Repeat gastroscopy is routinely performed to confirm gastric ulcer healing but it has a low diagnostic yield for malignancy, an Australian study has found.
A retrospective evaluation of gastric ulcer follow-up at two Victorian centres found that repeat gastroscopy was performed in 440 (55%) of 795 patients with new gastric ulcers.
Malignancy was diagnosed in 7% of patients with gastric ulcers, most of which (83%) were identified at initial gastroscopy, according to endoscopy reports from St Vincent’s Hospital and Western Health in Melbourne over a five year period from 2013 to 2017.
Eight cancers were identified at repeat gastroscopy with malignancy yield of 2%.
The study investigators, led by gastroenterologist Dr Linda Yang of St Vincent’s Hospital, noted that three cases of malignancy were diagnosed in patients with benign initial ulcer histology, while one was diagnosed during follow-up in a patient with benign histology but no repeat gastroscopy.
Malignant ulcers were more likely to be located in the body than the antrum (Odds Ratio 0.92), cratered in morphology and larger (median 20 vs. 11 mm) compared with benign ulcers.
Predictors of benign ulcers were absence of endoscopic suspicion (OR 0.1), complete healing on repeat gastroscopy (OR 0.5) and benign initial histology (OR 0.12).
The study authors noted that current guidelines recommend follow up gastroscopy at eight to 12 weeks after index gastroscopy for gastric ulcer, but there is a lack of consensus regarding the ideal timing and selection of cases, and no established ulcer biopsy protocols.
In the Australian real world setting there were several reasons why almost half of patients did not have follow- up gastroscopy for gastric ulcer. These included nonsuspicious appearance (27%), malignancy at index gastroscopy (12%), and advanced age or comorbidities (4%). There was also a high rate (24%) of patients failing to attend their repeat gastroscopy appointment.
The authors said these findings emphasised the need for ulcer biopsy at index gastroscopy when clinically appropriate, noting that most malignant gastric ulcers were diagnosed on index gastroscopy when ulcer biopsies were taken.
“Although endoscopic surveillance of gastric ulcers is a recognised practice, repeat gastroscopy may not be achieved in all patients with gastric ulcers, and when clinically appropriate, all gastric ulcers should be sampled with at least 3 samples at initial gastroscopy,” they wrote.
“Although the additional yield of malignancy at follow-up gastroscopy is low at 2%, our data supports the current strategy of repeat endoscopic assessment given variables in obtaining adequate ulcer histology and the lack of reliable endoscopic predictors of a malignant ulcer,” they concluded.
The findings are published in the Journal of Clinical Gastroenterology.