title: Follow-up endoscopy for benign-appearing gastric ulcers has no additive value in detecting malignancy: It is time to individualise surveillance endoscopy.
abstract: OBJECTIVE
  To determine the diagnostic accuracy of endoscopic follow-up for gastric ulcers.
  
  
  METHODS
  All cases of gastric ulcers diagnosed at our teaching hospital between September 2005 and November 2011 were reviewed. The cases were selected by using ENDOBASE, an endoscopy documentation system. The characteristics of the ulcers and their histology were analysed.
  
  
  RESULTS
  During the study period 321 cases with a gastric ulcer were diagnosed, including 214 benign ulcers (67 %) and 107 malignant ulcers (33 %). The mean age of the population was 71 years. In 200 patients (62 %) the ulcers were classified as benign appearing at the first endoscopy. However, in five of these patients, the ulcers eventually were malignant. In all of these five patients the index gastroscopy revealed a non-benign histology. Therefore, the sensitivity of a benign appearance of the ulcer in combination with histology at the first endoscopy is 100 % to rule out malignancy. In 121 patients (38 %) the ulcers were explicitly labelled as potentially malignant in the report of the first endoscopy. Of these potentially malignant-appearing ulcers, 102 (84 %) were indeed malignant as confirmed by histology. The other 19 ulcers (16 %) were benign at follow-up. The sensitivity of the three potential malignant characteristics at endoscopy was: dirty base 79 %, elevated border 94 % and irregular border 91 %. The specificity was 93, 82 and 89 %, respectively. The median diameter of the ulcers was significantly higher in the malignant group compared to the benign ulcer group (p < 0.0001). The accuracy of endoscopic malignancy diagnosis was as follows: sensitivity of 0.98 and specificity 0.84, positive predictive value 0.84 and negative predictive value 0.98. In total, 546 gastroscopies were performed in these 321 patients, of which 225 were follow-up endoscopies. By not monitoring ulcers considered benign in both appearance and histology, 173 gastroscopies would not have been performed, resulting in a decline of 77 % of the follow-up endoscopies performed.
  
  
  CONCLUSIONS
  Endoscopic follow-up of gastric ulcers considered benign by appearance and with benign histology showed no additive value in detecting unsuspected malignancy in this study. This strategy could reduce health costs and save distress to patients.
authors.affiliation: Department of Gastroenterology and Hepatology, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands. ericgielisse@hotmail.com.
authors.forename: Eric A R
authors.initials: EA
authors.lastname: Gielisse
authors.affiliation: Department of Gastroenterology and Hepatology, Kennemer Gasthuis, Haarlem, The Netherlands.
authors.forename: Johan P
authors.initials: JP
authors.lastname: Kuyvenhoven
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D005773:Gastroscopy; D006801:Humans; D008297:Male; D008875:Middle Aged; D011230:Precancerous Conditions / Q000150:complications / Q000473:pathology; D013274:Stomach Neoplasms / Q000175:diagnosis*; D013276:Stomach Ulcer / Q000150:complications / Q000473:pathology*; D055815:Young Adult
keywords: Follow-up endoscopy; Gastric cancer; Gastric ulcer; Gastroscopy