop for maintenance. Two scoops during high-demand periods.

As Dr. Franklin puts it: "L-glutamine is a crucial amino acid. It is the energy source for the stomach lining cells. They need to have that complete gut supplement going in the entire time. Otherwise those ulcers are just destined to come back."

Should You Always Scope?

A common question. Dr. Franklin recommends it when possible, particularly before and after treatment so you know what you are dealing with and whether it actually healed.

"You can waste a lot of valuable time by not scoping," he said. "You want to know if your truck has got a transmission problem or if it is the radiator. You want to know so that when it comes to showtime, you have got the right thing fixed."

Dr. Keith adds a useful perspective on what a clean scope tells you too: "If we do not find ulcers, we do not think there is a foregut problem. Let us look at the hindgut. Let us start to evaluate that because there is maybe something off in the brewery when the kitchen is fine."

Actionable Checklist: Breaking the Ulcer Cycle

• ✓ Keep forage available at all times, every day including travel days
• ✓ Feed small amounts of alfalfa before exercise to buffer acid splash
• ✓ Split grain into smaller, more frequent meals
• ✓ Use NSAIDs at the lowest effective dose for the shortest time necessary
• ✓ Replace electrolytes during hauling and heavy work
• ✓ Start gut supplement support before problems show up, not after
• ✓ Increase dosing during high-stress periods including hauling, competition, and NSAID use
• ✓ Know your horse's baseline and watch for stacked signals
• ✓ Scope before and after treatment when possible
• ✓ Work with your veterinarian to address the root cause, not just the symptoms

We Asked the Vets: Your Questions Answered

If my horse has ulcers, can I just treat with omeprazole and be done?
Treatment heals the ulcers. It does not change the environment that caused them. As Dr. Franklin explains, "You can deal with the ulcers, but they are going to come back unless you make the strides to improve that gastrointestinal environment." Scope before and after treatment, address the root management factors, and keep gut support in place throughout training.

Can I just keep my horse on omeprazole indefinitely to prevent recurrence?
The stomach acid you are suppressing has important jobs. As Dr. Franklin explains, it sterilizes the digestive tract against pathogens, breaks down protein for muscle repair, and helps absorb calcium for bone health. Long-term suppression quietly undermines all three. "You can essentially cause a horse to be nutritionally deficient in calcium by keeping it on low doses of omeprazole constantly," he said. Work with your veterinarian to address the root cause rather than suppressing indefinitely.

When should I start gut supplementation?
Before you see a problem. "If you are waiting until you see the horse get cinchy, get a poor hair coat, start to lose weight, start to not recover well, have loose manure, you are way behind the eight ball," Dr. Franklin said. As soon as the horse is in training, the risk factors are in play. That is when support should start.

What is the difference between foregut and hindgut ulcers?
Foregut ulcers form in the stomach, primarily in the unprotected squamous region. Hindgut ulcers form in the cecum and colon, driven by undigested starch fermenting back there and disrupting the microbial environment. They can occur simultaneously or independently. A clean gastroscope does not rule out a hindgut problem. As Dr. Keith puts it, if there is maybe something off in the brewery when the kitchen is fine, the scope gives you that answer so you can look further back.

Does a bad gut actually affect my horse's joints?
Yes. "There is a gut joint axis," Dr. Franklin explains. "These inflammatory molecules get absorbed, they lodge in the joint, they create joint inflammation. You could have a bad gut and it is going to create joint pain." That is part of why the postbiotic in 6666 Complete Gut Protection has been shown in research to reduce inflammatory markers measured directly in the joint.

What signs should I watch for that are not obvious?
Dr. Keith points to stocking up in the legs as one often-overlooked sign. Other subtle signals include fetid-smelling manure, not recovering as quickly between training sessions, leaving a little grain in the bucket, and horses that are just slightly unsettled or unwilling without a clear reason. Look for the stack, not just one sign in isolation.

Why does it matter whether a supplement addresses both the foregut and hindgut?
"There are a lot of supplements that only address one or the other," Dr. Keith explains. Since the two systems are deeply interconnected, a supplement that only targets the stomach leaves the hindgut exposed, and vice versa. The goal is a product that tells the whole story from end to end without asking horse owners to stack multiple products to cover the gaps.

When to Call Your Veterinarian

Contact your veterinarian if your horse shows recurring signs of gastric distress, including girthiness, behavioral changes around feeding, recurring colic, unexplained weight loss, or poor performance that does not resolve. Scoping is the only way to confirm whether ulcers are present and how severe they are. If ulcers keep returning despite treatment, something in the management program needs to change, not just be retreated.

Ulcers are a management problem. Change the environment, not just the symptom.

As Dr. Keith puts it: "Every one of the issues that we have talked about in the gut today is a fire. If we are really proactive about our fire prevention, then we can anticipate that longevity and wellness and performance is more dependable."

Support the system every single day.

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-The 6666 Equine Supplements Team