The Diagnostic Yield of Site and Symptom-Based Biopsies for Acute Gastrointestinal Graft-Versus-Host Disease: A 5-Year Retrospective Review

Abstract

Background Graft-versus-host disease (GVHD) complicates half of hematopoietic stem cell transplants (HCT), and the gastrointestinal tract is commonly affected. Endoscopic biopsies have a key role in the diagnosis. The optimal procedure(s) to perform and site(s) to biopsy remain unclear. Methods We retrospectively analyzed the charts of all adult patients who underwent allogeneic HCT at Duke University Medical Center between 1/1/05 and 1/1/11 and extracted data from those who underwent endoscopic biopsy for suspected GVHD. All histology was re-evaluated by blinded pathologists using 2006 NIH diagnostic criteria and then compared to the original clinical diagnosis of GVHD. Results A total of 169 adult patients underwent 250 endoscopic procedures to evaluate GVHD. The sensitivity of biopsies for clinical GVHD was 76 and 72 % for upper and lower tract sites, respectively. In the presence of nausea, upper tract biopsies were positive for GVHD in 65 %, 70 % while lower tract biopsies were positive in 61–70 %. In the presence of diarrhea, lower tract biopsies were positive in 65 %, while upper tract sites were positive in 64–69 %. Twenty six (40 %) of the sixty-five endoscopies that simultaneously sampled upper and lower tract sites had discordant results. All were histologically positive for GVHD, yet 15 % of upper tract biopsies and 25 % of lower tract biopsies were negative. Conclusions In this large review, the overall sensitivity of biopsies taken during EGD and Flex-Sig was 76 and 72 %, respectively. A symptom-driven biopsy approach was not clearly supported as upper tract and lower tract biopsies were similarly diagnostic for GVHD regardless of symptoms.

Use of the National Institutes of Health Consensus Guidelines Improves the Diagnostic Sensitivity of Gastrointestinal Graft-Versus-Host Disease

“…In addition, the site of GI symptoms did not always correlate with the site of histologic changes seen on biopsy. 31 Although our original, unaltered specificity was low (50%), that was in the context of our intentionally blinded study methods. Specifically, the pathologists were blind to all clinical information, and each biopsy site was evaluated independently and later given one overall score for the endoscopy, based on the most severe diagnosis, thus favoring a diagnosis of likely GVHD.…”

Late Gastrointestinal Complications of Allogeneic Hematopoietic Stem Cell Transplantation in Adults

“…In the event of multiple endoscopic procedures, only data surrounding the first endoscopy was considered so as to count each patient only one time. Endoscopic findings and complications were reported separately (9) and not included here, though histological findings were re-examined as described below and included.…”

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

“…In our clinical practice, we generally do not use purgatives in patients who have received HSCT and who are undergoing lower endoscopy; the volume of diarrhoea in this patient population usually allows for adequate inspection of the mucosa without the need for additional bowel cleansers. Importantly, newer data suggest that upper and lower endoscopy have similar diagnostic yields, even in patients who present with diarrhoea 76,77 . If EGD is performed in such patients, duodenal biopsies have a diagnostic yield higher than other sites of the upper gastrointestinal tract 78 .…”