Endoscopic biopsy strategies for gastric ulcers: an updated systematic review.

Abstract

To systematically summarise recent evidence on endoscopic biopsy for gastric ulcer. Systematic review of clinical studies. PubMed, Embase, Cochrane Library, Web of Science, CNKI and CiNii Research were searched for studies published from 2015 to May 2025. 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. 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. 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. 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. CRD420251157851.