Introduction

Current guidelines recommend 12 week follow up for gastric ulcer surveillance. This represents a significant proportion of follow up oesophago-gastro-duodenoscopies (OGDs). Debate is ongoing regarding the need for universal endoscopic follow-up to ensure gastric ulcer healing.

Aims & Methods

Aims: We aimed to assess the value of follow-up OGD for gastric ulcer healing in Connolly Hospital Endoscopy Unit with regards to cancer diagnosis and the yield of index biopsies.
Methods: Patient endoscopy data for gastric ulcers diagnosed 2021-2023 via Endoraad were examined. All gastric biopsies including index biopsy of ulcers were reviewed. Time to repeat procedure was recorded.

Results

147 documented diagnoses of gastric ulcers were identified for the study period (51% female, mean age 60.2). 56% (n=83) of ulcers were biopsied at index OGD. 6 (4% of total) malignancies were diagnosed at index biopsy with no malignancies diagnosed on repeat, chi sq., p =0.02. 76% (n=111) had a repeat procedure, with 43% (n=63) meeting the target of 12 weeks. 16% (n=24) index biopsies taken were HLO positive. Following review of the images by three gastroenterology consultants; 26.% (n=38) were deemed erosions rather than ulcers. Of those deemed ulcers their Forrest classification are as follows; 34% (n=50) Forrest 3, 8% (n=13) Forrest 2c, 2% (n=3) Forrest 2b, 2% (n=3) Forrest 2a and 6% (n=10) Forrest 1b. The remaining 20% of images (n=30) deemed not a gastric ulcer included: malignancy, healed ulcers and severe gastritis. Regarding findings at second scope, 20 patients (18.3%) had persistent ulceration, with no new malignancies identified. Of note, of those not followed, 95% were biopsied at index procedure and had benign features. The average time to repeat procedure was 9.7 weeks.

Conclusion

​The Covid pandemic and HSE ransomware attack may have significantly contributed to delay in repeat procedures. ​However, the majority of patients had either index ulcer biopsies or repeat endoscopy performed. The cancer yield of FU-OGD after ​benign biopsies remains low. Strategies to reduce the burden of ​FU-OGD such as risk stratification approach using high quality index examination, ulcer features and index biopsies may aid selective patient follow-up, improve ​yield of repeat procedures and reduce burden on the patient and health service.

Introduction

Gastric ulcers are associated with malignancy in 8.5% of cases, prompting recommendations for follow-up oesophagogastro-duodenoscopies (OGDs) to confirm ulcer healing and exclude malignancy. However, the incidence of malignancy at follow-up endoscopy is low, and no consensus exists on patient selection and optimal timing. This study evaluates current follow-up practices and the diagnostic yield of follow-up OGDs.

Aims & Methods

This study evaluates current follow-up practices and the diagnostic yield of follow-up OGDs. We conducted a retrospective cohort study of consecutive patients diagnosed with gastric ulcers between 2020 and 2023. Data on risk factors, endoscopic and histological findings from index and follow-up OGDs and surveillance data were analyzed.

Results

A total of 297 patients were identified (58.2% male; mean age 73.2 ± 15.5 years; median Charlson Comorbidity Index: 5.5). The main risk factors were Helicobacter pylori infection (52.7%) and NSAID use (31.3%). Gastric neoplasia was diagnosed in 26 patients. Biopsies were obtained in 34% of index OGDs (mean: 4.3 ± 1.8 biopsies), detecting 69.2% of neoplasia cases (n=18). Follow-up OGD was performed in 46.8% of patients, primarily within eight weeks (24%), diagnosing the remaining 30.8% of neoplasia cases. Among these, only one case did not show endoscopic suspicion of neoplasia in the index OGD. In three cases with malignant macroscopic suspicion at index OGD, initial biopsies revealed metaplasia, but follow-up OGD confirmed neoplasia. Predictors of malignancy included suspicious appearance (p=0.028; AUROC=0.939), larger ulcer size (p<0.001), and non-antral location (p=0.041). A minimum of 3 to 4 biopsies appeared optimal for diagnosis, and follow-up timing did not significantly impact diagnostic yield.

Conclusion

Our analysis suggests that ulcers with a benign endoscopic appearance, small size, and non-antral location may not require follow-up OGD. These findings challenge the need for universal surveillance, that is rarely applied in clinical practice, and emphasize the importance of risk stratification for targeted follow-up in patient management.

