Re-evaluating Gastric Ulcer Re-evaluation: Low Malignancy Yield and High Cost in a 19-Year Retrospective Cohort Study

Abstract

Background: Routine endoscopic re-evaluation of gastric ulcers (GUs) is widely recommended to exclude malignancy. However, in modern practice, particularly in low-to-intermediate gastric cancer prevalence settings, the diagnostic yield, cost-effectiveness, and necessity of universal surveillance are increasingly debated.

Objective: To evaluate compliance with British and Irish guidelines recommending repeat gastroscopy for GUs, identify predictors of malignancy, and assess the diagnostic yield and healthcare cost of ulcer re-evaluation in a large tertiary centre.

Methods: We retrospectively analysed 2132 index GUs from 56,874 gastroscopies performed between May 2006 and August 2024. Demographic, endoscopic, and histological data were collected. Malignancy outcomes were determined by cross-referencing with histology databases. Binary logistic regression identified predictors of malignancy. Surveillance rates, ulcer healing, and inflation-adjusted costs were assessed.

Results: Eighty-six ulcers (4%) were diagnosed as gastric malignancies. Of these, 96% were identified at index histology; three were diagnosed at short-interval re-evaluation following inadequate or false-negative biopsies. No malignancies were detected during routine surveillance of benign-appearing ulcers with adequate histology. Macroscopic concern was the strongest predictor of malignancy (odds ratio 66.9, p < 0.01), alongside older age, male sex, and non-antral ulcer location. Surveillance was performed in 59% of benign ulcers at a mean interval of 12.5 weeks. None of the 837 patients with benign ulcers who did not undergo re-evaluation developed gastric cancer during 19 years of follow-up. Re-evaluation procedures represented 2.5% of total endoscopy workload, at a cumulative cost of €1,028,016.

Conclusion: Routine re-evaluation of GUs that appear benign and have adequate negative histology provided minimal diagnostic benefit while generating significant healthcare costs. A selective approach, focusing on ulcers with suspicious endoscopic features, inadequate biopsies, or unresolved symptoms, would better allocate resources and avoid unnecessary procedures.

Keywords: Biopsy; Gastroscopy; Healthcare costs; Stomach neoplasms; Stomach ulcer.