Upper Versus Lower Endoscopy in the Diagnosis of Graft-Versus-Host Disease

Cloutier, Justin; Wall, Donna A.; Paulsen, Kristjen; Bernstein, Çharles N.

doi:10.1097/mcg.0000000000000609

Cited by 11 publications

(4 citation statements)

References 19 publications

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“…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 .…”

Section: Diagnosismentioning

confidence: 99%

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

Naymagon

Wong

et al. 2017

Nat Rev Gastroenterol Hepatol

126

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Haematopoietic stem cell transplantation (HSCT) is central to the management of many haematological disorders. A frequent complication of HSCT is acute graft-versus-host disease (GVHD), a condition in which immune cells from the donor attack healthy recipient tissues. The gastrointestinal system is among the most common sites affected by acute GVHD, and severe manifestations of acute GVHD of the gut portends a poor prognosis in patients after HSCT. Acute GVHD of the gastrointestinal tract presents both diagnostic and therapeutic challenges. Although the clinical manifestations are nonspecific and overlap with those of infection and drug toxicity, diagnosis is ultimately based on clinical criteria. As reliable serum biomarkers have not yet been validated outside of clinical trials, endoscopic and histopathological evaluation continue to be utilized in diagnosis. Once a diagnosis of gastrointestinal acute GVHD is established, therapy with systemic corticosteroids is typically initiated, and non-responders can be treated with a wide range of second-line therapies. In addition to treating the underlying disease, the management of complications including profuse diarrhoea, severe malnutrition and gastrointestinal bleeding is paramount. In this Review, we discuss strategies for the diagnosis and management of acute GVHD of the gastrointestinal tract as they pertain to the practising gastroenterologist.

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Section: Diagnosismentioning

confidence: 99%

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

Naymagon

Wong

et al. 2017

Nat Rev Gastroenterol Hepatol

126

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“…The organ with the highest sensitivity for biopsy remains controversial, some recommend gastric biopsies and others recommend rectosigmoid biopsies (16)(17)(18). The Lerner classification is the most widely used histopathological scoring system for acute intestinal GVHD based on apoptotic bodies, crypt destruction, and mucosal denudation.…”

Section: Discussionmentioning

confidence: 99%

Liver-Intestinal Involvement in Graft Versus Host Disease in Pediatric Hematopoietic Stem Cell Transplantation Patients: Ten Years of Experience in 2 Centers of Latin America

et al. 2022

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Objectives: To describe the behavior and characteristics of children with diagnosis of graft versus host disease (GVHD) with liver-intestinal involvement. Methods: Retrospective cohort study of pediatric patients with history of hematopoietic stem cell transplantation for diagnosis of GVHD with gastrointestinal (GI) or liver involvement, from 2 pediatric centers. Results: Between 2007 and 2017, 57 pediatric patients presented with liver or intestinal GVHD; 74% with GI GVHD, 11% with liver GVHD, and 15% with liver-intestinal involvement. Diarrhea (96%) and abdominal pain (55%) were the most frequent symptoms. Endoscopies were performed in 88%, and 35% required a second procedure to confirm diagnosis. Normal-appearing mucosa was observed in 17% of upper GI endoscopies and in 29% of colonoscopies. Endoscopic pathological findings were observed mainly in colon (62%). There was greater severity on colonoscopic classification in those with liver-intestinal compromise than in those with GI compromise only. Overall mortality was 26%. Conclusion: GI and liver GVHD diagnosis may present serious complications. GI involvement tends to manifest early, so it is appropriate to suspect it in the first days after transplantation, unlike liver involvement, which occurs late when other organs are involved. We did not observe a direct relationship between endoscopic and histological classification. Both GI and liver involvement in GVHD could predict greater target organ involvement.

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“…We report the largest cross-sectional study to date on the management and safety of endoscopic evaluation of aGVHD in patients who have undergone HSCT. A number of prior studies have found that symptoms such as diarrhea often occur in the presence of aGVHD in the lower GI tract, warranting evaluation with FS, while upper GI symptoms such as nausea and vomiting warrant evaluation with EGD[ 6 , 14 , 16 , 18 , 19 , 22 ]. On the contrary, we found that combined EGD and FS with biopsies resulted in at least an 80% diagnostic yield in patients with any presenting symptom.…”

Section: Discussionmentioning

confidence: 99%

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

Rajan

Trieu

Lin

et al. 2020

WJGE

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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.

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Upper Versus Lower Endoscopy in the Diagnosis of Graft-Versus-Host Disease

Cited by 11 publications

References 19 publications

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

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

Liver-Intestinal Involvement in Graft Versus Host Disease in Pediatric Hematopoietic Stem Cell Transplantation Patients: Ten Years of Experience in 2 Centers of Latin America

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

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