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Original research
Risk stratifying gastric ulcers: development and validation of a scoring system
  1. William M Brindle1,
  2. Rebecca K Grant1,
  3. Marianne Smith1,
  4. Meghan Suddaby1,
  5. Angus Wallace1,
  6. Sarah-Louise Gillespie1,
  7. Nicholas I Church1,
  8. Colin L Noble2,
  9. Ian D Penman1,
  10. John N Plevris1,
  11. Alexander R Robertson2,
  12. Eleanor F Watson2,
  13. Christian P Selinger3,
  14. Rahul Kalla1,
  15. Gail S M Masterton1
  16. On behalf of EGAR (Edinburgh GI Audit and Research) Collaborative
  1. 1The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh, UK
  2. 2The Edinburgh IBD Unit, Western General Hospital, Edinburgh, UK
  3. 3Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  1. Correspondence to Dr William M Brindle, The Centre for Liver and Digestive Disorders, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK; william.m.brindle{at}


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.

  • gastrointestinal cancer
  • gastric and duodenal ulcers
  • gastrointesinal endoscopy

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  • RK and GSMM are joint senior authors.

  • Twitter @gastronautian, @rahul_kalla

  • Contributors WMB contributed to the conception of the work, data collection, interpretation of the data and drafting of the manuscript. RKG contributed to data collection, analysis and interpretation of the data and performed critical revision of the manuscript. MSm, MSu, AW and S-LG contributed to data collection and critical revision of the manuscript. NIC, CLN, IDP, JNP, ARR and CPS performed critical revision of the manuscript. EFW contributed to data collection and performed critical revision of the manuscript. RK and GSMM were senior authors and contributed to the conception of the work and performed the critical revision of the manuscript for important intellectual content. Guarantor of article: WMB.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval In accordance with NHS Health Research Authority guidelines, specific ethical review and approval was not considered necessary as this research is a retrospective audit using data already obtained as part of regular clinical care.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Deidentified data available on request via corresponding author.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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