Risk stratifying gastric ulcers: development and validation of a scoring system

Abstract

ObjectiveDebate is ongoing regarding the need for universal endoscopic follow-up to ensure gastric ulcer healing. We aimed to assess the value of follow-up oesophago-gastro-duodenoscopies (OGDs) for gastric ulcer healing and stratify patients according to risk of malignancy by developing a risk score.Design/methodAll patients in National Health Service (NHS) Lothian with an index OGD and a diagnosis of gastric ulcer between 1 January 2014 and 31 December 2018 were identified. Data were analysed with logistic regression to identify factors significantly associated with a diagnosis of cancer; a risk score was derived and externally validated.Results778 patients were identified and 60.3% (469/778) of patients had a follow-up OGD. 8.6% (66/778) of patients were diagnosed with cancer. No cases of cancer were found on follow-up OGD of a benign appearing ulcer with negative biopsies. Macroscopic suspicion of malignancy was present at index OGD in 100% (3/3) of those diagnosed with cancer on subsequent OGDs. Older age (p=0.014), increased ulcer size (p<0.001) and non-antral location (p=0.030) were significantly associated with malignancy. A risk score (area under the curve (AUC) 0.868, p<0.001, minimum score=0, maximum score=6) was derived from these variables. 78.0% of patients with malignant ulcers scored ≥3, only 15.8% with benign ulcers scored ≥3 (negative predictive value (NPV) 97.4%). External validation yielded an AUC of 0.862 (p<0.001) and NPV of 98.6%; 84.0% of those with malignant ulcers scored ≥3.ConclusionUlcers with a combination of macroscopically benign appearances, at least six negative biopsies and a low risk score do not necessarily need endoscopic follow-up.

Untitled

“…Similarly, non-selective beta-blockers (NSBB) are effective in reducing hepatic venous wedge pressure in patients with clinically significant portal hypertension and only those patients who are not candidates for NSBB may need endoscopic screening 26. Similarly, it has been suggested that gastric ulcers which look benign macroscopically, have a low-risk score based on location and size and have six negative biopsies may not need endoscopic surveillance as currently recommended by most societies 27. Coeliac disease can be diagnosed and monitored using serological testing, thereby limiting the need for endoscopic biopsy confirmation to a small number of selected patients 28.…”

“… 26 Similarly, it has been suggested that gastric ulcers which look benign macroscopically, have a low-risk score based on location and size and have six negative biopsies may not need endoscopic surveillance as currently recommended by most societies. 27 Coeliac disease can be diagnosed and monitored using serological testing, thereby limiting the need for endoscopic biopsy confirmation to a small number of selected patients. 28 Similarly non-invasive tests such as faecal calprotectin can be used to avoid unnecessary endoscopic procedures 29 with a low likelihood of significant pathology.…”

Gastroduodenal injury and repair: novel targets for therapeutic intervention

“…The risk stratification score for gastric ulcers is based on patient age, ulcer size and ulcer location, with follow-up recommended for higher scoring patients with larger nonantral ulcers. The paradigm suggests that if ulcers have a macroscopically benign appearance, at least six biopsies are negative for gastric cancer, and the risk stratification score is low, the patient likely does not need long-term endoscopic follow-up [22 ▪ ].…”

“…Work in the past year proposed a novel risk stratification paradigm to justify repeat endoscopy follow-up for gastric or duodenal ulcers [22 ▪ ]. The risk stratification score for gastric ulcers is based on patient age, ulcer size and ulcer location, with follow-up recommended for higher scoring patients with larger nonantral ulcers.…”

“…Gastric and duodenal ulcers, which repair by regenerative mechanisms, are often followed by repeat endoscopy to ensure ulcer healing has occurred because it is possible that some ulcers will develop malignant lesions [22 ▪ ]. In addition, a retrospective study recently showed that the ulcer recurrence rate over 5 years is about 30%, with NSAID usage and H. pylori infection/acid hypersecretion denoted as the major risk factors for recurrence [23 ▪ ].…”