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

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.

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.

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.

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.

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.