Gastric ulcers: malignancy yield and risk stratification for follow-up endoscopy

Missed Opportunities for Screening or Surveillance Among Patients with Newly Diagnosed Non-cardia Gastric Adenocarcinoma

BACKGROUND

Screening for gastric cancer is not recommended despite rising rates in certain U.S.

POPULATIONS

We determined possible missed opportunities for the detection and surveillance of preneoplastic lesions among gastric cancer patients in a VA hospital.

METHODS

This retrospective cohort study included consecutive, newly diagnosed non-cardia gastric adenocarcinoma patients from 11/2007 to 10/2018 at the Houston VA Hospital. We identified missed opportunities for screening based on risk factors (non-White race, smoking, alcohol, Helicobacter pylori infection, gastric ulcers, family history of gastric cancer). We additionally determined missed opportunities for surveillance of known high-risk lesions. Associations between receipt of prior endoscopy for screening or surveillance and cancer-related outcomes (stage, treatment, survival) were determined using logistic regression models.

RESULTS

Among 91 gastric cancer patients, 95.6% were men, 51.6% were black, 12.1% were Hispanic, with mean age of 68.0 years (standard deviation 10.8 years). The most common risk factors included non-white race (68.1%), smoking (76.9%), alcohol use (59.3%) and prior H. pylori (12.1%). Most patients had ≥ 1 risk factor for gastric cancer (92.6%), and 76.9% had ≥ 2 risk factors. Only 25 patients (27.5%) had undergone endoscopy prior to cancer diagnosis. Of 14 with known high-risk lesions (i.e., gastric intestinal metaplasia, dysplasia, ulcer), only 2 (14.3%) underwent surveillance endoscopy. Receipt of prior endoscopy was not associated with differences in cancer outcomes.

CONCLUSIONS

Most patients with newly diagnosed gastric cancer had ≥ 2 known risk factors for gastric cancer but never received prior screening endoscopy. Among the few with known prior preneoplastic lesions, endoscopic surveillance was not consistently performed.

A prospective, open-labeled, and randomized trial for assessing safety and clinical utility of gastric biopsies during emergency gastroscopy for patients with bleeding gastric ulcers

OBJECTIVE

There is no consensus on whether a gastroscopic biopsy is necessary during the emergency treatment of gastrointestinal (GI) diseases such as gastric ulcer bleeding. In this study, we examined the clinical utility and safety of an emergency gastroscopic biopsy for the assessment of gastric ulcer bleeding.

METHODS

We enrolled 150 patients with a single bleeding gastric ulcer after emergency gastroscopy (EG) from April 2020 to April 2022. The patients were randomly divided into the biopsy and no biopsy groups, and they were followed-up until June 2022 to examine whether recurrent gastric ulcer bleeding had occurred.

RESULTS

Re-bleeding occurred in 15 out of 150 (10%) patients. We diagnosed malignancies in 17 (11.3%) patients and validated 14 (9.3%) of them during the initial gastroscopy procedure. Factors that could predict the occurrence of gastric ulcer re-bleeding with biopsy during EG included an absence of ischemic heart disease (odds ratio [OR] = 0.395, confidence interval [CI]: 0.24-0.65, p ≤ .005), renal disease (OR = 1.74, CI: 0.77-1.59, p ≤ .005), and using warfarin or oral anticoagulants (OR = 11.953, CI: 3.494-39.460, p ≤ .005). No significant differences were observed in 60-day bleeding (p = .077) and the duration of hospitalization (p = .700) between the two groups.

CONCLUSIONS

Patients undergoing biopsy during EG did not exhibit an increased risk of re-bleeding compared with those who did not undergo a biopsy. An early biopsy facilitates an early pathologic diagnosis, early clinical intervention, safe discharge of low-risk patients, and improved outcomes in high-risk patients.

Evaluation of Endoscopic Practices and Outcomes in Follow-up of Gastric Ulcers

GOAL

The aim of this study was to evaluate current practice in gastric ulcer follow-up to establish diagnostic yield and predictors of malignancy.

BACKGROUND

Repeat gastroscopy is routinely performed to confirm gastric ulcer healing and exclude malignancy. However, the incidence of malignancy at follow-up endoscopy is low, without consensus regarding case selection and timing.

STUDY

New gastric ulcers diagnosed on gastroscopy at 2 institutions in Australia were identified through keyword search of endoscopy reports over a 5-year period (2013 to 2017). Data collected included patient demographics, clinical presentation, and endoscopic and histologic findings from initial and subsequent gastroscopies.

RESULTS

Of 795 patients, repeat gastroscopy was performed in 440 (55%). Malignancy was diagnosed in 52 (7%) with 83% identified at initial gastroscopy. Eight cancers were identified at repeat gastroscopy with malignancy yield of 2% (8/440). Three were diagnosed in patients with benign initial ulcer histology (3/286, 1%). One cancer was diagnosed during follow-up in a patient with benign histology but no repeat gastroscopy (1/286, 0.3%). Predictors of benign ulcers were absence of endoscopic suspicion [odds ratio (OR) 0.1 (0.03-0.13), P≤0.005], complete healing on repeat gastroscopy [OR 0.5 (0.34-0.70), P=0.036] and benign initial histology [OR 0.12 (0.43-0.90), P≤0.005].