References

1.Brindle WM, Grant RK, Smith M, et al. Risk stratifying gastric ulcers: development and validation of a scoring system. Frontline Gastroenterology 2022;13:111-118
2.Gielisse EA, Kuyvenhoven JP. Follow-up endoscopy for benign-appearing gastric ulcers has no additive value in detecting malignancy: It is time to individualise surveillance endoscopy. Gastric Cancer. 2015;18(4):803-809. doi:10.1007/ s10120-014-0433-4
3.Sarwar R, Hanson J, Shaukat A, et al. Determining the Endoscopic Follow-Up for Gastric Ulcers Based Upon Endoscopic Appearance and Histology. American Gastroenterological Association. October 2022. Poster Presentation

Introduction

Peptic ulcers are a common gastrointestinal condition with potential risks for recurrence and complications. Timely follow-up, particularly repeat endoscopy, is critical for confirming ulcer healing and minimizing unnecessary interventions or missing gastric cancer. The National Institute for Health and Care Excellence (NICE) recommends repeat esophagogastroduodenoscopy (OGD) 6–8 weeks following gastric ulcer diagnosis to confirm healing.

Aims & Methods

Aim: To evaluate compliance with NICE guidelines for repeat endoscopy following a gastric ulcer diagnosis within a large UK hospital trust.
Methods: A retrospective audit was conducted on patients diagnosed with gastric ulcers from October 2022 to September 2024 at Barts Health NHS Trust. Patient records, endoscopy reports, and laboratory results were reviewed to assess whether follow-up endoscopy occurred and its timing relative to NICE recommendations.

Results

A total of 62 cases were identified and their follow up were recorded. Out of 62 patients (mean age 58 years), 53 (85%) underwent follow-up, while 9 (15%) did not. Only 12% received follow-up within the 6–8-weeks guideline window, while 50% had follow-up within 9 weeks. Most follow-ups (70%) occurred within 24 weeks. A Kaplan-Meier survival analysis (figure 1) was performed to visualise time-to-follow-up, showing a gradual increase in follow-up rates over time, with a plateau reached by 24 weeks. This analysis highlighted delays in achieving the recommended 6–8-week benchmark and demonstrated that only a minority of patients received follow-up in a timely manner.
Follow-up timing influenced diagnostic outcomes. Patients reviewed before 6 weeks had a higher rate of ongoing ulcers (44%), often prompting further investigations (figure 2). Those seen between 6–8 weeks had complete ulcer healing. Among patients reviewed at 8–12 weeks and beyond 12 weeks, 27% still had ongoing ulcers, though the majority had healed. Notably, patients with follow-up beyond 12 weeks often underwent repeated endoscopy for continued management.
Non-compliance was primarily due to failure to request follow-up (56%), patient non-attendance (33%), and medical inappropriateness (11%).

Conclusion

Although most patients received follow-up endoscopy, adherence to NICE-recommended timing was suboptimal. Our study shows that while most patients were eventually followed up, only a small proportion were reviewed within the ideal 6–8-week window. Patients who had early follow-up (<6 weeks) often still had ongoing ulcers, necessitating unnecessary investigations due to insufficient healing time. Conversely, patients with follow-up after 12 weeks typically required repeated endoscopy for ongoing management. To optimise care, systems should be improved to ensure timely and targeted follow up. Further research should explore only targeted cases merit follow ups and patient-level factors contributing to delayed follow-up adherence.
Figure 1: Kaplan-Meier Survival Curve for Follow-Up Endoscopy After Peptic Ulcer Diagnosis.
The curve illustrates the cumulative proportion of patients without follow-up endoscopy over time since initial peptic ulcer diagnosis. A steep initial decline indicates that most follow-ups occurred within the first 24 weeks. However, only a small proportion of patients received follow-up within the NICE-recommended 6–8 week timeframe. The plateau after 24 weeks reflects the reduced likelihood of follow-up beyond this point.
Figure 2: Outcomes of Follow-Up Endoscopy After Peptic Ulcer Diagnosis by Timing Interval

References

Disclosure

None

Introduction

All patients in the UK with a diagnosis of gastric ulcer are recommended to have a follow-up endoscopy within 12 weeks. However, in a low-risk population, such measures may not be necessary. We have assessed a recently developed risk stratification model for gastric ulcers (Brindle Frontline 2022) in a single provider.

Aims & Methods

The aim of this study was to assess the pick up rate of gastric cancer on follow-up endoscopy for patients diagnosed with gastric ulcers and validate a risk stratification model. A retrospective service evaluation was performed between June 2019 to June 2023 at Sandwell and West Birmingham NHS trust of all patients with an endoscopic diagnosis of gastric ulcer. Patients were followed up until ulcer healing, cancer diagnosis or no further planned follow-up.

Results

461 patients were studied: median age 63 [interquartile range (IQR) 52-72]; 74% male; and median Charlson comorbidity index 3 (IQR 2-5).
The majority of ulcer diagnoses came from outpatient endoscopy - 69.6%. The ulcer biopsy rate was 64.4% and lower biopsy rates were seen in those who had inpatient endoscopy (41.4%) and therapy (12.1%). The median number of biopsies taken was 4 (IQR 2-5). Additional diagnoses were as follows; gastritis 77%, no additional diagnosis 8%, premalignant lesions 4% (e.g. chronic gastric atrophy) and lymphoma 3%.

