Site specific diagnostic yield of endoscopic biopsies in Gastrointestinal Graft-versus-Host Disease: A tertiary care Center experience

Daniel, Fady; Hassoun, Lara; Husni, Mohammad; Sharara, Alaa; A, Soweid; Barada, Kassem; Haffar, Basel; Massoud, Radwan; Shaib, Yasser H.; Al-Hashash, Jana; Bazarbachi, Ali; Cheikh, Jean El

doi:10.1016/j.retram.2018.08.001

Cited by 11 publications

(6 citation statements)

References 15 publications

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“…9,10 Adult studies have suggested that, while GI-GVHD is a dynamic process that can affect all segments of the GI tract, the terminal ileum and colon are the most frequently involved sites. 11,12 To our knowledge, there is no international consensus on the optimal endoscopic approach to make the diagnosis in children. Adult studies have identified the rectum and distal colon as the sites with the highest sensitivity, even in patients with symptoms suggestive of upper GI tract involvement.…”

Section: Introductionmentioning

confidence: 99%

“…It is widely agreed that endoscopic evaluation of bowel mucosa is not reliable for diagnosis of GI‐GVHD, and therefore, histological evaluation remains the gold standard 9,10 . Adult studies have suggested that, while GI‐GVHD is a dynamic process that can affect all segments of the GI tract, the terminal ileum and colon are the most frequently involved sites 11,12 …”

Section: Introductionmentioning

confidence: 99%

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Diagnostic utility of upper and lower gastrointestinal endoscopy for the diagnosis of acute graft‐versus‐host disease in children following stem cell transplantation: A 12‐year experience

Koh

Cole

Evans

et al. 2021

Pediatric Transplantation

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Background Endoscopically obtained mucosal biopsies are the gold standard for diagnosing acute graft‐versus‐host disease of the gastrointestinal tract (GI‐GVHD). There is no consensus on the ideal endoscopic approach in children. We aimed to ascertain which gastrointestinal sites and endoscopic approaches were most helpful for diagnosing acute GVHD and whether clinical symptoms can guide the endoscopic approach. Method A single‐center retrospective review of all pediatric stem cell transplants (SCT) between January 1, 2007, and December 31, 2018. Of those with histologically diagnosed GI‐GVHD, sensitivities of individual GI sites for making the diagnosis were calculated. Clinical symptoms were compared with GI site yielding diagnosis. Results 216 allogeneic SCTs were performed in 199 patients. 37 of 52 suspected GI‐GHVD cases underwent endoscopy. There was marked variability in the endoscopic approaches chosen. 82% of these cases had lower gastrointestinal symptoms. 21 cases had histologically proven GI‐GVHD. 19 (90%) of these had GVHD of non‐gastrointestinal sites; 10 (48%) had concurrent infections. The most‐sensitive GI sites were the rectosigmoid and duodenum (86% and 76%, respectively). Overall sensitivity of upper GI endoscopy (UGIE) and lower GI endoscopy (LGIE) was 86% and 90%, respectively. There was no statistically significant association between clinical symptoms and site at which histological diagnosis was obtained. Conclusion We observed variability in the endoscopic approach used by clinicians. UGIE and sigmoidoscopy had high sensitivities for diagnosing GVHD, regardless of symptoms. LGIE had minimal additional diagnostic value. This would support a standardized approach with UGIE and sigmoidoscopy for all children with suspected GI‐GVHD.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Diagnostic utility of upper and lower gastrointestinal endoscopy for the diagnosis of acute graft‐versus‐host disease in children following stem cell transplantation: A 12‐year experience

Koh

Cole

Evans

et al. 2021

Pediatric Transplantation

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“…Certain endoscopists may argue that complete ileocolonoscopy, which requires insertion into the terminal ileum, is not widely accepted, as it is completely invasive and associated with a high risk of complications (8). However, we believe that careful endoscopic insertion techniques will enable rapid endoscopic diagnosis of acute intestinal GVHD.…”

