Why is a biopsy requested for peptic ulcer disease (PUD)?

Why Biopsy is Requested for Peptic Ulcer Disease

Biopsy is requested for peptic ulcers primarily to exclude gastric malignancy in gastric ulcers and to detect H. pylori infection, with the decision individualized based on ulcer location, patient risk factors, and clinical presentation. 1

Primary Indications for Biopsy

Gastric Ulcers: Malignancy Exclusion

All gastric ulcers should be biopsied or at minimum strongly considered for biopsy to rule out gastric cancer, as approximately 10% of gastric ulcers are actually malignant. 2

• When gastric ulcer biopsies are performed, specimens should be taken from both the base and edges of the ulcer to maximize diagnostic yield 1
• A minimum of six biopsies is recommended (four from the ulcer margin and two from the ulcer base) to achieve adequate diagnostic accuracy 2
• Biopsy from the base of healing or healed chronic gastric ulcers may detect early gastric cancer that would be missed by edge biopsies alone 3

Risk Stratification Allows Selective Approach

The 2024 AGA guidelines provide a practical framework: biopsy of gastric ulcers may be omitted only in very low-risk patients (young non-Hispanic white patients taking NSAIDs) with benign-appearing ulcers (shallow, flat ulcer with associated erosions) 1

Duodenal Ulcers: Biopsy Rarely Needed

Routine biopsies of duodenal ulcers are not necessary, as the malignancy rate is only 0.024% 1, 2

• Duodenal ulcers are managed without biopsy in uncomplicated cases 1
• Giant duodenal ulcers represent a rare exception where biopsy may be considered 2

H. pylori Detection

Regardless of ulcer location, biopsy of the surrounding gastric mucosa should be performed to detect H. pylori infection, which is a major causative factor in peptic ulcer disease 1

Optimal Biopsy Protocol for H. pylori

• Obtain 5 biopsy specimens from specific locations: greater and lesser curve of gastric body, incisura, and greater and lesser curve of the antrum 1
• Place specimens in 2 separately labeled jars (body; antrum/incisura) to improve diagnostic accuracy 1
• Gastric body biopsies are especially critical in patients using proton pump inhibitors due to proximal migration of H. pylori organisms from antrum to body 1
• H. pylori may be present despite normal-appearing stomach mucosa 1

Follow-up Considerations

Gastric ulcers require follow-up endoscopy approximately six weeks after discharge to confirm healing and exclude malignancy, whereas duodenal ulcers typically do not require routine surveillance 4

• Gastric ulcer healing on endoscopy does not prove benignity, making repeat endoscopy with biopsy mandatory 2
• PPI therapy should be continued until follow-up endoscopy confirms healing 5

Surgical Context

In surgical cases for bleeding or perforated ulcers, gastric ulcers require resection or at least biopsy to exclude malignancy, while duodenal ulcers are managed with suture and vessel ligation without routine biopsy 1, 4, 5

Common Pitfalls to Avoid

• Never assume a gastric ulcer is benign based on endoscopic appearance alone—approximately 10% harbor malignancy 2
• Do not rely on antral biopsies alone in PPI users—H. pylori migrates proximally and may be missed 1
• Avoid taking only edge biopsies from gastric ulcers—base biopsies increase cancer detection 3
• Do not perform routine esophageal or duodenal biopsies in simple dyspepsia evaluation—they add no diagnostic value 1