Implementation of a novel protocol for endoscopic follow-up of gastric ulcers

Introduction

A local ‘gastric ulcer follow-up’ protocol was developed, externally validated and implemented locally in May 2021. Under the local protocol, patients with low ulcer risk scores based on ulcer size, location and patient age with benign biopsy results at index oesophagogastroduodenoscopy (OGD1), are not offered endoscopic follow-up to check healing (OGD2). We investigated the uptake of this protocol and its impact on patient outcomes.

Methods

Patients diagnosed with a gastric ulcer at OGD1 in NHS Lothian from 24/5/21–16/1/22 were identified. OGD1 reports were reviewed and data were gathered, including the ulcer risk score components, score documentation, biopsy rates and if the decision to request an OGD2 or to discontinue surveillance was made in accordance with the protocol. Electronic patient records were reviewed at follow-up post OGD1 to assess for subsequent diagnoses of upper gastrointestinal (UGI) cancer.

Results

In total 143 patients were diagnosed with a gastric ulcer at OGD1. The ulcer risk score could be calculated for 65.0% of patients but was documented in only 15.4% of OGD1 reports. The OGD1 biopsy rate was 65.0%. of the patients who did not have an OGD2 requested (n=81), 54.3% (44/81) of decisions followed the protocol; a cost saving of £24,640. There were no UGI cancers identified at review in patients who did not have an OGD2 performed in accordance with the protocol (median follow-up: 15 months, IQR 14–17 months). OGD2s were requested for 43.4% (n=62) of patients. of the patients with an OGD2, 62.9% (n=39) of requests followed the protocol, in three of these cases patients were diagnosed with cancer at OGD2 (dysplasia had been present at OGD1 in 2/3). None of the 16.1% (n=10) of requests which were made contrary to the protocol identified new pathology. Six patients underwent OGD2s for follow-up of concomitant pathology; protocol adherence could not be determined in seven patients as a component of the risk score was not documented.

Conclusions

The gastric ulcer protocol has been shown to be a safe and cost-effective method to tailor follow-up endoscopy for gastric ulcers. Protocol adherence has demonstrated no missed diagnoses of cancer at follow-up. Measures are currently being undertaken to improve uptake within Lothian.