Endoscopic biopsy strategies for gastric ulcers: an updated systematic review

Clinical Snapshot

Key Findings

• P Value: Not reported

• Effect Size: No pooled effect size calculable; narrative findings suggest most malignancies are identifiable at initial endoscopy, with repeat biopsy during healing/scarring detecting some additional missed cancers; four well-targeted biopsies may be adequate for depressed or polypoid lesions, while infiltrative or suspicious lesions may require more extensive sampling

• Primary Outcome: Diagnostic yield for gastric malignancy according to biopsy strategy (timing, number, and site)

• Nnt Or Sensitivity: Not reported; no sensitivity, specificity, or NNT data extractable from the narrative synthesis. Diagnostic accuracy metrics for specific biopsy strategies were not pooled.

• Confidence Interval: Not reported; no quantitative synthesis performed

Clinical Application

The qualitative recommendations — biopsy at initial endoscopy, lesion-targeted sampling with individualisation based on endoscopic appearance and clinical suspicion — are feasible within standard endoscopy practice. However, the lack of quantitative thresholds (e.g., precise biopsy numbers for specific lesion types) limits operationalisation into standardised protocols. Australia has a relatively low incidence of gastric cancer compared to East Asian countries (approximately 6–7 per 100,000), meaning the pre-test probability context differs substantially from the populations likely represented in this review. The RACGP and Gastroenterological Society of Australia (GESA) do not currently have specific national guidelines on the optimal number or site of biopsies for gastric ulcers. Endoscopy is performed under the MBS (Medicare Benefits Schedule), and biopsy practice is largely guided by endoscopist judgement and international guidelines (e.g., British Society of Gastroenterology, European Society of Gastrointestinal Endoscopy). H. pylori testing from gastric biopsies is relevant in the Australian context given PBS-listed eradication therapy. This review does not address H. pylori diagnostic yield. The findings, while directionally consistent with current practice, do not provide sufficient evidence to prompt a change in Australian endoscopy protocols. Clinicians should continue to apply individualised clinical judgement, with particular attention to high-risk features (size >2 cm, irregular margins, non-healing ulcers) warranting more intensive sampling and follow-up endoscopy. Adult patients undergoing upper gastrointestinal endoscopy for gastric ulcers or ulcerative gastric lesions, particularly where malignancy is a diagnostic consideration. Most directly applicable to populations with moderate-to-high gastric cancer prevalence.

Abstract

OBJECTIVE: To systematically summarise recent evidence on endoscopic biopsy for gastric ulcer. DESIGN: Systematic review of clinical studies. DATA SOURCES: PubMed, Embase, Cochrane Library, Web of Science, CNKI and CiNii Research were searched for studies published from 2015 to May 2025. ELIGIBILITY CRITERIA: Original studies involving adults with endoscopically diagnosed gastric ulcers or ulcerative gastric lesions directly informing biopsy strategy were eligible if they evaluated biopsy timing, number, site or related diagnostic outcomes. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently screened studies, extracted data and assessed risk of bias using the Newcastle-Ottawa Scale. Owing to substantial clinical and methodological heterogeneity, findings were synthesised narratively. RESULTS: Seven studies were included and grouped into four domains: biopsy timing, biopsy number, biopsy site and safety. Available data suggested that most malignancies may be identifiable at the initial endoscopy examination although repeat biopsy during ulcer healing or scarring might still detect some missed cancers. Evidence on the biopsy site remained limited and inconsistent, and findings from healed-phase ulcers further suggested that the anatomical site alone may be insufficient to guide biopsy strategy. Available studies also indicated that four well-targeted biopsies may be adequate for some depressed or polypoid lesions whereas more extensive sampling might be needed for infiltrative or otherwise suspicious lesions. Limited safety data did not show a clear increase in adverse events with broader biopsy strategies or the biopsy of stabilised bleeding ulcers. CONCLUSIONS: Contemporary evidence on endoscopic biopsy for gastric ulcers remains limited, heterogeneous and largely observational. Available data suggest that biopsy at initial endoscopy and adequate, lesion-targeted sampling may improve diagnostic yield, while follow-up and intensive sampling should be individualised according to endoscopic appearance, histological findings and clinical suspicion. PROSPERO REGISTRATION NUMBER: CRD420251157851.

References

1. 1.Wang, M., Chen, Y., Yang, M., Zhang, K., & Wang, W. (2026). Endoscopic biopsy strategies for gastric ulcers: an updated systematic review. BMJ Open. https://doi.org/10.1136/bmjopen-2026-119032