title: Accuracy of the initial endoscopic diagnosis in the discrimination of gastric ulcers: is endoscopic follow-up study always needed?
abstract: BACKGROUND
  Endoscopic follow-up study of gastric ulcers has been recommended routinely because of the possibility that a gastric neoplasm will be missed in the initial endoscopy. Some authors, most of them reporting data from areas of low gastric carcinoma incidence, have questioned this policy because of the low numbers of curable cancers detected and the high cost of such a program.
  
  
  OBJECTIVE
  To assess the accuracy of endoscopy diagnosis of gastric ulcers, and to evaluate the efficacy and cost of a gastric ulcer follow-up endoscopic program in an area with an intermediate incidence rate of gastric cancer.
  
  
  METHODS
  A retrospective study was used to identify all the gastroscopies in which a gastric ulcer had been diagnosed during a 6-year period. The endoscopic impression was compared with the histologic diagnosis, sensitivity, specificity, positive and negative predictive values, and the likelihood ratio. Patients who completed a follow-up program also were reviewed. For each neoplasm discovered, the number of endoscopies and global cost were calculated.
  
  
  RESULTS
  In the 741 gastroscopies performed, 547 gastric ulcers were diagnosed in 529 patients. Biopsies were taken in 330 patients, in whom 341 gastric ulcers were found. At the index endoscopy, 41 gastric neoplasms (12.4%) were diagnosed. The accuracy of endoscopic malignancy diagnosis was as follows: positive predictive value of 0.68, negative predictive value of 0.98, sensitivity of 0.82, and specificity of 0.95. The likelihood ratio was 16. A total of 117 patients completed the follow-up program. Three new cases of gastric cancer (2.6%) were identified. In these three cases, the initial opinion of the endoscopist was uncertain. In the authors' experience, the cost of each gastric cancer diagnosed has been $4.653 (U.S. dollars).
  
  
  CONCLUSIONS
  The endoscopic impression correlates with the histologic diagnosis even in a area of intermediate gastric cancer incidence. Endoscopic follow-up study may be restricted to cases of uncertain or malignant endoscopic impression.
authors.affiliation: Francesc de Borja Hospital, Valencia, Spain.
authors.forename: Marco
authors.initials: M
authors.lastname: Bustamante
authors.forename: Francesc
authors.initials: F
authors.lastname: Devesa
authors.forename: Abdul
authors.initials: A
authors.lastname: Borghol
authors.forename: Juan
authors.initials: J
authors.lastname: Ortuño
authors.forename: Maria Jose
authors.initials: MJ
authors.lastname: Ferrando
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D003266:Continuity of Patient Care; D003937:Diagnosis, Differential; D005260:Female; D005500:Follow-Up Studies; D005773:Gastroscopy / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013274:Stomach Neoplasms / Q000175:diagnosis*; D013276:Stomach Ulcer / Q000175:diagnosis* / Q000473:pathology