Factors Associated with Malignant Gastric Ulcers: A 10-year Retrospective Cohort Study.

BACKGROUND

Gastric ulcers carry a recognized risk of underlying malignancy. Regional evidence remains limited in the Middle East, where historically high Helicobacter pylori prevalence contrasts with comparatively low gastric cancer incidence. This study evaluated the prevalence of malignant gastric ulcers and identified clinical and endoscopic predictors of malignancy.

METHODS

A retrospective cohort of all patients diagnosed with gastric ulcer between 2014 and 2024 at Hamad Medical Corporation was analyzed. Local protocols mandate biopsy and follow-up endoscopy, although real-world adherence varies. Collected variables included demographics, ulcer morphology, H. pylori status, and clinical exposures. Ulcer size was categorized as small (<1.25 cm), medium (1.25-3.0 cm), and large (>3.0 cm). Logistic regression and ROC analyses were used to evaluate predictors and model performance.

RESULTS

Among 473 patients, 39 (8.2%) had malignant ulcers. Ulcer size was the strongest predictor of malignancy; medium and large ulcers demonstrated markedly increased odds in univariate and multivariable analyses. Age, sex, smoking, alcohol use, H. pylori status, and ulcer location showed no independent associations. The multivariable model achieved an AUC of 0.868, compared with 0.790 using ulcer size alone. Adenocarcinoma was the predominant subtype.

CONCLUSION

Malignant gastric ulcers accounted for a meaningful minority of ulcer presentations. Ulcer size was the dominant predictor of malignancy, while demographic, lifestyle, and microbial factors added limited discriminatory value. These findings support emphasizing ulcer size in risk stratification and ensuring universal biopsy of all gastric ulcers, with timely follow-up for medium and large lesions.