RECENT evidence on gastric ulcer biopsy strategies has shown that initial endoscopic sampling and targeted approaches may improve diagnostic yield, according to an updated systematic review of clinical studies. The review assessed evidence on biopsy timing, number, site, and related diagnostic outcomes in adults with endoscopically diagnosed gastric ulcers or ulcerative gastric lesions.
The systematic review included studies published from 2015 to May 2025 and evaluated evidence from seven studies grouped across biopsy timing, biopsy number, biopsy site, and safety. Two reviewers independently assessed eligible studies, extracted data, and evaluated risk of bias using the Newcastle-Ottawa Scale.
Due to substantial clinical and methodological differences between studies, the findings were synthesised narratively. The available evidence remained limited, heterogeneous, and largely observational, highlighting the need for further research into optimal gastric ulcer biopsy strategies.
Data suggested that most malignancies were identifiable during the initial endoscopy examination. However, repeat biopsy during ulcer healing or scarring could still identify some cancers that had been missed initially.
Evidence regarding biopsy site remained limited and inconsistent. Findings from healed phase ulcers suggested that anatomical location alone may not be sufficient to determine the most appropriate biopsy strategy.
Available studies indicated that four well targeted biopsies could be adequate for some depressed or polypoid lesions. More extensive sampling may be required for infiltrative or otherwise suspicious lesions where the risk of missed pathology could be greater.
Safety data were limited but did not demonstrate a clear increase in adverse events with broader biopsy strategies or biopsy of stabilised bleeding ulcers. The findings support an approach that combines adequate lesion targeted sampling with consideration of individual clinical circumstances.
The review concluded that gastric ulcer biopsy strategies should be tailored according to endoscopic appearance, histological findings, and clinical suspicion. Follow-up assessment and intensive sampling may remain important for selected patients when initial findings do not fully resolve diagnostic uncertainty.
Reference
Wang M et al. Endoscopic biopsy strategies for gastric ulcers: an updated systematic review. BMJ Open. 2026;16(7):e119032.
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