Colonoscopy and Sigmoidoscopy are Equally Effective for the Diagnosis of Colonic Acute Graft-versus-Host Disease in Patients with Diarrhea after Allogeneic Stem Cell Transplantation: A Prospective Controlled Trial

Abstract

Colonic acute graft-versus-host disease (aGVHD) affects approximately 10% of patients who have undergone allogeneic stem cell transplantation (allo-SCT). Diarrhea is a major clinical sign but also a common post-transplantation symptom in these patients. Comprehensive histopathologic examination of the colon is therefore regarded as crucial to establish a diagnosis, but the colonic segment that should be targeted for a diagnostic biopsy remains a topic of debate. The primary objective of this study was to compare prospectively colonoscopy with sigmoidoscopy regarding their capabilities to provide a histopathologically proven diagnosis of colonic aGVHD. Thirty-seven allo-SCT patients with diarrhea all underwent a colonoscopy. All biopsies collected from the descending colon were regarded as also attainable by sigmoidoscopy, whereas biopsies collected in regions further up the colon (from the transverse and ascending colon) were regarded as acquirable exclusively by colonoscopy. Biopsies attainable by colonoscopy and sigmoidoscopy were positive for GVHD in 25 (68%) and 24 (65%) patients, respectively (95% confidence interval for difference of proportions, -.185 to .245; P = .978; z = .0271 by the z-test). Sigmoidoscopy is as effective as colonoscopy in establishing a diagnosis of colonic aGVHD in patients who have diarrhea after allo-SCT.

Graft-vs-Host Disease Colitis After Lung Transplant

“…Most of the studies support rectosigmoid biopsies, given their high sensitivity (82%-95%) regardless of the symptom profile. 11,12 In hemopoeitc stem cell transplant patients with diarrhea, colonoscopy and sigmoidoscopy are equivalent in diagnosing GVHD, so the latter may benefit patients with a high procedural risk. 12 Endoscopically, GVHD displays erythema, edema, erosions, and denudation of mucosa; however, approximately half of patients with normal colonoscopies and 60% with normal EGDs had histologic evidence of GVHD-strongly supporting obtaining biopsies irrespective of normal-appearing mucosa.…”

“…11,12 In hemopoeitc stem cell transplant patients with diarrhea, colonoscopy and sigmoidoscopy are equivalent in diagnosing GVHD, so the latter may benefit patients with a high procedural risk. 12 Endoscopically, GVHD displays erythema, edema, erosions, and denudation of mucosa; however, approximately half of patients with normal colonoscopies and 60% with normal EGDs had histologic evidence of GVHD-strongly supporting obtaining biopsies irrespective of normal-appearing mucosa. 13 Chimerism or the presence of donor lymphocytes in the patient's peripheral blood can confirm clinical suspicion of GVHD.…”

Effective and less invasive diagnostic strategy for gastrointestinal GVHD

“…In the past, there was a report describing the usefulness of magnifying endoscopy for the terminal ileum 19 . However, recent studies indicated that the rectosigmoidoscopy is sufficient for diagnosing gastrointestinal GVHD 8 10 11 12 . It could be ideal to scope up to the proximal colon or the ileum to identify the activity of GVHD more precisely.…”

“…Many recent studies have reported that a biopsy from the lower intestinal tract has equal or superior sensitivity for the pathological diagnosis of gastrointestinal GVHD compared to a biopsy from the upper gastrointestinal tract 4 5 6 7 8 9 . Furthermore, some studies reported that a biopsy from the rectosigmoid portion, rather than from the right colon or the ileum, is sufficient for diagnosis 8 10 11 12 . Since upper GI endoscopy and total colonoscopy are more invasive than rectosigmoidoscopy, rectosigmoidoscopy with biopsy has been regarded as the more useful way to diagnose gastrointestinal GVHD in recent years.…”

Therapeutic targets and emerging treatment options in gastrointestinal acute graft-versus-host disease

“…Flexible sigmoidoscopy is as sensitive as full colonoscopy. [19] Upper GI endoscopy is often performed, as the small bowel may be the major source of diarrhea, although this approach is not universally accepted. [20] Although GI GVHD symptoms may start as early as 9 days after HCT, they often do not start until patients have been discharged from the hospital, and accurate measurements of outpatient diarrheal output are not routinely available.…”