CT in the clinical and prognostic evaluation of acute graft-vs-host disease of the gastrointestinal tract

Abstract

Objective: To determine the role of abdominal CT in assessment of severity and prognosis of patients with acute gastrointestinal (GI) graft-vs-host disease (GVHD).

Methods: During 2000-2004, 41 patients with a clinical diagnosis of acute GI-GVHD were evaluated. CTs were examined for intestinal and extra-intestinal abnormalities, and correlated with clinical staging and outcome.

Results: 20 patients had GVHD clinical Stage I-II and 21 had Stage III-IV. 39 (95%) had abnormal CT appearances. The most consistent finding was bowel wall thickening: small (n=14, 34%) or large (n=5, 12%) bowel, or both (n=20, 49%). Other manifestations included bowel dilatation (n=7, 17%), mucosal enhancement (n=6, 15%) and gastric wall thickening (n=9, 38%). Extra-intestinal findings included mesenteric stranding (n=25, 61%), ascites (n=17, 41%), biliary abnormalities (n=12, 29%) and urinary excretion of orally administered gastrografin (n=12, 44%). Diffuse small-bowel thickening and any involvement of the large bowel were associated with severe clinical presentation. Diffuse small-bowel disease correlated with poor prognosis. 8 of 21 patients responded to therapy, compared with 15 of 20 patients with other patterns (p=0.02), and the cumulative incidence of GVHD-related death was 62% and 24%, respectively (p=0.01). Overall survival was not significantly different between patients with diffuse small-bowel disease and patients with other patterns (p=0.31). Colonic disease correlated with severity of GVHD (p=0.04), but not with response to therapy or prognosis (p=0.45).

Conclusion: GVHD often presented with abdominal CT abnormalities. Diffuse small-bowel disease was associated with poor therapeutic response. CT may play a role in supporting clinical diagnosis of GI GVHD and determining prognosis.

Figure 1

Diffuse small-bowel involvement in graft-vs-host disease (GVHD). A 48-year-old man with clinical Grade IV GVHD. Patient died of GVHD. (a) Unenhanced scan shows marked small-bowel wall thickening (arrow). (b) Enhanced study shows the “water halo” sign in small-bowel wall (arrow).

Figure 2

Small and large bowel involvement. A 41-year-old man with clinical Grade IV graft-vs-host disease (GVHD). Patient died of GVHD. Unenhanced scan shows bowel wall thickening (thin white arrows), more severe in the large bowel (long arrow). Orally ingested gastrografin is present in the renal pelvis on both sides (thick white arrows).

Figure 3

Gastric involvement. A 24-year-old woman with clinical Grade IV graft-vs-host disease. Patient died from relapse of underlying disease, non-Hodgkin's lymphoma. Unenhanced study shows gastric wall oedema and thickening (thick black arrow). Contrast material is seen in the renal pelvis on the right (thick white arrow). Thickening of gall bladder wall is seen as well (thin black arrow).

Figure 4

Intestinal and extra-intestinal involvement. A 59-year-old woman with Grade IV graft-vs-host disease (GVHD). Patient died of GVHD. (a) Unenhanced scan shows the “water halo” sign in the large bowel (arrow). (b) Contrast-enhanced coronal reformation demonstrates large-bowel wall thickening and marked mucosal enhancement (thick white arrow). Gallbladder wall thickening (thin black arrow) and periportal oedema (thick black arrow) are seen as well.

Figure 5

Extra-intestinal findings. A 34-year old-man with Grade IV graft-vs-host disease (GVHD). Patient died of GVHD. A scan through the pelvis shows the “accordion” sign in the large bowel (arrow) and moderate ascitis (a).

Figure 6

Cumulative incidence of graft-vs-host disease (GVHD)-associated mortality. Patients with diffuse intestinal involvement had a higher risk for death as a direct result of GVHD than patients with other patterns of intestinal involvement. CI, confidence interval.

Figure 7

Overall survival from CT study. Similar survival with different patterns of intestinal involvement.