Abstract
Background
Graft-versus-host disease (GVHD) is a common complication of allogeneic bone marrow transplantation. Severe GVHD carries significant morbidity and mortality and remains one of the leading causes of treatment failure. Unfortunately, intestinal GVHD may present with a variety of non-specific symptoms and diagnosis based on clinical presentation is often inaccurate; biopsy is therefore needed for definitive diagnosis. At present, the optimal endoscopic approach to the diagnosis of gastrointestinal GVHD remains uncertain.
Aims
The primary aims of our study were: (1) to evaluate the yield of upper versus lower endoscopy, and (2) to determine which anatomic regions were most likely to provide a histologic diagnosis.
Methods
We conducted a prospective study of 27 consecutive patients who had undergone stem cell transplantation within the past 100 days and were referred to the Yale Gastrointestinal Procedure center between August 2002 and February 2006 for the evaluation of suspected acute GVHD. All patients underwent standardized endoscopic evaluation of the upper and lower gastrointestinal tract with biopsies. The diagnostic yield of upper versus lower endoscopy was compared in all patients.
Results
GVHD was identified in 18 of the 27 patients (67%). Of those with GVHD, 15 patients (83%) had diffuse intestinal involvement. Six of 10 patients (60%) with an endoscopically normal EGD had GVHD on biopsies of the upper gastrointestinal tract. Six of 13 (46%) patients with an endoscopically normal appearing colonoscopy had GVHD on colonic biopsies. Two of 18 (11%) patients had isolated GVHD of the upper intestinal tract and 1 (6%) had isolated colonic GVHD. Rectal biopsy alone identified 89% (16 of 18) of GVHD cases and all 16 cases of GVHD with colonic involvement. A diagnosis of GVHD was not altered by the additional performance of biopsy of the proximal colon or terminal ileum.
Conclusions
In the present study, the majority of cases of acute GVHD demonstrate diffuse upper and lower gastrointestinal involvement with rectal, sigmoid, gastric and duodenal biopsies having similarly diagnostic yield. Based on our findings, we recommend starting with flexible sigmoidoscopy with rectal biopsy alone in patients who are poor candidates to undergo full colonoscopy with sedation or in those in whom GVHD is strongly suspected based on clinical findings. However, more extensive evaluations may be necessary to rule out infection and should be considered in those with no contraindications to sedation and in whom other differential diagnoses are also being considered.
Similar content being viewed by others
References
Storb R, Antin JH, Cutler C. Biol Blood Marrow Transplant. 2010;16:S18–S27. Epub 9/24/2009.
Ferrara JLM, Deeg HJ. Graft-versus host disease. NEJM. 1991;324:667–674.
Appleton AL, Sviland L, Pearson EDJ, et al. The need for endoscopic biopsy in the diagnosis of upper gastrointestinal graft-versus-host-disease. J Pediatr Gastroenterol Nutr. 1993;16:183–185.
Roy J, Snover D, Weisdorf S, et al. Simultaneous upper and lower endoscopic biopsy in the diagnosis of intestinal graft-versus-host disease. Transplantation. 1991;51:642–646.
Cox GJ, Matdui SM, Lo RS, et al. Etiology and outcome of diarrhea after marrow transplantation: A prospective study. Gastroenterology. 1994;107:1398–1407.
Roy J, Snover D, Weisdorf S, et al. Simultaneous upper and lower endoscopic biopsy in the diagnosis of intestinal graft-versus-host disease. Transplantation. 1991;51:642–646.
Iqbal N, Salzman D, Lazenby A, Wilcox M. Diagnosis of gastrointestinal graft-versus-host disease. Am J Gastro. 2000;95:3034–3038.
Thompson B, Salzman D, Steinhauer J, Lazenby A, Wilcox CM. Prospective endoscopic evaluation for gastrointestinal graft-versus-host disease: determination of the best diagnostic approach. Bone Marrow Transplant. 2006;38:371–376.
Shulman HM, Kleiner D, Lee SJ, et al. Histopathologic diagnosis of chronic graft-versus-host disease: National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: II Pathology Working Group Report. Biol Blood Marrow Transplant. 2006;12:31–47.
Iqbal N, Salzman D, Lazenby A, Wilcox M. Diagnosis of gastrointestinal graft-versus-host disease. Am J Gastro. 2000;95:3034–3038.
Ross W, Ghosh S, Dekovich A, et al. Endoscopic biopsy diagnosis of acute gastrointestinal graft-versus-host disease? Rectosigmoid biopsies are more sensitive than upper gastrointestinal biopsies. Am J Gastroenterol. 2008;103:982–989.
Epstein R, McDonald G, Sale G, Shulman H, Thomas E. The diagnostic accuracy of the rectal biopsy in acute graft-versus-host-disease: A prospective study of thirteen patients. Gastroenterology. 1980;78:764–771.
Cox GJ, Matdui SM, Lo RS, et al. Etiology and outcome of diarrhea after marrow transplantation: A prospective study. Gastroenterology. 1994;107:1398–1407.
Wu D, Hockenberry D, Brentnall T, et al. Persistent nausea and anorexia after marrow transplantation: A prospective study of 78 patients. Transplantation. 1998;66:1319–1324.
Roy J, Snover D, Weisdorf S, et al. Simultaneous upper and lower endoscopic biopsy in the diagnosis of intestinal graft-versus-host disease. Transplantation. 1991;51:642–646.
Thompson B, Salzman D, Steinhauer J, Lazenby A, Wilcox CM. Prospective endoscopic evaluation for gastrointestinal graft-versus-host disease: determination of the best diagnostic approach. Bone Marrow Transplant. 2006;38:371–376.
Ross W, Ghosh S, Dekovich A, et al. Endoscopic biopsy diagnosis of acute gastrointestinal graft-versus-host disease? Rectosigmoid biopsies are more sensitive than upper gastrointestinal biopsies. Am J Gastroenterol. 2008;103:982–989.
Ross W, Ghosh S, Dekovich A, et al. Endoscopic biopsy diagnosis of acute gastrointestinal graft-versus-host disease? Rectosigmoid biopsies are more sensitive than upper gastrointestinal biopsies. Am J Gastroenterol. 2008;103:982–989.
Acknowledgment
We are grateful to the nursing staff at Yale Gastrointestinal Procedure Center for their support and technical assistance in this study.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Aslanian, H., Chander, B., Robert, M. et al. Prospective Evaluation of Acute Graft-Versus-Host Disease. Dig Dis Sci 57, 720–725 (2012). https://doi.org/10.1007/s10620-011-1938-x
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10620-011-1938-x