Introduction While the National Institute for Health and Care Excellence (NICE) recommends a follow-up gastrocopy (FU-OGD) within 8 weeks for all gastric ulcers to exclude malignancy, internationally this recommendation is controversial. This audit examined the impact of this NICE guideline.
Methods All patients with a first endoscopic diagnosis of gastric ulcer between January 2012 and September 2013 at this large teaching hospital were included. Patients with known gastric ulcers prior to the study period or those referred for tertiary assessment were excluded. Patient demographics, data on endoscopic appearance and histological reports were recorded. We analysed endoscopic assessments, compliance with NICE guidance and the malignancy yield.
Results 432 patients (53% male) with a mean age of 65 years presented with a gastrointestinal bleed (38%), anaemia (13%), dyspepsia (18%) or other symptoms (31%). 142 patients were not biopsied initially (73% GI bleed, 6% anticoagulation, 21% no reason). Of these 96 received FU-OGD for biopsies after a median of 7 days. 290 patients had an average of 4.8 biopsies taken on index endoscopy. Of these 194 underwent repeat OGD after a median of 70 days. Only 33% underwent FU-OGD within the recommended time frame. Reasons for not undergoing FU-OGD were failure to request (10%), deemed medically inappropriate (98%), death before FU-OGD due (12%), patient non-attendance (24%), malignancy on 1st biopsy (9%) and unknown (26%). Ulcer healing was found in 236 patients. Gastric neoplasia was found in 27 patients (19 adenocarcinomas, 2 cases of dysplasia, 5 lymphomas, 1 melanoma) leading to a diagnosis of malignancy in 6% of patients with gastric ulcers. Of these 25 (93%) were diagnosed on first biopsy. After excluding those patients without follow-up, the cancer yield of FU-OGD after initially benign biopsy was 2 of 225 patients (0.9%).
Conclusion In this large cohort of patients with gastric ulcers 6% were found to have malignant disease. Of these over 90% were diagnosed with first biopsy, highlighting the need for all gastric ulcers to be biopsied. For many patients FU-OGD was deemed inappropriate. A high non-attendance rate was also noted, which may relate to the uncomfortable and invasive nature of endoscopy. While rapid FU-OGD for biopsies was achieved in those with no initial biopsies, many patients waited longer than the recommended 8 weeks after initial benign biopsies. However, the cancer yield of FU-OGD after benign biopsies remains low. Strategies to reduce the burden of FU-OGD for both patients and the health service would be highly desirable.
Disclosure of Interest R. Cochrane: None Declared, S. Thanaraj: None Declared, A. Sainsbury: None Declared, C. Selinger Grant/research support from: Ferring, Nycomed, Shire, Warner Chilcott.