Assessing the yield and safety of endoscopy in acute graft-vs-host disease after hematopoietic stem cell transplant

Abstract

BACKGROUND Acute gastrointestinal (GI) graft- vs -host disease (aGVHD) is the most complication of hematopoietic stem cell transplant (HSCT) in patients with hematologic malignancy. Limited data exists on endoscopic evaluation of GVHD in post-HSCT patients with differing GI symptoms. Further, the diagnostic value of gross endoscopic findings as well as the safety of endoscopy in this commonly thrombocytopenic and neutropenic patient population remains unclear. AIM To understand the diagnostic value of symptoms and gross endoscopic findings as well as safety of endoscopy in aGVHD patients. METHODS We analyzed 195 endoscopies performed at City of Hope in patients who underwent allogeneic HSCT less than 100 d prior for hematologic malignancy and were subsequently evaluated for aGVHD via endoscopy. The yield, sensitivity, and specificity of diagnosing aGVHD were calculated for upper and lower endoscopy, various GI tract locations, and presenting symptoms. RESULTS Combined esophagogastroduodenoscopy (EGD) and flexible sigmoidoscopy (FS) demonstrated a greater diagnostic yield for aGVHD (83.1%) compared to EGD (66.7%) or FS (77.2%) alone with any presenting symptom. The upper and lower GI tract demonstrated similar yields regardless of whether patients presented with diarrhea (95.7% vs 99.1%) or nausea/vomiting (97.5% vs 96.8%). Normal-appearing mucosa was generally as specific (91.3%) as abnormal mucosa (58.7%-97.8%) for the presence of aGVHD. Adverse events such as bleeding (1.0%), infection (1.0%), and perforation (0.5%) only occurred in a small proportion of patients, with no significant differences in those with underlying thrombocytopenia ( P = 1.000) and neutropenia ( P = 0.425). CONCLUSION Combined EGD and FS with biopsies of normal and inflamed mucosa demonstrated the greatest diagnostic yield regardless of presenting symptom and appears to be safe in this population of patients.

Compromiso gastrointestinal por enfermedad de injerto contra huésped

“…Los estudios endoscópicos son pieza fundamental en el estudio de la EICH. En general, tienen un buen rendimiento y son seguros, con bajas tasas de complicación (11) . La presentación de la EICH varía dependiendo de la extensión y gravedad, y puede ir desde zonas parcheadas de mucosa con eritema leve y superficial hasta ulceraciones con esfacelación y denudación completa de la mucosa (Tabla 1).…”

“…La diarrea por lo general una colonoscopia completa. Al momento de la toma de biopsias se deberán evitar zonas con inflamación muy grave, por la dificultad en la interpretación para el patólogo y para reducir el riesgo de hematomas (en pacientes con trombocitopenia) e inclusive perforación, particularmente en el duodeno e íleon (11) . Se recomienda de igual manera el uso de antibióticos profilácticos en pacientes con conteo de neutrófilos < 500 células/µL.…”

“…El rendimiento diagnóstico de los estudios endoscópicos con biopsias es variable: 67 %-80 % para la EGD, 58 %-80 % para la rectosigmoidoscopia (RSC), 83 %-87 % para la colonoscopia, 87 %-100 % para la ileocolonoscopia y 92 %-93 % para la EGD con RSC (11,13) . Varios estudios sugieren que la RSC con toma de biopsias del colon distal podría tener mayor precisión en el diagnóstico de EICH aguda (82 %-95 %), por lo que se considera el estudio inicial de elección, además por su facilidad para la preparación y realización (13) .…”

Flexible sigmoidoscopy may be sufficient for initial evaluation of suspected immunotherapy‐mediated colitis: A cross‐sectional study

“…Flexible sigmoidoscopy with rectosigmoid biopsy has demonstrated efficacy in the evaluation of disease severity in these patients. 16 Because the majority of our patients underwent full colonoscopy with pan-colonic biopsies, we were able to determine that rectosigmoid biopsies using flexible sigmoidoscopy alone were sufficient for diagnosing IMC in patients with clinical symptoms.…”