Cancer was suspected in 8.7% of ulcers at the initial endoscopy and confirmed histologically in 7%. Cancer diagnoses were in older patients - median age 67 (IQR 59-76) - and all met the urgent two week wait referral criteria for suspected cancer.

Repeat endoscopy for ulcer healing was not done in 32% (reasons included frailty, non-attendance or cancer diagnosis). Two cancers were diagnosed on follow-up endoscopy but both were suspected on index endoscopy -in one the index biopsies did not confirm cancer and in the second no biopsies were taken due to GI bleeding.
Using the risk stratification model proposed by Khalla and Masterton, which required 6 biopsies taken at index endoscopy along with a risk score of less than 3 (consisting of age, ulcer site and ulcer size), 15.6% met the low-risk criteria, where repeat endoscopy may not be required. In that group there were no cancers diagnosed on the second endoscopy.

Conclusion

The risk stratification model appears to perform well suggesting that at least 15.6% of our current endoscopies for gastric ulcer follow-up may not be necessary. Further multi-centre validation of the model is needed.

References

Brindle WM, Grant RK, Smith M, Suddaby M, Wallace A, Gillespie SL, Church NI, Noble CL, Penman ID, Plevris JN, Robertson AR, Watson EF, Selinger CP, Kalla R, Masterton GSM; EGAR (Edinburgh GI Audit and Research) Collaborative. Risk stratifying gastric ulcers: development and validation of a scoring system. Frontline Gastroenterol. 2021 Feb 26;13(2):111-118. doi: 10.1136/flgastro-2020-101759. PMID: 35295750; PMCID: PMC8862450.

Introduction

Gastric ulcers can be categorized into malignant (ulcerative gastric cancer) and benign types. Although endoscopy with biopsy remains the gold standard for diagnosis and differentiation, it has limitations. Studies report a sensitivity of 92% and specificity of 84% for detecting malignant ulcers via endoscopy, yet approximately 5% of endoscopically diagnosed malignant ulcers are histologically confirmed as benign. Furthermore, biopsy rates among endoscopists vary widely (22.4%–52.9%), and increased biopsies often yield unnecessary negative results, burdening both patients and clinicians. While artificial intelligence (AI) has shown promise in assisting diagnosis, existing studies primarily focus on single-center, static image classification (normal mucosa, benign/malignant ulcers), which diverges from real-world clinical practice requiring dynamic, holistic lesion analysis.

Aims & Methods

We aimed to develop a deep learning-based model using multicenter data to enable real-time detection and classification of gastric ulcers during endoscopy, thereby improving diagnostic accuracy and guiding biopsy decisions. A total of 21,592 endoscopic images were retrospectively collected from three tertiary hospitals in China, including 1,424 images from 263 histologically confirmed malignant ulcers, 7,767 images from 1,470 benign ulcers, 1,490 normal mucosa images, and 10,911 frames extracted from 11 endoscopy videos. These were split into training, validation, and test sets (8:1:1 ratio). A real-time instance segmentation model was developed using the YOLOv8 architecture, with performance evaluated on the test set.

Results

For benign ulcers, the model achieved a precision, sensitivity, and specificity of 99.25% (95% CI: 98.70%–99.61%), 99.25% (95% CI: 98.70%–99.61%), and 94.07% (95% CI: 89.20%–97.27%), respectively. For malignant ulcers, precision, sensitivity, and specificity were 94.07% (95% CI: 89.20%–97.27%), 94.07% (95% CI: 89.20%–97.27%), and 99.25% (95% CI: 98.70%–99.61%), respectively. The overall precision for differentiating benign and malignant ulcers was 96.66% (95% CI: 97.91%–99.21%).

Conclusion

This multicenter study successfully developed an AI model based on an enhanced YOLOv8 architecture for real-time differentiation of benign and malignant gastric ulcers. The model demonstrates high diagnostic accuracy, offering potential to optimize endoscopic evaluations and biopsy protocols in clinical practice.

