Seeing What's Out of Sight: Wireless Capsule Endoscopy's Unique Ability to Visualize and Accurately Assess the Severity of Gastrointestinal Graft-versus-Host-Disease

Abstract

Early recognition of gastrointestinal graft-versus-host disease (GI GVHD) after allogeneic hematopoietic stem cell transplantation (alloHSCT) is vital to initiation of therapy. However, the most common location, the small bowel (SB), is difficult to access with upper and lower endoscopy (UGE/LGE). Wireless capsule endoscopy (WCE) is a noninvasive technology allowing complete SB evaluation. The capsule location can also be tracked to identify motility derangements. From August 2006 to July 2007, 11 alloHSCT patients with GI symptoms underwent WCE, and visual grading was performed. UGE and LGE with biopsies were done when clinically indicated. All patients had evidence of probable acute GVHD (aGVHD) on WCE. WCE revealed lesions of greater severity than those seen by UGE or LGE in most patients. WCE demonstrated that 45% of patients had delayed gastric transit time. WCE is an excellent, noninvasive method for assessing GI GVHD, with the ability to more accurately assess the severity of GVHD, evaluate clinical symptoms, and follow response to treatment.

Making the diagnosis of gastrointestinal GVHD: is evaluation of the ileum necessary?

“…Preliminary reports of this technology in the setting of acute GVHD are inconsistent as to the predominance of mucosal findings in the terminal ileum. 18,19 Abdominal computerized tomography in the setting of acute GVHD also fails to demonstrate selective ileal involvement as the most common pattern seen is diffuse involvement of both large and small intestine in 86% of patients. 20 So, although provocative, the report by Kreisel et al provides insufficient reasons to alter our current practice of emphasizing rectosigmoid biopsies.…”

Small Bowel Capsule Endoscopy

“…In two series, 7/9 and 3/7 patients, respectively, with lesions detected by upper and lower endoscopy had more severe lesions detected by SBCE in the small bowel, which were not accessible by conventional endoscopy. In these cases, SBCE made the overall assessment more accurate [287,289]. A normal SBCE study essentially ruled out aGI GvHD effectively changing the therapeutic course [291].…”

“…An exact and early diagnosis is important to initiate a specific treatment or adapt the ongoing immunomodulating therapy. In several small series, patients with suspected aGI GvHD underwent SBCE without complications in any stage of the disease with the procedure being well tolerated [287,289,290]. Endoscopic findings correlated with the histopathologic staging.…”

“…Patients developing diarrhoea, nausea, vomiting, abdominal pain, anorexia or hematochezia after allogenic stem cell transplantation may suffer from acute gastrointestinal graft-versus-host disease (aGI GvHD). As a common complication, it is associated with an increased morbidity and mortality rate [287]. Differential diagnosis includes viral and bacterial infections such as cytomegalovirus, Epstein-barr virus or Clostridium difficile.…”

Rectal biopsy, rather than ileal, is appropriate to confirm the diagnosis of early gastrointestinal graft-versus-host disease

“…Previous studies have also suggested that rectal biopsy has a high diagnostic yield in GI-GVHD [11][12][13]. However, it was also reported that the initial pathological changes occur in the ileum in patients with acute GI-GVHD, potentially indicating the essential pathogenesis of GI-GVHD [14]. Considering these reports, there have been no established recommendations regarding the optimal site of examination for acute GI-GVHD in the GI tract.…”