Late Gastrointestinal Complications of Allogeneic Hematopoietic Stem Cell Transplantation in Adults

Abstract

Gastrointestinal (GI) complications including graft-versus-host disease (GVHD) are a major cause of morbidity and mortality in allogenic stem transplant recipients. Although several studies have previously looked into the acute GI complications, fewer smaller studies have reported late complications. In this large study we focus on the late (100 days post-transplant) GI complications in allogenic stem transplant recipients. In this single-center, retrospective study of all adult allogenic stem cell transplant recipients who had their transplant at Duke University over a 6-year period, 479 patients underwent allogenic stem cell transplant, of whom 392 recipients survived for at least 100 days post-transplant. Late GI symptoms were noted in 71 patients, prompting endoscopic evaluation. The primary endpoint of our study was the diagnosis of GI-GVHD based on endoscopic findings, whereas overall survival and nonrelapse mortality were the secondary endpoints. Of the 71 patients who underwent endoscopy, 45 (63%) had GI-GVHD. Of these 45 patients, 39 (87%) had late acute GVHD, 1 (2%) had chronic GVHD, and 5 patients (11%) had overlap disease. Of the patients who did not have GVHD, the symptoms were mostly related to infectious and inflammatory causes. Less common causes included drug toxicity, food intolerance, disease relapse, and motility issues. In a multivariate analysis the factors most indicative of GI-GVHD were histologic findings of apoptosis on the tissue specimen (odds ratio, 2.35; 95% confidence interval, 1.18 to 4.70; P = .015) and clinical findings of diarrhea (odds ratio, 5.43; 95% confidence interval, 1.25 to 23.54; P = .024). The median survival time from the first endoscopy was 8.5 months. The incidence of nonrelapse mortality at 6 months was 31% in patients with GI-GVHD and 19% in patients without GI-GVHD (P = .42). All patients with GI-GVHD were on steroid therapy, and 31% of them received total parenteral nutrition. In our population close to one-fifth of allogenic transplant recipients experienced late GI complications, warranting endoscopic evaluation. Most of these patients were found to have GI-GVHD that had a high incidence of nonrelapse mortality at 6 months and close to one-third of these patients needed total parenteral nutrition.

Long-term health outcomes of allogeneic hematopoietic stem cell transplantation

“…In survivors of HCT with late gastrointestinal manifestations including nausea or vomiting, diarrhea, abdominal pain or cramping, and anorexia, investigation with endoscopy found GI GVHD as the most common etiology, followed by infections, predominantly cytomegalovirus ( 33 ). Other persistent gastrointestinal complications of HCT include xerostomia, esophageal stricture, and malnutrition are also typically associated with cGVHD ( 34 ).…”

How I approach diarrhea in hematological transplant patients: A practical tool

“…Lastly, patients who survive the 1-year landmark post-HSCT are at risk for new-onset and chronic diarrhea. 12 For instance, patients with B-cell dysfunction, hypogammaglobulinemia, or those receiving immunosuppressive therapy for GVHD remain at high risk for recurrent CDI, norovirus, enteroviral diarrhea, and community-onset bacterial gastroenteritis (e.g., Campylobacter, Salmonella). Furthermore, parasitic infections (e.g., strongyloidiasis, giardiasis, amebiasis) can present in those engaging with high-risk exposures, and their clinical presentation can overlap with other GI syndromes observed in HSCT patients, such as exocrine pancreatic insufficiency (as seen in chronic GVHD), or small-intestinal bacterial overgrowth (SIBO).…”

“…Lastly, patients who survive the 1‐year landmark post‐HSCT are at risk for new‐onset and chronic diarrhea 12 . For instance, patients with B‐cell dysfunction, hypogammaglobulinemia, or those receiving immunosuppressive therapy for GVHD remain at high risk for recurrent CDI, norovirus, enteroviral diarrhea, and community‐onset bacterial gastroenteritis (e.g., Campylobacter, Salmonella ).…”

Low Rate of Infectious Enterocolitis in Allogeneic Stem Cell Transplant Recipients with Acute Diarrhea: A Prospective Study by the GETH-TC

“…Acute diarrhea is a common and often debilitating complication in recipients of allogeneic hematopoietic stem cell transplantation (HCT) [1]. An appropriate diagnostic assessment is essential since several conditions may coexist, although graft-versus-host disease (GVHD), drug-related toxicity, and infectious enterocolitis are the main suspects [2,3]. In an effort to find a readily treatable cause, infectious enterocolitis is usually the first cause of diarrhea to be studied through fecal microbiology.…”