Abstract
Graft versus host disease (GVHD) of the gut is associated with significant morbidity and mortality after allogeneic hematopoietic cell transplant (allo-HCT). No guidelines exist regarding repeat endoscopy after failure of first-line treatment with steroids. We aimed to study if repeat endoscopic biopsy can be helpful in these patients to guide treatment decisions. We retrospectively reviewed medical records of all patients who underwent repeat endoscopy for clinical suspicion of gastrointestinal (GI) GVHD after allo-HCT. Of the 318 patients, 24 underwent endoscopy twice after allo-HCT. At first endoscopy, 20 patients (80%) showed abnormal findings: 16 with GVHD alone, 1 with GVHD plus Cytomegalovirus (CMV), and 3 with GVHD plus infectious colitis. On repeat endoscopy in these 20 patients with GVHD, 6 showed improvement leading to de-escalation of therapy, 8 showed worsening of GVHD including detectionof CMV in 2 patients, and 2 hadno histological changes. One patient with simultaneous GVHD and CMV diagnosed on first biopsy, displayed significant improvement leading to de-escalation of therapy. Three patients with GVHD along with infectious colitis on biopsy subsequently showed improvement on repeat biopsy leading to de-escalation of therapy. Among 4 patients with normal findings on first endoscopy, 3 had GVHD and 1 had epstein-barrvirus-associated post-transplant lymphoproliferative disorder (EBV-PTLD) on repeat procedures. This study supports the usefulness of repeat endoscopy in persistently symptomatic patients when there is no improvement after the initial treatment based on the results of the first endoscopy. Repeat endoscopy may guide therapy without significant complications.
Article PDF
Avoid common mistakes on your manuscript.
References
Jenq, RR,van den Brink, MR. Allogeneic haematopoietic stem cell transplantation: individualized stem cell and immune therapy of cancer. Nat Rev Cancer 2010;10;213–21.
Hough, R, Rocha, V. Transplant outcomes in acute leukemia II. Semin Hematol 2010;47;51–8.
MacMillan, ML, Walters, MC, Gluckman,E. Transplant outcomes in bone marrow failure syndromes and hemoglobinopathies. Semin Hematol 2010;47;37–45.
Gratwohl, A, Heim, D. Current role of stem cell transplantation in chronic myeloid leukaemia. Best Pract Res Clin Haematol 2009;22;431–43.
Auner, HW, et al. Reduced intensity-conditioned allogeneic stem cell transplantation for multiple myeloma relapsing or progressing after autologous transplantation: a study by the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 2013;48;1395–400.
Kroger, N, Mesa, RA. Choosing between stem cell therapy and drugs in myelofibrosis. Leukemia 2008;22;474–86.
Dignan, FL, et al. Diagnosis and management of acute graft-versus-host disease. Br J Haematol 2012;158;30–45.
Tabbara, IA, et al. Allogeneic hematopoietic stem cell transplantation: complications and results. Arch Intern Med 2002;162; 1558–66.
Harris, AC, et al. International, multicenter standardization of acute graft-versus-host disease clinical data collection: a report from the Mount Sinai Acute GVHD International Consortium. Biol Blood Marrow Transplant 2016;22;4–10.
Socie, G, Ritz, J. Current issues in chronic graft-versus-host disease. Blood 2014;124;374–84.
Schulenburg, A, et al. Early and late gastrointestinal complications after myeloablative and nonmyeloablative allogeneic stem cell transplantation. Ann Hematol 2004;83;101–6.
Fallows, G, Rubinger, M, Bernstein, CN. Does gastroenterology consultation change management of patients receiving hematopoietic stem cell transplantation? Bone Marrow Transplant 2001;28;289–94.
Ferrara, JL, Deeg, HJ. Graft-versus-host disease. N Engl J Med 1991;324;667–74.
Jagasia, M, et al. Risk factors for acute GVHD and survival after hematopoietic cell transplantation. Blood 2012;119;296–307.
Parfitt, JR, Jayakumar, S, Driman, DK, Mycophenolate mofetil-related gastrointestinal mucosal injury: variable injury patterns, including graft-versus-host disease-like changes. Am J Surg Pathol 2008;32;1367–72.
Couriel, D, et al. Acute graft-versus-host disease: pathophysiology, clinical manifestations, and management. Cancer 2004;101; 1936–46.
Epstein, RJ, et al. The diagnostic accuracy of the rectal biopsy in acute graft-versus-host disease: a prospective study of thirteen patients. Gastroenterology 1980;78;764–71.
Washington, K, Jagasia, M. Pathology of graft-versus-host disease in the gastrointestinal tract. Hum Pathol 2009;40;909–17.
Ponec, RJ, Hackman, RC, McDonald, GB. Endoscopic and histologic diagnosis of intestinal graft-versus-host disease after marrow transplantation. Gastrointest Endosc 1999;49;612–21.
Luft, T, et al. Serum cytokeratin-18 fragments as quantitative markers of epithelial apoptosis in liver and intestinal graft-versus-host disease. Blood 2007;110;4535–42.
Reinhardt, K, et al. Monocyte-induced development of Th17 cells and the release of S100 proteins are involved in the pathogenesis of graft-versus-host disease. J Immunol 2014;193;3355–65.
Ali, AM, DiPersio, JF, Schroeder, MA. The role of biomarkers in the diagnosis and risk stratification of acute graft-versus-host disease: a systematic review. Biol Blood Marrow Transplant 2016;22;1552–64.
Major-Monfried, H, et al. MAGIC biomarkers predict long-term outcomes for steroid-resistant acute GVHD. Blood 2018;131;2846–55.
Srinagesh, HK, Levine, JE, Ferrara, JLM. Biomarkers in acute graft-versus-host disease: new insights. Ther Adv Hematol 2019;10;1–8.
Martínez, C, et al. Serial intestinal endoscopic examinations of patients with persistent diarrhea after allo-SCT. Bone Marrow Transplant 2012;47;694–9.
Bhutani, D, et al. Incidence, risk factors, and outcome of cytomegalovirus viremia and gastroenteritis in patients with gastrointestinal graft-versus-host disease. Biol Blood Marrow Transplant 2015;21;159–64.
Author information
Authors and Affiliations
Corresponding author
Additional information
Peer review under responsibility of the International Academy for Clinical Hematology
Data availability statement: The data that support the findings of this study are available from the corresponding author, upon reasonable request.
Rights and permissions
This is an open access article distributed under the CC BY-NC 4.0 license (http://creativecommons.org/licenses/by-nc/4.0/).
About this article
Cite this article
Shabbir, E., Farooq, U., Yanes, B. et al. Repeat Endoscopy Affects Patient Management in Gastrointestinal Graft-Versus-Host Disease. Clin Hematol Int 2, 69–73 (2020). https://doi.org/10.2991/chi.d.200220.001
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.2991/chi.d.200220.001