Introduction Intestinal Graft versus host disease (iGvHD) is a common complication of haematopoetic stem cell transplantation (HSCT) associated with significant morbidity and mortality. Gastroenterologists are frequently consulted to assist with the diagnosis which is based on histological findings. Endoscopic evaluation practice varies between units with some favouring symptom guided investigations and others advocating lower gi endoscopy with rectosigmoid biopsies as the approach with the highest sensitivity. In this study we describe the diagnostic efficacy of upper versus lower gi endoscopy (and biopsy sampling) in supporting the diagnosis of iGvHD.
Method Post HSCT patients with symptoms suggestive of iGvHD who underwent simultaneous upper and lower gi endoscopy in one centre over the last 3 years were identified through prospectively kept electronic patient records. All of them had biopsies taken during procedure from relevant areas (duodenum, terminal ileum, right colon, L colon/rectosimgoid). Continuous variables are presented as medians followed by interquartile range. Categorical comparisons were performed using chi-square test. Predictive values are followed by 95% confidence intervals.
Results We identified 32 eligible patients [median age: 50 (33, 60), female: male ratio 1:1). Presenting gi symptoms included diarrhoea: 29/32 (88%), anorexia/ weight loss: 14/32 (44%), nausea/vomiting: 11/32 (34%), abdominal pain/ bloating: 4/32 (13%), rectal bleeding: 3/32 (10%). The median time post HSCT was 107 (55, 178) with 15 patients presenting in <100 and 17 in >100 days post liver transplantation. There were 8/15 (53%) patients diagnosed with acute GvHD and 10/17 (59%) with chronic GvHD affecting the gut. There was no difference in the gi segments involved in acute and chronic forms of iGvHD, with 18/18 patients having left colon/rectosigmoid, 14/18 (77%) right colon, 8/18 (44%) terminal ileal and 3/18 (16%) duodenal involvement. Duodenal biopsies were positive in only 3/8 (38%) patients with small bowel involvement based on a positive terminal ileal biopsy. The negative predictive value of duodenal biopsies for the diagnosis of iGvHD was 68% (53, 81).
Conclusion iGvHD in either acute or chronic form appears to always affect the rectosigmoid/ left colon. A flexible sigmoidoscopy with biopsies should suffice to rule in or out the diagnosis. Duodenal biopsies do not appear to provide any additional diagnostic benefit in the context of iGvHD investigation.
Disclosure of interest None Declared.
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