GASTRIC-ULCERS AT ENDOSCOPY - BRUSH, BIOPSY, OR BOTH

Objectives: All gastric ulcers discovered at endoscopy are potentially malignant. Concurrent use of both histological biopsy and cytological brushing has been advocated as a means of increasing the diagnostic y ield for neoplasia at the time of initial endoscopy. The purpose of th is analysis was to determine the impact of these diagnostic strategies on the cost-effectiveness of detecting malignancy in patients with a gastric ulcer. Methods: The diagnostic performance of biopsy and brush ings in detecting gastric malignancy was estimated from a metaanalysis of published reports, Nondiscounted direct costs were determined from patient resource consumer profiles from the perspective of a Canadian hospital. A decision tree was used to compare diagnostic strategies ( biopsy alone, brushing alone, or biopsy and brushing) in a hypothetica l cohort of patients found to have a gastric ulcer at endoscopy. Effec tiveness was expressed as diagnostic days saved. Results: No strategy achieved dominance. The brushing strategy was the most cost-effective, but its cost-effectiveness ratio was only slightly lower than that of biopsy. Cost differences between the biopsy and brushing strategies w ere small (less than $6 per case), performing both biopsy and brushing slightly improved the true-positive rate but resulted in a doubling o f the false-positive rate, which in tuna led to unnecessary laparotomi es. The impact of the high false-positive rate was also seen in the in cremental cost of performing both brushings and biopsy ($168-$423 per case). Conclusions: For gastric ulcers discovered at endoscopy, the pr eferred strategy is to perform either cytological brushing or histolog ical biopsy. The previously recommended strategy of performing both cy tological brushing and histological biopsy should be reconsidered.