Repeat Endoscopy Affects Patient Management in Gastrointestinal Graft-Versus-Host Disease

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 detection of CMV in 2 patients, and 2 had no 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.

Clinical Manifestation of Cytomegalovirus-Associated Protein-Losing Enteropathy in Children

“…Moreover, adverse events related to endoscopy cannot be overlooked, such as ventilatory problems, linked to sedation and anaesthesia, as well as perforation and bleeding, secondary to the endoscopic procedure [ 40 , 41 , 42 ]. Conversely, endoscopy should be encouraged to differentiate CMV-associated PLE and graft-versus-host disease in transplant patients [ 43 , 44 ]. Even though the histological findings are ambiguous, as they may be similar to a CMV infection (epithelial apoptosis, crypt abscesses, degeneration of crypt cells, nuclear atypia) [ 45 ], our study showed that the CMV PCR on digestive tissue was relevant for the diagnosis in immunosuppressed patients and will help differentiate both diagnoses in this specific indication.…”

Acute graft-versus-host disease

“…Non-specific signs of lower GI acute GVHD on CT scan include bowel wall thickening, abnormal mucosal enhancement, bowel dilatation and air or fluid levels suggestive of ileus 91 . Endoscopic manifestations of acute GVHD include spotted or diffuse erythema, patchy erosion, scattered ulceration and active bleeding [92][93][94] (Fig. 4d).…”

Practicing Clinical Hematology During the COVID-19 Outbreak: A Challenge Like No Other

“…In this new issue of Clinical Hematology International , you will read some high-level clinical reviews [ 2 , 3 ] and original reports [ 4 – 5 ], in addition to a diverse set of material. We hope you will continue to enjoy the IACH activities.…”