Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Oct 16, 2020; 12(10): 341-354
Published online Oct 16, 2020. doi: 10.4253/wjge.v12.i10.341
Assessing the yield and safety of endoscopy in acute graft-vs-host disease after hematopoietic stem cell transplant
Anand V Rajan, Harry Trieu, Peiguo Chu, James Lin, Trilokesh Dey Kidambi
Anand V Rajan, Harry Trieu, Peiguo Chu, James Lin, Trilokesh Dey Kidambi, Department of Medicine, City of Hope Medical Center, Duarte, CA 91010, United States
Anand V Rajan, Department of Medicine, UCLA-Olive View Medical Center, Sylmar, CA 91342, United States
Harry Trieu, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, United States
Trilokesh Dey Kidambi, Department of Gastroenterology, City of Hope, Duarte, CA 91010, United States
Author contributions: Trieu H and Rajan AV contributed equally to this work; Trieu H, Rajan AV, and Kidambi TD designed the research study with input from Lin J; Chu P performed the pathological analysis; Trieu H and Rajan AV performed the research, analyzed the data, and wrote the manuscript; all authors have read and approve the final manuscript.
Institutional review board statement: The study was reviewed and approved for publication by our Institutional Reviewer. Please see separate IRB approval form.
Informed consent statement: All study participants identities were anonymized and details that might disclose their identities were omitted. For this type of study formal consent is not required.
Conflict-of-interest statement: All the authors have no conflict of interest related to the manuscript.
Data sharing statement: The original anonymous dataset is available on request from the corresponding author at
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Trilokesh Dey Kidambi, MD, Assistant Professor, Department of Medicine, City of Hope Medical Center, 1500 E Duarte Road, Duarte, CA 91010, United States.
Received: July 22, 2020
Peer-review started: July 23, 2020
First decision: August 22, 2020
Revised: August 28, 2020
Accepted: September 8, 2020
Article in press: September 8, 2020
Published online: October 16, 2020
Processing time: 83 Days and 22.6 Hours
Research background

Gastrointestinal (GI) graft-vs-host disease (GVHD) is the most common complication of hematopoietic stem cell transplant (HSCT) and is often diagnosed via endoscopy with biopsy.

Research motivation

Limited data exists on optimal endoscopic strategy and safety for GVHD evaluation in cancer patients who have had HSCT.

Research objectives

To create a strategy of endoscopic approach based on symptoms, gross endoscopic findings, and biopsy location as well as understand the safety of endoscopy in acute GVHD (aGVHD) patients.

Research methods

We analyzed 195 endoscopies performed at City of Hope in patients who underwent HSCT for hematological malignancy and were evaluated for aGVHD.

Research results

Evaluation using 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 in patients with any presenting symptom. Biopsies obtained from either the upper or lower GI tract, specifically the rectosigmoid colon, demonstrated comparably high yields in patients with diarrhea (95.7% vs 99.1%) or nausea/vomiting (97.5% vs 96.8%). Normal-appearing mucosa was generally as specific (91.3%) for the presence of aGVHD on biopsy as the presence of endoscopic abnormalities (58.7%-97.8%), however sensitivity was low. Adverse events occurred in a small proportion of patients, including bleeding (1.0%), infection (1.0%), and perforation (0.5%). There was no significant difference in occurrence of adverse events in thrombocytopenic compared to non-thrombocytopenic patients (P = 1.000) and neutropenic compared to non-neutropenic patients (P = 0.425).

Research conclusions

Combined EGD and FS with biopsy of the stomach and rectosigmoid colon results in the greatest diagnostic yield for most patients referred for evaluation of aGVHD, independent of symptoms. Biopsy of normal appearing mucosa is warranted, and endoscopic evidence of severe inflammation is specific for more histologically severe GVHD. In resource limited settings, or in patients with high risk for sedation related complications, FS with rectosigmoid biopsies may be an appropriate approach given reasonable yield for detection of aGVHD. Our study also found no significant difference in adverse events between thrombocytopenic and neutropenic patients, confirming the safety of endoscopy in this patient population.

Research perspectives

Future, larger, controlled studies are needed to control for confounders and more accurately model the risk associated with endoscopy in the thrombocytopenic and neutropenic groups.