S1609 Utility of Surveillance Endoscopy for Gastric Ulcers: Are We Scoping Too Much?

Introduction: After diagnosing a gastric ulcer, it has become routine practice to perform a repeat endoscopy several weeks later to ensure ulcer healing and to rule out malignancy. Current guidelines for surveillance endoscopy (SE) are based on little to no evidence. We suspected that the majority of these ulcers were benign and did not need SE, and that most malignant ulcers are apparent at index endoscopy and diagnosed by biopsies. As a quality improvement (QI) initiative, we sought to develop a more precise algorithm for determining the need for SE. We anticipated this would reduce cost and endoscopy burden while preventing missed cancer diagnoses. Methods: Using the Plan-Do-Study-Act QI methodology, local and national recommendations were evaluated for current practice. Pre-intervention data was collected from February 2019 to July 2021 using endoscopy software from 2 tertiary care institutions in Houston, TX. This data was reviewed to determine risk factors for gastric cancer. An expert panel (D.G., M.T., R.S., G.K.) then developed an algorithm for SE incorporating these and other published risk factors, as well as expert opinion. Results: There were 198 patients in our cohort (Table), and 147 were men. The average age and overall ulcer size were 61.1 years and 14.5mm, respectively. Malignant ulcers were found in 16 patients (8%), as follows: 11 gastric, 4 lymphoma, and 1 lung. Most patients were male (10), and the average age was 54.4 years. The average ulcer size was 25.6mm. Importantly, the majority were biopsied on index endoscopy (15, 94%). One patient not initially biopsied was diagnosed with gastric cancer on SE. Upon review of endoscopic images, 14 (87.5%) had malignant features defined as: size over 2cm, irregular borders, and elevated ulcer edges with base discoloration. For the 182 patients without malignancy, 61 (33.5%) had malignant ulcer features. Of these, 40 (65.6%) were biopsied on index endoscopy. Given that some ulcers would not have been diagnosed as cancer as they had no malignant features at index endoscopy, the expert panel felt that all ulcers should be biopsied initially. Those with high-risk features would then need surveillance. An algorithm was established from this pre-intervention data (Figure). Conclusion: The pre-intervention data establishes a baseline for our QI project and helped us create a more precise algorithm for SE. Most importantly, we have incorporated biopsies for all ulcers at index endoscopy.Figure 1.: Gastric ulcer biopsy and surveillance algorithm Table 1. - Gastric ulcer characteristics. Note: 40 of 61 ulcers with malignant features were biopsied on initial EGD Number Male/Female Average Age (years) Ulcer Size (mm) Malignant Features (%) Biopsied on Initial EGD (%) Malignant Ulcer 16 10/6 54.4 25.6 14 (87.5%) 15 (94%) Non-malignant Ulcer 182 137/45 61.7 13.5 61 (33.5%) 40 (65.6%)1 Total 198 147/51 61.1 14.5 37.9% 67.9%