Endoscopic diagnosis of acute intestinal GVHD following allogeneic hematopoietic SCT: a retrospective analysis in 175 patients

Abstract

Diagnosis of acute intestinal GVHD (aGVHD) following allogeneic hematopoietic cell transplantation is based on clinical symptoms and histological lesions. This retrospective analysis aimed to validate the 'Freiburg Criteria' for the endoscopic grading of intestinal aGVHD. Grade 1: no clear-cut criteria; grade 2: spotted erythema; grade 3: aphthous lesions; and grade 4: confluent defects, ulcers, denudation of the mucosa. Having excluded patients with infectious diarrhea, we evaluated 175 consecutive patients between January 2001 and June 2009. Setting a cutoff between grade 1 (no change in therapy) and grade 2 (intensification of immunosuppression), macroscopy had a sensitivity of 89.2% (95% confidence interval (CI): 80.4-94.9%), a specificity of 79.4% (95% CI: 69.6-87.1%), a positive-predictive value of 79.6% (95% CI: 70.0-87.2%) and a negative-predictive value of 89.0% (95% CI: 80.2-94.9%). In all, 20% of patients with aGVHD in the lower gastrointestinal tract (GIT) had lesions only in the terminal ileum. In all patients with aGVHD ≥2 of the upper GIT, typical lesions were also found in the lower GIT. Ileo-colonoscopy showed the highest diagnostic yield for aGVHD. In conclusion, the 'Freiburg Criteria' for macroscopic diagnosis of intestinal aGVHD provide high accuracy for identifying aGVHD ≥2.

Figure 1

Time interval between SCT and endoscopy.

Figure 2

Histological findings in different grades of intestinal aGVHD. Apoptotic crypt cell loss (grade 1) or loss of single crypts (grade 2) are marked by arrows. Grade 3: loss of contiguous crypts (white ellipse). Grade 4: complete denudation of the mucosa.

Figure 3

(a) Examples for macroscopic grading of aGVHD as grade 2. (b) Examples for macroscopic grading of aGVHD as grade 3. (c) Examples for macroscopic grading of aGVHD as grade 4: Confluent defects, ulcerations and complete denudation of the mucosa. The white flap is sloughed mucosa.

Figure 4

Distribution of different grades of aGVHD in the gastrointestinal tract. Frequency of histological grading of intestinal aGVHD in the different parts of the gastrointestinal tract. Term. ileum, terminal ileum.

Figure 5

Diagnostic yield of histology of different parts of the gastrointestinal tract. (a) Only colonoscopy vs colonoscopy+ileoscopy. Number of patients with histologically proven aGVHD ⩾1 in: only colon; colon and terminal ileum; and only terminal ileum. Number of patients with histologically proven aGVHD ⩾2 in: only colon; colon and terminal ileum; only terminal ileum. (b) Ileo-colonoscopy vs upper GIT endoscopy vs combination of both. Number of patients with histologically proven aGVHD ⩾1 in: only lower GIT; lower and upper GIT; and only upper GIT. Number of patients with histologically proven aGVHD ⩾2 in: only lower GIT; lower and upper GIT; and only upper GIT. Term. ileum, terminal ileum.