References

1.Dooley CP, Larson AW, Stace NH, et al. Double-contrast barium meal and upper gastrointestinal endoscopy. A comparative study. Ann Intern Med. 1984;101(4):538-545. doi:10.7326/0003-4819-101-4-538
2.Lv SX, Gan JH, Ma XG, et al. Biopsy from the base and edge of gastric ulcer healing or complete healing may lead to detection of gastric cancer earlier: an 8 years endoscopic follow-up study. Hepatogastroenterology. 2012;59(115):947-950. doi:10.5754/hge10692
3.Graham DY, Schwartz JT, Cain GD, Gyorkey F. Prospective evaluation of biopsy number in the diagnosis of esophageal and gastric carcinoma. Gastroenterology. 1982;82(2):228-231.
4.Januszewicz W, Wieszczy P, Bialek A, et al. Endoscopist biopsy rate as a quality indicator for outpatient gastroscopy: a multicenter cohort study with validation. Gastrointest Endosc. 2019;89(6):1141-1149. doi:10.1016/j.gie.2019.01.008
5.Namikawa K, Hirasawa T, Nakano K, et al. Artificial intelligence-based diagnostic system classifying gastric cancers and ulcers: comparison between the original and newly developed systems. Endoscopy. 2020;52(12):1077-1083. doi:10.1055/a-1194-8771
6.Liu Y, Zhang L, Hao Z, et al. An xception model based on residual attention mechanism for the classification of benign and malignant gastric ulcers. Sci Rep. 2022;12(1):15365. Published 2022 Sep 13. doi:10.1038/s41598-022-19639-x

Introduction

Ulceration at the gastrojejunostomy is a late complication following gastric bypass surgery, usually responsive to high dose PPI. However, in refractory cases, patients may require surgical treatment. Recently, a new technique of endoscopic jejunal flap over-suturing has been reported with exceptional success rates. We aimed to evaluate the implementation of this approach in our practice.

Aims & Methods

Consecutive patients with symptomatic marginal ulcers, who failed to response to a two-month course of high dose PPI were included. Patients were treated with endoscopic suturing of a jejunal flap over the ulcer. In case of a narrow anastomosis, a self-expandable metallic stent (SEMS) was used alone or in combination with suturing. The stent was removed after 2 months. Endoscopy was repeated 8 weeks after the procedure. Technical success was defined as a fully covered marginal ulcer. Clinical success was defined as an ulcer heal on repeat endoscopy, while persistent ulcer, perforation or need for surgical repair was considered as failure.

Results

Ten patients were included, seven after Roux-en-Y gastric bypass and after 3 single anastomosis gastric bypass. All patients were negative for Helicobacter Pylori, deny alcohol abuse or NSAIDS use, 2 patients were active smokers at the time of diagnosis. All patients were on chronic PPI at the time of diagnosis, and the average therapy duration was 27 months. Jejunal over-suturing was performed in 9 patients of them 3 in combination with a SEMS, and 1 patient was treated only with a SEMS. Overall technical success rate was 100%, and a clinical success rate was 50% with 4 patients going through surgery thereafter. No adverse events occurred during the procedure or follow up period.

Conclusion

To date, marginal ulcers remain a dreaded late adverse event necessitating prolonged PPI use, repeat endoscopies and even revisional surgery. Endoscopic treatment to promote healing of refractory marginal ulcers appears safe. Technical success was achieved in all patients while clinical success only in half. However, since the only alternative treatment is surgery the endoscopic approach should still be considered. The lower than expected clinical success might be related to a more PPI resistant population compared with previous published series. Further research is needed to determine the appropriate therapeutic algorithm.

Introduction

Endoscopic resection is increasingly used for gastric gastrointestinal stromal tumors (GISTs), but data on long-term outcomes in intermediate to high risk cases are limited.

Aims & Methods

This study aimed to evaluate the long-term outcomes of patients with intermediate- to high-risk gastric GISTs who underwent endoscopic resection. Key endpoints included recurrence-free survival (RFS), overall survival (OS), and the incidence of late postoperative complications. We conducted a retrospective analysis of patients who underwent endoscopic resection for gastric GISTs at the First Affiliated Hospital of Zhengzhou University, China, between July 2012 and April 2020. All included patients were followed for more than five years. Critical prognostic factors, such as risk stratification, tumor characteristics, and treatment modalities, were analyzed. A total of 129 patients were reviewed, among whom 25 intermediate- or high-risk patients met the inclusion criteria and were enrolled in the study.

Results

Among the 25 patients included, the median follow-up duration was 80.0 months, with no recurrence observed. Both disease-free survival (DFS) and overall survival (OS) rates were 100% at the last follow-up. Tumor sizes ranged from 21 mm to 100 mm; 15 patients (60%) had tumors measuring 21–50 mm, and 10 patients (40%) had tumors measuring 51–100 mm. The majority of tumors were located in the gastric fundus (48%). Postoperative complications occurred in 4 patients (16%), all of whom recovered well after treatment. Risk stratification revealed that 21 patients (84%) were classified as intermediate risk and 4 patients (16%) as high risk. Twelve patients (48%) underwent EFTR, and another twelve (48%) underwent ESD. A mitotic index of ≤10 per 50 high-power fields (HPF) was observed in 92% of cases.

Conclusion

Endoscopic resection demonstrates excellent long-term efficacy and safety for intermediate to high risk gastric GISTs, with no recurrence and favorable survival rates observed in follow-up beyond 5 years.