Less invasive diagnosis of gastrointestinal graft-versus-host disease

Katsuyo Endo and colleagues at Tonoku University in Sendai, Japan, conducted a retrospective analysis of endoscopic features associated with graft-versus-host disease (GvHD), when evaluated via rectosigmoidoscopy. Rectosigmoidoscopy is a less invasive technique than total colonoscopy. The aim of this study was to assess the usefulness of four distinct colonoscopic findings for diagnosis of GvHD, using the less invasive technique.

The four findings were orange peel appearance, spotty redness, small mucosal sloughing and diffuse mucosal defect. Orange peel appearance is associated with submucosal edema. Spotty redness indicates crypt cell apoptosis and lymphocyte invasion. Small mucosal sloughing is indicative of crypt cell destruction. Diffuse mucosal defect is thought to represent severe crypt cell necrosis.

For this study, all included patients had a diagnosis of gastro-intestinal (GI) GvHD following allogeneic stem cell transplant.

Key findings:

• N = 70 patients
• Median age = 39 years (2–63 years)
• Median day of colonoscopy after transplant = +42 (+15–159)
• Colonoscopy method
  • Rectosigmoidoscopy: 82.9%
  • Beyond sigmoid colon: 17.1%
• Stem cell source
  • Bone marrow: 44.2%
  • Peripheral blood:15.7%
  • Cord blood: 40%
• Colonoscopy findings
  • Orange peel: 94.3%
  • Spotty redness: 64.3%
  • Small mucosal sloughing:70%
  • Mucosal defect: 8.6%
• Concurrent colonoscopy features
  • Negative for all findings:1.4%
  • 1 finding: 20.8%
  • 2 findings: 26%
  • 3 findings: 48.6%
  • 4 findings: 5.2%
• Correlation of crypt apoptosis on biopsy to colonoscopy finding
  • Orange peel: 87.5%
  • Spotty redness: 83.3%
  • Small mucosal sloughing: 87.2%
  • Mucosal defect: 88.9%

The results of this study lend to a hypothesis that GI GvHD is best described as a sequential transition of pathologic changes in the GI tract. The theoretical evolution in disease is submucosal edema, lymph invasion and apoptosis of crypt cells, followed by progressive glandular necrosis.  In the observed patients, diffuse mucosal defects had the lowest incidence of occurrence; however, it was also associated with the most severe cases of GI GvHD. These findings are helpful and may lend consideration for a revised diagnosis standard for GI GvHD.