Risk and Reward of Gastric Ulcer Re-evaluation: Are we Over-calling and Over-scoping?

Aims British Society of Gastroenterology (BSG) guidelines suggest repeat gastroscopy at 6-8 weeks to assess gastric ulcer (GU) healing. We aimed to audit our practice against these guidelines, determine our surveillance yield for gastric malignancy and determine which risk factors are associated with malignancy.

Methods Our endoscopy and histology databases were queried for GUs and gastric malignancies (GMs). Microsoft Excel and R were used for data collation and analysis.

Results 2,132 index GUs were identified over 18 years ending Aug-2024. 78 (3.7%) of these were subsequently diagnosed with GM. 70 (90%) thereof were diagnosed on index histology. Of the 8 remaining, 6 had no index histology for a macroscopically suspicious GU. Of these 6, 4 were diagnosed on histology pertaining to a second procedure on average 11.5 days post-index. The 5th and 6th on repeat 50- and 135-days post-index. The 7th, an 83-year-old multi-co-morbid inpatient, had a macroscopically suspicious GU with non-diagnostic index histology (slough) and was subsequently diagnosed on re-look 17.4 weeks later. The 8th, a similar 82-year-old, had false negative index histology but was diagnosed on a short interval repeat 8 days later. 59% (n=1,215) of index GUs were followed by a surveillance between 5 and 52 weeks later. Mean interval was 12.5 weeks. 20% (n=244) were persistent and 80% (n=971) had healed at re-look. There was no difference in time-to-rescope between the persistent and healed groups (p=0.51). Index ulcers identified by consultant endoscopists were no more or less likely to be followed by a surveillance procedure (OR 1.22, 95% CIs:0.82-1.83, p=0.328). Gender was not a predictor of surveillance (p=0.3), whereas age≥80 was a negative predictor (OR 0.61, 95% CIs: 0.52-0.71, p<0.01). If any of the strings; “suspicious”, “malignant”, “malignancy”, “obstruct”, “rolled”, “cancer”, “concerning”, “mass”, “raised edge”, “deform”, “suspicion” or “neoplas” were used in a positive sense in the report, in terms of referring to suspicion for a malignant GU, the odds ratio of a subsequent malignant diagnosis was 8.37 (95% CIs:6.3-11.13, p<0.001). Age (≥ 50) (OR: 1.81, 95% CIs:1.11-2.96, p=0.02) and a non-antral location (OR: 1.897, 95% CIs:1.40-2.57, p<0.01) were also predictors, whereas male gender was not (OR 1.28, 95% CIs:0.95-1.71, p=0.1) [1] [2].

Conclusions Our data suggests that re-look yield for a non-suspicious GU with adequate index histology approaches zero. Health service costings suggest we spent EUR1,004,625 on 1,425 re-looks that may have done greater good elsewhere. We suggest moving towards the individualised approach advocated for by the American Society of Gastrointestinal Endoscopy and avoiding repeat procedures for non-suspicious erosions/ulcers of<1cm with negative adequate histology in patients with a clear aetiology and resolution of symptoms after treatment.

Publication History

Article published online:
27 March 2025

• References

• 1 ASGE Standards of Practice Committee. Banerjee S, Cash BD. et al. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc 2010; 71 (04): 663-668
• 2 Beg S, Ragunath K, Wyman A. et al. Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS) [published correction appears in Gut. 2017 Dec;66(12):2188. 10.1136/gutjnl-2017-314109corr1]. Gut. 2017; 66 (11): 1886-1899