Section: Discussionmentioning

confidence: 99%

Observer agreement for the diagnosis of intestinal acute graft‑vs.‑host disease based on the presence of villous atrophy in the terminal ileum

et al. 2020

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Intestinal graft-vs.-host disease (GVHD) is a serious complication of allo-hematopoietic stem cell transplantation (allo-HSCT). Villous atrophy in the terminal ileum is considered a useful diagnostic indicator for GVHD. However, the inter-and intra-observer agreement regarding the ileocolonoscopic findings indicative of acute intestinal GVHD, i.e., villous atrophy in the terminal ileum, are currently insufficient in multiple institutions. Thus, the present study aimed to investigate the incidence of villous atrophy in the terminal ileum to diagnose acute intestinal GVHD and determine the inter-and intra-observer agreement regarding this result for experienced endoscopists from multiple institutions. Consecutive patients who underwent allo-HSCT were referred to our institution between May 2008 and September 2015. A total of 54 patients underwent total ileocolonoscopy after allo-HSCT due to suspected intestinal acute GVHD. Subsequently, three observers from different institutions evaluated the cases for the presence of villous atrophy in the terminal ileum. In this study, the pathology results were a gold standard to evaluate the predictive value of ileocolonoscopy detection. Definitive pathological and non-pathological GVHD was diagnosed in 22 and 32 cases, respectively. The results of examining whether villous atrophy could predict GVHD were as follows. For three observers (A, B and C), the sensitivity of villous atrophy in the terminal ileum was 86.4, 77.3 and 79.2%, respectively, whereas the specificity was 62.5, 62.5 and 86.7%, respectively. The positive predictive value (PPV) and negative predictive value (NPV) of villous atrophy for GVHD were as follows: The PPV of appearance was 61.3, 58.6 and 82.6%, respectively, whereas the NPV was 87.0, 80.0 and 83.9%, respectively. Kappa coefficients for the inter-observer reliability were 0.85, 0.63 and 0.63 for observers A and B, A and C, and B and C, respectively. The intra-observer kappa coefficient was 0.88 for observer A, 0.73 for observer B and 0.75 for observer C. A substantial observer agreement was achieved for the analysis of villous atrophy in the terminal ileum and the agreement for the predictive histological diagnosis was also excellent. Based on the results of the present study, identification of villous atrophy in the terminal ileum was a clinically effective diagnostic parameter, even if different endoscopists were involved in the diagnosis at multiple institutions. The present study was registered as a trial with the University Hospital Medical Information Network (UMIN; registration no. UMIN000025390).

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“…Vote: strongly agree, 75%; agree, 12.5%; disagree, 12.5% Key evidence: There is consensus that complete ileocolonoscopy is indicated for the majority of pediatric lower endoscopic procedures. There are select indications where ileal intubation may not be required, including motility catheter placement, sigmoidoscopy for graft-versus-host disease, or monitoring for therapeutic response in ulcerative proctitis (49,50). It is important to recognize that a large proportion of pediatric patients undergoing ileocolonoscopy are being investigated for suspected or known inflammatory bowel disease (IBD), which in some cases is only ascertainable by mucosal inspection of the cecum and terminal ileum.…”

Section: 5%mentioning

confidence: 99%

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopists and Endoscopists in Training

Walsh

Lightdale

Leibowitz

et al. 2021

J. pediatr. gastroenterol. nutr.

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Introduction: High-quality pediatric endoscopy requires reliable performance of procedures by competent individual providers who consistently uphold all standards determined to assure optimal patient outcomes. Establishing consensus expectations for ongoing monitoring and assessment of individual pediatric endoscopists is a method for confirming the highest possible quality of care for such procedures worldwide. We aim to provide guidance to define and measure quality of endoscopic care for children. Methods: With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopists. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.Results: The PEnQuIN working group achieved consensus on 6 standards that all providers who perform pediatric endoscopy should uphold and 2 standards for pediatric endoscopists in training, with 7 corresponding indicators that can be used to identify high-quality endoscopists. Additionally, these can inform continuous quality improvement at the provider level. Minimum targets for defining high-quality pediatric ileocolonoscopy were set for 2 key indicators: cecal intubation rate (!90%) and terminal ileal intubation rate (!85%). Discussion: It is recommended that all individual providers performing or training to perform pediatric endoscopy initiate and engage with these international endoscopist-related standards and indicators developed by PEnQuIN.

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Site specific diagnostic yield of endoscopic biopsies in Gastrointestinal Graft-versus-Host Disease: A tertiary care Center experience

Cited by 11 publications

References 15 publications

Diagnostic utility of upper and lower gastrointestinal endoscopy for the diagnosis of acute graft‐versus‐host disease in children following stem cell transplantation: A 12‐year experience

Diagnostic utility of upper and lower gastrointestinal endoscopy for the diagnosis of acute graft‐versus‐host disease in children following stem cell transplantation: A 12‐year experience

Observer agreement for the diagnosis of intestinal acute graft‑vs.‑host disease based on the presence of villous atrophy in the terminal ileum

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopists and Endoscopists in Training

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