Acute graft-versus-host disease of the gut: considerations for the gastroenterologist

Abstract

Haematopoietic stem cell transplantation (HSCT) is central to the management of many haematological disorders. A frequent complication of HSCT is acute graft-versus-host disease (GVHD), a condition in which immune cells from the donor attack healthy recipient tissues. The gastrointestinal system is among the most common sites affected by acute GVHD, and severe manifestations of acute GVHD of the gut portends a poor prognosis in patients after HSCT. Acute GVHD of the gastrointestinal tract presents both diagnostic and therapeutic challenges. Although the clinical manifestations are nonspecific and overlap with those of infection and drug toxicity, diagnosis is ultimately based on clinical criteria. As reliable serum biomarkers have not yet been validated outside of clinical trials, endoscopic and histopathological evaluation continue to be utilized in diagnosis. Once a diagnosis of gastrointestinal acute GVHD is established, therapy with systemic corticosteroids is typically initiated, and non-responders can be treated with a wide range of second-line therapies. In addition to treating the underlying disease, the management of complications including profuse diarrhoea, severe malnutrition and gastrointestinal bleeding is paramount. In this Review, we discuss strategies for the diagnosis and management of acute GVHD of the gastrointestinal tract as they pertain to the practising gastroenterologist.

Clinical Outcomes and Healthcare Resource Utilization for Gastrointestinal Acute Graft-versus-Host Disease after Allogeneic Transplantation for Hematologic Malignancy: A Retrospective US Administrative Claims Database Analysis

“…Most of the fatal cases of aGVHD involve severe lower GI GVHD [2]. Patients with acute lower intestinal GVHD experience substantial symptoms, often voluminous secretory watery or bloody diarrhea, abdominal pain, and GI bleeding [28]. The true proportion of patients who develop acute GI GVHD is difficult to determine from the published literature.…”

Mitochondrial neurogastrointestinal encephalomyopathy: approaches to diagnosis and treatment

“…The procedure carries a mortality risk of 63%, with survival being dependent on an human leukocyte antigen 10/10 match and the absence of gastrointestinal and liver disease [46,83] . Gastrointestinal disease is a critical factor in the pathophysiology of graft versus host disease and can lead to the activation of host antigen presenting cells and donor T-cells [103] . Patients with MNGIE are likely to present a higher risk of developing gut graft versus host disease because of the disease-related gastrointestinal damage.…”

Newly found arsons ignite the fire of gut GVHD

“…Alloreactive T cell activation has been proposed to begin in the mesenteric lymph nodes (MLNs) and Peyer's patches (13,14). Acute GVHD in the gut, the most common site of acute GVHD, results in a high mortality rate (15) and is primarily mediated by alloreactive CD4 + T cells. While transient in vivo depletion of donor CD4 + T cells effectively prevents the induction of acute gut GVHD (16), the subset of CD4 + T cells that initiates gut GVHD remains unclear.…”