CONCLUSIONS

Seven percent of new gastric ulcers were malignant with most identified with biopsy on initial gastroscopy. Malignancy yield from follow-up gastroscopy was 2%. Diagnostic yield of endoscopic follow-up may be low in ulcers with benign appearance and adequate histology. However, current practice of repeat gastroscopy is warranted in the absence of patient-based and lesion-based predictors of malignancy.

Seasonal Variation of Presentation of Perforated Peptic Ulcer Disease: An Overview of Patient Demographics, Management and Outcomes

Background

Perforated peptic ulcer disease (PUD) is one of the most common causes of acute peritonitis. It carries significant mortality and morbidity. Several previous studies have reported a seasonal variation in the presentation of patients with perforated ulcers. Here we present this study from our experience in a Northern Irish acute district hospital.

Methods

A retrospective cohort study was conducted on perforated peptic ulcer patients who presented to Altnagelvin Area Hospital emergency department between 2015 to 2020. Data on patient demographics, clinical presentation, investigations, management and outcomes were collected. Primary outcome was to investigate if seasonality was associated with the incidence of perforated peptic ulcers. Follow-up data were also collected. Seasons were defined as per UK Met Office.

Results

A total of 50 patients presented with perforated PUD. Male to female ratio was approximately 3:2. Peaks were noted in spring and winter. April was the most common month for presentation followed by December. Smoking was the most common risk factor followed by alcohol abuse. Fourteen patients (28%) were either very frail or had contained perforations and were conservatively managed. Three deaths were noted (6%). Thirteen patients (26%) required ICU admission at some stage in their management.

Conclusion

Slight seasonal variation was noted in the presentation of perforated peptic ulcers in our study with a higher incidence in the winter and spring months. The month of April was noted to have the peak incidence of the disease in our study.

Differentiation Between Malignant and Benign Endoscopic Images of Gastric Ulcers Using Deep Learning

Background and Aim

Endoscopic differentiation between malignant and benign gastric ulcers (GU) affects further evaluation and prognosis. The aim of our study was to evaluate a deep learning algorithm for discrimination between benign and malignant GU in a database of endoscopic ulcer images.

Methods

We retrospectively collected consecutive upper gastrointestinal endoscopy images of GU performed between 2011 and 2019 at the Sheba Medical Center. All ulcers had a corresponding histopathology result of either benign peptic ulcer or gastric adenocarcinoma. A convolutional neural network (CNN) was trained to classify the images into either benign or malignant. Endoscopies from 2011 to 2017 were used for training (2011-2015) and validation (2016-2017). Hyper-parameters, image augmentation and pre-training on Google images obtained images were evaluated on the validation data. Held-out data from 2018 to 2019 was used for testing the final model.

Results

Overall, the Sheba dataset included 1978 GU images; 1894 images from benign GU and 84 images of malignant ulcers. The final CNN model showed an AUC 0.91 (95% CI 0.85-0.96) for detecting malignant ulcers. For cut-off probability 0.5, the network showed a sensitivity of 92% and specificity of 75% for malignant ulcers.

Conclusion

Our study displays the applicability of a CNN model for automated evaluation of gastric ulcers images for malignant potential. Following further research, the algorithm may improve accuracy of differentiating benign from malignant ulcers during endoscopies and assist in patients' stratification, allowing accelerated patients management and individualized approach towards surveillance endoscopy.

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

OBJECTIVE

Debate 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/METHOD

All 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.

RESULTS

778 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.

CONCLUSION

Ulcers with a combination of macroscopically benign appearances, at least six negative biopsies and a low risk score do not necessarily need endoscopic follow-up.

Characteristic of Stomach Ulcers, Complicated by Bleeding

Background. The benign nature of the gastric ulcer, determined during the initial video esophagogastroduodenoscopy (VEGD) in the presence of a hemorrhage or under the conditions of unstable hemostasis, is not a permanent characteristic of the pathological process, since most examinations do not include multifocal biopsy due to the danger of recurrent bleeding.

Objectives: to evaluate the inflammatory changes, regenerative abilities of the peri-ulcer area and to predict malignization in the nearest post-hemorrhagic period.

Methods. The work contains the examination data (VEGD, brush biopsy, morphological and immunohistochemical examinations) of 49 patients urgently admitted to the surgery with gastrointestinal bleeding, and further verification of gastric ulcer. Entry criteria were bleeding of the ulcer in the gastric mucosa, located in the antrum or the lesser curve with low risk of recurrent bleeding (Forrest 2C), presence of Helicobacter pylori.

