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Endoscopy Biopsy in Different Sites for the Diagnosis of Lower and Upper Gastrointestinal Graft-Versus-Host Disease
Introduction
Graft-versus-host disease (GvHD) is a major cause of mortality in allogeneic stem cell transplantation (ASCT). This study assessed the distribution and concordance of GvHD in upper and lower gastrointestinal (GI) biopsies and its correlation with CMV infection and extra-intestinal manifestations of GvHD.
Methods
We performed a review of records from patients that had undergone ASCT from 2005 to 2013 in our institution and had GI GvHD diagnosis by histological samples from upper and/or lower endoscopy. We also evaluate presence of extra-intestinal manifestations of GvHD at the time of biopsy and CMV infection on histological and blood samples.
Results
One hundred and eighty nine patients had performed ASCT during this period. Twenty eight patients (14.8%) had upper and/or lower acute GvHD diagnosis confirmed by biopsy. Extra-intestinal manifestation of GVHD was: skin in 19 (67.9%) and liver in 6 (21.4%) patients. Five (17.9%) had the 3 organ involvement. The GI GvHD staging was: I in 7 (25%), II in 4 (14.3%), III in 9 (32.1%) and IV in 8 (28.6%) patients.
The frequency and correlation between involvement of different parts of GI-GVHD are presented in Tables 1, 2 and 3.
Nine (32.1%) had a positive blood sample for CMV and 5 (17.9%) had a histological sample (one in stomach, 3 in colon and one in rectum). Only one patient had both positive samples. There is no association between GI-GVHD staging and CMV infection on blood (p=0.885) and on biopsy (p= 0.859).
The median follow up was 7.2 (1.8-90.6) month. Overall survival was 40% in 60 months and patients with stage IV GVHD had a less survival ( P= 0.004).
Conclusion
Because sigmoid tract was the most frequent site of lower GI-GVHD involvement and only in 7.4% of cases failed to identify this disease, a retosigmoidoscopy may be an effective procedure for GI-GVHD diagnosis. However, CMV infection may be underdiagnosed with this approach.
Table 1. Correlation between involvement of different parts of gastrointestinal tract – rectal biopsy versus colon/ileum biopsies
Colon/ IleumBiopsy Positive
| Colon/IleumBiopsy Negative
| Total
| |
Rectal biopsy – Positive
| 16
| 7
| 23 (85.2)
|
Rectal biopsy – Negative
| 2
| 2
| 4 (14.8)
|
Total
| 18 (66.7)
| 9 (33.3)
| 27 (100)
|
p-value = 0.180 (Mc Nemar test)
| |||
Table 2. Correlation between involvement of different parts of gastrointestinal tract – rectal biopsy versus stomach biopsies
Stomach biopsy – Positive
| Stomach biopsy – Negative
| Total
| |
Rectal biopsy – Positive
| 8
| 2
| 10 (37)
|
Rectal biopsy – Negative
| 10
| 7
| 17 (63)
|
Total
| 18 (66.7)
| 9 (33.3)
| 27 (100)
|
p-value = 0.039 (Mc Nemar test)
| |||
Table 3. Correlation between involvement of different parts of gastrointestinal tract – colon/ileum biopsies versus stomach biopsies
Colon/ IleumBiopsy Positive
| Colon/IleumBiopsy Negative
| Total
| |
Stomach biopsy – Positive
| 9
| 14
| 23 (85.2)
|
Stomach biopsy – Negative
| 1
| 3
| 4 (14.8)
|
Total
| 10 (37)
| 17 (63)
| 27 (100)
|
p-value = 0.001 (Mc Nemar test)
| |||