Biopsy Sampling in Upper Gastrointestinal Endoscopy: A Survey from 10 Tertiary Referral Centres Across Europe

Abstract

Background: Guidelines give robust recommendations on which biopsies should be taken when there is endoscopic suggestion of gastric inflammation. Adherence to these guidelines often seems arbitrary. This study aimed to give an overview on current practice in tertiary referral centres across Europe.

Methods: Data were collected at 10 tertiary referral centres. Demographic data, the indication for each procedure, endoscopic findings, and the number and sampling site of biopsies were recorded. Findings were compared between centres, and factors influencing the decision to take biopsies were explored.

Results: Biopsies were taken in 56.6% of 9,425 procedures, with significant variation between centres (p < 0.001). Gastric biopsies were taken in 43.8% of all procedures. Sampling location varied with the procedure indication (p < 0.001) without consistent pattern across the centres. Fewer biopsies were taken in centres which routinely applied the updated Sydney classification for gastritis assessment (46.0%), compared to centres where this was done only upon request (75.3%, p < 0.001). This was the same for centres stratifying patients according to the OLGA system (51.8 vs. 73.0%, p < 0.001). More biopsies were taken in centres following the MAPS guidelines on stomach surveillance (68.1 vs. 37.1%, p < 0.001). Biopsy sampling was more likely in younger patients in 8 centres (p < 0.05), but this was not true for the whole cohort (p = 0.537). The percentage of procedures with biopsies correlated directly with additional costs charged in case of biopsies (r = 0.709, p = 0.022).

Conclusion: Adherence to guideline recommendations for biopsy sampling at gastroscopy was inconsistent across the participating centres. Our data suggest that centre-specific policies are applied instead.

Keywords: Biopsy sampling; CLO test; Gastritis; Gastroscopy; MAPS; OLGA; Sydney.

Fig. 1

Frequency of endoscopic signs of gastritis and sampling pattern. a Displayed is the prevalence of endoscopic signs of gastritis in the cohort for each centre. This was defined as mucosal irritation, for example, erythema, and presence of erosions, but did not include more advanced changes such as ulcers or tumours. b Proportion of sample sets taken per centre in patients with endoscopic signs of gastritis. These were mutually exclusive, but additional samples from the oesophagus might have been taken for each category that were not included in this analysis. Comparisons were done by χ² test across all centres as outlined in the methods section.

Fig. 2

Sampling pattern variation in procedures undertaken for different indication. a Comparison of the rate of samples taken from different locations in patients with and without endoscopic signs of gastritis as defined in the main text. b Proportion of biopsies taken from different sampling sites across the whole cohort according to the 4 main procedure indications. c Specific sampling patterns according to the 4 main procedure indications. Comparisons were done by χ² test across all centres as outlined in the methods section. Ant, gastric antrum; Bod, gastric body; D1, duodenal bulb; D2, second part of the duodenum; Fund, gastric fundus; GOJ, gastro-oesophageal junction; Inc, Incisura; Oeso, oesophagus.

Fig. 3

Sampling of the oesophagus and the GOJ in patients with dysphagia or Barrett's oesophagus. a Sampling of GOJ and oesophagus (including multiple level sampling) in patients investigated for dysphagia. b Sampling of GOJ and oesophagus (including multiple level sampling) in patients with endoscopic signs of Barrett's oesophagus. This included both patients under endoscopic surveillance and incidental cases. Comparisons were done by χ² test across all centres as outlined in the methods section. GOJ, gastro-oesophageal junction.

Fig. 4

Association of biopsy sampling with influencing factors. a Proportion of procedures with biopsies taken in relation to the patients' age in years as displayed on the x axis. No statistically significant association was found. b Relative proportion of procedures with biopsies taken per centre in relation to additional costs for biopsy sampling in € as displayed on the x axis. This did not include costs for pathology, but the fixed rate added to regular fees in case any biopsies were taken. Interestingly, biopsies were taken significantly more often in centres where these extra costs were higher. There was a significant association with r = 0.709, p = 0.022. Spearman's rank correlation test was applied for statistical analysis. MAPS, European guidelines on the management of epithelial precancerous conditions and lesions in the stomach; OLGA, Operative Link for Gastritis Assessment.

Fig. 5

Association of biopsy sampling with local clinical practice. a Relative proportion of procedures with biopsies taken according to local histopathology practice. Displayed are the ratios for centres which routinely score inflammatory changes routinely according to the updated Sydney protocol, those which score upon request by the endoscopist and those which score when feasible, that is, when marked changes are present. b Relative proportion of procedures with biopsies taken according to local histopathology practice. Displayed are the ratios for centres which routinely stratify patients according to the OLGA system, those which stratify upon request by the endoscopist, and those which give a staging when feasible, that is, when marked changes are present. Four centres do not apply OLGA at all. c Relative proportion of procedures with biopsies taken according to local clinical practice. Displayed are the values for centres in which surveillance regimens according to MAPS/MAPS II are fully established and for those who have planned to implement these. Comparison was done by χ² test as outlined in the methods section. MAPS, European guidelines on the management of epithelial precancerous conditions and lesions in the stomach; OLGA, Operative Link for Gastritis Assessment.