Effective and less invasive diagnostic strategy for gastrointestinal GVHD
submitted 28. März 2017
accepted after revision 31. August 2017
01. März 2018 (online)
Background and study aims Rectosigmoidoscopy with biopsy has been regarded to be a useful procedure to diagnose gastrointestinal graft-versus-host disease (GVHD). However, little is known about the specific colonoscopic features of gastrointestinal GVHD. In this study, we focused on the 4 unique colonoscopic findings – orange peel appearance, spotty redness, small mucosal sloughing, and diffuse mucosal defect – which are possible specific findings of gastrointestinal GVHD. We aimed to estimate the usefulness of these four unique colonoscopic findings in the rectosigmoid portion to diagnose gastrointestinal GVHD.
Patients and methods Seventy patients who were histologically diagnosed with gastrointestinal GVHD at our institute were retrospectively enrolled. Colonoscopic findings were reviewed, focusing on the four characteristic findings. The percentage of the positive cases for the characteristic findings was calculated. The final scoping portion and the number of cases showing any of the four characteristic findings in the rectosigmoid portion were also evaluated. The relationships between biopsy sites and the histological findings were also evaluated.
Results Orange peel appearance was observed in 66 cases (94.3 %). Spotty redness was observed in 45 cases (64.3 %). Small mucosal sloughing was observed in 49 cases (70.0 %). Diffuse mucosal defect was observed in six cases (8.6 %). The number of cases that were concurrently positive for one, two, and three findings were 16 (20.8 %), 20 (26.0 %), and 34 (48.6 %), respectively. Fifty-eight cases (82.9 %) were investigated up to the rectosigmoid portion, and 12 (17.1 %) were investigated beyond the sigmoid colon. All of the cases showed at least 1 of the 4 characteristics in the rectosigmoid portion. The percentage of crypt apoptosis in the biopsy specimen from orange peel appearance, spotty redness, small mucosal sloughing, and diffuse mucosal defect were 87.5 %, 83.3 %, 87.2 %, and 88.9 %, respectively.
Conclusion Orange peel appearance, spotty redness, small mucosal sloughing, and diffuse mucosal defect are the characteristic colonoscopic findings useful for diagnosis of gastrointestinal GVHD. These findings are frequently observed in the rectosigmoid portion. The histological detection rates for crypt cell apoptosis from these findings are high. Identifying the four characteristic findings on rectosigmoidoscopy and taking biopsies from these areas could be essential for the diagnostic strategy for gastrointestinal GVHD.
- 1 Gratwohl A, Brand R, Apperley J. et al. Graft-versus-host disease and outcome in HLA-identical sibling transplantations for chronic myeloid leukemia. Blood 2002; 100: 3877-3886
- 2 Przepiorka D, Weisdorf D, Martin P. et al. 1994 Consensus Conference on Acute GVHD Grading. Bone Marrow Transplant 1995; 15: 825-828
- 3 Nomura K, Iizuka T, Kaji D. et al. Clinicopathological features of patients with acute graft-versus-host disease of the upper digestive tract. J Gastroenterol Hepatol 2014; 29: 1867-1872
- 4 Ross WA, Ghosh S, Dekovich AA. et al. Endoscopic biopsy diagnosis of acute gastrointestinal graft-versus-host disease: rectosigmoid biopsies are more sensitive than upper gastrointestinal biopsies. Am J Gastroenterol 2008; 103: 982-989
- 5 Sultan M, Ramprasad J, Jensen MK. et al. Endoscopic diagnosis of pediatric acute gastrointestinal graft-versus-host disease. J Ped Gastroenterol Nutr 2012; 55: 417-420
- 6 Crowell KR, Patel RA, Fluchel M. et al. Endoscopy in the diagnosis of intestinal graft-versus-host disease: is lower endoscopy with biopsy as effective in diagnosis as upper endoscopy combined with lower endoscopy?. Ped Blood Cancer 2013; 60: 1798-1800
- 7 Lee KJ, Choi SJ, Yang HR. et al. Stepwise endoscopy based on sigmoidoscopy in evaluating pediatric graft-versus-host disease. Ped Gastroenterol Hepatol Nutr 2016; 19: 29-37
- 8 Ma C, Maluf HM, Liu TC. Acute graft-versus-host disease is more prevalent and severe in the lower than the upper gastrointestinal tract. Human Pathology 2015; 46: 1480-1487
- 9 Wild D, Sung AD, Cardona D. et al. The diagnostic yield of site and symptom-based biopsies for acute gastrointestinal graft-versus-host disease: A 5-year retrospective review. Dig Dis Sci 2016; 61: 806-813
- 10 Johansson JE, Nilsson O, Stotzer PO. Colonoscopy and sigmoidoscopy are equally effective for the diagnosis of colonic acute graft-versus-host disease in patients with diarrhea after allogeneic stem cell transplantation: A prospective controlled trial. Biol Blood Marrow Transplantation 2015; 21: 2086-2090
- 11 Ip S, Marquez V, Schaeffer DF. et al. Sensitivities of biopsy sites in the endoscopic evaluation of graft-versus-host disease: Retrospective review from a tertiary center. Dig Dis Sci 2016; DOI: 10.1007/s10620-016-4142-1.
- 12 Minamino H, Machida H, Tominaga K. et al. Rectal biopsy, rather than ileal, is appropriate to confirm the diagnosis of early gastrointestinal graft-versus-host disease. Scand J Gastroenterol 2015; 50: 1428-1434
- 13 Kreisel W, Dahlberg M, Bertz H. et al. Endoscopic diagnosis of acute intestinal GVHD following allogeneic hematopoietic SCT: a retrospective analysis in 175 patients. Bone Marrow Transplantation 2012; 47: 430-438
- 14 Roy J, Snover D, Weisdorf S. et al. Simultaneous upper and lower endoscopic biopsy in the diagnosis of intestinal graft-versus-host disease. Transplantation 1991; 51: 642-646
- 15 Mashiba T, Usami A, Soga Y. et al. Endoscopic findings of intestinal graft-versus-host disease following allogenic bone marrow and peripheral blood stem cell transplantation. [In Japanese with English abstract]. Gastroenterol Endosc 2003; 45: 929-934
- 16 Ponec RJ, Hackman RC, McDonald GB. Endoscopic and histologic diagnosis of intestinal graft-versus-host disease after marrow transplantation. Gastrointest Endoscop 1999; 49: 612-621
- 17 Oomori S, Takagi S, Kikuchi T. et al. Significance of colonoscopy in patients with intestinal graft-versus-host disease after hematopoietic stem cell transplantation. Endoscop 2005; 37: 346-350
- 18 Hiejima E, Nakase H, Matsuura M. et al. Diagnostic accuracy of endoscopic features of pediatric acute gastrointestinal graft-versus-host disease. Dig Endoscop 2016; DOI: 10.1111/den.12604.
- 19 Onozawa M, Yonezumi M, Kawarazaki M. et al. Usefulness of magnifying endoscopic evaluation of the terminal ileum for a patient with graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Ann Hhematol 2005; 84: 106-109