Results. Brush biopsy allowed determining the benign nature of ulcerative lesions in 98 % of the patients during the two-day period following the first VEGD. Morphological study revealed dysplasia at the edge of ulcerative lesion with first signs of regeneration in 14.3 % of the patients. In the presence of dysplasia, we noted a vibrant response (+++) with COX-2 (×400), even if the ulcerous defect was smaller than 1.0 cm.

Conclusion. Considering our results, it is necessary to develop a strict algorithm for dynamic follow-up of patients with gastric ulcers, complicated by bleeding.

Acute upper gastrointestinal bleeding: a guide for nurses

This article outlines latest evidence-based care for patients with acute upper gastrointestinal (GI) bleeding. It aims to help gastroenterology and general medical ward nurses plan nursing interventions and understand the diagnostic treatment options available. Acute upper GI bleeding can present as variceal or non-variceal bleeding and has a high death rate. Endoscopy is used for diagnosis and to provide therapy, prior to which the patient should be adequately resuscitated and assessed. Various therapies can be initiated at endoscopy, depending on the source of bleeding. If bleeding continues in spite of these therapies, further interventions such as the Sengstaken tube, oesophageal stents, radiological or surgical treatments may be required. After endoscopy, it is important to have a plan for ongoing treatment. Patients may require acid suppression treatment or eradication of Helicobacter pylori as part of their treatment plan. They may in additional require correction of their haemoglobin levels and follow-up endoscopy. It is essential that nurses caring for such patients are aware of the current UK guidance and help patients to adhere to agreed treatment plans.

Giant gastric ulcers: Malignancy yield and predictors from a 10-year retrospective single centre cohort

BACKGROUND AND STUDY AIMS

Gastric cancer is known to reside in some gastric ulcers but what predicts this association is still unclear. Historically it has been thought that the increasing size of gastric ulcers may be a predictor for harbouring malignancy. Giant gastric ulcers are arbitrarily defined as ≥3 cm. The aim of this retrospective study was to examine patients with giant gastric ulcers within a single tertiary centre over a 10-year period. Our primary outcomes included the malignancy yield in giant gastric ulcers and to determine if any demographic, clinical or endoscopic predictors for malignancy exist. Secondary outcomes included the 30-day and 12-month mortality.

METHOD

Patients with giant gastric ulcers ≥3 cm presenting from September 2005 to December 2015 were included in the study. Malignancy yield was obtained by looking at histology reports. Predictors for malignancy were tested using binary logistic regression, after demographic, clinical and endoscopic variables were tested using univariate analysis and for collinearity.

RESULTS

A cohort of 111 patients was included for the final analysis. Forty-two giant gastric ulcers were malignant, equating to a yield of 37.8% (95% CI 28.8-46.8). Binary logistic regression revealed predictors for malignancy included: ulcer location being within the fundus, cardia or incisura (odds ratio (OR) 4.417; 95% CI 1.10-17.76; P = 0.036); younger age of patient (OR 0.202; 95% CI 0.06-0.71; P = 0.013); and endoscopic 'non-suspicion' (OR 0.138; 95% CI 0.049-0.39; P < 0.001). Patient's 12-month mortality for giant gastric ulcer was 61.9% (26/42) for malignant and 21.9% (11/73) for benign histology.

CONCLUSION

We have shown a high malignancy yield of 37.8% (95% CI 28.8-46.8) and a 12-month mortality of 61.9% for malignant giant gastric ulcers and 21.9% for benign giant gastric ulcers. Predictors for malignancy in patients with giant gastric ulcers include ulcer location, patient's age and endoscopist's 'suspicion' during endoscopy.

The Acute Upper Gastrointestinal Bleed

Upper gastrointestinal bleeding (UGIB), defined as intraluminal hemorrhage proximal to the ligament of Treitz, can range from mild and asymptomatic to massive life-threatening hemorrhage. For the purposes of this article, the authors define an acute UGIB to be one that results in new acute symptoms and is, therefore, potentially life-threatening. UGIB requires a systematic approach to evaluation and treatment, similar to the management of a trauma patient. Surgeon involvement in UGIBs remains integral despite the rare need for operative management. Endoscopy is the primary tool for diagnosis and treatment.

Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS)

This document represents the first position statement produced by the British Society of Gastroenterology and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, setting out the minimum expected standards in diagnostic upper gastrointestinal endoscopy. The need for this statement has arisen from the recognition that while technical competence can be rapidly acquired, in practice the performance of a high-quality examination is variable, with an unacceptably high rate of failure to diagnose cancer at endoscopy. The importance of detecting early neoplasia has taken on greater significance in this era of minimally invasive, organ-preserving endoscopic therapy. In this position statement we describe 38 recommendations to improve diagnostic endoscopy quality. Our goal is to emphasise practices that encourage mucosal inspection and lesion recognition, with the aim of optimising the early diagnosis of upper gastrointestinal disease and improving patient outcomes.